U.S. GOVERNMENT PUBLISHING OFFICE

35–387 WASHINGTON : 2019

VA HEALTHCARE: MAXIMIZING RESOURCES IN 

PUERTO RICO 

FIELD HEARING 

SAN JUAN, PUERTO RICO 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED FIFTEENTH CONGRESS 

SECOND SESSION 

MONDAY, MARCH 12, 2018 

Serial No. 115–50 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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

Leonard.horne on VACREP0180 with DISTILLER

(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

DAVID P. ROE, Tennessee, Chairman 

GUS M. BILIRAKIS, Florida, Vice-Chairman 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

AMATA COLEMAN RADEWAGEN, American 

Samoa 

MIKE BOST, Illinois 

BRUCE POLIQUIN, Maine 

NEAL DUNN, Florida 

JODEY ARRINGTON, Texas 

JOHN RUTHERFORD, Florida 

CLAY HIGGINS, Louisiana 

JACK BERGMAN, Michigan 

JIM BANKS, Indiana 

JENNIFFER GONZALEZ-COLON, Puerto 

Rico 

TIM WALZ, Minnesota, Ranking Member 

MARK TAKANO, California 

JULIA BROWNLEY, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

KATHLEEN RICE, New York 

J. LUIS CORREA, California 

KILILI SABLAN, Northern Mariana Islands 

ELIZABETH ESTY, Connecticut 

SCOTT PETERS, California 

JON TOWERS, Staff Director 

RAY KELLEY, Democratic Staff Director 

SUBCOMMITTEE ON HEALTH 

BRAD WENSTRUP, Ohio, Chairman 

GUS BILIRAKIS, Florida 

AMATA RADEWAGEN, American Samoa 

NEAL DUNN, Florida 

JOHN RUTHERFORD, Florida 

CLAY HIGGINS, Louisiana 

JENNIFER GONZALEZ-COLON, Puerto Rico 

JULIA BROWNLEY, California, Ranking 

Member 

MARK TAKANO, California 

ANN MCLANE KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

LUIS CORREA, California 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Veterans’ Affairs are also published in electronic form. The printed 

hearing record remains the official version. Because electronic submissions are used to 

prepare both printed and electronic versions of the hearing record, the process of converting 

between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process 

is further refined. 

Leonard.horne on VACREP0180 with DISTILLER

(III) 

C O N T E N T S 

Monday, March 12, 2018 

Page 

VA Healthcare: Maximizing Resources In Puerto Rico ........................................ 1 

OPENING STATEMENTS 

Honorable Brad Wenstrup, Chairman ................................................................... 1 

Honorable David P. Roe, Member .......................................................................... 2 

Honorable Jennifer Gonzalez-Colon, Member ....................................................... 3 

WITNESSES 

Mr. Augustin MontanezAllman, Puerto Rico State Director of Veterans Affairs ....................................................................................................................... 6 

Dr. Rafael Rodriguez, Puerto Rico Secretary of Health ....................................... 8 

Dr. Victor Ramos, Puerto Rico College of Physicians and Surgeons, .................. 11 

Dr. Miguel LaPuz, Director of VISN8, the VA Sunshine Healthcare Network 

of the U.S. Department of Veterans Affairs. ...................................................... 13 

Accompanied by: 

Dr. Antonio Sanchez, Acting Director of the VA Caribbean Healthcare 

System 

Mr. Luis Ratchford, Jr., Deputy of Second Secretary for Emergency Management and Resilience for the Department of Veterans Affairs. 

Leonard.horne on VACREP0180 with DISTILLER

Leonard.horne on VACREP0180 with DISTILLER

(1) 

VA HEALTHCARE: MAXIMIZING RESOURCES 

IN PUERTO RICO 

Monday, March 12, 2018 

U.S. HOUSE OF REPRESENTATIVES, COMMITTEE ON VETERANS’ AFFAIRS, SUBCOMMITTEE ON OVERSIGHT

AND INVESTIGATIONS, Washington, D.C. 

The Subcommittee met, pursuant to notice, at 10:14 a.m., in the 

Leopoldo Figueroa Hearing Room, Puerto Rico Capitol Building, 

Constitution Avenue, San Juan, Puerto Rico, Hon. Brad Wenstrup 

[Chairman of the Subcommittee] presiding. 

Present: Representatives Wenstrup, Gonzalez-Colon, and Roe. 

OPENING STATEMENT OF BRAD WENSTRUP, CHAIRMAN 

Mr. WENSTRUP. I wish you a good morning, and thank you all for 

joining us today. I’m Congressman Brad Wenstrup and I represent 

Ohio’s Second Congressional District and I’m honored to serve as 

the Chairman of the Committee on Veterans Affairs Subcommittee 

on health. I’d like to begin by thanking Congresswoman GonzalezColon for her determination and drive, and bringing the Subcommittee’s focus to the specific issues faced by what is perhaps 

our most rural subcategory of American Veterans, those who reside 

in Puerto Rico, the U.S. Virgin Islands, and the Pacific Island Territories of Guam, the Northern Mariana Islands, and American 

Samoa. 

I’m also pleased to be with the Chairman of the Committee, Dr. 

Phil Roe, today, and we are honored to have with us, Nicole 

Rosario from Troop 546, and it is the 106th Anniversary of the Girl 

Scouts, and we welcome to the dais today. 

[Applause.] 

Mr. WENSTRUP. In so many cases, veterans of the island territories face enormous challenges while receiving health care from 

the VA. From traveling vast distances for care, hundreds if not, 

thousands of miles in some cases, either by boat or plane, to physician and provider shortages which can cause lengthy wait times, 

access to VA care for those veterans can be highly burdensome as 

many of you know. My goal for this hearing is to identify opportunities for VA to build and improve upon its relationships with local 

public and private health care entities and hopefully reduce the 

burden we ask these veterans to endure. 

I also hope to gain a better understanding of what the immediate 

needs are for VA facilities to the Caribbean to fully recover from 

the devastation of Hurricanes Irma and Maria. In this discussion 

Leonard.horne on VACREP0180 with DISTILLER

2 

we should take the opportunity to look towards the future needs 

of veterans of the Caribbean and discuss what steps VA can take 

today to address the future needs of the veterans served here. 

Before I finish my opening remarks, I want to take a moment to 

bring attention to the Herculean effort put forward by VA employees, to keep facilities operational both during and after Hurricanes 

Irma and Maria. Over 800 VA employees weathered these storms, 

leaving house and home to the elements and stayed at the facilities 

to be with the veterans they are charged with caring for. Veteran 

service organizations of the Islands helped tremendously in this life 

saving effort by conducting house calls and checking in on injured, 

elderly, and bedridden veterans. The strength and resilience of the 

veterans of Puerto Rico is truly beyond measure and I’m honored 

to be here today. We are in this together. We are with you in this 

recovery. Estamos juntos en esto. Estamos con ustedes. With that 

attempt to Spanish, I’ll yield to our Full Committee Chairman, Dr. 

Phil Roe for five minutes for any opening remarks he may have. 

OPENING STATEMENT OF HONORABLE DAVID P. ROE 

Mr. ROE. Thank you, Dr. Wenstrup, and buenos dias. I am Dr. 

Phil Roe, representative of Tennessee First Congressional District 

and it’s the only district in America that has two Presidents, Andrew Jackson, Andrew Johnson, also Davy Crockett was a member 

of Congress from the First Congressional District, so I have big 

shoes to fill. You know, as I’m also honored to serve as the Chairman of the House Veterans’ Affairs Committee. As an Army captain in 1973, I served in the Second Infantry, Division Medical Battalion stationed near the DMZ in Korea, Camp Casey and other 

places there, and I never dreamed years later that I would find myself traveling to the United States and its territories, conducting 

field hearings focused on veterans’ health care for some four and 

and a half decades after completing my service in uniform, but here 

were are today. Thank you, all for being here and graciously 

hosting us this examination of VA Healthcare in Puerto Rico and 

the U.S. Virgin Islands. 

I want to extend a very special thank you to Congresswoman 

Gonzalez-Colon for her, both her help and friendship, planning this 

hearing as well as her tenacity and unending support for American 

veterans. You have a true champion here, especially those in Puerto Rico and the Caribbean, and other Pacific territories of the 

United States. I want to thank you, Jenniffer, for that. 

[Applause.] 

Mr. ROE. The veterans of Puerto Rico have fought valiantly in 

every conflict since World War I. Today, your sons and daughters, 

brothers and sisters, fight alongside Tennesseans and Ohioans in 

lands far, far, away. Puerto Rican shed the same blood on the same 

battlefields, on the same foreign soil in order to keep our collective 

Nation safe. We are eternally grateful for the sacrifices made by 

those who’ve worn the uniform, that is exactly why we are here 

today. 

Over the past several months, the people of Puerto Rico have 

navigated their way through the worst national disaster to hit this 

small island territory since 1928, almost 100 years. In September 

a category of four, maybe a five, Hurricane Maria cost more than 

Leonard.horne on VACREP0180 with DISTILLER

3 

94 billions dollars in property damage and took at least 112 lives. 

Throughout Hurricane Irma and Maria, as well as the during the 

recovery, the San Juan VA Medical Center remained open for business, staffed by 800 dedicated employees and running on generator 

power. 

