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[Senate Hearing 109-365]
[From the U.S. Government Publishing Office]

                                                        S. Hrg. 109-365
 
      FORGOTTEN VETERANS: IMPROVING HEALTH CARE FOR RURAL VETERANS

=======================================================================

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED NINTH CONGRESS

                             FIRST SESSION

                               __________

                            AUGUST 16, 2005

                               __________

       Printed for the use of the Committee on Veterans' Affairs

 Available via the World Wide Web: http://www.access.gpo.gov/congress/
                                 senate

                                 ______

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                     COMMITTEE ON VETERANS' AFFAIRS

                    LARRY E. CRAIG, Idaho, Chairman
ARLEN SPECTER, Pennsylvania          DANIEL K. AKAKA,  Hawaii
KAY BAILEY HUTCHISON, Texas          JOHN D. ROCKEFELLER IV, West 
LINDSEY O. GRAHAM, South Carolina        Virginia
RICHARD BURR, North Carolina         JAMES M. JEFFORDS, (I) Vermont
JOHN ENSIGN, Nevada                  PATTY MURRAY, Washington
JOHN THUNE, South Dakota             BARACK OBAMA, Illinois
JOHNNY ISAKSON, Georgia              KEN SALAZAR, Colorado
                  Lupe Wissel, Majority Staff Director
               D. Noelani Kalipi, Minority Staff Director

                            C O N T E N T S

                              ----------                              

                                  DATE
                                SENATORS

                                                                   Page
Salazar, Hon. Ken, U.S. Senator from Colorado....................     1

                               WITNESSES

Condie, Michael, Routt County Veteran Service Officer............     5
    Prepared statement...........................................     7
Riedinger, Fred, La Plata County Veterans Service Officer........     9
    Prepared statement...........................................    11
Biro, Lawrence A., Director, Veterans Integrated Services Network 
  19.............................................................    12
    Prepared statement...........................................    14
Murphy, Michael W., Director, Grand Junction VA Medical Center...    16
    Prepared statement...........................................    17
Allin, Cephus, M.D., AFGE Member and Employed at the Ft. Collins 
  VA Outpatient Clinic...........................................    19
    Prepared statement...........................................    20
Watkins, Charles, Veterans of Foreign Wars, Colorado Department 
  Chief of Staff, Craig, CO......................................    28
    Prepared statement...........................................    29
Stanko, James W., American Legion District 14 Commander, 
  Steamboat Springs..............................................    31
    Prepared statement...........................................    32
Leonard, George, World War II Veteran, Durango, CO...............    34
Richards, Howard, Southern UTE Indian Tribe Past Chairman, 
  Vietnam Vet, Ignacio, CO.......................................    34
    Prepared statement...........................................    35
Rothman, Paula, Gulf War Veteran, Grand Junction, CO.............    36
    Prepared statement...........................................    37
Stroncek, Hank, World War II Veteran, Steamboat Springs, CO......    38
Yoast, Leonard, World War II Veteran, Hayden, CO.................    39
Adams, Michael, Iraq War Veteran, Norwood, CO....................    39
    Prepared statement...........................................    40

                                APPENDIX

Mackenzie, Earl, President, Local 1014, American Federation of 
  Government Employees, AFL-CIO..................................    43
Letters to Hon. Ken Salazar from:
    Darrell Anderson.............................................    44
    Erin T. Cavitt...............................................    44
    Tom Gangel...................................................    45
    Karl B. Gills................................................    46
    Paul G. Olson................................................    47
    T.A. Ottman, USMC............................................    47
    Gar Williams.................................................    47
Letter to Mr. Gar Williams from Sue Lyster.......................    48

      FORGOTTEN VETERANS: IMPROVING HEALTH CARE FOR RURAL VETERANS

                              ----------                              

                        TUESDAY, AUGUST 16, 2005

                               U.S. Senate,
                    Committee on Veterans' Affairs,
                                                    Washington, DC.
    The committee met at 9:37 a.m., in the City Hall 
Auditorium, 250 North Fifth Street, Grand Junction, Colorado, 
Hon. Ken Salazar presiding.
    Present: Senator Salazar.

   OPENING STATEMENT OF HON. KEN SALAZAR, U.S. SENATOR FROM 
                            COLORADO

    Senator Salazar. Let me go ahead and call the hearing of 
the Senate Veterans' Affairs to order this morning here in 
Grand Junction, Colorado. I would like to welcome each and 
every one of you who is here today. I appreciate your 
attendance at this hearing.
    I also, at the outset, wanted to thank staff from the 
Veterans' Affairs Committee that has traveled from Washington 
to be with us here today. They are Alex Sardegna and Sara 
Hofstetter over here to my left. They do a wonderful job of 
working with Senator Larry Craig from Idaho and with Senator 
Danny Akaka from Hawaii, along with my other colleagues on the 
Veterans' Affairs Committee. I appreciate them coming down from 
Washington and spending some time with us.
    To my left are two key people whom I would hope the 
veterans of Colorado, and especially those of you on the 
Western Slope, get to know. Carlos Monje is my staff on 
veterans' issues and has helped write much of the legislation 
that we have sponsored in the Senate on veterans issues. 
Matthew McCombs who has joined our staff here in Grand Junction 
is an Iraq war veteran. Matthew just recently returned from 
Iraq, and he will be working with us here in the Grand Junction 
office and, hopefully, addressing some of the issues and 
helping us address some of the issues that we are working on 
today.
    Way at the left standing in the doorway is Bennie Milliner. 
Bennie Milliner is a Vietnam era vet who is on my staff and 
also in charge of working on veterans issues for us here in 
Colorado. So thank you all for being here.
    Now, we are here this morning to examine the challenges 
that rural veterans are facing across Colorado. I want to thank 
the veterans and the volunteers and all of the State and 
Federal officials who are here today at this hearing.
    When I went to Washington as a U.S. Senator for the State 
of Colorado, I asked to serve on the Veterans' Affairs 
Committee. I did so because I believe that the freedoms that we 
enjoy in this great Nation of ours and the celebration of 
democracy that we engage in every day, including what we are 
doing here today, is a result of the great actions that today's 
veterans and the veterans of the past have taken to defend the 
democracy and the freedoms that we so enjoy here in this 
country today. So my work on the Veterans' Affairs Committee is 
my way of saying thank you to all of you veterans, to my father 
who is a proud soldier of World War II, my brothers who have 
served, to my uncle who left his life on the soils of Europe 
defending our country in World War II. My service on that 
committee, hopefully, will make a difference as I work with my 
colleagues on that committee to address the issues that our 
veterans face around our country.
    I have been honored to work on that committee to resolve 
some of the issues that we have faced even in this last year, 
including the billion-dollar shortfall that we had with respect 
to funding for health care for veterans and joining my 
colleagues in a successful amendment that we passed in the 
Senate to have another billion-and-a-half dollars for health 
care for veterans just for this year alone to build that 
shortfall. I am also working with the Veterans' Affairs 
Committee to make sure that we avoid a similar budgetary 
problem in the future.
    Here in Colorado, closer to home, we have worked very 
closely with my colleagues, both in the House of 
Representatives and the Senate and with former Secretary 
Principi and now Secretary Nicholson in moving forward with 
what, hopefully, will become a crown jewel of veterans health 
care in America, and that is a new hospital that is being 
planned or proposed for construction at Fitzsimmons. That 
hospital should be a state-of-the-art facility because of the 
other hospitals and health-care expertise that is going to be 
located at Fitzsimmons. We hope that is a project that we can 
bring to reality. I appreciate the efforts of Secretary 
Nicholson and Secretary Principi and the staff of the Veterans 
Administration working with us on that project.
    My family has farmed the same lands in the San Luis Valley 
now for almost 150 years. It was on that ranch, as I was 
growing up as a young man, where we didn't have a telephone and 
we didn't have electricity. It wasn't until 1981 that the phone 
lines and the power lines reached out to our ranch. Although we 
were poor in material goods, we were rich in the spirit and the 
values of our parents.
    During World War II, as I said earlier, my father was a 
soldier in World War II, spent time in Hawaii during the days 
of Pearl Harbor. Four years ago he died at the age of 85. He 
was forever proud to have been a veteran. He was a lifetime 
member of the VFW Post 4849 in La Jara, Colorado in the San 
Luis Valley. Before he passed away he asked us to bury him in 
his World War II uniform, because he was so proud of his 
service to our country.
    My mother at the age of 20 came from a village that had no 
name, and, yet, was working with that greatest of generations 
in the War Department at the time making sure that we defended 
our country from that great world war.
    As I have gone to Washington as a U.S. Senator for 
Colorado, I believe that some of the values that we had in the 
past to make sure we were supporting those who defended the 
cause of freedom and those who have stood up for rural America, 
that we have not given it as high a priority as perhaps we 
should. You know, I come from one of the poorest and most rural 
counties in the State of Colorado. I know that in rural America 
we sometimes face challenges that are not faced in communities 
where you have populations of 100,000 or two-million people. It 
was my decision to go ahead and ask the Veterans' Affairs 
Committee to hold this hearing here in Grand Junction so we 
could learn more from the VA on how we can better serve our 
veterans in rural areas and how we can address the issues that 
the Veterans Administration currently has questions about 
health care.
    Rural America has given up its sons and its daughters to 
the cause of freedom in numbers that far exceed its proportion 
of the country's population. These American heroes have not 
sought praise or thanks. They came back from the battle field, 
rejoined their communities, and quietly went to work as 
Americans. They have done their job to serve Americans. We 
must, as a Nation, do our job in now keeping our commitment to 
the nation's veterans.
    Veterans in rural areas are in poorer health than their 
urban counterparts. A 2004 study found that rural veterans 
scored worse than urban veterans, both in overall health and 
mental health. Because of the distance and difficulties of 
obtaining care, many rural veterans put off preventive as well 
as necessary treatment which results in poor health and 
ultimately increased health costs.
    In Colorado more than 65,000 veterans live in rural 
communities. Thousands more live in small towns that are spread 
across our great state. In too many rural corners of Colorado 
there are isolated pockets of veterans who do not have access 
to VA care.
    We have on our panel two representatives from the VA. I 
have to give Mike Murphy and Larry Biro credit for running 
outstanding programs. VISN 19 has consistently been rated at 
the top as a service network in the Nation and here in Grand 
Junction. I know both of you and thousands of VA and employees 
are doing great work to improve care for rural veterans within 
a very tight budget that you cannot fully control. I appreciate 
the work that you do on those issues every day. I look very 
much forward to hearing from you.
    Clinic access, we will hear from veterans in northwestern 
Colorado who have to drive as many as 360 miles round trip 
through windy mountain roads to reach the VA Medical Center in 
Grand Junction. Many of them have to make this trip just to 
have basic checkups or to fulfill their prescriptions. This is 
a grueling trip that takes an economic and physical toll on our 
veterans and leads many to not seek care.
    I believe that we need additional VA outpatient clinics in 
rural Colorado. For too long tight budgets and bad priorities 
have slowed the building of new clinics across the country. 
Earlier this year I introduced legislation that would have set 
aside 150-million dollars over several years to establish new 
clinics for rural America. Even though a bipartisan group of 12 
Senators co-sponsored this amendment, it was not approved this 
year. I hope to work with both my Democratic and Republican 
colleagues on the Veterans' Affairs Committee to move forward 
with this initiative for next year. I look forward to the 
support of veterans' service organizations in this particular 
effort.
    Today we also will hear from veterans across southern 
Colorado who have access to extremely good VA clinics but have 
to face administrative red tape and often lack the specialized 
care in those communities.
    We will hear a representative of the Southern Ute Tribe 
where we will hear the unique challenges that Native Americans 
and veterans for Native Americans face in our country.
    We will also hear from brave and dedicated State officials 
in veterans' groups who are providing transportation services 
to rural veterans. Often these transportation programs are 
created on shoestring budgets with volunteered drivers and 
borrowed vehicles. Such programs currently exist out of the 
people who support those programs in Alamosa, in La Plata 
County, Moffat, Prowers, Weld Counties and even VSO's in 
Denver, Colorado. These are successful programs, but financial 
constraints place these programs in jeopardy.
    I introduced Senate bill 1191, the VetsRide Act, to help 
programs like these survive. The bill provides small grants to 
State veterans' service officers and veterans' service 
organizations that help provide transportation to VA medical 
centers or otherwise assist in providing medical care to 
veterans in remote rural areas. This bill has earned the 
support of 10 Senate co-sponsors including 5 influential 
Republican and Democratic Senators. I am negotiating with my 
colleagues on the Senate Veterans' Affairs Committee to get the 
legislation approved so that we can continue these 
transportation programs that are a lifeline to many rural 
veterans.
    Today we also will discuss a number of other important ways 
that the VA can extend care into rural areas in a cost-
effective way. The first is a fee basis or contract care. To 
provide, the VA can pay for routine care for local third-party 
providers if the VA cannot provide that care itself. Fee-basis 
care can be an important tool in extending health care to rural 
vets.
    Unfortunately, the VA's fee-basis policies vary widely 
across the country, and the weak budgets that we have provided 
to the VA has left thousands of rural veterans without the care 
that they would otherwise receive.
    The second is tele-medicine. Although nothing can replace 
the personal touch of a medical professional, tele-medicine can 
extend care and improve lives of veterans. For instance, tele-
medicine can allow the diabetic veteran to keep in close 
contact with their doctors even if they are hundreds of miles 
away.
    I recently heard from a Denver psychiatrist who was issuing 
tele-medicine to treat rural veterans in La Junta and Alamosa 
for Post Traumatic Stress Disorder. This technology holds great 
promise, but right now it impacts a very small percentage of 
veterans. We need to invest in these technologies so that rural 
veterans can have access to better care.
    At the heart of many of these problems is a need for 
additional VA funding. I personally believe we need to make 
funding for the Veterans Health Administration mandatory so 
that the VA never has to ration care and so the veterans never 
have to worry about losing their health care.
    Rural areas are the heart of our forgotten America, and 
rural veterans too often are our forgotten veterans. I look 
forward to hearing the testimony of our witness and working 
together to keep our promises that our Nation has made to all 
of our veterans including rural vets.
    Before we proceed to the first panel, I would like to go 
over a few ground rules established by the Committee on 
Veterans' Affairs for this hearing. Because of the time 
constraints of this hearing, we will have to limit today's oral 
testimony to the witnesses approved by the Committee. I 
understand that many of you have concerns and experiences you 
would like to share, and I would like to keep the official 
record open so that your written testimony can be part of the 
record of this hearing. My staff has testimony forms that you 
can fill out, and you can fill them out here and return them to 
my office via the instructions that are laid out in that form.
    Second, I will ask the witnesses today to limit their 
important testimony to 5 minutes. We have a card system in 
place to remind you of when your time is expiring. Matthew will 
hold those times up. Green means you go, just like a traffic 
light. Yellow means you have 1 minute left, so be careful. Red 
means your time is up. We have a large number of witnesses, so 
I will ask the witnesses to hold their comments down to the 
time that we have allotted.
    In our first panel we will hear from Federal and State 
officials, and in our second panel we will hear from the 
veterans' service organizations.
    Our first panel will consist of Michael Condie who is the 
Routt County Veterans Service Officer.
    Fred Riedinger who is the Veterans Service Officer for La 
Plata County.
    Larry Biro who is Director of Veterans Integrated Service 
Network 19, and who has done a great job working with us on the 
Fitzsimmons project.
    Dr. Mike Murphy who is the Director of the Grand Junction 
VA Medical Center.
    And Dr. Cephus Allin who is a member of the American 
Federation of Government Employees who works at the Ft. Collins 
VA outpatient clinic.
    With that, I am going to ask Mr. Condie to please proceed.

