RURAL VETERANS’ ACCESS TO PRIMARY 

CARE:

SUCCESSES AND CHALLENGES

Field Hearing

before the

Committee on 

Veterans’ Affairs

House of Representatives

Subcommittee on Health

one hundred ninth congress

first session

August 22, 2005

Hearing Held In Bangor, Maine

Printed for the use of the Committee on Veterans’ Affairs

Serial No. 109-21

For sale by the Superintendent of Documents, U.S. Government Printing Office

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23-330.PDF
Committee on Veterans’ Affairs

Steve Buyer, Indiana, Chairman

 Michael Bilirakis, Florida Lane Evans, Illinois, Ranking

 Terry Everett, Alabama Bob Filner, California

 Cliff Stearns, Florida Luis V. Gutierrez, Illinois

 dan burton, Indiana Corrine Brown, Florida

 Jerry Moran, Kansas Vic Snyder, Arkansas

 richard H. baker, Louisiana Michael H. Michaud, Maine

 Henry E. Brown, Jr., South Carolina Stephanie Herseth, South 

 Jeff Miller, Florida Dakota

 John Boozman, Arkansas Ted Strickland, Ohio

 Jeb Bradley, New Hampshire Darlene Hooley, Oregon

 Ginny Brown-Waite, Florida Silvestre Reyes, Texas

 Michael R. Turner, Ohio ShellEy Berkley, Nevada

 Tom Udall, New Mexico

Jim Lariviere, Staff Director

Subcommittee on Health

 Henry E. Brown, Jr., South Carolina, Chairman Michael H. Michaud, Maine

 Cliff Stearns, Florida, Vice Chairman Ranking

 Richard H. Baker, Louisiana Bob Filner, California 

 Jerry Moran, Kansas Luis V. Gutierrez, Illinois

 Jeff Miller, Florida Corrine Brown, Florida

 Michael R. Turner, Ohio Vic Snyder, Arkansas

Jeffrey Weekly, Subcommittee Staff Director

(II)
CONTENTS

August 22, 2005

 Page

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40

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45

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51

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55

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35

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71

76

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87

Rural Veterans’ Access To Primary Care: Successes and 

Challenges ...............................................................................

OPENING STATEMENTS

Chairman Brown ........................................................................ 

Hon. Michael H. Michaud, Ranking Democratic Member ......

Witnesses

Chirico-Post, Jeannette, M.D., Network Director, VA New

 England Healthcare System ..................................................

Prepared statement of Dr. Chirico-Post ...................................

Sims, John H., Jr., Director, Togus VA Medical Center .........

Prepared statement of Mr. Sims ..............................................

Lessard, Roger, President, AFGE Local 2610 .........................

Prepared statement of Mr. Lessard ..........................................

Simoneau, Don, Vice Commander, The Department of Maine

 American Legion ....................................................................

Prepared statement of Mr. Simoneau ......................................

Laweryson, Gary, Chairman, Maine Veterans Coordinating

Committee ...............................................................................

Prepared statement of Mr. Laweryson .....................................

STATEMENTS FOR THE RECORD

Hon. Thomas H. Allen, 1st Congressional District, Maine .....

Hon. Olympia J. Snowe, U.S. Senator, Maine .........................

Ronald W. Brodeur, Adjutant, Department of Maine of the 

 Disabled American Veterans .................................................

COL Edward L. Chase, USAF (Ret), Chairman, Legislative

  Committee, Pine Tree Chapter, Military Officers Association of America .......................................................................

Roger Landry, Former Maine State Representative, and CoChair of Maine’s Task Force on Veterans’ Health Services ..

Timothy J. Politis, Chief Executive Officer, Maine Veterans’

 Home ......................................................................................

Peter W. Ogden, Director, Bureau of Veterans Services, State

of Maine ..................................................................................

 (III)
38

59

90

113

INFORMATION FOR THE RECORD

“Most Wired 2005” USNews.com article by Josh Fischman ....

“Differences in Health-Related Quality of Life in Rural and

 Urban Veterans,” American Journal of Public Health, 

 October 2004 ..........................................................................

VA Health Care, Department of Veterans Affairs booklet .....

Cost Estimates for Maine CBOCs and Access Points .............

 

(IV)
(1)

RURAL VETERANS’ ACCESS TO PRIMARY CARE:

SUCCESSES AND CHALLENGES

Monday, August 22, 2005

U.S. House of Representatives, 

Subcommittee on Health,

Committee on Veterans’ Affairs,

Washington, D.C.

 The Subcommittee met, pursuant to call, at 9:06 a.m., at Eastern 

Maine Community College, Room 501, Rangeley Hall, 354 Hogan 

Road, Bangor, Maine, Hon. Henry E. Brown, Jr., [Chairman of the 

Subcommittee] Presiding.

 Present: Representatives Brown and Michaud. 

 Mr. Brown of South Carolina. Good morning. My name is Henry 

Brown and I chair the Health Subcommittee of the Veterans Committee. I’m from South Carolina.

  It is a real pleasure to be up in Maine. This is my first stop. And,

you know, I left that 95 degree heat, it just came down from a hundred degrees. So, it’s been a real pleasure this morning to wake up 

and enjoy the nice cool temperatures that you folks have here.

 It’s a real pleasure to be here. I know Mike Michaud and I serve 

together in Congress, and two years ago we served on the Veterans 

Benefits Subcommittee. And then I got to be Chairman of the Health

Subcommittee, and Mike got to be Ranking Member on that Subcommittee, so it’s been a real good working relationship. And our goal as 

the chair of the Health Committee is to try and improve the health 

care delivery for veterans. And we try to do some things to get us 

up with the 21st Century and deal with some other issues that we 

have.

 And we’re grateful today to come and listen to you, the veterans, 

and make absolutely sure that this is working; not just in South Carolina or in Texas, but in Chicago and also in Maine.

 Rural healthcare is a big issue for us, because, in a state like Maine, 

and even some little areas in South Carolina, where accessability to 

good healthcare is a major concern.

 We also have with us some staff members of the Senate. And I know 

Mark Kontio is here -- Mark, would you raise your hand -- thanks for 
2

coming -- from Senator Olympia Snowe’s office. Jon Ford from Senator Collins’ office. Matt LaPointe from Thomas Allen’s office.

 Although the Senators and Congressman Allen were not able to 

come, I’m pleased that Congressman Allen asked us to submit his 

statement in the record, and we will certainly be happy to do that.

[The statement of Thomas Allen appears on p. 33]

 Before delving into the subject of today’s hearing, I would like to 

extend my heart-felt thanks to both my staff and Mr. Michaud’s staff 

I would like to recognize Jeff Weekly and Dolores Dunn from my staff 

- - Mike, if you would recognize your staff -- 

 Mr. Michaud. Yes, Linda Bennett, from my staff, as well as my 

staff from the State of Maine, and several are here today.

 I would like to thank them -- and your staff, Chairman Brown -- for 

coordinating this hearing. I appreciate all of the hard work.

 Mr. Brown of South Carolina. Well, I certainly appreciate the hospitality that you’ve shown, Mike, and your staff since we have been 

here together. And I look forward to going to Togus later today and 

see the medical facility up there.

 Today we examine how the VA is providing primary care to veterans in rural Maine; what challenges the VA confronts in providing 

care for veterans in the state; and what unique and innovative measures serve as potential solutions to meet these challenges.

 The panels we will hear from today, because of their roles inside 

and outside of VA, will help us better understand the current state of 

play for Mainers and the gaps that have developed due to the rural 

make-up of the state.

 As Chairman, it is my hope that when gaps in treatment or clinical 

care are identified, we put significant effort behind developing new

and innovative approaches to providing care for those who live long 

distances from VA medical centers or community-based outpatient 

clinics.

 We must remember, however, Maine is not alone when it comes to 

providing rural care to our veterans. So, the solutions we consider 

as policymakers -- those already in use, or new ideas generated as a 

result of this hearing -- should be exportable to other states and localities in the United States, so that all eligible and enrolled veterans 

can benefit.

 I now yield to my good friend, Mike Michaud.

 Mr. Michaud. Thank you very much, Mr. Chairman. And once 

again, I want to welcome you, your staff, and staffs from other lawmakers. I welcome you to the State of Maine, and hopefully you’ll 

have an enjoyable stay while you are here. I want to thank Eastern 

Maine Community College for allowing us to use their facility here 

this morning, I really appreciate that.

 I also want to thank all of the veterans who are here today. I know 
3

a lot of them have traveled great distances to get here, several over 

three hours this morning, so I really appreciate your time and effort 

to come here this morning.

 Mr. Chairman, I want to especially thank you for agreeing to hold 

this hearing in the State of Maine. And there’s another hearing in 

South Carolina next month.

  I know the Chairman and I are definitely united in a bipartisan

effort to look at taking care of our veterans. It is a high priority for 

both of us.

 It is a great honor to serve with you, Mr. Chairman, in a bipartisan 

effort over the last three years to make sure that the veterans get the 

services they need.

 I’m also very pleased that the Democrats and Republicans came 

together earlier this year to correct the shortfall that we received in 

the original budget as it relates to veterans.