Think about this, while hurricane force winds and rising flood 

waters ravaged neighborhoods and family homes across this island, 

over 800 VA employees put the veterans they served above themselves, left their homes to the elements, and stayed to accomplish 

their mission. That, is an amazing story that needs to be told to 

the Nation. 

Today, I hope to hear a great deal about what resources were 

available during those two major storms and recovery, and how 

those resources were leveraged to meet the emergent needs of the 

veterans and the people of Puerto Rico and the Virgin Islands. 

From our short time on this island, it’s apparent that there’s much 

still to do, and I’m eager to jump into that conversation, with that, 

Mr. Chairman, I will yield back. 

Mr. WENSTRUP. Thank you, and I now yield five minutes to Ms. 

Gonzalez-Colon for any opening remarks she may have. 

OPENING STATEMENT OF JENNIFER GONZALEZ-COLON 

Miss GONZALEZ-COLON. Thank you, Mr. Chairman, and thank 

you to the whole Committee and Chairman Roe and Chairman 

Wenstrup to be here on the Island. And, I sent our invitation to 

know what’s, to be in Puerto Rico after a hurricane, and the needs 

of our veterans. For me, it’s a pleasure and as a first and only 

Member representing Puerto Rico in that Committee, we are making history today, having the first hearing of this Committee in 

Puerto Rico since the, 1946, when the Committee was created. So, 

thank you for that. 

Today is a historical day for all veterans in Puerto Rico, not just 

for having this hearing, but also I’m a proud Member of the Committee, and have witnessed firsthand the hard work and unwavering commitment to our veterans shown by Chairman Brad 

Wenstrup and Chairman Roe. On behalf of the veterans of Puerto 

Rico, and their families, I want to express my sincerest gratitude 

for holding this hearing. 

I also want to thank our panel, Mr. Montanez, Dr. Miguel LaPuz, 

Dr. Antonio Sanchez, and Dr. Rafael Rodriguez, and Dr. Ramos for 

their participation and invaluable insight into the current health 

care related concerns that affect our veteran population. I very 

much look forward for your testimonies and your opinion on how 

to improve those services in Puerto Rico. 

Puerto Ricans have participated in every armed conflict alongside our mainland counterpart since World War I. They have been 

carrying the U.S. flag and fought and bled for freedom and values 

that make our country great. They have also similarity to all veterans across the Nation, return home with illness, disabilities, and 

wounds, visible, and invisible that require medical attention. 

Our veterans and their family members, some of them, men and 

women here today have need and deserve to have the best medical 

care and attention available. They deserve the best and we owe 

them nothing (sic) than that. Puerto Rico currently has single VA 

Leonard.horne on VACREP0180 with DISTILLER

4 

hospital and VA clinics around the Island. They are at the forefront 

of the care received by approximately 93,000 veterans residing in 

Puerto Rico and the U.S. Virgin Islands. There are some intrinsic 

challenges with receiving medical services in these facilities, given 

the Islands’ rural landscape. For many years, I have heard multiple veterans state, the issues that they have been with receiving 

care through the VA system, often due, to first, the extended travel 

time to go to the clinic. Second, which is particularly hard to our 

older veterans and their family members, then, second, the limited 

provided availability in the physicians that they need in the hospital, and third, the staffing shortages overall. 

To make matters worse, Puerto Rico was struck by two consecutive hurricanes of historical force. And there still families without 

power, more than 130,000 people without power on the Island, with 

limited access to drinking water and communication services. Our 

veterans were not spared with those hurricanes. As you can imagine, events like this, exacerbates any health condition and create 

even a higher demand on reliable health care services. Not to mention the PTSD conditions. 

The Hospital continued operating through the storm and even offered services to nonveteran patients and assisted neighborhood 

hospitals and clinics. Nevertheless, it suffered some structural 

damage and needs some repairs. And, for that, I need to commend 

my fellow chairmen of this Committee, because during the last supplemental approved during this year, this Committee recommended 

and the House approved more than 94 million dollars to the repairs 

of the VA clinics in Puerto Rico, U.S. Virgin Islands, Texas, and 

Florida. With that, they also included 11 million dollars to services 

related to VA system, that are important to our Nation, but specifically to Puerto Rico. 

They also approved in the VA, more than 75.1 million dollars to 

repair the Veterans Health facilities in Texas, Florida, and Puerto 

Rico, and 93 million dollars for the response overall. And, 4.1 million dollars to repair Puerto Rico National Cemetery and Veterans 

Benefits Administration in Houston. Eleven point one million to 

cover the cost of medical services including transportation, medical 

supplies, and mobile medical units during the storms. 

This is not enough. It’s a good beginning, but I know that we can 

identify those resources like the clinic of Arecibo that this Committee is going to be looking at this afternoon. In addition to that 

clinic, Arecibo and Vieques, were still significantly impacted. Veterans receive care at the Arecibo clinic are currently being treated 

at intense. Essentially, a field hospital on a parking lot belonging 

to a municipality coliseum, veterans residing in Vieques are being 

treated through the medical home visits, and I cannot stress 

enough the importance of every single one of our VA clinics. 

It’s imperative that we locate new facilities that meet VA standards, and swiftly as possible, so that our veterans can receive appropriate care in safe accessible and working facilities. It is also 

important that we are aware and understand the list of health care 

benefits available to them. Every veteran population is different, 

and I have noticed that most of my constituent veterans prefer to 

receive care at the VA facilities on the Island. 

Leonard.horne on VACREP0180 with DISTILLER

5 

It is important for them to understand that there are other options in the case that the VA facility does not match the quality 

of reduced waiting time compared to an outside provider. However, 

I hear that many of them do not use it, they miss information, and 

medical providers, or other even other veterans. I look forward to 

listening to all of those comments and knowing if we can improve 

the access provider through choice, and making sure veterans and 

providers are aware of the benefits available through the programs. 

Our veterans in Puerto Rico are facing a lot of challenges and 

struggles. We have a single veteran home located in the municipality of Juana Diaz. We have learned that the demands have exceeded housing capacity, and we have also noticed, that like many 

other state veterans’ homes, the state shared needed to compliment 

the Federal share of cost is becoming increasingly more challenging 

to meet, leaving the homes with issues when trying to maintain an 

infrastructure and operational utilities, as well as taking care of 

our veteran residence while welcoming new ones. 

And, I also want to express out that we finally are working to 

have our first Fisher House in Puerto Rico. Since the hospital is 

located in San Juan, veterans reside in other municipalities must 

travel to this facility without having any place to their families to 

stay when they’re receiving treatment. For that I’m pleased to announce that we are working with the Secretary of Health, Dr. 

Rafael Rodriguez and the Governor of Puerto Rico just identified 

the land in ‘el Hospital Psiquiatrico’, and we are waiting for the 

transfer of those deeds to the VA Administration so we can finally 

have our first Fisher House in Puerto Rico. 

The reason for that, is because of the land ownership and I’m 

proud to inform that on May of this year, the president of the Fisher Foundation and the VA construction management team will be 

visiting the Island to inspect the site and give feedback on next 

steps for turning this program into reality on the Island, finally. 

[Applause.] 

Miss GONZALEZ-COLON. With that I want to conclude saying 

thank you to our veteran population and to all of you that are in 

the audience today. I want to acknowledge your presence here with 

us, and I would love to have you standing to give a round of applause to the people of the American Legion, to the people of the 

Paralyzed Veterans of America, to the people of the Disabled American Veterans, to the people of the Military Order of the Purple 

Heart, to the Blind Veterans Association, to the Veterans of Foreign Wars, to the Military Officers Association of America, Military 

Officers from Mayaguez, the Military Order of the World Wars, 

Vietnam Veterans of America, and our proudest, proudest sons, the 

people from the 65 Regiment, the ‘Borinqueneers’. Thank you, all 

of you for being here today and thank you Chairman for your time, 

and I yield back. 

[Applause.] 

Mr. WENSTRUP. Well, thank you, very much Congresswoman. Before I introduce our witnesses, I want to remind everyone here 

today, that today’s event is a formal congressional hearing. We will 

have only one panel of witnesses and only those invited to testify 

will be permitted to speak. There will be an opportunity after the 

hearing for those of you in our audience to come up and speak with 

Leonard.horne on VACREP0180 with DISTILLER

6 

me, with Dr. Roe, with Congresswoman Gonzalez-Colon, or our 

staff, if you have any questions or comments or need further assistance. 

With that being said, we’re here today with several local medical 

leaders who helped guide the ship through many difficult storms. 

Joining us on our first panel this morning, is Mr. Augustin 

MontanezAllman, the Puerto Rico State Director of Veterans Affairs, Dr. Rafael Rodriguez, the Puerto Rico Secretary of Health, 

Dr. Victor Ramos, from the Puerto Rico College of Physicians and 

Surgeons, and Dr. Miguel LaPuz, Director of VISN8, the VA Sunshine Healthcare Network of the U.S. Department of Veterans Affairs. 

Dr. LaPuz is accompanied by Dr. Antonio Sanchez, Acting Director of the VA Caribbean Healthcare System as well as Mr. Luis 

Ratchford, Jr., Deputy of Second Secretary for Emergency Management and Resilience for the Department of Veterans Affairs. Thank 

you, all for being here today, and for all the good work each of you 

do to serve your veteran neighbors in Puerto Rico and across the 

Caribbean. Mr. MontanezAllman, we will begin with you and you 

are now recognized for five minutes, sir. 

