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IMPROVING FEDERAL HEALTH CARE IN 

RURAL AMERICA: DEVELOPING THE WORKFORCE 

AND BUILDING PARTNERSHIPS 

HEARING 

BEFORE THE

SUBCOMMITTEE ON THE EFFICIENCY AND 

EFFECTIVENESS OF FEDERAL PROGRAMS AND THE 

FEDERAL WORKFORCE 

OF THE

COMMITTEE ON 

HOMELAND SECURITY AND 

GOVERNMENTAL AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED THIRTEENTH CONGRESS 

FIRST SESSION 

MAY 23, 2013 

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

Printed for the use of the Committee on Homeland Security 

and Governmental Affairs 

( 
(II) 

COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS 

THOMAS R. CARPER, Delaware Chairman 

CARL LEVIN, Michigan 

MARK L. PRYOR, Arkansas 

MARY L. LANDRIEU, Louisiana 

CLAIRE MCCASKILL, Missouri 

JON TESTER, Montana 

MARK BEGICH, Alaska 

TAMMY BALDWIN, Wisconsin 

HEIDI HEIKAMP, North Dakota 

TOM COBURN, Oklahoma 

JOHN MCCAIN, Arizona 

RON JOHNSON, Wisconsin 

ROB PORTMAN, Ohio 

RAND PAUL, Kentucky 

MICHAEL B. ENZI, Wyoming 

KELLY AYOTTE, New Hampshire 

RICHARD J. KESSLER, Staff Director 

JOHN P. KILVINGTON, Deputy Staff Director 

KEITH B. ASHDOWN, Minority Staff Director 

LAURA W. KILBRIDE, Chief Clerk 

LAUREN CORCORAN, Hearing Clerk 

SUBCOMMITTEE ON THE EFFICIENCY AND EFFECTIVENESS OF 

FEDERAL PROGRAMS AND THE FEDERAL WORKFORCE 

JON TESTER, Montana, Chairman 

MARK L. PRYOR, Arkansas 

CLAIRE MCCASKILL, Missouri 

MARK BEGICH, Alaska 

TAMMY BALDWIN, Wisconsin 

HEIDI HEITKAMP, North Dakota 

ROB PORTMAN, Ohio 

RON JOHNSON, Wisconsin 

RAND PAUL, Kentucky 

MICHAEL B. ENZI, Wyoming 

TONY MCCLAIN, Majority Staff Director 

BRENT BOMBACH, Minority Staff Director 

KELSEY STROUD, Chief Clerk 
(III) 

C O N T E N T S 

Opening statement: Page 

Senator Tester .................................................................................................. 1 

Senator Portman .............................................................................................. 2 

Senator Begich .................................................................................................. 14 

Senator Heitkamp ............................................................................................ 17 

WITNESSES 

THURSDAY, MAY 23, 2013 

Robert A. Petzel, M.D., Under Secretary for Health, Veterans Health Administration, U.S. Department of Veterans Affairs ................................................. 4 

Yvette Roubideaux, M.D., Acting Director, Indian Health Service, U.S. Department of Health and Human Services .......................................................... 6 

Tom Morris, Associate Administrator, Office of Rural Health Policy, Health 

Resources and Services Administration, U.S. Department of Health and 

Human Services ................................................................................................... 8 

Matt Kuntz, Executive Director, National Alliance on Mental Illness for Montana ....................................................................................................................... 22 

Ralph Ibson, National Policy Director, Wounded Warrior Project ...................... 24 

ALPHABETICAL LIST OF WITNESSES

Ibson, Ralph: 

Testimony .......................................................................................................... 24 

Prepared statement .......................................................................................... 74 

Kuntz, Matt: 

Testimony .......................................................................................................... 22 

Prepared statement .......................................................................................... 63 

Morris, Tom: 

Testimony .......................................................................................................... 8 

Prepared statement .......................................................................................... 57 

Petzel, Robert A. M.D.: 

Testimony .......................................................................................................... 4 

Prepared statement .......................................................................................... 31 

Roubideaux, Yvette M.D.: 

Testimony .......................................................................................................... 6 

Prepared statement .......................................................................................... 48 

APPENDIX 

Responses to post-hearing questions for the Record: 

Mr. Petzel .......................................................................................................... 83 

Ms. Roubideaux ................................................................................................ 113 

Mr. Morris ......................................................................................................... 122 

Mr. Kuntz .......................................................................................................... 138 

(1) 

IMPROVING FEDERAL HEALTH CARE 

IN RURAL AMERICA: DEVELOPING THE 

WORKFORCE AND BUILDING PARTNERSHIPS 

THURSDAY, MAY 23, 2013 

U.S. SENATE,

SUBCOMMITTEE ON THE EFFICIENCY AND EFFECTIVENESS OF

FEDERAL PROGRAMS AND THE FEDERAL WORKFORCE, 

OF THE COMMITTEE ON HOMELAND SECURITY

AND GOVERNMENTAL AFFAIRS,

Washington, DC. 

The Subcommittee met, pursuant to notice, at 10:05 a.m., in 

room SD–342, Dirksen Senate Office Building, Hon. Jon Tester, 

Chairman of the Subcommittee, presiding. 

Present: Senators Tester, Begich, Heitkamp, and Portman. 

OPENING STATEMENT OF SENATOR TESTER 

Senator TESTER. We will call to order this hearing of the Subcommittee on the Efficiency and Effectiveness of Federal Programs 

and the Federal Workforce. This morning’s hearing is titled, ‘‘Improving Federal Health Care in Rural America: Developing the 

Workforce and Building Partnerships.’’ I look forward to hearing 

from our witnesses about efforts made by the Federal health care 

workforce to address the needs of rural America, including veterans 

and Native Americans. 

Today we will discuss some of the challenges of this task, including efforts to recruit and retain a quality Federal health care workforce, and we will highlight opportunities for collaboration, cost 

sharing and exploring stronger partnerships between agencies and 

local providers. 

As a Montanan and someone who has worked very closely with 

veterans and the Native American population, I am aware of the 

challenges in rural and frontier areas of accessing quality health 

care in a timely manner. Addressing these challenges will certainly 

require a multifaceted approach. We need to invest in technologies 

like telemedicine and bring health care closer to home. We need to 

expand the number of mobile clinics and Vet Centers and improve 

transportation options for folks that are forced to travel significant 

distances to receive the health care that they need. 

But we also need to address chronic health care workforce shortages in rural communities in agencies like the Veterans Administration (VA) and the Indian Health Service (IHS). Far too often we 

have seen new facilities sit idle because we cannot recruit enough 

mental health professionals to a particular area, or we have seen 
2 

veterans diverted for care because of nursing shortages at a particular facility. 

But this is not a VA-specific problem. It is a rural problem, and 

it is a national problem. We need government agencies to aggressively and effectively work together to make progress and to ensure 

they are working in collaboration and not in competition. This collaboration should not only be happening between Federal agencies; 

it should be happening at the State level, and it needs to be happening in more rural areas. 

In these communities the Federal health care workforce needs to 

leverage its limited resources to empower local partners to more effectively increase access to care. Just because a veteran lives in a 

place like Havre, Montana, does not make him or her less deserving of timely and quality health care. 

We have some great witnesses with us here today, and as we discuss these critical issues in more detail, I look forward to hearing 

from each of them. 

I will now turn it over to Ranking Member Senator Portman for 

his opening statement. 

OPENING STATEMENT OF SENATOR PORTMAN 

Senator PORTMAN. Thank you, Mr. Chairman, and thank you for 

having the hearing today on an incredibly important issue in Montana, in Ohio, and around the country. It is an important topic, and 

I think the testimony we are going to get today is going to shed 

light on some of these issues facing rural health care in particular. 

Thanks to the witnesses for being here, this panel and the coming 

panel. 

One of the most important functions that our Federal Government must fulfill, of course, is the care of our veterans. We need, 

as we are going to into Memorial Day, to think about that. They 

are out there defending us, in essence, and their mission continues, 

when they get home. We have to be sure we are there with them. 

And there are acute health care problems right now facing over 6 

million veterans in rural communities, including a lack of sufficient 

health care providers and the need to travel, as the Chairman said, 

significant distances to seek care in many cases. 

Like our urban veterans, our rural veterans returning from Iraq 

and Afghanistan are coping every day with both the visible and the 

invisible wounds of war. But, unfortunately for those in rural 

areas, help is not as readily available. 

I would like to discuss these topics in the context of traumatic 

brain injury because it is often referred to as the signature wound, 

unfortunately, of the wars in Iraq and Afghanistan. The Department of Defense (DOD) now estimates that over 266,000 

servicemembers have suffered traumatic brain injuries (TBIs), from 

2000 to 2012. At the same time, the Congressional Research Service (CRS), has estimated that over 100,000 servicemembers who 

have served since 2000 suffer from post-traumatic stress (PTSD). 

So it is one thing to be able to get our rural veterans treatment 

for an orthopedic issue or even help maybe on a diabetes management program, but often it is another thing entirely to present the 

full scope of treatment needed for a veteran suffering from the effects of TBI or post-traumatic stress. 
3 

I know our witnesses recognize the scope of the problem, and 

each of your departments has embarked on a number of initiatives 

to address those problems. I look forward to hearing more about 

that today. 

I will say I am concerned that we are making internal adjustments and small steps forward, whereas the size of the problem is 

bigger than that. It is daunting. And the longer we take to address 

it, the worse it is going to become. 

I think the treatments that we are now providing for our veterans are not as effective as they could be, and I think the pilot 

projects and assessments are important. But I think we have a bigger problem that we need to address, and that is what we will talk 

about today. 

Tragically, we are now losing, we are told, 22 veterans a day to 

suicide. Fundamental changes are needed to occur from the way 

VA interacts with our veterans to the model for providing care, and 

we will talk about that. 