 That bipartisan effort was put forth in a supplemental budget, that 

the President signed on August 2nd, and we’re very pleased with the 

additional funding.

  The budget shortfall definitely hurt the veterans’ access to care and

quality of care; it was put at risk.

  In Maine, the VA had to put a hold on filling many staff positions

until the new funds were released.

  I must say I am surprised that the VA Central Office was caught

by surprise by the shortfall in June. The Bangor Daily News had 

reported back in January that there was a 14 million dollar shortfall 

at the Togus VA Medical Center.

 I hope that we can continue working in a bipartisan manner and 

keep the dialogue open to make sure that we find long-term solutions

for VA funding.

 I’m fully supportive of mandatory funding.

 If members of Congress, the President and his Cabinet, and federal 

employees are guaranteed healthcare benefits, then I think veterans

should be guaranteed their healthcare benefits as well.

  As we tackle the underlying flaws that we find in the budget process, we also must look at how do we take care of Priority 8 veterans 

as well.

 Mr. Chairman, we have a proud tradition here in Maine in answering the call to service. One in six Mainers are veterans. And we are 

very pleased with that.

 We have a new generation of veterans who are risking their lives 

in Iraq and Afghanistan.

 Americans from small rural towns, in your state and mine, have 

taken on more than their share of answering the call to serve their 

country.

 I think it’s important to the returning soldiers who need the help 

readjusting once they get back home, that we will provide that help. 
4

We’ll be looking at the need also for quick access for mental health 

services to prevent the chronic mental health problems that we are 

seeing.

 We must not fail these heroes by ignoring that need. I look forward 

to hearing from Veterans Integrated Service Network, or VISN, 1 

Director, Dr. Post; and Togus VAMC Director, Jack Sims -- looking 

forward to their testimony, and the efforts to expand the capacity to 

serve veterans in the state of Maine, which is definitely needed.

 I’m also looking forward to hearing from them as well on the opening of CBOCs that were proposed under the CARES recommendations.

Veterans need these clinics. We must move forward to get these 

clinics up and running. Telemedicine is great. I believe telemedicine 

is important, but it’s not the answer for all of the problems that we 

have.

 We must make sure that we do not forget that, with telemedicine, 

we must have adequate staff -- whether it’s psychiatrists or eye doctors to meet the demand. No amount of technology will make up that 

difference.

 I’m also concerned about the way mental health patients are being 

integrated into primary care. Many veterans suffer from depression, 

post-traumatic stress disorder, and other mental health problems.

 There simply are not enough mental health care specialists to meet 

the demand. We’re looking forward to hearing about that issue.

 If you look at the statistics, Mr. Chairman, last year VISN 1 spent 

only 60 percent of what it did nine years ago to treat veterans with 

serious mental illness.

 Also, VISN 1 only had 78 percent of the mental health staff that it 

had back in 1996.

 I am concerned that this means a reduction in the care for our veterans. I’m looking forward to hearing the testimony from the VISN 1 

Director and Togus VAMC Director Jack Sims.

 I want to thank you both for taking the time to come here this 

morning.

 Thank you.

 Mr. Brown of South Carolina. Thank you very much, Mike.

  At this time we’ll call the first panel to come forward. Our first

panel is Dr. Chirico-Post, appointed Director of the New England 

Healthcare System in 2000. She oversees a network of healthcare 

centers throughout the six New England states.

 Mr. John Sims has served as the Director of the VA Medical Center 

for 15 years. His leadership has been instrumental in helping veterans in rural Maine access a broad range of medical services.

 And let’s start with you, Doctor.
5

STATEMENTS OF JEANNETTE CHIRICO-POST, M.D., 

 NETWORK DIRECTOR, VA NEW ENGLAND HEALTHCARE

 SYSTEM; AND JOHN H. SIMS, JR., DIRECTOR, TOGUS VA

 MEDICAL CENTER

STATEMENT OF DR. JEANNETTE CHIRICO-POST

Dr. Chirico-Post. Good morning. Mr. Chairman and members of 

the committee, thank you for the opportunity to appear today to discuss Rural Veterans Access to Primary Care: Successes and Challenges.

 The New England Healthcare System is comprised of the six states 

in New England as an integrated health care delivery system to 

provide comprehensive quality, innovative care, in a compassionate 

manner to all veterans it serves.

 We serve a population of 240,000 veterans with a total budget of 

over $1.4 billion dollars. Our eight medical centers operate approximately 1900 beds, and we have about 26,000 admissions to those 

beds.

 The network is committed to provide the right care at the right 

time in the right place and at the right course.

 We are committed to the unique healthcare challenges that Maine 

faces.

  We are fortunate to be affiliated with premier medical schools in

the country, including New England College of Osteopathic Medicine. 

And we are a leader in research and post-graduate education.

 I’m pleased today to discuss the many areas in which VA is excelling in the state of Maine. Currently there are no significant waiting

lists or backlog for new primary care patients in Maine. 71.6 percent 

of new patients are seen within 30 days, and 94 percent of the established patients are seen within 30 days.

 We’ve had outstanding performance in Maine in high risk, high 

volume areas, such as cancer screening and diabetic care.

 Access is enhanced in New England through a total of 38 operational community-based outpatient clinics, with the quality at the 

same standard as it is at the medical centers.

VHA has committed to the expansion of service and the transformation of mental health care, and the spectrum of services in Maine 

include both inpatient and outpatient services.

 The network very successfully secured funding recently throughout the six states in support of those mental health services.

 A grant recently received provides for the expansion of services to 

treat additional areas though substance abuse disorders, but not limited in that area.

 We have a number of special programs that were initiated and 

flourished in support of the frail elderly in Maine. These home com-
6

munity-based care programs include other areas such as hospice-veteran partnerships that exist.

 Telemedicine is a strategy to meet some of the rural healthcare 

needs in the network, including those veterans who need special services at a distance.

 The goal is to provide an electronic network capable of supporting the veteran patient wherever they live by providing innovative 

means of communication between the patient and the healthcare provider on site.

Care coordination/Home Tele-health programs provide the tools to 

help patients self-manage their care, reducing hospitalizations and 

enabling them to live in the least restrictive environment.

 A recent article from the US News and World Report entitled, 

House Calls, discusses telemedicine and the VA’s use of this innovative medical tool.

 And I would like to submit a copy of this for the record.

 Advances in telemedicine and technology are included through the 

innovative implementation of My HealtheVet, which will allow the 

veteran access through the Internet for pharmacy refill functionality.

 In addition to that, through the technology, we are able to establish 

consultation for our patients and additional referrals so the patients 

do not have to travel long distances.

 We work collaboratively with the Department of Defense to insure 

a seamless transition for our returning service members. Our computerized patient record system provides a sharing of data in a secure 

fashion.

 There are other areas in which telemedicine has provided enhanced 

access to the veterans of Maine, including dermatology, psychiatry, 

pathology, cardiac monitoring through electrocardiograms.

VA is committed to ensuring a seamless transition from active duty 

to civilian status for our newest veterans returning from conflict in

Afghanistan and Iraq.

 To date, over 5,000 veterans are enrolled in the network, including over 500 in Maine. These veterans are primarily seeking care 

through primary care, dental care, and mental health services.

 Additionally, we have 18 Vet Centers located throughout the network, five in the state of Maine.

 In summary, the VA has implemented numerous innovations to 

meet the rural health care challenges facing our Maine veterans. 

And today’s veterans will know, in whatever setting they receive their 

healthcare, that they are receiving the highest quality of healthcare 

from the professionals who provide that care to our Nation’s veterans.

 Mr. Chairman, that concludes my statement. I truly appreciate 

the opportunity to share with you how VA New England Healthcare 
7

System provides quality and compassionate healthcare to the veterans of New England.

Mr. Brown of South Carolina. Thank you, Dr. Chirico-Post. At 

the conclusion of Mr. Sims’ remarks, we’ll then have some questions. 

Thank you.

[The attachment appears on p. 38]

[The statement of Dr. Chirico-Post appears on p. 40]

 Mr. Brown of South Carolina. Mr. Sims?

STATEMENT OF JOHN H. SIMS, JR.

 Mr. Sims. Mr. Chairman, Congressman Michaud, thank you very 

much for the opportunity to speak to you today about Rural Veterans 

Access to Primary Care in Maine.

  At Togus, as well as throughout the entire health care field, there

is now a sustained emphasis on outpatient services, an emphasis that 

has significantly reduced hospitalization stays and more clearly focuses on outpatient clinics and their available services.

 Although we have changed the manner in which we provide our 

care, we continue to provide the same broad range of services and 

high quality care that we have always provided to an ever increasing 

number of Maine veterans.

 During my 15-year tenure as Director of the Togus VA Medical 

Center, there’s been a remarkable and sustained shift in the delivery 

of health care services in Maine. In particular, the VA has been progressive in its attempt to provide rural health care access.

  Today there are five full-time community-based outpatient clinics -

- CBOCs -- in Maine, several of which have been expanded more than 

once to meet the increased demand.

 These full-service CBOCs are located in Caribou, Bangor, Calais, 

Rumford and Saco. And, in addition, we have a part-time clinic located in Fort Kent which operates as a satellite of our Caribou CBOC. 