STATEMENT OF MR. MONTANEZALLMAN 

Mr. MONTANEZALLMAN. Good morning. My name is Augustin 

Montanez Allman, I’m the veterans’ advocate for the government of 

Puerto Rico and a veteran of Persian Gulf War and a recipient of 

the Bronze Star Medal. On behalf of our team, we welcome you to 

Puerto Rico and we are grateful for the opportunity we are given. 

We want to welcome you, Dr. Wenstrup and also Dr. Roe, and also 

we are very glad that Gonzalez, Jenniffer Gonzalez was able to get 

this hearing here in Puerto Rico. We appreciate it and welcome to 

Puerto Rico. 

I want to make a disclaimer, I’m not a doctor, nor am I health 

professional, but obviously the information I’m going to bring is 

what we have observed and also what we have received from veterans that have come to the office to bring in some information. 

First, I would like to talk a little bit about the mission of the office 

and how we relate it to VA. Our mission is to enforce Federal and 

Puerto Rico laws and regulations regarding USA veterans living in 

Puerto Rico, which also coordinates some social services. Because 

of its regulatory functions as Ombudsman, the office operates independently and is the main government agency that ensures the social economic well being of veterans and their families. 

Our office oversees the management of the Veterans State Cemetery and the Veterans Home serving 147 veterans. Under my direction, the Veterans Home regain the VA certification and has met 

inspections every year without a single jeopardy finding. We had 

the last inspection two weeks ago, and we didn’t have no 

(sic)jeopardy findings in that inspection. 

Our office works with the USA Department of Veterans Affairs 

and its three administrations. We refer homeless veterans to programs of the Veterans Medical Center and we facilitate VA relations with the community and serve as a liaison with USA veterans 

organizations in Puerto Rico. The Veterans Home has received 

emergency support from the Veterans Medical Center, I have to 

Leonard.horne on VACREP0180 with DISTILLER

7 

mention they gave us a lot of support during the hurricane from 

the San Juan hospital. 

I would like to talk about the situation of Puerto Rico, veterans 

in Puerto Rico. Veterans living in Puerto Rico come from the five 

USA armed forces and are from every war and conflict since World 

War I. Some are native Puerto Rican, others are retired or business 

owners, some are seasonal residents, and others are foreign born 

USA veterans that, from countries such as Dominican Republic, 

Mexico, and Columbia. 

VA accounts for a population of about 93,000 veterans. Our office 

thinks that the population is higher in numbers since numerous 

veterans in Puerto Rico are not receiving VA benefits or services 

because of different reasons. The current situation of VA health 

care, we understand that most of VA health care service in Puerto 

Rico are high quality and many cases, better than most of the private sector, but it should still exist such as, number one, not 

enough capacity to serve all eligible veterans, number two, not all 

type of services available are provided. Number three, no specialized health facilities like trauma centers or mental health centers. 

Number four, shortage of specialized medical professional in areas 

also scarce in the private sector. Five, location, transportation, and 

information issues impacting access to service. Number six, additional training for medical contractors to manage effectively, veterans’ cases. And, number seven, VA takes too long to take the 

payments some times for private sector health care providers. 

Some clinics are still operating from mobile units and tents due 

to hurricane damage. The clinics do not provide all the services of 

the Medical Center. The Medical Center in San Juan has only 295 

beds for medical patients, and 30 beds for mental health patients, 

that is expected to meet all the needs of over 93,000 veterans. 

There’s a shortage of specialists such as radiologists, psychiatrists, 

and hand surgeons. None of the clinics in the Medical Center have 

a VA trauma center or mental health residential facility. Even in 

contract services, there’s not enough capacity some times. Access to 

service is an issue like in the rural areas in the United States. But, 

like the 50 States, veterans in Puerto Rico do not have the representative in Congress that can legislate and vote to improve 

those situations. 

The best practice that we saw during the hurricane, we have to 

mention, the hospital was among the few hospitals that was operating, running during the hurricane and the black out. Its representative was present at the center of emergency operations of 

the government of Puerto Rico to coordinate efforts. Really, they 

did a really good job coordinating with our office and other state 

agencies. 

Our office was allowed to participate in all the VAH daily briefings and I was given a daily report about the situation of the veterans and the service of the hospital, and the clinics. VA facilitated 

equipment and ITC lines to enable, to set up a temporary service 

area where staff assisted veterans with over 900 FEMA claims. We 

have three persons working at the hospital, helping the veterans 

with their FEMA claims. 

Some recommendations. In the medical mental health service operation, we understand that facilitate the state and municipal 

Leonard.horne on VACREP0180 with DISTILLER

8 

agencies, and nonprofit organizations, can submit proposals for 

grants for health care created services, that we can maximize, you 

know, our resources in the Island. 

Number two, implement an integrated holistic approach to 

health care, different from other parts of the United States where 

you have different types of programs, and here in Puerto Rico is 

limited what we have. Number three, expose Veterans Health Administration orientation for private health care providers. Sometimes, veterans have come to the office complaining how the way 

some of the private provider have been dealing and, you know, 

working with them allocate a small space in the clinics to service 

area for my office and other agencies like the one we set up, we 

have in Ponce, and are proposed for Mayaguez and Arecibo support 

the Puerto Rico Department of Health Plan to expand the state 

trauma center, to designate an area that service veterans and military only, and at a later time, we will serve a backup trauma center to the one that can be created at the San Juan Medical Center. 

Begin a feasability study to build a trauma center at the San 

Juan Medical Center. It’s something that the veterans have been 

asking for many years. Things that we recommend during disaster 

preparedness or disaster relief efforts, set up a reliable communication backup system with satellite phones between VHA, state agencies, key medical and mental health service providers, and first responders. Implement a policy that VHA facilitates equipment, an 

ITC line to enable my agency and other VSOs to set up temporary 

service area. 

Provide medical and mental health service to all category veterans not eligible under normal operations, and I would like to 

mention at this part, here in Puerto Rico some veterans of Category 8, they cannot receive service in the hospital. When we had 

the problem with the hurricane that the private sector was not 

working completely, some of these veterans were having problems 

because they could not be served during the hurricane, the idea is 

that during the emergency they can be given service. 

On behalf of the veterans residing in Puerto Rico, we appreciate 

the opportunity to share our office insights, and your efforts to improve the health service provider to our veterans, we look forward 

to collaborate on our goals, on that goal. Thank you. 

[THE PREPARED STATEMENT OF MR. MONTANEZALLMAN APPEARS

IN THE APPENDIX]

Mr. WENSTRUP. Well, thank you. Dr. Rodriguez, you are now recognized for five minutes and if we could try to keep it to five minutes 

Dr. RODRIGUEZ. Yes, I will. 

Mr. Wenstrup. so we can have time for questions, thank you. 

STATEMENT OF DR. RAFAEL RODRIGUEZ 

Dr. RODRIGUEZ. I will try. Yeah sure. Good morning, Mr. Chairman, Brad Wenstrup, Congresswoman Jenniffer Gonzalez, and a 

special thanks to Chairman Phil Roe, and Ms. Christine Hill. On 

behalf of the Governor of Puerto Rico, Ricardo Rossello, thanks you 

for your presence and dedication in supporting Puerto Rico and our 

U.S. veterans. 

Leonard.horne on VACREP0180 with DISTILLER

9 

This is a historical Veteran Committee congressional field hearing, the first that I witnessed and I am honored to have been asked 

to participate. Congresswoman Gonzalez, the veteran community of 

Puerto Rico is most grateful for bringing the House of Veterans Affairs Committee here to our State Capitol and we salute you for 

this accomplish (sic). On behalf of all of U.S. veterans residing in 

Puerto Rico, I want to give you a warm Puerto Rican welcome. 

Today, I come before you not only as a Secretary of Health of the 

Government of Puerto Rico. I come as a former Chancellor of the 

University of Puerto Rico Medical Science campus, but as an active 

reserve component soldier physician for almost 30 years of military 

service and a veteran. I am, also I am proud of being an American 

soldier. 

I am privileged to provide testimony for the record, for this oversight field hearing. President Trump’s Administration and the U.S. 

Congress have begun the process of funding the most immediate 

emergency needs in Puerto Rico. I am sure that during the short 

visit to the Island six months after Hurricane Irma and Maria, you 

have obtained a deep appreciation and need awareness that much 

more remains to be accomplished to stabilize Puerto Rico, especially in the mountain regions and to serve the Island on the path 

for full recovery and reconstruction. 

The scale and scope of catastrophe in Puerto Rico in the aftermath of Hurricane Maria, knows no historic precedence. The 

islandwide, devastation presented an extraordinary challenge to 

the U.S. citizens of Puerto Rico, to the local government, and the 

Federal government. The hurricanes brought high speed sustained 

winds, heavy rain, and the devastating flooding the likes of which 

the Island have never seen before. Roads and bridges fell and roads 

broken by debris across the Island, leaving communities stranded 

and unable to obtain life saving aid, food, water, and medicine for 

a period of weeks. More than 472,000 housing units were destroyed 

or experienced major damages, forcing hundreds of thousands of 

U.S. Puerto Rican U.S. citizens to seek refuge in shelters, home of 

families and friends, and in the worse case scenario to migrate to 

the mainland. 