When I am back home in Ohio, I regularly talk to our veterans 

about their interactions with the VA. Some are very positive. Some 

of the stories I hear from our rural veterans are likely similar to 

what the Chairman hears in Montana: long drives, even longer 

drives in Montana probably; expensive drives sometimes to get the 

kind of treatment that they need; uncoordinated appointments; 

varying customer service. When a TBI patient who may find it difficult to remember his or her appointments, may find it difficult to 

follow directions, or even interact with other people, has to drive 

a couple hours to an appointment, and when he shows up a little 

late after driving through a blizzard and has to reschedule his appointment for weeks later, we are not setting that person up for 

success. And, unfortunately, the stories that I have heard are not 

isolated, and I know, again, in Montana some of the same stories 

are out there. 

So we have to leverage the resources of our Nation for these men 

and women who have given so much to us. We have providers 

throughout our country who stand ready to support this population 

of over 6 million rural veterans if given the opportunity to do so. 

And connecting our rural veterans with the right treatment I think 

is something we ought to be focused on, and we will talk about that 

today. 

So, again, thanks to our witnesses. Mr. Chairman, I look forward 

to the testimony today and discussing these issues. 

Senator TESTER. Well, thank you, Senator Portman. I would just 

like to say thank you for your opening statement, and as we kick 

off the first hearing on this Subcommittee, I want to say I look forward to working with you to help improve issues, whether it is 

health care or something else. This is a pretty broad-based Subcommittee. 

Senator PORTMAN. Yes, likewise. 

Senator TESTER. So I look forward to working with you to get 

some good things done. 

I would like to welcome our first panel of witnesses who have all 

spent years in public service working to increase access to health 

care for rural Americans, and they have all dealt extensively with 
4 

1The prepared statement of Mr. Petzel appears in the Appendix on page 31. 

the challenges of recruiting and retaining a quality health care 

workforce. 

First of all, I would like to introduce Dr. Robert Petzel. He is the 

Under Secretary of Health in the Department of Veterans Affairs. 

He has served in that capacity since February 18, 2010. In this position, he oversees the health care needs of some 8 million veterans 

currently enrolled in the Veterans Health Administration (VHA), 

the Nation’s largest integrated health care system. VHA employs 

over 272,000 staff members at more than 1,700 sites across this 

country. Last year, the VA treated 6 million patients during 80 million outpatient visits and 692,000 inpatient admissions. 

Welcome, Dr. Petzel. It is great to see you, and we look forward 

to your testimony and look forward to getting you back in Montana. 

Next we have Dr. Yvette Roubideaux, who is the Director of Indian Health Service, IHS, at the U.S. Department of Health and 

Human Services (HHS). She has served in that capacity since 2009. 

IHS provides a comprehensive health service delivery system for 

approximately 2.2 million American Indians and Alaska Natives 

from 566 federally recognized tribes in some 35 States, and they 

serve a critical role in my State of Montana. 

Dr. Roubideaux, it is good to see you again. We look forward to 

your testimony. 

And last, but certainly not least, we have Tom Morris, who is the 

Associate Administrator for the Office of Rural Health Policy 

(ORHP) in the Health Resources and Services Administration 

(HRSA), an agency within the U.S. Department of Health and 

Human Services. Tom’s office serves as a critical research and policy resource on rural health issues, and it administers a number 

of critical grant programs that enhance the delivery of rural health 

care. Additionally, his office works very closely with local partners 

to increase access and to build capacity within those communities. 

Tom also happens to serve on the Veterans Rural Health Advisory 

Committee (VRHAC). 

Welcome, Tom. It is good to have you here. 

OK. We will start with Dr. Petzel. You will have 5 minutes for 

your oral testimony. Know that your full written testimony will be 

made a part of the record, so with that, Dr. Petzel, you may proceed. 

TESTIMONY OF ROBERT A. PETZEL, M.D.,1 UNDER SECRETARY 

FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. 

DEPARTMENT OF VETERANS AFFAIRS 

Dr. PETZEL. Chairman Tester, Ranking Member Portman, and 

Members of the Subcommittee, thank you for the opportunity to 

speak with you today about how VA recruits, retains, and deploys 

a quality health care workforce to ensure that veterans can access 

the health care that they have earned and deserve. 

VA is committed to providing veterans with quality, timely, and 

accessible health care as close to their home as possible. Veterans’ 

mental health is a top priority for VA. As a part of President 

Barack Obama’s Executive Order (EO) to improve access to mental 
5 

health services for veterans, servicemembers, and military families, 

VA has made significant progress to increase its mental health 

workforce to meet the needs of veterans. 

As of May 14, 2013, VA has hired 1,367 new mental health clinical providers. In addition to that, we have hired 2,063 mental 

health providers to fill existing vacancies, so over the last 10 

months, VA has hired almost 4,000 additional mental health providers. And in addition to that, we have begun hiring a new group 

of people called peer specialists, and today 261 of them have been 

hired. 

We are aware of the challenges to recruit and retain a quality 

health care workforce and are implementing a number of creative 

recruitment strategies to ensure access to care for all veterans. 

These efforts to increase the awareness of employment opportunities including national advertisements through television commercials, public service announcements. To meet the mental health 

needs of veterans and their families, VA has also begun to hold facility-based mental health summits with the purpose of building 

and expanding coalitions with community providers, organizations 

in the communities, and Federal and State agencies. 

VA is dedicated to improving access and quality of care for rural 

veterans by developing innovative practices to support the unique 

needs of veterans residing in geographically remote areas. 

VA has used a number of programs, including Project Access Received Closer to Home (ARCH) and Patient-Centered Care, in order 

to provide eligible veterans coordinated and timely access to care 

through a network of non-VA medical providers who meet VA quality standards. 

VA will continue to look for and implement new ways to broaden 

access through innovative approaches to bringing care to veterans. 

Telehealth enhances health care, especially in rural and geographically remote areas, where it can be difficult to recruit health 

care professionals and where travel distances are excessive. 

VA is a national leader in telehealth-based care. In fiscal year 

(FY) 2012, VHA provided care to half a million patients through 

video clinical conferencing, store-forward technology, telehealth, 

and tele-home health. This number is set to rise to 830,000 in 

2013. 

Specialty Care Access Network Extensions for Community 

Health Outcomes (SCAN-ECHO), is one initiative that VHA is 

using to ensure the delivery of specialty care services to improve 

access to specialists. SCAN-ECHO leverages telehealth to allow 

health care specialists from a regional center to offer expert advice 

to providers in rural health care settings. 

Another initiative is MyHealtheVet. This offers veterans online 

access to the VA health care system, and it is designed to give 

them greater control over their health and wellness. Features of 

the system include the ability to communicate with providers, refill 

prescriptions, and to access their electronic medical record. 

VA optimizes the delivery of treatments by using technologies 

and tools such as mobile applications. These mobile applications 

can help veterans build resilience and manage their daily challenges. The award-winning PTSD Coach mobile app, co-developed 
6 

1The prepared statement of Ms. Roubideaux appears in the Appendix on page 48. 

with the Department of Defense, provides an opportunity to better 

understand and manage the symptoms associated with PTSD. 

Prolonged exposure (PE) therapy coach, is a mobile application 

for patients to use with their therapist during prolonged exposure 

therapy as a treatment companion. 

VA maintains partnerships and continuously seeks to foster relationships with government and nongovernment organizations to 

bring value to veterans and expand access to the care they have 

earned and deserve. 

VA has a strong history of collaborating with community mental 

health clinics, including federally qualified centers. These locally 

developed community partnerships provide mental health services 

to veterans in areas where direct access to VA health care is limited by either geography or workload. 

In response to President Barack Obama’s Executive Order, VA, 

working closely with the Department of Health and Human Services, initiated 15 pilot projects to evaluate how these partnerships 

can help bring mental health services in areas that are experiencing difficulty in providing direct care. We are committed to 

building an accessible system that is responsive to the needs of 

America’s veterans. VA continues to implement its rural workforce 

strategy to recruit locally and utilize the necessary resources, including collaboration, technology, and partnerships, to achieve 

these goals. 

I thank the Subcommittee for the opportunity to appear before 

you to discuss this important issue, and I am prepared to answer 

any questions you may have. 

Senator TESTER. Thank you for your testimony, Dr. Petzel. 

And we will move to Dr. Roubideaux. 

TESTIMONY OF YVETTE ROUBIDEAUX, M.D.,1 ACTING DIRECTOR, INDIAN HEALTH SERVICE, U.S. DEPARTMENT OF 

HEALTH AND HUMAN SERVICES 

Dr. ROUBIDEAUX. Thank you, Chairman Tester, Ranking Member 

Portman, and Members of the Subcommittee. My name is Dr. 

Yvette Roubideaux, and I am the Acting Director of the Indian 

Health Service, and I am pleased to provide testimony on our efforts to develop and support the Federal health care workforce. 

IHS’s workforce plays a critical role in supporting the overall 

mission of the IHS as a rural health care system addressing a population with significant disparities in health and access to care. 

IHS shares similar challenges faced by rural communities across 

the Nation. Many of our IHS facilities are in rural and remote locations where recruitment and retention of employees, especially 

health care providers, present unique challenges. 

IHS vacancy rates for health professionals have actually improved over the past few years, but they still remain an issue. For 

example, dental vacancies were greater than 30 percent, but an increased focus on recruitment and retention reduced those vacancies 

to approximately 10 percent. However, continued efforts to improve 

recruitment, retention, and support of our Federal workforce are 

critical. 
7 

Over the past few years, IHS has implemented a number of reforms to change and improve the agency, and many of these efforts 

have contributed to better support and strengthen IHS’s workforce 

since many of our reforms were based on input and recommendations from our employees and our stakeholders. 

IHS also supports programs such as the American Indians Into 

Medicine, American Indians Into Psychology, and the Quentin N. 

Burdick American Indians Into Nursing Programs which help develop students’ interest in health professions and encourage them 

to return to their communities and work for IHS in the future. 

The IHS Health Professions Scholarship Program is a key strategy for the agency in developing the future American Indian/Alaska Native (AI/ANs) workforce. 

The IHS Loan Repayment Program is one of our most effective 

recruitment and retention tools for the recruitment of a variety of 

positions in our workforce. 

The IHS has worked to strengthen our recruitment and retention 

strategies through gathering input from our workforce and our 

stakeholders to better understand the needs of our workforce. And 

another important strategy to improve recruitment and retention is 

to improve the workplace environment at IHS to better support our 

workforce. 

