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96–127 2015

CHALLENGES IN RURAL AMERICA: 

INFRASTRUCTURE NEEDS AND ACCESS TO CARE 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED THIRTEENTH CONGRESS 

SECOND SESSION 

THURSDAY, AUGUST 14, 2014 

Serial No. 113–84 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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


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COMMITTEE ON VETERANS’ AFFAIRS 

JEFF MILLER, Florida, Chairman 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida, Vice-Chairman 

DAVID P. ROE, Tennessee 

BILL FLORES, Texas 

JEFF DENHAM, California 

JON RUNYAN, New Jersey 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

PAUL COOK, California 

JACKIE WALORSKI, Indiana 

DAVID JOLLY, Florida 

MICHAEL H. MICHAUD, Maine, Ranking 

Minority Member 

CORRINE BROWN, Florida 

MARK TAKANO, California 

JULIA BROWNLEY, California 

DINA TITUS, Nevada 

ANN KIRKPATRICK, Arizona 

RAUL RUIZ, California 

GLORIA NEGRETE MCLEOD, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

TIMOTHY J. WALZ, Minnesota 

JON TOWERS, Staff Director 

NANCY DOLAN, Democratic Staff Director 

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

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

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

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

various electronic formats may introduce unintentional errors or omissions. Such occurrences 

are inherent in the current publication process and should diminish as the process is further 

refined. 


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C O N T E N T S 

Thursday, August 14, 2014 

Page 

Challenges in Rural America: Infrastructure Needs and Access to Care ........... 1 

OPENING STATEMENTS 

Jeff Miller, Chairman .............................................................................................. 1 

Prepared Statement ......................................................................................... 50 

Gus Bilirakis, Vice Chairman ................................................................................. 4 

Kristi Noem, Congresswomen From: South Dakota ............................................. 5 

WITNESSES 

Bryan Brewer, President, Oglala Sioux Tribe ....................................................... 8 

Prepared Statement ......................................................................................... 52 

Tim Jurgens, Commander, American Legion Department of SD ........................ 10 

Prepared Statement ......................................................................................... 55 

Robert Nelson, Veteran ........................................................................................... 12 

Prepared Statement ......................................................................................... 73 

Amanda Campbell, Community Stakeholder ........................................................ 14 

Prepared Statement ......................................................................................... 89 

Patrick Russell, Co-Chair, Hot Springs Safe the VA Committee ........................ 15 

Prepared Statement ......................................................................................... 98 

Larry Zimmerman, Secretary, Department of Veterans’ Affairs, State of SD ... 17 

Prepared Statement ......................................................................................... 116 

Steven Julius M.D., Chief Medical Center and Acting Director, Veterans 

Integrated Service Network 23, VHA, U.S. Department of Veterans’ Affairs 30 

Prepared Statement ......................................................................................... 116 

Accompanied by: 

Stephen DiStasio, Director, VA Black Hills Health Care System, 

Veterans Integrated Service Network 23, VHA, U.S. Department 

of Veterans’ Affairs 


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CHALLENGES IN RURAL AMERICA: INFRASTRUCTURE NEEDS AND ACCESS TO CARE 

Thursday, August 14, 2014 

COMMITTEE ON VETERANS’ AFFAIRS, 

U.S. HOUSE OF REPRESENTATIVES, 

Washington, D.C. 

The committee met, pursuant to notice, at 10:05 a.m., at the 

Mueller Civic Center, 801 South 6th Street, Hot Springs South Dakota, Hon. Jeff Miller [chairman of the committee] presiding. 

Present: Representatives Miller and Bilirakis. 

Also Present: Representatives Noem and Smith. 

OPENING STATEMENT OF CHAIRMAN JEFF MILLER 

The CHAIRMAN. The committee will come to order. 

Before I begin, I’d like to take care of one minor procedural detail. I ask unanimous consent that Congresswoman Kristi Noem 

and Congressman Smith be allowed to sit at the dais today and 

participate in the hearing. Without objection, so ordered. 

Good morning, everybody, and thank you for joining us this 

morning. I am Jeff Miller, Chairman of the House Committee on 

Veterans’ Affairs. I come from the panhandle of Florida where 

thousands live like millions wish they could. 

The CHAIRMAN. I have never been to South Dakota. What a 

beautiful State. Thank you so much for your warm hospitality. It 

is a pleasure to be here with you today. 

I am joined by the vice chairman of the full committee, another 

Floridian, Congress Gus Bilirakis, from the 12th district of Florida 

and, of course, I have already said Congressman Adrian Smith 

from the 3rd district of Nebraska and your Congresswoman and my 

good friend, Kristi Noem, from right here in South Dakota. 

The CHAIRMAN. I think it is important that you know that Kristi 

is known in Washington as a leader, and this field hearing is being 

held today because Kristi asked us to come here and hold this field 

hearing. It is important to note that she has been involved in the 

issue in regard to your facility here in Hot Springs from the very 

beginning, and when it comes to veterans affairs issues, she is not 

shy about coming up to me on the floor and talking about the 

issues that affect her constituents here in South Dakota. 

Earlier this morning, I was able to have a tour of the Hot 

Springs campus so we could see the facility. Firsthand I will tell 

you this—I had not heard about this facility until Kristi brought 

it to my attention several months ago. The first thing I did was go 

to the Internet and start looking at photographs. The photographs 


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do not do it justice. What a beautiful and wonderful historic facility. 

The CHAIRMAN. It is very clear that this community and that facility have a storied past, taking care of those that have worn the 

uniform of this Nation, and it is our hope that some way, somehow 

we will find a way to continue that storied history that is held 

within the walls of that magnificent structure. 

So, again, thanks to you all for being here today. Thank you 

again. Let me say this before we start. If you are able to stand, 

please stand, anybody who has worn the uniform and is a veteran 

of this country. If you cannot stand, just wave to us, but I would 

like to recognize the veterans in this audience today. 

The CHAIRMAN. Thank you very much for your service. Again, we 

are here today to ensure that you receive the quality health care 

in a timely fashion that you have earned by wearing the uniform 

of this country. I know the Black Hills Health Care System, which 

has campuses in Fort Meade and here in Hot Springs, has the 

same desire, and that is to provide you the quality health care that 

you expect and certainly you have earned. 

I just want to give a little background, if I can. In April, you 

know that the House Committee on Veterans’ Affairs was able to 

break open, unfortunately, what is probably one of the largest crises that has ever happened within the Department of Veterans Affairs and maybe even the Federal Government. We found that VA 

employees were actually manipulating wait time schedules. Unfortunately, we have had veterans who have died because of those manipulations. And unfortunately, VA still has a long way to go to 

correct that wrong that was perpetrated on you. 

I have pledged to the new Secretary, Secretary McDonald, that 

our committee will, in fact, work as a partner with him in trying 

to help restore the trust in VA that you would want to have and 

you would expect to have. But I have also told him that we will 

not give them a honeymoon period, if you will, because our oversight continues, oversight of the second largest agency in the Federal Government, over 330,000 employees and a budget of over 

$150 billion a year. 

I think that it is important to understand that the veteran is sacred, not the VA. And that is what I think you would want us as 

Members of the United States Congress both in the House and the 

Senate to feel as we have conducted a very aggressive schedule of 

oversight hearings in the House in particular. You may have 

caught us on Monday evenings for some late night hearings that 

started at about 7:30. Some went to 1 o’clock in the morning trying 

to get VA to come forward and be as transparent as they possibly 

could in trying to get to the bottom of this issue. We wanted them 

to explain to us some of the initiatives that they have undertaken 

to try to fix the backlog that exists out there not only when it 

comes to provision of health care but also the process of disability 

claims and the processing problems that exist there. 

VA will claim that they have cut the backlog in half. To be very 

honest with you, I do not trust those numbers. I would certainly 

expect that there are many of you that would feel the very same 

way. While they may have rushed some things out the door in an 

attempt to cut that number down, what they did was they actually 


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adjudicated some incorrectly and they also sent you into the appeals process which, of course, comes off of their books and does 

not count as a backlog claim, but for you the veteran, it is certainly 

claimed. 

You know that the President signed last week a landmark piece 

of legislation that for the first time I think will change the way 

that VA provides health care. They continue to try to provide it the 

way that they did in the 1950’s and the 1960’s, but things have 

changed. Certainly the younger veterans of today from Iraq and Afghanistan understand that health care is delivered differently. 

Those of you from wars and conflicts prior to that or even in peacetime understand things are delivered in a different way. We have 

got to meld them together if we possibly can. 

We reformed in a very small way a couple of things. Number one, 

we gave VA the ability to hold managers accountable. If they do 

not do the right thing, they should be able to be fired. 

The CHAIRMAN. There are very few people, up until the law was 

signed, that the Secretary could actually fire at will. Now, out of 

the 330,000, we actually have added another 450. That is a first 

step. Accountability is important. 

Transparency is important. VA needs to tell the truth. There is 

no reason that they should hide news, even when it is bad. They 

should bring that news forward so that each and every one of us 

understands what is going on at VA. 

I think thirdly what this bill did was give the ability to look from 

the bottom up within VA, a true look at how VA delivers the services and the benefits that you have earned and from an outside 

perspective, not from within VA. VA is very good at trying to analyze itself and then putting forth the best picture possible that they 

can. This will be done by an independent group or groups over the 

next 9 months. 

I will tell you this. Not one law that Congress creates will change 

the culture within VA. That has to be done within individuals. 

They cannot continue to have a culture of what I call corruption, 

what the White House calls corrosive. Same thing. They have to do 

the right thing in serving the veterans of this country. 

Here in Hot Springs, I know that you have been faced with an 

issue now for a number of years, and we are going to take testimony this morning as to what the community thinks, what the veterans think, and certainly we will hear from VA this morning as 

well. We have heard from VA about the significant issues that they 

have to contend with. But in a community like yours, I will say 

this, that it is important for the community to be involved, and to 

see this many people turn out today is a true blessing for this community and to see the signs in all the local businesses. I have got 

to say thank you to Kristi and her staff and the other members 

that are here today. 

I would also ask unanimous consent before we begin. Both Senators have asked that they have statements entered into the 

record. So without objection, that will be done. 

The CHAIRMAN. You have a Senator who is the chairman of the 

Appropriations Committee that could help you in this issue. You 

should talk to him about it. It is very important. I would think he 


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should be here, if he could, if not today, certainly at another time 

to talk to you about this issue that is so important. 

With that said, I want to recognize the vice chairman of the full 

committee, Mr. Bilirakis, for his opening statement. 

[THE PREPARED STATEMENT OF JEFF MILLER APPEARS IN THE APPENDIX] 

OPENING STATEMENT OF VICE CHAIRMAN GUS BILIRAKIS 

Mr. BILIRAKIS. Thank you, Mr. Chairman. And I will be very 

brief. 

But I do want to thank you, Mr. Chairman, because you are responsible for these reforms. The bill that passed this last month 

came out of our committee. 

And I will tell you this. You have an outstanding Congressperson 

in Kristi Noem. She is so very well respected on both sides of the 

aisle in Washington, DC. And she is fighting for you, particularly 

for our true American heroes, our veterans. 

So I do have a brief statement, Mr. Chairman. 

Thank you, Mr. Chairman, for holding this important field hearing to ensure that VA has the capacity to provide veterans quality 

health care in the VA Black Hills Health Care System. 

I would also like to thank all of the members of the community 

who gather here today to address the concerns and challenges that 

veterans in rural areas face so we can work towards improving 

these issues. I look forward to hearing from local veterans and 

stakeholders in the community on their views, opinions, and concerns on the current VA health care system and how we can better 

provide quality health care for our veterans. That is the bottom 

line. 

And you know, we are U.S. Representatives. We not only represent our district but the entire United States. So we will fight on 

your behalf. 

It is my understanding that many veterans must travel 100 

miles or so to your nearest VA hospital, and once you arrive, you 

are troubled to find that the hospital does not provide the services 

you need. I want to address these issues today so that we can find 

effective solutions to provide for each of our veterans’ unique needs 

and improving a system that can benefit each one of our Nation’s 

true American heroes. South Dakota has a longstanding history of 

health care and support for our veterans, with facilities provided 

for over 107 years. What beautiful facilities they are too. I was very 

impressed with the services you provide here. We must keep them 

here. With the expectation for both rural and highly rural veterans 

to increase, it is imperative that veterans continue to have access 

to these facilities and services. 

I remain hopeful that through our hearing here today we can 

find the right path forward that best suits the needs of our veterans and this community. I look forward to hearing the testimonies, and I thank you very much. What a beautiful place this 

is. Thanks for having us here today. 

I yield back. 

The CHAIRMAN. I now recognize your Congresswoman, Kristi 

Noem, for a brief opening statement as well. Kristi? 


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OPENING STATEMENT OF HON. KRISTI NOEM 

Ms. NOEM. Well, thank you, Mr. Chairman. It is a good day. I 

am glad we are all here, and I am glad to see all of you here as 

well. 

I want to, first of all, thank the chairman for coming and for having this congressional hearing, Representative Bilirakis for coming 

and traveling so far as well, as well as Representative Smith who 

has constituents that are impacted by the proposed closure of this 

facility as well. 

Welcome to the veterans’ town. Hot Springs has always been 

known in South Dakota as the veterans’ town. The entire town 

wraps its arms around our veterans, cares for them, helps heal 

them. It is not just about buildings. It is not just about doctors and 

nurses. It is about coming to a place where everyone loves you, appreciates your service to this Nation, cares for you, and wants you 

to be healed and as well as you ever were at one point in your life. 

The Hot Springs VA Hospital has been slated for closure ever 

since the Department of Veterans Affairs announced a plan to realign the Black Hills Health Care System in 2011. For nearly 3 

years, the tristate delegation has worked together and had a number of serious conversations and also serious reservations regarding 

that plan. 

I am very appreciative of your willingness to hear from the Hot 

Springs community, the veterans who are served from this hospital. We have some of them testifying today. Their perspective 

cannot be left out of this conversation. 

I have been very troubled by the VA’s disregard of stakeholder 

grievances. I am also very concerned about the data that they have 

been using that has justified the hospital’s closure, and I believe 

it is incorrect. I have seen overwhelming evidence of data discrepancies, including a very concerning cost-benefit analysis that was 

conducted last year. Additionally, there appears to be a systematic 

dismantling of services at the hospital. 

[Applause.] 

Ms. NOEM. I believe that the true potential of this hospital has 

not been reached and that the services that our veterans deserve 

must return to Hot Springs immediately. 

[Applause.] 

Ms. NOEM. Late last month, the VA released the findings of an 

audit that the VA conducted of the Black Hills Health Care System. I was very disappointed to see that the Black Hills Health 

Care System had considerably lower marks than other hospitals 

that were in the area and the national average. These numbers are 

unacceptable. I believe that the VA must address those numbers 

and those statistics by bringing services back to Hot Springs and 

ensuring that veterans are receiving the care that they deserve. 

I know that there are many other issues surrounding the Hot 

Springs VA, including the environmental impact statement process, 

the National Environmental Policy Act, or NEPA, compliance, costs 

for mothballing the facility, the restriction of access that Native 

American veterans would face if the Hot Springs facility were 

closed, and the potential for mental health treatment at the facility. 


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I look forward to all of the witnesses and the wisdom and perspective that they will share with us throughout this committee 

hearing. 

I know in South Dakota that many veterans are satisfied with 

the care that they get because we have got good people here in 

South Dakota that grew up here helping to take care of them. We 

are very blessed to have them to care for those who have earned 

the distinction of being called a veteran. However, given recent reports of VA scandals and audit findings, I do not think it is appropriate to move forward with closing a facility that the veterans rely 

on. 

[Applause.] 

Ms. NOEM. So ensuring that this facility is able to continue serving the men and women who have worn America’s uniform is on 

my top priorities. 

I again thank Chairman Miller for holding this critical hearing 

as the community fights to restore the Hot Springs VA facility to 

full service so we can properly serve those veterans who have so 

honored us by serving us. Thank you. 

The CHAIRMAN. I now recognize Congressman Adrian Smith for 

his opening statement. Adrian. 

Mr. SMITH. Thank you, Mr. Chairman. Thank you, Mr. Vice 

Chairman Bilirakis. Thank you to everyone who has shown up here 

today. 

I am grateful to have the opportunity to represent part of Nebraska in the United States House of Representatives and certainly 

representing more specifically the veterans who have so sacrificially served, as well as their families who have supported our veterans along the way as well. 

I want to thank our witnesses here. I appreciate the opportunity 

to work with you along this journey. It has been quite a journey, 

and I am grateful that we can interact so positively and hopefully 

bring about a positive result in standing behind I think not just the 

building, not just individuals one at a time, but perhaps that is the 

case too, but this community, this community of veterans. I have 

to think that the community—and when I say ‘‘community,’’ I actually kind of mean a three-State area, if you will, Mr. Chairman. 

In fact, how many are here today from Nebraska? Do you want 

to raise your hands? 

Mr. SMITH. Very good. 

Maybe even some folks from Wyoming. Any folks from Wyoming 

as well? Okay. There we go. 

Mr. SMITH. We know that there was an official announcement on 

December 12th, 2011 when the VA announced its plans to reduce 

the services at Hot Springs, moving all inpatient services to Rapid 

City. I immediately sent a letter to former Secretary Shinseki expressing disappointment and concern with the proposal. And, of 

course, we know that services have been changing in a less than 

positive fashion even prior to December of 2011. Specifically, I was 

concerned, following this announcement, it would jeopardize access 

to care of thousands of veterans, many of whom reside in the 3rd 

district of Nebraska. 

I have since sent or signed onto seven additional letters regarding this proposal. Reducing services at Hot Springs and requiring 


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many rural veterans from Nebraska to drive upwards of 6 hours 

round trip for care will cause many to not seek or delay seeking 

the services they need. It will put an unnecessary burden on their 

families who help transport and care for them. Rural veterans already find it increasingly difficult to access the care they require. 

Approximately 3.4 million veterans, 41 percent of the total enrolled 

in the VA health care system, live in rural or highly rural areas 

of the country. 

I have appreciated the VA’s cooperation with my and my colleagues’ requests to hold additional meetings and delay any final 

decisions. And I appreciate former Secretary Shinseki agreeing to 

meet with the Save the VA Committee per our request. 

But I remain concerned that this is not enough and the VA has 

not fully and transparently addressed these concerns that we have 

expressed. Reducing services at Hot Springs will reduce services for 

our veterans who have already sacrificed so much. At a time when 

we are working so hard to improve access, increased transparency 

and accountability within the VA and improve the quality of care, 

this proposal simply does not make sense. 

Again, I appreciate the community support here today. I have to 

think that community support and accountability like this would 

prevent other problems in the VA that we have seen in other parts 

of our country. 

So, again, I want to thank Chairman Miller. Thank you for holding this hearing today and also everyone else who has worked so 

hard to preserve access to care here in Hot Springs, South Dakota. 

Thank you. I yield back. 

The CHAIRMAN. We are going to begin the hearing today with a 

group of witnesses that are already seated at the table, and in just 

a minute, I am going to recognize Kristi to introduce the witnesses 

at the table. 