One of the most distressful situation in providing health services 

to the population at large was, did not cease in communication, further compounded of two neighbor islands, Vieques and Culebra. 

Due to the condition they have endured, many of our citizens decided to relocate in the continental USA on their own. During my 

recent visit to Orlando and tour to the Orlando VA at Lake Nona, 

we informed that more than 900 of our veterans have enrolled in 

the VA Health System, programs in the State of Florida, of which 

300 enrolled in the facility at Lake Nona. And, just imagine the 

other states that could be veterans also like Chicago, Pennsylvania, 

Texas, New York, New Jersey, you name it. 

Our health situation was concerning even before the storm. Diabetes and HIV present major concerns to our citizens. Also we experienced over the last few years outbreak of Zika, Dengue, and 

Chikungunya. Thank God, we ended the Zika epidemic outbreak on 

last June, and about 2 or 3 months, they removed the travel advisory for Puerto Rico in terms of Zika infection. 

Leonard.horne on VACREP0180 with DISTILLER

10 

The need of behavioral health services are highlighted after the 

passing of Hurricane Irma and Maria. Also, I believe that more 

analysis needs to be made concerning the mental health status in 

the Island. The data before and after the storm is concerning. The 

mental health and suicide hotline received more than 26,000 calls 

between October and December of 2017. Of those, 9,000 callers expressed suicidal behavior. Six thousand were able to verbalize a 

plan to end their lives and more than 2,000 had the intention. That 

is very concerning. 

Every single one of those calls is a saved life. However, not everyone with suicidal ideation called the hotline. In 2017, there is 

an increase of suicide by 29 percent in comparison with previous 

years. There were 196 suicides registered in 2016, and on 2017 

ended with 253 suicides, 57 suicides more. As of February of this 

year, we report only 24 suicides, a reduction from last year at the 

same time. 

The Department of Family, equivalent to the Social Services Department in the continental U.S. provide mental health and care 

services to elderly and their providers of care. This is another area 

where the VA and the Puerto Rico Health Department should collaborate as all are U.S. citizens residing in Puerto Rico requiring 

help. This collaboration can take with the support with of the best 

of Puerto Rico Medical Science campus. Our health care system can 

assist the VA with their access and keeping the veteran closer to 

their homes. Every single town and municipality in Puerto Rico 

have a primary care center. This take care from the state government health centers of treatment and diagnosis or Federal funded 

tertiary health clinics. Veterans can access these clinics and centers faster and would reduce the appointment waiting time issues 

as the VA currently has. 

Another area we’re over? One? Okay, let me okay, another area 

that our government is interested is to import the potential of 

transfer land to the U.S. Department of Veterans Affairs. We are 

proposing that the Fisher House foundation build such facility on 

the VA campus in San Juan which is adjacent to the Puerto Rico 

Medical Science campus. 

At the end of the day, I am responsible of the well being of the 

U.S. citizens residing in Puerto Rico. Veterans are heroes that have 

earned a series of benefits, but more important, they are U.S. citizens that I need to assist in the maintain the healthy as all U.S. 

citizens in this beautiful island and part of our great Nation. 

There should be more areas of collaboration than the one we 

have. After all, we have the same goals to deliver the best possible 

health care service with the limited resources to the U.S. citizen residing in Puerto Rico. Thank you, so much for this opportunity. 

[THE PREPARED STATEMENT OF DR. RODRIGUEZ APPEARS IN THE

APPENDIX]

Mr. WENSTRUP. Thank you very much. 

[Applause.] 

Dr. Ramos, you’re now recognized for five minutes. 

Leonard.horne on VACREP0180 with DISTILLER

11 

STATEMENT OF DR. VICTOR RAMOS 

Dr. RAMOS. Thank you, Chairman Wenstrup, Chairman Roe, and 

Resident Commissioner Gonzalez and Member of the Committee. 

My name is Victor Ramos, and I am the President of the Puerto 

Rico Physician and Surgeon College, an organization comprised of 

all licensed physicians in Puerto Rico. On behalf of the more than 

9,000 physicians in Puerto Rico that I represent, I thank you for 

this opportunity to participate in this conversation here with you 

today, on maximizing the VA resources in Puerto Rico, to impact 

the health of our veteran population. 

Also, here with me Dr. Jorge Vidal, of the Puerto Rico Radiologist Society and Dr. Rafael Zaragoza of the Allergy Physicians representing the private sector. Chronic understaffing has been the 

national problem for the Department of Veterans Affairs for many 

years now, and Puerto Rico unfortunately is not the exception. 

Ways in which to mitigate the shortage of providers within the VA 

Health System has been a constant topic of discussion at the administrative and legislative levels. And, many feel initiative have 

been implemented which is not the solution found. However, our 

demographic and geographic particularities have amplified the VA 

Health System national problem of chronic understaffing. 

According to the Department of Veterans Affairs, there are over 

93,000 veterans registered as resident of Puerto Rico. Sixtyfive percent which are over 65 years old, a number slightly higher than the 

national average. Although small in size, our jurisdiction is mostly 

rural, with VA Health System treatment concentrated in the San 

Juan metropolitan area. Access to this facility is difficult to age related health conditions of the veteran population, as well as the 

lack of integrated public transportation system. And, in contrast to 

the stateside population, our veterans use the VA Health System 

prior than other health insurance they might possess as their primary health care provider. 

This perfect storm of an aging population which recall in health 

intervention, and overall utilization as compared to other jurisdiction is further combined by the exodus of physicians in large part 

of specialty from Puerto Rico. The staff position in the VA Health 

System in Puerto Rico remain open and funded, but requirement 

hindered by the lengthy and archaic bureaucratic hurdles that physicians make to jump through in order to be considered. Employee 

staff is fuller subject to high tax in Puerto Rico which are compound by the economic pressures upon physicians merely because 

of the higher cost of living in Puerto Rico. Lateral move within the 

VA Health System from Puerto Rico to other jurisdiction automatically result in the defacto rise with money in physician’s pocket at 

the end of the day. 

Although the government of Puerto Rico has incentivized physicians to stay in Puerto Rico by granting them special tax rate for 

staying in or returning to the Island, more needs to be done to stop 

the emigration and bring them back to the Island. Therefore, the 

VA must find ways to making more attractive for physicians to 

apply for staff positions, and to remain in those positions in jurisdiction like Puerto Rico with particular high under staffing issues. 

The Veteran Choice program is one of the ways VA is improving 

access to care for veterans, but allowing them to receive care from 

Leonard.horne on VACREP0180 with DISTILLER

12 

nonVA facilities, connecting them to timely and convenient access 

to health care in terms of waiting for a VA appointment or traveling long distance to a VA facility. This program apply in full force 

in Puerto Rico, however, it faces the same under staffing problem 

in countering VA facilities because of the burdensome bureaucratic 

requirements to physicians to participate. 

The VA Health System could provide better care to the patient 

by opening its program to additional providers, merely by simplifying the contracting procedure. I am aware of the budgetary and 

public policy concern of programs such as the Veterans Choice program. Our objective is to obtain health care, however, the effective 

matters subprogram for example, by requiring initial referral from 

the VA Health System to explicit medical care physician in the 

community, with periodic oversight visit to the VA clinics, will 

greatly benefit patient by making health care more accessible as 

well as help resolve schedule congestion and under staffing. 

Easier and responsible access to physician outside the VA Health 

System will also help break the circular problem of lack of ability 

specialty to treat the veteran population in Puerto Rico. Physicians 

and to a larger extent, specialty are leaving Puerto Rico for stateside jurisdiction because of the hard cause they’ve been providing 

their service in Puerto Rico. In 2016, Puerto Rico has losing an average of one doctor a day. Last year, prior to Hurricane Maria, 700 

physicians had left Puerto Rico. I estimate that a larger number 

will leave this year. Of the 400 cardiologists in Puerto Rico a few 

years ago, today we have less than 100. The number of 

anaesthesiologists had decreased in the same proportion. Very few 

neurologists and surgeons remain. And, in the Island where diabetes is one of the principle health problems, there is an urgent need 

for endocrinologists. It is not a rare occurrence to call a doctor for 

an appointment, only to be told that appointments are 3 to 6 

months away. 

Nor, is it easy to call all the doctors in sustained specialty in the 

phone book, only to be told that they are no longer accepting new 

patients. Yes, this is partly due to the local factor suggestive of the 

cost of living and utility cost. However, is also due to the inequalities in Medicare reimbursement rate between our Island doctor in 

Puerto Rico and their stateside counterpart for the same service 

under the same terms and conditions. For example, after 20 years 

the district applicable in Puerto Rico was finally equate to the, of 

the U.S. Virgin Islands, although that number does not take into 

account the cost associated with the Jones Act, which does not 

apply to U.S. Virgin Islands. It is also to the strong market power 

of Medicare advantage applied in Puerto Rico, who regulate by 

CMS, force the providers to accept rates much lower than those in 

similar markets or be driven out of their practice for lack of patients. 