   STATEMENT OF MICHAEL CONDIE, ROUTT COUNTY VETERAN SERVICE 
                            OFFICER

    Mr. Condie. Well, one of the things that is interesting 
about this whole thing is--thank you very much for having us 
here from Steamboat Springs. I did send a number of pieces of 
paper, literature, to Carlos Monje, letters from the Yampa 
Regional Medical Center, letters from the Mental Health 
District, and a letter from myself.
    Specifically, I want to say living in a rural area, which 
you are quite familiar with, is rather trying to begin with. I 
also have a map here that I want everyone to see about the 
empty quarter. We are considering the empty quarter. We have 
nothing. We have no representatives from the VA in our 
northwestern Colorado. Travel takes roughly 3\1/2\ hours 
starting in Steamboat Springs to Grand Junction. It's 191.5 
miles one way from Steamboat Springs to the Grand Junction VA 
Hospital. So, essentially, the day is shot for an individual.
    What I do is, like what I did today, is I rent a vehicle 
from the Ford dealership in Steamboat Springs, hire a driver, 
usually a veteran who is unemployed to drive. Because a 
volunteer from that region to drive a vehicle down to Grand 
Junction or to Denver, you aren't going to do it. It doesn't 
happen.
    Even though I approached both the VFW and American Legion 
membership to be volunteers, they say they will do it at the 
moment, but when it comes down to the time when you need a 
driver, it doesn't happen. So I pay the drivers $75 for the 
round trip, rent a vehicle. Like today, I rented a six-place 
Ford Explorer 2005. I get a pretty good deal because the owner/
manager of Steamboat Motors Ford Dealership is an Army veteran, 
so they provide me a better deal on rental vehicles.
    But, other than that, the veterans who utilize the 
transportation system, which I created 4 years ago, because I 
kind of got angry. There was a veteran who needed 
transportation to the VA hospital at least four times a year to 
take care of physical issues, a World War II veteran. It took 
so much from his family to get him down here, whereas, 
something had to happen.
    What happened was I started writing grants. I have been 
writing grants for the last 4 years to obtain funding. I write 
grants through the Veterans Trust Fund of Colorado. For this 
year, I wrote a grant through the Yampa Foundation, which is an 
organization that comes out of Steamboat Springs. I planned to 
write a grant in October through the Yampa Electrical 
Association. So that tells me that those folks and the public 
in general support the veterans, and they support veterans' 
issues.
    I get the money from grants. I put the funding in Alpine 
Bank at Steamboat Springs. It's in an account that doesn't cost 
me anything, and it's an interest-bearing account. Not a whole 
lot of interest, but, hey, it's something. Veterans who need 
transportation, can get transportation to the Denver VA 
Hospital or to the Grand Junction VA Hospital on demand.
    Today the vehicle that I rode in transported five veterans. 
I have another vehicle that's leaving Steamboat Springs at 9 
o'clock that will transport one veteran, and he's a World War 
II veteran, served in the Pacific. The two veterans that came 
with me, the two older veterans that came with me, are World 
War II veterans. One veteran worked with the Army Air Corps in 
the Pacific. The other veteran was with the Coast Guard, and he 
served in the Atlantic and he served in the Pacific. These guys 
have seen a lot, and they utilize the VA system because health 
care in Routt County in northwestern Colorado is expensive. 
It's hard for veterans to be able to pay for and acquire 
affordable health care.
    The thing here, is that what takes place for the veterans 
of Routt County--well, it looks like I got 1 minute left, sir--
what takes place in Routt County is that having a CBOC, or a 
Community-Based Outpatient Clinic, does not mean concrete and 
bricks. It means contract. We have three major hospitals on 
Route 40. We have a hospital in Kremmling, we have a hospital 
in Steamboat Springs, and we have a hospital in Craig.
    Steamboat Springs is the newest. They have a very good and 
technically advanced infrastructure. The thing here is the care 
and the interests of all three hospitals, in their 
conversations with the VA, are very interesting. There are 
doctor groups up in Steamboat Springs that would like to have 
an interest with the VA and/or a contract with the VA. 
Realistically, having a contract would be the best thing to do. 
Having a contract in one of the better hospitals would be the 
best deal for the veterans in that region.
    I did bring a map, and I will either show it or provide it 
to this panel. Like I was saying earlier initially, northwest 
Colorado is the empty quarter, but, yet, in Routt County alone 
we have over 1,800 veterans, in Moffat County a similar amount. 
We do need something in northwestern Colorado.
    If the Senator is interested in looking at the map, you can 
look at it real quick, and then I will shut my mouth and move 
on, sir.
    Senator Salazar. I think there is probably a copy that 
shows the empty----
    Mr. Condie. Well, it's a bigger map, sir.
    Senator Salazar. Oh, it's a bigger one. Go ahead and show 
it.
    Mr. Condie. OK. Right here in this area, sir, in 
northwestern Colorado, the reason why I have it circled, it's 
the empty quarter. There is nothing there.
    Down here where I have only orange spots, these are either 
a hospital here, CBOCs in these three locations, and all these 
locations are CBOCs and hospitals here. Essentially the eastern 
part of Colorado and southern part of Colorado got all the 
CBOCs. Northwestern Colorado got nothing, and we need 
something.
    [The prepared statement of Mr. Condie follows:]

      Prepared Statement of Michael Condie, Routt County Veteran 
                            Service Officer

    It's important to understand the problems of living in a rural area 
with limited resources that provide human services to the existing 
population. There are numerous subcultures in this region. The 
agrarian, recreational and the sub-subcultures that support both 
regional activities cause this area to be attractive to the population. 
A percentage of this population is made of Military Veterans who 
inhabit all facets of the subcultures that make up the social structure 
of the region.
    What this letter is going to concentrate on is the military 
veteran. The military veteran lives in this region for numerous 
reasons. They were born and raised here, or they moved here for a 
better life. The military veteran had earned many benefits for serving 
in this country's military--the most important is health benefits. The 
problem with accessing this benefit earned is the long distances to VA 
Facilities located in metropolitan areas that have high density of 
population. These long distances equal hundreds of miles round trip 
from where the veterans live. As the veteran population ages, the 
ability to access this benefit becomes more difficult. This difficulty 
is exacerbated by weather and road conditions--lack of public 
transportation and the infirmities of the veteran. The physical 
infirmities are caused by life style, service-related injuries or old 
age.
    Just getting to a VA facility can be troublesome because of the 
limited routes available. There are three routes from this region that 
terminate at Interstate 70. Route 40 over Rabbits Ears pass, Route 13 
out of Craig, or Route 131 connecting to Route 40 out of Steamboat 
Springs. All routes are fraught with the difficulties of winter, elk 
and deer migratory movement and potentially difficult road conditions.
    Let's concentrate on getting to I-70 during the daytime (night 
travel on these routes becomes inherently difficult because of 
aforementioned hazards). During the winter, travel becomes difficult to 
impossible. Blowing snow, snow buildup on the roads, coupled with the 
isolation of the road routes causes major difficulties for travelers. 
Periodically, Rabbit Ears Pass is closed because of snow, requiring use 
of Route 131 or Route 13 to access I-70. Traveling Route 131 from 
Steamboat Springs to Wolcutt is not recommended especial1y during the 
winter. Route 13 from Craig to Meeker, and from Meeker to Rifle, is 
difficult during winter months, and the population in this region is 
isolated. Once I-70 is reached, a veteran would go west to Grand 
Junction or east to Denver. The Routt or Moffat County Veterans Affairs 
Offices provide transportation for needy veterans either to Denver or 
Grand Junction VA Medical Facilities.
    The Veterans Transportation Fund was created by the Routt County 
Veterans Affairs Officer to provide transportation for veterans in 
Routt County who cannot or do not drive or have infirmities. The Moffat 
County Veterans Affairs Officer had a vehicle donated by the local Ford 
Dealership in Craig. The Routt County Veterans Affairs Officer writes 
grants to obtain funding rents vehicles from the Ford dealership in 
Steamboat Springs, hires an unemployed veteran with a good driving 
record and good insurance at $75 per trip. This vehicle then picks up 
veterans at pre-
arranged locations. The first location is the Veterans Affairs Office 
in Steamboat Springs; the second location is the American Legion Hut in 
Hayden; the third pick-up spot is McDonalds restaurant in Craig, and 
the fourth location would be at the office building where the Rio 
Blanco VSO is located.
    Currently, transportation for veterans has been solved to a certain 
extent but is still an issue in the northwestern part of Colorado. 
There are some veterans who could get to the VA facilities on their own 
even without a vehicle, if there was public transportation availab1e. 
There is no public transportation from the northwest region of Colorado 
to the metropolitan areas where VA facilities are located. The only 
transportation system in this region is with expensive Alpine Taxi to 
the Denver Airport with one stop on the way at I-70 and Kipling St. 
Veterans with a fixed income cannot afford the taxi service; however, 
the Veterans Affairs Officer of Routt County provides funds to purchase 
round-trip taxi tickets for veterans upon request. (Call DAV Disabled 
American Veterans located at the Denver VA Hospital and arrange for 
transportation from and to Kipling and I-70.)
    Another issue for consideration is CBOC (community-based outpatient 
clinic) in this region to take care of veterans. Understand a CBOC is 
not a concrete and brick structure but a contract with an existing 
medical facility with the infrastructure that has the ability to 
provide health care to veterans. There are those who advocate providing 
VA services at the three major hospitals in this region: Yampa Regional 
Medical Center, Steamboat Springs, hospital in Kremmling, Memorial 
hospital in Craig. That may work in a perfect world; however, reality 
dictates a CBOC centralized in the northwestern region. Getting a CBOC 
in the northwest region of Colorado requires careful thought and the 
understanding that it will cost the VA more money. Further, a CBOC will 
have to accommodate veterans from a large geographical area, including 
Moffat, Routt, Rio Blanco and Grand Counties. Potentially, veterans 
from Eagle and Jackson Counties and upper Garfield County could use a 
CBOC centralized in northwestern Colorado to include lower portions of 
Wyoming.
    This is all conjecture, but it is important to verbalize thoughts 
to show cause for an idea to materialize. The (5) counties that make up 
northwestern Colorado encompass 13,788 square miles of area. The 
prevailing rational is going to apply to Veteran density; hence, the 
location of CBOC's in Colorado. Northwestern Colorado is never going to 
meet VA rules that govern location of a CBOC because the population is 
too spread out. One wonder's why the Administration in charge of VISN-
18&19 would have planned to have a CBOC in each quadrant of Colorado, 
and then place other CBOC's where needed based on the growing veteran 
population. ``Alas'' they didn't. It's clear to me that the long view 
didn't factor in the planning stage of locating CBOC's in Colorado.
    The long view I refer to is tied into the growing veteran 
population in northwestern Colorado. ``So,'' the bottom line is, 
veterans are required to drive great distances to procure a benefit 
earned. The veterans of northwestern Colorado get short-changed. Money 
was spent to accommodate the veterans on the East Coast of the United 
States and the eastern slope of Colorado as well as for continued 
maintenance and upkeep on cement and bricks of aging buildings. It 
makes a person wonder why some VA facilities can't be consolidated and 
the funding redirected to the have-nots.
    The military is going through down-sizing and reorganization with 
BRAC--why can't the VA follow the same process? Let's call it VARC 
(veterans affairs reorganization and consolidation). 'The problem with 
northwestern Colorado is it's out-of-sight and out-of-mind.
    As Always, Semper Fi.

    Senator Salazar. Thank you, Mr. Condie, for your service to 
our veterans and for your testimony.
    Fred Riedinger, from the VSO from La Plata County.

 STATEMENT OF FRED RIEDINGER, LA PLATA COUNTY VETERANS SERVICE 
                            OFFICER

    Mr. Riedinger. First, Senator, I would like to thank you 
for coming to this area and for giving us this opportunity.
    To quote from the latest issue of the VFW Magazine, ``We 
know how to turn civilians into soldiers, but not soldiers into 
civilians.'' To this we add a veteran is trained to turn off 
hunger, thirst and pain to get the job done. He continues 
living this style when he returns to civilian life. Most take 
the position he served his country to protect it and wishes not 
to be a burden when he returns to civilian life.
    Although veterans face many of the same issues of veterans 
in other rural areas, we seem to be more isolated with access 
over a number of major passes.
    There are a number of good things happening here: The care 
at our local VA-contracted clinic with Health Net Federal 
Services has become outstanding and stand out in the VA clinic 
system. The health care delivered from Albuquerque VA Medical 
Center is excellent, and I regularly receive favorable comments 
from the veterans and their families about both the service and 
staff. Our local VA clinic has received recognition for 
excellence from Health Net Federal Services.
    Since January 2002 there has been local collaboration to 
provide assistance to veterans and their families.
    Senator Salazar. Excuse me, just one second. Can everyone 
hear? Is the microphone on?
    Mr. Riedinger. I think so.
    Senator Salazar. Speak up just a little bit so----
    Mr. Riedinger. Sorry.
    Senator Salazar [continuing]. We can make sure we have 
everybody hear.
    Mr. Riedinger. Since January 2002 there has been local 
collaboration to provide assistance to veterans and their 
families. The Veteran Service Office of La Plata, La Plata 
County Human Services, Southern Ute Veterans Association, 
Veterans of Foreign Wars Post 4031 and its auxiliary, the 
Durango Army National Guard Family Assistance Center, the 
Durango Blue Star Moms Chapter 1, the Durango Disabled American 
Veterans Chapter 48, private citizens and veterans' families 
provide 24/7 support in various ways.
    Resources to fund these efforts have always been slim but 
are even more difficult to generate now. The needs have not 
diminished, but the funding has. Coldwell Banker has partnered 
with the veterans' organizations to raise funds for a matching 
grant that allowed us to acquire two DAV vans and two 
electrical scooters. This business is committed to further 
projects for vets.
    The VSO's from La Plata County, Archulta and San Juan 
Counties work cooperatively in enrolling veterans into the 
Durango VA clinic.
    However, these successful efforts should be supplements to 
and not a replacement for the VA providing funding to the 
degree we presently need. Your 1191 is going to go a long ways 
toward that.
    The Colorado Board of Veterans' Affairs provides grants 
from their share of the Tobacco Settlement. These funds provide 
the mainstay for our transportation program now. Of great 
concern is the fact that these funds will be gone in 2007. This 
is where your H.R. 1191 is going to make a big difference. The 
VA Veterans Service Center in Denver has provided assistance 
and advice that has made this office efficient, has been 
instrumental in our successful service to veterans, and is 
deserving of a compliment from you, Senator.
    Several matters are not positive and would benefit from 
more permanent solutions.
    There have been changes in the overnight accommodations for 
the Albuquerque VA Center. The funding has been severely 
restricted for per diem and overnight stays.
    This has resulted in veterans canceling compensation and 
pension examinations. For those that go, they may be asked to 
stay overnight and have to do so at their own expense. It is 
important to know that many of these individuals are World War 
II veterans who are in medical need and often financial need as 
well.
    In addition, the requirements for physical exams for 
drivers have become burdensome. This has resulted in a loss of 
13 drivers for our DAV vans. I am down to one driver now. I 
originally had twenty-two volunteers, but they are restricted.
    This further complicates trying to get someone to 
Albuquerque for examinations. It would be helpful if the rules 
were the same at the various centers, as Grand Junction does 
not have the restrictions on overnight and per diem that 
Albuquerque has.
    I will provide additional information to staff regarding 
individual veterans that I would like to pursue through Senate 
Salazar's office.
    Thank you for the opportunity to participate in this panel.
    I was asked to mention a specific issue. There is a 
gentlemen here right now I was talking to about ionization 
radiation exposure. I have two veterans with documented 
service-connected problems due to radiation. The overexposure 
is known. A veteran's exposure is above what was determined to 
be overexposure in 1958. It is now known that the acceptable 
level of exposure then is far greater by today's acceptable 
level. The evidence is that his fate at the end of a 2-year 
study must be completed before a determination will be made and 
an award considered. The new standard will only say his 
exposure is greater. I believe that compensation should be 
awarded based on the evidence submitted, not delayed for a 
study that will only determine the extent of overexposure.
    Senator Salazar. Mr. Riedinger, I appreciate the specific 
case, and if you will help me make sure that you get that 
letter to me, and we will take up that specific case.
    Mr. Riedinger. They have been submitted.
    Senator Salazar. So I appreciate your testimony, and I 
appreciate what you do for veterans in southwestern Colorado.
    Mr. Riedinger. Thank you. It's been submitted, sir.
    Senator Salazar. We will include that in the record, and 
also we will take a look at the specific case.
    Mr. Riedinger. Thank you.
    [The prepared statement of Mr. Riedinger follows:]

    Prepared Statement of Fred Riedinger, La Plata County Veterans 
                            Service Officer

     ISSUES AND PROBLEMS FACED BY VETERANS IN THE FOUR CORNERS AREA

    Although veterans face many of the same issues as veterans in other 
rural areas, we seem to be more isolated, with access over a number of 
major passes.
    There are a number of good things happening here.
    The care at our local VA-contracted clinic with Health Net Federal 
Services has become outstanding and a standout in the VA Clinic system. 
The health care delivered from the Albuquerque VA Medical Center is 
excellent and I regularly receive favorable comments from the veterans 
and their families about both the service and the staff. Our local VA 
clinic has received recognition for excellence from Health Net Federal 
Services.
    Since January 2002, there has been local collaboration to provide 
assistance to veterans and their families. The Veterans' Service 
Office, La Plata County, La Plata County Human Services, Southern Ute 
Veterans Association, Veterans of Foreign Wars Post 4031 and its 
auxiliary, the Durango Army National Guard Family Assistance Center, 
Durango Blue Star Moms Chapter One, Durango Disabled American Veterans 
Chapter 48, private citizens and veterans' families provide 24/7 
support in various ways. Resources to fund these efforts have always 
been slim, but are even more difficult to generate now. The needs have 
not diminished but the funding has. Coldwell Banker has partnered with 
the veterans' organizations to raise funds for a matching grant that 
allowed us to acquire two DAV vans and 2 electric scooters. This 
business is committed to further projects for vets.
    The VSO's from La Plata, Archuleta and San Juan Counties work 
cooperatively in enrolling vets into the Durango VA Clinic.
    However, these successful efforts should be supplements to and not 
a replacement for VA-provided funding in the degree we presently 
experience.
    Colorado Board of Veterans Affairs provides grants from their share 
of the Tobacco Settlement. These funds provide the mainstay for our 
transportation program now. Of great concern is the fact that these 
funds will be gone in 2007.
    The VA Veterans Service Center in Denver has provided assistance 
and advice that has made this office efficient and has been 
instrumental in our successful service to veterans and is deserving of 
a compliment from Senator Salazar.
    Several matters are not positive and would benefit from more 
permanent solutions.
    There have been changes in the overnight accommodations for the 
Albuquerque VA Center. The funding has been severely restricted for per 
diem and overnight stays.
    This has resulted in veterans canceling compensation and pension 
examinations. For those that go, they may be asked to stay over night 
and have to do so at their own expense. It is important to know that 
many of these individuals are WWII vets who are in medical need and 
often, financial need as well.
    In addition, the requirements for physical exams for drivers have 
become burdensome. This has resulted in a loss of about 13 drivers for 
our DAV vans. This further complicates trying to get someone to 
Albuquerque for exams.
    It would be helpful if the rules were the same at the various 
centers, as Grand Junction does not have the restrictions on overnight 
and per diem that Albuquerque has.
    I will provide additional information to Staff regarding individual 
veterans that I would like to pursue through Senator Salazar's office.
    Thank you for the opportunity to participate in this panel.