IHS has made improvements in background checks, the hiring 

process, and credentialing and privileging of providers to ensure 

that we have a quality Federal workforce. 

IHS has also worked to make our salaries more competitive with 

the private sector, which is especially important for health professional improvement. 

IHS has leveraged many partnerships to help develop and support its Federal workforce with other Federal agencies, academic 

institutions, and tribal communities. 

Our partnership with the Health Resources and Services Administration has helped us recruit more health professionals to work 

in IHS through their National Health Service Corps Scholarship 

and Loan Repayment Programs. 

Our partnership with the VA has helped us improve coordination 

of care for American Indian and Alaska Native veterans through 

implementation of our 2010 Memorandum of Understanding 

(MOU) and our 2012 VA–IHS National Reimbursement Agreement. 

Those are helping our workforce improve access to quality health 

care for American Indian and Alaska Native veterans. 

Our partnerships with academic institutions are extremely important to our recruitment and retention efforts because of the link 

it provides to students and new graduates seeking places to serve. 

One of our most powerful recruitment and retention strategies is 

our partnership with our communities. As more of our Federal 

workforce feels at home and supported by those communities, the 

likelihood that they will become a long-term member of that community will increase. 

In summary, the Federal workforce is essential to the core mission of the Indian Health Service and its delivery of accessible and 

quality health care services to American Indian and Alaska Native 

communities. While there is much more to do, we appreciate the 
8 

1The prepared statement of Mr. Morris appears in the Appendix on page 57. 

opportunity to testify at this hearing to further discuss opportunities for improvement. 

Mr. Chairman, this concludes my testimony. I am happy to answer questions. 

Senator TESTER. Thank you, Dr. Roubideaux. We appreciate your 

testimony. 

We will go to Mr. Morris. 

TESTIMONY OF TOM MORRIS,1 ASSOCIATE ADMINISTRATOR, 

OFFICE OF RURAL HEALTH POLICY, HEALTH RESOURCES 

AND SERVICES ADMINISTRATION, U.S. DEPARTMENT OF 

HEALTH AND HUMAN SERVICES 

Mr. MORRIS. Mr. Chairman, Ranking Member Portman, and 

Members of the Subcommittee, thank you for the opportunity to 

testify today on behalf of the Department of Health and Human 

Services, the Health Resources and Services Administration, about 

the Federal Office of Rural Health Policy. 

For 25 years, the office, which was created by Congress, has 

served as a focal point for rural health activities within HHS. We 

are charged with advising the Secretary on the impact of HHS policies, regulations, and programs on rural communities. This includes an ongoing focus on issues related to the training, recruitment, and retention of health care professionals in rural communities. We also administer several grant programs related to capacity building from community-based pilot programs to State programs focused on improving the quality and financial performance 

of small rural hospitals. We welcome opportunities to discuss ways 

to help rural communities attract and retain needed health care 

providers. This is a priority for the office, for the Department, for 

HRSA, and for the Administration. 

There are nearly 50 million people living in rural areas. That 

represents about 16 percent of the population spread across 80 percent of the land mass of the United States. The rural health care 

system is heavily focused on primary care and chronic disease management, relies heavily on safety net providers like small rural hospitals, federally qualified health centers, and rural health clinics, 

as well as solo providers and small group practices. 

The Office of Rural Health Policy funds several initiatives that 

focus on building up that rural capacity. This ranges from our work 

with the 50 State Offices of Rural Health, which we provide grants 

to, as well as our work through the Rural Hospital Flexibility 

Grant Program and the Small Hospital Improvement Grant Program, which works to improve question and financial performance 

for small rural hospitals. 

HHS’s investment in rural communities, though, goes far beyond 

the ORHP programs. For example, HRSA administers the National 

Service Corps, which offers a lifeline to rural communities. They 

support loan repayment and scholarships for health care providers, 

and almost half of those providers are in rural areas. 

HRSA training programs in primary care, behavioral health, 

dentistry, and nursing play a key role in training the next generation, and we are also heavily focused on investing in community- 
9 

based residency training for physicians, whether that is through 

our teaching health center program in which 15 of the 22 grantees 

serve rural communities or through our work supporting the 23 

rural training tracks across the country. Our studies indicate that 

70 percent of the graduates of these rural training tracks stay in 

rural practice, and we are focused on increasing student interest in 

those programs and also working with communities to start new 

rural training tracks. 

Rural areas also benefit greatly from the HHS and State Conrad 

30 J–1 visa waiver programs which place foreign-trained physicians in communities that need them the most. Our office also 

works with each of the States through the National Rural Recruitment and Retention Network, which placed 1,767 clinicians in 

rural areas in the past year. 

Telehealth plays a key role in increasing the reach of the health 

care workforce. We have long supported grants to link urban specialists with rural communities in need, and yet we are seeing 

through our grant programs new and emerging technologies, such 

as E-emergency care, E–ICU, as well as tele-home monitoring. 

Telehealth technology also plays a key role in extending the 

reach of the limited mental health workforce, particularly in rural 

areas where psychiatrists and psychologists are often scarce. 

We also currently are funding a three-State telehealth pilot that 

includes Montana and Alaska to link rural veterans to telehealth 

and health information exchange to enhance their care. 

At HRSA, we are also working within the range of Federal partners through the White House Rural Council to train the workers 

needed to operate and maintain these health information technology systems, whether we are talking about electronic health 

records, telemedicine, or health information exchange. We expect 

this to be a key job growth area in the coming years as these technologies continue to be deployed in health care. 

Thank you again for providing the opportunity to share HRSA’s 

and the Office of Rural Health Policy’s mission with you today and 

the efforts we have underway to focus on rural working challenges. 

I am pleased to respond to your questions. 

Senator TESTER. Well, thank you, Mr. Morris, for your testimony. 

Around 10:30 there will be a vote called, and what we are going 

to do is stagger it out, so we are not going to adjourn. We will just 

stagger out, and then when Rob comes back, he can do it; otherwise, if we both have to be gone, we will kick it over to either Senator Begich or Senator Heitkamp. All right? Thank you. Could we 

put 7 minutes on the clock, please. 

Dr. Petzel, the VA has made a commitment to hire 1,600 new 

mental health care professionals and I think about 300 support 

staff. You correct me if my numbers are wrong. Where are we at 

on those hirings both for the clinicians and for the support staff? 

Dr. PETZEL. The numbers are correct, Mr. Chairman. In terms of 

the clinical providers, we have two ways that we look at this. One 

is the actual positions that were identified that have been filled, 

and as of the 14th of May, we have filled about 1,356 of that 1,600 

clinical mental health providers. 

Another way that we look at this is that every quarter we are 

able to assess the number of clinical providers providing direct care 
10 

that we actually have on board. So we went back and looked at 

what we had on board in May 2012 when we began this effort, and 

now I have the most recent data from March 2013, and that indicates that we have an additional 1,556 people on board providing 

mental health care than we did back in May. So we believe that 

we are well on our way to meeting that goal. And we have basically 

hired almost all within a few short of the administrative personnel 

that were part of the 1,900. 

Senator TESTER. What are the totals, the 1,556 additional from 

what they were, what are your total number of mental health—— 

Dr. PETZEL. I believe that the total mental health that we have 

on board providing direct patient care is about 18,600. So that 

would include psychiatrists, psychologists, mental health nurse, 

clinical mental health specialist nurses, psychiatric social workers, 

the master’s trained counselors and master’s trained family therapists. 

Senator TESTER. As you well know, in Montana—and I think this 

could be said for all of rural/frontier America—we have struggled 

to overcome shortages in mental health professionals for years. So 

unless we are getting a healthy portion of new hires, which you 

have indicated we have, we are unable to make up ground with the 

impacts of PTSD and TBI and the issues of the unseen—we will 

just call them the ‘‘unseen injuries’’ coming back from war. 

You talked about where we are today. Moving into the future are 

there long-term efforts for assessment? And if so, are there longterm efforts for recruitment that go with those assessments as we 

move forward to help bring in more young folks into the eye of 

rural America? 

Dr. PETZEL. Well, first of all, Mr. Chairman, there are ongoing 

recruitment efforts, and these will continue because we have continuing developing vacancies. I am pleased to say that the vacancy 

rate has actually dropped from slightly over 13 percent amongst 

clinical mental health providers to a little bit below 11 percent, and 

that is a significant number when you are talking about almost 

20,000 mental health professionals. 

We are assessing and will assess actually continuously whether 

or not we are meeting the access needs and the access standards 

that we have described. And if we discover that we are not able to 

do that because we do not have the personnel available, we will 

continue to add to the mental health workforce. 

But I think that it would be useful if I could take 1 minute—— 

Senator TESTER. Sure. 

Dr. PETZEL [continuing]. To describe the other things that we are 

doing that are relatively new efforts, the most important of which 

is the use of telehealth and telemental health to deal with the 

shortage of psychiatrists, which we and everybody has difficulty recruiting into rural areas. I know you are very familiar with that. 

We have set up regional centers of psychiatry that communicate 

with our community-based outpatient clinics and provide consultation and therapy by a telemental health from remote areas such as 

Spokane, Washington, where we are having difficulty recruiting 

psychiatrists, into one of these centers in an urban area where we 

are able to recruit psychiatrists. We have no difficulty recruiting 
11 

psychiatrists to New York or Minneapolis or Houston or San Francisco. And these regional centers are proving to be very effective. 

The telemental health therapy is very well received by veterans. 

They like the idea that they do not have to travel great distances. 

They are not befuddled and frustrated by a 45-minute drive, even 

across town in an urban area. And that is going to be a major effort 

in the next 2 years to help us provide the psychiatrist services in 

remote areas. 

Senator TESTER. Well, thank you, and thank you for your work. 

Dr. Roubideaux, I want to talk about some of the challenges that 

may be unique to Indian country as you seek to recruit and to train 

and to retain quality health care folks. Time and again we hear 

about administrators who must bring in folks from outside the area 

as primary care docs, as specialists, as nurses. These are highly 

skilled but high-paying jobs, especially in Indian country. 