In addition to primary care, an essential part of that primary care at 

our CBOCs is the provision of preventive health services and health 

promotions as well, in addition to disease prevention programs.

 We also have two VA mental health clinics located in Bangor and 

Portland.

 To better serve the Maine veterans, four of these CBOCs were recently expanded or relocated, and the remaining CBOC in Calais will 

soon be in its new location. And we’re hopeful that that will occur in 

October of this year. We’re on schedule.

 We’ve also been able to increase access to mental health throughout the state. The Bangor CBOC has adjacent mental health clinic 

which is fully staffed and operates on a full-time basis.

 Mental health support for our Saco CBOC is provided by the newly 
8

expanded and relocated mental health clinic in Portland.

 Tele-mental health is in place in Caribou and is planned for Calais 

when that CBOC is relocated later this year.

 Finally, the Rumford CBOC now has an onsite mental health clinician one day a week with plans to expand that service when additional resources become available.

  One of the most significant changes in VA health care in Maine has

been the extraordinary increase in the number of enrolled veterans 

selecting VA as their preferred choice for health care services.

 In 1999, we had a total enrollment of 19,000 veterans in the State 

of Maine. 2004, the end of last fiscal year, that was up to 36,000 veterans seeking their care from VA.

  The significant piece then with regards to rural health care is that,

back in 1999, only one-third of the veterans, were getting their care 

at a CBOC. In 2004, half of our enrolled veterans are now getting 

their care out in the rural areas. Obviously, that shows that the veterans want to get their care closer to where they live.

 The Togus Healthcare System has been coordinating very closely 

with the Maine National Guard and various reserve units to conduct 

outreach for the Operation Iraq Freedom/Operation Enduring Freedom veterans as they’re returning.

  The outreach efforts include healthcare and non- medical benefit

briefings as well as information on readjustment counseling by the

Vet Centers.

Currently, approximately 550 of these veterans have enrolled for 

VA healthcare, and about 80 percent of those are actively seeking 

some type of medical and/or mental health care.

 At this point, the vast majority of veterans have only required outpatient health care.

  In May 2004, the CARES Decision identified six additional sites of

care throughout Maine, that were authorized pending the availability of resources and validation with the most current data.

 To better meet the needs of the under served veteran populations, 

the majority of these newly authorized sites will be located in more 

rural areas of Maine, which would significantly further the attainment of a primary goal of providing veterans quality health care closer to their homes.

 Togus will continue to closely monitor implementation of these 

sites of care.

 To date we have about 69 patients receiving various stages of adjunctive care through tele-health devices. Our Home-based primary 

care unit has been using video phone devices for more than a year 

to provide follow-up and on-going care to patients in individual and 

residential home settings.

 Physician assistants and nurses use these devices to review medications, look at wounds, complete psychosocial assessments, conduct 
9

follow-up reviews for medication changes, and determine if there 

have been any other changes or medications have been changes.

 To better serve the veterans of Maine, we must continue to monitor 

their needs and find ways to meet the challenges those needs present.

 America’s veterans have earned the best care we can possibly provide, and it’s our distinct privilege to provide them with the highest 

levels of customer service.

 We will continue to coordinate closely with Maine’s veterans and 

with national and state Veterans Service Organizations, as we do our 

very best to address our veterans’ concerns.

 We certainly sincerely appreciate your interest and support in 

helping the VA to successfully accomplish our sacred mission of providing world-class care to all those who have so honorably served our 

great country.

 Thank you very much.

[The statement of Mr. Sims appears on p. 45]

 Mr. Brown of South Carolina. Let me just say, I thank both of 

you for coming today. Also, let me thank you both for addressing the 

challenges that we have in rural America to find the veterans and

find some adaptable services, that we are committed to support and

sort of move away from the institutional type of setting in the hospitals we have in place and try to get needs and services closer.

 I noticed, Dr. Post, in your testimony you talked about the wait 

time. I’m just wondering, how is the wait time for specialty-type performance?

 Dr. Chirico-Post. We continue to face significant challenges in

meeting VHAs own standards in providing specialty services within 

30 days.

 And throughout the network, there’s a variation, if you would, in 

those challenges, primarily depending on the availability of specialist.

  We don’t have significant delays in neurology -- I happen to be a

neurologist -- but we do have significant delays in gastroenterology,

eye care, orthopedic care.

  There are those sub-specialities that are difficult to recruit in certain areas.

 We have in place a system whereby there’s a prioritization, if you 

would, for the veteran who needs that care, and how that care might 

be rendered.

 If we can not provide the care in a timely fashion in one of our institutions, then we seek to do that for that veteran outside the VA on 

a fee basis.

Mr. Brown of South Carolina. How about mental health.

Dr. Chirico-Post. Let me speak to mental health as well.
10

 We have an integrated model, if you would, of the delivery of services of mental health that run the gamut from simple things that may 

be managed through -- through a primary care office; like depression

in the early stages can be managed by a primary care physician.

 So, those who are seriously mentally ill, they may require services 

of a psychiatrist. I’m very proud, in New England, that one of the 

standards that VHA uses to measure how well we’re doing in providing those services, is to look at the percentage of mental health care 

visits in our community-based outpatient clinics, where the enrollees 

total over 1500. And we do very well in that -- in that network. We’re 

not perfect. We face challenges in several of the areas.

 And, again, I’ll go back to the issue of the principal resource of the 

provider being a scarce specialty to get enough of.

 From an innovative point of view, what we have done in the network is two things. One is that, you’re probably very well aware of 

our computerized patient records. There’s no health care organization that has a computerized system like this, so that a veteran who 

is seen in Caribou, Maine, and has consulted with me in Massachusetts, I can pull up the record, as well as in California.

 That serves as a basis, I think, for coordination continuity, especially in referrals.

 That’s one thing.

 The other thing that we have done more recently is establish direct 

linkups through telemedicine that Mr. Sims talked briefly about, especially between Caribou and Togus.

 When I was chief of staff at Providence, Mr. Sims and I established 

a relationship in dermatology between Providence and Togus.

 The challenge that we faced in psychiatry, I think, is the gamut of 

illnesses that the individuals may have when they come to seek their 

care from us.

 So, we attempt to better coordinate that care. We have other resources especially in the state of Maine that we tap into, called outreach centers or Vet Centers.

  In all of New England, we have 18, and in Maine we have five.

 Recently there’s been separate funding for those Vet Centers. VA

New England received a number of those in support of that, and we 

have worked very closely with our vet centers in outreach.

 Because, sometimes the veteran doesn’t want to come to the hospital, and is much more comfortable seeing a comrade at the Vet Center, and then can get referred into Togus.

 Mr. Brown of South Carolina. Do you experience difficulty in seeing the transfer between the DOD and the VA as far as their medical 

records.

Dr. Chirico-Post. Seamless transition at this time in this country 

is the best it’s ever been, I think.

 The VHA has on the ground folks in Department of Defense to se-
11

cure a better coordination of those individuals once they get out.

  We have an office in VHA for seamless transition. I have a person

in the network, Mr. Sims has a person in the facility, that we rely on 

as the point person for just that issue.

 The electronic medical record is a challenge. There are some incompatibilities that exist right now, but both Department of Defense 

and VHA are committed to enhancing those technical challenges that 

we face to improve the response that might exist there.

 We have in the network a standardized system whereby, we go out 

to the reserve units, even before they go to discuss what will be available for them when they come back; we do the same thing when they 

come back.

  We have readily accessible to them a specific place that they can

call at any one of the medical centers when they call in, so that we 

can be there for them.

 Mr. Brown of South Carolina. I know that Mr. Michaud has some 

questions, too, but let me just ask one further question.

 In the four major services, do you have any opportunities to coordinate services, like with the medical universities, in those eight 

regions that you’re involved in?

 I know in South Carolina, in our rural areas, we have, like, family 

health clinics for our newer vets. I’m hearing reports that they were 

recommended that we need more coordination between our county 

governments and state governments and the VAs.

 Do you all have -- 

Dr. Chirico-Post. On the network side, we’re very fortunate to 

have relationships, whether it’s through the state government or 

through the medical schools, and other healthcare partners that we 

can partner with.

Just here in the state of Maine, we have a wonderful relationship 

with our state veteran homes, from a long-term care point of view, 

where we work in conjunction with them.

 For the last several years, I’ve been the co- chair of the homeless 

coordinated program through New England. And that brings to the 

table the state governments -- all of the New England states, the 

chairperson for Veterans’ Affairs, for example, of the state; the VA, 

and Social Security, to interact and integrate and coordinate resources and services one with the other.

 So, we do try to take advantage of that.

 Mr. Brown of South Carolina. In South Carolina we are looking 

at -- we also have a VA hospital in the same region or the same -- approximately in the same vicinity as a medical university hospital.

 We’re looking to replace both of those facilities, and move the VA

hospital closer to the medical university, where so many of the offices

are located. And that would help with the cost of the testing equipment, it would be a good mix to do that.
12

 Dr. Chirico-Post. At the present time, as a consequence of the 

original proposals and recommendations out of the CARES process, 

we’re also looking at integrating, if you would, three of the facilities 

in Eastern Massachusetts. And part of the equation of that is the 

relationship with the schools. And part of the equation is, how do 

you best utilize that technology? How do you better integrate the 

research programs?