    Senator Salazar. If I may now turn it over to Larry Biro, 
who appeared before me in Washington, DC. and the Senate 
Veterans' Affairs Committee many times. He is doing great work 
on behalf of VISN 19.

 STATEMENT OF LAWRENCE A. BIRO, DIRECTOR, VETERANS INTEGRATED 
                      SERVICES NETWORK 19

    Mr. Biro. Thank you, Senator Salazar, for giving me the 
opportunity to speak before you and my fellow veterans on 
what's going on in VISN 19 in terms of delivering care to the 
rural veteran.
    Just a sideline, we left the meeting with Secretary 
Nicholson, actually a field visit to Fitzsimons, to look at the 
property yesterday. Mr. Milner was with us, and at 4 o'clock we 
looked at that. So we are working hard on the Denver project 
and continue to do that.
    Senator Salazar. Thank you.
    Mr. Biro. So what I will be doing is giving you the overall 
perspective of VISN 19. Dr. Murphy will talk about the local 
arrangements here in this catchment area.
    As you mentioned already, I would like to re-mention, that 
the VA or VHA healthcare program is mentioned over and over as 
the benchmark in terms of quality of care, and just as recently 
as July 18 in US News and World Report an article came out----
    Senator Salazar. Larry, if I may, can you get the 
microphone just a little closer to make sure that everybody can 
hear you throughout the room? I don't know, our sound system is 
not doing as well as it should.
    Mr. Biro. OK. The Veterans Health Administration was 
written up again in the July 18th edition of US News and World 
Report as a health care system second to none.
    VISN 19, Senator, as you pointed out, is No. 1. In 2004 our 
performance measures and our customer satisfaction, or 
veterans' satisfaction scores, were the best in the United 
States. The two hospitals which were the best in our network 
were Grand Junction and Denver. So if you want care that is 
second to none, the best, the best in the United States, it's 
here in Colorado as we stand, and we are going to do that again 
in 2005.
    Just let me briefly talk a little bit about what's going on 
here in VISN 19. First, we make three promises: First, that the 
care will be second to none. The hands-on provision of care to 
any veteran will be second to none.
    The second, that we will maintain and expand services. We 
do not go backwards in 19. We will continue to expand services, 
and the issues of providing more care to rural veterans is 
obviously an area where we can continue to expand.
    The third promise is that each and every veteran will be 
personally satisfied in the services that they get from our 
network.
    Now, you may be thinking we have had two witnesses say that 
they are dissatisfied with access. There are two tracks of 
satisfaction. One, is the experience the veteran has when they 
come to one of our facilities and get care. They need to be 
personally satisfied.
    The second track is the broader of providing care, but we 
will stand behind those three promises and to continue to work 
those as long as I am here.
    The network is large. I think you know it's 22 percent of 
the United States' contiguous area. It has about 700,000 
veterans. It's about 2.5 percent of the veteran population. It 
covers four states major, Colorado, Wyoming, Montana and Utah, 
plus about four other states on the periphery. We have 6 
medical centers and 32 CBOCs. Right now we are serving about 
140-some-thousand, 150,000 veterans. That's doubled essentially 
since 1996.
    Essentially in your statements you have covered how we 
deliver care to the rural veteran. The first and foremost is 
the community-based outpatient clinic. We have 32 of them. Some 
are a direct provision of care by VA employees, some are 
contract.
    If you look at the number, as I said, there are about 800 
of these clinics across the United States. If we were 2.5 
percent, we should have about 17 or 18 clinics, and we have 
those thirty-two clinics. So they are all over. I think pretty 
much everybody is covered where they are at. There are big 
ones; there are little ones. The Colorado Springs clinic is 
gigantic. You have probably seen it--the one in Billings, 
Montana, and they are down as small as 80 people in Sidney, 
Nebraska. So we have got clinics, and that's the first way we 
deliver care to the rural veteran is through CBOCs.
    The second, as you had mentioned, is that we have a 
transportation network. We have the biggest transportation 
network of the VHA, 21 networks. The statistics are amazing. 
The DAV transported 26,000 patients for the first three 
quarters of 2005 traveling 1.4-million miles. The drivers in 
those first three quarters volunteered essentially 54,000 hours 
and it continues to go on. We continued to develop that system, 
and we need it.
    The third is tele-medicine. As you mentioned, that's an 
emerging technology that allows the veteran to stay in his home 
and for us to get him electronically. Our program is the second 
biggest in the VHA. That's pretty amazing since the biggest 
program is VISN 8, which is the biggest concentration of 
veterans in any area in Florida, so our program is quite large 
with the goal of expanding it. Even at that, it's several 
hundred at this time. Tele-medicine goes beyond the individual 
care. We have link-ups for dermatology, radiology, various 
tests between Denver, between Grand Junction and several 
different areas.
    We are very proud of our program with the Native Americans. 
We do outreach for PTSD at four reservations right now and plan 
to expand to several others.
    Just very quickly, CARES was in 2004. In May 2004 they came 
out with a CARES decision for VISN 19. We mentioned the new 
facility in Denver and three CBOCs. Those three CBOCs were Cut 
Bank, Montana; Lewiston, Montana; and the west valley of Utah. 
That document gave us to 2012 to complete those CBOCs and open 
them.
    Our plan was to open them in 2005. Given limited resources, 
we did not open them in 2005. Our goal is to open all of them 
in 2006 then move beyond to look at other CBOCs.
    As you mentioned we are constrained to a certain extent by 
the directive the VHA has on the size of CBOCs and how they are 
to be constructed. That is a challenge. We need to get that 
directive changed, because as it stands now rural CBOCs will be 
disadvantaged. They are not big enough. They don't meet the 
requirement. The resources would be recommended to be put 
somewhere else.
    Once we get our clearance and we establish the CBOCs as 
recommended by CARES, we will go on to look at all the other 
CBOCs that have been requested. That's the challenge as you 
have laid out, and your legislation would help us. I probably 
have on the docket somewhere between 15 and 20 CBOCs, anywhere 
between Colorado, Montana and Utah and Wyoming.
    Senator Salazar. Fifteen or twenty requested?
    Mr. Biro. Fifteen or twenty requested. All the way from the 
east side of Colorado along the Kansas border, all the way over 
to here, all the way up into the border of Canada and Montana. 
My challenge is how do you prioritize those with the resources 
that I have, and how do you approach them? There are not enough 
resources. There will never be enough money to do everything 
that everybody wants to do. That's what medicine is. But that's 
the way we are going. That would be the plan. Finish the CARES 
recommendations in 2006, move on with a prioritized list of 
CBOCs for 2007 and work through those.
    So, in summary, I stand behind my three promises, that the 
care will be second to none, in 19; that we will maintain and 
expand services, and we have. We have expanded by taking care 
of 5 percent more this year than last year. We are going to 
continue to expand that way plus programs. We will work on 
every veteran being personally satisfied with the services that 
they have received. Thank you.
    [The prepared statement of Mr. Biro follows:]

Prepared Statement of Lawrence A. Biro, Director of Veterans Integrated 
                          Services Network 19

    Senator Salazar and other Members of the Committee, I appreciate 
the opportunity to appear before you today to discuss veterans' rural 
healthcare in VISN 19 and in the State of Colorado, in particular.
    I will discuss these issues from an overall VISN perspective and 
defer to Dr. Michael Murphy, Director of the Grand Junction VAMC whose 
catchment area includes western Colorado, for issues related to that 
health care facility.
    In a recent article published by the Washington Monthly, Jan/Feb 
2005, ``The Best Care Anywhere,'' the Veterans Health Administration 
(VHA) was cited as producing the highest quality care in the country. 
In fiscal year 2004, VISN 19 was rated No. 1 within the Veterans Health 
Administration, as evaluated by the national performance measures and 
the veteran patient satisfaction scores.
    VISN 19 makes three promises to all our veterans regardless of 
where they live or where they receive their health care. These promises 
will be our measures of success: Provide high quality of care second to 
none; Maintain and expand services; and Personal veteran satisfaction.
    VISN 19 (the VA Rocky Mountain Network) spans an area of 470,000 
square miles across nine states and is, geographically, VA's second 
largest health care network. There are over 700,000 veterans residing 
within VISN 19. VISN 19 serves an area covering all of Utah; most of 
Wyoming, Montana, and Colorado; and portions of Nevada, Idaho, Kansas, 
Nebraska, and North Dakota. The geographic area contained within VISN 
19 varies from highly urban cities, to rural communities, to remote 
frontier areas. The terrain varies from arid desert to high altitude 
mountains, both made more difficult during the winter months. For 
fiscal year 2005, VISN 19 employs a workforce of 4,650 fulltime 
equivalent (FTE) employees with an operating budget of $589 million 
dollars. In fiscal year 2004, our facilities provided care to almost 
142,000 unique patients, up from 80,000 in FY 1996. The number of 
patients treated is up an additional 5,000 in fiscal year 2005.
    VISN 19 has, from its inception, focused on providing primary care 
and outpatient mental health services closer to where veterans live. 
This focus has resulted in the establishment of a significant number of 
clinics throughout the VISN. There are currently 32 Community-Based 
Outpatient Clinics (CBOCs) in VISN 19. These CBOCs range in size from 
small contract clinics such as Sidney, Montana, to large and more 
complex clinics such as those in Colorado Springs, Colorado; Billings, 
Montana; and Pocatello, Idaho. Clinics in Colorado are located not only 
in Colorado Springs but also in Pueblo, Lamar, La Junta, Alamosa, 
Montrose, Ft. Collins, Greeley, Lakewood and Aurora.
    There continue to be many veterans in VISN 19 who are 
geographically isolated from VA health care services. In the past 
several years, there has been significant interest expressed by 
Congressional representatives, Veteran Service Organizations, and 
individual veterans in establishing new CBOCs at locations throughout 
the VISN. These locations include Elko, Nevada; Northwestern Colorado; 
Eastern Colorado/Western Kansas; and Afton, Wyoming. At the request of 
stakeholders, VISN representatives have attended town hall meetings in 
Afton, Wyoming, Goodland, Kansas and Elko, Nevada. I have personally 
met and had extensive conversations with many Congressional 
representatives to discuss the possibility of new CBOCs in several of 
those and other locations.
    The VA Rocky Mountain Network continues to pursue new and 
innovative approaches to reach veterans in rural, remote and frontier 
locations. VISN 19 partners with Veteran Services Organizations such as 
the Disabled American Veterans, to provide an external transportation 
system which is vital to many veterans obtaining their health care at 
VA facilities. For the first three quarters of fiscal year 2005, the 
DAV transported 25,771 patients, traveled 1,372,863 miles, and 
volunteered 53,684 driver hours for the VA Rocky Mountain Network. VISN 
19 has also been a leader in the development of Care Coordination Home 
Tele-health programs and other telemedicine initiatives which allow 
veterans to receive their care in their homes or at remote locations.
    In 2003-2004, the Veterans Health Administration (VHA) underwent a 
landmark study of VA's heath care infrastructure known as the Capital 
Asset Realignment for Enhanced Services (CARES). Among the elements of 
the draft National CARES Plan were proposals to expand the numbers of 
CBOCs throughout the country. In VISN 19, there were three public 
hearings at which stakeholders were provided an opportunity to comment 
on the draft National CARES Plan. In May 2004, the Secretary of 
Veterans Affairs issued his CARES Decision. In that decision, as it 
pertains to VISN 19, the Secretary identified three new CBOCs as 
priorities for implementation by 2012. Those were West Valley, Utah, a 
suburb of Salt Lake City; Lewiston, Montana; and Cut Bank, Montana.
    VISN 19 plans to address other CBOC locations after activating the 
clinics identified as priorities in the Secretary's CARES decision. We 
wanted to activate the three priority clinics in late fiscal year 2005. 
However, resources to undertake establishment of these three new CBOCs 
are not available. Both northwestern and northeastern Colorado may be 
considered as locations for placement of CBOCs. The veterans who reside 
in these areas must travel hundreds of miles to access VA health care 
often through difficult terrain during the winter months. We will 
pursue additional CBOCs throughout the VISN as soon as resources allow.
    VA criteria for planning and activating CBOCs are contained in VHA 
Handbook 1006.1. All CBOC business plans must be developed in 
accordance with this Handbook and approved by VA Central Office. The 
criteria emphasize the need for sufficient population and workload 
projections, but other unique factors, such as geographic barriers, 
travel times, and medically underserved areas, are also taken into 
consideration. The business plan must also address the costs and 
benefits of establishing a VA-staffed CBOC or a CBOC based on 
contracting with local health care providers. VISNs must also ensure 
that resources are in place to open new CBOCs, including the capacity 
to manage specialty care referrals and inpatient needs of the 
populations to be served. Proposals are scored based on these criteria. 
Proposals with high enough scores are approved by VA Central Office. A 
CBOC proposal in either northwestern or northeastern Colorado would be 
evaluated with these criteria and prioritized within the network.
    VISN 19 recognizes successful improvement to veteran rural health 
care requires a multi-faceted approach. In order to provide veterans 
with the high quality health care they need and deserve, we will 
continue to encourage VHA as an organization to fully re-examine our 
approach to the provision of health care in rural and frontier areas.
    In summary, VISN 19 has experienced a significant workload growth 
over the past few years. We have established many new CBOCs throughout 
the VISN. There are locations where additional clinics are needed. Our 
plan is to continue with the activation of the three CARES priority 
clinics as resources become available. Additional clinics sites will be 
seriously considered, proposals developed and submitted when sufficient 
funding is identified.
    Thank you, Mr. Chairman. This concludes my formal remarks. I would 
like to entertain any questions the Committee Members may have.

    Senator Salazar. Thank you, Directly Biro. Now we will hear 
from Dr. Mike Murphy, Director of the Grand Junction VA Medical 
Center.
    Dr. Murphy.