If the VA Health System became a market participant, it will 

open a new pool of patients for these physicians, and provide an 

alternative to the abuse of both private and public insurance. It 

would create a reason for physicians’ specialty to stay in Puerto 

Rico because they call us to do so. More physician means accessibility to health care, which translate to help their patient and 

lower health care cost. We cannot lose sight of the fact that a large 

Leonard.horne on VACREP0180 with DISTILLER

13 

number of veterans also posses other insurance. Either private insurance through their employer or from the government’s Medicaid 

support program. The overutilization of the VA Health System in 

Puerto Rico tax limit resources to the benefits of other health insurance. The responsible integration of our health care provided 

into the care of the veteran population, allows a cosharing of these 

expenses, with other health insurance plans correlated cost to the 

VA Health System and maximizing results. 

As for that Legislator, I know that you face an incredible challenge in finding a solution that will for approximate 21 million veterans in the United States, throughout the world. I am grateful for 

this time you take to come to Puerto Rico and for your interest to 

learn about the specific problem facing our veteran population and 

for your openness and availability to do something about it. Our 

Resident Commissioner is a tireless fighter for our health and well 

being and I thank you for having join our health fight. Respectfully 

submitted. 

[THE PREPARED STATEMENT OF DR. RAMOS APPEARS IN THE APPENDIX]

Mr. WENSTRUP. Thank you. Dr. LaPuz, you’re now recognized for 

five minutes. 

STATEMENT OF DR. MIGUEL LAPUZ 

Dr. LAPUZ. Good morning, Chairman Roe, Chairman Wenstrup, 

and Representative Gonzalez-Colon and honored guests. I appreciate the opportunity to discuss the Department of Veterans Affairs 

Caribbean Healthcare System and the provision of health care in 

Puerto Rico. I’m accompanied today by Dr. Antonio Sanchez, Acting 

Director of the VA Caribbean Healthcare System, and Lewis Ratchford, Deputy Assistant Secretary for Office Operations, Security, 

and Preparedness. 

The health care system consist of a tertiary care, a medical center, and ten outpatient clinics located throughout Puerto Rico and 

Virgin U.S. Islands (sic), the U.S. Virgin Islands. The Medical Center includes multidisciplinary and ambulatory facilities and 280 

operational acute care beds, including 12 blind rehabilitation beds 

and 122 operational nursing home beds. Services are provided to 

a population of approximately 93,000 veterans. 

VA’s first mission is to improve the Nation’s preparedness for response to war, terrorism, national emergencies, and natural disasters by developing plans and taking actions to ensure continued 

service to veterans, as well as to support national, state, and local 

emergency management, public health, safety, and homeland security efforts. The Health System’s ability to maintain critical operations throughout the historical hurricane season of 2017, is a testament to VA’s commitment of significant resources and planning 

to these efforts. 

The 2017 hurricane season was one of the costly season on 

record. VISN8 facilities were directly impacted by two major hurricanes. Hurricane Irma barreled through the Caribbean on September 8, devastating St. Thomas, and leaving nearly 1 million 

people without power in Puerto Rico. In the aftermath of Hurricane 

Irma, the Medical Center as a key partner in the national response 

Leonard.horne on VACREP0180 with DISTILLER

14 

to disasters, mobilized emergency response units to the Luis Munoz 

Marin International Airport to receive patients from the U.S. Virgin Islands through the activation of the Federal coordinating center. Through the collaborative efforts of Federal, state, and local 

governments and nongovernment organizations, the unified emergency response teams received 92 patients. All patients were assessed upon arrival at the airport, and then transported to multiple 

hospitals in the metropolitan area, including San Juan VA Medical 

Center. 

On September 20, while still recovering from Hurricane Irma’s 

impact, Hurricane Maria, a category five storm hit Puerto Rico 

with forces beyond those imaginable. Tremendous impacts to critical infrastructure were widespread. Nearly the entire Island was 

without power, water, and telephone service and conditions of 

roads and buildings were perilous. Because of VA’s investment in 

emergency preparedness and response resources, the hospital was 

able to maintain critical hospital operations throughout the storm 

and was able to bring community based unexpect into operations 

within weeks. 

Additionally, we were in a position to offer assistance to other 

health care systems more severely impacted by the hurricane. 

These efforts did not come without certain limitations and challenges. Immediately following the storm, VA outpatient clinics relied on generator power and limited communication capabilities including data resources. Roughly, 23,000 appointments were cancelled as direct result of the hurricane. Staff have reached out to 

all veterans since appointments were cancelled, more 21,000 appointments were rescheduled, but the remainder not indicating the 

need for an appointment. 

We are currently focused on preparing for this year’s hurricane 

season. Efforts on the way to preparing advance include outreach 

to vulnerable and high risk veteran populations, building on established relationships and community partners, updating these 

agreements to ensure a timely response after natural disaster and 

exploring more reliable voice and data communication strategies. 

Most importantly, there are 27 million dollars in high risk infrastructure improvements that must be completed before the beginning of the upcoming hurricane season. We remain committed to 

providing exceptional health care and emergency preparedness, 

pursuing this objective in close collaboration with our Federal partners, leading national organizations, local government agencies, 

veteran service organization, and other nonprofits. 

We welcome the opportunity to expand current efforts as well as 

establish new agreements that will benefit veterans throughout 

Puerto Rico and the U.S. Virgin Islands. The VA remains committed to open dialog regarding joint efforts and enthusiastically 

encourages their development. While VA excelled during times of 

crisis, there is still action required to ensure the needs of veterans 

in Puerto Rico and the U.S. Virgin Islands are consistently met. 

Sustaining the momentum and preserving the gains made so far, 

requires continued attention and investment of financial resources. 

Failure to provide such resources will severely jeopardize our ability to sustain our progress and will put at risk thousands of veterans and their families in the future. It is critical that we conLeonard.horne on VACREP0180 with DISTILLER

15 

tinue to move forward after the hurricanes and continually improve 

the system of care that is provided by VA Caribbean Healthcare 

System. Mr. Chairman, this concludes my testimony, my colleagues 

and I are prepared to answer questions. 

[THE PREPARED STATEMENT OF DR. LAPUZ APPEARS IN THE APPENDIX]

Mr. WENSTRUP. Well, thank you all very much for your testimonies We will now take time for questions and I will yield myself 

five minutes for questions, and I would like to start with you, Dr. 

Rodriguez, if I may. 

Dr. RODRIGUEZ. Sure. 

Mr. WENSTRUP. You’ve talked a little bit about academic relationships between health care systems and also, I know yesterday, we 

also discussed opportunities for military medical personnel to engage as we do say, in San Antonio where the San Antonio Medical 

Center provides for the community, trauma, and everything. And, 

then there’s programs such as the Air Force has which is the Sea 

Stars program, centers for sustainment of trauma and readiness 

skills, and they embed military personnel into private level one 

trauma centers to engage, to provide care and to train. 

And, so in your view, what are some opportunities for military 

medical personnel, active and reserve, to train, provide care, augment care for veterans and residents of Puerto Rico? 

Dr. RODRIGUEZ. Thank you, Mr. Chairman. As we discussed yesterday the most typical example of that is Brook Army Medical 

Center where they, is open for treatment of trauma patients from 

the civilian part. By a chance I was staff neurosurgeon there on 

2005 when I was deployed there, so I know, I worked very closely 

with that type of endible (phonetic). In Puerto Rico, we have other 

VA centers as well known by you. Academic centers help the VA 

in order to give services. They share faculty and also improve the 

health care of the veteran population. 

We used to have that close relationship many years ago. I remember when I was in my residency, my residency by that time, 

that we rotate and have a formal rotation at the VA, and the faculty of neurosurgery shared credentialing between both academic, 

the academic center and VA. As well, faculty from the Veteran Administration Hospital also served as teaching there, in the civilian 

sector. So, I think that is a thing that we have to explore to seek 

again that type of relationship between the academic and the VA 

for the well being of the veteran population. I think that will be 

fantastic to return that policy again, and to be sure that we can 

work as good neighbors. 

Mr. WENSTRUP. Thank you. Dr. LaPuz, you have any comment 

on that and is there any relationship right now with Fort Buchanan and the VA from the health care standpoint? 

Dr. LAPUZ. Yes, sir. There is already an existing relationship between the DoD and the VA, and I will yield to Dr. Sanchez who 

can talk to the specifics of that relationship. 

Mr. WENSTRUP. Thank you. 

Dr. SANCHEZ. Good morning, Dr. Wenstrup and Dr. Roe, and 

Congresswoman Gonzalez-Colon. Thank you very much for the opportunity. For me it’s a privilege to be here, and thank you very 

Leonard.horne on VACREP0180 with DISTILLER

16 

much for yesterday’s visit to our facility on behalf of all the veterans and as well as the workforce that I represent. For us it was 

an honor having you there and thank you for the great work that 

you have been doing. 

The VA Caribbean Healthcare System for many, many years has 

been doing a lot of affiliations and collaboration with the Department of Defense, mainly with the Buchanan base clinic that we 

have there. We share some clinics, for example for phlebotomy labs 

there. There’s a lot of patients that go there because we had some 

parking issues in the past, more than now, and then we have been 

in that kind of collaboration and actually our facility trained part 

of the DoD mortuary personnel in different partnership of education as well. It is limited and I welcome all of the possibilities 

to continue expanding our services. Three weeks ago, I received a 

visit of Commander Lozano who is the Buchanan Clinic director, 

and he told me that they are in conversation after the hurricane 

to construct probably a new clinic in Buchanan and he wants us 

to be part of that planning phase since the beginning, and I think 

that is a great collaboration and everything that I am listening 

now, I think that we need to take advantage of that momentum 

and work all collaboratively. 