I had a group of eighth graders in my office yesterday from down 

at Crow, and one of the questions they asked me was: How do we 

get more doctors and nurses from Crow country in the Crow hospital? These are eighth graders, these are 12-, 13-year-old kids that 

understand what is going on. 

Can you talk about the challenges of recruiting in Indian country? 

Dr. ROUBIDEAUX. Well, our challenges are significant, and we 

certainly would like to recruit more individuals from our tribal 

communities to work in our facilities and to be health professionals. The challenges are of social and economic issues in the 

communities, schools, and things like that, and then they have to 

travel far away for their education, and sometimes they do not 

come back. 

So our health professions programs help us recruit and retain 

American Indians and Alaska Natives to work in our system. 

The Indian preference law helps us a lot because about, I would 

say, approximately three-quarters of our employees right now are 

American Indian/Alaska Native. The place where we have a difficulty recruiting American Indians and Alaska Natives is in some 

of the health professions that require training at a distance from 

the Indian reservation and so recruiting them back to work is a 

challenge, but our loan repayment programs really help with that. 

Senator TESTER. OK. I am going to kick it over to Senator 

Portman. 

Senator PORTMAN. [Presiding.] Thank you, Mr. Chairman, 

Dr. Petzel, I wanted to ask a little about using non-VA providers 

for rural veterans. I know that you have capacity issues—we just 

talked about that—despite hiring over 1,500 new positions in the 

last year or so on the mental health side. 

Beyond capacity issues, where sometimes you do have to use a 

private or a fee service, what is the threshold? How far do you require a veteran to go to seek services? How do you define ‘‘geographic inaccessibility? ’’ Which I know is one of your criteria. 

Dr. PETZEL. Thank you, Senator Portman. We have definitions of 

rurality that involve both distances—60 miles would be an example—and time—60 minutes—to services. But those are not really 

used in any great sense when we are evaluating whether somebody 

should be ‘‘fee’d’’ as we call it, or cared for in the community. Much 
12 

of it has to do with the convenience of them being—or inconvenience of them being able to travel. If you have an 81-year-old gentleman who lives even 60 miles from a medical center, it is a burden to ask that individual to travel for a routine clinic appointment. And even for some individuals who are much closer but have 

to travel across an urban area, that can be a daunting task for 

somebody who is 81 years old. 

So we try to do two things. No. 1, an option is fee’ing that care, 

that is, providing the care in the local community, and we have two 

pilots that are running right now looking at that option. But another one that we are doing using in increasing numbers is what 

we call tele-home health, a video camera in the patient’s home, instruments to monitor the patient’s weight, electrocardiogram 

(EKG), blood pressure, and regular contacts with their primary 

care provider at their clinic or their medical center. It has proven 

very effective in taking care of patients with multiple chronic diseases, and in not—providing them with the opportunity to not travel to a clinic. We reduce emergency room visits by 40 percent in 

patients where we have done this and studied it. We have reduced 

clinic visits by 38 percent. And we have reduced hospitalizations by 

almost a third by providing this care in the home with constant 

communication. 

Senator PORTMAN. For mental health treatment, is that as effective as it is for other kinds of treatment? We talked earlier about 

the fact that we have so many of our veterans with PTSD or TBI. 

So maybe for somebody who is, again, recovering from an orthopedic procedure or somebody who is on dialysis, maybe you can 

work through some of these issues using some of the telemedicine 

you are talking about. But how about for mental health? Is it more 

of a challenge? 

Dr. PETZEL. Telemental health is remarkably well accepted. It 

began actually in the VA on an Indian reservation, on the Rosebud 

Indian Reservation in South Dakota, almost 10 years ago now, as 

a study, treating PTSD by telemental health, by a researcher at 

the University of Colorado. It proved to be very successful and was 

really the impetus for spreading telemental health around the 

country. The acceptance rate by this and the satisfaction rate by 

this is over 90 percent for the patients that use it. 

I will tell you an anecdote very quickly. A man lives in New Jersey, has to travel 45 minutes to get to his psychiatrist who works 

in one of the medical centers there, and he described live on the 

video camera the experience, 45 minutes through traffic, he is frustrated, he is angry, and he is not the same kind of person that he 

normally is by the time he shows up for that appointment. 

When he does a telemental health therapy episode, he is sitting 

in his own home. He is comfortable. He has not driven across 

urban traffic. He is relaxed, and he is an entirely different person. 

And the therapy session has a dramatically better effect. 

It works. It works very well, and we are going to be exploiting 

this to the maximum over the next several years. 

Senator PORTMAN. Do you think that using non-VA providers, 

particularly for mental health and TBI, is something that you are 

doing adequately? I notice in the data that you provided the Committee that about 2 percent of VA mental health patients are seen 
13 

by non-VA providers every year. DOD, as you know, has a policy 

with TRICARE that is a little different where they use non-DOD 

mental health providers for TRICARE recipients on a more regular 

basis. What is your policy? And, again, is only allowing 2 percent 

of our veterans to seek treatment by the many providers outside 

of the VA system appropriate? 

Dr. PETZEL. Well, I think that should be expanded, Senator. I 

have no doubt that 2 percent is not as much as is needed and as 

could be, and we are, in fact, doing it. The new non-VA care arrangement called PC3 is going to have in it a mental health component, and we will be expanding that. 

The issues are making sure that those non-VA providers are facile with PTSD, particularly traumatic brain injury and depression 

and the things that we see as a result of combat. But we are expanding and we intend to expand our use of non-VA providers. 

The pilot that we are doing with the federally qualified health 

centers I think is an example of that. We have committed to piloting in 15 locations how this works when we have a contract with 

a federally qualified health care provider. Those are up and running, 15 of them. Five more are going to be added relatively shortly, and I have no doubt that the network is going to expand. 

Senator PORTMAN. I notice the data you provided us goes up to 

2010, and it does show an increase from 2007 to 2009, actually a 

decrease in 2010 from 2009. But are you suggesting that your data 

for 2011 and 2012 and 2013 would show an increase? 

Dr. PETZEL. Certainly, Senator, 2012 will show an increase. I do 

not know about 2011 looks like, but 2012 should certainly show an 

increase. 

Senator PORTMAN. On telehealth or telemedicine, you have given 

us some important information in your testimony and then in an 

answer to my earlier question, and I appreciate that. By your own 

count, you are seeing over a million mental health patients a year 

now. Clearly a lot more of our veterans need this service. If we assume these patients are dispersed like the veteran population as a 

whole, that is at least 300,000 mental health patients will be in 

rural areas or highly rural areas already seeking treatment and 

likely just as many who need treatment who are not seeking it. 

Through these health programs that are telemedicine, telemental 

health programs, how many patients have been connected? 

Dr. PETZEL. That is a very good question. Presently it is about 

83,000 patients that we have delivered telemental health services 

to. 

Senator PORTMAN. And how many of those 83,000 have to go to 

one of your community-based outpatient clinics (CBOC) in order to 

get that service? 

Dr. PETZEL. Almost all of them, Senator, would be going to some 

location where we have telemental health services. There have 

been a few, but not many, that we have—as the gentleman I described in New Jersey, where we have set this up in their home. 

That is with the shrinking of—— 

Senator PORTMAN. That is a pilot program that you think should 

be expanded? 

Dr. PETZEL. It is not a pilot. It is just in its infancy, and yes, it 

will be expanded. I think that we have demonstrated—these pa-
14 

tients have demonstrated the fact that they are better therapy sessions, better therapy patients when we see them in the context of 

their home. 

Senator PORTMAN. Anything we can do to help you expand that 

capacity into the home? 

Dr. PETZEL. I think we have the resources, Senator. We have the 

money to buy the equipment. The price has shrunk dramatically, 

and it is basically just a Web cam now, a high-quality Web cam on 

a computer. The thing that we need help with around the country, 

all of us do, is psychiatrists. There just are not enough psychiatrists in this country to meet the country’s mental health needs, 

much less meet the needs of rural veterans, people that are being 

treated by the Indian Health Service. That is probably one of our 

largest issues. 

Senator PORTMAN. Thank you, Dr. Petzel. I appreciate your testimony. Senator Begich. 

OPENING STATEMENT OF SENATOR BEGICH 

Senator BEGICH. [Presiding.] Thank you very much. And, Dr. 

Petzel, thank you very much for your work and your times to Alaska and other work your agency has done, especially around—we 

call it the ‘‘Heroes Card,’’ but the work you have been doing with 

Indian Health Services and delivering health care services to rural 

veterans, especially in roadless areas in Alaska where it is very difficult, as you know, to get access. 

I want to ask you a general question, but first I again want to 

commend you for moving forward. I know our tribes have been very 

motivated, and hopefully—I have given them the task, after a period of time, to be working with us on any issues that may come 

up to make sure we continue that process so that a veteran, no 

matter where they live in rural Alaska, will have access to health 

care and not worry about having to fly all the way to Anchorage 

or Seattle, depending on the service they need. 

Can you just give me a quick update on how that is working and 

how you feel the success of that is? 

Dr. PETZEL. Thank you, Senator Begich. I want to just mention 

that I had dinner last night with Katherine Gottlieb from the 

Southcentral, and I mentioned we were having the hearing, and 

she said to send her regards. 

Senator BEGICH. Very good. Thank you. 

Dr. PETZEL. We have had great success, I think, in working with 

Southcentral and the other tribes in Alaska. The contract that we 

have for sharing services with Southcentral has been very effective 

in providing specialty services. We also have some instances where 

in more remote areas veteran patients are being seen in tribal facilities, obviating the need to travel back to either Fairbanks or to 

Anchorage. 

Then the second issue, the number of people that are having to 

travel out of Alaska down to Seattle or to Portland for services has 

shrunk dramatically, and I would say that with very few exceptions 

we are going to eliminate that need in the not too distant future. 

I mean, there are some quaternary things such as bone marrow 

transplants, et cetera, which Seattle is the obvious place to go. 

Senator BEGICH. Right, sure. 
15 

Dr. PETZEL. But, otherwise, our goal is to not have veterans in 

Alaska traveling out of Alaska in order to receive care. I think we 

are making progress, sir. 