VA New England has received -- the largest number of dollars from 

all of the VHA research comes to New England.

 So, we still have a number of those physicians and Ph.D. Individuals who do the research and observations, if you would, in the VHA.

 But, in addition to that, provide quality care to the veterans.

 Mr. Brown of South Carolina. We also have some outpatient clinics, but we have a combination with DOD also, with an air force base 

in Charleston; and so that’s another way of sharing.

 Thank you for your patience in answering my questions. And I

think Congressman Michaud may have some questions now.

Mr. Michaud. Thank you very much, Mr. Chairman.

 Once again, I want to thank you, Dr. Post and Mr. Sims, for your 

testimony. We enjoyed it.

 Dr. Chirico-Post, I want to congratulate you. I understand that 

you’re going to receive the VHA Recognition Award, so I want to congratulate you.

 Dr. Chirico-Post. Thank you very much.

 Mr. Michaud. We are here to help you do whatever we can to make 

sure that we take care of the veterans.

  I want to be more specific to the state of Maine. If you look at New

England, you can practically fit all of New England inside the State of

Maine. Maine’s a very large state. We can drive another hour north 

of here, and that would be the center point for the State of Maine. So, 

it’s a big state.

 I’m concerned that, with this tight budget, that money for the clinics that have been recommended under the CARES process, and the 

timing to get those programs up and running. My concern is, whether or not that funding will come out of the existing budget of Togus 

VAMC facility. I definitely do not agree with that.

 The VISN will need additional funding for these clinics. With the 

supplemental budget that was passed, will that help move these clinics forward?

 Particularly, when you look at where these clinics are located, 

whether it’s Dover-Foxcroft, Lincoln, Houlton, Lewiston-Auburn area 

-- a lot of these areas -- I know the VA has been working with local 

healthcare providers to move these clinics forward, and this will be 

great.

 So, my question is, when will they be up and running?

 The second part of that question is, have you estimated the cost 
13

for each one of these clinics, what it will cost to get them up and running?

 Dr. Chirico-Post. Let me begin to answer that question, and some 

of the specifics of the resources required to open up the individual

clinics, Mr. Sims may have those specific dollars associated with it.

 Let me also thank you for the 1.5 supplemental that we have received. I think that -- I have given my professional career to veteran 

healthcare.

 And to be recognized in that way, to receive the additional resources, I think demonstrated that, as good stewards of those resources, 

which I believe we are in the network, and Mr. Sims is in the State 

of Maine, that we will take those resources and do what’s best for the 

veteran.

 So, having said that, the supplemental clearly brings us closer to 

the implementation of the recommendation of the CARES program.

 We go back in history to the foundation of the CARES program, 

which was to look at the capital assets that we had, and provide for 

enhanced services. That’s what it was.

 And the particular recommendation for -- that affects us and in our 

discussion today was, if you look out from a demographic point of view 

over the next ten and twenty years, you realize that the numbers, the 

sheer numbers that will come to us in VHA, would increase.

 And New England, 25 years ago, we might not have said that. But, 

clearly, three years ago, when we started the process for CARES, and 

we keep updating our numbers.

 And as Mr. Sims has said, in Maine, of the six New England states, 

the greatest market penetration is in Maine. So, on average, about 27 

percent of our veterans in Maine come to receive their care through 

VHA.

  CARES recognizes, given our definition of urban rural and highly

rural, that we could -- I would say for the network, 97 percent of the 

veterans who seek their care have access to care within 30 minutes. 

That’s not true of Maine. It’s less than 60 percent. I think it’s 56 or 

57 percent.

 So, the recommendations to open the clinics in Lincoln, and to 

speak out to those other areas, that probably will be outreach.

 We originally, in the CARES proposal, started out looking at telemedicine throughout Maine. There were other opportunities. CARES

was not saying that you have to do it in one way or the other.

 I think the network, with the facility, will come forward and say, 

this is what we would like to do.

  So, the first order of business, I think, is to open Lincoln. And then

after that, to take a look at the other access points, if you would, and 

what’s the best way of doing that.

Clearly, the CARES recommendation came out at the end of -- the 

middle to end of ‘04. In ‘05, the process of protocol we need to follow 
14

is to go back into headquarters requesting to open it.

  And one of the issues for us was the financial feasibility, which we

could not do in ‘05.

 We don’t know what the budget’s going to be for ‘06. Given the 

supplemental that we received in ‘05, we’re fortunate that we’re able 

to do a number of new things for the organization.

 A new CAT scan for Maine. A mobile MRI unit on station in Togus 

at least two days a week. We would never have been able to do that.

 I think the total dollars that came to Mr. Sims out of the supplemental was something like 13 million. And that includes both the 

equipment and the maintenance that’s there.

 To get back to your question. That obviously puts us in a better 

position to be able to put together the papers and the protocol, and 

we have to see what the budget’s going to be for ‘06, to move forward 

in that regard.

 Because, we want the same things that you want, and that’s better 

access for the veterans.

 Mr. Michaud. This may call for Mr. Sims to answer. That 13 million, was that FY 05?

 Dr. Chirico-Post. Yes.

 Mr. Michaud. Now, that 11 million dollars that was borrowed, was 

that all for Togus, or was that part of VISN 1?

 Dr. Chirico-Post. Let me deal with the 11 million.

 Before we got the supplemental back in the spring, we assessed 

that we needed 11 million dollars in capital to do what we considered 

high priority safety issues for the organization.

  We never did borrow 11 million, we only borrowed five million. And

that was to be paid back with the beginning of the next fiscal year.

  So, the 11 million -- and I don’t have that figure off the top of my

head, how much of that were for projects here in Maine, but it was a 

fair share.

 As I look at the budget across the network, the Maine budget is that 

it has increased over certainly the five years that I have been network

director. And the apportionment that Maine receives in equipment 

and NRN has always been slightly greater, mostly because there’s 

36,000 veterans for us to take care of, and almost 1000 employees 

that we manage in the state of Maine.

 Mr. Michaud. The centers, Mr. Sims, how soon can they get up and 

running?

 I know, it’s the goal to come closer, but I don’t know when they’re 

going to be up and running, No. 1.

 My next question is, I’ve been hearing a lot from the veterans in the 

Lewiston-Auburn area, and what are your thoughts about a Lewiston-Auburn CBOC?

 Mr. Sims. First of all, we continue to, in anticipation of being able 

to get these up and running -- we’ve had ongoing discussion in many 
15

of the communities already. They’ve been identified.

Certainly in Lincoln, with a local facility there. The CEO, we’ve 

had discussion about possibly -- about the possibility of space, and 

how we might do that.

  In the Houlton area there’s a definite interest on the part of veteran

groups there to secure a building and have that be available for us.

 So, there’s ongoing planning in place, so that once the resources 

are available, we can move quickly and get these up in a reasonable 

time.

  Now, once we have that final notification, there are other logistics

that are required. Actually getting the equipment, getting the furniture in place, and having the space open and ready to work in.

 Lewiston-Auburn is an area that I think, certainly now, is a large 

demographic area -- second largest population concentration in the 

state -- and it’s far enough away from Togus and our other sites that 

I think that it makes sense for that to be a site for us in the future as 

we get to that point in the planning process.

Certainly, again, a fair amount of veteran interest in that area. 

We’re working very closely with the various grassroots efforts that 

are in place there to get a suitable site when that comes.

 Mr. Michaud. I see my time’s running out, Mr. Chairman. But, if 

I might, Mr. Sims, you testified -- or your testimony indicates that 22

percent of the newest veterans enrolled at Togus are using mental 

health services. 

 If this rate continues, will VA be able to provide mental health services without increasing the staff level?

 I know Maine has had an increase in funding in the VA. But, when 

you also look at Maine, 16 percent of our population is veterans. Percentage-wise, we’re one of the highest in the country.

 Likewise, when you look at those who are actively serving in Iraq 

and Afghanistan, we are way up there in numbers. We need the services. Being a rural state, that makes it much more problematic.

 So, do you think that the mental health resources will be there?

Mr. Sims. I absolutely do think so. We just recently added two new 

psychiatrists to our mental health department.

 In fact, one of those just recently came off active duty, and had 

served in Iraq, and so is very well qualified to know some of the things

that the returning soldiers are facing.

 So, we’ve added new psychiatrists, other mental health staff. We 

are fully staffed in mental health at this time.

 We have emphasis on the returning veterans, and the issues that 

they’re facing, particularly within our PTSD program.

 As Dr. Post mentioned, we have other programs coming online at 

our outbase clinic as well. And I think we’re in a good position right 

now to be able to deal with any of those issues that would come up.

 Mr. Michaud. How is Togus integrating mental health services 
16

into primary care?

 Mr. Sims. Again, there is close coordination. With the computerized medical records, the primary care providers can see what’s being 

done on the mental health side; and the mental health side can see 

the progress notes from the primary care providers. And it’s just an 

integration of the whole services.

 They’re located at Togus in close proximity to each other, and so 

consultation as needed between the providers and -- again I think, 

they are very well coordinated, and mental health services are in 

good shape.

 Mr. Michaud. Would you be able to provide the cost for clinics as 

far as what it would cost to get clinics in Lincoln and Dover and all 

other recommended sites?