If we can expand or decompress the facility that we have, by expanding services for our veterans, it will be a win to win relation 

for all the veterans. That is our purpose for that. 

Mr. WENSTRUP. So, Buchanan is providing some ancillary services right now. Are they seeing patients as well, veteran patients 

as well? 

Dr. SANCHEZ. Yes, they receive for phlebotomy, for laboratory 

and we collaborate with our chief of pathology to help them to 

maintain the accreditation of their labs, and in some, while the reservist, that is another agreement that we have, while the reservist 

are active, we receive military active for any emergency care in our 

facility as well. That is part of our agreement that we have with 

the DoD as well. But, as I said, there is room for continued enhancing all of that. In the past we had been in conversation to have colocated clinics. For example, for the compensation and pension 

exams, we do those in our facility. Last year we were in collaboration in the planning phase in using some buildings that they have 

available, and had colocated clinics to assure that the soldier in the 

transition going out of the military and then becoming part of the 

VA System and also with the Veterans Benefit Administration. One 

part is done in the Buchanan base and another part is done by us 

in the hospital, so we were in those planning of having the collocation. But, now with the Commander Lozano thinking, and he has 

been working with the Department of Defense, that the clinic could 

be remodeled and a new clinic, they probably can have more space, 

and then we can work other initiatives at the same time. 

Mr. WENSTRUP. Thank you, my time has expired. Dr. Roe, you’re 

now recognized. 

Mr. ROE. Thank you, Mr. Chairman and first of all, I want to 

just give a shout out to all the veterans that are here and the Puerto Rican people for undergoing an incredible hardships during the 

past several months after not one, but two major hurricanes that 

hit this Island, and really devastated much of your infrastructure, 

Leonard.horne on VACREP0180 with DISTILLER

17 

so your patience Job would be proud of you, I can tell you in the 

Bible. 

Christine Hill is a staff director for the Subcommittee on Health, 

but she also is a former B1 bomber pilot. Me being a infantryman, 

I stayed a little closer to the ground, myself. 

[Laughter.] 

Mr. ROE. A couple of things that I wanted to go over just quickly, 

Mr. Chairman, is that I heard several things and I will just mention these. Dr. Ramos brought these out, we heard this in our VSO 

roundtable this morning, and we heard it yesterday, both in the 

public health hospital and in the VA Hospital, of chronic understaffing, both in mental health and in others, so and hiring takes 

too long. Dr. Ramos, you’re absolutely right, VA is glacial in hiring 

physicians. We see it stateside where you get a gastroneurologist 

and it may take six months to hire them, and in private practice 

would take me two days to hire that person. 

The other thing that was brought up about paying in a timely 

fashion. Medicare pays about 95 percent of its claims in a month. 

The VA is about 60 percent. The Secretary is very aware of that. 

That’s one of the problems in the Choice Program that needs to be 

worked out. So, we hear you loud and clear. I wanted to share that 

with you. 

I heard something this morning that I’d like Dr. LaPuz get some 

clarification on. In your written testimony, you stated that the VA 

at the Caribbean Health Center was able to reach 100 percent of 

over 3,000 veterans identified as being members of a vulnerable 

population, which included veterans experiencing homelessness, 

those requiring hemodialysis, those dependent on ventilators, those 

that are high risk for suicide, and those with severe mental health 

issues. Assisted by FEMA, VA staff used round air sea transportation methods to meet with each veteran to confirm his or her well 

being. But, what we heard this morning though, in the roundtable 

was is that, as many as 90 percent of the people that the VSOs met 

and I won’t mention which one, there was no visit from the VA. 

And, so how do reconcile those? One say that they didn’t get out 

to see the veterans, and you say that you got out to all of them. 

So, how do you reconcile that? 

Dr. LAPUZ. We identified the high vulnerability, the highly vulnerable veterans, and those veterans that are the homeless veterans, the ones that are requiring chronic care, the ones that are 

actually enrolled in our home based primary care, the ones that are 

involved in the Macomb program for example, which is a mental 

health intensive case management program. So, in that category of 

veterans, we in all of the situations as part of our hurricane hardening, we reached out to them to make sure that even before the 

hurricane hits, that they’re actually prepared for those situations. 

So, it is not reaching out to all of the veterans enrolled. It is 

reaching out to all the veterans that are belonging to that high risk 

population. 

Mr. ROE. Do you meet with the VSOs or not you particularly, because you’re the director, but do the local VA maybe, Dr. Sanchez 

better for you, but you reach out to these folks to reconcile these 

differences because, I think that’s extremely important, because 

Leonard.horne on VACREP0180 with DISTILLER

18 

their perception of what happened and your perception of what 

happened are two different things. 

Dr. SANCHEZ. Yeah, thank you for the opportunity to clarify that, 

and definitely we work very close with the veteran’s service organization leaders and they were part, most of them were part of this 

effort of identifying a lot of veterans that needed our intervention 

because they needed health care issues, you know, and a lot of 

them, thanks to the great job that they were doing, outreaching. 

Remember, this was a complete catastrophe in Puerto Rico, all the 

veterans and all the citizens had major, major issues, problem with 

communication. So, definitely is part of our process with the VSOs 

to clarify what was the total population that we reached out, and 

there was a lot of other needs in veterans, that not necessarily was 

health care related needs. And, then is when our social work coordinator with the local agency to help them, let’s say, housing, food, 

clothing, other kind of things that in our scope, in our, as a hospital we can’t help them, but we helped them to coordinate with 

the other agencies through FEMA, and all of that. But, definitely 

something that we can clarify more to them. 

We have been tracking and we were tracking all those, more 

than 3,000 special or vulnerable patients because of their condition. 

Their lives were critical, patients on ventilator, we needed to assure that they had a generator in their house, if not and we 

brought several of them to the facility because they didn’t have a 

good generator. Patients in anticoagulation medication, we needed 

to assure they had, but it took time, because the roads and the 

streets were completely impacted. There was a lot of problem to 

reach out to them, and that’s why the VSO went to the street and 

helped us. I received as a Commander in the incident command 

post, they were constantly referring and we were reaching out to 

them. 

But definitely we will accept your recommendation, Dr. Roe. Actually tomorrow we have already planned what we call a VSO strategic planning, because prior to the hurricane, the VSO created 

what they call a coalition of VSOs. In Puerto Rico they met with 

me and we were planning this strategic planning, and unfortunately because of the hurricane, it was, you know, delayed, but it 

is going to happen tomorrow in my facility. In order to create a 

strategic planning to address all and prioritize all of those areas 

that they have been bringing because a lot of things that we have 

been doing through the years, has been thanks that they have 

brought out to us and they have been advocated together with the 

Federal government, with their organization, moving among us 

there is other areas that we need to continue working all together. 

So, I will touch base about that 

Mr. ROE. I would say that they are a tremendous resource for 

you— 

Dr. SANCHEZ. Oh, yes, definitely, and I’m very proud 

Mr. ROE [continued]. —and they can be very helpful, and I would 

like to ask, and this my time has expired, I’m going to yield back, 

but a question that maybe we can get it from Mr. Ratchford or Dr. 

LaPuz in writing, is, what lessons have been learned with this particular hurricane, the two, and then sort of an after action report, 

Leonard.horne on VACREP0180 with DISTILLER

19 

and then how are you better preparing since unfortunately the hurricane season is just a couple months away. I yield back. 

Mr. WENSTRUP. Thank you. Ms. Gonzalez-Colon, you’re now recognized. 

Miss GONZALEZ-COLON. Thank you, Mr. Chairman. First of all I 

want recognize some people in the audience today, like, General 

Isabelo Rivera, our National Guard, general from Puerto Rico, 

thank you for coming here. And, I want to thank Chairwoman from 

the Veterans Affairs Committee in the House, Lourdes Ramos, and 

Chairman of the Veterans Affairs Committee in the Senate side, 

Jose Luis Dalmau, Jose Aponte former speaker of the House and 

Chair of the Federal Affairs Committee in the House, is also with 

us today and with us during the roundtable, and Representative 

Felix Lasalle from the western part of the Island, thank you, for 

being here today. 

Having said that, we got a lot of questions. Yesterday we went 

to the VA facilities and we account of the situation regarding the 

clinics in the VA System. One of them, we’re going to visit today 

in the afternoon which is the clinic from Arecibo, where some, 

many people are receiving their services in tents. So, same thing 

happened with the situation in Vieques. So, Mr. LaPuz, my first 

question will be, are we using the mobile units to serve those areas 

or not? 

Dr. LAPUZ. Yes, Ma’am. We’re using the, right now what we have 

there is a, in Arecibo we have a western shelter— 

Miss GONZALEZ-COLON. Mmhm. 