But before, I would like to give you an idea of how a congressional hearing works. Each person will be given 5 minutes for their 

opening statement. There is a little clock right in front of me. It 

has some lights on it. As long as that green light is on, you are 

good to go. When you get to the yellow light, some people say it 

is a minute. Some people say it is 30 seconds, but understand it 

is kind of time to wrap up. When it gets to red, that means, obviously, time is up. When it starts blinking, I have no idea what is 

going to happen. 

[Laughter.] 

The CHAIRMAN. Look, if it goes to red and it blinks a little bit 

and you have more to say, don’t you worry about a thing. All right? 

We want to hear from you. 

Can I ask a favor? Do you mind if I take my coat off? Is that 

okay? All right. Guys, if you want to take your coats off—— 

The CHAIRMAN. It is going to get hot. 

Kristi, you are recognized to introduce the folks that are here on 

our first panel. Thank you very much. 

Ms. NOEM. Thank you, Mr. Chairman. I am very proud to have 

the witnesses here today seated at the first panel. 

First to testify will be President Bryan Brewer, who is President 

of the Oglala Sioux Tribe, who represents many veterans. And I appreciate his input throughout this entire process. 


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We also have Commander Tim Jurgens here. He will be speaking 

on behalf of the American Legion, and we appreciate their leadership on this issue as well. 

Mr. Bob Nelson will be speaking as a veteran but also as an integral part of the Save the VA Committee. So I have always appreciated his candid conversations that he has had with me as well. 

Amanda Campbell will speak as well. She has been a very important part of the Save the VA Committee. She has worked through 

the EIS process and lends a lot of information and wisdom to that 

process, and we really appreciate her insight and ability of her to 

testify here today. 

Pat Russell will speak after Amanda. Pat has been a spokesperson for the Save the VA Committee, a very important one that 

has done a very fine job of coming to Washington, DC and articulating the concerns and the facts around the proposal that the VA 

has put forward and how the community feels and what their heart 

is on the issue. 

Last we have Larry Zimmerman who will be speaking as well. 

He is South Dakota’s Secretary of Veterans Affairs, and if there are 

any veterans’ issues going on in South Dakota, Larry’s heart is 

there and he shows up and always gives us his perspective. 

So I would ask that all of you share your thoughts, your hearts, 

and your minds on this proposal and your perspective. It will be 

very beneficial to all of the members here today on the committee, 

and we certainly appreciate you being here. 

The CHAIRMAN. Thank you very much, Kristi. 

And again, all of your written comments will be entered into the 

record as is the custom of our committee. We are grateful that you 

would be here to testify today. 

Mr. President, President Brewer, you are recognized for your 

opening statement. 

STATEMENT OF BRYAN BREWER 

Mr. BREWER. Good morning. [Speaking native language.] My 

name is [speaking native language.] My English name is Bryan 

Brewer, and I am President of the Oglala Sioux Tribe and I represent approximately 40,000 people on our reservation. Today I am 

also speaking for the Sicangu Nation of Rosebud and also the 

Cheyenne River Sioux Tribe. 

I am also a veteran. I served in Vietnam from—I was in the service from 1965 to 1969. I served three tours as a Navy Seabee. I am 

a combat veteran. And I am also a disabled American, and I use 

the facilities here at Hot Springs. I have been using the facilities 

here for over 15 years, and it is something that we all cherish our 

times when we come up here. 

I am aware of the recent concerns nationally regarding the VA 

health care system. You know, most of the health care that I needed—they all have been provided. Everything that I needed I could 

get here. There is a specific care that could not be handled here. 

I was sent to various other places, to Sturgis. I went to Omaha 

once and they flew me to Minneapolis one time. So the care is here. 

We need to utilize it. 

While it maybe seems isolated, it serves veterans beyond South 

Dakota and many from our sister Lakota tribes of the Cheyenne 


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River and Rosebud. Over the years, I have met veterans from Wyoming, Montana, Nebraska, North Dakota, and sometimes beyond 

depending on what services they have come to receive. So this facility is crucial to the veterans in this entire region. 

One of my big concerns is that the numbers of the Lakota veterans—and I seen a letter that was sent to Senator Tim Johnson, 

and our numbers were not included in that, the Lakota veterans. 

As you are aware, there is a current memorandum of understanding between the VA and the Indian Health Service to encourage cooperation and resources between the two departments. While 

this partnership has been shown to work well for our sister tribes 

in other parts of the country, the preference for local American Indian veterans is to get their health care from the Hot Springs VA. 

Here we are consistent with our health care providers, quick responsiveness to our arising health issues, trust in confidentiality in 

our provider and patient exchanges, and for the most part, appointments are timely and prompt. 

As outlined in the 2010 report on IHS by former Senator Byron 

Dorgan, IHS in the Aberdeen area struggles and has a difficult 

time to meet the basic health needs of its patients. The VA recognizes that we as veterans have very unique health care needs and 

works hard to provide services to address those needs. For many 

reasons, IHS is an overwhelmed system and is not equipped to address the very precise and delicate nature and delivery of care that 

veterans require. 

One example of care veterans require is the treatment of post 

traumatic stress disorder. The PTSD treatment center here at the 

Hot Springs VA has the reputation of being one of the best treatment programs in the country. You know, we need to expand this. 

I appreciate the cultural competency and sensitivity of the staff 

and leadership here at the Hot Springs VA. It is one place I can 

come and I feel I am treated the same as my non-Indian counterparts. We are all treated with professionalism. We are all treated 

with dignity and respect. We are all treated as all American veterans. 

Over the years, I have seen many American Indians join the staff 

here. The Hot Springs VA supports and encourages the use of traditional Lakota practices. We are allowed to use a smudge with our 

medicines, sing our prayer songs, and are supported with our inipi, 

our sweat lodge ceremonies. These are conducted by local tribal 

members. The PTSD treatment program has components specifically tailored to the American Indian veterans. And I would like to 

thank Richard Galliani for all that he has done with our Lakota 

patients here. 

Culturally for the Lakota, the Hot Springs area has significance 

in regards to the healing properties and being a place to collect 

some of our traditional Lakota herbs and medicines. Located near 

Hot Springs, Wind Cave is a sacred site to us Lakota. It marks the 

place where we emerged from Mother Earth to the outside world. 

In a recent letter written to newly appointed Secretary Robert 

McDonald, delegates stated in that letter, ‘‘For more than 100 

years, veterans however been coming to Hot Springs to receive 

health care.’’ We can appreciate this historical significance, as our 

ancestors have been coming to the Hot Springs area for thousands 


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of years. For us Lakota, it makes sense that this area with is beauty and healing powers would be where a VA facility would be built. 

To date, there has never been a census of the veterans on our 

reservation. We estimate that there are over 3,500 Oglala Lakota 

veterans on our reservation. And we know that not all these veterans currently utilize the VA. Some are unaware of the services 

that they have a right to access. Locally we have partnered with 

the Disabled American Veterans and the American Legion to help 

inform and recruit veterans to use the VA. Our hope is by increasing the amount of veterans to the VA, revenue to the Hot Springs 

VA and overall area will also increase. 

In conclusion, the Hot Springs VA has a long history, strong cultural ties, and an undeniable commitment to veterans’ health. As 

I sit here today, I think of all the veterans, the warriors, the heroes 

from our communities who passed through the walls of the Hot 

Springs VA. They came here for care, for healing, for camaraderie, 

and some came here for the final days. Closing the VA in Hot 

Springs not only changes the landscape of Hot Springs and western 

South Dakota, it robs veterans of the unique and specialized care 

that have received for decades and should receive for decades to 

come. 

I want to thank all of you. Mr. Miller, Chairman, I really want 

to thank you for coming to South Dakota. Mr. Bilirakis, Mr. Smith, 

and Kristi, I really want to thank you for making this all happen 

today. [Speaking in Native Language.] 

[THE PREPARED STATEMENT OF MR. BREWER APPEARS IN THE APPENDIX] 

The CHAIRMAN. Thank you very much, Mr. President. 

The CHAIRMAN. I wanted to say thank you in Lakota. I tried to 

look it up on my iPhone but I am not even going to try. 

[Laughter.] 

Mr. BREWER. Pilamiya. 

The CHAIRMAN. Thank you. 

Commander Jurgens, you are recognized for 5 minutes. 

STATEMENT OF TIM JURGENS 

Mr. JURGENS. Thank you, Chairman Miller and members of the 

committee. 

Forty one veterans. That is the projected decline in veteran population between now and the year 2020 according to VA’s own data. 

41 veterans. 

With a market penetration 20 percent higher than the national 

average, the Black Hills VA medical service should be championed 

as a model of efficiency, not targeted for dismantling. It is clear 

that veterans in the Black Hills catchment area value the use of 

the VA. Reducing services and making VA treatment options more 

difficult to access violates the agreement our Federal Government 

has made with our Nation’s veterans. 

Chairman Miller and members of the committee, on behalf of our 

National Commander, Dan Dellinger, and the 2.4 million members 

of the American Legion, thank you for holding this important hearing to help the VA and our Government understand how critically 

important it is to maintain the services we have here in Hot 


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Springs and not degrade the services our veterans have relied on 

since 1909. 

Last week, the President signed the VA Health Care Access and 

Accountability Act into law. Our National Commander was present 

at the bill signing, and our national staff worked closely with your 

staff over the course of several months to ensure that the bill addressed the immediate needs of this country’s veterans. As you 

know, that bill contains a provision that mandates VA to release 

veterans from VA-provided care and further burdens the Federal 

Government to absorb the additional expense of contracting that 

same care that the VA is incapable of providing in a timely manner. 

The proposed realignment transfers several services currently offered at Hot Springs to the Rapid City facility while relying on the 

Fall River civilian community facility for additional support at a 

contracted rate. While the American Legion opposes closing the Hot 

Springs hospital anyway, it was interesting and telling that after 

the VA announced this new proposed partnership, the American 

Legion met with the board of directors of the Fall River hospital, 

and as we have noted in our written testimony, no such agreement 

had been worked out and that as of March of this year, they have 

repeatedly asked VA for details regarding any proposed arrangement. But VA never responded. 

Realignment of Hot Springs services will disenfranchise more 

than 4,000 veterans. Rapid City is more than 60 miles one way 

from Hot Springs, which means that the vast majority of veterans 

who have services transferred from Hot Springs to Rapid City will 

immediately qualify for and be issued choice cards and leave the 

VA system. 

The American Legion spends tens of thousands of dollars annually conducting site visits to VA hospitals around the country. Our 

staff and members have hundreds of years of experience working 

with and for VA. Our members rely on us for accurate, meaningful, 

and timely information, which we painstakingly provide. As such, 

the American Legion has presented VA with a list of recommendations that we believe will best support our local veteran community 

and is in the best interest of VA. 

VA should not relocate and/or close medical services until a new 

facility is in place or in order to accommodate the health care needs 

of the veterans in Hot Springs catchment and/or surrounding 

areas. 

VA should maintain the same level of care and/or services and 

provide equal understanding of veterans’ health care needs if contracted to non-VA medical facilities. 

If the VA medical center was to be closed, VA should plan to 

open a super CBOC to provide both primary and specialty care 

services. 

VA should keep the domiciliary on the Hot Springs campus to 

provide long-term extended care to meet veterans’ long-term care 

needs. 

The VAMC should search opportunities to make use of the State 

Veterans Home in Hot Springs. 

Future plans should reflect necessary services that veterans in 

the Hot Springs catchment and surrounding areas need. 


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And finally, without viewing a finalized contract with the local 

hospital in Hot Springs, the American Legion at this time cannot 

ensure reconfiguration of inpatient services will provide the same 

quality care that veterans are currently receiving at Hot Springs. 

Every day in America, 82 people take their own life. That is one 

every 17 and a half minutes. 26 percent of suicides are veterans. 

And yet, only 7 percent make up the population. The stakes could 

not be higher. Any degradation of services for veterans in this area, 

especially services associated with mental health, would be tantamount to reckless endangerment. The mental health of veterans is 

something the American Legion takes very seriously, and we adamantly oppose by resolution eliminating or reducing services to veterans in the Hot Springs area in any way. 

Thank you. Thank you, Mr. Chairman and the members of the 

committee. 

[THE PREPARED STATEMENT OF MR. JURGENS APPEARS IN THE APPENDIX] 

The CHAIRMAN. Thank you, Commander. 

Mr. Nelson, you are now recognized. 

STATEMENT OF ROBERT NELSON 

Mr. NELSON. Chairman Miller, Vice Chairman Bilirakis, Congresswoman Noem, Congressman Smith, welcome and thank you 

for taking the time to come to Hot Springs to hear our concerns 

about the VA’s proposed closure of the Hot Springs VA. 

My name is Bob Nelson. I served 4 years in the Navy and after 

my discharge in 1974, I began working at the Hot Springs VA Medical Center. After 36 years of serving America’s veterans, I retired 

in December of 2012. 

Eighteen years ago, the VA merged two rural VA hospitals into 

the Black Hills Health Care System. That decision has eroded medical services and in many cases eliminated available services and, 

as a result, access to care for veterans wanting to use the Hot 

Springs VA. Some of these veterans travel 150 miles one way from 

rural and highly rural America and from medically under-served 

areas in southwestern South Dakota, northwestern Nebraska, and 

eastern Wyoming. 

The VA insists the current domiciliary in Hot Springs and its associated substance abuse and PTS programs should be moved to 

Rapid City because Rapid City has the largest majority of veterans. 

In fiscal year 2010 and in fiscal year 2011, over 90 percent of the 

domiciliary patients came from locations other than Rapid City. 

From 2008 through 2011, a total of 448 veterans were in a homeless shelter in Rapid City despite an average daily census in the 

Hot Springs domiciliary of only 76 veterans. A daily census that is 

24 veterans under the authorized daily census for the domiciliary. 

The wait times to get into treatment programs in the domiciliary 

grew from 92 days in fiscal year 2010 to 157 days in fiscal year 

2011. If there is a wait time to get into the domiciliary, should it 

not be because the domiciliary is full? 

The cost to have veterans in that—— 

Mr. NELSON. The cost to have veterans in that homeless shelter 

from 2008 through 2013 was $3.3 million. 


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The VA has said publicly Hot Springs averages five hospital inpatients daily, which is insufficient to maintain staff proficiency 

over time and stresses recruitment and retention. The number is 

actually six inpatients, and the VA always neglects to mention the 

four nursing home care unit patients that are also on the same 

ward as the inpatients. The medical staff is not taking care of only 

five patients per day. They are taking care of 10 patients per day, 

twice the number the VA uses publicly. 

The VA’s own internal audit of the Black Hills Health Care System found 14 percent of schedulers at the Black Hills Health Care 

System said they were instructed to change the waiting times after 

a veteran first requested an appointment. 

In December of 2011, the VA’s announcement of the proposed 

Hot Springs closure was seen by many veterans as an attempt to 

marginalizes us. They had reduced us to green dots on a Power 

Point slide. 

In spite of these criticisms, veterans that are still able to use the 

Hot Springs hospital echo what other veterans across the country 

are saying. The quality of care they receive is excellent. The proposed closure of the Hot Springs VA, their access point to health 

care, is what angers them. 

The employees of the Hot Springs VA who work every day under 

difficult circumstances to provide care to America’s veterans are 

victims of friendly fire, wounded by the very administrators entrusted to care for America’s veterans. 

Chairman Miller, on behalf of the veterans who want to continue 

to use the Hot Springs VA, we need your committee’s help. This 

has never been a proposal by the VA. The VA is moving forward 

with their plan. Without congressional intervention, the VA will 

likely close the Hot Springs hospital. Local management for 2 and 

a half years has repeatedly heard from the veterans that use the 

Hot Springs hospital, and the VA continues to turn a deaf ear to 

those veterans’ concerns. Black Hills management is either unable 

or unwilling to stand up for the veterans they are charged to serve. 

Maybe they just do not know how. 

It is time to follow the lead of the national American Legion and 

call for a change in the current management of the Hot Springs 

VA. Veterans who want to continue to receive their care at Hot 

Springs and Hot Springs employees deserve better than an administration that has taken what was once a fully functional hospital 

and reduced it to little more than a transfer station to other hospitals. 

Mr. NELSON. Veterans who depend on Hot Springs VA for their 

care deserve administrators who understand the needs of rural veterans. 

And finally, Chairman Miller, Save the VA is asking you to support South Dakota’s congressional delegation to have Secretary 

McDonald personally visit the Hot Springs VA. The first facility in 

the VA system to provide medical care for our country’s veterans, 

Hot Springs is the granddaddy in the VA system, and we are proud 

to say also a national landmark. 

This concludes my oral testimony. Again, thank you for the opportunity to speak to you today. I will be happy to answer any 

questions you may have. 


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[THE PREPARED STATEMENT OF MR. NELSON APPEARS IN THE AP- PENDIX] 

The CHAIRMAN. Thank you, Mr. Nelson. 

Ms. Campbell, you are recognized. 

STATEMENT OF AMANDA CAMPBELL 

Ms. CAMPBELL. Good morning and thank you. Welcome to Hot 

Springs and thank you for coming. 

We have said in the past that what has happened to the Hot 

Springs VA is a local example of a national problem. A toxic cocktail of four things has brought us to this current point: negligent 

management lacking integrity, poor and manipulated data, bad decisions based on that poor data, and agency inertia. 

We have recently seen a change in Washington, DC with the removal of Dr. Petzel and Secretary Shinseki. 

Ms. CAMPBELL. In his final remarks, the Secretary said that the 

problems that this agency faced can be fixed. I believe that to be 

true 100 percent. We are hopeful and we are anxious to see how 

the new VA leadership in DC continues to heal this broken system. 

I ask you folks to hold onto your hats because I am going to say 

something that you probably never heard before. What has happened in DC in the last few months is exactly what needs to happen in the Black Hills. 

Ms. CAMPBELL. We are calling for the immediate removal of the 

Black Hills VA Health Care System Director. 

Ms. CAMPBELL. We are calling for the implementation of a leadership with national support for that leadership that does not reduce the National Environmental Policy Act to a predetermined 

process and an exercise in box-checking. 

We are calling for a leadership that does not violate the National 

Historic Preservation Act by neglecting to consult with the Advisory Council on Historic Preservation, the South Dakota State Historic Preservation Office, or the Tribal historic preservation officers. 

In 2010 and in 2011, the VA made the following statements. 

Number one, the Hot Springs facility is in poor physical condition. 

Number two, the Hot Springs facility has outlived its useful life. 

Number three, the Hot Springs facility is not ADA compliant. 

Number four, rehabilitating an old facility to meet historic preservation standards is too costly. 

And last but not least, quality care cannot be offered in the historic layout of the Hot Springs facility. 

We are calling for a leadership that does not decide to decommission a national historic landmark, a sacred site, and a national 

treasure with a legacy of care based on an uneducated and an unqualified opinion of two administrative staff and agency inertia. We 

are calling for a leadership that does not make those statements 

without first conducting a valid structural assessment, a feasibility 

study into the rehabilitation of that structure, and an adequate 

consultation with the required partners, and last but not least, a 

common sense discussion about what is best for rural veterans. 

I will tell you that a structural assessment was finally conducted 

by a qualified architectural firm with the experience. The words 


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used to describe that facility were not poor. It was not unuseful. 