Senator BEGICH. Fantastic. Let me ask you on the mental health, 

because, since I have been here, that has been an issue, and I appreciate I think the regulatory change you made to eliminate 

copays on mental health providers on mental health services. Alaska has been—and you know this, and so it is kind of repeating the 

obvious—that we have been on the forefront of telehealth and 

many different avenues from health care to mental health to delivery of just about everything you can imagine through telehealth. 

If, let us say, I am an Alaskan who needs services through telemedicine, and my doctor is in Idaho, does that doctor that I am 

doing telemedicine have to be licensed in Alaska? 

Dr. PETZEL. The short answer is no. 

Senator BEGICH. OK. 

Dr. PETZEL. First of all, in the VA, as in I think every Federal 

health care entity, you need to have a license in a State, but you 

do not have to have a license in the State in which you are practicing. So the licensure issue is really not a problem. What you 

need—the problem, if it arises, is not the credentialing, which is 

what licensing is about. 

Senator BEGICH. Right. 

Dr. PETZEL. It is the privileging. You need to have that individual have the right kind of privileges in the right organization. 

So if a doctor in Boise was doing specialty care for somebody at the 

Anchorage facility, they would have to be privileged at both Anchorage and at Boise. 

We are working to try and smooth out this process of privileging. 

Senator BEGICH. Good. 

Dr. PETZEL. Credentialing is not an issue. It is—— 

Senator BEGICH. Thank you for kind of splitting the two issues. 

I knew there was an issue here, and it is on the privileging situation. 

Dr. PETZEL. Correct. 

Senator BEGICH. Is there anything legislatively we need to do. I 

know we did some stuff with DOD on their end, on active, that 

Senator Kelly Ayotte and I did in an authorization bill a couple of 

years ago to fix that problem. There were a few more issues they 

had, but to make sure no matter where an active military member 

would go, they could get their mental health services delivered 

from whatever doctor they had at any time. Is there anything legislatively we need to do? 

Dr. PETZEL. Senator Begich, I do not know. 

Senator BEGICH. OK. 

Dr. PETZEL. The privileging issue is something that has to do 

with the regulating bodies in medical care, the Joint Commission. 

So the Joint Commission requires that an individual be privileged 

at the point where they are delivering the care. There is no law, 

there is not even a Federal regulation that has anything to do with 

privileging. It is basically a requirement that the Joint Commission 

has, and we have been working with them to try and find ways to 

make it easier to have people privileged at various places. But 
16 

right now privileged is the right of the medical center or the clinic 

that is delivering the care. 

Senator BEGICH. OK. Very good. Let me again say thank you for 

all the work that you guys have done in regards to getting what 

I called the ‘‘Heroes Card,’’ but really delivery for health care for 

veterans no matter where they live, the services they have earned 

and deserve. So thank you for that. 

Dr. PETZEL. I would like to also just comment on the fact that 

working with the IHS and tribes in Alaska has just been wonderful. That has been a very good example of Federal collaboration. 

Thank you. 

Senator BEGICH. They are a great group up there. 

Let me ask you, Dr. Roubideaux, if I can—again, Dr. Petzel, 

thank you very much for that. 

As you know, we have a significant problem—and, again, I want 

to echo what Dr. Petzel said. I think our Indian Health Services 

tribes are doing fantastic work in the delivery of health care. I 

would argue that we have the best, if not, the top in the country 

when it comes to delivery in the most harsh climates, conditions, 

and situations. So I agree that we have some incredible and very 

innovative approaches that we are making headway in. 

But one of the issues—and you have heard me talk about this 

before, and that is this consistent problem of staffing packages and 

how do you make sure that you have a vacancy rate of 30 percent 

in some of your categories, as you described. But the bigger issue 

is we have, as you know, a hospital in Barrow, one being developed 

in Kenai, Nome is completed, Matsu, a beautiful facility, the whole 

top floor is empty because they do not have a staffing package. 

They cannot deliver the services that the Federal Government contracted with them to do. 

You got about $53 million last year in the CR nationwide. Just 

the one in Fairbanks TCC will take $8 million of that. 

How are we going to solve this? Because, it is one thing to have 

a clinic in an urban area, but to get someone hired in a rural area 

like in Alaska, you cannot do it the day they are open. It does not 

make any sense. 

How are we going to solve this? Because this is honestly unacceptable. We have invested lots of money in these facilities, and 

then we do not staff them. What is the answer here? Because these 

are in rural areas. 

Dr. ROUBIDEAUX. Well, the answer is for us to work together on 

the appropriations that will help us get the staffing packages, and 

I am pleased to report that the President’s budget for 2014 in 

terms of staffing packages for new and replacement facilities, including joint venture facilities and Federal facilities in Alaska and 

in Oklahoma, helps us catch up to the amounts that we need to 

catch up. It has been a difficult budget climate over the past few 

years, but fortunately through our colleagues and through our 

working with the tribes, our proposal for $77 million in new staffing really helps us catch up. 

Senator BEGICH. Is that enough? 

Dr. ROUBIDEAUX. That is enough to catch up with the need for 

the facilities that are planned to be open in 2014. And so right now 
17 

we are doing our 2015 budget formulation and trying to estimate 

which ones will be open then as well. 

Senator BEGICH. OK. Let me ask one last question, and then I 

have to go vote. This one, I will use the Matsu facility. They have 

a top floor that is available. They are going to fill it up. VA has 

a clinic down the street that is at capacity. It does not have full 

service, but it is a clinic. Why don’t we just take the clinic that the 

VA has, take the space that is beautiful space, put it in there and 

have a collaborative effort? It is all Federal money. 

Dr. ROUBIDEAUX. Well, the great thing about our—— 

Senator BEGICH. Is that a good idea? 

Dr. ROUBIDEAUX. Because the VA–IHS MOU allows us to do that 

through sharing of facilities and staff, we have started to do that, 

and we hope to do more. 

Senator BEGICH. VA, good idea? 

Dr. PETZEL. Absolutely. We would be delighted if that kind of arrangement worked for both parties. 

Senator BEGICH. Fantastic. We want to work with you specifically on that project, so I think that is a huge opportunity to create 

a great model. 

Thank you. I have to go vote. 

Senator TESTER. [Presiding.] Yes, you do. Senator Heitkamp. 

OPENING STATEMENT OF SENATOR HEITKAMP 

Senator HEITKAMP. Thank you, Mr. Chairman, and thanks to all 

the Members of the panel. Lest you think that this is an unimportant issue to North Dakota, I want to point out that the two Senators whose names were invoked in the testimony were Senator 

Conrad and Senator Burdick, both from North Dakota and both 

deeply concerned over a long period of time about the issue of rural 

health delivery. Whether it is veterans, whether it is our Native 

Americans, or whether it is just mom and dad on the farm, this is 

a critical issue for us, and it is a critical infrastructure issue for 

the development and the continued viability of rural America. 

And so I thank the Chairman for bringing this very important 

issue to the forefront, and I have obviously more questions than 

what I have time for, and so I would ask for an opportunity to submit some additional questions going forward. 

But I want to first make a point. We have heard every bit of your 

testimony across the board, talking about telemedicine, talking 

about the need to do things a little differently, expand your capacity by using the technology. Are you so convinced that the technology is available in Indian country or in rural America? The 

kinds of things that you think you can do in Washington, DC, do 

you really believe you can do in Hoople, North Dakota? Is there the 

infrastructure backbone, the amount of technology? And have you 

looked at those issues going forward when you are promoting telemedicine as a solution? 

Dr. PETZEL. Senator, I will take a crack at that first. Ten years 

ago, the technology was clunky. It required special telephone lines 

that were often difficult to get into in terms of remote areas. But 

that whole technology landscape is changing dramatically. 

No. 1 is that we can now use a high-resolution Web camera to 

provide the same kind of fidelity of image, et cetera, that we—— 
18 

Senator HEITKAMP. I do not mean to interrupt, but is that true 

in every remote location in the United States? 

Dr. PETZEL. Well, we can put that technology anyplace, and we 

can then use the Internet in order to—— 

Senator HEITKAMP. What happens if the Internet is intermittent 

and dial-up? 

Dr. PETZEL. If it is dial-up, it works. We have not run into those 

kinds of difficulties really any place. We have been on Rosebud. We 

have been providing services of this nature on Pine Ridge. We are 

going to be providing those services in Devils Lake in North Dakota. And every place we have used it, it has been, No. 1, reliable 

but I think more importantly it is very well accepted by the patients. When they see that as an alternative to driving 100 miles 

to Fargo, they will take it in a minute. And they like it, and they 

get good care with it. 

So, yes, I am convinced that this is going to be the wave of the 

future. 

Senator HEITKAMP. Mr. Morris, I would like to hear your response to that, because you are beyond—I mean, your umbrella is 

a little broader. 

Mr. MORRIS. Yes, ma’am. I think there are some challenges in 

terms of broadband access, which I think is what you are trying to 

get at, is there enough capacity to use the full extent of the technology that I agree with Dr. Petzel works very well. And we can 

get back to you for the record with some—I know there has been 

some analysis of where there are some broadband gaps. 

The Federal Communications Commission (FCC) has done some 

revisions to its universal service program for rural health care that 

we think is going to be a key tool in sort of that last mile and expanded capacity for those areas, and that was just announced I 

think within the last couple months. 

In addition to that, some of the investments in the Recovery Act 

through both the Department of Commerce and the Department of 

Agriculture helped close some of that gap, but there are areas still 

that are not accessible. 

Senator HEITKAMP. I do not think there is any doubt there is still 

a digital divide in this country, and that is my point. My point is 

we cannot offer a solution to the remoteness in rural health care 

and say we are going to solve it with telemedicine, and then not 

have the highway that is going to take you there. And so I will 

pledge this. I am chairing on the Ag Committee the Rural Development Subcommittee, and this is an area that goes beyond telemedicine, but this is obviously an absolute critical component of rural 

development in my opinion. 