  STATEMENT OF MICHAEL W. MURPHY, DIRECTOR, GRAND JUNCTION VA 
                         MEDICAL CENTER

    Dr. Murphy. Thank you. I would like to thank you, Senator 
Salazar, and Members of the Veterans' Affairs Committee for the 
opportunity to discuss the role and function of Grand Junction 
VA Medical Center in serving veterans residing along the 
western slope of Colorado and southeastern Utah. We certainly 
share the Committee's interest in providing high quality 
accessible care to veterans throughout our service area.
    The Grand Junction VA Medical Center is a Complexity Level 
IV facility located here in Grand Junction where we have served 
veterans 55 years. We also operate a staffed CBOC, located in 
Montrose. That activity opened in 1999.
    Grand Junction's mission is to provide primary and some 
secondary-level medical, surgical and psychiatric services 
which include inpatient care in acute medicine, surgery and 
psychiatry, as well as a near full range of primary and 
secondary medical, surgery and Psychiatric Outpatient Services.
    Specialized programs included mental health services, 
outpatient substance abuse treatment, same-day surgery, 
audiology, computerized tomography or CT, and a mobile MRI 
imaging.
    Patients requiring tertiary care are transferred to VA 
facilities in Denver or Salt Lake City, and that transfer is 
accomplished usually by air ambulance. When patients are not 
stable for transport to Denver and Salt Lake, we utilize St. 
Mary's here in Grand Junction. We also routinely obtain some 
specialty care on a contract or fee basis. Through arrangements 
with St. Mary's we obtain radiation therapy, cardiac care, and 
other specialized services. Utilizing scarce medical specialty 
arrangements in the community, we are able to provide urology, 
ophthalmology, ENT, orthopaedics, neurology and podiatry 
services.
    While these arrangements allow this facility to provide 
care beyond the spectrum normally expected in a Level IV 
facility, there are still some services which we are not able 
to provide and which are outside the scope of the mission for a 
primary care facility. We are not tertiary facility.
    We also have a 30-bed transitional care unit which provides 
rehabilitation services largely focusing on veterans who have 
had strokes, amputations and joint replacements. By the way, 
Grand Junction does do hip and knee joint replacements, 
somewhat remarkable for a Level IV facility.
    We also provide traditional nursing home services and 
hospice care in our transitional care unit. Our patient service 
area spans 40,000-square miles which includes the entire 
western slope of Colorado from Durango to Wyoming. We extend 
180 miles east from the Utah border into the heart of Rockies. 
We serve the two southeast-most counties in Utah as well.
    We serve a veteran population of approximately 37,000 vets 
with 10 percent of those residing in the northwestern corner, 
Rio Blanco, Moffat and Routt Counties of Colorado.
    These numbers include Priority 8 group vets which are 
currently not eligible for enrollment in VA health care if they 
are not already enrolled.
    This year we will actually see and provide health service 
to approximately 10,000 vets with about 700 of those residing 
in the northwestern corner of Colorado. We at Grand Junction VA 
Medical Center are acutely aware of the access challenges, 
distance, geography, severe weather and hazards of wildlife. In 
a recent trip up through the northwest corner I witnessed more 
antelope and deer then I have seen in many years. So I 
appreciate the risks and hazards there particularly at 
nighttime.
    These challenges are exacerbated by the fact that we have a 
relatively small number of vets spread over a huge geographical 
area. For example, in the northwest corner where we have 700 
vets that we are serving, they are spread out over 10,000 
square miles. The logistics of providing care for them are not 
inconsequential.
    We agree that Veterans should not have to forego their VA 
health benefits, which as Mr. Biro says very frequently, they 
have earned, are entitled to and eligible for as a result of 
where they live. Nobody asked them their ZIP code when they 
were drafted or volunteered.
    The challenge, however, is how do we provide that 
reasonably accessible care in a manner that is second to none 
in quality, which VA, VISN 19 and Grand Junction have become 
known for, that is at the same time cost effective and within 
current law, regulation and policy, and within existing 
resources.
    Grand Junction remains eager to discuss possible solutions 
to the access issue which is so perplexing to yourself, to 
veterans, and, I assure you, to those of us at the medical 
center as well. We stand ready to work with all stakeholders to 
arrive at innovative, workable and supportable solutions.
    This concludes my statement on behalf of the Grand Junction 
VMC. Again, I would like to thank you for the opportunity to 
speak on behalf of the Medical Center and the veterans that we 
serve here on the Western Slope. Thank you.
    [The prepared statement of Mr. Murphy follows:]

  Prepared Statement of Michael W. Murphy, Director of Grand Junction 
                           VA Medical Center

    I would like to express my sincere appreciation for Senator 
Salazar's interest and concern for the veterans. We are privileged to 
serve and look forward to working with him wherever possible to make 
improvements in our health care delivery. Thank you for this 
opportunity to speak today on behalf of the Grand Junction VA Medical 
Center (VAMC).
    The Grand Junction VAMC is a part of the VA Rocky Mountain Network 
(VISN 19), which includes six facilities in Utah, Montana, Colorado and 
Wyoming. The facilities in Denver and Salt Lake City serve as tertiary 
referral hospitals for the VISN.
    The Grand Junction VAMC consists of one facility located in the 
city of Grand Junction, Colorado, and one Community-Based Outpatient 
Clinic in Montrose, Colorado. The VAMC provides services to 37,000 
veterans residing in 15 counties on the Western Slope and two counties 
in southeastern Utah. The main patient building was constructed during 
the period of 1947-1949. A Nursing Home Care Unit was added in 1975 and 
currently functions as a 30-bed rehabilitative long-term care facility. 
A two-story outpatient clinical addition was completed in 1988.
    The VAMC is a Complexity Level IV facility, which celebrated its 
50th year of service to veterans in 1999. It operates 53 beds comprised 
of 23 acute care and 30 Transitional Care Unit beds. The VAMC provides 
primary and secondary care including acute medical, surgical and 
psychiatric inpatient services, as well as a full range of outpatient 
services. Specialized programs include a Mental Health Care Center, 
substance abuse treatment, same day surgery, observation beds, 
computerized tomography (CT) and mobile MRI imaging. Patients requiring 
tertiary care are transferred to Denver or Salt Lake City.
    When necessary and appropriate, hospitalization and specialty care 
are provided locally on a contract or fee for service basis. Through an 
agreement with local St. Mary's Hospital, the largest healthcare 
facility on the Western Slope, we obtain radiation therapy and other 
specialized medical services. The VAMC benefits from scarce medical 
specialty agreements with community specialists who provide urology, 
ophthalmology, ENT, orthopedic, neurology and podiatry services. These 
agreements enable us to provide a spectrum of care and services, which 
far surpasses comparably sized VA medical centers.
    The VAMC was the recipient of the 2001 Presidential Award for 
Quality and the 1999 Robert W. Carey Quality Award Trophy. These 
achievements are especially noteworthy because both were earned upon 
the first application. Of further note, it is the first and only 
organization ever in VA to earn the Presidential Award for Quality.
    The Colorado counties in our patient service area (PSA) extend 
northward from the medical center nearly 200 miles to the Wyoming 
border, southward approximately 150 miles to the northern borders of 
the counties of Montezuma, La Plata and Archuleta and 190 miles east 
into the Rocky Mountains. Montezuma, La Plata and Archuleta, formerly 
assigned to Grand Junction and VISN 19, were reassigned to VISN 18 in 
the latter 1990's. Grand Junction's approximately 40,000 square mile 
PSA is primarily rugged, isolated, mountainous terrain, made all the 
more difficult in winter. We have continuously been aware of and 
managed our planning efforts to include such considerations for 
veterans residing in the remotest reaches of our PSA.
    Also in the 1996-1997 timeframe, VISN 19 initiated a comprehensive 
strategic planning process with all its VAMCs which resulted in a 
mutual decision with the Grand Junction VAMC that we would prepare a 
business plan proposal for a community-based outpatient clinic (CBOC) 
in Montrose, Colorado. This decision, made after reviewing other areas 
of our PSA, including northwest Colorado, was based upon VA planning 
guidelines in place at that time that included thresholds for veteran 
population and projected users. Montrose was projected to serve a five-
county area comprised of Delta, Gunnison, Montrose, Ouray and San 
Miguel, in our southwestern PSA. A total of 8,045 veterans resided in 
this area at that time and has since grown to 9,599. By comparison, 
total veteran population in northwest Colorado, comprised of the 
counties of Moffat, Rio Blanco and Routt, was 3,491 in 1996 and is 
currently 3,597.
    Our Montrose CBOC proposal was ultimately approved by the Secretary 
of Veterans Affairs in 1998, endorsed by Congress, and the clinic 
opened in January 1999. It has been successful to date, meeting the 
needs of underserved veterans in the CBOC's five-county service area.
    During VHA's national effort to realign existing resources with 
current and projected needs, known as the Capital Asset Realignment for 
Enhanced Services (CARES) planning process, we participated with VISN 
19 once again to conduct extensive strategic planning which included 
analysis of potential sites for CBOCs. None were identified for the 
Western Slope based on current guidelines for veteran population and 
the number of projected users.
    VA CBOC planning guidelines, contained in VHA Handbook 1006.1, 
released in 2004, continue to emphasize need based upon veteran 
population, focusing in particular on the number of veterans, enrollees 
and actual users in the Priority 1-6 (P1-6) levels. Current P1-6 
veteran data show northwest Colorado, comprised of Moffat, Rio Blanco 
and Routt County, have low numbers overall that do not appear to 
support development of a CBOC business plan. The dispersal of the 
veteran population, totaling 3,597, across approximately 10,325 square 
miles adds to the difficulty in achieving effective, efficient delivery 
of VA care.
    Although the veteran numbers in northwest Colorado are low, 
demographics alone are not the sole criteria. Other barriers including 
distance to existing VA care sites, adverse weather conditions, 
hazardous roads and medically underserved areas must also be factored 
into the decision process. Regardless, business plans, when submitted, 
ultimately require approval by the Secretary of Veterans Affairs based 
upon a comprehensive assessment of how all planning criteria are met. 
The Grand Junction VAMC will continue to work with VISN 19 to develop 
proposals for CBOCs in rural areas such as northwest Colorado so they 
can be evaluated and prioritized within available resources.
    In summary, we agree that veterans should not have to forego their 
benefits or access as a function of where they live. The Grand Junction 
VAMC remains eager to discuss possible alternative delivery methods 
that are within our resources and within applicable VA regulations and 
guidelines.
    This concludes my statement on behalf of the Grand Junction VAMC. 
Once again, I thank Senator Salazar for his interest and concern for 
the welfare of our veterans and their access to health care. I will be 
happy to answer any of your questions.

    Senator Salazar. Thank you, Dr. Murphy. Thank you for the 
great job you do with the Grand Junction Medical Center.
    We will now hear from Cephus Allin who is a member of the 
American Federation of Government Employees and who works at 
the Ft. Collins outpatient clinic.

 STATEMENT OF CEPHUS ALLIN, M.D., AFGE MEMBER AND EMPLOYED AT 
              THE FT. COLLINS VA OUTPATIENT CLINIC

    Dr. Allin. Good morning. I am Dr. Cephus Allin. I am a 
member of the American Federation of Government Workers, and 
for the last year I have been the sole physician in the Ft. 
Collins CBOC. I want to make it clear to the Committee----
    Senator Salazar. Dr. Allin, can you----
    Dr. Allin. Sure.
    Senator Salazar [continuing]. Make sure the microphone is 
close to your mouth as you speak so we can make sure that 
everybody can hear in the back?
    Dr. Allin. For the last 3 years I have been the sole 
physician in the Ft. Collins CBOC. I want to make it clear to 
the Committee that I am testifying here only on my own personal 
observations, opinions and recommendations. I am not here 
before you to give views of the Department of Veterans' 
Affairs, as are Director Biro and Dr. Murphy.
    I would like to thank you personally for inviting me to 
testify today. It's a very rare honor and privilege for those 
of us who actually touch veterans to provide testimony to those 
who shape our professional lives.
    Ft. Collins can hardly be considered rural. It has 120,000 
people with upwards of a quarter-of-a-million in the catchment 
area. So how would I qualify as a rural provider?
    Ft. Collins has veterans who drive 150 miles one way to see 
me because I am the closest VA provider. This is the reason we 
are here, to project VA benefits out to rural locations.
    I have three proposals: First, would be a meds proposal. 
Congress needs to enact legislation to allow non-VA physicians 
to write prescriptions for our veterans using the VA formulary.
    Second, would be to initiate sharing agreements, and this 
is different from privatization. But initiate sharing 
agreements with the 25 Colorado critical access hospitals.
    And, third, to establish a strong central fee-basis program 
for non-VA providers.
    My first proposal on medications, there is considerable 
bargaining power in the VA formulary. This leverage drives 
medication costs down. Many veterans enroll in the VA solely to 
receive these low-cost medications. Our veterans have more time 
than money and will endure the waits and delays found at many 
facilities to avoid choosing between food and medication.
    The VHA Directive 2002-074, the National Dual Care Policy, 
requires that a VA provider take an active role in patient 
management and documentation even after a qualified non-VA 
physician has provided timely care.
    The restrictions in Senate Bill 614 removes eligibilities 
for care even as it extends it to prescription coverage. Dual 
care is a travesty when there is so many without any care. 
Please, please give them their medications without limitations. 
They served without limitations.
    My second proposal is a sharing agreement. Again, this is 
not privatization. Senator Salazar has taken a leadership 
position on supporting our rural critical access hospitals. As 
part of a bipartisan effort, preserved Federal funding for our 
hospitals.
    Critical access hospitals are, by definition, part of the 
rural communities. The map of those facilities was so 
compelling that it is the first page in my written handout. 
Many of these hospitals already have staff who perform primary 
care and could function in that capacity for our veterans. Many 
of them have an existing information technology infrastructure 
onto which the VA data structure might be projected.
    We need sharing agreements as we have with the Department 
of Defense. We need sharing agreements as we have with the 
Indian Health Service. We need agreements in rural America so 
our Veterans' Service Officers only have to arrange travel 
across town rather than across the state.
    The third proposal is a central fee-basis proposal. The 
March 2005 Office of the Inspector General report indicates the 
VA does an excellent job of managing on-station, fee-basis 
funds. We should expand this expertise into rural off-station 
services.
    When a rural physician sees one of our veterans, they 
should be able to send a bill to a central fee-basis office for 
payment. If payment were prompt and higher than the Medicare 
rate, the VA would be considered an insurer of choice for rural 
providers.
    We need as many CBOCs as you can possibly fund everywhere 
in the State. Still, we won't be able to project an appropriate 
amount of bricks or mortar into rural communities. CBOCs are 
expensive, and the pressure on hospital directors to place them 
in urban areas which will return the greatest number of new 
patients is overwhelming. What we can project are care and 
caring into the rural setting. We need to support non-VA 
providers who offer care to our veterans by providing them a 
generous reimbursement. We need to support the rural hospitals 
through which we will be able to project our information 
infrastructure, and we need to support our veterans by 
supplying the medications they need from providers near their 
home.
    Again, I would thank you, Senator Salazar, for inviting me 
here to present my own views, and I would be happy to answer 
any questions.
    [The prepared statement of Mr. Allin follows:]

  Prepared Statement of Cephus Allin, M.D., AFGE Member and Employed 
                at the Ft. Collins VA Outpatient Clinic

    Good morning, I am Dr. Cephus Allin. I am a member of the American 
Federation of Government Workers. For the last 3 years I have been the 
sole physician in the Fort Collins CBOC.
    I would like to personally thank Senator Salazar for inviting me to 
testify today. It is a rare honor and privilege for those who actually 
treat veterans to provide testimony to those who shape our professional 
lives.
    Fort Collins can hardly be considered rural: 120,000 in the city 
with upwards of a quarter of a million in the catchments area. So how 
do I qualify as a rural provider? I have veterans who drive 150 miles 
to see me, because I am the closest VA provider.
    This is the reason we are here today. To project VA benefits out to 
our rural veterans.
    I have three proposals:
    (1) Congress needs to revise Public Law to allow Non-VA Physicians 
access to the VA formulary for our veterans. The MEDS ONLY proposal.
    (2) Initiate sharing agreements with the 25 Colorado Critical 
Access Hospitals. The Sharing Agreement proposal.
    (3) Establish a strong Fee Basis program for Non-VA providers. The 
Fee Basis proposal.

                        PROPOSAL ONE: MEDS ONLY

    There is considerable bargaining power in the combined DoD/VA 
formulary. This leverage drives medications costs down and many 
veterans enroll with the VA solely to receive these low-cost 
medications.
    Many of our veterans have more time than money and will endure the 
waits and delays found at some VA facilities to avoid choosing between 
food and medications.
    VHA Directive 2002-074: VHA National Dual Care Policy requires that 
a VA provider take an active role in patient management and 
documentation even after a qualified Non-physician has already 
delivered timely care. Dual care is a travesty when so many are without 
any care.