The words were excellent condition, very good condition, good condition, constructed of inexpensive and readily available materials, 

and no historic preservation premium should be anticipated. 

We are calling for a leadership that does not manipulate the interpretation of ADA regulations to insist on new costly construction 

versus economical rehabilitation of a facility that is already 100 

percent ADA compliant and has been since the 1970’s in areas 

where the patients receive care and reside. 

We are calling for a leadership that recognizes the outstanding 

level of care offered here because of that legacy of healing over the 

last 107 years and because of the nationally recognized care in that 

existing facility. 

We are calling for leadership that does not violate its own handbook and directive 7545 of the VA handbook. 

We are calling for leadership that does not instill fear of reprisal 

in hundreds of its employees. 

We are calling for leadership that does not employ a real estate 

firm to offer major repurposing options of a national historic landmark without even setting foot onto the campus. Mind you, this is 

the same firm that the VA OIG found to be off by $49 million regarding the consolidation of the Brecksville and the Wade Park facilities—$49 million annually. 

We are calling for a leadership that does not violate five executive orders with its intention to close, one of those being the removing of the access of Native Americans to sacred sites, another being 

the impact on low-income and minority populations, and yet another to consider the location of agency operations within historic 

districts. 

In closing, we have provided you with volumes of data that we 

cannot summarize in 5 minutes, but all of this data points towards 

a restoration of services here in Hot Springs. We are calling for a 

leadership that recognizes the legacy of healing, the potential, the 

advocate community, and rural and therapeutic setting, a healing 

environment, and bottom line, the desires and the needs of our veterans. 

Thank you. 

[THE PREPARED STATEMENT OF MS. CAMPBELL APPEARS IN THE

APPENDIX] 

The CHAIRMAN. Thank you, Ms. Campbell. 

Mr. Russell, you are recognized. 

STATEMENT OF PATRICK RUSSELL 

Mr. RUSSELL. Representative Miller, Representative Bilirakis, 

Representative Noem, Representative Smith, I am Patrick Russell, 

Army veteran, a medical technologist at the Hot Springs VA, President of the American Federation of Government Employees Local 

1539, and co-chair of the Save the VA Committee in Hot Springs. 

On behalf of the Save the VA Committee, I would like to welcome you to Hot Springs, and we appreciate the opportunity to 

share our concerns about the proposal to close the Hot Springs VA 

Medical Center. 

There are many issues that need to be taken into consideration 

on this proposal, but I will limit my oral statements to the loss of 


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services and personnel and the impact to the loyal employees and 

the veterans that we serve. 

Management of the Black Hills Health Care System has systematically been dismantling the Hot Springs VA since 1996. This was 

an observation made by Senator John Thune on January 28, 2013 

in a meeting with Secretary Shinseki, Senators Enzi, Barrasso, 

Johanns, Johnson, and Government Dennis Daugaard and Representative Noem. This systematic dismantling has caused undue 

hardships on the veterans and lowered the morale of the employees 

who have been bearing the brunt of a greater workload. 

Since 1996, we have seen the complete loss of surgery services 

to include orthopedic surgery, colonoscopy, and upper GI endoscopy, cataract surgery, and general surgery and anesthesia services. We have seen the loss of radiologists and fluoroscopy and 

other onsite radiologist-assisted procedures. We have lost our ICU 

unit. The emergency room is now downgraded to urgent care. We 

have lost our cardiac rehab clinic. We have lost the ability to ventilate patients in respiratory distress. We have lost the sleep lab. We 

have lost the pacemaker clinic, nuclear medicine, stress tests, a 

cardiology clinic, and a neurology clinic. The list continues to grow, 

and as these clinics and services are lost, our veterans are forced 

to travel longer distances for services they once received here. 

Many of the veterans we serve come from rural and highly rural 

areas where these services are not available in their local community hospitals and clinics. 

In March of 2004, in a hearing before the Senate Veterans Affairs Committee, the CARES Commission recommended that the 

Hot Springs VA Medical Center retain its current mission to provide acute in patient medical, domiciliary, and outpatient services. 

The commission did not concur with designating this facility as a 

critical access hospital. 

During the recent scoping meetings for the environmental impact 

statements, we heard from veterans in Pine Ridge, South Dakota; 

Chadron, Nebraska; Alliance, Nebraska; and Scottsbluff, Nebraska 

saying they now travel farther for their treatment, and they have 

all commented on the great quality of care they have received from 

the employees at the Hot Springs VA. Closing this facility will further reduce access into the VA system. The veterans we serve will 

be put into longer lines or perhaps waiting lists at VA medical centers where they will be referred. 

In the Black Hills proposal to close this facility, they state that 

they will absorb the 300 Hot Springs employees and nobody will 

lose a job. However, they go on to state that over a 5 to 10 year 

period, they will eliminate 300 positions throughout the system 

through attrition.t a time that the House Veterans’ Affairs Committee is looking at access and waiting times, much of which is attributable to not having enough staff to handle the workload, Black 

Hills management wants to close an access point and reduce the 

staff. This will only make the issues worse. As a taxpayer, I feel 

my taxes will be wasted on building a domiciliary we already have. 

As a veteran receiving care at the Hot Springs VA, I have had to 

travel to Fort Meade to undergo procedures that were once available in Hot Springs. 


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Veterans have paid for their care by service to their country. We 

should not have to beg to retain that care. 

Mr. RUSSELL. But as a representative of the employees who work 

at the Hot Springs VA Medical Center, I see the pain and anguish 

as they are being pushed to their physical, mental, and emotional 

limits by a management that has cut their numbers and limited 

what they can do for the heroes that we serve every day. 

Mr. RUSSELL. The VA’s entire plan does not do justice to the veterans, the taxpayers, or the employees of the Hot Springs VA. 

What our veterans earned we deliver. 

This concludes my oral statement. I thank you for your time and 

willingness to hear our statements. 

[THE PREPARED STATEMENT OF MR. RUSSELL APPEARS IN THE AP- PENDIX] 

The CHAIRMAN. Thank you, Mr. Russell. 

Secretary Zimmerman, you are recognized. 

STATEMENT OF LARRY ZIMMERMAN 

Mr. ZIMMERMAN. Thank you, sir. Good morning, Chairman Miller, Vice Chairman Bilirakis, Representative Noem, and our Representative from the State of Nebraska, and members of the committee. I am pleased to be here today to present our concern for 

the health care challenges faced by veterans in rural America. 

My name is Larry D. Zimmerman. I serve as Governor 

Daugaard’s Secretary of the South Dakota Department of Veterans 

Affairs. Our department is the voice for South Dakota’s 75,000 veterans. I served active duty from 1973 to 1976 in the 4th Infantry 

Division at Ft. Carson, Colorado and served 29 years in the South 

Dakota National Guard, most recently serving as the State Command Sergeant Major. I had the distinct honor to complete a tour 

of duty in Afghanistan in support of Operation Enduring Freedom 

as the Operations Sergeant Major for the nine northern provinces 

in that country. 

South Dakota is fortunate to have three VA health care facilities 

in our State, 12 community-based outpatient clinics, and three vet 

centers. We are fortunate to have 66 county veterans service officers and seven tribal veterans service officers and over 20 service 

organizations that are committed to enhancing the lives of our veterans. 

In 1889, the Grand Army of the Republic secured territorial legislation to construct a veterans home. It is our understanding the 

Dakota Territory was the first of all territories to provide a home 

for their veterans. In 1907, the Battle Mountain Sanitarium opened 

its doors in Hot Springs to focus on short-term medical needs of 

veterans. All through over the years, both facilities have changed 

their names—although they have, the VA Black Hills Health Care 

System and the Michael J. Fitzmaurice State Veterans Home have 

worked together to provide care for the veterans for over 107 years. 

I give you some numbers that reflect the State veterans home 

use of the VA here in Hot Springs in the past year. 

Veterans health care is a critical issue and is important we honor 

the promise to take care of those individuals who secured and protected our freedoms. During a 1-year window, the Michael J. 

Fitzmaurice State Veterans Home transported our heroes to the VA 


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health care facilities here in Hot Springs 1,272 times for urgent 

care, eye care, dental care, dialysis, respiratory care, x-rays, urology, podiatry, and mental health care. In addition, during that 

same 1-year time frame, 40 of our heroes from the home were admitted to acute care at the VA Black Hills Health Care System 

here in Hot Springs, and 108 times for higher level care they were 

transported to Rapid City via the VA. Additionally, thousands of 

veterans drive from other States, tribal lands, and many of South 

Dakota’s most rural areas to receive that medical care here. 

Our heroes deserve the opportunity to enjoy the rest of their lives 

and being assured they will have access to quality health care. 

South Dakota has a strong legacy of taking care of our veterans, 

and we at Michael J. Fitzmaurice State Veterans Home will guarantee that our heroes’ needs will be taken care of no matter what 

the decisions. 

In closing, I appreciate the support that your committee has 

given and to all the issues relating to veterans. I appreciate the invitation to present this information to you and will be pleased to 

answer any questions you may have. 

On a personal note, I just had knee replacement 7 weeks ago at 

our VA facilities in the Hills. The care and giving that those people 

from the VA gave me was outstanding. 

We do have issues. I totally understand that. We need our health 

care facilities. But I want everybody to please remember that the 

representatives and/or employees of these great VA facilities have 

a heart and a mind to take care of our heroes, and they do that 

with every ounce of their ability. They do take care of us. Change 

is not good sometimes. We want to represent the veterans of the 

State. I hope that you as a committee can understand the need and 

see the crowd that represents the veterans of this great State. 

Thank you for your time, Mr. Chairman. 

[THE PREPARED STATEMENT OF MR. ZIMMERMAN APPEARS IN THE

APPENDIX] 

The CHAIRMAN. Thank you very much to all of you for your testimony. 

Before I recognize Kristi for questions, I just want to make one 

quick comment. If there is one single employee that is singled out 

for reprisal for speaking the truth, I hope you will contact me directly because that is not acceptable. The men and women in this 

room fought for the ability for people in this country to speak their 

minds, even if their government disagrees with it, and if that happens, please let me know. 

And with that, Kristi, you are recognized for any questions. 

Ms. NOEM. I wanted to start with Bob. I would like you to expand a little bit. The VA has continuously used demographic data 

to justify the closure of the VA facility. I would like you to expand 

on what the Save the VA Committee has done to refute some of the 

data that VA is currently using and how you arrived at some of the 

numbers that you did and how that is different than what you feel 

the VA system is using to justify closure of this facility here. 

Mr. NELSON. Thank you. After the VA made the announcement 

in 2011, we got together to try to figure out how we are going to 

make some sense of this. Pat is employed there. I am a former employee. There are a lot of folks that were saying this just does not 


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make any sense. So through the Freedom of Information process, 

we started asking all kinds of data of the VA, the number of veterans that were on wait lists for domiciliary, just all the stuff that 

is in my written testimony. And time after time, the Freedom of 

Information requests confirmed what the employees were telling 

us, is that the numbers that the VA is putting out there are to put 

a spin on their proposal. It is my own personal belief that the VA 

did not expect to find themselves in this situation. 

In the summer of 2011, veterans and employees were starting to 

get a sense that something was happening up there that the VA 

was not telling us about. So it is when we approached South Dakota’s congressional offices and started expressing the concerns that 

we need to have somebody look into this. And at the time, South 

Dakota’s congressional offices got on board with us, as they have 

been from 2011, and they asked Secretary Shinseki to come to Hot 

Springs and talk about what was going on. He was not willing to 

do that. So we ended up in Washington. 

But consistently the VA, I think, has tried to defend a decision 

after they made it, and they have done a poor job of doing it because when they go back and they try to scramble and put a spin 

on what the true data is, they just cannot do it. 

Yesterday I gave to your staff, Chairman Miller, a little thumb 

drive that has all of the data that we have collected, the Freedom 

of Information Act requests. So I encourage you to interpret that 

data, have your staff and interpret it on your own. The resolutions 

that have come from the Native American tribes, just all the supporting documents. But what we have found is that consistently everybody that has used that facility disagrees with the presentation—the icing that the VA has put on their proposal. They did 

not expect to have to defend it. 

In so many other cases—New Orleans was a good example that 

we found. They just went through the process. Nobody called them 

on it. We called them on it, and they have been struggling for 2 

and a half years to make sense of it. 

Ms. NOEM. I wanted to follow up with President Brewer. I wanted you to speak a little bit about the veterans that we have currently living on Pine Ridge. And some of the suggestions by the VA 

have been that they could receive care through IHS. Now, you 

know and I know the challenges that IHS faces and how the contract dollars run out so early in the year. But I would like you to 

go into a little bit more detail about how that is not really feasible 

to transfer veteran care over to IHS services because of the lack 

of funds that are there. 

Mr. BREWER. You know, the people on the Pine Ridge reservation—they cannot meet the needs of our people. Our people are 

dying every day. They cannot afford to send them out. They cannot 

afford to pay their bills. They may transfer them out, and yet that 

person will be responsible for paying for their bills. And what happens to the people that are sent out? Their credit is ruined and everything else. IHS—they just cannot do it. They cannot meet the 

needs. They do not have the money. They do not have the facilities. 

Yet, now they are going to make an MOA to take on the 3,500 veterans just from Pine Ridge on. And with our special needs, they 

will never meet them. 


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Kristi, it is not only Pine Ridge, but it is also the other reservations, Rosebud, Cheyenne Eagle Butte. The veterans are going to 

start dying because they are not going to get any services. They 

will not be able to do it. 

And one of the problems is that the VA does not pay its bills. So 

if they do send us someplace, we are going to have a difficult time 

there also. 

Ms. NOEM. Thank you. I have run out of time. We will move on. 

The CHAIRMAN. Mr. Smith, I would like to recognize you for your 

questions. 

Mr. SMITH. Thank you. 

Number one, I appreciate, again, your insight and certainly the 

remarks shared here today. 

Perhaps some of my questions are better suited for our next 

panel, but I do want to point out also that Senator Fischer and 

Senator Johanns have also worked on this issue from Nebraska. 

I am glad that the facility here does not know a State boundary. 

I say that as a Representative on another side of the State line. So 

I say thank you. 

But more specifically here, I guess, Mr. Nelson, as a former employee, looking at the big picture here, how do you feel like perhaps 

a bureaucracy in Washington, DC perhaps unintentionally—there 

is just a big disconnect there. I co-chair the Rural Veterans Caucus, 

this effort that we have in the House to focus on the needs that 

are unique to rural America, rural veterans most specifically. Certainly limiting the services in various facilities or closing or reducing, however anyone wants to call it—how much do you think 

might be an unintentional disconnect, nonetheless a disconnect, between the bureaucracy in Washington and what is really happening here in middle America? 

Mr. NELSON. I am not confident it is an intentional disconnect, 

other than at the cabinet level position, the Secretary’s position. 

Dr. Petzel came from VISN 23. He came from Minneapolis, Sioux 

Falls, Sturgis, Hot Springs. He knows the situation out here. What 

frustrates us in this whole argument and one thing that we have 

tried to not focus on because it would seem to be pitting us against 

foreign aid, but the reality is we are—I say ‘‘we’’—it is tough to 

move away from 36 years of service out there. 

Fort Meade and Hot Springs are part of one system. But in this 

whole presentation, the VA continues talking about Rapid City and 

what needs to happen up there. And they should know their own 

system well enough to know that Fort Meade up around Rapid City 

and Hot Springs serve geographically different areas of veterans. 

The veterans that are in the Rapid City area did not historically 

come to Rapid City for the majority of their care. Prior to the 

CBOC being placed in Rapid City, they went up to Fort Meade. 

The veterans that come to Hot Springs have always come from the 

reservations. They have come from southwestern South Dakota. 

They have come from northwestern Nebraska, your area, your veterans. They have come from Wyoming. 

And in this whole proposal, the VA is willing to sacrifice those 

veterans who have traditionally used Hot Springs in my opinion. 

The VA is going to say we are not sacrificing them. We are going 

to provide them with CBOC’s all over the place, and they can go 


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to private health care. CBOC’s are fine. CBOC’s are necessary. For 

a veteran to travel 150 miles, if you can put a CBOC out there for 

an occasional visit, that is fine. But CBOC’s are doctors’ offices. 

They are open 9:00 to 5:00 Monday through Friday, excluding Government holidays. They should not be a feeder system into private 

health care. 

Mr. SMITH. And perhaps not every day either. Right. 

Mr. NELSON. CBOC’s should not be a feeder system into private 

health care. Veterans have unique medical conditions that they 

need to be taken care of that the private health care does not deal 

with on a daily basis. Folks within the VA system understand how 

to recognize those things that veterans present with. 

So I personally do not think in this particular case that there is 

a disconnect—there was a disconnect at the Washington bureaucracy level other than with Secretary Shinseki. I personally think 

Secretary Shinseki is an honorable man. I think he got lousy advice. His people failed him and they knew better. 

Mr. SMITH. Thank you. 

And perhaps briefly before my time runs out, could you Bob or 

Pat elaborate on the capacity for Hot Springs to be a mental health 

care hub? We know that the needs of veterans are changing over 

time due to various impacts. But can you speak to that? 

Mr. NELSON. Pat, would you like to do that? 

Mr. RUSSELL. I believe that Hot Springs has the capacity to take 

back many of the services that have been discontinued. They currently have lots of room in the domiciliary, and staff have even requested in the PTSD program that they create more cohorts so 

they can get more veterans through the PTSD program. Of course, 

with that, you are going to need staffing. Perhaps they need more 

room. 

But the problem that I have seen is that the VA, rather than creating administrative offices in the domiciliary and patient care 

areas—they should be leasing or buying the historical properties in 

Hot Springs per executive order several years ago that the President said the VA should be utilizing these properties. We have the 

Carnegie Library. We have several other buildings where they 

could be moving places like the call center and telehealth off of the 

hill, creating more rooms for exam rooms or patient care areas. We 

have the capacity. There is room up there if things were done right. 

I feel the biggest problem is in recruitment. We keep hearing 

from our current administration that nobody wants to live in Hot 

Springs and they cannot recruit people. All I know is that in 1995 

this facility had five surgeons. We had two certified nurse anesthetists. We had a complete staff of doctors. There was no problem 

getting a professional to live in Hot Springs. But suddenly we hear 

on the news people from the VA saying that we cannot get anybody 

who wants to live in Hot Springs. I do not believe that. We have 

the capacity, and if things are done right, this could be a very viable medical center providing the care that our veterans earned. 

Mr. SMITH. Thank you. 

The CHAIRMAN. Mr. Bilirakis. 

Mr. BILIRAKIS. Thank you, Mr. Chairman. 

I would like to hear from Mr. Nelson or Mr. Russell or anyone 

else who wants to comment on this particular question. We were 


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visiting the dialysis unit at Hot Springs this morning, and again, 

the patients seemed to be very satisfied. I was very impressed with 

the unit. Where are these patients going to go if they do not have 

family? How are they going to travel to Rapid City or other locations? I mean, what is going to happen to these patients? Can you 

elaborate on that, sir? Why do we not start with Mr. Nelson? 