I have a question for Dr. Roubideaux as well. Obviously Senator 

Begich and the work that has been done in Alaska is very intriguing to us in North Dakota. We think we have remote locations. We 

think that we have a great deal of difficulty. And I would tell you 

that where you hear a lot of praise from him in terms of Indian 

Health Service, that is not what I hear in my State. What I hear 

is intermittent services. I hear about clinics shutting down because 

they do not have the capacity and do not have the staff to even 

open up on a Friday. That overflow goes to other hospitals. 
19 

And so I am very concerned about the long-term commitment 

and appreciation that you have about the concern that Native 

Americans in my State have about the quality of their health care. 

Dr. ROUBIDEAUX. I want to reassure you that we are absolutely 

committed to providing health care services to the best of our ability to the American Indians and Alaska Natives throughout the 

country, including in different areas. And you are absolutely right. 

There are differences among areas. It tends to track around the difference between the proportion of more direct service programs 

versus more tribally managed programs. And there are flexibilities 

around tribal management that are really helping Alaska do some 

really innovative things. But we still have the Federal trust responsibility and our commitment to the direct service programs in 

North Dakota and throughout the regions in the country. And so 

we are still working very hard to try to get these same types of improvements in those programs. 

Senator HEITKAMP. And not to prolong it, but I will tell you this: 

That there are concerns about squashing innovation, especially in 

the mental health area, within the Indian Health Service because 

it does not fit with what people may see as traditional models. And 

I would like to have a longer conversation with you about that 

going into the future. But we need to be innovative in Indian country in order to provide these services. We need to continue to develop the workforce and the technical expertise of anyone who 

wants to offer their services, but particularly the programs that we 

have at the University of North Dakota (UND) to train Indian doctors and Indian nurses. 

And if I can just indulge just one additional question on Heroes, 

I am very interested in looking at modeling the Heroes Health 

Card program that Senator Begich has been able to get a pilot on. 

I am very interested in modeling that in North Dakota, and particularly as it relates to Native American veterans. I think anyone 

who understands Indian country knows that very many Native 

Americans in terms of a percentage of their population serve in 

really double, triple, quadruple numbers in the armed services. 

When they come home, they have access to Indian Health, they 

have access to Veterans, but neither one seems to work for them. 

And so we do not want people who have chemotherapy who are 

entitled to veterans services to have to get on a bus and drive 10 

hours and literally wait in Fargo another 8 hours while the other 

patients on the bus get their services. As somebody who understands chemotherapy, that is not a healthy thing to do to people. 

And so we really believe that North Dakota would be a great additional site, Dr. Petzel, for modeling a Heroes Health Card in the 

Lower 48. 

Dr. PETZEL. We would be delighted to talk with you about that. 

Senator HEITKAMP. Terrific. 

Dr. PETZEL. And I would just make a comment. In North Dakota 

and South Dakota, which is where I used to work, 50 percent of 

the Native American adult males are veterans. That is a huge 

number. 

Senator HEITKAMP. Yes. 

Senator TESTER. Thank you, Senator. 
20 

I have a question for Tom Morris. Tom, you are Administrator 

of the Office of Rural Health Policy, and you are a member of the 

Veterans Rural Health Advisory Committee. You have an informed 

perspective on a lot of the issues we have talked about today. Could 

you tell me what the biggest challenges to greater collaboration between agencies like the VA and HHS might be? 

Mr. MORRIS. Well, we have had a good partnership with the VA, 

and their Office of Rural Health I think was created in 2007, and 

they reached out to us very early on to sort of learn the lessons we 

learned over the last 25 years about what it is like to sort of be 

a voice for rural within a large organization. And that collaboration 

has continued, as you mentioned. I am on the VA Rural Advisory 

Committee. And I think it has taken a little time for us to understand the unique challenges that the VA has and how that intersection takes place between the VA providers and private providers. But, I think the fact remains that so often veterans who are 

returning from the previous two wars especially are predominantly 

rural, and they are coming back to their towns, and they are seeing 

care both from their local providers and then they may also be 

going to the VA for some more specialized care. 

And so the challenge but also I think the opportunity is how we 

can both, the private sector and the VA, dually care for those patients, and part of it involves making sure that, as you share patient information or you do telehealth, you meet the privacy and 

security challenges of the VA’s firewall. But I think there is 

progress being made there through an initiative they have around 

Blue Button, which is a form of health information exchange. 

We have a veterans pilot program right now—and one of the 

grantees is in your State of Montana, and also Alaska and Virginia—in which we are putting money in to put telehealth equipment into hospitals and clinics, and then reaching out to the VA 

so that, for instance, a veteran might be able to get their PTSD 

treatment from a VA provider without having to leave their home 

community, even if there is not a CBOC or a veterans clinic in that 

location. And so that program is really still in its infancy. We are 

recompeting it right now to award another 3 years of grants. And 

our hope is that that can serve as a pilot for ways that the private 

providers that care for veterans can also reach out to the VA in 

their regions and dually care for those patients as effectively as 

possible. 

And then we are in conversations with the VA Office of Rural 

Health about looking at a number of pilot sites really to focus on 

this whole notion of health information exchange so that as the veteran sees care in both places, the patient information, the medical 

record, goes back and forth between both groups. 

Senator TESTER. Very good. I would be remiss if I did not ask 

this question that Senator Begich alluded to, because I have Dr. 

Roubideaux here and Dr. Petzel here, and it is the collaboration between the VA and the IHS. I would expect you both, since you are 

sitting side by side, to say it is working great. But what are the 

challenges that you faced with the collaboration that you have done 

together? That is the first question to each of you. 

And the second question is: Do you have all the policy flexibility 

you need to be able to do collaboration? In many cases you are 
21 

serving the same group of people. So if you could talk about what 

the challenges have been and then talk about if, in fact, from a policy standpoint if you have the flexibility you need. Whoever wants 

to go first, go ahead. 

Dr. ROUBIDEAUX. Well, I think that we really appreciate our 

partnership with the VA and their willingness to try to dig in and 

deal with some of the challenges we face. We are two different systems with two different authorities, and sometimes we have to 

work through those issues. 

There is also the enormous need and the distances that really 

challenge us as we work together, but I have been requiring my 

area directors and my Chief Executive Officers (CEOs) to work 

with the VA over the past 2 years and meet with them, and that 

is actually going really well. So we are starting to have the conversations we need to have to work through some of the challenging issues. So that relates to the policy issues, and I think the 

reimbursement agreement was a great opportunity for us to understand each other’s authorities and understand some of the innovative ways that we could collaborate and innovative things that we 

could do. And so I really appreciate our partnership with the VA 

because they are willing to dig at some of the hardest challenges 

we are facing. 

Senator TESTER. From your perspective, Dr. Petzel? 

Dr. PETZEL. I would say that in terms of Washington, and here 

the collaboration is excellent, the attitude, the desire to make this 

work for both of us, the desire particularly from our perspective to 

serve veterans wherever they might be is unparalleled. 

The issue for me is generally how this is executed locally, and 

on both sides. I am not saying it is either the VA or the IHS or 

the tribes. But it works better in some areas than it does in others. 

Alaska I think is an example of where it works wonderfully. We 

have sharing agreements with every tribal organization in Alaska. 

We are going to have reimbursement pilots in almost all of the 

State. 

In other parts of the country, we have difficulty with our people 

getting together with the IHS people, and I think that my responsibility is to be sure that the attitude that we evince in Washington 

is transmitted down to the level where the work is being done. 

But I would also agree with Dr. Roubideaux. It is, as I would 

look at it in the main, working very well. We have a number of 

places around the country where we do sharing. We have clinics located from the VA’s perspective on tribal grounds. The reimbursement agreement I think was a huge step forward, ten pilots piloting that reimbursement agreement to work out the kinks in terms 

of charges and how bills are paid and patients move back and 

forth. 

There is always room for improvement, Mr. Chairman, and that 

is in my mind at the local level where we need to be sure that people are doing everything they can do to develop these cooperative 

relationships in places like Devils Lake, in places like the Crow 

Reservation, in the Billings clinic, et cetera. 

Senator TESTER. Right. OK. Thank you all very much. 

Did you have any further questions, Senator Heitkamp? 

[No response.] 
22 

1The prepared statement of Mr. Kuntz appears in the Appendix on page 63. 

Senator TESTER. OK. I just wanted to thank you all for your testimony and thank you for the question-and-answer session we have 

had. This record is going to be open for 15 days, so if there are additional questions—and I know there will be because I will have 

some myself, and I am sure the others will, too—or additional comments that you want to be put in the record, you certainly can do 

it over the next 15 days. Thank you all for your service, and thanks 

for being here this morning. 

Now we will go to the second panel, so, Matt Kuntz and Ralph 

Ibson, if you would come up, and we will get the name tags 

changed. 

I would like to welcome our second panel of witnesses who both 

have worked tirelessly over the years to advocate on behalf of policies that improve health outcomes and increase access to care for 

more folks. 

We have, first of all, Matt Kuntz. I have known Matt for a while 

now. He is from the great State of Montana and represents the 

best of Montana. Born and raised in Helena, Matt graduated from 

West Point, served with distinction as an Army infantry officer. 

Matt’s advocacy on behalf of our veterans, which is spurred by personal loss, has been recognized by President Obama. Currently he 

practices law and serves as executive director of the National Alliance on Mental Illness for Montana. Matt took on this role to support, educate, and advocate for all Montanans suffering from serious mental illness and their families. He has done a tremendous 

job in that capacity, and I am proud of his work and the work of 

the National Alliance on Mental Illness. Welcome, Matt. 

Next we have Ralph Ibson. Ralph is the national policy director 

of the Wounded Warrior Project (WWP). In that capacity, he heads 

up research and policy development on health, benefits, and economic empowerment issues for the Wounded Warrior Project. He 

formerly served as general counsel at the Department of Veterans 

Affairs and is also a veteran of the United States Army. 

Thank you for your service, and welcome, Ralph. 

Each of you will have 5 minutes for oral testimony. Know that 

your entire written testimony will be made a part of the record. So 

we will start with you, Matt, with your oral testimony. 