 Mr. Sims. We could provide some preliminary costs. Again, it’s 

going to depend on what the lease cost may be ultimately and, you 

know, the size of the clinic when we finally configure it. But, we could

come up with some preliminary costs for you. We could get that to 

you, yes.

 Mr. Michaud. I would appreciate that.

[The information appears on p. 112]

Mr. Brown of South Carolina. Thanks Mike. Let me follow up 

along with that same line of questioning. I think you proposed five

new clinics in -- I think you said 2000, and your patient load was, like, 

what, 19,000; and I think in 2004 you had like 36,000.

 Do you anticipate by adding these new health centers that those 

numbers will go up, or do you think those numbers will be just shifted 

around to the new locations?

 Mr. Sims. We will do some shifting around, clearly that’s our intent 

for some of these. But, we know from past experience that when we 

open up these outbase clinics, that there will be new enrollments as 

well.

 And we’ve had some projections in some areas. And in Lincoln, 

for example, we’re expecting maybe as many as 400 new enrollments 

initially, and then probably some growth from there.

 But, certainly, there will be some new growth. As we put these 

CBOCs out in the rural areas, as Dr. Post mentioned, the market 

penetration greatly expands and grows in those areas because, when 

it’s there, they come.

 Mr. Brown of South Carolina. Are you finding that the veterans

are citizens of Maine, or are they migrating from some other regions 

in the United States.

 Mr. Sims. Mostly it’s Maine citizens, but certainly we get a wide 

variety. And we’re here to take care of the veterans of the United 

States of America, and we do that.

 Mr. Brown of South Carolina. I represent the coast of South Caro-
17

lina and it’s getting to be a destination of choice for retirees. In fact, 

I think it would be a good connector if we could spend winters in 

Myrtle Beach and summers up here.

 Let me ask you one other question. Do you have an idea of how 

much you’re spending for fee services now?

Dr. Chirico-Post. The network spends over 70 million dollars in 

fee services.

 Mr. Brown of South Carolina. And how much of that is in Maine.

 Dr. Chirico-Post. About 20.

 Mr. Sims. Probably about 20 million dollars, yes. It’s a significant

amount here in Maine -- 

 Mr. Brown of South Carolina. Do you see that that is costing VA

health centers more money?

 Mr. Sims. That again is our expectation, as we put these places 

closer to where the veterans live, because they’ll get their healthcare 

from us rather than the fee -- 

 Mr. Brown of South Carolina. You understand that this is a cost 

saving -- 

 Mr. Sims. Absolutely.

 Mr. Brown of South Carolina. Let me ask you just one other question and then we’ll move on to the next panel. Do you have facility 

specific data in terms of the numbers seeking enrollment solely for

the purposes of ordering or refilling prescriptions.

 Mr. Sims. I’m not sure that we do, quite frankly. It’s been significant, but I think it’s tapered off some recently, so -- 

 If we have it, I’ll get it.

 Mr. Brown of South Carolina. Let me ask another question then 

to follow up on that.

  I know, I think, in order to get a prescription filled or refilled, you

must see your doctor.

 Mr. Sims. Correct.

Mr. Brown of South Carolina. How do you feel about filling the local doctor’s prescriptions; would that help the patient load some.

 Mr. Sims. Well -- 

 Mr. Brown of South Carolina. I know that, as a policy, that may 

be something that you’d want to take a look at, but I’m just curious to 

have you address that.

 Mr. Sims. Well, the VA was established as a healthcare provider, 

not a pharmacy. And so, certainly anything that would deviate from 

that would require legislation to allow that sort of thing to happen.

 And I think that would be the response. But, there certainly is 

a significant amount of co-managed care that does go on in the VA

system, where some veterans prefer to stick with their local provider, 

and then come to the VA because of the prescription benefit.

 I think that as we open up additional sites of care, if we’re closer to 

where the veteran actually resides, that they’ll be more apt to go to 
18

VA care initially, and not seek out their local provider.

  I know we have a significant number of veterans who, once they do

come to VA, find out how good the care is, how wide the variety of care

is, and have transferred their care entirely to VA. So -- 

 Dr. Chirico-Post. A final comment that I will make on that, VHA,

through its extensive performance measurements system has demonstrated both on the inpatient and outpatient side of the house that 

we are a leader in quality, a benchmark for other healthcare organizations.

 A recent study in preparation for this that I looked at was to compare -- the joint commission publishes a performance through ORECS

and in Togus -- Togus is above other healthcare organizations in those 

inpatient performances.

 That didn’t happen by accident, it’s by coordinating the care.

 And for those of us who provide that care -- I think there has to be a 

different policy decision to support the prescription only in the VHA.

 We don’t have that policy yet.

 Mr. Brown of South Carolina. Right. And we’ve established that. 

I was just curious to know how you might feel about that.

 I know you said that your mission is to take care of these veterans and, you know, prescriptions are part of their healthcare too. I

don’t know why they would separate that, but I was wondering if you 

would just have a response to that.

 Thank you all. Mike, do you want to -- 

 Mr. Michaud. Yes. Mr. Chairman, I have, actually, several more 

questions, and I would request permission to submit the questions for 

the record so we could get the response from Dr. Post and Mr. Sims.

  As well as I want to thank you both for coming today. And I definitely encourage Mr. Sims to try to get those numbers to us, and really work hard with the hospitals out there in the community. I know 

they’re real anxious to do whatever they can to make sure that they 

can work with the VA to get the clinics up and running, because we 

definitely do need them.

 Mr. Brown of South Carolina. Thank you very much. Let’s move 

up our next panel.

 Our second panel is Don Simoneau, Vice Commander of the Department of Maine American Legion; Mr. Gary Laweryson, Chairman of the Maine Veterans Coordinating Committee; and Mr. Roger 

Lessard, President, of Local 2610 of the American Federation of Government Employees. And Mr. Lessard has been an employee of the 

VA for over 20 years.

 And we welcome you guys and we’ll ask Mr. Lessard to begin.
19

STATEMENTS OF ROGER LESSARD, PRESIDENT, AFGE LOCAL 2610; DON SIMONEAU, VICE COMMANDER, THE

 DEPARTMENT OF MAINE AMERICAN LEGION; AND GARY

 Laweryson, CHAIRMAN, MAINE VETERANS COORDINAT-

 ING COMMITTEE

STATEMENT OF ROGER LESSARD

 Mr. Lessard. Thank you, Mr. Chairman. It’s my pleasure to be 

here today. Of course, I represent approximately 800 VA employees 

in professional and nonprofessional positions at the VA facilities affiliated with Togus; also including the Bangor, Calais and Caribou

community clinics.

  Rural healthcare markets face significant challenges as compared

to urban markets, including a limited number of specialists, less access to expensive technologies, and a less affluent patient population.

 At the same time, rural Americans are disproportionately represented in the military. Thus, it is no surprise that a disparity in 

healthcare exists between veterans living in rural areas and their 

urban and suburban counterparts.

 A recent study by public health experts found that veterans living 

in rural areas experience a lower health-related quality of life. As a 

result, the veterans’ health care costs are estimated to be as high as 

11 percent greater in rural areas.

 Here in Maine, we are very familiar with these healthcare challenges. Maine ranks fourth in the nation when it comes to the share 

of veterans living in rural areas.

  Togus VA Director Jack Sims testified before the CARES Commission two years ago that only 59 percent of the enrollees have access 

to primary care services within the CARES travel time criteria, and 

only 52 percent have access to acute hospital care.

 The Togus VAMC has experienced a dramatic growth in demand 

for services over the last four years. We average between 300 to 400 

new enrollees per month.

 Similarly, our community based outpatient clinics have experienced 

tremendous increases in demand in the past few years. As a result, 

our veterans are forced to wait longer for needed medical care.

 For example, there is currently a four-month wait for ultrasounds 

in radiology, as well as a wait list for cardiology, urology, and other 

specialty care.

 The CARES Commission warned the VA of this likely surge in 

demand in its February 2004 Report to Secretary. Specifically, the

Commission recommended the addition of five CBOCs in Maine, including one in Lincoln.

 However, due to lack of funding, and contrary to the CARES Com-
20

mission’s recommendations, no new CBOCs have opened up to serve 

Maine’s veterans more promptly and closer to home.

 If and when we area able to open additional CBOCs, we will not be 

able to adequately staff them given the current hiring freeze.

 Since the start of this year, we have only been able to hire one 

new employee for every two we lost. If the freeze continues, our only 

alternative will be to take staff away from another CBOCs, causing 

shortages and delays there instead.

 Lack of funding and cuts in FTEs also affect our ability to deliver 

timely care in other ways. We have been forced by budget cuts to 

delay the implementation of important innovations such as our nurse 

case management system.

 Also, we had to delay needed capital improvements and medical 

equipment purchases, including a much needed MRI machine as discussed below.

  Despite years of short staffing, I am proud to represent a staff that

has been continuously dedicated to the caring of our veterans. At the 

same time, I also have to care about our dedicated employees who 

become ill and stressed because of mandated overtime. Prolonged 

overtime and other pressures also are causing more or our older staff 

members to take early retirement, which further adds to the staffing

problem.