Mr. NELSON. I am not sure how many years ago, but the Hot 

Springs dialysis unit became the first dialysis unit within the VA 

system to be able to accept Medicare patients. They did that not 

to exclude veterans. And I do not know what the capacity is today, 

but for conversation purposes, let us say that they have a capacity 

of being able to do 20 patients a day, 20 dialysis patients a day. 

As long as the need for veterans are under that 20, if there is extra 

capacity there, 15 veterans need dialysis, then the Hot Springs VA 

can provide care to five Medicare patients. Unique. It does not happen anywhere else in the country. 

So prior to that, those dialysis patients were traveling to Rapid 

City typically, and when you are on dialysis, one of the things that 

I experienced when I was up there is that people walk into dialysis 

or people that see patients walk into dialysis and walk out of dialysis think those people are not very sick. They walked in, they 

walked out. These people are on the fine edge. If they do not get 

their dialysis, they are in trouble quick. So they are not in good 

health. So to ask them to get on the road and travel somewhere 

else and spend 2 and a half to 3 hours in a dialysis treatment and 

then go back home when they are whipped anyway, it is a concern 

we have had all along. We talk about that. Dialysis—it is one of 

the proud things that Black Hills has hung onto. 

But I am not sure where they are going to go, and I do not know 

what all the resources are. Rapid City is the closest. I think if you 

would talk with Dr. Birch I believe is the consultant that comes 

down, I think he will tell you that there is not a lot of extra capacity in this area. And he has always appreciated coming down here. 

So it is a question that troubles us. 

Mr. BILIRAKIS. Mr. Russell, would you like to comment on that? 

Mr. RUSSELL. I am thinking in the original proposal, they were 

talking about establishing a dialysis clinic adjacent to the Fall 

River Hospital. However, but nobody ever talked to the president 

of Fall River Hospital about it. I think another thing they mentioned was putting a dialysis unit up at the State home. I do not 

know if there have been further discussions on that. That is all 

talk. 

All I know is I do not think the veterans are being taken into 

consideration because the other alternative is them either traveling 

more often to get their dialysis or having to relocate to Rapid City 

or someplace that would have dialysis available. It serves a great 

need because the unused capacity is used for Medicare patients 

who are not veterans. So it is a good use of VA resources to help 

recoup some of the costs the VA is expending in maintaining that 

dialysis unit. I do know that the employees up there are very, very 

dedicated to what they do, serving not only the veterans but also 

the Medicare patients that they do see. 

Mr. BILIRAKIS. Thank you. 


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I do not want to take too much time, but Mr. Brewer, can you 

elaborate? I understand that this is a very exceptional, special 

PTSD treatment center at Hot Springs, and I am very interested 

in this issue. What is so unique? Why do veterans travel across 

country to get to Hot Springs for treatment of PTSD? I want to 

know myself, but also tell me what is so unique about this and how 

can we bring even more veterans, expand the services here at Hot 

Springs with regard to PTSD? Thank you. 

Mr. BREWER. I have to say that I have not been through the program yet. Time has not allowed it. My physician has asked me to 

go to it, tried to get me into it, but I have not had the time yet. 

You know, people come from all over the country. I have heard 

of stories where guys have hitchhiked in here, veterans from back 

East, hitchhiked to Hot Springs, South Dakota hoping to get into 

the PTSD program here. It has that reputation of helping and healing people. You cannot cure anyone with PTSD. We know that, but 

they can give you things that will help you, things to do. And I cannot tell you what they do here, but they do a great job. 

And I think it would be nice to visit with some of the staff here 

because it needs to be expanded. I know there is a number of people that want to come through our program. This program here 

should be for our veterans nationwide to be able to travel to Hot 

Springs, South Dakota to get it because it is the best here in Hot 

Springs. 

Mr. BILIRAKIS. Thank you, Mr. Chairman. I yield back. 

The CHAIRMAN. Thank you very much. 

Mr. Nelson, in your testimony, you said overwhelmingly veterans 

have told Black Hills management that they want the Hot Springs 

VA to remain open. Tell me what the reaction has been to you and 

the veterans in this community from the management in regard to 

your pleas and the information that you have provided to them regarding keeping this facility open. 

Mr. NELSON. When I referred to veterans have overwhelmingly 

told them, that has been over the 2 and a half year span. When 

the VA first made the announcement, veterans were telling them 

no, do not do this. They would give their individual stories why 

that would not happen. That has been consistent from the original 

announcement in 2011 to today’s meeting. 

You have seen the turnout that we get when we talk about closing the VA. And what we get from the VA are respectful smiles, 

nodding of the head, and then going about business as usual. They 

have done nothing to indicate to us that they have heard the veterans’ pleas to keep this facility open. What they did was agree to 

enter into—Secretary Shinseki said, well, we will do an EIS process. But there is not anything about that process in the way it was 

presented that leads any of us to believe that there is not a predetermined decision here. What they are doing now they should 

have done 3 to 4 years ago. It should have been a question. The 

EIS process is about a Federal agency saying we think we have a 

problem here. Let us take a look at it and see if we are right and 

then let the public provide input and arrive at a conclusion. The 

VA never did that. 

As I have stated earlier, they made their decision and they will 

not honestly tell anybody what is behind that decision because I do 


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not think they can defend it. They are going to tell you today that 

we have looked at the numbers and it makes sense to do this. 

I provide a lot of data in my written testimony. But I do not 

think we have gotten through to the VA. That is just another example of why you folks are out here. We are grabbing at straws, 

anything we can do to try to keep this facility here. I am not convinced the VA still gets it. 

The CHAIRMAN. Mr. Secretary, you had said in your testimony 

that there had been 1,272 different times that people had been 

transported from the State home. How many patients? Can you 

break it down to individuals? 

Mr. ZIMMERMAN. Yes, sir. We have capacity for 135. We have 52 

skilled nursing care rooms and 48 residential. And that 52/48 is 

what we are building and putting in the new facility. I also have 

a larger residential capacity in one. But that is just that 135 resident and nursing care capacity. And we as a State veteran home 

have a level of care, and so when someone has a heart attack, they 

are brought to the VA, as the VA has levels of care that they have 

to go out of that facility maybe to the Rapid City regional hospital, 

and I mentioned some transports of that. But it is the 114 to 120 

daily census capacity that does those visits, and that is daily appointments and/or high level of care needed, a patient fall or a 

nursing care resident in our dementia unit or something and bring 

him down. So the 1,272 is daily appointments and others. 

The CHAIRMAN. So if this facility were to close, where would 

those residents have to go? 

Mr. ZIMMERMAN. I would have to yield to some of the Save VA 

Committee not to answer but in their answers they have given. It 

is kind of unsure. I mean, right now it would be the Hot Springs 

hospital which we take some of our residents’ spouses to or Rapid 

City, minus there being a facility that we can transport them to 

here in town. 

The CHAIRMAN. Mr. Russell, you said in 1995 things were going 

very well in regard to the number of surgeons and people that were 

employed. Then all of a sudden, something happened. What happened? 

Mr. RUSSELL. There was a shotgun wedding they call a merger, 

a consolidation of Fort Meade and Hot Springs. 1995 our center director was Daniel Marsh and Fort Meade was a separate facility. 

And for 2 years, they had been having discussions about collaboration between Hot Springs and Fort Meade about doing certain 

things to lower the costs, such as if you are going to order supplies, 

let us make it one big order instead of two separate smaller orders. 

What can we do to collaborate working with each other? After 2 

years, they came out and announced the consolidation, the consolidation of Fort Meade and Hot Springs. 

And from that period on, it was not too long after that, the first 

thing we lost was our laundry services. We had a laundry that was 

doing not only the work for our facility but we were doing the laundry for Pine Ridge, Ellsworth Air Force Base, Sioux San Hospital 

up in Rapid City. We were contracting out the services in order to 

help recoup some of the costs for laundry. That was gone. That was 

closed up. Everything was moved up to Fort Meade. 


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And shortly after that, our surgery department became ambulatory surgery only, no more inpatient surgery. And over the last several years, they have gradually eliminated surgeons and programs. 

And as of last April, the last surgeon to leave was the ophthalmologist who would do the eye surgery, cataract surgery. They would 

not renew his contract down here. They renewed his contract at 

Fort Meade, but not in Hot Springs. That was the last surgery we 

had in Hot Springs. 

So 1995, whether it is the cardiac rehab clinic, the radiologists, 

the pathologists, the histology lab, all these things have been taken 

out a brick at a time. They realized in 1995 you cannot wreck that 

facility with a wrecking ball. If you cannot wreck it with a wrecking ball, you take out a brick at a time. Every program is a brick. 

Every employee is a brick. Pretty soon, the wall is so unstable, it 

crumbles. That is that they are doing by reducing the programs 

and services, hoping the wall crumbles and they can close it up. 

The CHAIRMAN. We will do a quick second round of questions if 

the members have them. Kristi, you are recognized. 

Ms. NOEM. Pat, at any point in your conversations with the VA, 

did they indicate to you that they were considering what would be 

best for our veterans’ health care needs? 

Mr. RUSSELL. Using their logic, perhaps. But I do not think they 

are listening to the veterans themselves. 

Mr. RUSSELL. The original announcement was made down here 

on December 12th, 2011, and that week there were meetings in 

Rapid City and Kyle, Pine Ridge, Chadron, Scottsbluff, Alliance, 

and overwhelmingly, from the very beginning, veterans were saying we do not want to go to the local community hospital. There 

was a veteran in Scottsbluff that stood up and said we will not go 

to that hospital because they will kill us there. I want to go to the 

Hot Springs VA. 

Mr. RUSSELL. And on April 12th, 2012, Representative Noem, 

Senator Johnson, and Senator Thune were at the American Legion 

here in Hot Springs, standing room only. People were standing outside the doors on a Thursday morning for a 1-hour meeting. And 

they expressed their opinions. People talked. Veterans came to the 

mike, and not one of them advocated closing down our VA. 

And we have just completed the scoping meetings for the environmental impact statement, and I attended the ones in Pine 

Ridge, Chadron, Alliance, and Scottsbluff. Not one veteran advocated closing the VA. Every one of them said keep it open. We want 

our health care. We do not want to have to drive more. 

I do not think they are listening. It is we have made up our 

mind. We are not going to listen to the data. We have already 

made up our mind and that is what is very troubling to me is that 

they are not listening to the veterans. They are not listening to the 

taxpayers. And by God, I do not think they are listening to our 

Senators or our Representatives either because they feel—— 

Mr. RUSSELL. It appears that being a cabinet Department, they 

are above all of our congressional people that have been elected. 

Ms. NOEM. Well, you are right. I came down here. The announcement was made in December. I came here first February 4th, and 

I told you I would come back with the whole delegation and we did. 

We came back in April. After they continued down the process of 


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continuing to follow through with closure of the facility, the delegation together sent a list of questions to the VA and asked them to 

answer these questions that we specifically were asking of them, 

cost-benefit analysis, consideration of care for veterans, the facility, 

the compliance with ADA requirements, a list of questions. It took 

them 134 days to answer our questions. 134 days. When we finally 

did get the answer, it was not a clear consensus with their data, 

what they were using, compared to what your data, what you were 

using. So I will say absolutely. It has been a very frustrating process. 

We did ask the Secretary to come here as well. He did not. When 

we did finally meet with him, I called his office many, many times. 

Never once received a return phone call from him. I could pick up 

the phone, call the Secretary of Agriculture, and he is on the phone 

30 seconds later, but the Secretary of the VA—cannot get him to 

return a phone call. So I will tell you that has been my frustration 

through the process as well. 

But I want you to talk a little bit today so the committee has a 

full understanding of how they have treated the employees and especially, Pat, I want you to speak about how they offer openings 

for employment, how they offer temporary openings, not permanent 

placement, and then how long the openings exist. I was downtown 

this morning, had a man tell me that he believes one position was 

only open for 8 hours and closed again, and they said they could 

not find any applicants. Well, it was only open for 8 hours. 

So I would like you to speak to that because I think it shows 

some of the process where they justify not being able to find somebody to live in Hot Springs, how they conducted that led to the result of not getting people who could fill those positions. 

Mr. RUSSELL. Thank you for asking that question because it is 

somewhat of a game they play. When they talk about not being 

able to recruit people to work in Hot Springs, they will open up a 

nursing position and they will open it up as a temporary job not 

to exceed 2 years. Not many people, especially if they have families, are going to relocate for a temporary position that may not be 

there in 2 years. 

The other example. We had a medical technology position that 

was open up in the laboratory. The announcement was open for 8 

hours and closed. The vacancy is still there. It still has not been 

filled. 

They are creating new position descriptions of jobs. It is inconceivable. They have recently created four positions for medical technologists in the Black Hills Health Care System, but as a requirement for that job, you may be working at Fort Meade one day, you 

may be working at Hot Springs the following day. You do not know 

where you are going to work. The travel—I do not know whether 

that would be on company time or a company car, but part of that 

would be pulling call in Hot Springs. So if you have a person from 

Sturgis that accepted the job thinking they are working at Fort 

Meade and they say you are going to work now in Hot Springs and 

you are pulling call, where do you stay for call? They do not have 

anyplace for them to stay. They will have to rent a hotel room. So 

the requirements they are putting out for these jobs are totally unrealistic. 


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And besides that, problems I see having employees driving back 

and forth between Fort Meade and Hot Springs. You are talking 

about an hour and a half one way, 3 hours for a total day. That 

is windshield time. You are not behind the bench. You are not producing results. What measurable workload have you done by commuting back and forth? It is a waste of taxpayer money. It is a 

waste of professional time. 

The jobs that are being eliminated—they are telling other employees just work harder—work smarter not harder. We have been 

hearing that since 1995, and that is why in my statement I said 

that the people are physically, mentally, and emotionally drained 

and exhausted because they have been working harder. 

The CHAIRMAN. Mr. Smith, any more questions? 

Mr. SMITH. Yes. 

President Brewer, you mentioned briefly that the VA does not 

pay its bills. Could you elaborate on that? 

Mr. BREWER. I am very concerned that they do not. They do not 

pay their bills on time. And I am very concerned that if we are sent 

to a facility and that facility is aware—and they probably are—that 

the VA does not pay its bills in a timely manner, we are going to 

be put on the bottom of the list. We are not going to become a priority. So this is a big concern for us. 

Mr. SMITH. You mentioned, I think, the population that you represent is about 41,000. How many veterans would you say are in 

that population? 

Mr. BREWER. On our reservation, we estimate we have over 3,500 

veterans alone in Pine Ridge. That is not counting Rosebud or 

Cheyenne Eagle Butte. 

Mr. SMITH. Any rough estimate what those other reservations 

and tribes would—— 

Mr. BREWER. Less than Pine Ridge. Pine Ridge is the largest. I 

do not have those figures with me. 

Mr. SMITH. Thank you. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Mr. Bilirakis. 

Mr. BILIRAKIS. Thank you, Mr. Chairman. I appreciate it. 

Just one question for Ms. Campbell. In your testimony, you state 

that the DoD conducted a study released in February of 2013. The 

report supported the fact that rehabilitation of masonry buildings 

constructed prior to World War II is more cost-effective as opposed 

to new construction options. Are you aware of the costs to update 

the Hot Springs facility? And do they fall in line with this study’s 

conclusions? 

Ms. CAMPBELL. Bottom line—we do not know a bottom line figure 

mainly because the VA has neglected—despite the fact that they 

have moved forward with their planned decommission, they have 

not conducted a feasibility study to determine if, indeed, it is feasible to rehabilitate the facility. Based on past projections, based on 

past estimates, construction estimates and rehabilitation estimates, 

at the VA, the VA at Hot Springs specifically, I think we tossed 

around a number of right around $20 million to bring the facility 

into 100 percent full compliance and a variety of other issues and 

elements. 


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The report about the masonry structures, about how easy those 

are to rehabilitate fall directly in line with reports from the National Trust for Historic Preservation, also from the Tenor report 

and a variety of others that say that it is 10 times easier and significantly more cost-effective to rehabilitate historic structures, as 

directed by several Federal regulations, than it is for new construction. 

Another cost that we did not talk about that has not been considered is the cost of mothballing a national historic landmark. I believe—and this is data that has been rattling around in my mind 

for quite a while, but I believe we were looking at a figure of about 

$128 million over the course of several years it would require to 

abandon and mothball a national historic landmark. That would be 

money that would be mandatory and required in conjunction with 

new construction and staffing and filling those new buildings. 

Mr. BILIRAKIS. Thank you very much. 

Would anyone else on the panel—— 

Mr. BILIRAKIS. Can you please elaborate on this issue? Thank 

you. 

Mr. NELSON. Yes. I would just like to add to what Amanda has 

said. The frustration with this whole thing—and she has referred 

to the Treanor report. The Treanor report shreds everything that 

the VA has said about what is not possible with that facility. As 

she alluded to earlier in one of her comments, the firm that the VA 

has based their numbers on never even stepped site on the VA here 

to make the assessment. That company used data that was provided to them by the VA. 

Thanks to Representative Noem, Senator Johnson, and Senator 

Thune pressing Secretary Shinseki about coming to Hot Springs. 

When he declined to do that, what he did is he said what I am 

going to do is I am going to instruct the VISN 23 in Black Hills 

to sit down with Save the VA folks, congressional staff, the veterans service officers—I talked a little bit about that in my written 

testimony—to figure out where do we disagree. And it became apparent very quickly that, again, the VA was working with their 

own data that I do not think they understood. So we pressed them 

to have a historic preservation specialist come in and assess that 

property. That is the result of the Treanor report. 

And what he talks about in there is that until the VA comes out 

with how they would redesign the buildings there, what they would 

want, what kind of medical facilities, it is very tough to come up 

with an estimate of what it is going to take to do it. 

So for us, it is just another example of if the VA was sincere in 

wanting to honestly look at this and see if they had made the right 

decision, they would not have resisted coming up with alternate 

plans. They should have gone back to an architect and said, okay, 

here is how we think it would look if we do not abandon the facility. Just another example of that is not the direction they want to 

go, so that is not what they are going to do. They want out of Hot 

Springs. 

Mr. BILIRAKIS. Thank you so much. Appreciate it. 

The CHAIRMAN. Thank you, Mr. Bilirakis. 

Mr. President, it has been said a couple of times that there is a 

zero number for veterans on Pine Ridge, that VA does not include 


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those numbers. Could you explain to me if there are no veterans 

on Pine Ridge, why you just opened a veterans cemetery there in 

July? 

[Laughter and applause.] 

Mr. BREWER. We have a very beautiful cemetery now, and I 

would like to thank the Veterans Administration for that. I would 

like to invite all of you to come see it sometime. It is very beautiful. 

But, yes, a good question. And if they close up Hot Springs, we 

will probably be filling it up pretty fast too. 

[Applause.] 

The CHAIRMAN. Mr. President, Kristi will tell you that that was 

one of the places that I desperately wanted to visit while I was 

here, and unfortunately, time will not allow it. But after landing 

in Rapid City—and I am not going to stay in Rapid City anymore. 

I am going to come and spend the night in Hot Springs. All right? 

[Applause.] 

The CHAIRMAN. I love old hotels and look forward to coming 

back. 