TESTIMONY OF MATT KUNTZ,1 EXECUTIVE DIRECTOR, 

NATIONAL ALLIANCE ON MENTAL ILLNESS FOR MONTANA 

Mr. KUNTZ. Thank you, sir. Good morning, Chairman Tester, 

Ranking Member Portman, and Members of the Committee. I am 

really honored to be here to testify. As you mentioned, I came into 

the National Alliance on Mental Illness (NAMI) line of work the 

hard way, like most of us do, but I am really honored to try to help 

out as many people as possible, especially our rural vets. 

I would like to start out by just saying what the view from Montana is. As you know, it is a very big State with 147,000 square 

miles, just over 1 million people, with roughly six people per square 

mile. We have one of the Nation’s highest per capita rates of military service, and we are home to over 108,000 veterans, which is 

about 16.2 percent of the population. Our Indian Health Services 
23 

needs, we have 12 tribes and 7 reservations with over 66,000 Montanans of Native American heritage. 

The scarcity of mental health professionals in Montana is pretty 

hard to comprehend, and it really is a major difficulty for our families. But the best way to describe it is we have one psychiatrist between Billings and Bismarck, North Dakota. That is a stretch of 

about 400 miles on the interstate, which is roughly the distance between Boston and D.C. One psychiatrist to cover all that area. 

There are fill-ins by psychiatric nurses and telepsychiatry, but one 

warm body. 

And I think the other thing that needs to be mentioned because 

it underlies everything in Montana is the oil development in the 

Bakken, and our eastern Montana and western North Dakota is 

overtaxed with pretty much all infrastructure issues, but especially 

mental health. And it is taking what was a crisis and turning it 

into something really terrifying. 

So I just wanted to give some quick realities of what happens in 

Montana, especially with our vets, to show interlinked all of these 

different agencies are. For instance, if there is a veteran in Darby, 

Montana, who goes into crisis, he would probably be moved 16 

miles to Hamilton to stay at Western Montana’s private inpatient 

crisis center. After being there for a day or two, he will then be 

transported to Helena where the VA’s inpatient unit is—that is 100 

miles—and then will eventually return to his home community 

where he will be treated either by the VA through telepsychiatry 

or by the private health contractor. And that is just how it looks 

from us. 

Some of the things that I think that are really good that are happening in Montana is that the contracting system with the private 

providers is absolutely essential. The psychiatric nursing program 

at Montana State is really helping us fill the needs, and telepsychiatry has hit almost a critical mass in Montana, especially with the 

Centers for Medicare and Medicaid Service (CMS) grant for $7.7 

million for Montana and Wyoming. 

Peer services is developing well, and I guess one of the things 

that I would really like to see more is a residency program. I think 

that we all talk about how bad we need psychiatrists, but the fact 

is every State that needs psychiatrists also needs a psychiatric residency program. And if they are able to do some of these things, if 

they are able to provide the services through telemedicine, maybe 

there is a way to structure those residency programs a little bit 

more flexibly as well. 

Also, the loan repayment programs, our Nation really relies on 

our inpatient psychiatrists, and how they should be taken care of 

in loan repayment is a little bit different than outpatient psychiatrists. 

Thank you, Senator Tester, and I am willing to answer any questions. 

Senator TESTER. Thank you, Matt. I appreciate your testimony. 

Next we have Ralph Ibson. 
24 

1The prepared statement of Mr. Ibson appears in the Appendix on page 74. 

TESTIMONY OF RALPH IBSON,1 NATIONAL POLICY DIRECTOR, 

WOUNDED WARRIOR PROJECT 

Mr. IBSON. Chairman Tester, thank you for inviting Wounded 

Warrior Project to testify this morning. With our mission of honoring and empowering those wounded in Iraq and Afghanistan, the 

mental health of our returning veterans is among our very highest 

priorities, and I am honored to be here with Matt. 

With our focus we see that, despite extensive Federal efforts 

there remain wide gaps in meeting the mental health needs of this 

generation of warriors. Let me highlight one critical concern. 

Many who served in Iraq and Afghanistan remain reluctant to 

receive mental health care. Research indicates that half of those 

who need care are not getting it, and a high percentage of those 

who elect to pursue care drop out prematurely. Much more 

progress is needed to reverse these trends, in our view. 

Many factors play a role in that process, but in some cases, it 

also appears to be a function of family issues. And while current 

law, law that you helped enact, Mr. Chairman directs VA to provide needed mental health services to immediate family members 

of the Operation Enduring Freedom and Operation Iraqi Freedom 

(OEF/OIF) veterans, VA has not implemented that provision. 

To your focus this morning, Mr. Chairman, nowhere are the gaps 

in meeting warriors’ mental health needs wider than in rural 

America. VA policy says in essence, and as discussed earlier, that 

VA facilities must be able to provide veterans needed mental 

health care, and if they cannot because of lack of onsite staff or 

geographical inaccessibility, other options must be used, including 

telehealth or contract arrangements. 

But even veterans who live in remote areas often encounter local 

VA reluctance or even resistance to authorizing community-based 

care. With limited exceptions, we see only modest VA use of contract arrangements to overcome access gaps. And as indicated, with 

55 percent of U.S. counties, all rural, having no practicing mental 

health clinicians and situations as Matt described in Montana, 

VA’s policy of providing contract care is hardly a comprehensive 

answer. And with the drawdown of forces in Afghanistan, the access challenge will only grow. 

We do see promise in programs mentioned this morning. VA’s 

telemental health capability has seen exponential growth, and we 

certainly see room for VA to greatly expand use of telemental 

health to engage more warriors and are pleased that Dr. Petzel 

agrees, as reflected in his testimony. 

A second important programmatic effort was sparked by the directive in the President’s Executive Order of last August, that VA 

hire and train 800 veterans to serve as peer-to-peer counselors. We 

see that as a model for winning warriors’ trust in entering into 

mental health treatment and staying in treatment. And we also see 

it as having potential in rural areas. Our one concern is that the 

initiative is not really targeted at supporting OEF/OIF veterans, 

where the need is greatest, in our view. That, Senators, as you 

know, also incorporate a peer-to-peer model, and we see that as a 

key aspect of the success of that program and are pleased, again, 
25 

at Dr. Petzel’s acknowledgment that this is a program that needs 

to expand. 

Finally, let me suggest that many OEF/OIF warriors with PTSD 

and other mental health conditions are also struggling to readjust 

to a new normal, to uncertainties about finances, career, education, 

employment. And no single VA program necessarily addresses that 

full range of issues that many young warriors face. Few, if any, VA 

programs are embedded in a veteran’s community, and yet VA and 

community each has a distinct role to play. For some veterans, as 

we see it, community reintegration may take a community-wide effort, and we see a role here for VA. But as yet we see no real centralized effort to harness such partnerships. 

With limited exceptions, VA mental health programs are generally not focused or integrated with the adjacent community, and 

while VA has broad authority to enter into partnership with community providers and Congress just last year in the National Defense Authorization Act (NDAA) strongly encouraged that, we do 

not see much happening on that front. 

Finally, we believe VA should work with communities in providing needed mental health services to wounded warriors. This 

should include providing training to clinicians on military culture 

and the combat experience. Simply having more providers or access 

to providers who do not really understand the experience veterans 

have been through or PTSD is not itself a real answer. 

We look forward to working with the Subcommittee on the important issues discussed this morning, and thank you for consideration of our views. I am happy to answer questions. 

Senator TESTER. Well, thank you, Ralph. Thank you both for 

your testimony. I appreciate it very much. 

I am going to start with you, Ralph, on what you just last said, 

because I think it is an issue that I have heard from the veterans 

themselves, and that is the training of the clinicians, making sure 

that when a veteran who has some issues goes and sees a clinician, 

that they actually have an understanding of what got that person 

to the point where they are. 

How do we best do this? It seems to me that there are several 

steps involved, and, by the way, you correct me if I am wrong. First 

you have to build the partnership, and then you have to make sure 

the folks who are dealing with the veterans understand what the 

veteran has been through. How is the best way to move forward 

with that from a VA perspective? Because I think you are spot on, 

quite frankly. 

Mr. IBSON. Well, Mr. Chairman, I think you have really put your 

finger on an important point or emphasized an important point, 

and that is that the treatment process has to begin with developing 

a relationship of trust, and I think essential to that is that the veteran perceive that the provider understands his or her problems, 

understands where he or she has been. And, the VA has done a heroic job of training its clinicians on evidence-based therapies. I do 

not purport to be an educator or, to have insight on the best way 

of training, but I do not see the equivalent focus on helping ensure 

that those providers really understand veterans. And I do see that 

even as VA has expanded and has filled many of those vacancies, 
26 

hiring 1,300-plus, when veterans encounter a clinician who they 

perceive does not understand them, they leave. 

Senator TESTER. Yes, I agree with that, and that is the worst 

possible outcome, quite frankly, as far as care goes. 

Matt, despite significant investments that have been made to address the complex wounds of war, we continue to see—and you deal 

with this firsthand—high rates of depression, divorce, domestic 

abuse, an unacceptably high number of servicemembers, as has already been pointed out today, commit suicide every day. It is overwhelming and at times it is difficult to tell whether we are actually 

making progress, making a significant impact on what is going on 

out there. 

We need to ensure that the VA is able to identify and treat these 

folks with their issues in a meaningful way, and we need to ensure 

that they are appropriately staffed in a rural area like Montana. 

You talked about Billings and Bismarck, 400 miles away. We have 

a training staff, but sometimes there is no staff to train in certain 

areas because there are not mental health professionals there. 

As an advocate you have been personally involved with this epidemic. You have seen the investments that have been made. You 

talked about telemedicine. Are there other things out there that 

are working besides telemedicine? And is telemedicine working 

well? 

Mr. KUNTZ. Sir, I think telemedicine is working well. It is a 

great, wonderful thing, and the Tribal Veterans Rep program was 

one of the first ones that brought it to Montana, and it is valuable. 