                    PROPOSAL TWO: SHARING AGREEMENT

    Senator Salazar has taken a leadership position on preserving the 
rural Critical Access Hospitals and as part of a bipartisan effort 
preserved Federal funding for these rural hospitals.
    Critical Access Hospitals are by definition part of rural 
communities. The map of those facilities is so compelling that it is 
the first page in the handout.
    Many of these hospitals already have staff who perform primary care 
and could function in that capacity for us. Many of them have an 
existing Information Technology infrastructure onto which the VA 
infrastructure might project.
    We need sharing agreements, as we have with Department of Defense, 
we need sharing agreements as we have with Indian Health Service. We 
need rural sharing agreements so our VSO's have only to arrange travel 
across town rather than across the state.

                       PROPOSAL THREE: FEE BASIS

    The March 2005 Office of the Inspector General report indicates 
that the VA does an excellent job of managing on-station Fee Basis. We 
should expand this expertise into rural, off-station services. When a 
rural physician sees one of our veterans, they should be able to send 
the bill to a Central Fee Basis Office for payment. If payment was 
prompt and, perhaps double the Medicare rate, veterans would 
immediately become the preferred patrons in rural practice.
    We won't be able to project a significant amount of bricks, mortar 
or staff into rural communities. CBOCs are expensive and the pressure 
on Hospital Directors to place them in areas which will return the 
greatest number of new patients is almost overwhelming. About 11 
percent of our CBOCs are in counties designated as rural (fewer than 
100 people per square mile).
    What we can project are care and caring into the rural setting. We 
need to support Non-VA providers who offer care to our veterans by 
providing them a generous reimbursement; we need to support the rural 
hospitals through which we will be able to project our information 
infrastructure and we need to support our veterans by supplying the 
medications they need from providers near their homes.
    Again, I would like to thank Senator Salazar for inviting me to 
this forum and I would be happy to answer any questions.

    Senator Salazar. Thank you very much, Dr. Allin and members 
of the panel for your testimony this morning. I know you have 
also submitted written comments that we will make a part of the 
record here this morning.
    I am going to ask a number of questions. In the interest of 
time, I am going to ask the panel to respond to them. Some of 
them are specifically addressed to a couple of you.
    The first question is to Director Biro, and that is the 
decision of the Veterans Health Administration and VISN 19 not 
to place a clinic in northwest Colorado. We heard Mr. Condie 
talk about the empty quarter in northwest Colorado. When I look 
at the map of Colorado that shows the different CBOCs that we 
have in this State, the different facilities, it seems to me we 
have two rural quarters that are uncertain. We have northwest 
Colorado, and we also have the northeastern part of our State. 
I know that in your testimony you talked about the fact that we 
still had not completed the recommendations of CBOC as set 
forth in the CARES Commission recommendations.
    My question to you is: How can we move forward in an 
expedited manner to ensure that we do have a CBOC in northwest 
Colorado as well as northeast Colorado? How can I as a Senator, 
how can the Veterans' Affairs Committee, help you address that 
issue into the future?
    So write that one down for a second, because I am going to 
try to go through all of my questions before we have the panel 
members respond.
    As part of that question also, Director Biro, the criteria 
that are used now for the decisions that are made with respect 
to the location of the CBOCs, they don't seem to be consistent 
to me in terms of where the CBOCs are being placed. Is there 
something that we can do to help clarify that criteria from a 
legislative point of view?
    Second, Dr. Biro and Dr. Murphy, if you would also just 
address the budgetary issues with respect to VA's health care 
as it relates to rural areas. Dr. Murphy, you in particular 
here on the ground in Grand Junction--too much energy behind 
those microphones--the budgetary issue that we see in terms of 
serving vets who live far away from Grand Junction, for 
example, in northwest Colorado, how you see us addressing those 
budgetary issues.
    Mr. Riedinger and Mr. Condie, you both live the reality 
every day of having to go out and raise money and work with the 
dealerships to provide the transportation services so that our 
veterans do have access. I would like for you to comment on how 
a creation of a CBOC, Mr. Condie, up in northwest Colorado, 
might be helpful to the efforts of serving veterans there. Also 
if you would talk just about the financial challenges that we 
have in terms of providing transportation.
    On fee-based care, you heard both Dr. Murphy and Dr. Allin, 
Director Biro and their comments. So, Dr. Biro, I would like 
you to respond to their testimony with respect to fee-based 
care and how we as a Nation can move forward to address some of 
the concepts and proposals that Dr. Allin and Dr. Murphy talked 
about.
    I have heard your testimony on tele-medicine. I will 
withhold my question there. I guess, the financial question I 
would have would be on Native American veterans. We have 
hundreds of thousands of Native American veterans from all wars 
that have provided a great service to our country. I know in 
the next battle we are going to hear some issue there specific 
to Native Americans.
    So with that, I would ask you to keep your responses to all 
those questions relatively short. So why don't we start with 
you, Director Biro, since most of those questions were directed 
to you, I will give you 5 minutes, and then I will give the 
other members of the panel 2 minutes a piece to respond to 
whatever they want with respect to those questions or any of 
the testimony that you have heard here this morning.
    Director Biro.
    Mr. Biro. Getting a CBOC in northwest Colorado: Basically, 
as I outlined, it's a question of resources and priorities. The 
way I set the priorities, it seemed as reasonable as I could, 
is that we could take care of capital asset realignment for 
enhanced services first. That seemed to be--something that was 
concrete I could do and I could lay out.
    After that the rest, and I would say somewhere between 15 
and 20, we really don't have priorities for. Maybe one in every 
location, geographical location, might be a way to do that. It 
was kind of a Maslovian thing that, you know, we were doing 
those three promises. I had no money to do a CBOC, so, very 
frankly, I didn't work on the priorities. That made sense. I 
could do that.
    Moving ahead, the things that you have done. It's no 
secret, what you have said, rural areas are neglected. There is 
no office, a central office, for rural health. There is no 
advocacy among the previous representative in this area. Mr. 
McGinnis introduced this legislation a couple of years ago. We 
discussed this briefly with the leadership of VA, which is 
basically gone now, that the rural area is not represented. It 
is an urban focus or a suburban focus, and that's something 
that needs to be looked at. That's something certainly your 
committee could do. Give some clear direction to our board of 
directors to say we want some additional attention to the rural 
situation.
    Everything you said, rural veterans are sicker, it is worse 
to live out in the country than it is to live in, wherever, 
downtown Denver or downtown Salt Lake. So that's the issue.
    So moving ahead to northwest Colorado and how you can help 
would be all the good things that you have done already. 2006 
is going to be better than 2005. If we are going to have money 
to do that, we need to keep that going forward to have that 
money. To focus that money on rural projects is the right thing 
to do. That would be one way of getting somebody's attention. 
So those would be my two suggestions to move it ahead. Either 
way, a nonmonetary of having something and the authorization 
saying you need to develop--have an office for rural health, 
and you need to put that in the plan one way or another, get a 
report on that.
    The criteria--I don't know about the placement. The 
criteria is what I said. You will have problems doing virtually 
every community-based outpatient clinic in VISN 19 because we 
don't have the population. We scored the northwest clinic. It 
has a score card in the back of policy directive, and we don't 
make it. It would require some sort of waiver to do northwest 
Colorado or virtually every one of the ones that we have.
    Now, are they amenable to changing that? Sure. Have we 
worked on it? Not really, but since again funds were tight 
there were not CBOCs going on, we didn't take that up. But we 
certainly should take that up. So the criteria is biased 
toward--let's say toward urban areas and toward networks that 
have a lot of money. Because you have to certify. You cannot 
break those facilities.
    Budgetary issues, historic. 2005 was a tight year. We got 
about a 4 percent increase. VISN 19 gets its fair share of 
funds. I use a simple formula, and I advocate for veterans 
within the Veterans Health Administration and VISN 19 all the 
time. We are 2.5 percent to the veteran population. We would 
expect that we would get 2.5 percent of any appropriation, any 
special money, any money that comes out that we need to get 2.5 
percent. We have certainly gotten that 2.5 percent and more.
    So we recognize our growth, which is about the second 
biggest in the VHA and the VERA process, our equitable 
distribution process. Any process to send funds to the field 
has been recognized.
    But 4 percent is a tight, very tight, budget. Our cost per 
delivery of care went up 3 percent alone. So that left us 1 
percent per capita. So that left about 1 percent to do anything 
else. So funds were tight, but we delivered.
    I would like to say that you have not heard any horror 
stories in 19. I met my promises. Dr. Murphy has met those 
promises over and over again. We will do everything in our 
power to deliver to veterans the care that they have earned, 
deserved and are entitled to. I wouldn't be testifying if I 
can't do that. You will have somebody else here, because I will 
not--I cannot do the job if I can't do the job.
    Senator Salazar. Will you comment briefly on the fee for 
services proposal?
    Mr. Biro. Right. The fee basis, just very quickly, Title 
38, the law is very prescriptive in fee basis. It's reserved 
primarily--or not primarily--for service-connected veterans. 
It's in the law. I have got the law here, and it's very clear 
that you have to be service connected to get fee basis. It's 
very tightly controlled. The last element, and it's an ``and'', 
is inability to get services in a particular area.
    So the way fee basis is used, the way the directives are, 
is primarily to take care of service-connected veterans. It is 
very tightly controlled. That's all I can say. We have an 
office that does that. There may be some inconsistency where 
other people are using it to take care of other-than-
nonservice-connected veterans. I can't address that.
    Then closing with Native Americans, I am very proud of the 
VISN 19 program. We have what's called tribal veterans 
representatives from every tribe in our area. They reach out to 
veterans.
    I am very proud of our PTSD program that is, again, a very 
personalized program. We have tribal outreach workers who go 
out and look for veterans who have PTSD and any problem as far 
as that's concerned.
    I know the representative from the North Ute Tribe is going 
to speak to you. We are in the process of doing an MOU with the 
Indian Health Services in the service area for the Northern Ute 
Tribe.
    We have a full-time outreach person, Mr. Richardson, who is 
out somewhere right now in his pickup truck and is out in those 
four states working those veteran issues. I am in constant 
contact with the tribes and their tribal councils and 
presidents of the tribes, and we endeavor to reach out to them. 
We have a very culturally sensitive program. We have Native 
American healers. Actually, in Riverton, Wyoming we have a 
sweat lodge on our property, so we do whatever is necessary. 
That goes down to every veteran will be personally satisfied.
    Senator Salazar. Thank you, Director Biro. In the interest 
of time I will have each of the panelists, if you wish, to go 
ahead and give us a 2-minute comment on the questions I asked 
for the points that were made by Director Biro. Why don't we 
start with you, Dr. Murphy and then Dr. Allin.
    Dr. Murphy. Grand Junction has been rather fortunate in its 
funding level and has basically had adequate funding to do our 
business as usual. We haven't had the funding to expand and 
develop new areas of activity, but we have done well. It's not 
only a quality organization, it's been a highly efficient 
organization for several years certainly preceding my arrival 
here a few months ago.
    We do have some outreach in the form of tele-health. We 
have health buddies that go into the home to monitor patients, 
as you talked about, with blood pressure, chronic obstructive 
pulmonary disease, and hypertension. We are beginning very 
shortly to have tele-psychiatry which will operate between our 
home base here in Grand Junction and the CBOC in Montrose where 
patients can come in, we will have the tele-health equipment 
there, and we can do tele-psychiatry there. We are doing some 
tele-work where it involves going from facility to facility. 
Some you can do from home to facility, others of it is health 
care facility to health care facility. We are getting involved 
in both.
    We have been able to expand our medical staff to support 
some of the beyond-primary-care activities that I mentioned, 
and neuro-orthopaedic surgery is an example of that. That's a 
very expensive program to run, and, yet, we have been able to 
support that with funds that VISN 19 has provided. I think 
that's an excellent service considering that we represent the 
VA for 180 miles toward Denver and probably that far toward 
Salt Lake all the way to----
    Senator Salazar. Would a CBOC in northwest Colorado help?
    Dr. Murphy. It probably would. We are challenged by the 
VA's criteria at the moment.
    Senator Salazar. But if we were to change the criteria and 
figure out a way of putting a CBOC up there, it would help in 
connection with health care delivery services including tele-
medicine?
    Dr. Murphy. We might have a base to have some tele-health 
out there in a CBOC. I mean, all things are possible with 
money, so----
    Senator Salazar. Got to get the numbers, right?
    Dr. Murphy. Yeah, get to the numbers. I would mention 
something on your VetsRide bill. Grand Junction tried a number 
of years ago with its own funds to set up a bus transportation 
system where a bus from here was contracted and made the route 
up to Routt County and back. It was discontinued for low 
ridership. On some days we actually had almost zero to zero 
vets riding it.
    I think the plan that your legislation proposes, where the 
rides would emanate from the counties, probably would be more 
effective in trying to manage it on our end. So I think that 
the approach that your bill has to offer probably is an 
extension beyond what we were not able to do successfully, just 
because the ride was too long to vets. It was just too much of 
a day. If it emanates from there, I think it might work better.
    Senator Salazar. Thank you Dr. Murphy.
    Dr. Allin.
    Dr. Allin. I believe, along with Director Biro, that the VA 
provides care second to none. The CBOCs, a staffed CBOC, is the 
first best option for that care anywhere, rural, suburban or 
urban care, the VA and its providers do the best job.
    That being said, there are going to be some areas where it 
will be impossible to put brick and mortar. In that area there 
are veterans who have earned the right to care from the VA. 
There must be other ways to provide them with local care.
    If you can fund CBOCs, I would say absolutely with employed 
staff. If you cannot fund that, then place in the very rural 
areas, one to six civilians per square mile, the ability to 
provide our veterans with some help.
    Senator Salazar. Thank you, Dr. Allin.
    Mr. Riedinger.
    Mr. Riedinger. What I have experienced with the 
transportation program is it's gone from difficult to almost 
suppressive. We have two vehicles. There is a Colorado trust 
fund which makes it easy to get a vehicle. The hard part is 
maintaining a volunteer program.
    Our trips to Albuquerque can be as long as 16-hour days. 
Sometimes, I mentioned before, veterans hospitals will say, 
``Well, we can't complete your exams today. You need to stay 
over.'' So then there is an accommodation problem, because 
there are no accommodations except for, I believe, radiation 
treatments for cancer.
    I went from 22 prospective drivers to one that stuck it out 
through the process. Even the qualification process that's 
imposed by the medical center, it's a laborious process, and 
it's a turnoff to volunteers.
    Senator Salazar. So your suggestion, then, would be to take 
a look at the per-diem reimbursement that we currently provide 
for vets that have to take these rides to seek health care in 
places that are at some distance?
    Mr. Riedinger. A lot of this is the paperwork. There were 
some fatalities within the system, so they are paying attention 
to the medical health of the driver. What has happened is they 
are constantly adding what it takes to qualify. It takes a long 
time and requires a trip to Albuquerque to be qualified to 
begin with.
    Senator Salazar. Thank you, Mr. Riedinger and Mr. Condie, 
for your concluding comments?
    Mr. Condie. Yes, sir. The transportation issue out starting 
in Steamboat Springs and going through Hayden and going through 
Craig and going through Meeker is normally done on a demand 
basis. They call me or they call the VSO in Craig who is the 
representative of Moffat County. We can get the veterans down 
to the hospital. All we need is time to do that.
    I have five drivers I select from to break up driving on 
one individual. I do provide the vehicles, new vehicles, air 
conditioned vehicles. The idea of purchasing a vehicle is not 
practical. You have to find someplace to park it, you have to 
find somebody to maintain it, and you have to find somebody to 
insure it. It's not practical.
    So the process which I do I found practical. I have been 
doing it for 4 years. I will continue to do it to provide 
transportation for veterans starting at Steamboat Springs to 
Grand Junction. I provide transportation through the Alpine 
Taxi service that starts in Steamboat to Denver. I buy a round-
trip ticket for the veteran.
    There is no public transportation in our region, none at 
all. So the thing here is, if myself or other folks like me 
don't make the effort, nothing gets done. Having a CBOC or 
having a partnership with one of the hospitals on Route 40 
would work out best for the veterans in that region.
    The veterans in that region encompass over 14,000 square 
miles, and the thing here is that's Jackson, Grand, Routt, 
Moffat, Rio Blanco, northern parts of Garfield County. The 
thing is there is no place for these vets to go except to have 
to travel. That's the best I can say, sir.
    Senator Salazar. Thank you very much, Mr. Condie, and to 
all the members of the panel for the time you have taken to 
appear here before us and for the testimony that you have 
provided.
    We will take about a 3-minute break while we get the other 
panel to come forward, and then we will resume the hearing in 
about 4 minutes. Thanks very much.
    [Recess.]
    Senator Salazar. Why don't we go ahead and resume the 
hearing. We are going to hear from our second panel today, and 
I would like to welcome Charlie Watkins who is the Colorado 
Department Chief of Staff for the VFW. He lives in Craig 
Colorado, and I had the honor of meeting with him up there just 
last night.
    Jim Stanko, an Army veteran who has been home for, it 
seems, forever and has been a strong advocate for the veterans' 
issues we are talking about in northwest Colorado.
    George Leonard, a World War II Navy veteran who has been 
active in the Durango veterans community for many years.
    Howard Richards, former chairman of the Southern Ute Indian 
Tribe and a great leader in our State and a Vietnam veteran. 
Thank you for being here.
    Paula Rothman who came here to Grand Junction after having 
served in the Army during the first Gulf war. Thank you for 
being here.
    Hank Stroncek, a World War II veteran with the Coast Guard 
and who currently lives in Steamboat Springs.
    Leonard Yoast is 85 and doesn't look it, looks much 
younger. He's a World War II veteran from Hayden, Colorado.
    And Michael Adams, a physician's assistant from Iraq who 
now works as a health care professional in Norwood.
    Thank you all for your service, and thank you for being 
here today. Because of the number of panelists that we have, I 
am going to ask you if you can limit your comments down to 
about 4 minutes. We have received your written testimony, and 
that testimony will become a part of the record.
    So with that why don't we start with Charlie Watkins and 
take testimony from him.