Dr. LAPUZ [continued}. —so we have a, almost a complete clinic 

which is actually in house, in the western shelter, so that you will 

see that shortly. However, we have a contracting, it’s already in 

contracting, trying to identify a new location for the Arecibo clinic 

so we can also begin construction of the new clinic. So, we expect 

that, that is going to be before the end of the month, we’ll have a 

clarity regarding the location that has been identified through the 

bid process. 

Miss GONZALEZ-COLON. Can you answer directly my question, in 

terms of how many mobile units are we using in Puerto Rico? 

Dr. LAPUZ. Oh, I’m sorry, I’ll defer to Dr. Sanchez regarding the 

number of mobile units. 

Miss GONZALEZ-COLON. Thank you. 

Dr. SANCHEZ. Yes, immediately after we started to work with the 

emergency, we received from the state two mobile units, one from 

Tampa, and one from Orlando in the 

Miss GONZALEZ-COLON. Are they in use right now? 

Dr. SANCHEZ. They are being used. 

Miss GONZALEZ-COLON. Where? 

Dr. SANCHEZ. One in Arecibo, as part of the compound that we 

have there with the western shelters, specifically for the mental 

health clinic, and the other one is being used in Vieques. Vieques, 

we were doing home visits until like, 3 weeks ago, when we were 

able, working with the Puerto Rico Health Department and FEMA 

Miss GONZALEZ-COLON. To move that mobile unit. 

Dr. SANCHEZ. and we moved, and the mobile unit and now we 

have it there with all the utilities. 

Leonard.horne on VACREP0180 with DISTILLER

20 

Miss GONZALEZ-COLON. Okay, how many doctors and nurses are 

those mobile units are using? 

Dr. SANCHEZ. Well, in Arecibo we are using all the staff of the 

clinic. We have 

Miss GONZALEZ-COLON. So, besides my question will be, sorry 

about that. 

Dr. SANCHEZ. Ahhah. 

Miss GONZALEZ-COLON. My question will be, besides the mobile 

unit and the tents that are, or the clinic that you are using, do you 

receive with the mobile unit more human resources to attend the 

patients or not? Or you’re just using the physical facility? 

Dr. SANCHEZ. Yes, we are using the same staff from Arecibo 

Miss GONZALEZ-COLON. Okay. 

Dr. SANCHEZ. all of them are in the compound, and the same 

staff that are 3 staff, is a physician, a clerk, and a nurse. In 

Vieques, they are the same that they were doing home visits, now, 

they are located in just one of the mobile units. 

Miss GONZALEZ-COLON. The VA and the Congress just approved 

11.1 million dollars to mobile units and medical service including 

transportation for the areas impacted by the hurricanes, so I expect 

part of that money is going to be, directly to those areas in Vieques 

and the areas that have been affected directly by the hurricane 

here in Puerto Rico, and I would love to have a report on the issues 

of those monies to the Island, if the Chairman of the Committee 

allows me to request that information. 

The second will be in terms of, how many veterans have been 

able to be treated in those 2 facilities, in those 2 mobile units. Do 

you have the count of those numbers or not? 

Dr. SANCHEZ. Well, yes, on a daily basis and Dr. Roe and Dr. 

Wenstrup yesterday were able to see the tracking that we are following in the incident command post center. We track on daily 

basis all the veterans 

Miss GONZALEZ-COLON. How many? 

Dr. SANCHEZ. we have seen. 

Miss GONZALEZ-COLON. How many? 

Dr. SANCHEZ. I don’t have it from my, but we can get it you 

Miss GONZALEZ-COLON. Okay, perfect. Can you provide it later 

on? 

Dr. SANCHEZ. Definitely. 

Miss GONZALEZ-COLON. Thank you. Well, my third question will 

be in terms of the VA clinic of Vieques. I know you’re in a process 

of leasing, finding a new lease, and I know the challenges in 

Vieques to establish a new one, so let me know, just me as a Member of Congress, but to Dr. Rodriguez and Mr. Montanez, if we can 

assist in any way with the local authorities to facilitate that kind 

of transition. Inclusive the VA clinic in Arecibo, Arecibo is the 

major region that attends people coming from Utuado, although we 

have a clinic there, and from the northern part. I heard someone 

say that you’re willing to move that clinic out of Arecibo. If that 

is the case, I will tell you that I’m going be opposed, because so 

many veterans in that area, know the place, is more easy to get 

to there because of differential rural areas on the side. 

My next question will be in terms of the lack, shortages of professionals. We talked yesterday about ophthalmologist, oncologist, derLeonard.horne on VACREP0180 with DISTILLER

21 

matologist, among other professional in the health care area, in I 

receive like many of the people here, they request that have been 

waiting for three or four months to get an appointment. Most of 

them when they visit a VA clinic in the States, that’s not the case. 

They may even receive an appointment less than 15 to 20 days. So, 

why if we are in an island, and we can’t cross state lines by a 

truck, or by a train, just by an airplane, we need to wait 3 and 4 

months to get an appointment when you got a VA hospital here, 

you got multiple clinics and the people here deserve to have right 

away their appointment, medical appointment. Why is the reason 

our people need to wait 3 and 4 months to get an appointment? 

[Applause.] 

Dr. LAPUZ. And, we truly recognize that, but like what Dr. 

Ramos is saying, that part of the issue that we’re encountering in 

the Island is that there are in specific specialties, a reduction of the 

available physicians. 

Miss GONZALEZ-COLON. Can you list that, can you list that (sic) 

professionals that the VA is lacking personnel? 

Dr. LAPUZ. Sure, and I just like to make sure that there is a 

common understanding. So, when the VA in San Juan cannot meet 

that demand, we are actually utilizing Choice. But, the problem in 

the community in San Juan, and you’re very aware of this, Ma’am, 

that there are situations in which that is also lacking in the private sector. So, we could not the general problem is, how do we attract specific specialities in Puerto Rico? And, because that’s the 

one that will be, the determinant of how we are going to solve this 

specific specialty issue. 

Miss GONZALEZ-COLON. Do you got (sic) the list of physicians, the 

list of professionals that we’re lacking of in the Veterans. 

Dr. LAPUZ. Yes, Ma’am, we’ll provide that to you. 

Miss GONZALEZ-COLON. Okay. And, I know I’m running out of 

time, and thank you, Chairman for his indulgence here. I know 

that when we visited yesterday the trauma center of the Centro 

Medico, and we don’t have a trauma center in the VA Hospital in 

Puerto Rico. Same thing of the lack of services in surgery, mental 

care, and we even received complaints in terms of how difficult it 

is for the blind veterans to just cross, pass across the hospital. Are 

we looking on those renovations to accommodate the needs of the 

blind veterans on the Island, instead of letting them go through the 

whole hospital to receive services. 

[Applause.] 

Dr. LAPUZ. Yes, Ma’am, we’re looking at, all of the enhancement 

that will be required, including the concerns of our, the impaired 

veterans. 

Miss GONZALEZ-COLON. Please include the bricks (phonetic) on 

the entrance, in terms of reviewing the needs of maintained those 

bricks that may have put some, a lot of strength and difficulties to 

the blind veterans arriving to the VA Clinic. 

My last question, but I will provide more questions to the Committee so they can okay, perfect. So, my last question during this 

round then will be the issues regarding the caregivers. A lot of our 

veterans are receiving care by the caregivers, and those coordinators from the VA must conduct house visits to make sure the veteran is doing well, and the caregiver is participating as expected. 

Leonard.horne on VACREP0180 with DISTILLER

22 

I know there are two major barriers here. One can be the language barrier and the other one would be conducting those visits 

in the rural areas for the recertification process. In that term, how 

can we fix the visits in those rural areas. I know we got people 

from the Paralyzed Veterans if I recall well, that told us that, 

you’re using the VA system, the P.O. box addresses as their main 

contact information, and with those P.O. box addresses, you can’t 

visit a veteran in the Island. Did the VA so this is a two way question, did the VA correct those addresses so they can visit the veterans in those areas? And, the second one, regarding the barriers 

to the caregivers’ recertification process? 

Dr. LAPUZ. I’ll let Dr. Sanchez speak to the specifics of the caregiver program. 

Miss GONZALEZ-COLON. Thank you. 

Dr. SANCHEZ. Yes, in terms of the mail address, definitely it is 

a challenge in Puerto Rico because, a lot of appointments, not only 

for caregiver visits, we use the mail. In difference from the mainland, our addresses are HCO1 rural, very rural and they’re not 

standardize like in the mainland. So, a lot of letters that we send 

are returning back, so are very difficult. So, what we have been 

doing, we met 2 months ago with the U.S. Postal Office and we 

navigate with them because they have a special software to standardize using the bar codes in the letters, and we are in the project 

to adopt that. While that happens, what we are requesting to all 

the veterans is that, every time that they do checkin, in our facilities, please update their addresses to assure that is the most updated one, one that is clear enough in order that we can visit them 

and not rely on the P.O. box or the rural one for the boxes that 

is a challenge for the organization. We receive a lot of return from 

the mail because they cannot deliver it. It happens, you know, constantly. 

Miss GONZALEZ-COLON. Can you provide the number, telephone 

number to all those veterans that are suffering from sleep apnea 

and do not have power in their house, to provide any generators 

to comply with their care? Like all veterans that receive that kind 

of service in Florida, and we’re missing that to a lot of veterans 

here that are not receiving those kind of generators, because 

they’re living in a zipcode number in Puerto Rico? 