 These staff shortages have forced us to hire agency staff -- an unsatisfactory stopgap measure which ends up costing the taxpayer 

more, while affecting the quality and safety of the medical care we 

provide to our veterans.

 The veterans in our state need new facilities and more staff to meet 

their medical needs. Additional CBOCs will allow us to provide more 

timely care and reduce the long distances that many veterans have 

to drive to see a doctor.

 We will not help the rural veteran -- what will not help the rural 

veteran is an increased use of costly fee basis services.

 Another VISN recently estimated that fee basis care costs 35 percent more than care provided by a VA facility. One must also consider the difference in quality in care delivered by an outside provider 

who lacks the training and resources available within the VA.

  Finally, veterans and taxpayers in Maine will benefit from the acquisition of an MRI machine at Togus.

Currently, we have to pay high prices to outside providers because 

we do not have our own MRI or PET Scan machines, diverting scarce 

health care dollars from other needs.

 If we had our own MRI machine, we could save close to a million 

dollars a year, even after including the cost of the purchase. In addition, our veterans would be able to get their screenings in- house.

 This has changed, by the way, because now we are proposing to get 

an MRI machine and PET Scan in Togus.
21

 We are grateful for the recent good news that the current shortfall in VA health care dollars has been partially addressed through 

supplemental funding. These additional dollars will enable us to undertake some of the capital improvements that we had to delay.

 In the long term, there should be a better way to provide reliable 

funding for the medical needs of returning soldiers and other veterans.

 Every budget cycle, our dedicated staff as well as the veterans we 

serve are left wondering whether there will be enough funding for 

hospital beds and doctor visits.

 Uncertain funding also takes a toll on our ability to plan for the 

long-term needs of current and future veterans.

 Thank you again for the opportunity to testify on behalf of the Maine 

veterans and thank you also for holding this hearing in Maine.

 We at Togus will continue to provide the best care for our veterans. 

I am proud and grateful that as elected officials that you have recognized how this shortfall has hurt veterans and that measures are 

needed to rectify the problems that have resulted.

 I pray that our veterans will never again have to experience these 

problems in accessing health care.

 Thank you.

 Mr. Brown of South Carolina. Thank you, Mr. Lessard. And thank 

you for your service. 

[The statement of Mr. Lessard appears on p. 51]

 Mr. Brown of South Carolina. At the conclusion of all three of 

these presentations, we’ll have some questions.

STATEMENT OF DON SIMONEAU

 Mr. Simoneau. Chairman Brown, Congressman Michaud, I thank 

you for the opportunity to testify before you today on behalf of the 

American Legion, Department of Maine, regarding Access to Primary 

Care for Rural Veterans in the State of Maine.

 According to the 2000 Census, many rural and non- metropolitan 

counties across the nation had the highest concentrations of veterans 

in the civilian population aged 18 and over from 1990 to 2000.

 The State of Maine has the fourth highest proportion of veterans 

living in rural areas in the nation at 15.9 percent. Studies have further shown that veterans who live in rural areas are in poorer health 

than their urban counterparts.

 And I present to you an article from the American Journal of Public 

Health, October 2004, to go on record to show that article and that 

study.

 The Capital Asset Realignment for Enhanced Services, CARES

Commission, report released February 2004 specifically mentioned
22

the Far North Market, which is Maine.

 Only 59 percent of the veterans in Maine are presently within the 

CARES own guidelines, to access primary care services.

  The subsequent CARES decision released in May 2004 identified

156 priority community based outpatient clinics, six of which are 

slated for Maine.

CBOCs were designed to bring health care closer to the veteran, 

and that means in the community where the veteran resides.

  After a long, hard fought battle the final commission report and the

CARES decision decided that, indeed, VISN1, and more importantly, 

Maine, needed these CBOCs to provide adequate primary care access 

to a mostly rural population.

 The CARES decision of May 2004 directed that VISN begin immediate preparation of proposals for development of CBOCs for that 

same year. However, upon inquiry to the Veterans Administration 

Central Office, the American Legion has learned that business plans

have not been submitted or revalidated during 2005, and are not anticipated until the final 2006 budget allocations are distributed and

reviewed by VISNs.

 The CBOCs of VISN 1 listed in the CARES decision are all designated for the State of Maine. The American Legion does not understand this delay. Nearly two years will have passed in preparing the 

proposals.

 Additionally, establishing a CBOC is not a not a short process, and 

now the timeline has been considerably pushed back. The VA can ill 

afford a time lapse as lengthy as two years when it comes to providing 

health care to our rural veterans.

 The nation is in the midst of a war on terror, and delaying the delivery of quality health care is not in the best interest of any veteran.

 Of special note is the provision of mental health services within the 

CBOC setting. Mental health specialists within the VA all agree that 

CBOC should provide mental health services; however, they do not.

 The committee on care of veterans with serious mental illness, has 

been monitoring this issue for years and has advocated in their annual report to Under Secretary of Health that CBOCs need to provide 

mental health services.

 It has been reported that up to 30 percent of the returning veterans from Operations Enduring and Iraqi Freedom will have mental 

health problems to include post-traumatic stress disorder.

 In 2005, Togus reported approximately 365 Operations Enduring 

Freedom and Iraqi Freedom veterans enrolled for healthcare with 

approximately 260 actively seeking medical and or mental health 

services.

 While the VA does not believe returning veterans will have a major 

impact on Togus, they are continuing to monitor it.

 The American Legion cautions the Togus facility on their optimis-
23

tic view of returning veterans and their impact on the system.

 Let us not forget that the returning veteran suffers from multiple 

physical and mental wounds and is resource intensive to treat. Those 

that put their life on the line so that we may enjoy our carefree lifestyles deserve nothing but the best, and we can not deny them their 

deserve treatment.

 What is of growing concern to the American Legion is the increasing number of veterans who are put on electronic wait lists. For example, in medical specialities, if a veteran is a service-connected at 

50 to 100 percent, priority group 1, you can usually be seen within 30 

to 45 days. However, if you are not in that priority group, you can 

wait up to year for specialties such as ophthalmology or orthopedics.

 The VA budget woes are well documented, and the American Legion 

has played a key role in bringing these shortfalls to the forefront.

 The American Legion has advocated for assured funding to ensure 

shortfalls such as that experienced by the VA this year does not happen in the future.

 Again, I thank you for the opportunity -- for giving the American 

Legion this opportunity to express our views for the Department of 

Maine. We look forward to our continued work with Congress on 

these important issues.

 Thank you, sir.

[Applause.] 

[The statement of Mr. Simoneau appears on p. 55]

[The attachment appears on p. 59]

 Mr. Brown of South Carolina. I would also like to thank Mr. Simoneau for the help you put in for locating graves of the departed veterans.

 And I was just curious as I read that last night, that there’s an initiative in other states and other regions to do a similar thing.

 Mr. Simoneau. When I started that a few years ago, it was a local 

thing, because my Post said that we need to make sure that we flag

the veterans.

 And now I’m getting phone calls from all over the country. I mean, 

I’ve had people from Ohio and Florida contact me and say, how did 

you start this, and, you know, where do you go from there. So -- 

Thank you, sir.

 Mr. Brown of South Carolina. Okay. Mr. Laweryson.

STATEMENT OF GARY LAWERYSON

 Mr. Laweryson. Chairman Brown, Congressman Michaud, we 

appreciate testifying on behalf of the Maine Veterans Coordinating 

Committee. We represent 14 organizations and speak as a united 
24

voice for the veterans of Maine.

 The VA CARES program, short for Capital Asset Realignment Enhanced Services, studied the access to Maine’s rural veteran population and concluded more Community Based Outpatient Clinics 

-- CBOCs -- were needed along Maine’s North-South corridor and 

Western Maine.

 These CBOCs would provide a greater number of Maine’s rural veterans the much need access to quality outpatient and specialty care.

  Every CBOC site within Maine is filled to capacity and are in need

of expansion to be able to continue to provide the quality care Maine’s 

veterans have come to expect. The CARES study shows Maine is 

greater in area and rural veteran population than the other entire 

VISN 1 areas.

 In 2004, the VA’s computer projections were 154,000 veterans in 

Maine that were eligible for care in the VA system.

 These projections did not take into account the veterans who move 

to Maine’s rural areas to escape the fast life, nor Maine’s growing 

retired veteran population.

 Through the efforts of the Maine Veterans Coordinating Committee and its subsidiary organizations, Togus VAMROC enrolled 500-

700 new veterans each month for over two years.

 Although this trend has slowed, Togus continues to enroll new veterans each month.

 Now that Maine’s National Guard and Reserve components are returning from Afghanistan and Iraq, many with wounds and illnesses 

requiring VA care, the need for access will again increase.

 Maine’s current VA system is stretched to the breaking point, and 

it is imperative that new CBOCs are made available to provide timely 

access to the services.

  Due to Maine’s unique geographical size, it is difficult for many of

Maine’s veterans to travel to the existing sites. Maine has no mass 

transit system. Maine’s veterans rely on the DAV shuttle bus for 

transport to Togus and the CBOCs.

 However, in the northern counties, there is only one bus available. 