    STATEMENT OF CHARLES WATKINS, VETERANS OF FOREIGN WARS, 
         COLORADO DEPARTMENT CHIEF OF STAFF, CRAIG, CO

    Mr. Watkins. Good morning, Senator. I would like to take 
this opportunity to thank you for all you are doing for our 
veterans to right the tragic wrongs of our government in the 
Veterans' Administration.
    I strongly believe that the Veterans' Affairs 
Administration has been severely lacking in leadership at the 
medical center and regional office level for many years. Many 
of the employees have lost sight of the mission of the 
Veterans' Affairs, which is to care for our veterans. They feel 
the VA exists just so they can have a job.
    The VA and the government have created many artificial 
roadblocks' rules over the years that have hindered and 
precluded the health care of our veterans. No one told us when 
we went off to war if we came home and became successful later 
in life we would lose our health care. They have changed the 
rules obtaining health care so many times that it is difficult 
even for an attorney to decipher if you qualify and what you 
must do to receive your health care. The means test is a 
typical example. If you don't see a doctor in the VA facility 
for 2 years, once again, care is denied. If you go to the 
emergency room at a local hospital, your bills will not be 
paid.
    These are just a few of the arbitrary rules of the VA.
    Their rules even become more arbitrary in deciding service 
conductibility and what percent you should receive. The VA 
never re-evaluates their medical retirees, but every veteran 
who is drawing disability will be re-evaluated every 2 to 3 
years. We need to eliminate these arbitrary rules.
    Several years ago when the VA closed the VA Medical Center 
at Ft. Lyon, Colorado, they put in a CBOC in Lamar, La Junta, 
Pueblo, Alamosa, Durango, and Montrose which is 60 miles from 
one of the No. 1 VA hospitals in the nation. Now they are 
thinking that they need a CBOC in Rifle. Once again, that's 60 
miles away. We need a CBOC in northwest Colorado.
    In northwest Colorado we are greatly concerned about the 
health care of our aging veterans. Our counties are spending a 
great deal of money annually to transport veterans to the 
nearest VA facility. Many of our elderly veterans cannot drive 
and many have no family to transport them. They are required to 
travel up to 300- to 500-mile round trip just to get their 
health care, which can take 3 to 5 hours over windy mountain 
roads. During winter months the time can be significantly 
increased because of bad weather, open range cattle, and deer 
and elk migrations which endanger their safe travel to the VA.
    The long distance to the VA to obtain needed health care is 
taking its toll on many of our veterans. It is almost 
counterproductive because of the length of travel to the VA. 
Many veterans require several days just to recover from the 
trip. Although there is funding for local care, it is extremely 
difficult to get approval, and I don't know of a single request 
that we have submitted that has been approved.
    The veterans of northwest Colorado served their country 
honorably and they deserve the same consideration for health 
care that is given to veterans in other parts of the country. A 
CBOC in our area would aid significantly in the health care of 
our veterans.
    I shutter to think that this country is not willing to 
uphold its responsibility to care for our veterans who made 
many sacrifices to ensure the security and freedom this country 
and many others enjoy. Our government thinks nothing of putting 
soldiers in harm's way to protect the rights of others. We 
spend hundreds of millions of dollars annually to aid and prop 
up foreign countries around the world. Charity should start at 
home caring for our veterans.
    At times, I think we should give every soldier a Medicare 
card when he gets out of the service and let him get his health 
care where he lives, and we could shut down many of the VA 
facilities saving millions of dollars. Medicare may not be the 
answer, but it seems to work.
    Our government over the years has promised our soldiers 
they would be taken care. The veterans have fulfilled their 
obligation to the country. It is now time for our country to 
fulfill its obligation to our veterans. In this country today 
we take better care of criminals who are incarcerated than we 
do honorably discharged veterans.
    There is a famous quote by Calvin Coolidge that reads, 
``The Nation which forgets its defenders will itself be 
forgotten.'' We are seeing evidence of that today as our 
recruiters are not meeting their quotas. The youth of this 
country are ours. They are very bright. They see the country as 
not taking care of us. Why should it take care of them? Knowing 
full well they will not be taken care of, they are not willing 
to serve.
    If we are asking a soldier to stand in harm's way, we 
assume a responsibility to care for him in his time of need.
    We, of northwest Colorado, want to ensure our veterans 
receive the health care they deserve and that it is timely. It 
should be second to none, and it should be relatively 
convenient. Nowhere else in the State are veterans required to 
travel so far or endure so much to receive the health care that 
they so rightfully deserve.
    Thank you, sir, for allowing me to testify today.
    [The prepared statement of Mr. Watkins follows:]

   Prepared Statement of Charles Watkins, Veterans of Foreign Wars, 
             Colorado Department Chief of Staff, Craig, CO

    Good morning Senator Salazar. I would like to take this opportunity 
to thank you for all you are doing to help our veterans and right the 
tragic wrongs of our government and the Veterans Affairs 
Administration. I strongly believe that the Veterans Affairs 
Administration has been severely lacking in leadership at the Medical 
Center and Regional Office level for many years. Many of the employees 
have lost sight of the mission of the Veterans Affairs, which is to 
care for our veterans. They feel the VA exists just so they can have a 
job.
    The VA and the government have created many artificial roadblocks 
and rules over the years that hinder and preclude the health care of 
our veterans. No one told us when we went off to war that if we became 
successful later in life we would lose our health care. They have 
changed the rules for obtaining health care so many times that it is 
difficult even for an attorney to decipher if you qualify and what you 
must do to receive your health care. The means test is a typical 
example. If you don't see a Doctor in a VA facility for 2 years, once 
again your care is denied, if you go to the emergency room at a local 
hospital your bills will not be paid. These are just a few of the 
arbitrary rules of the VA. Their rules even become more arbitrary in 
deciding service-connected injuries and what percentage you should 
receive. The VA never re-evaluates their medical retirees, but every 
veteran will be re-evaluated every 2 to 3 years to reduce their 
disability. We need to eliminate these arbitrary rules.
    Several years ago when the VA closed the VA Medical Center at Fort 
Lyon, CO they put in a CBOC in Lamar, La Junta, Pueblo, Alamosa, 
Durango, and Montrose, which is only 60 miles from the VA Hospital in 
Grand Junction. Now they think they need a CBOC in Rifle, once again it 
is 60 miles from Grand Junction. There was no consideration given to 
northwest or northeast Colorado to provide health care for those 
veterans. It is time we rectify this situation and put a CBOC in NW 
Colorado.
    In NW Colorado we are greatly concerned about the health care of 
our aging veterans. Our counties are spending a great deal of money 
annually to transport veterans to the nearest VA. Many of our elderly 
veterans cannot drive and many have no family to transport them to 
their appointments. Our veterans are required to travel 300-500 miles 
round trip just to get their health care, which can take 3-5 hours one 
way over winding mountain roads. During winter months the time can be 
significantly increased because of bad weather, open range cattle and 
deer and elk migrations, which endanger their safe travel to the VA.
    The long distance to the VA to obtain needed health care is taking 
its toll on many of our veterans and it is almost counter productive. 
Because of the length of travel to the VA many veterans require several 
days just to recover from the trip. Although there is funding for local 
care, it is extremely difficult to get approval and I don't know of a 
single request that has been approved. The veterans of NW CO served 
their country honorably and they deserve the same consideration for 
health care that is given to veterans in other parts of the country. A 
CBOC in our area would aid significantly in the health care of our 
veterans and particularly our aging veterans.
    I shutter to think that this country is not willing to uphold its 
responsibility to care for our veterans who made many sacrifices to 
ensure the security and freedom this country and many others enjoy. Our 
government thinks nothing of putting soldiers in harms way to protect 
the rights of others. We spend hundreds of millions of dollars annually 
to aid and prop up foreign countries around the world. Charity should 
start at home by caring for our veterans. At times I think we should 
give every soldier a Medicare card when he gets out of the service and 
let him get his health care where he lives and we could shut down many 
of our VA facilities saving millions of dollars. Medicare may not be 
the best possible care, but it seems to work.
    Our government, over the years promised our soldiers they would be 
taken care of. The veterans have fulfilled their obligation to our 
country and it is now time for our country to fulfill its obligation to 
our veterans. In this country today we take better care of criminals 
who are incarcerated than we do our honorably discharged veterans. 
There is a famous Calvin Coolidge quote which reads: ``The Nation which 
forgets its defenders will itself be forgotten.'' We are seeing 
evidence of this today, as our recruiters are not meeting their quotas. 
The youth of this country are ours. They are very bright and they see 
that the government has lied to us in the past and we have not been 
taken care of. They are not willing to serve this country, knowing full 
well they will never be taken care of either. If we ask a soldier to 
stand in harms way we assume a responsibility to take care of him in 
his time of need.
    We in NW CO want to ensure our veterans receive the health care 
they deserve and that it is timely. It should be second to none and it 
should be relatively convenient. Nowhere else in the State are veterans 
required to travel so far or endure so much to receive their health 
care. We value our veterans and their contributions to this country and 
we would greatly appreciate your assistance in obtaining a CBOC in NW 
CO to serve our veterans.
    Thank you Senator Salazar for allowing me to testify today.

    Senator Salazar. Thank you very much, Mr. Watkins.
    Audience. Can our president get involved in it?
    Senator Salazar. We will hear from the panelists, and, 
again, for anyone here who wants to provide us with comments 
and testimony, we have forms. If you will provide us that 
testimony, we will make sure that it is included as part of the 
record for the Senate Veterans' Affairs Committee.
    Mr. Stanko.

   STATEMENT OF JAMES W. STANKO, AMERICAN LEGION DISTRICT 14 
                  COMMANDER, STEAMBOAT SPRINGS

    Mr. Stanko. Yes, thank you, again, Senator Salazar, for 
allowing us to come down and speak.
    I think basically what I would like to address is some of 
the things that were touched on even in the earlier panel is 
that veterans health care, even though it's an issue that 
concerns us in northwest Colorado, is just the tip of an 
iceberg of really a health care issue across the United States. 
It shows that our health care is in a critical condition.
    This is what is placing a stress on the veterans is the 
fact that--or on the VA is the fact that a lot of people are 
losing their health care and are having to turn to the VA to 
receive health care. It's not going to get any better, because 
as more young men and women and the people who are serving come 
out, they are going to need health care. If they can't afford 
it through insurance and certain things like this, they are 
going to keep turning to the veterans' health care.
    A statistic that was just brought out that really kind of 
amazed me is that I heard this figure: 700,000 veterans in 
Region 19 of the CARES, but only 146,000 or 150,000 of them are 
in the system. But that doubled since 1996. Well, if it doubled 
in the 5 years or 4 years or 10 years, it's going to double and 
triple in the next few years.
    I think the real solution that we need to look at is that 
we need to look at reforming what was already some of the 
programs within the VA itself. If this Title 38 is a hindrance 
to getting local health care, that's something that I think we 
need to look at and take care of.
    I am extremely concerned when we talk about going to CBOCs 
and building brick and mortar, because I don't think this is 
the way to go. I think the way to go is a contract service. 
Even the VA hospital here in Grand Junction, they just said 
they contract out to St. Mary's. They have to contract some of 
their services. Wouldn't it make more sense to start 
contracting services in local communities where veterans can go 
to their own doctors, doctors that they are familiar with, in 
surroundings that they are familiar with, and come up with some 
sort of a fee-based system or some sort of a system using 
Medicaid, using Medicare, getting it all combined into one 
thing? As was mentioned by one gentleman where you could have 
your VA medical card, go to any facility, you can get the 
medical care that you need. You can present that card to that 
hospital. That group can then bill one entity, like the VA, 
which could also get some added money and stuff from Medicaid 
and Medicare.
    I think keeping the CBOCs or keeping contract services 
locally is great, too, because it keeps local tax dollars 
local. We all pay Federal income tax. This is some way to keep 
some of that local tax money back into the local hospitals.
    By also having local veterans come to local hospitals, it 
also builds the patient base for that hospital so that they can 
get better funding and grants or have better care and services 
because they have a bigger base.
    The three hospitals in northwest Colorado all seem to agree 
that this is the thing that they would like to do. I have 
letters and resolutions from each of the three hospitals, the 
Kremmling Memorial Hospital District, the Yampa Valley Medical 
Center and the Memorial Hospital in Craig. They are all 
addressed to you, Senator. I am going to present them to your 
aide here. I would like for you to read them. But in each of 
these letters these hospitals are willing to work with the VA 
to provide health care.
    I think this can be accomplished, not only in Colorado, but 
in all of those rural states in CARES 19, but it's going to 
take some changing of the rules. That's what I think we need to 
start here in northwest Colorado. This hearing today is--
northwest Colorado wants to be the leader, not only in getting 
CBOC or health care, but in starting to change the rules to 
make the VA more effective to serve what they are supposed to 
serve, the veterans of the United States.
    [The prepared statement of Mr. Stanko follows:]

  Prepared Statement of James W. Stanko, American Legion District 14 
                      Commander, Steamboat Springs

