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[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]

           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
       
              
              [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

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

                    U.S. GOVERNMENT PUBLISHING OFFICE
                    
35-387                    WASHINGTON : 2019        
        
        
        
        
        
                     COMMITTEE ON VETERANS' AFFAIRS

                   DAVID P. ROE, Tennessee, Chairman

GUS M. BILIRAKIS, Florida, Vice-     TIM WALZ, Minnesota, Ranking 
    Chairman                             Member
MIKE COFFMAN, Colorado               MARK TAKANO, California
BRAD R. WENSTRUP, Ohio               JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American    ANN M. KUSTER, New Hampshire
    Samoa                            BETO O'ROURKE, Texas
MIKE BOST, Illinois                  KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine                J. LUIS CORREA, California
NEAL DUNN, Florida                   KILILI SABLAN, Northern Mariana 
JODEY ARRINGTON, Texas                   Islands
JOHN RUTHERFORD, Florida             ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana              SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto 
    Rico
                       Jon Towers, Staff Director
                 Ray Kelley, Democratic Staff Director

                         SUBCOMMITTEE ON HEALTH

                     BRAD WENSTRUP, Ohio, Chairman

GUS BILIRAKIS, Florida               JULIA BROWNLEY, California, 
AMATA RADEWAGEN, American Samoa          Ranking Member
NEAL DUNN, Florida                   MARK TAKANO, California
JOHN RUTHERFORD, Florida             ANN MCLANE KUSTER, New Hampshire
CLAY HIGGINS, Louisiana              BETO O'ROURKE, Texas
JENNIFER GONZALEZ-COLON, Puerto      LUIS CORREA, California
    Rico

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.
                            
                            
                            
                            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.

 
           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 Gonzalez-Colon 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 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 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 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.
    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 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 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 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.
    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.
    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.

                 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 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 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 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 continue 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 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, 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 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, 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.
    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, dermatologist, 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.
    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 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 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 (phonetic) 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.]

                                 [all]
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