But let me also say, Ms. Campbell, your $20 million number may 

be right, may not be right. We do not know. But it is the only number that we have to deal with. And I just would make this closing 

comment to you. 

We are spending $60 million to restore the dome on the United 

States Capitol Building. Now, it needs to be done. It really does. 

It needs to be done. But it is a historic landmark. And so is this 

facility. 

[Applause.] 

The CHAIRMAN. In the bill that was signed by the President last 

week that was passed jointly by the House and the Senate in the 

conference committee, we appropriated $5 billion, with a B, and 

within that $5 billion, there is an allocation for minor construction 

and also delayed care on facilities. So there is money that is now 

available for VA, should they choose to use it. The fact that they 

will say that there is no money does not hold water because it is 

available. 

I just want to say thank you. I wish we had a little more time 

for another round of questions, but we have a second round of panelists that have come here to speak today. I just want to say from 

the bottom of my heart thank you for fighting so hard to save not 

only the history of this town, but some of the history of the United 

States of America. We appreciate your fight. Thank you. 

[Applause.] 

The CHAIRMAN. And with that, we will excuse the first panel and 

say thank you very much for being here. 

We will call the second panel to come forward. 

And I want to ask a favor of everybody, if you would. Everybody 

in this room that wore the uniform of this country wore it to allow 

other people to speak, even when you may disagree with what they 

have to say. So I would beg your indulgence as to the two gentlemen that are here today speak. We are here to get information 

from them. We will continue to press for answers to questions that 

have not been answered. But again, I would ask that you treat 

them with the same respect that you treated the first panel beVerDate Aug 31 2005 14:33 Nov 04, 2015 Jkt 000000 PO 00000 Frm 00033 Fmt 6633 Sfmt 6633 Y:\96-127.TXT PAT

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cause they are here representing the Department of Veterans Affairs. 

So, again, joining us from the Department is Dr. Steven Julius, 

Acting Network Director and Chief Medical Officer for Veterans Integrated Service Network 23. He is accompanied by Stephen 

DiStasio, Director of the VA Black Hills Health Care System. I appreciate them being here today. 

Dr. Julius, you are recognized for your opening statement. Thank 

you, sir. 

STATEMENT OF STEVEN JULIUS 

Dr. JULIUS. Thank you, Chairman Miller. Good morning—or I 

guess in a couple minutes it is good afternoon—Chairman Miller, 

Congressman Bilirakis, Congressman Smith, and Congresswoman 

Noem. Thank you for the opportunity to discuss the VA Black Hills 

Health Care System’s commitment to providing veterans high quality, patient-centered care and to address rural health care and access to care. 

I am accompanied today by Mr. Stephen DiStasio, Director of the 

VA Black Hills Health Care System. 

VA Black Hills provides primary and specialty medicine, extended care and rehabilitation services, surgical and mental health 

services, as well as residential rehabilitation treatment programs. 

VA Black Hills consists of two medical centers located at Hot 

Springs and Fort Meade, South Dakota, and VA-staffed community-based outpatient clinics located in Rapid City and Pine Ridge, 

South Dakota and Newcastle, Wyoming. In addition, six contract 

CBOC’s are located in South Dakota and two are located in Nebraska. 

In fiscal year 2013, there were approximately 35,000 total veterans within the VA Black Hills service area. Of the approximately 

35,000, approximately 21,000 were enrolled for health care services, and 19,207 of the enrolled unique veterans were served. This 

reflects an enrolled penetration rate of 60 percent in fiscal year 

2013, one of the highest in VHA. 

The Hot Springs and Fort Meade campuses are particularly noteworthy as sites of historical significance. Hot Springs is the Battle 

Mountain Sanitarium National Historic Landmark with a proud 

history of caring for veterans extending back to the early 1900’s. 

The Fort Meade cavalry post is known for its substantial military 

presence, extending back to the 1880’s. We understand the significance of these sites and we appreciate the rich history they bring 

to the community. 

Maintaining and improving the aging buildings, ranging from 40 

to over 100 years old, significantly increases the cost of operation 

at both facilities. Existing operating rooms at both hospitals are 

reaching 40 years of age. The current residential rehabilitation 

treatment program building at Hot Springs is over 100 years old, 

and the structure is not compliant with the Architectural Barriers 

Act. For these and other reasons, VA Black Hills has the highest 

costs per unique patient of all VISN 23 facilities and one of the 

highest in all of VHA. 

VA Black Hills is committed to meeting veterans’ needs in western South Dakota, Nebraska, Wyoming, and North Dakota. We 


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have conducted a review of the services provided and the Department has determined that improvements and reconfigurations to 

VA Black Hills operations are needed to maintain the safety and 

quality of care it provides. We believe this will increase the scope 

of services available to veterans closer to their homes while being 

good stewards of public funds. 

VHA is concerned about its ability to preserve the quality and 

safety of care at Hot Springs, given that the volume of inpatient 

activity is so low. In these circumstances, it is difficult to recruit 

and retain skilled providers, as well as maintain their competencies. Surgical procedures at Hot Springs have been curtailed 

due to an inability to recruit and retain surgeons and anesthesia 

providers. In addition, all of the hospitalists and after-hours physicians are temporary staff hired on contract to fill staffing needs. 

The most significant changes proposed by the Department involve replacing the current medical center in Hot Springs with a 

new community-based outpatient clinic and relocating the residential rehabilitation treatment program to Rapid City, South Dakota. 

The overall goal of the reconfiguration is to realign services and resources to provide safe, high quality, accessible, and cost-effective 

care closer to where veterans live. 

To be transparent and make optimal decisions regarding veteran 

care, VA has openly shared access and quality data with stakeholders. VA Black Hills sites of care are insufficient to provide 

ready access to care to all veterans within the large, highly rural 

service area. The limited availability of specialists is also a barrier, 

requiring some veterans to travel to VA sites in Minneapolis or 

Omaha for needed specialty care. The recruitment and retention of 

physicians, nurses, and other health care providers has also been 

difficult with physician specialists particularly problematic. 

VA Black Hills has addressed these challenges by expanding the 

use of non-VA care to provide access to services locally and shorten 

waiting times. Major benefits for veterans and their families have 

been the reduction of travel to VA tertiary care sites and of outof-pocket travel expenses, as well as the opportunity to be close to 

home and receiving medical care. VA Black Hills has also steadily 

increased the utilization of telehealth services. Through the end of 

fiscal year 2014’s third quarter, over 1,100 clinical video telehealth 

encounters have been completed. 

In conclusion, the VA Black Hills Health Care System, in conjunction with health care providers throughout its service area, is 

committed to providing high quality care and services for our veterans. Our location in a highly rural landscape presents VA with 

some challenges, the most significant of which is the ability to recruit and retain highly skilled physicians and nurses. Despite these 

challenges, we continue to focus on improving veterans’ access to 

care. 

We sincerely appreciate the opportunity today to appear before 

this distinguished panel to share with you the great service that 

the VA Black Hills Health Care System provides to our Nation’s 

heroes every day. 

We are pleased to respond to any questions or comments you 

may have. 


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[THE PREPARED STATEMENT OF DR. JULIUS APPEARS IN THE AP- PENDIX] 

The CHAIRMAN. Thank you very much, Doctor. 

Kristi, you are recognized for opening questions. 

Ms. NOEM. You spoke specifically just now about the Hot Springs 

facility being the highest cost operating facility within VISN 23. Is 

that correct? 

Dr. JULIUS. That is correct. 

Ms. NOEM. Can tell me how you evaluated that cost? 

Dr. JULIUS. Well, it has to do with the total cost per unique patient. 

Ms. NOEM. Per patient. Okay. Just hold on there 1 second. 

So when you remove services, do you remove the ability to service patients? If you are offering less services at a facility, these patients then have to go to other facilities to get treatment if they 

needed service. Is that correct? 

Dr. JULIUS. That is correct. 

Ms. NOEM. So after you have removed services the past several 

years, when did you evaluate the cost of running the facility and 

the number of patients that are served? What date did you run the 

cost of that? 

Dr. JULIUS. The high cost per patient for VA Black Hills as an 

entire system—— 

Ms. NOEM. Well, I am concerned specifically about how you evaluated that the Hot Springs facility was the highest cost operating 

facility within VISN 23. 

Dr. JULIUS. If I said that, that was incorrect. The VA Black Hills 

Health Care System—— 

Ms. NOEM. As a whole is the highest cost. 

Dr. JULIUS. As a whole. 

Ms. NOEM. So you are not laying the blame on the Hot Springs 

facility, that this facility for some reason is the anchor that is dragging down the rest of the system? 

Dr. JULIUS. No. There are challenges in a highly rural environment for all VA healthcare. So Fort Meade shares some of that as 

well. 

Ms. NOEM. Thank you for that clarification. That is what I was 

concerned about is that you were evaluating the cost based on per 

patient served at the facility, which I do not think is a fair assessment considering the services that have been removed from there. 

Obviously, patients are going to have to go get treated somewhere 

else, and it would obviously increase the cost per patient served. 

Other questions that I have for you is tell me why you do not 

offer permanent positions to employees at the Hot Springs facility. 

You said in your statement that you were offering temporary ones. 

Why do you not open it up for permanent positions? 

Dr. JULIUS. I am not aware of that. I would refer that to Mr. 

DiStasio. I am not aware that I mentioned in the statement—— 

Ms. NOEM. Well, you talked about people that were employed at 

Hot Springs and that there were some temporary positions that 

were employed at a certain time. It was in your statement. I could 

look it up for you too, if you do not remember. 

[Applause.] 

Ms. NOEM But you talked about—— 


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Dr. JULIUS. No. I think—— 

Ms. NOEM [continuing]. Temporary positions. Tell me about your 

hiring processes. Maybe that would be—for over the last 5 years 

your hiring processes. 

Dr. JULIUS. To answer your question specifically, we were talking 

about the after-hours physicians, locum tenens providers. VA Black 

Hills for a long time has been attempting to recruit permanent positions for those people, the hospitalists that we have in the hospital, the people who are there after hours. Due to an inability to 

do that, we have had to rely on what are called locum tenens physicians, or contracted physicians, temporary physicians, that are 

hired and come in for the weekend or for a week to cover the hospital. 

Ms. NOEM. So tell me what your ideal hiring process would look 

like. How do you traditionally—if you were to fill positions, how 

long would the job position be open? How would you advertise? So 

that everybody is aware what the normal process is. 

Dr. JULIUS. Well, typically we would post an opening saying that 

we have an opening for a hospitalist, for a critical care physician, 

for a surgeon. We would publish it in various places in which doctors view that. It would be open. We would be asking for resumes. 

People would submit them. We would look at them. We would 

interview them if we felt it was appropriate and hire them as permanent staff. That would be the ideal goal, and that is what we 

have tried to do all along. That leads to a stable medical staff in 

which you can be assured of the quality of the care that you are 

getting rather than the situation where you have new doctors coming in all the time, which also may be qualified but you do not 

know. 

Ms. NOEM. And you followed that process here in Hot Springs at 

this facility within the last several years. You have gone through 

that entire process you just laid out. 

Dr. JULIUS. As far as I know we have. I will defer to Mr. DiStasio 

if he knows differently. 

Ms. NOEM. There is some discrepancy in that. We have had Save 

the VA Committee members that have come to us and told us it 

has been very different. So I would love to have you, Mr. DiStasio, 

talk a little bit about the hiring processes and tell me if you disagree with them. Do you disagree with them in what has happened 

here at Hot Springs in how vacant positions have been filled and 

if permanent positions have been offered? 

Mr. DISTASIO. Just to add to Dr. Julius’ comment about providers, he described very accurately what we call a continuous and 

open announcement for physicians, and that is across the entire 

system. And the fact that we are using locum tenens is a commitment to keep the services open. 

There are, indeed, within the system some positions that are advertised as permanent and some that are temporary. We make 

management decisions every day about how are we going to structure the workforce, where do we need in fact temporary help because we perhaps have an employee who is out for an extended illness, if you will. 

I did listen carefully, as there were some descriptions and I believe you used the example of 8 days or 8 hours. I encourage people 


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to bring those to my personal attention, and if they bring it to 

yours, please share it with me. I would like to understand—— 

Ms. NOEM. Well, I heard it this morning and that is why I 

brought it to you today at the hearing. 

Mr. DISTASIO. I cannot say that is true in my system. I would 

share that we have about 140 positions at any time in some sort 

of phase of recruitment. We share that with our union partners so 

that they see the same information. And it is a way of making a 

partnership because we are all responsible for recruiting. 

Ms. NOEM. Has a permanent position been offered at this facility 

in the last 2 years? 

Mr. DISTASIO. Yes, ma’am. 

Ms. NOEM. All right. I am out of time. I will have more questions 

later. 

The CHAIRMAN. Mr. Smith. 

Mr. SMITH. Thank you, Mr. Chairman. 

And to our panel, I realize you are probably messengers here 

today. I imagine you might find parts of your job frustrating. But 

we are at a position here that I know has frustrated many. Can 

you tell me, as briefly as you can, what kind of veteran input you 

gathered from affected veterans that would lead to the December 

2012 decision? 

Dr. JULIUS. The input that we got was—it was not a decision. It 

was basically a proposal. Obviously, administrators within VA, hospital administrators we have are always looking at the future and 

need to do due diligence as far as planning, planning for changes 

as far as the demographics, planning for changes in availability of 

services, those things. And so as part of this ongoing process then, 

the initial suggested proposal came out in December of 2011. 

We were instructed by the Secretary at the time, after it had already been discussed with the Secretary, that we needed to and 

wanted to—and we did—held multiple town hall meetings which 

were discussed earlier by the earlier panel all over the area, starting in Hot Springs and going to Rapid City and going to various 

places. The purpose of those town hall meetings was to get the very 

thing that you are saying, to say this is what VA is thinking. These 

are the problems that we anticipate in the future that we are going 

to have in order to ensure that you have reliable healthcare. This 

is what we are proposing. This is what we have heard. We can see 

that people have to travel a long ways for care. Perhaps this is a 

better solution that we could purchase care. 

Anyway, we presented it. Steve and I went around to—and the 

network director, Jan Murphy, went around to all of these various 

town halls in the different States, presented the proposal and 

asked for feedback. And we got a lot of feedback, as people have 

mentioned before. Most of it was negative but not all of it. 

Mr. SMITH. And I think you can appreciate the dynamics in play 

here today. 

Now, you mentioned that it is difficult to recruit medical professionals. I would say that is not unique to any town, large city in 

America. There are various challenges. I will not get into some of 

the other healthcare distractions we have at the Federal level these 

days. But I will say at least my sense of it is there has been a question about VA commitment to this facility for some years now, even 


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prior to December 2012. And so was that taken into account in 

terms of evaluating the difficulty of recruiting various professionals, providers? 

Dr. JULIUS. I missed your question. The fact that there appeared 

to lack of support for—— 

Mr. SMITH. Lack of commitment to the facility by the VA in general. I mean, there is a list here of discontinued clinical services beginning in 1996. Now, was that ever taken into account in terms 

of—I do not want to get ahead of myself here. But I would think 

if there were a decision made by the VA that would outline the 

commitment that the VA would make to this facility, if that were 

definitively announced, would it not lead to perhaps a better position to recruiting professionals? 

Dr. JULIUS. Oh, I think absolutely. 

Dr. JULIUS. I would comment, yes, I think absolutely. I think the 

uncertainty and the lengthy uncertainty of the process that has 

gone on now for this many years without a decision has definitely 

adversely affected our ability to recruit to Hot Springs. If you are 

a young professional and realize that the situation that you are 

coming to might change in the future, you are going to be more reluctant. So I would agree. 

Mr. SMITH. Now, in terms of reimbursement, we heard concerns 

about delayed reimbursement to non-VA facilities. Would you say 

that that is a concern? 

Dr. JULIUS. I am not aware that it is. I certainly trust what 

President Brewer was saying. We track that now. That has been 

a problem in VA that has been an irritant to the former Secretary 

about why VA does not pay its bills, and so we have been tracking 

payment for non-VA care. We want to get 90 percent of it paid 

within 30 days. Black Hills Health Care System, the last time that 

I checked, was paying 89 and a certain percentage, so almost 90 

percent within the required goal of 30 days. 

Mr. SMITH. Let us talk about reimbursement—oh, my time has 

expired. 

The CHAIRMAN. We will come back. 

Mr. Bilirakis. 

Mr. BILIRAKIS. Thank you, Mr. Chairman. 

Dr. Julius, what are the current primary specialty and 

healthcare wait times for, let us say, mental healthcare as well, 

wait times for veterans within the VA Black Hills Health Care System service area? Currently. 

Dr. JULIUS. I would like to allow Mr. DiStasio to answer for his 

facility. 

Mr. DISTASIO. Thank you for the question. 

For actual wait times—and this is to completion of appointment—in primary care in June, which is the last released data that 

we have, it is about 17 days for a new patient—excuse me—primary care patient. For an established primary care patient, it is 

about 3 days. 

Mr. BILIRAKIS. Can you say that again? 

Mr. DISTASIO. I’d be glad to repeat that. Thank you. 

For a new primary care patient, it is about 17 days. 

The CHAIRMAN. Will the gentleman yield? 

Mr. BILIRAKIS. Yes. 


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The CHAIRMAN. I heard this for the first time in Roswell, New 

Mexico last weekend that there is a new metric now that VA is 

using. It is called prospective primary care patient. Why did you 

change the measurement? All we want to know is how long does 

it take a patient to receive an appointment and get their primary 

care taken care of. After all of this stuff that hit the fan, somebody 

somewhere has come up with a new metric to measure by. Why? 

Wait, wait, wait, wait. 

The CHAIRMAN. And I promise you that it did not come from the 

Black Hills Health Care System. It came down from the mountain 

in Washington. Why? 

Mr. DISTASIO. You know, in my experience as a healthcare leader, one of the things a bureaucracy can do is try to standardize the 

operational definitions of the data they use so that you can make, 

if you will, apples-to-apples comparisons between facilities. 

What I have in front of me is the objective data for the time it 

actually takes us to complete an appointment in primary care, specialty care, and mental health for new and established patients. 

The CHAIRMAN. All right. Established patients. What is that 

number? What is that number? 

Mr. DISTASIO. The number for primary care is about 3 days. 

The CHAIRMAN. All right. Ladies and gentlemen, turn around 

and watch this. Anybody in here get your primary care appointment within 3 days? 

[Chorus of noes.] 

The CHAIRMAN. One hand. One hand. I just do not get it. Your 

numbers still do not add up. I yield back. 

Mr. BILIRAKIS. I will go ahead and take the next question in the 

second round. I will yield to Ms. Noem or the chairman. 

The CHAIRMAN. You are yielding to me. 

Mr. BILIRAKIS. Sounds good. 

The CHAIRMAN. All right. Thank you. 

Mr. BILIRAKIS. Since you are the chairman. 

The CHAIRMAN. Dr. Julius, Kristi asked about the discrepancy in 

cost of unique patients within the system. If you know that number 

for the system, certainly you know the number for Fort Meade and 

you know the number for Hot Springs. So what is the cost for a 

unique at Hot Springs and the number at Fort Meade? 