    Thank you for allowing me to present testimony on veterans' health 
care. I would like to take this opportunity to address some issues 
which are of importance to veterans of Northwest Colorado and through 
out all rural areas of Colorado.
    Health care is becoming a national issue with the cost of insurance 
becoming a financial burden to many families. Employers are looking to 
cut benefits as a way to reduce costs and many veterans, especially 
those in their late 50s and early 60s, are getting caught up in this 
loss of benefits; therefore, they are turning to the VA as a means of 
having some form of health insurance. This is putting a strain on the 
Veterans' Administration.
    This is a problem that will not go away. There is a steady growth 
of men and women who have served their country reaching an age where 
they will be looking to the VA for heath care. We also have those that 
are currently serving; these service members will be coming into the 
system in just a few years. The VA health care system needs some 
serious overhauling in order to accommodate these future veterans. The 
time to start this is now and one of the places we can start is here in 
Northwest Colorado.
    Northwest Colorado is one of the few areas of the State that 
Veterans have to drive more than 180 miles to reach a VA health care 
facility. Because we are in a very mountainous area, a trip to a VA 
facility can become a dangerous adventure. Weather conditions and 
dodging game animals on the road is something our older World War II 
and Korean War veterans should not have to do. Many of the Viet Nam era 
veterans are also in or approaching their sixties and driving for them 
can also be difficult.
    The solution that American Legion members of our Post, along with 
members of other Posts in the District, would like to suggest is to 
establish VA health care contracts with local medical facilities for 
basic healthcare. A contract with local medical facilities would 
accomplish several things. First, it allows veterans to get basic 
healthcare in a facility they are familiar with and with medical 
personnel they know, trust, and are comfortable with all without the 
stress of travel. Second, this allows tax-payer dollars to remain 
local. Third, it would generate more patient activity for the local 
hospital which would help with hospital income. This solution would 
save resources, the local hospital's already exist; no new facilities 
would need to be built, equipped, and staffed. This would save the 
Veterans' Administration financial resources. Veterans' would be 
working with healthcare givers who are already familiar with their 
medical history, thus saving time resources (no review of medical 
history needed), medical testing (the local doctor knows which tests 
have been done, thus, no duplication of testing), and with minimal 
traveling, the veteran would save serious money on fuel costs. It is a 
solution which will help at both the local, state, and national levels.
    Two American Legion members of our Post, Gar Williams, a Department 
of Colorado Jr. Vice Commander, and Mike Condie, the County Veterans 
Affairs Officer, have been working hard on getting local medical 
facilities to come on board with this idea. To this end, I am able to 
present a letter from the Yampa Valley Medical Center in Steamboat 
Springs and a Resolution from the Kremmling Memorial Hospital District 
affirming that they would be willing to work with the VA to provide 
services to veterans. The Craig Memorial Hospital has also indicated 
they would work with the VA. These documents show that there is a 
willingness of the medical facilities in Northwest Colorado to work 
with the VA to come up with a contract that would benefit Veterans at 
the local level.
    This contract system would not only benefit Northwest Colorado, but 
would also help rural communities in the other three remote corners of 
the State. Contracting for health care is not a new idea for the VA. In 
fact it already happens in many rural areas in other States. As an 
example, in Western Nebraska, the VA employs practicing nurses to visit 
and care for veterans.
    Another alternative is to actually get a Community-Based Outpatient 
Clinic in Northwest Colorado. Steamboat Springs has been suggested as 
the site for this clinic because it is central to all Counties 
involved. However, as I have pointed out, this is a duplication of 
services. A CBOC would have to contract space, and equipment, mostly 
likely from the local hospital. Also the Visiting Nurses of Northwest 
Colorado are trying To get a clinic for the care of seniors and the 
community of Oak Creek is trying to find a way to fund their clinic, so 
why another clinic? Money used to fund a clinic that duplicates 
services could be better used to contract services for veterans. But if 
a CBOC is the only alternative the VA has to offer the Veterans of 
Northwest Colorado, then we'll take it.
    I would also like to take this opportunity to support your bill, 
The VetsRide Act S. 1191. This is a very positive step in helping 
veterans in rural areas. As a veteran's organization we are very 
pleased with the amendment on Community-Based Outpatient Clinics. Also, 
if Northwest Colorado does not end up with health care contracts or a 
CBOC, the transportation grants would be a tremendous asset in solving 
the funding problems we have in getting veterans to a VA hospital.
    I would like to encourage Senator Salazar to join with the American 
Legion position in supporting mandatory funding for the VA, especially 
VA healthcare. This is the real solution to the health care funding 
problem. Even though the current Administration claims an increase in 
VA funding, this funding is woefully inadequate. Men and women that 
have served or are currently serving deserve and have earned the right 
to reasonable health care and our Government needs to accept this 
responsibility and step forward with mandatory funding.
    I, along with many veterans that did not serve in a combat zone or 
situation are very concerned with the Administration's position to 
create a ``core constituency'' will place undue financial burdens on 
the class 7 and 8 veterans. Every person that has put on a military 
uniform has made a sacrifice. They have left their homes, loved ones 
and friends to defend in some way their country and the liberties and 
freedoms of all Americans; and now a majority is being told they are 
not really veterans. The Veterans Committee needs to be made aware of 
the fact that it takes 10 to 12 or even more military personnel to 
support each combat soldier. When you put on a military uniform you 
become part of the United States Military and your job is to preserve, 
protect and defend the Constitution and it doesn't make any difference 
if you're a clerk, cook or rifleman. There should be no difference in 
classification when it comes to obtaining health care. Just as a side 
note, President George Bush would not be eligible for VA health care if 
a ``core constituency'' is set up. I would encourage Senator Salazar as 
a member of the U.S. Senate Committee on Veterans Affairs to fight and 
stop this slap in the face of all those Veterans who have helped 
preserve the safety and freedoms of this country from non-combat place 
or at a non-combat time.
    Finally, I would like to suggest an idea that might solve some of 
the VA health care funding. Could the VA set up some sort of VA health 
care insurance plan? The plan could include low minimum premium paid by 
any veteran that signed up. The insurance would only be for the 
veteran, but it would allow the veteran to be treated at any medical 
facility. The insurance funding pool would come from the premiums, 
money from the VA, and veterans Medicaid and Medicare benefits could 
also be added to the pool. This way any veteran that signed up and paid 
premiums would be covered at any medical facility with that facility 
receiving payment from only one entity, the VA insurance.
    Again thank you for the opportunity to express my views on the VA 
health care system. Hopefully these suggestions will help you in your 
efforts to make health care better and available to all veterans in the 
State of Colorado.

    Senator Salazar. Thank you, Mr. Stanko. Thank you very 
much.
    Mr. Leonard.

 STATEMENT OF GEORGE LEONARD, WORLD WAR II VETERAN, DURANGO, CO

    Mr. Leonard. Mr. Stanko saved my day. I have got the same 
idea, make it local control. I am sorry for laughing, but he 
went through the same thing I was going to talk about.
    But I did haul veterans here into Grand Junction, and I can 
guarantee you that the roads do get pretty hairy. If we could 
make some kind of a deal with doctors, and whatnot, and 
hospitals in our own area, that would save time, money and 
expense and wear and tear on the drivers. It would be a lot 
safer. And he's covered most of it right there.
    Senator Salazar. I appreciate your attendance, and 
appreciate the passion of that advocacy that both of you share 
for veterans and for the veterans particularly in northwest 
Colorado.
    Chairman Richards.

 STATEMENT OF HOWARD RICHARDS, SOUTHERN UTE INDIAN TRIBE PAST 
               CHAIRMAN, VIETNAM VET, IGNACIO, CO

    Mr. Richards. Good morning, Mr. Senator, my fellow comrades 
here in attendance today. I would like to thank you for 
allowing me to testify on behalf of the Southern Ute Veterans' 
Association of the Southern Ute Indian tribe.
    I am an enrolled member of the Southern Ute Indian Tribe 
and cofounder of the Veterans Association, which was formed--
primarily the mission was to assist tribal veterans in the 
following areas: Health, training and housing because of the 
inability of the county Veterans' Service Officers to meet the 
needs of a tribal veteran. I will speak a little to that as I 
move forward.
    In 1994 the Southern Ute Tribal Council upon the urging of 
the association funded a Tribal Veterans' Service's Officer 
position to assist both tribal and non-tribal veterans on the 
education of veterans' benefits and other issues.
    I would like to add until the Veterans' Administration can 
address our concerns of veterans of yesterday and today, and, 
most important, future veterans, they will always find 
themselves between a rock and a hard place.
    Now, I am going to speak toward a bullet point that I 
provided to this Committee labeled ``Entitlement and 
Benefits``:
    As Indian tribes, as sovereign nations, we should have the 
ability for a government-to-government consultation with the 
Veterans' Administration. That's probably our biggest push in 
the Association that the southern Ute Indian Tribe should speak 
directly to the VA. Because when you get to the County 
Veterans' Officers and other people involved in the system, it 
slows the system down. With the ability that is found under 
1990, President Clinton's executive order in respect to 
government-to-government relationship, I think we need to start 
there with the Southern Ute Tribe and the VA.
    The other issues that I want to speak to are the means 
tests, which is to include income guidelines, eligibility 
requirements on income level, and the $25,000 threshold they 
have for eligibility. I will come back to that one, and I am 
going to expound on that a little bit.
    I have talked and I have heard today about memorandums of 
understanding with other Federal agencies to include the Indian 
health and the VA. I am yet to see an agreement that stipulates 
how that is going to work. I have heard talk about it today. We 
have asked for that document, and I don't know where it's at.
    The other issue, very briefly, is I think the native 
population or the American Indian has to have some 
representation or a position on the rating board with respect 
to claims.
    Also, I think that the Southern Ute Indian Tribe's future 
participation on committee appointments, whether at the State 
or Federal level, is probably a must. Because as the VA moves 
forward, the VSO's move forward, I believe that the Native 
American is somewhat left out in their discussion, in the 
dialog. Because we as native people or Indian tribes are 
unique, Mr. Senator, and you talked about tradition and customs 
when we look at health issues. The utilization of medicine men 
in treatment of our people of our aches and pains are there. 
They are probably not part of the system in the VA, that we are 
unique and we need specialized medicine, if you want to call it 
that.
    So when we talk about the threshold and the eligibility 
requirements outlined in the means test, that because as the 
tribe moves forward in its development and its wealth that the 
future veteran if he didn't sign up within a period of time 
will not get enrolled in the VA system.
    I think that concludes my testimony, Mr. Chairman, and I 
look forward to working with this committee as we move forward.
    Right now, very quickly in closing, that the tribe has 
recognized that the Indian Health Service, they are located in 
Ignacio, is not meeting the needs of the Indian population, the 
Southern Ute Tribal population. So the tribe is in the process 
of contracting Indian health from the government for that 
reason. It's the hope of the Southern Ute Tribal Council that 
each and every veteran, each and every tribal member as we move 
forward in developing our health benefit package for tribal 
members, that we can carry a card, what's illustrated, and 
that's coming down very quickly. That you can present that to 
any doctor of your choice for your medical treatment, because 
of the problems that we are seeing, not only with the VA, but 
with the Veterans' Administration and Indian Health.
    So, in closing, Mr. Senator, I want to thank you for the 
short time that you allowed me to testify before you. Thank 
you.
    [The prepared statement of Mr. Richards follows:]

   Prepared Statement of Howard Richards, Southern UTE Indian Tribe 
                Past Chairman, Vietnam Vet, Ignacio, CO

    First, I would like to thank this committee for allowing me to 
testify today on behalf of the Southern Ute Veterans Association of the 
Southern Ute Indian Tribe.
    Second, my name is Howard D. Richards, Sr. and I am an enrolled 
member of the Southern Ute Indian Tribe. I am one of the co-founders of 
the Southern Ute Veterans Association.
    Third, the formation of the Southern Ute Veterans Association's 
primary mission was to assist Southern Ute Indian Tribal veterans in 
the following areas: (1) Health, (2) Training, and (3) Housing. Another 
reason for the formation of the association was the county's veteran's 
service officer inability to meet our tribal veterans' needs.
    Fourth, in 1994, the Southern Ute Tribal Council upon the urging of 
the Southern Ute Veterans Association funded a tribal veteran service 
officer's position. This position assisted both tribal and non-tribal 
veterans on the education of veteran's benefits and other issues.
    In conclusion, I would like to add: until the Veterans 
Administration, (VA) can address our concerns of veterans of yesterday 
and today and most important future veterans they will find themselves 
between a ``Rock and A Hard Place''.

                         ENTITLEMENTS/BENEFITS

     Tribal: Federal Government Relationship. (Gov't to Gov't). 
EX Order, 1990. President Bill Clinton.
     Means Test: Income Guidelines; Eligibility Requirements-
Income Level; and $25,000.00 Threshold.

    Senator Salazar. Thank you very much, Chairman Richards.
    We will now hear from Paula Rothman.

 STATEMENT OF PAULA ROTHMAN, GULF WAR VETERAN, GRAND JUNCTION, 
                               CO

    Ms. Rothman. Thank you. I would like to start, Senator 
Salazar, by thanking you for all the work you are doing to help 
veterans receive better health care.
    Shortly after I returned from the Persian Gulf War, I was 
diagnosed with a disease called scleroderma. From 1992 to 2000 
I used the VA hospital in Tampa, Florida.
    Scleroderma is a disease that is best followed by a rheuma-
tologist. Because the VA hospital in Tampa had a number of 
different fellows, internships, internists all participating as 
part of the USF training program from the medical school there, 
I wasn't able to see the doctor every quarter.
    So I requested fee basis, and they went ahead and sent me 
out to a specific rheumatologist so I could see the same 
rheumatologist every quarter.
    In 2002 I moved to Grand Junction. A large part of my 
decision to move to Grand Junction included my access to care 
and the fact that there was a large VA hospital here. It was 
really a disappointment for me to learn that the VA here did 
not contract with a rheumatologist to see patients. Instead, 
they expect patients to travel to Denver, to Salt Lake City for 
rheumatology care.
    I have traveled to Denver for care in 2004, and I cannot 
remember if I also did in 2003. But I requested fee basis for a 
rheumatol-
ogist here in Grand Junction. I was denied, although Dr. Clark, 
my primary care physician, requested this from the Chief of 
Staff here. I appealed this decision through the patient 
advocate and was then denied again in October 2004. I was told 
they denied the request because there were no long-term 
rheumatologists in Grand Junction, and they did not want my 
care to suffer.
    Scleroderma is a serious illness that should be tracked by 
a rheumatologist. However, as a full-time employee it's very 
difficult for me to travel to Denver. In Tampa I was told that 
I should be seen quarterly, and I have seen a rheumatologist 
since I moved to Grand Junction once or twice. I can't remember 
exactly which.
    I don't feel it's appropriate for me to take a full day off 
from work every quarter to drive, you know, 10 hours round trip 
to Denver and then however long it takes for me to wait to see 
the rheumatologist in Denver.
    In addition to scleroderma, I have had two melanomas and a 
carcinoma. The dermatologist noted those moles when I was in 
Tampa and requested that they get removed. I didn't point them 
out. As a board-certified dermatologist, he noted them and 
said, ``These need to come off.'' Unfortunately, the VA 
hospital in Grand Junction does not have a dermatologist on 
staff from what I have been told. I am sure the doctor at the 
Grand Junction VA hospital, I am sure they are very competent 
at their specialties, and I appreciate all the care I get from 
Dr. Clark whom I respect very much.
    However, the dermatologist in Tampa practicing in his 
specialty noted the changes in these moles and he likely saved 
my life by removing them. I am not positive my general 
practitioner, Dr. Clark, would be as adept at noting these 
changes.
    In preparation for my testimony on August 12th, I contacted 
the patient advocate at the Grand Junction VA hospital to 
ensure my testimony would be correct. He brought this to the 
attention of the Chief of Staff. On that day he actually 
reopened my appeal and approved me for fee-basis care. So now I 
am able to see a rheumatol-
ogist using fee basis as of last Monday, even though my appeal 
was closed almost a year ago.
    I feel my care at the VA Hospital in Grand Junction is very 
good in certain areas and lacking in others. I have wonderful 
access to my primary care physician, Dr. Clark. Her nurse has 
always called me back within 24 hours, usually much faster. 
Whenever I have had appointments the care I have received is 
very thorough.
    However, the lack of an onsite rheumatologist and 
dermatologist is a serious weakness in my health care. This 
weakness could be mitigated by using a fee-basis program to 
ensure all veterans get the care they need or by hiring these 
specialists for monthly clinics.
    I was paid approximately $50 for travel the last time I 
drove to Denver, and this is just slightly less than the 
specialist I went to see in Tampa was receiving. I think she 
was receiving about $60-$80 depending on the length of my time.
    Thank you for the opportunity to speak before you.
    [The prepared statement of Ms. Rothman follows:]

        Prepared Statement of Paula Rothman, Gulf War Veteran, 
                           Grand Junction, CO

    I was diagnosed with a service-connected illness called Scleroderma 
shortly after separating from the Army. From 1992 until 2000, I used 
the VA hospital in Tampa and was approved for fee-basis care as 
Scleroderma is an illness that is best followed by one Rheumatologist. 
I was concerned in Tampa that I was being seen by a different 
specialist on most visits. The Tampa VA is a teaching hospital 
associated with the University of South Florida Medical School and the 
large number of interns, residents, and fellows made it difficult to 
maintain continuity of care. Therefore, I requested and was granted the 
ability to consult a Tampa Rheumatologist under the fee basis program 
so that I would see the same doctor each visit.
    In 2002, I moved to Grand Junction. A large part of my decision to 
move to Grand Junction included my access to care and the fact that 
there was a large VA hospital here. It was quite a disappointment to 
learn the VA hospital has not contracted with a Rheumatologist in Grand 
Junction to see patients. Instead, they expect patients to travel to 
Denver or Salt Lake City for Rheumatology care. I have traveled to 
Denver for care but in 2004 (or possibly 2003); I requested fee basis 
visits to a Rheumatologist here in Grand Junction. I was denied, though 
Dr. Clark requested it from the Chief of Staff. I appealed this 
decision through the patient advocate and was denied again. I was told 
they denied the request because there were no long-term Rheumatologists 
in Grand Junction and they did not want my care to suffer.
    Scleroderma is a serious illness that should be tracked by a 
Rheumatologist. However, as a full-time employee, it is very difficult 
for me to travel to Denver. In Tampa, I was told I should be seen 
quarterly to track my illness, but I have seen a Rheumatologist one to 
two times since I moved to Grand Junction solely due to the hardship of 
traveling to Denver. I do not feel it is appropriate to take a full day 
off from work quarterly for 10 hours worth of travel and the time it 
takes to wait and see the doctor in Denver.
    In addition to Scleroderma, I have had three serious cancers that 
required treatment including two moles with melanoma and one with basil 
cell carcinoma. I was lucky that these were caught early after seeing a 
Dermatologist in Tampa as part of the VA hospital fee-basis program. 
This Dermatologist noted the moles and suggested they were removed.
    Unfortunately, the VA hospital in Grand Junction does not have a 
Dermatologist on staff. I am sure the doctors at the Grand Junction VA 
hospital are very competent at their specialty and I appreciate all the 
care I get from Dr Clark, who I respect and appreciate very much. 
However, the Dermatologist in Tampa practicing in his specialty noted 
the changes in my moles and likely has saved my life by removing them. 
I am not positive a General Practitioner/Internist is as adept at 
noting these kinds of skin changes as a board certified Dermatologist 
would be as this is not the specialty of a General Practitioner/
Internist.
    Note: In preparation for my testimony on August 12, 2005, I called 
the Patient Advocate on at the Grand Junction VA hospital to ensure my 
testimony would be correct. He brought this to the attention of the 
Chief of Staff and informed me in a call later that my appeal has now 
been approved and I would be granted the ability to see a 
Rheumatologist as part of the fee basis program. After this call, I 
requested a referral from Dr. Clark to see a fee-basis Dermatologist 
and this request is pending currently.