Many of Maine’s rural veterans are on a limited, fixed income and are

unable to afford transportation to Togus or the nearest CBOC. Nor 

can these veterans afford health insurance or access to local care.

 The Maine Veterans Coordinating Committee believes Togus 

should be expanded to become a full service VA Regional Medical 

Center, independent of Boston. Maine’s rural veterans must now 

travel several hours one way to obtain care at Togus or a CBOC.

 To require Maine’s veterans to travel three to eight hours more to 

Boston for tertiary care is unacceptable. Maine has one of the top 

rated Cardiac Surgery Centers in the nation, and is leading the nation in long-term care and end-of-life care provided to our veterans.

 Sending Maine’s veterans to Boston removes the family and local 
25

veteran support system sorely needed to effect recovery of its veterans.

 While the majority of the nation is urban or metro, and have showed 

a slower growth, rural Maine has demonstrated a sustained growth 

pattern and will continue this trend.

 Lastly, the Maine Veterans Coordinating Committee would urge 

the VA to open lines of communications to all veterans, not just 

in Maine. In the past, the veterans have not felt the VA was user 

friendly. As a result, many older veterans and those serving on active duty have failed to avail themselves of the quality care provided 

by the current VA system.

 In Maine, the veterans are banding together to educate our veterans on the many services available to them. Operation I Served 

is a joint project initiated to provide information to Maine’s veterans, their spouses and families on services through the VA system, 

educational benefits, tax relief, financial assistance, employment assistance, housing assistance, and long-term-care options through the 

VA and Maine’s Veterans Homes systems.

 Our program has received requests and been supplied to many 

other states.

 Again, on behalf of the Maine Veterans Coordinating Committee 

and the Maine veterans we represent, thank you for allowing us the 

opportunity to speak to you.

 The Maine Veterans Coordinating Committee looks forward to continuing to work with Congress to enable the VA to provide quality 

services to all veterans.

[Applause.]

 Mr. Brown of South Carolina. Thank you very much. And thank 

you for that report.

[The statement of Mr. Laweryson appears on p. 64]

 Mr. Brown of South Carolina. We’ll continue the questions.

 Mr. Simoneau, while this hearing is focused on primary care, do 

you think there’s any utility in using new innovative technology such 

as telemedicine to help fill the current gap of specialized services you

mentioned in your testimony, like tele-psychiatry?

 Mr. Simoneau. Congressman, I guess my own -- my own gut instinct is that, if I’m suffering from PTSD, or I’m suffering from mental illness, I want to talk to a person. I don’t want to sit in front 

of a telecommunication device and testify in front of something that 

scares the puppy out of me.

 And I believe that a doctor or a therapist immediately for that patient needs to be there for that type of service.

 Mr. Brown of South Carolina. Do you see any line of treatment 

where telemedicine might work, like eye examinations, blood sugar 
26

checking, and many other different types of diagnostic testing situations that you believe it could fit.

 Mr. Simoneau. I believe there are places that tele-communication 

will work. But I think that we have to be real careful in placing what 

items in front of that type of situation.

 If we’re talking about a doctor being able to look at reports and do 

things with telecommunication with a patient that are paper-work 

intensive or such, yes.

 But, when it gets down to an exam, where you’re really talking 

about the nuts and bolts of what’s going on with the patient -- a lot of 

these people have been through stresses already in their lives.

 And to put them under the stress of a television camera I think is 

unfair. There are places they can be used, I agree. But, I think we 

have to be very careful in picking those areas.

 Mr. Brown of South Carolina. Mr. Laweryson, your written testimony suggested that VA is not notifying younger and older veterans 

of the services available through the VA. I know there’s the American Legion and other avenues.

 What type of outreaches would you like to see that aren’t currently 

taking place in Maine or other regions of the nation?

 Mr. Laweryson. Well, sir, I think the VA has to overcome the past 

transgressions.

 What I mean by that is, the communications. The VA right now is 

user friendly. From the Vietnam era on, it wasn’t user friendly. And 

that stigma sat there for a long time. We have seen an increase of 

Vietnam veterans coming, and that’s due to the fact that this -- we’re 

used to working with the VA on that. Communication goes out, and 

then it’s up to the service organizations to get the word out, and explain to them that this is a user-friendly system now.

  And, as Mr. Sims eluded to, once they get in there they find out --

you know, it’s like Christmas. This place is fantastic.

 And then they come back out and spread the word again. But, it’s 

a fact that we need to get that word to them, especially the older ones 

right now with the economy the way it is and the fuel. There’s tough 

times ahead in the state of Maine, especially -- an hour north or here, 

either side of 95, is a bit lonely. There’s not much out there.

 And a lot of your combat veterans, not just from Maine, but from 

other states, gravitate to this solitude. There’s a great number up 

there that are hiding.

 The 154,000 veterans that we have, and -- we feel it is higher -- and 

our objective or goal is to notify as many of them as we can. That’s 

why we went from 16,000 to 36,000. And we tend to make Jack earn 

his money up there, get another 10 to 15,000 enrolled.

 Mr. Brown of South Carolina. Mr. Simoneau, do you have any 

suggestions of how we might be able to reach the veterans and notify 

them of the services available.
27

 Mr. Simoneau. I believe part of our problem in the state of Maine 

is how rural we are.

 You can go an hour from here and not have cell phone communication down the street. You can go across the street and not have communication on the Internet.

 There’s a lot of people within the state of Maine who don’t have TV 

cable. There’s a lot of access issues within the state of Maine that are 

really prevalent to the state of Maine because of the type of state we 

are.

 Reaching those people is a full-time job, and I’m not sure how we 

can better do that.

 The veteran organizations go out there, but you need to understand, some of these veterans are really skeptical about a veterans 

organization. You know, what do they want from me.

 And they’re afraid of the VA system. The VA turned me down when 

I got home from World War II. I went over to see them and they said, 

sorry, you’re okay, go home. And that veteran in 1946 went home.

 And now, when he’s 80 years old, we try to tell them, you know, you 

need to go to Togus, you need to get some help.

 He looks at me and he says, but they sent me away in 1946.

 And you would be surprised how many veterans that are out there 

that are that way. And I’m talking 1946, World War II veterans.

 But, we can do the same thing with the Korean veterans, and we 

can do the same thing with the Vietnam era veterans, and I’m sure 

down the road with the Iraqi Freedom veterans, we’re going to have 

that same issue.

 How do we do that? I’m not sure.

 We’ve done local areas where we bring in people from the VA, people from the Maine Veteran Services, and we sit down and we ask 

veterans to come to the community to apply for help, to talk to people. 

Those fair-type systems work very well.

 But, to put them on in a state as rural as Maine is tight skating.

 Mr. Brown of South Carolina. Do you have something like a mailing list? I know the post office gets to everybody, I would assume

that, even up here -- 

 Do you have up here a mailing list where you have everybody recorded?

 Mr. Simoneau. I believe, under the Freedom of Information Act, 

and all of the other requirements for protecting peoples’ rights, that’s 

one of the drawbacks of those rights, and that protection.

 The names are out there, but we don’t have access to them. We 

have access to the 26,000 members of the American Legion here in 

the state of Maine, but we don’t have access to the 156,000 that are 

actually veterans.

Mr. Brown of South Carolina. Okay. Mr. Michaud.

 Mr. Michaud. Thank you very much, Mr. Chairman.
28

 Mr. Laweryson, you talked about the Operation I Serve program. 

I was really intrigued by that. And living in the state of Maine all 

my life, I know how rural the state of Maine is, and it’s problematic 

particularly when you look at the economic hardships which we have 

had over a number of years with mill closings and what have you.

Currently we’re going through the BRAC process and we don’t 

know how that’s going to end up for bases in Maine.

 In the program, Operation I Serve, how do veterans know about 

that program? I know it’s difficult. We do have telecommunications

here, but is there a website, or an 800 number that they can call in? 

Do you do mailings?

Can you tell us a little bit more about the program?

 Mr. Laweryson. The I Serve, we have a website, www.mainedvs.

org. They get the information from there. The packets come out in 

the county where it’s most rural up there.

  Every town office gets a copy of this on CD as well as the paper one.

And that was done through the coordinating committee. We got the 

funds ourselves, and we got a veteran up there, John Wallace, who’s 

working on his own.

 And we’ve got this as far south as North Carolina now. I retired 

from the Marine Corps down there. And when I went down there this 

summer, I dropped it off at the VA transition site at Camp Lejeune. 

 We also picked up the VA transitional list, and we’re in the process 

of sending them all over the states, which is the major military installations.

[To Chairman Brown.] South Carolina will get theirs shortly.

 But, the veterans returning from active duty, the ones in Maine, 

we got to let them know. Because when I decapped, we knew nothing about Maine. I grew up here, but I didn’t know what the services 

were.

 And I come back and worked through the system. So, what we did 

is put down the state commanders and the Maine Veterans Coordinating Committee the one with the BBS, and he’s sit down and come 

up with a list of phone numbers, points of contact in the state, federal 

level.

 We amend this every three to four months. We’re putting on all 

of the elected officials now. The governor’s on board with this. He

made the announcement the 11th of November. He was kicking this 

off. He fully supports it.

 We’re grass roots. We’re paying for it for ourselves. It isn’t costing 

the state anything.