Dr. JULIUS. I am sorry, Mr. Chairman. I do not have that information with me. We will be glad to take that for the record. I do 

not have it broken out because it is an integrated healthcare system. Now, we can talk to our CFO, and I am sure we can come up 

with something close to what you are asking for. But the two systems do not operate entirely independently. So there are things 

that are shared costs and those things. 

The CHAIRMAN. This is not unique to this health system because 

when we asked Dr. Lynch in a hearing in Washington what it costs 

to see a patient at VA, they have no idea. None. It is beyond me. 

If you go into the private sector, I guarantee you every CFO or 

CEO will tell you to the penny what it costs to see a patient. And 

yet, you have known for quite some time that we were going to 

come and have this hearing and that one of the biggest questions 

was going to be how much it costs to see a patient at this facility. 

And you do not have the answer. So for the record, if you would, 


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please get that number to us as soon as possible. When I say as 

soon as possible, a week is sufficient, not the 2 years. 

The CHAIRMAN. How much of the $35 million that is estimated 

to be spent on non-VA care in this region—I guess that is the number that you are talking about—will be allocated to the PC3 program? 

Mr. DISTASIO. Very little of those funds will go to PC3. 

The CHAIRMAN. And the reason is? 

Mr. DISTASIO. Still a developing market. Our landscape here in 

the Black Hills is that the contractors or the providers that PC3 

is approaching are the same ones, if you will, that we use already 

as part of our non-VA care network. So it is fair to say there is not 

a lot of competition in this market, and I am sure their conversations are ongoing about trying to establish a robust PC3 contract. 

The CHAIRMAN. So can you tell me how many? You said not 

much. But can you tell me how many authorizations have been 

issued through PC3? Close. It does not have to be exact. 

Mr. DISTASIO. No. I would never estimate for you, but I am glad 

to come back with a better number in the near future. 

The CHAIRMAN. You did not give me any number. 

Mr. DISTASIO. No number. 

The CHAIRMAN. Okay. I was going to say do not come back with 

a better one. Come back with a number. 

Mr. DISTASIO. A number. 

The CHAIRMAN. The accuracy of the data that VA has used to 

support closing the Hot Springs campus has been called into question. You heard that this morning. Could you respond to some of 

those numbers and the criticism that you heard this morning? Because I think it is important. We heard them. We need to hear 

what your numbers are. So, Mr. DiStasio or Dr. Julius, either one. 

Mr. DISTASIO. I think we always have an opportunity to check 

with each other when you have two parties that, if you will, have 

numbers that, if you will, differ. One of the things that is striking 

about the data we collect is that we have to make sure that we are 

both looking at the same site and the same currency date and the 

same operational definition for the numbers. 

I know there has been a lot of dialogue about the cost of renovation. When we in VA estimated what it would cost to rework the 

Dom, we had to make sure that we were fully compliant with various laws and access. We wanted to have a model of care that was 

better for our veterans. And we were required to show that those 

costs—what they extrapolated over 30 years of operation. So our 

number was much beyond just the renovation portion of it, if you 

will. 

You know, I do agree with Save the VA’s point, though. That is 

a grand old building. It is not going to blow down. It is not going 

to fall down. It is not going to flood. But in my estimation, it is not 

appropriate for healthcare services for the next generation of veterans. Thank you. 

The CHAIRMAN. Wait, wait, wait. Come on, everybody. 

What is it appropriately ready for? 

Mr. DISTASIO. My largest concern about the Dom is, of course, 

the setting for our veterans, the privacy that they have or do not 

have, restroom access, those sorts of things. 


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I think there could be some alternative uses for that building 

that would help bring better things for the community and VA. We 

are currently conducting an alternative use study, which gives us 

the ability to begin looking nationwide and seeing what opportunities could be available. 

I hope you are aware we received last week a proposal under the 

environmental impact statement process from an Iowa group that 

in fact prepared a rather lengthy prospectus on another possible 

use for some of those buildings at least. 

The CHAIRMAN. Ms. Noem? 

Ms. NOEM. Dr. Julius, how many veterans do you say you service 

on Pine Ridge? Or how many veterans do you say are there that 

the VA actually counts? 

Dr. JULIUS. We have it and I am looking right now. 

The CHAIRMAN. Pause the clock for a minute while they are looking it up so Ms. Noem does not lose her time. 

Mr. DISTASIO. So I have some data in front of me that was prepared in May of 2013 trying to get to the root of this. And we used 

a number of different sources. Let me just run through them very 

quickly. 

Ms. NOEM. What do you use when you are evaluating whether 

to keep this facility open or not? I just want that number. What 

number do you say that you have on Pine Ridge that would use 

this facility? 

Mr. DISTASIO. Our records show that we serve 1,370 Native 

Americans. 

Ms. NOEM. 1,370. 

Mr. DISTASIO. But there is a caveat. The Native American veterans are not required in our system to identify themselves as 

such. So there could be more. 

Ms. NOEM. But I will tell you that I have been going through this 

for the last 2 and a half years with the Hot Springs community and 

with you, and the entire time the Pine Ridge reservation and the 

Oglala Tribe have told us that they believe they have 3,500 veterans. Tell me what you have done to try to reconcile the numbers 

so that you can identify the veterans that they have and reconcile 

the numbers and come to some kind of conclusion on how many 

veterans really are represented by that tribe. 

Mr. DISTASIO. Thank you for the question. 

My personal effort has been to communicate with Chairman 

Brewer on a personal level and a letter to his office describing if 

you have more veterans, names, lists, whatever, we would gladly 

take a copy. We have also done that with our county veterans service officers and our tribal veterans service officers. We are also 

waiting to see what happens with Secretary Zimmerman’s Reach 

All Veterans initiative, which I think will be an important part 

of—— 

Ms. NOEM. So have you come closer together in number? Have 

you reconciled after you wrote these letters? I know there was ongoing dialogue over the past 2 and a half years. Have you come 

closer together at agreement on how many veterans are actually 

served? What number are you currently using to evaluate how 

many are serviced by this facility? 

Mr. DISTASIO. The 1,370 number is—— 


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Ms. NOEM. You have not moved off your number at all. 

Mr. DISTASIO. That is the best number we have to date. 

Ms. NOEM. Does the sole responsibility of counting those veterans on Pine Ridge rest on them and not on you? 

Mr. DISTASIO. It does not. We took another few steps and we 

went to the Census facts and then we went to the National Center 

for Veterans Analysis. They gave us a number of the vet population 

of about 2,435. 

Ms. NOEM. So that might be a good number to use. 

Mr. DISTASIO. It may be. Again, the caveat was these were for 

veterans who resided in the counties that encompassed the reservations and they include known non-Native American veterans. But 

if we use that range of 1,370 to 2,400, we hope we have got the 

best math possible at this moment. 

Ms. NOEM. Did you do any kind of outreach to the tribe or go 

down there and try to register veterans? You did? 

Mr. DISTASIO. We did. 

Ms. NOEM. You had meetings down there and invited all the veterans to come in and get signed up for care through the VA facility? 

Mr. DISTASIO. That is correct. 

Ms. NOEM. How many veterans did you gain during that process? 

Because you are using the same number that you used 2 and a half 

years ago. Are you saying a single veteran did not show up and 

say, hey, you were not counting me before? 

Mr. DISTASIO. Well, I personally have been down there a few 

times each year over the last 5 or 6 years, and in my personal observations, we have enrolled one or two at each event. There could 

be others of similar numbers at other events, but I can capture 

that data for you and bring it back. 

Ms. NOEM. That would be great. 

Dr. Julius, I would like you to speak to the recent audit. In late 

July, the VA released the results of their internal audit for all of 

the VISN’s in the country. Out of the all the hospitals within VISN 

23, Black Hills Health Care System had the worst results. Rapid 

City staff was instructed to not use the electronic wait list required 

by the VA for scheduling. The staff was also instructed to manipulate data throughout the Black Hills Health Care System. This is 

an audit that was done internally by the VA. I would like you to 

speak to that audit and tell me how those results impact you personally and what you are doing to change the delivery of 

healthcare to veterans in this area and how closing down the Hot 

Springs facility will help you better serve the veterans within your 

system. 

Dr. JULIUS. Congresswoman Noem, thank you for the question. 

Concerning the audit results, yes. I mean, this was obviously a 

crisis for VHA when the news from the Phoenix VA came out and 

the Secretary then tasked senior leadership to audit the scheduling 

practices at all of the 128 medical centers and all CBOC’s more 

than 10,000 veterans. And I was a part of that group. I went to 

another VISN. I took part in these very audits. 

What I would say is obviously if we get any scheduler that says 

they felt that they were instructed to manipulate the data, that is 

unacceptable. And from the data, like I said, we tried to meet with 


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maybe 10 schedulers. And so it is often difficult to tell. If one 

scheduler said that they were feeling they were encouraged to do 

that, we would put it down. And that would be a certain percentage that had answered yes to that question. I do not know how pervasive that is. But like I said, anytime any one of our scheduling 

people are feeling that they have been instructed, implied or 

overtly, to manipulate the scheduling package, that is unacceptable. 

As a result of that, then we have also been instructed—so me as 

the acting network director, Steve as a center director, we have 

been meeting regularly with the schedulers at all sites of care and 

having this very discussion and saying, you know, this is a crisis 

for VHA. We have been accused of losing our integrity. We have 

to earn our credibility back. We cannot earn it back if we are having stuff like this going on. And I realize these schedulers are the 

front line folks, but we as senior leaders need to be giving them 

the message that, no, you know, the wait times are the wait times. 

Whatever they are you are putting in. The desired date is what the 

veteran says. And we do not want anybody to feel that they are in 

any pressure to do something that they—— 

Ms. NOEM. So who has been fired? 

Dr. JULIUS. I am not sure we have anybody that needs to be fired 

for that within the VA Black Hills or VISN 23. 

Ms. NOEM. So you do not trust what your schedulers have told 

you. That is the discrepancy that we have is this is an internal 

audit done by the VA, and your schedulers felt they were told to 

manipulate data, that they were instructed by staff to not use the 

electronic wait list. We had a discussion earlier here about your 

wait list, that the veterans largely in the room did not agree with 

the waiting times. So we do have a problem here in the Black Hills 

Health Care System, which our veterans are certainly paying the 

consequences. I want to know if there have been any actions taken 

within the healthcare system in the Black Hills in regards to this 

audit. 

Dr. JULIUS. Well, plenty of actions of what I just said. No personnel actions that I am aware of because, again, these were comments that we solicited from schedulers without attribution. We 

wanted them to be as candid as they could possibly be. It was also 

instructed we are not trying to get anybody in trouble. We want 

to know what is actually going on. And so in trying to create an 

environment of psychological safety, they answered candidly about 

the way that they felt things were going. Now we are going back 

and saying—I think in the data you have to interpret it again that 

not all schedulers said that. 

Ms. NOEM. No. I agree. I do not believe every scheduler said 

that. But I would like to know what changes you are implementing. 

As a leader, as a manager, as a director of this healthcare system, 

I want to know how you personally are taking action to make sure 

this does not happen again and that our veterans are not having 

long wait times. 

Dr. JULIUS. Well, one of the first things I think that nationally 

they realized that contributed to this was our performance metric 

of—performance goal of getting people in within 14 days of their 

desired date. That was a good stretch goal. That was a good aspiraVerDate Aug 31 2005 14:33 Nov 04, 2015 Jkt 000000 PO 00000 Frm 00044 Fmt 6633 Sfmt 6633 Y:\96-127.TXT PAT

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tional goal. That is something that we strive to do. All of us would 

like to have an appointment as near our desired date as possible. 

But I think when that goal was put into place, it was an unrealistic 

goal and we did not have the infrastructure as a system to actually 

meet that. But then it went from an aspirational goal into a performance measure where all of a sudden it was put into people’s 

annual performance plans. And I think the unintended consequence of that is that was then viewed as a stringent, more serious thing. I am going to be judged whether my performance this 

year was satisfactory. 

And for whatever reason—like I said, I do not believe any of our 

senior leaders are telling schedulers to cheat, to change the data, 

but somewhere in the system, in mid-managers or somewhere, they 

were hearing the message or it was implied that we need to meet 

this metric, and they did the things that they should not have 

done. 

So the Secretary immediately ordered that any reference in anybody’s performance plan to a 14-day metric be removed. They have 

all been removed. The other things that we have talked about is, 

like I said, that facility directors now will meet with schedulers at 

all sites of care every 30 days and have listening sessions to discuss what their life is like, what are they hearing, what are the 

barriers, what are their challenges. Then the VISN director is instructed to every 90 days visit every medical center and do the 

same thing, meet with the schedulers representing the VISN now 

and again reiterating our core values and that we do not want this 

behavior in VHA. We cannot have it. And like I said, we are rightfully accused of having lost our integrity, and we now need to 

spend time earning that back. 

The CHAIRMAN. Mr. Smith. 

Mr. SMITH. Thank you. 

Let us discuss reimbursement levels if indeed it would come to 

the point where other entities outside the VA would be reimbursed 

for the care of veterans. Has that reimbursement schedule been established? 

Dr. JULIUS. On the new veterans’ access act you mean? 

Mr. SMITH. Well, on the premise that there would be veterans 

cared for outside the VA system, has a reimbursement level plan 

been established? 

Dr. JULIUS. I am obviously not an expert in the intricacies of the 

new law that was passed. It was my understanding that the reimbursement rate would be at Medicare rates, but if needed, higher 

rates could be negotiated locally if that were necessary to obtain 

care. 

Mr. SMITH. Because we have veterans who would come from 

Scottsbluff, for example. We have veterans who would come from 

Gordon, who would come from Chadron, who would come from Alliance, among other places. So we have got critical access hospitals 

in some of these communities, not all of them, but critical access 

hospitals that have a level of reimbursement. Would that level of 

reimbursement be similar? Would it be the same? Could you guarantee that? Has there been any groundwork done to establish those 

reimbursement levels? 


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Dr. JULIUS. To that specific question, I guess I cannot answer 

that. Steve, do you have any additional information? 

Mr. DISTASIO. Thank you, Congressman Smith. 

We have had some preliminary discussions with them about 

their approachability about taking care of veterans. We are well 

aware of the reimbursement rates for critical access hospitals. But 

at this point in the process, it is really premature for us to enter 

into any contracts, but at the point that would be done, I think 

that conversation is possible, what will be the rate for what services that are provided. 

Mr. SMITH. And I can appreciate that. 

And I actually misspoke earlier when I said December 2012. It 

is actually December 2011, as many in the room full well are familiar with that. 

Now, it would seem to me that as major of a decision as it would 

be—the proposal—and I hope that the VA will abandon its proposal 

to reduce its services in Hot Springs. And this is not about saving 

an historic building. I love old buildings. I love old architecture. 

And I think we have a very unique situation here, though, where 

we have got, yes, an historic location with a very unique mission, 

and I hope that we can combine those missions because I happen 

to think that if there is a will, there is a way to get this done. And 

I think it can be done without adding a greater burden on rural 

veterans who already travel a good ways to get to Hot Springs. It 

is even further, we know, to Rapid City or Fort Meade. 

So I think it is vital that we enter the decision with eyes wide 

open in terms of what reimbursement levels are. I struggle to think 

that the 3 years has not been enough time to investigate what reimbursement levels would be. We have heard that there are delays 

in payments. That has been a consistent concern within the VA 

over time. I am frustrated as someone who has voted to continually 

increase funding to the VA, and we hear about various situations 

throughout public policy where agencies are expected to do more 

with less, and yet, we have significantly increased the funding and 

again a few weeks ago. And I would hope that the funds could be 

utilized to maintain the mission and objective in Hot Springs. 

Thank you. 

The CHAIRMAN. Mr. Bilirakis. 

Mr. BILIRAKIS. Thank you. That applause was not for me. 

We have increased the funding by 40 percent in the last few years, and then we have given another $5 billion for additional 

healthcare providers. 

I am going to get back to the building for Dr. Julius. In your testimony, you state that the current residential rehabilitation treatment program—the building at Hot Springs is not compliant with 

the Architectural Barriers Act. Can you elaborate on which section 

of the act that the building is violating and how long has it been 

in violation? 

Dr. JULIUS. No. I am sorry I do not have the particulars as far 

as—— 

[Laughter.] 

Dr. JULIUS [continuing]. What is involved with the Architectural 

Barriers Act. We had talked previously about the Americans with 

Disabilities Act, but I was informed by my highers-up in VACO 


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that Federal buildings are not subject to that, but we are subject 

to the Architectural Barriers Act. 

Mr. BILIRAKIS. Excuse me, sir. I do not want to interrupt. But 

I do want to state that you are aware that there is a violation or 

a couple violations. This is what was stated by the VA. Are you 

not? 

Dr. JULIUS. That is my understanding, yes. 

Mr. BILIRAKIS. Now, have any of these violations—have any steps 

been taken to correct these violations, if there are violations? 

Dr. JULIUS. Well, again, without knowing exactly what was going 

on—I mean, certainly some things are. You know, the ramps that 

we talked about—typically they are too steep. And so we have 

made some corrections as you saw this morning. And elevators 

have been installed to mitigate some of the deficiencies of the 

building. But what specific parts of the act are in violation I cannot 

answer it accurately. 

Mr. BILIRAKIS. Mr. DiStasio, please. 

Mr. DISTASIO. No, sir. I am unable to cite a specific chapter. But 

our folks in construction and facility management at VACO who 

have looked at the building and helped us clarify what standards 

we are required to meet by law consistently point out emergency 

exits and the angle of the ramps that you saw this morning. 

Mr. BILIRAKIS. Do you not think it would be more efficient, less 

costly to actually take care of any of these violations, bring them 

up to code, if there are any, than the reconfiguration plan proposed 

by the VA? 

Mr. DISTASIO. I think this is a key point that needs ongoing discussion is which is the most viable cost, renovation or new construction. And of course, I am including operating costs over a 

number of years. 

We also have to look at something bigger than the Americans 

Barriers Act. We have to look at whether or not the veterans can 

have privacy, can they have a private bathroom versus a communal 

bathroom down the hall. 

Mr. BILIRAKIS. Well, the thing is that you guys are pleased with 

this building, are you not? Are you pleased with the services? 

Mr. BILIRAKIS. I mean, that is what should matter. In my opinion, Washington should not be making these decisions. Our veterans should be making these decisions. 

Well, thank you very much. I yield back. Thank you. 

The CHAIRMAN. If you would excuse me, sir. Thank you very 

much for your service. Thank you for your service. 

If you would, tell me exactly how stakeholder and congressional 

delegation feedback has been incorporated in your proposal. 

Mr. DISTASIO. Through the initial hearing period that occurred 

in late 2011 and 2012, we took comments from almost 3,000 people, 

as I recall, and we took it in emails and letters. We handed out 

comment cards. All of that was collected and then summarized. 

In our ongoing conversations with VA central office, we shared 

what we were hearing in terms of thematics. And it is accurate to 

say that the very largest majority of people were saying do not do 

this. 

Nonetheless, my concern has always been about conserving quality and safety of care. And so we have discussed very carefully with 


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our VA leadership how do we balance these two things, if you will, 

a very heartfelt request from the veterans, do not take away this 

building, with the challenge of making sure that we do not harm 

a veteran. 