Dr. SANCHEZ. We can work with that, generators are issued by, 

prosthetic service some eligibility criteria, but at the same time we 

recognize the need for some special need for veterans and we 

partnered with the Cruz Roja, American Red Cross and they had 

a great program that we worked in collaboration with them and 

they reached out, a lot of veterans provide in the generators, so, 

but it’s more to come on that. We need to continue working collaboratively with the resources that the law allow us, based upon eligibility and the community, and the American Red Cross as an example with that. 

Miss GONZALEZ-COLON. Thank you, Chairman. 

Mr. WENSTRUP. Thank you. We talked about provider shortage 

and the challenges that we face, and it’s not just in the VA. It’s 

across the country. In my district I have an urban area where 

there’s pretty good access to care, but I have a lot of rural areas, 

and we have a hard time getting physicians to those areas, to want 

Leonard.horne on VACREP0180 with DISTILLER

23 

to go there, live there, and practice there. It is a challenge that we 

face throughout. And, that’s a whole other topic for another day on 

how we can increase our residency programs, people going into 

medical schools, expanding our medical schools, etc. 

But, I do want to go back to the one thing we talked about. You 

know, we have people that, many people have gotten their medical 

education through the military, and they serve in the military. 

And, there are some medical treatment facilities where they now 

serve that are not very busy. And, we have both active component 

and reserve component. And, reserve component are obligated to do 

a couple weeks a year, weekends, and month, and to fill in some 

time. And, that’s why I want to take this situation we’re in, and 

try to see we all work together so that we can provide care, not 

only for our veterans, but for our civilians, and how we can implement that in many ways, and perhaps use our military to fill some 

of those voids which will not only serve the people we intend to 

serve, but give those providers and opportunity to see more patients to practice their craft, to be better at what they do. It’s a 

training exercise as well. So, I look forward to working with all of 

you in that regard, not only here in Puerto Rico, but across the 

United States of America where there are some opportunities of situations we find ourselves in. 

I do also want to go back to what Dr. Roe asked about, Mr. 

Ratchford, do you you’re like the Allstate mayhem guy. You get to 

go to all the things, where there’s a problem, right? Emergencies 

and building resilience, and there’s always lessons learned, so I do 

look forward to hearing back from you on what we’ve learned from 

this and how we can prepare better, and I would like to you’ve 

come this far to be with us today, and maybe just take a minute 

to discuss what you face and what you look forward to the future 

as far the service that you provide. 

Mr. RATCHFORD. Thank you, Dr. Wenstrup, and also recognizing 

Dr. Roe, and Congresswoman Gonzalez-Colon. Hurricane Irma and 

Maria were both challenging events for Puerto Rico and also the 

Caribbean. One of the things that the Department of Veterans Affairs we did and I think it really changed the outcome of our hurricane response efforts, we recognized logistical challenges associated 

with the Caribbean, is that we had to get ahead of that first, before 

we can start talking response and how we were going to help the 

Island Nation recover from what was going on. 

So, we worked in close collaboration with FEMA, helped the 

Human Services and also the Department of Defense to make sure 

we were able to move resources to give to our responders on 

ground, because people are easy. Goods and services hard to get 

here, especially during a crisis. We were fortunate enough, we 

moved about 128 short tons of equipment to include several response vehicles, to mobile medical units, mobile vet centers, mobile 

pharmacies, logistic sport vehicles, and other resources such as 

generators, AC units, shelters, and trucks to help move things 

around the Island, and get response personnel the tools they need, 

be part of the solution. 

What we’ve identified in our after action reviews that we’ve done, 

we’ve done some of them and headquarters, is that logistics is a integral part of the response effort and you have to think about that 

Leonard.horne on VACREP0180 with DISTILLER

24 

up front. Lessons learned, we also have noted is been as far as, 

working with the whole of government. We’re stronger together 

than we are by ourselves. We saw a lot of that during response effort at the Federal level, to where it took us a brief second to come 

together and realize, we all have things that we’re good at, and we 

all have shortcomings that by design, we’re not able to do in our 

organization makeup, but if bring ourselves together, we fill each 

other’s gaps, and we work stronger in becoming a viable force and 

responding to these types of disasters. 

Today, we have our emergency management team from across 

the Nation, within the Veterans Health Administration, meeting 

right now in Virginia, talking about not only lessons learn with 

this type of event, but other types of catastrophic events that we 

face across the Nation, and how as a preparedness community, we 

can come together, be a part of the solution, and create the environment so that health care can be provided without a hiccup, so 

that restoration services can happen without a hiccup, so that infrastructure can be restored without a hiccup we recognize that 

through emergency management and preparedness, we create that 

environment so that others can be successful. 

Mr. WENSTRUP. Thank you. 

Mr. ROE. Very briefly, I know we have to move on to visit some 

other things, but all of that is great, but if the people of Puerto 

Rico don’t know it, it doesn’t do any good. If you don’t know where 

to go when that event happens, and all that planning if we keep 

it to ourselves, doesn’t help all these people sitting out here in the 

audience at all. 

I think that we learned today about informing people about what 

they should do in the event of a hurricane in the neighborhood, and 

the western part of the Island where it’s less populated, what do 

they do? Where do they go if something happens, where can you 

get water and food, and help, and so forth. I think that was a, is 

something we learned and I’ve learned in that the things that 

we’ve had, the catastrophic events we’ve had in my district, is that 

the people have to understand. 

I want to, Mr. Chairman, thank you, and certainly Jenniffer, 

thank you for inviting us here. We’ve learned a lot on our visit. We 

intend to learn some more before we go back to Washington. We 

will share these things that we’ve learned with our colleagues on 

the Veterans Affairs Committee which is a bipartisan committee. 

We try to check Republican, Democrat at the door, and do what’s 

right for veterans. So, I’d like to, again, thank you for the opportunity to be here. I yield back. 

Miss GONZALEZ-COLON. Thank you, Mr. Chairman, and I just got 

two more comments. First of all, I want to recognize Mr. Bernard 

Johnson, the VA Regional Director for the Island, thank you, for 

being here today. I got two comments and one question. One is that 

we need to fight to get Puerto Rico out of the overseas definition 

in terms of tricare prime. I mean, our veterans need to be treated 

as all American citizens. Not because their zipcode is different. 

And, right now, tricare prime do not apply to the Island, just because under the Department of Defense, we’re considered an overseas territory. So, that’s the first request. I’ve been writing some 

letters to the Department of Defense. It’s been contablized (phoLeonard.horne on VACREP0180 with DISTILLER

25 

netic) at 29.7 million dollars, just including the coverage of Puerto 

Rico as part of the tricare prime. So, that’s one of the challenge I 

will love the Committee to coordinate with me to try to achieve 

that kind of equality for the veterans in the Island. 

The second will be, we got a facility state veteran home in Juana 

Diaz. It is 20 years old, it’s deteriorating. The state matching requirement has been a challenge for providing maintenance for all 

those projects. We need to see how the VA can help us out in making any adjustment that we can make to account for houses located 

in rural areas or impacted by natural disasters. 

In the other hand, I think we should look forward to enforce any 

comparative agreement with pharmacies and other Federal agencies, so no veteran, and no service to our veterans is turned down 

during a hurricane or any other period. And, that’s happening in 

a more frequent way in Puerto Rico, where pharmacies and doctors 

are turning down our veterans, and that’s something we need to 

work together to achieve a better understanding and a better way 

to serve our men and women in uniform. Having said that, I’m 

looking forward to have the transfer of the land for the Fisher 

House so we can finally get that, not just for the people of Puerto 

Rico, but for the people that are coming from the Virgin Islands, 

to receive those kind of services. 

I want to thank all the personnel from the VA that helped us out 

during this hurricane season. I know that most of you rode out the 

hurricane in those facilities. I know how hard is that, because I did 

that in my own house, but one of the main issues that remains 

there, it’s how our facilities are going to comply with the new 

standards and how our people are going to receive the service that 

they need. I hope the allocation of funds that were included in the 

third supplemental are going to be enough for all the VA clinics 

and the National Cemetery, if not, feel free to tell me what resources do you need to make those things happen to our veterans 

in the Island. With that, I want to thank all the Members, all people who served and fought for our Nation. We are grateful for your 

service and for the people that are here today, and thank you, 

Chairman Wenstrup and Chairman Roe for allowing me, as the 

only Member representing 3.4 million American citizens in Puerto 

Rico, to have a voice on behalf of our veterans, even when I can’t 

vote on the floor. Thank you, and welcome to Puerto Rico. 

[Applause.] 

Mr. WENSTRUP. I want to once again thank all of our witnesses 

today for your insights and to all those here in audience for taking 

the time to be with us this morning, and thank you for the hospitality and the warm reception that we’ve have had here. It’s been 

a pleasure being in Puerto Rico with you, and I look forward to taking your comments and your suggestions and your ideas back with 

me to D.C. This time I ask you now on consent that all Members 

have five legislative days to revise and extend their remarks and 

include extraneous material. Without objection, so ordered, the 

hearing is now adjourned. 

[Whereupon, the Subcommittee was adjourned.] 

Æ 

Leonard.horne on VACREP0180 with DISTILLER