 But, it’s helpful to the state because we’re getting the veterans in 

here. It’s a slow process.

 At town meetings I think would be the way to go.

 The VA wasn’t allowed to go up and actively enroll because they 

were shut down, because of the waiting list. Our philosophy was, if 
29

you could get the numbers then you could justify them paying or getting the money to us. And it works.

 And Jack Sims down there, at VA Togus, is doing a phenomenal job 

taking care of our veterans, and he wants to do a better job. That’s 

why we’re trying to get the veterans in there.

 It’s a challenge. And other states have asked us for it, and they’re 

starting to -- I think the key word is you work together. All of the veteran organizations have to work together. Dance on the same sheet 

of music, and we’re also building the VAs.

  They get this out to the congressmen’s offices and the senator’s offices, and they’re aware of this, because they’re getting an influx of

senior citizen centers, hospitals.

 Get it out there and get it in front of them. Things are getting tight 

out there, and these people have got to make decisions. Do put heat 

in the house? Do I pay for the pills? And it’s getting to the point 

where some of their kids bring them in to us.

 It works. The CBOCs are critical. If they can’t travel down to 

Bangor, we’ve got one in Lincoln, we got one in Houlton -- that’s the 

North-South corridor. And the western corridor goes across Route 2 

and goes over towards Rumford and that area. And, of course, Lewiston-Auburn is a large city for Maine.

 Mr. Michaud. And don’t forget Dover-Foxcroft.

 Mr. Laweryson. Well, no, we can’t forget that.

 Mr. Michaud. How would you -- to follow up on that question.

 What I’ve seen, particularly when Great Northern, where I worked 

for 30 years, shut down and filed bankruptcy, a lot of the workers

there are veterans.

 How do you convince someone who’s working currently -- has good 

health care benefits, do not need them to go to the VA at all, how do

you convince them to sign up to make sure that they’re taken care of? 

Is there a lot of resistance?

 Mr. Laweryson. It is and it’s due to a lot of rumors up there. And 

the rumors are rampant.

 You can come out here and say, you know, the VA is the way to go. 

And someone else is out there saying, you don’t want to go to VA because -- they’ll kill you, and it’s slow, the waiting list is prenominal.

 Well, in some cases it is and some cases it isn’t. It’s the education 

system. Again, this is part of it.

Category 8s, there’s going to be a wait, Category 7s, there’s a wait.

 There’s a priority list, and the priority list is there for a reason. 

There’s a priority given your treatment for the VA.

 They need to understand this. Once they’re made aware of it, and 

what’s available, there’s not a problem. They feel that they can go 

down there and get into this.

 But there are a lot of veterans out there who really need to be in 

there, they’re just unaware.
30

 And we need -- as the veterans that are active now, we have to communicate to them, and do so on a level that they will understand and 

are comfortable with, so they you can come to the VA and get proper 

treatment.

 Mr. Michaud. Mr. Simoneau, in your testimony, you raised concerns about electronic waiting lists. And, actually, I think the VA

Inspector General came out with a report that says that the VA is 

under-reporting the number of veterans on the list, and that they’re 

over-reporting the number of veterans who are receiving services 

within 30 days.

Can you elaborate more on the problems at Togus and at the clinics?

 Mr. Simoneau. I won’t elaborate on numbers, because I guess, as 

you can see, numbers will tell whatever you want to say.

 I’ll elaborate on the fact of people that I know of within the system.

 And people I knew within the system get very frustrated. They 

think they have an appointment. They think they’re all set, and then 

all of a sudden they’re on this list and, oh, by the way, your appointment isn’t this month, it’s not next month. We’ll get back to you.

 I get real nervous over electronic wait lists. I’m just not sure -- once 

again, we’re taking a person out of the middle of that system.

 Mr. Michaud. To follow up on that question that’s very similar, 

what would you recommend that we would do at the federal level, in 

the sense that there are waiting lists, and the veterans are waiting 

and going for services after retirement?

 Is there something that we could do to help in the short term to 

help veterans? 

 Mr. Simoneau. I believe that we need to come up with some sort of 

emergency funding for these veterans. I believe we need to come with 

some sort of pilot program where a veteran who applies for assistance 

in Togus, or Rumford, or Portland, wherever, when he applies for assistance, he needs assistance now. It’s not six months from now.

 But, he’s also not eating well, he’s not paying the rent well, he’s not 

paying the electric bills well. He has no assistance out there to help 

him get by, until when he gets his paperwork done, that says, oh, yes, 

he’s PTSD, a hundred percent, he should have been qualified for that

two years ago.

 But, there’s no safety net out there for him. When he applies for 

it, from the time he applies until the time he actually sees somebody, 

where the system is kicking in, time goes by and the veteran is hanging out there on a thread.

 And those are the veterans that sooner or later run away from the 

system because, well, gee, I can’t do that, and I don’t know where to 

go.

 So, we need to come up with some sort of safety net, be it an emer-
31

gency-type funding mechanism, or something that can temporally 

get that veteran through a tough time that he finds himself in. And

there’s got to be a way to do that. And we need to be able to sit down 

and figure that out, because those veterans are walking away from

the system that they need, but they’re afraid they’re going to starve 

to death before they get through it.

 Mr. Michaud. My last question is for Mr. Lessard.

 Since Congress has provided additional funding--and the legislation was just signed recently--for the budget short-fall at the VA, has 

Togus started to fill some of the vacancies, or started to conduct some

of the needed repairs at Togus?

 Mr. Lessard. Congressman Michaud, not as of yet. We have tried 

to fill some of the gaps, but they’re not fully staffed as of yet. And I’m

sure that we will be working on that in the near future.

 Mr. Michaud. Can you give any examples of lack of adequate staff? 

What are they doing to veterans’ access to care?

 Mr. Lessard. It’s delaying some of the clinics, I believe, in some of 

the areas where they’re short- staffed.

 It’s also causing -- as I mentioned in my testimony, we are causing 

older nurses that would remain for another four or five years to retire

early, due to the mandated overtime due to the short falls in staff.

 It has a great demoralizing effect on the employees.

 Mr. Michaud. Thank you.

 Mr. Brown of South Carolina. Okay. Thank you very much, Gentlemen, for your testimony, and for what you do to support our veterans. I know I had the privilege this past Memorial Day to go to 

Normandy and be a guest speaker. And what a moving experience it 

is. We saw all those flags, over 9,000, of those Americans who never

got a chance to come home; a lot of 17- and 18- and 19-year-old kids. 

The price of freedom of this nation is tremendous.

 And I pledge to you, and Mr. Michaud certainly has been supportive, as part of the Health Subcommittee, assure you guys and you 

girls that you’ll have support up here.

 And it’s been a real pleasure for me to come today and be part of 

this session.

  And you can be absolutely sure that we try to find other ways to

make the problems up here much better, and support the staff and 

the various operations around the nation.

 But, it can’t happen unless we have the feedback from folks like 

you. And we thank you for taking your time in coming and being 

with us today, and the preparations you made to make these presentations.

 And I do thank you. Thank you all for coming and being part of 

this process.

  Mr. Sims, I guess I have one other official thing -- I think you have

something you wanted to submit for the record, and I’ll also note that 
32

at this time.

 Mr. Michaud. And I guess you have been reading my mind, Mr. 

Chairman, because we work so closely here, I was going to actually 

mention that Mr. Sims wanted that included for the record.

 And, once again, Mr. Chairman, I want to thank you for taking the 

time to have one of the two hearings that we’re having in the country 

as it relates to healthcare for veterans in Maine. And the State of 

Maine really appreciates that. And I want to thank all of the veteran 

organizations and veterans that came out this morning to be with 

us.

  Thank you for your testimony, it definitely has been enlightening,

and we’ll be sitting down with the Chairman to move forward.

 So, once again, thank you very much.

 Mr. Brown of South Carolina. This meeting stands adjourned. 

Thank you very much for coming.

[The statement of Senator Olympia Snowe appears on p. 35]

[The statement of Ronald W. Brodeur appears on p. 66]

[The statement of COL Edward L. Chase, USAF (Ret.) appears on 

p. 70]

[The statement of Roger Landry appears on p. 75]

[The statement of Timothy J. Politis appears on p. 78]

[The statement of Peter W. Ogden appears on p. 86]

[The information appears on p.89]

[Whereupon, at 10:39 a.m., the Subcommittee was adjourned.]
(33)

APPENDIX
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August 2005 field hearing in Maine.

Rep. Michaud, asked Mr. Jack Sims, Director of the Togus VAMC, 

if he could provide the Subcommittee with the cost for clinics in 

Lincoln, Dover-Foxcroft and the other recommended sites (e.g, Lewiston-Auburn). Mr. Sims replied that yes, he could provide preliminary costs which are provided below. 

CBOC Name Start Up Costs 

Unnamed (TBD) CBOC (4,000 uniques) $1,433,865 

 

Lincoln (1,168 uniques) $822,000 - $1,027,500 

 

Dover-Foxcroft (768 uniques) $555,298 

Houlton (300 uniques) $525,662 

S. Paris (300 uniques) $525,662 

Farmington (300 uniques) $525,662 

 

Start Up Costs Est from $4,388,149 to $4,593,649 

113