The CHAIRMAN. If I could, Doctor, this is a little off topic, but are 

you credentialed? Are you currently credentialed? Do you see patients within the VA system? 

Dr. JULIUS. Not currently, no. 

The CHAIRMAN. No. 

Dr. JULIUS. I did until 5 years ago, yes. 

The CHAIRMAN. I have a little bit of a problem with the way VA 

does this because when we had the backlog that erupted—actually 

it was back to April 9th, but there are physicians within the system that could not see patients. Are you paid for one job? Are you 

paid for more than one job in your current position? 

Dr. JULIUS. I assume I am paid for one job, being the Chief Medical Officer of the network. 

The CHAIRMAN. Well, certain pay scales are set. If you are a physician, then you get paid for being a doctor. You get paid for being 

Chief Medical Officer. You get paid for being the VISN Director. 

Can you explain—— 

Dr. JULIUS. My salary is determined by the fact that I am a physician. 

The CHAIRMAN. Despite the fact that some of the most serious 

problems within South Dakota in regard to wait times were here, 

did either of you receive a bonus in the last several years? 

Dr. JULIUS. I received a performance award for last year’s performance, yes. 

Mr. DISTASIO. And I did also, the first time during my period as 

a Director for about 3 years now. 

The CHAIRMAN. Can you tell us how much it would cost, because 

I think there has to be some type of an idea, to bring the facility 

to the ADA compliance? How much money are we talking about? 

Mr. DISTASIO. The financial analysis that was done included a 

significant focus on those costs. I did not bring that with me. Certainly the Members of Congress from this district have those figures, and of course, we are glad to provide them also as a question 

for the record. 

The CHAIRMAN. And also for the committee, if you would provide 

that for us as well. I think it is pretty important that we figure it 

out. 

I do not know if we have a failure to communicate. 

The CHAIRMAN. But let me ask you this. You talked about Hot 

Springs being a difficult place to recruit physicians to come to and 

live. Rapid City—a little easier? 

Mr. DISTASIO. Yes, sir. 

The CHAIRMAN. How much easier is it to get a physician to go 

to Rapid City? 

Mr. DISTASIO. We have no physician vacancies in our operations 

in Rapid City. 

The CHAIRMAN. Here is something that I am wondering because 

you pay veterans to travel from here, and you are talking about 

hundreds of veterans having to travel to Rapid City, but one doc, 


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two docs, three docs. Why can they not live there and you pay them 

to travel down here? 

Mr. DISTASIO. We do that already. Our specialists that come 

down here may be assigned to Fort Meade, may be in Rapid City. 

Some are assigned here. So they may often serve patients in both 

locations. 

I would offer to you that sometimes when we are in negotiation 

with a high value asset, a specialist, if you will, in medicine and 

we discuss with them that we would like them to travel to serve 

our patient population, that can be a disincentive to them. 

The CHAIRMAN. That is unfortunate because it calls into question 

whether they are working for the right reason. Are they working 

for a buck or are they working to serve America’s heroes? 

[Applause.] 

The CHAIRMAN. And I would wonder if they are not willing to 

sacrifice, do we need them? 

[Applause.] 

The CHAIRMAN. I want to give Ms. Noem and Mr. Smith the opportunity to do another round of questions, if you have one, because we are scheduled to wrap up in about 11 minutes. So, Ms. 

Noem, you are recognized. 

Ms. NOEM. You cannot remember what your original proposal of 

moving the facility to Rapid City was, how much that would cost 

moving care services to Rapid City, putting clinics in. What was 

your original proposal? What was the cost of that? 

Mr. DISTASIO. It is never a good idea to try to recall off the top 

of your head—— 

Ms. NOEM. Well, the thing that is really unfortunate about the 

situation is that one of the biggest reasons you have used for closing down the Hot Springs facility has been cost and to the detriment of our veterans. So I would like to have a general conversation because the proposal has been around for years now. And it 

took a long time to get a cost analysis from the VA on what the 

investment would be to bring this facility up to what they would 

think would be something they could approve of, but you cannot remember that either. And so I do not need it to be down to the 

penny. Maybe just within $10 million of where it was would be 

good because it is your proposals and it is your analysis. 

And the Save the VA Committee—not once—not once—during 

their testimony did they not have an answer that we asked them. 

They had every single answer for everything. They had their data. 

They had their numbers. They had their facts. They were prepared. 

Their heart and guts is invested in this thing. And you have sat 

here over and over today and said you do not know. You will have 

to get us the information. That is not acceptable. 

[Applause.] 

Ms. NOEM. So at this point, I do not care if you are wrong. I really do not care if you are wrong. I want you to say something other 

than I will get that for you or I do not know. 

So what was your cost to get this facility up to where you would 

deem it—if that investment choice was made and what was your 

approximate cost for your original proposal of shutting down this 

facility and moving to the Rapid City area and Fort Meade? 


VACREP180 with DISTILLER
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Mr. DISTASIO. Congresswoman, I care about being accurate. I 

care about what is happening to veterans. I have those numbers. 

We have put them into the hands of your staff. We are glad to do 

that again. 

Ms. NOEM. They did not realize they were responsible to bring 

your numbers. But we are getting them right now. Hopefully by 

the end of the hearing, we will have them. 

Mr. DISTASIO. That is more than fair. I am always glad to continue this dialogue whether it is again in another hearing or perhaps in a visit in your office or mine. You deserve those answers. 

We will get them for you. 

Ms. NOEM. Okay. 

Secretary Shinseki, when we had a meeting with him in Washington, DC and talked about his decision to move forward with the 

EIS process—he promised that there would be no more reduction 

in services at this facility while we went through that process. 

However, I have heard from many veterans in the area, the Save 

the VA Committee, that we have continued to lose services. And 

you will have to clarify for me if this is accurate or not. I believe 

one of them—it was a conversation that happened several months 

ago about checkups for pacemakers no longer being done here in 

Hot Springs, stress tests being moved to different facilities. And so 

is it true that services throughout this process, even though the 

Secretary of the VA told us in that meeting he would not degrade 

the services here any more—is it is true that it has continued to 

happen throughout the process? 

Mr. DISTASIO. There are certainly episodic changes in services. 

And if I could address very simply the one about cardiac pacemakers. Our process in the past had been to have a primary care 

physician, if you will, oversee that program. The standard of care 

has exceeded that and it requires a cardiologist. We have no such 

person on staff. So we made a contract with a regional cardiology 

group. There really is only one in the Black Hills. And so we have 

been able to meet that standard of care which is more important 

to us than, if you will, not. That service is provided by those cardiologists at many locations in the Black Hills and then also remotely. 

Ms. NOEM. So you are saying the standard of care changed and 

that is why that service can no longer be offered here at Hot 

Springs. Is that a standard of care that is set within the VA or 

within the American Medical Association? That standard of care— 

where did that come from? 

Mr. DISTASIO. Those are generally set by the professional associations, for instance, cardiology. The American Medical Association certainly may sign onto that. 

Ms. NOEM. And then the VA makes the decision whether they 

choose to adopt those standards of care? 

Mr. DISTASIO. Generally speaking, we make every effort to meet 

the community standard of care, and in this case, that is how that 

is done here. 

Ms. NOEM. I anticipated that when the Secretary told us he 

would not reduce services, he would do everything in his power to 

make sure that services were not reduced throughout this process. 

And that is what is disappointing about it is that I felt as though 


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he should have made the investment to make sure we could deliver 

those services here and continue to see patients here while we 

went through the EIS process so it could be credible at the end of 

the day. 

Thank you. I am out of time. 

The CHAIRMAN. Mr. Smith. 

Mr. SMITH. Just in the interest of time, I do want to respect the 

limits of time. But I would highly discourage using the information 

that you say is driving the decision that it is so difficult to recruit 

professionals because there is seemingly abundant data that there 

is an eager reduction in services, and it would be very difficult to 

recruit anyone to a facility that does not seem to have a commitment behind it. 

[Applause.] 

Mr. SMITH. So I would humbly ask that you refrain from using 

many of these driving factors, seemingly driving factors in the decision because I just do not think it can be relevant and especially 

when perhaps any other facility, rural or urban, would be facing a 

similar challenge. So if you wish to respond, go ahead. 

Dr. JULIUS. Yes, thank you, Congressman. 

I totally agree. I totally agree that it is difficult to recruit when 

there is the uncertainty about what is going on. I think everybody 

has the same goal in mind, though, and that is that we are all trying to figure out how can we ensure that we are providing safe, 

quality, evidence-based care to our veterans. Standards of care 

change over time. We have noticed that in the surgical arena. We 

did a lot of surgeries in small hospitals in the past, and then there 

was a very famous bad example in VA in which we had terrible 

surgical outcomes as a result of that facility sort of overextending 

what the support the staff that they had to do that. That caused 

VA to reassess our surgical complexity models. All these things are 

continually evolving, and so it is not just a standard that just says, 

well, the way it was 20 years ago or 15 years ago or 5 years ago 

is the way it is going to be 2 years from now. 

Mr. SMITH. I fully understand the need for agility and flexibility 

and the ease of operation. But when there seems to be a self-fulfilling prophecy here, it is frustrating as a policymaker. It is frustrating as we do engage in how much money to spend—taxpayer 

dollars—to maintain the commitment that I think we can all agree 

we have to stand behind our veterans and their care. 

Dr. JULIUS. The reality is it is difficult to recruit and retain providers here. To your point—I grant that—the uncertainty of the situation exacerbates that. 

Mr. SMITH. I think that is an understatement. 

But I yield back. Thank you. 

The CHAIRMAN. Mr. Bilirakis. 

Mr. BILIRAKIS. No further questions. 

The CHAIRMAN. Ms. Noem. 

Ms. NOEM. Is it not true that you have justified the closing of 

this facility based on more veterans seeking services in Rapid City? 

I know that we have had conversations before, and I think, Mr. 

DiStasio, you and I have had that conversation before where you 

have said more and more veterans are choosing to go to Rapid City 

for their care and for their services. 


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Mr. DISTASIO. I would clarify that as the phenomenon we are 

seeing with distribution of the veterans. More and more of them 

live there. By nature of the kind of care they may need, regional 

health is our tertiary referral center. So they have to go to Rapid 

City. And then in addition, our specific effort to expand the spending of non-VA to save veterans from traveling to Minneapolis, 

Omaha, and so on has allowed them to seek care in Rapid City. 

And Congressman Smith also in Scottsbluff, Gordon, Alliance and 

so on. 

Ms. NOEM. But as we lose services here, it obviously would cause 

more veterans to seek care in Rapid City as well. You would agree 

to that. 

Mr. DISTASIO. Or some other local healthcare facility closer to 

their home. 

Ms. NOEM. Can you elaborate—well, no. I am going to pass. 

Mr. Chairman, I am very concerned. As a representative of the 

VA, do you believe that you are carrying out the mission of the VA? 

What is the mission of the VA, and do you believe that you are carrying out that mission when the decision is being made to go forward with vacating the Hot Springs campus? 

Mr. DISTASIO. There is no decision—— 

Ms. NOEM. Is there a mission of the VA? 

Mr. DISTASIO. There is. 

Ms. NOEM. What is that? 

Mr. DISTASIO. To care for those who have borne the battle. 

There is no decision to close this campus. And in fact, the proposal is to certainly change our inpatient footprint but to maintain, 

as someone requested, a specialty community-based outpatient clinic to serve veterans here locally and then any that choose to travel 

to this location. 

Ms. NOEM. You know, that reminds me. Have you had a conversation with the Fall River Hospital yet about caring for people 

in this area if this facility were to close? 

Mr. DISTASIO. I met personally with the board of the hospital 

twice. 

Ms. NOEM. What did they say to you? Do they have the capacity 

to—— 

Mr. DISTASIO. Their approach to the conversation was that essentially they did not want to have it at that time, that we would 

continue it at some later time. 

Ms. NOEM. Okay. Continue on. I am sorry I interrupted you. 

Mr. DISTASIO. Thank you. That was all. 

Ms. NOEM. The last question I have then is when you are looking 

at evaluating a facility, whether for closure or to continue to operate it, what are the factors that you consider? I know cost is a factor. What else are the considerations? Is it desires of the veterans 

or the best service and care of the veterans? Is that one of the factors as well? 

Mr. DISTASIO. First and foremost, it has been about delivery of 

care to the veterans. And it is focused almost entirely on quality 

and safety. Can we preserve that for our veterans? To be the leader 

of a healthcare organization or to be a physician or a nurse or a 

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eran would just be a nightmare in our lives and certainly a nightmare for—— 

Ms. NOEM. Do you think that would happen here at Hot Springs? 

Mr. DISTASIO. I am concerned that that could happen here. 

Ms. NOEM. How could that happen here at Hot Springs? 

Mr. DISTASIO. When you look at trying to recruit and retain people that have a full range of competencies, you have both the issue 

of them maintaining their competencies. Just as important for support staff is gaining the competency. So you might, in fact, have a 

nurse who does not have the depth of skill to recognize when a patient is getting in trouble and know when to notify a provider or 

to suggest that a transfer to a higher level of care be made. 

Ms. NOEM. So you believe they are not treating enough patients 

to maintain the competency levels that they need to properly care 

for the veterans? 

Mr. DISTASIO. That is part of the issue we are trying to deal 

with, yes. 

Ms. NOEM. So could you tell me what consideration you gave to 

the Save the VA’s proposal on the PTSD establishment of a center 

here in Hot Springs? And did it have potential, and did you consider using it as that kind of a facility as well? 

Mr. DISTASIO. I did consider it. I still consider it. I think one of 

the very strong strengths of their proposal was also the veteran industry concept. I was a little surprised, though, that we have not 

heard much from Save the VA on either of those two proposals over 

about the last year, and I was expecting them to comment on it in 

the environmental impact statement process. They chose not to. 

Ms. NOEM. Well, I think it might be because they have not gotten 

answers to their original questions. We are still arguing on—— 

Ms. NOEM. You have not been able to reconcile the data on number of veterans served in the area. You have not been able to reconcile the data on wait times. Then the audit came out which obviously showed we were not caring for our veterans in this 

healthcare system properly. So I think because they have never received clear answers from the VA on any of their original questions, why were they to put more work into a proposal they have 

already submitted to you that you have given them no feedback on 

and continue to push that when we still have all these unresolved 

issues? I do not fault them one bit for not bringing that up during 

this process because from the very beginning when they have been 

told something from the VA or from the Secretary, it has not been 

followed through on. 

With that, Mr. Chairman, I will yield back. 

The CHAIRMAN. Gentlemen, thank you very much for being part 

of the second panel. We appreciate you being here to answer our 

questions. We would ask that you continue to be open and transparent and listen to what the people in this community are saying. 

This is a very unique situation. We are not talking about a facility 

that was built 30 years ago. We are definitely talking about the 

heart of a community. I would not want to be on the watch when 

that heart quit beating. I think that the veterans here today are 

serious about trying to come up with solutions. We will do what we 

can. 


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And I want the folks in the audience to understand too that VA 

is not perfect and the private sector is not perfect. There will always be errors that will be made by both. We will not be able to 

please everybody. Lord knows, we in the political arena understand 

that probably better than most. But we will try. 

We are here today at Kristi Noem’s request to try to come to a 

resolution that is satisfactory to those that have borne the battle, 

their widows, and their orphans. That is the most important thing 

that we should all remember. As I said in my opening statement, 

the veteran is sacred. VA is not. We will continue to watch as these 

Members who have come here today and others within their delegation try to come to a resolution. I have got some ideas that I will 

share with Kristi offline when we get back in September. 

But, again, ladies and gentlemen, thank you for being here 

today. It has been an honor to be in Hot Springs. And next time 

I come, I will be spending the night here not in Rapid City. 

The CHAIRMAN. This hearing is adjourned. 

[Whereupon, at 1:06 p.m., the committee was adjourned.] 

APPENDIX 

PREPARED STATEMENT OF JEFF MILLER, CHAIRMAN

Good morning and thank you for joining us today. 

I am Jeff Miller, Chairman of the Committee on Veterans’ Affairs for the United 

States House of Representatives and Congressman from the First District of Florida, 

where—as we like to say—thousands live like millions wish they could. 

I am joined today by Congressman Gus Bilirakis, Committee Vice Chairman from 

the Twelfth District of Florida; by Congressman Adrian Smith from the Third District of Nebraska; and, by your Congresswoman and my friend, Kristi Noem, from 

right here in South Dakota. 

Rep. Noem (Kristi) is known in Washington for her hard work, steadfast leadership, and strong voice—particularly where the needs of servicemembers and veterans in South Dakota and around the nation are concerned. 

Earlier this morning, she led us on a tour of the Hot Springs campus so that we 

could see first-hand the services that are provided and the impact closure of that 

facility would have on the hard-working employees who work there and the deserving veterans who receive care there. 

During that visit, it became even more apparent to me what an ardent and impassioned advocate she is for her fellow South Dakotans. 

This community has a long and storied history of coming together to care for its 

military and veteran populations and, looking out on this audience, it is clear that 

passion and enthusiasm has never been more alive. 

Thank you all for taking time out of your day to join us and for the work that 

you do to support and honor our nation’s veterans. 

It is a honor to be in Hot Springs and I am grateful to Rep. Noem (Kristi) for 

inviting us here. 

Before I go any further, I would like to ask all of the veterans in our audience 

to please stand if you are able or raise your hand and be recognized? 

Thank you for your service. 

We are here today on your behalf to ensure that the care you receive is timely, 

convenient, accessible, and high-quality. 

The Department of Veterans Affairs (VA) Black Hills Health Care System—which 

has campuses in Fort Meade and Hot Springs—covers a service area of approximately one-hundred thousand (100,000) square miles across four states and has one 

of the highest enrolled veteran penetration rates in the country. 

As you all know, in April, a Committee investigation and whistleblower revelations exposed widespread corruption and systemic access delays and accountability 

failures across the VA healthcare system that left thousands of veterans—including 

some right here in your state—waiting for weeks, months, and even years for the 

health care they earned through honorable service to our nation. 

The Committee has conducted aggressive and historic oversight in the four 

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ers at all levels have resigned and been replaced; and, nationwide initiatives have 

been put undertaken. 

Just two weeks ago today, Congress passed a bipartisan Conference agreement 

that will improve accountability for VA employees; increase access to care for veterans facing lengthy waiting times for VA patients or residing far from the nearest 

VA facility; and pave the way for long-term reforms that will dramatically improve 

the Department for veterans today and for generations to come. 

However, no single law by itself will create the large scale cultural and structural 

reform that is truly needed in our nation’s second largest bureaucracy or address 

all of numerous and varied issues our veterans and those who care for them experience every day. 

Here in Hot Springs you have faced your fair share of obstacles with the Department of Veterans Affairs. 

Recently, VA has told us that one significant factor impacting access to care for 

veterans is the lack of clinical and administrative space across the VA healthcare 

system. 

Yet, here in Hot Springs, VA has a historic campus that the Department claims 

it can no longer use. In a community such as yours open communication is vital, 

particularly when an agency is considering an action that could have a significant 

impact on the very livelihood of that community. 

I share your concerns about the quality of the data VA has provided to support 

the Department’s proposal to close the Hot Springs campus while building new facilities and your frustration about the lack of transparency that seems to have characterized VA’s response to your concerns. 