There is no question. I think that one of the other things that I 

thought was really good was, as you know well, the VA really 

struggled to staff its inpatient facility in Helena, and it just sat 

open, and they could not run it due to lack of psychiatrists. And 

I think that the way that they were able to change their staffing 

structure to use it with one inpatient psychiatrist, one outpatient, 

and a couple of nurse practitioners, like that willingness to adapt 

to what actually happens on the ground in Montana, we do not 

have three inpatient psychiatrists to run a facility like that. And 

the VA learned. It took them awhile. 

But one of the other things I think is—like the peer support is 

critical and important, and it also provides much needed jobs for 

veterans that struggle with these kind of issues. But the retention 

of the counselors I think in some ways is a bigger issue than actually whether or not they have served. I know many veterans that 

I talk to just say it is a matter of kind of changing bodies in front 

of them. And if they open up their soul and describe their combat 

needs, describe all of their issues going on with them, and then the 

person is gone, I mean, I talked to one vet that works across the 

street, and he had three counselors in a year. I think that while 

we need to focus on getting the perfect, right training and everything—— 

Senator TESTER. Sure, yes. multifaceted. So what is the issue on 

retention? Why are they leaving? Is it salary? Quality of life? Are 

they burning out, getting out of the business? Why are they leaving? Why are we seeing turnover? 

Mr. KUNTZ. It is really hard to tell, sir. I think it is different for 

every one of them. But what shocks me is I guess how in the box 
27 

and how constrained they are, I mean, and the limits of what they 

are given to work with. I do think that they are pretty heavily 

worked. Hopefully they will be working with peer specialists, but 

also like they do not even give them business cards sometimes, no 

voicemail for some of these counselors. And how do you—— 

Senator TESTER. Right. I got you. 

Ralph, do you want to add anything to that as far as what is 

working and what is not working? 

Mr. IBSON. Well, I have seen that same telemental health demonstration that Dr. Petzel alluded to, and I would agree with his 

assessment, and I would agree as well with Matt’s perspective on 

the retention issue, which I think is not limited to counselors. We 

attempted about a year and a half ago to survey VA mental health 

clinicians, across the country and while I would not want to suggest it was a scientific survey, but it was disturbing to see results 

that suggested serious morale problems at many facilities. 

Now, this reflected a period of understaffing, and so I acknowledge that as well. 

Senator TESTER. Right. 

Mr. IBSON. But many spoke of the system as top-down, as failing 

to appreciate the importance of allowing clinicians to build that 

trust relationship, and of imposing performance requirements that 

were highly focused on evidence-based exposure therapies, which, 

while having solid evidence base, were not appealing to the veterans. Many of the veterans could not handle dealing on a weekly 

basis with re-exposure to the trauma they had experienced, and yet 

that was the directive from on high. 

VA has done a survey of its own mental health staff last September on clinician attitudes. I think it would be helpful to see the 

results of that survey. It would be helpful to understand the factors 

that drive the 10-percent vacancy data that Dr. Petzel cited. I 

think a system that honored its clinicians from those peer-to-peer 

counselors on up would be a system that would be a more successful one. 

Senator TESTER. I am going to ask you guys a question that I 

was going to ask Dr. Petzel, but I did not want to keep him here 

all day. But I think you guys can answer it in maybe a better way 

than he could because you are driving the bus at the other end of 

the experience here. 

Licensed professional mental health counselors, marriage and 

family therapists, they make up about 40 percent of the overall 

mental health independent practice workforce. In the VA, they 

make up less than 1 percent. Is there a reason for that? Are they 

less desirable as counselors? Or is there something out there I am 

missing? 

Mr. KUNTZ. Sir, there may be a reason for that, but I will just 

say flat out it is not a valid one. 

Senator TESTER. OK. 

Mr. KUNTZ. We need them. 

Senator TESTER. OK. Ralph, do you want to add anything to 

that? 

Mr. IBSON. I would not disagree with that perspective. 

Senator TESTER. OK. Good. I want to talk about the gaps that 

you talked about a little bit, Ralph, in your testimony. There are 
28 

some real inhibiting things in our society about people who go in 

for mental health treatment. There is a stigma attached to it. 

There can be employment problems afterwards, not because they 

have issues with mental health, but it is because the employer 

might not want them to begin with. 

What can we do to minimize the stigma, so these folks are more 

likely to go in and get help when they need it? Because it is curable. We know it is curable. It can be fixed. Or is there anything 

we can do about it? 

Mr. IBSON. Well, I do think there has been a probably 20-year 

or longer effort to address stigma. I think organizations like NAMI 

have played an important part in that. But there is evidence that 

suggests that veterans themselves, warriors of this generation, still 

are distrustful of mental health care. It is not solely a stigma issue. 

And I think the peer-to-peer counselors can play an enormously important part in belying those views and drawing warriors into 

treatment and helping sustain them in treatment. 

I agree with, again, Matt’s point that we have to honor those 

warrior employees, make them feel they are an important part of 

the team and make their working conditions appropriate. But I do 

think the infrastructure and the policies are in place to close those 

gaps. 

Senator TESTER. OK. Matt, do you have anything to add to that? 

Mr. KUNTZ. Sir, I have, I guess, two things. One is I think we 

need to take the magic out of what this is through research. I 

mean, a really big problem with the lack of understanding. And we 

do not understand the brain well enough, and especially these diagnostic patterns. With the Diagnostic and Statistical Manual 

(DSMs) changing and everything, the best clinicians really struggle 

to identify what a person has and, I mean, I think because we do 

not have valid scientific instruments to measure whether or not 

people have these conditions, they are measured by behavioral 

health surveys, it just leads to a level of distrust, and people do not 

have a way of saying, OK, my neuro circuitry is disrupted, so I get 

help for this. 

Senator TESTER. I understand. 

Mr. KUNTZ. Anything that we could do to improve that. 

The other thing, I think, is we have a lot of different anti-stigma 

efforts, but they do not really highlight people that had PTSD and 

depression in the past. We do not read about—or we do not see the 

anti-stigma things that talk about Winston Churchill’s depression, 

that talk about Abraham Lincoln’s depression. Some of the greatest 

Americans struggled with these conditions, and why don’t we bring 

them up? So I would love to see a little bit more of that. 

Senator TESTER. OK, good. I want to talk about partnerships, 

particularly between the VA and the Wounded Warrior Project, and 

there may be partnerships between NAMI and the VA that I am 

unaware of, or maybe there are some opportunities for partnerships that we could make them aware of. 

I have been aware of and, quite frankly, been out on some programs like Healing Waters in Montana, and you mentioned a 

project, Project Odyssey, in your testimony, which is maybe classified in the peer-to-peer program, or maybe it is separate—— 
29 

Mr. IBSON. Yes, sir, it has a strong element of peer-to-peer support. 

Senator TESTER. Yes. If you guys could shed light on programs 

like that, their effectiveness, and how we might be able to expand 

on other programs that could—there are programs out there working with animals, horses in particular, dogs, and just kind of talk 

about opportunities out there to collaborate on peer activities related to the outdoors to relieve stress. 

Mr. IBSON. Well, if I could followup, Mr. Chairman, Project Odyssey is one of 18 different programs our organization operates. It is 

a program that takes warriors out in retreat-like settings. It might 

be to Montana for an outdoor activity or mountains in Vermont, 

wherever. But it takes them out in groups that include a trained 

therapist and focuses on building peer-to-peer relationships to confront in some cases for the first time their post-traumatic stress 

disorder or other combat-related mental health conditions. It has 

been very successful in helping veterans confront those issues and 

get into treatment, to overcome the stigma and barriers. And it is 

a program that we have run for a number of years and ran in collaboration with VA Vet Center program, and to our disappointment, VA pulled out of it in about 2010. The suggestion was they 

lacked the authority or felt they lacked the authority to continue. 

Since then, Congress last year enacted legislation making it crystal clear that authority exists, and we had hoped that would lead 

to reinstitution of that partnership. That has not happened yet. 

Senator TESTER. Matt, do you have anything to add? 

Mr. KUNTZ. Yes, sir. My favorite program for this—I am totally 

biased because I was involved in helping start it. My sister, Dr. 

Janna Sherrill, and a veteran from Missoula, Jesse Scollin, started 

it up. It is called X Sports 4 Vets in Missoula. What it is, they 

take—it was based on taking veterans river boarding—I believe it 

was a 6-week program—and it engages them in an extremely high 

adrenalin activity, and then it was tied in with counseling afterwards, and the level of success in what I saw from that program 

was just astonishing. And the veteran participation, they not only 

joined it and they got involved in it, but they took it over themselves and run it. It really is amazing, and it is done in partnership 

with the Missoula Vet Center, and I know it is a model that could 

be expanded to other sports and stuff. But the neat thing about 

this in comparison to some of the other ones is it is not a retreat. 

It is kind of—it takes them in their community in a sport or something that they can do afterwards and gets them involved with a 

group of men and women that they eventually form bonds and 

friendships with, and it also introduces them to civilians like the 

rafting guide that helped start it. 

That was the first civilian that some of these vets have bonded 

with, and they respected him because he takes a little tiny raft on 

the Lochsa River, and it really is remarkable. But I have not seen 

any efforts from the top to try to expand that beyond Montana. 

Senator TESTER. Last question, and this is going to be a quick 

one for you, Ralph. Who funds your Project Odyssey now? 

Mr. IBSON. We get donations, typically small donations around 

the country. 

Senator TESTER. All private—— 
30 

Mr. IBSON. Yes, it is all private sector, no Federal. 

Senator TESTER. All right. 

Mr. IBSON. We do not take Federal money. 

Senator TESTER. All right. Thank you, guys, very much. I want 

to thank you again for your testimony this morning. I very much 

appreciate it. I think overall this hearing has underscored some of 

the important progress that I think we have made, but it also highlighted some additional efforts that we need to make. And I look 

forward to working with Ranking Member Portman and our witnesses here today on these issues to make sure we address the 

health care needs of our citizens and they are met regardless of 

where they live. And in that regard, I just want to thank you two 

fellows for being here this morning. Again, I appreciate your work. 

This hearing record will remain open for 15 days for any additional comments or questions that may be submitted to the record. 

And with that, the hearing is adjourned. 

[Whereupon, at 11:45 a.m., the Subcommittee was adjourned.] 
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