Unfortunately, data integrity issues and lack of transparency characterize much 

more than just VA’s responses here. 

I am also concerned that VA’s nationwide access audit found troubling scheduling 

practices were been in place in South Dakota, including instructions—against VA 

policy—to manipulate appointment waiting times. 

If VA leaders are so concerned about being unable to make the Department’s access goals that they would resort to manipulating data, why is VA not making full 

use of its existing facilities—in this case, Hot Springs—to ensure access to care for 

veterans across South Dakota? 

I look forwarding to hearing from today’s witnesses—local veterans, local stakeholders, and local VA officials—about what VA what actions have been taken and 

still need to be taken to improve access to care for veterans throughout the Black 

Hills and what need to be done to provide the highest level of care to those veterans 

who rely on services here in Hot Springs. 

As citizens and active community members, you are the true experts and I look 

forward to listening to your thoughts, ideas, and proposals. 

I thank you all once again for being here this morning. 


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PREPARED STATEMENT OF LARRY ZIMMERMAN

Good morning Chairman Miller, Vice Chairman Bilirakis, Representative Noem, 

and members of the committee. I am pleased to be here today to present our concern 

with the healthcare challenges faced by veterans in rural America. 

My name is Larry D. Zimmerman and I serve as Governor Daugaard’s Secretary 

of the South Dakota Department of Veterans Affairs. Our Department is the voice 

for South Dakota’s 75,000 veterans. I served active duty Army from 1973–1976 in 

the 4th Infantry Division at Ft Carson, Colorado, and served 29 years in the South 

Dakota National Guard, most recently serving at the State Command Sergeant 

Major. I had the distinct honor to complete a tour of duty in Afghanistan in support 

of Operation Enduring Freed as the Operations SGM for the nine Northern provinces in that country. 

South Dakota is fortunate to have three VA healthcare facilities in our state, 12 

community based outpatient clinics and three vet centers. We are fortunate to have 

66 county veterans service officers and seven tribal veterans service officers and 

over 20 veterans service organizations that are committed to enhancing the lives of 

our veterans. 

In 1889 the Grand Army of the Republic secured territorial legislation to construct a veterans home. It’s our understanding that Dakota Territory was the first 

of all territories to provide a home for their veterans. In 1907 the Battle Mountain 

Sanitarium opened its doors in Hot Springs to focus on short term medical needs 

of veterans. Although over the years, both facilities have changed names, the VA 

Black Hills Health Care System and the Michael J. Fitzmaurice State Veterans 

Home have worked together to provide care for our veterans for over 107 years. 

Veteran’s healthcare is a critical issue and it is important that we honor the 

promise to take care of those individuals who secured and protected our freedoms. 

During a one-year window, Michael J. Fitzmaurice State Veterans Home transported our heroes to the VA healthcare facilities in Hot Springs 1,272 times for urgent care, eye-care, dental care, dialysis, respiratory care, x-rays, urology, podiatry, 

and mental healthcare. In addition, during that same one-year time frame, 40 heroes were admitted to acute care at the VABHHCS in Hot Springs and 108 were 

transported to Rapid City via the VA. Additionally, thousands of veterans drive 

from other states, tribal lands and many of South Dakota’s most rural areas to receive medical care. 

Our heroes deserve the opportunity to enjoy the rest of their lives and be assured 

that they will have access to quality healthcare. South Dakota has a strong legacy 

of taking care of our veterans and we at the Michael J. Fitzmaurice State Veterans 

Home will guarantee that our heroes needs will be taken care of no matter what 

decisions are made of. 

In closing, I appreciate the support that your Committee has given us on all 

issues relating to veterans and I appreciate the invitation to present this information with you and I will be pleased to answer any questions you may have. 

f 

PREPARED STATEMENT OF DR. STEVEN JULIUS

Good afternoon Chairman Miller and distinguished members of the panel. Thank 

you for the opportunity to discuss the VA Black Hills Health Care System’s (VA 

BHHCS) commitment and accomplishments in providing Veterans accessible, high 

quality, patient-centered care and to specifically address rural healthcare and access 

to care in western South Dakota, northwestern Nebraska, eastern Wyoming, and a 

portion of southwestern North Dakota. I am accompanied today by Mr. Stephen 

DiStasio, Director of the VA BHHCS. 

VA BLACK HILLS HEALTH CARE SYSTEM OVERVIEW

VA BHHCS provides primary and specialty medicine, extended care and rehabilitation services, surgical and other specialty care, and mental health services, as well 

as residential rehabilitation treatment programs. VA BHHCS is a part of Veterans 

Integrated Service Network (VISN) 23, the VA Midwest Health Care Network, 

which includes facilities in South Dakota, North Dakota, Nebraska, Iowa, Minnesota, and portions of neighboring states. 

VA BHHCS consists of two medical centers located at Hot Springs and Fort 

Meade, South Dakota (approximately 90 miles apart); and VA staffed CommunityBased Outpatient Clinics (CBOC) located in Rapid City and Pine Ridge, South Dakota, and Newcastle, Wyoming. Contract CBOCs are located in Pierre, Winner, Mission, Eagle Butte, Isabel, and Faith, South Dakota, and Gordon and Scottsbluff, Nebraska. Compensated Work Therapy (CWT) programs are located in McLaughlin, 


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Eagle Butte, and Pine Ridge, South Dakota, serving Veterans on the Standing Rock, 

Cheyenne River, and Pine Ridge Indian Reservations. In addition, Transitional Residences are located in Rapid City, Sturgis, Pine Ridge and Hot Springs, South Dakota. VA BHHCS also has collaborative relationships with the Vet Centers in Rapid 

City and Martin, South Dakota. 

The VA BHHCS—Fort Meade Campus is identified as a rural medical center and 

the VA BHHCS—Hot Springs Campus is recognized as a highly rural medical center. The VA BHHCS has a service area of approximately 100,000 square miles covering parts of four states. The Hot Springs VA Medical Center is located in a community of approximately 3,900 residents. The Fort Meade VA Medical Center is located in the community of Sturgis with approximately 6,300 total residents. 

In FY13, based on calculations by VA’s National Center for Veterans Analysis and 

Statistics for Veteran Population, there were approximately 35,000 total Veterans 

within the VA BHHCS service area. Of the 35,000, approximately 21,000 were enrolled for healthcare services, and 19,207 of the enrolled unique Veterans were 

served. This reflects an enrolled penetration rate of almost 60 percent in FY13, one 

of the highest in VHA. 

There are approximately 1,033 dedicated VA staff members at the VA BHHCS 

who demonstrate their commitment to the care of Veterans every day. Often, employees travel to remote locations throughout the area to provide primary care, mental health, and other services to Veterans. 

VA BHHCS maintains 459,000 square feet and 77 acres of property at Hot 

Springs and 821,000 square feet and 220 acres at Fort Meade. Maintaining and improving the aging buildings at the Fort Meade and Hot Springs Medical Centers, 

ranging from 40 to over 100 years old, significantly increases the cost of operation 

at both facilities. 

• Existing operating rooms at the Fort Meade and Hot Springs VA hospitals 

are reaching 40 years of age. 

• The current Residential Rehabilitation Treatment Program (RRTP) building 

at Hot Springs is over 100 years old, and the structure is not compliant with 

the Architectural Barriers Act. 

• The Hot Springs and Fort Meade campuses are both sites of historical significance. Hot Springs is the Battle Mountain Sanitarium National Historic 

Landmark, with a proud history of caring for Veterans extending back to the 

early 1900s. The Fort Meade cavalry post is known for its significant military 

presence, extending back to the 1880s. 

VA BHHCS has the highest costs, per unique patient, of all VISN 23 facilities and 

one of the highest unit costs in all of VHA. In addition to the factors previously 

mentioned, this cost derives from a number of operational and infrastructure variables, the ratio of staff to Veterans served, and utility and maintenance costs of extensive buildings/acreage. 

VA BLACK HILLS’ PROPOSAL FOR RECONFIGURATION

VA BHHCS is committed to providing safe, high-quality, and accessible healthcare 

to the Veterans in western South Dakota and areas of the bordering states of Nebraska, Wyoming, and North Dakota. We have conducted a review of the services 

provided in this region. The Department has determined that improvements and reconfigurations to VA BHHCS operations are needed to maintain the safety and 

quality of care it provides. We also believe this will increase the scope of services 

available to Veterans closer to their homes, while being good stewards of public 

funds. 

VHA is concerned about its ability to preserve the quality and safety of care at 

Hot Springs. The Hot Springs Inpatient Medicine Unit (1East) has maintained a cumulative Average Daily Census (ADC) of approximately 5 patients per day from FY 

2010 to present. In these circumstances, it is difficult to recruit and retain skilled 

providers as well as maintain their competencies. As a result, surgical procedures 

at Hot Springs have been curtailed due to an inability to recruit and retain surgeons 

and anesthesia providers. In addition, all of the hospitalists and after-hours physicians are currently locum tenens providers, or temporary staff hired on contract to 

fill staffing needs. 

The most significant change proposed by VA BHHCS involves replacing the current medical center in Hot Springs with a new CBOC, and relocating the residential 

rehabilitation treatment program from Hot Springs to Rapid City, South Dakota. 

The overall goal of the reconfiguration is to realign services and resources, to provide safe, high quality, accessible, and cost-effective care, closer to where Veterans 

live. 


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In 2011, VA BHHCS began holding stakeholder meetings with Veterans, Veteran 

advocates, congressional offices, employees, community and business leaders, and 

the general public. VA conducted these meetings to answer questions, address concerns, and seek feedback to the proposals. On October 10, 2012, the Network and 

Facility Director briefed VA’s Secretary and his staff on the feedback received, alternative proposals received, and potential alternatives for consideration. At the invitation of South Dakota Senator Tim Johnson, the Secretary met with representatives 

from the community of Hot Springs, and staff from the offices of Senator John 

Thune and Congresswoman Kristi Noem, in Washington, DC on January 28, 2013. 

A follow-up meeting was held on May 6, 2013, with VA Central Office subject matter experts and community representatives to provide those representatives with a 

better understanding of the data VA used to develop and support the reconfiguration proposal. 

VA BHHCS initiated an Environmental Impact Statement (EIS) in early 2014, to 

evaluate the impact of the proposed reconfiguration of care in the Black Hills service area. VA has contracted Labat Environmental, Inc. through the required federal 

contracting process to assist VA with conducting the EIS process, including scoping, 

consultation, public involvement, EIS preparation, and finalization. In June 2014, 

ten public scoping meetings were held during this process at locations in South Dakota, Nebraska, and Wyoming. Additional public meetings will be conducted as the 

process continues. The EIS process is expected to take approximately 10–18 months, 

with a current completion date targeted for late 2015. Once the EIS is complete, 

the VA Secretary can make a decision regarding the proposed reconfiguration. 

FOCUS ON ACCESS

VA BHHCS leadership is committed to preserving access to healthcare services. 

To be transparent and make optimal decisions regarding Veteran care, VA has 

openly shared access and quality data with stakeholders. Access is a challenge for 

a variety of reasons. VA BHHCS sites of care are insufficient to provide ready access 

to care for all Veterans within the large, highly rural service area. The limited 

availability of specialists is also a barrier, requiring some Veterans to travel to VA 

sites in Minneapolis, Minnesota, or Omaha, Nebraska, for needed specialty care. 

The recruitment and retention of physicians, nurses, and other healthcare providers 

has also been difficult, with physician specialists in orthopedics, urology, psychiatry, 

internal medicine, and inpatient hospitalists particularly problematic. 

To address these challenges, VA BHHCS has expanded the use of non-VA care 

to provide access to services locally and shorten waiting times. This year, VA 

BHHCS is estimated to spend thirty-five million dollars for non-VA care, including 

inpatient, outpatient, and long-term care. A major benefit to Veterans has been the 

reduction of travel to VA tertiary care sites in Minneapolis, Minnesota, and Omaha, 

Nebraska; the reduction of out-of-pocket travel expenses for Veterans and their families; and the opportunity to be close to home when receiving medical care and services. 

In addition, VA BHHCS has steadily increased the utilization of telehealth services. Mental health, clinical pharmacy, cardiology, oncology, infectious disease, pulmonary, neurology, and other specialty services are provided to Veterans in Hot 

Springs via Clinical Video Telehealth. Through the end of FY 2014’s third quarter, 

1,153 Clinical Video Telehealth encounters have been completed. 

We are also working to improve communication with Veterans about appointment 

scheduling. VA BHHCS’ efforts to bundle appointments for Veterans, ensure that 

appointment letters are accurate, and that the telephone reminder system is used, 

are helping to reduce the current 10 percent no-show rate. 

The opening of a system-wide call center is providing Veterans the opportunity 

to get timely help with appointments, medication management, billing questions, 

and other matters. The center has been so successful that it now provides similar 

services for the Veterans served by the Fargo VA Healthcare System. In addition, 

other VA facilities have inquired about VA BHHCS providing call center support to 

their Veterans. Repeatedly, Veterans tell me how the call center makes it easier for 

them to conduct business with VA BHHCS. 

We consider an important part of access to be outreach to Veterans who may be 

unaware of the scope of services for which they might be eligible. VA BHHCS conducts numerous outreach events throughout our service area, with particular emphasis on the four Native American reservations, Cheyenne River, Pine Ridge, Rosebud, and Standing Rock. Special attention is also given to Veterans of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/ 

OND). Due to the large geographic service area, VA collaborates with other military, 

Veteran, and community service providers, to ensure Veterans and their families receive the care they need. Specialty OEF/OIF/OND case managers are assigned to 


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provide outreach to Veterans who live great distances from our main medical facilities, including those who are assigned to an outlying CBOC. Additionally, a Transition Patient Advocate works with the OEF/OIF/OND team assisting in an array of 

outreach efforts that facilitate integration of care for all generations of Veterans. 

Post deployment integrated care is available through the Patient Aligned Care 

Team Transition Clinic, a mobile team providing care at Fort Meade, Hot Springs, 

and the Rapid City Clinic. This team is staffed by a mid-level provider and a licensed practical nurse and is supported with a Medical Support Assistant for scheduling duties. As of this year, this clinic continues to serve the ongoing primary care 

needs of about 1,100 combat Veterans. 

As a result of the many actions taken to improve timely access to care: 

• Ninety one percent of new and established Veteran patients receiving direct 

care from VA BHHCS get an appointment within 30 days. 

• As of August 4, 2014, there are only four Veterans on the Electronic Wait 

List (EWL). The EWL count is the total number of all new patients (i.e., those 

who have not been seen in a specific clinic in the previous 24 months) for whom 

appointments cannot be scheduled in 90 days or less. 

• As of August 2, 2014, there are no Veterans on the New Enrollee Appointment Request (NEAR) List. The NEAR List is the total number of newly-enrolled Veterans, who have asked for an appointment during the enrollment 

process for whom an appointment has not yet been scheduled. 

VA DEPARTMENT OF DEFENSE (DOD) SHARING AGREEMENT

The VA BHHCS’ sharing program with DoD helps support a strong collaboration 

with VA and Ellsworth Air Force Base (AFB) leadership. VA continues to search for 

additional opportunities to share resources with DoD while improving cost effectiveness and efficiency in the provision of patient care. We are concentrating on the 

areas of radiology, dermatology, chronic pain management, and mental health. In 

2005, VA BHHCS and Ellsworth AFB successfully submitted a Joint Incentive Fund 

(JIF) proposal to purchase a Magnetic Resonance Imaging (MRI) system for VA and 

DoD to share. The agencies received $2 million from the JIF, to use for this purpose. 

In 2007, VA BHHCS and Ellsworth AFB successfully completed a JIF proposal for 

a Sleep Lab, and received $443,000 for this purpose. In June 2011, VA BHHCS, 

Ellsworth AFB, and VA Dakota’s Regional Office initiated disability examinations 

for active duty service members, through the Integrated Disability Examination 

System. More recently VA BHHCS is providing some surgical care and inpatient 

mental health services for active-duty military members through a local sharing 

agreement with Ellsworth AFB. 

Projects in development include more robust provision of dermatology, pain management, physical therapy, and laboratory services. When a new Rapid City CBOC 

is opened, co-locating some VA and DoD services will provide improved access and 

services for Veterans, active-duty members, and their family members. 

VA INDIAN HEALTH SERVICES (IHS) SHARING OPPORTUNITIES

VA BHHCS has taken the leadership role in the VISN 23 implementation of the 

national VA IHS Reimbursement Agreement, under which VA reimburses IHS for 

direct care services provided to eligible Native American Veterans in IHS facilities. 

VA BHHCS has developed strong relationships with the IHS and Tribal Health entities in Pine Ridge, Rosebud, Eagle Butte, and Rapid City, South Dakota, within the 

guidelines of the Reimbursement Agreement and is a leading VA facility in the 

amount of direct reimbursement to IHS facilities. A local sharing agreement with 

IHS supports non-Veteran Native American access to MRI services at Hot Springs. 

VA BHHCS also supports the direct referral of Native American Veterans seen in 

IHS facilities to VA specialty clinics, saving the Veteran an additional appointment 

with their primary care provider. 

Projects under consideration include the provision of mobile MRI/Computerized 

Tomography services to multiple IHS hospital sites, a jointly operated telehealth 

network for access to scarce medical specialists, and a potential fee-for-service arrangement for a Tribal Health-operated mobile clinic. 

OTHER SHARING OPPORTUNITIES

VA BHHCS enjoys positive relationships with other governmental agencies in the 

surrounding areas, and actively participates in the local community. VA BHHCS is 

the largest employer in both Sturgis and Hot Springs, South Dakota. VA BHHCS 

has strong relationships with the South Dakota State Veterans Home in Hot 

Springs; the Veterans Outreach Center in Rapid City, South Dakota; the Ellsworth 

AFB outside Rapid City, South Dakota; and the South Dakota and Nebraska Army 

National Guards. Through a lease agreement, the Fort Meade VA Medical Center 


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campus hosts the South Dakota Army National Guard 196th Regiment, which 

serves as a nationwide training center for hundreds of National Guard leaders every 

year. 

In addition, VA BHHCS has a positive and mutually supportive relationship with 

the single non-profit hospital system in western South Dakota, the Regional Health 

System, and its affiliated healthcare centers. 

There have been preliminary discussions with multiple community hospitals in 

South Dakota, Nebraska, and Wyoming, about establishing sharing agreements to 

care for Veterans. To date no sharing agreements have been completed; pending the 

decision on the reconfiguration proposal. 

CONCLUSION

VA BHHCS is committed to providing high-quality care and services for our Veterans. We continue to focus on improving Veterans’ access to care. Our location in 

a highly rural landscape presents VA with some of the same challenges faced by 

other healthcare systems in highly rural areas. The most significant of these is the 

ability to recruit and retain highly-skilled physicians and nurses. Throughout our 

service area, the scarcity of primary care providers and hospitalists is acute. 

We sincerely appreciate the opportunity to appear before this distinguished panel 

to share with you the great work that the VA BHHCS provides to our Nation’s heroes every day. We are pleased to respond to any questions or comments that you 

may have. 

Æ 


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