                                SUMMARY

    I feel my care at the VA hospital in Grand Junction is very good in 
certain areas and seriously lacking in others. I have wonderful access 
to my Primary Care Physician, Dr. Clark. Her nurse has always called me 
back within 24 hours for non-emergencies (usually much faster) and when 
I have had appointments, the care I have received is very thorough. Dr. 
Clark is and will continue to be my primary care physician even though 
I will have access to a Rheumatologist on a fee-basis case in the 
future. I would not want it any other way as I have all the respect in 
the world for the care I receive from Dr Clark.
    However, the lack of an onsite Rheumatologist and Dermatologist is 
a serious weakness in my health care. This weakness could be mitigated 
by using a fee-basis program to ensure all veterans get the care they 
need or by hiring these specialists for monthly clinics. I was paid 
approximately $50 for travel to and from Denver the last time I drove 
there, and this is just slightly less than what these specialists get 
paid for ongoing care consultations, if my memory from Tampa is 
correct.
    I would be glad to answer any questions you may have.

    Senator Salazar. Thank you, Ms. Rothman, for your 
testimony.
    Mr. Stroncek.

  STATEMENT OF HANK STRONCEK, WORLD WAR II VETERAN, STEAMBOAT 
                          SPRINGS, CO

    Mr. Stroncek. Mr. Salazar, I think Jim Stanko and, what's 
his name, Condie said it all for me and for all of the guys 
from Routt County and around the area.
    On the way coming down here, there was a car in front of us 
coming--as we left Hayden, and a deer came out. He spun around 
in front of us, and he went close to the ditch, he went over to 
the side, and he came back out again. We had to throw our 
brakes on and stop so we didn't plow into him.
    In another instance we came down about 2 years ago. We were 
going about 60 miles an hour, had a flat tire, and we nearly 
rolled it, and we came out OK. Nothing happened.
    But I would like to have it come into Steamboat to take 
care of us instead of driving back here. Because one day we 
might get banged up and, you know, never come back to the 
hospital. They may haul us back in a wagon. I am not very much 
of a speaker to speak of. Jim is good, Condie is good, but, me, 
I am just, forget it.
    Senator Salazar. Not at all, Mr. Stroncek, you are very 
good, and what you say is very true. Yesterday I just came down 
that same route, and I think we probably saw eight or nine deer 
close to the road. I can imagine traveling that same route late 
at night when it's dark. As a person who has not only run into 
deer with horses on roadways, I know exactly what you are 
talking about. I very much appreciate your testimony this 
morning, and thank you.
    Mr. Stroncek. I voted for you. I am glad that Peter never 
got in. Thank God. That's all I got to say. Good luck, God 
bless you, and carry on.
    Senator Salazar. Thank you for your service to our country 
and your testimony this morning.
    Mr. Yoast, I would like to hear from you.

  STATEMENT OF LEONARD YOAST, WORLD WAR II VETERAN, HAYDEN, CO

    Mr. Yoast. Well, I have very great respect for the hospital 
here in Grand Junction. My wife was a veteran in Germany, which 
I was a veteran in Japan, over in the islands, rather. We would 
come down to this hospital. We averaged about every 2 weeks 
between the two of us when she was in bad shape. I have lost 
her 7 years and 6 months today.
    The trip was terrible. Sometimes it was icy. In the 
summertime, when they were working on the roads, we would be 
stalled.
    I would like to get a place in Steamboat Springs, a clinic 
or a hospital, or Craig. Someplace where it was close. It was 
194 miles from my house to the Veterans' Hospital here in Grand 
Junction.
    But, they were always nice here in Grand Junction, the 
hospital was. The doctors, the nurses, were especially nice. 
But it took us a long time and hard trips to get here.
    I've lost my wife now. I come with Michael Condie, and he 
has been wonderful. He's really been a great help to us. I 
would like to get something started in either Craig or 
Steamboat Springs so we wouldn't have to go so far. Because 
when you get 85 years old, you just don't feel like going that 
far. Thank you very much.
    Senator Salazar. Well, I thank you very much, Mr. Yoast, 
for making the sacrifices you made for our country and your 
wife as well and for continuing to do good by appearing before 
our committee today to provide us your testimony. It's very 
much appreciated.
    Mr. Yoast. OK. Thank you.
    Senator Salazar. Mr. Adams.

   STATEMENT OF MICHAEL ADAMS, IRAQ WAR VETERAN, NORWOOD, CO

    Mr. Adams. Thank you very much. I think I would like to 
take the few moments that I have to address a couple of issues.
    First of all, support for what I have heard here today, the 
distance, the travel that is involved, the expense, the 
difficulty the veterans face living in a rural community and 
having to travel for their health care, I certainly would 
support fee-based systems so that they could stay within their 
community and receive their primary health care while still 
having access to the VA medical system for their inpatient 
rehab or other more sophisticated needs that they might have.
    I would also like to take a couple of minutes to speak to 
some of the veterans that are returning right now from this 
crisis in Iraq. There are particular--when you are coming back 
as a National Guard or Reserve soldier, you come back, you take 
your leave, you are getting re-integrated with your family, 
with your job. It is very difficult to get the time off to go 
and travel to get signed up into the system. If you came back 
with issues such as Post Traumatic Stress Disorder, depression, 
anxiety as a result of your service, you are trying to balance 
the needs of your family, trying to get re-integrated into job, 
and to take a day off to get back is very difficult. So, again, 
I would support more community-based services for our returning 
veterans as well as the other veterans we have heard here.
    I also find it somewhat likely that, particularly for the 
primary care kinds of issues, that it would be less expensive 
if we could keep them in the community rather than going 
through the cost and needs of setting up elaborate 
transportation systems in order to transfer these people 
throughout the State to go to highly centralized areas. I think 
the centralized model works good in an urban environment where 
there is a high population density and public transportation is 
available. But I think when you are talking about a community 
with these numbers of miles and special needs of the veterans 
in these communities, that we need to look into those 
communities to find at least some of those answers.
    I would like to thank you for having me here today.
    [The prepared statement of Mr. Adams follows:]

   Prepared Statement of Michael Adams, Iraq War Veteran, Norwood, CO

    As both a medical provider and a veteran of the Iraqi Conflict, it 
is my personnel belief that this country has an obligation to support 
its veterans.
    Veteran health care services are currently centered in urban areas, 
where it is more cost efficient to treat a large number of patients at 
a limited number of sites.
    However, this model overlooks a sub-group of vets who live in small 
rural communities, many who are found here in western Colorado. 
Providing medical services to these vets have a number of unique 
challenges, including: Distance to approved service facilities; Limited 
travel capabilities of an aging population; Isolated Geography of the 
Western Slope; and Weather, sometimes severe, creating further 
isolation.
    These challenges are further complicated by poor or declining 
health, and the limited incomes of many of our veterans.
    Our veterans need a strong system of central services such as a 
patient medical care, advanced diagnostics, rehab services. In rural 
area, this could be enhanced with partnership with community-based 
medical services. Services should be focused on primary care, allowing 
vets to seek their primary care and follow up services in their 
community, rather than traveling, at a minimum of several hours, and 
often overnight for the veterans and their families, to obtain care.
    In addition, community-based mental health services to help 
returning services personnel with mental health issues should be 
available. Returning service personnel have been placed under great 
stress. Frequent and extended deployments result in numerous problems 
and issues of depression, PTSD and raising divorce rates.
    Nonetheless, I have often seen veterans who choose not to be 
treated for primary and mental health services, due to the 
complications of travel for older veterans, the lost time from work and 
family for younger veterans, and the health and financial means to be 
able to travel for many veterans. Services available to veterans 
through existing community services would improve the health and 
outcomes of many of our veterans living in isolated rural communities. 
I would appreciate your consideration of the needs of these veterans, 
who although not the majority, are entitled to recognition of their 
service to our nation.
    Thank You.

    Senator Salazar. Thank you very much, Mr. Adams. I thank 
each and every one of you for your testimony. I want to make a 
few closing comments at the end of this hearing:
    I found the hearing very informative. I found the testimony 
that has been given to us by the officials you have heard from 
today, as well as our veterans, to be very informative to me. I 
am certain that my colleagues and friends on this committee, 
both Democrats and Republicans, hear the concern. That concern 
being how we can better serve the veterans who live in rural 
Colorado who are sometimes far away from the medical facilities 
that can provide their care.
    I take from this hearing a tremendous amount of information 
and issues that I will work on with my colleagues including 
looking at the suggestions that were made by several of you 
that we might create an Office of Veterans Affairs that deals 
specifically with the rural health care issue for veterans, 
i.e., hearing the cry for additional services in places that 
are remote, such as northwest Colorado.
    I have heard that same cry for services in places in 
northeast Colorado and places like Julesburg and Yuma and Wray. 
I hear that cry definitely here in the western slope.
    I hear the discussion and even the debate about whether we 
should move forward with a CBOC in northwest Colorado or figure 
out ways of doing fee-for-service contracts with the local 
hospitals in that area. That's certainly something I am 
confident is on the radar screen of Veterans' Affairs. So the 
issues and concerns that we have raised here today for me as 
one of your United States Senators who sit on the Veterans' 
Affairs Committee has been very valuable to me.
    Let me just in closing for this hearing remind you that if 
you have additional testimony that you might want to provide, 
and to those of you who did not get to testify today, I ask 
that you provide your testimony for us for the record, and we 
will keep the record open until some time passes to give you 
that opportunity.
    Finally, you know, for me one of the things that has always 
been a reality is that I told people that we need to understand 
that the world doesn't begin and end in Colorado Springs or in 
Denver, Colorado. That there is a whole other Colorado out 
there that is very much an America and a Colorado that has a 
set of struggles that we don't often see in the huge 
metropolitan areas.
    I always tell people in meetings that I have had in the 
capital in Denver that if you happen to live among that 
population of 2.8 million people and you have a meeting on 
Saturday morning at 8 o'clock in the capital, you can get up in 
the morning and go to your meeting, and by noon you go about 
your business.
    But if you happen to live in Craig, in Dove Creek, in 
Durango, in Trinidad, in my native valley, in Conejos County, 
in Julesburg, that same 8 o'clock meeting on a Saturday morning 
becomes an inevitable 1-day and most of the time a 2-day trip. 
Because you have to go there on a Friday night, stay over, go 
to your meeting. By the time you drive back, it's an additional 
5, 6, 7, 8 hours. In fact, if you are in Dove Creek, Colorado 
you are about 9 hours away from our capital. If you are in 
Craig, Colorado, you are probably 4\1/2\ hours away from our 
capital.
    So I understand that reality, and I believe that my 
colleagues on this Committee have an understanding about the 
challenges that face rural America and that face our rural 
veterans.
    Senator Larry Craig, for example, is from Idaho. He is a 
Republican with many of the same issues that we talk about here 
are similar kinds of issues that they face in Idaho.
    Senator Danny Akaka is a World War II veteran and one of 
the heroes of our Senate. He understands the importance of 
making sure that all veterans are served in every way possible 
and that the vision of serving each and every veteran is 
important to all of us.
    I look very much forward to working with my colleagues on 
this Committee to address issues and concerns that you have 
raised. This is not the last of the meetings, at least, that I 
will have with all of you. Because these issues are important, 
and I will continue to work on them in the years ahead.
    I thank you very much for your participation here this 
morning. Thank you.
    Mr. Watkins. Senator, I have something I would like to 
present to you.
    Senator Salazar. Mr. Watkins.
    Mr. Watkins. I would like to present that to you, Senator, 
to take back to Washington.
    Senator Salazar. Thank you very much, Charlie. It says, 
``The Nation which forgets defenders will itself be 
forgotten.'' So we must never forget our veterans. Thank you so 
much.
    The hearing is adjourned.
    [Whereupon, at 11:34 a.m., the committee was adjourned.]

                            A P P E N D I X

                              ----------                              

     Prepared Statement of Earl Mackenzie, President, Local 1014, 
          American Federation of Government Employees, AFL-CIO

    My name is Earl ``Scottie'' Mackenzie, and I am the President of 
Local 1014 of the American Federation of Government Employees (AFGE) in 
Cheyenne, Wyoming with field facilities in Colorado. AFGE represents 
more than 600,000 Federal employees who serve the American people 
across the Nation and around the world, including more than 150,000 
employees of the Department of Veterans Affairs (VA). Local 1014 
represents 157 VA defined professionals and non-professionals, (they 
are all professionals in my mind) in my bargaining unit. I want to 
extend my gratitude to Senator Salazar for the opportunity to discuss 
our concerns about providing health care to veterans in Colorado, and 
other distinguished members of the Senate Veterans' Affairs Committee.
    the challenges of delivering health care to veterans in colorado
    Rural health care 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 health care 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. Colorado has a higher share of share of rural veterans as 
compared to the country as a whole--14.1 percent of veterans in 
Colorado reside in rural areas as compared to the national average of 
12.7 percent.

           THE IMPACT OF BUDGET SHORTFALLS AND STAFFING CUTS

    Reductions in funding and FTE's affect our ability to care for 
veterans at the VAMC as well as our CBOCs. Every location that becomes 
short-staffed results in delays in appointments and backlogs in 
providing needed care.
    Without adequate funding and FTE's, we will not be able to operate 
new CBOCs when they are opened. If we take staff away from existing 
CBOCs, we will simply be shifting our staffing shortage and forcing 
other veterans to experience longer waiting times.
    Despite staffing shortages, our staff remains dedicated to the 
caring of our veterans. However, I also have to care about our 
dedicated employees who become ill and stressed because of mandated 
overtime. These staff shortages have forced us to hire agency staff, 
which cost the taxpayer more while impacting the quality of care we 
deliver and the safety of our patients. Prolonged overtime and other 
pressures also cause older staff members to take early retirement, 
which further adds to the staffing problem.

     RECOMMENDATIONS ADDRESSING THE HEALTH CARE NEEDS OF VETERANS 
                           IN RURAL COLORADO

    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.
    Expanding the use of telemedicine will complement, but cannot 
replace, these efforts to expand access. A telemedicine coordinator is 
needed to provide expanded services and ensure adequate coordination 
with CBOCs and hospitals that are also involved in treatment.
    What will not help the rural veteran is an increased use of fee-
based services as a substitute for VAMC and COBC care. Fee-based care, 
except in the rare exception when care is not available for a medical 
specialty or in a very remote area, is a bad deal for the taxpayer as 
well as the patient. Throughout the country, VISNs have found that fee 
basis services are significantly more expensive. In addition, these 
services sometimes lack the quality and unique treatment that is 
available with the VA facility. I challenge this VA committee to 
actually compare the actual FEE basis care costs for this VISN. We have 
seen cost estimates as high as 35 percent more.

                               CONCLUSION

    In closing, I thank you again for the opportunity to submit this 
written testimony on behalf of all of the veterans and thank you also 
for holding this hearing in this beautiful state. We at VAMC, weather 
it be in Grand Junction, Denver, Fort Collins, and Cheyenne will 
continue to provide the best of care for our veterans. Veterans deserve 
to have stable and sufficient funding for the medical care on which 
they depend, as well as a system that provides adequate access to care 
for rural communities.
                               __________
                                                     July 10, 2005.
Hon. Ken Salazar,
225 North 5th St. Suite 511,
Grand Junction, CO 81501.
    Dear Senator Salazar: I have the opportunity today to address you 
as State Commander of the Department of Colorado Veterans of Foreign 
Wars about some of the needs of our Colorado veterans who live in the 
Northwest and Northeast part of Colorado. Both of these areas have to 
travel in excess of 200 miles to receive medical attention.
    Our aging WWII Veterans are at times in worst condition when they 
arrive home after a 400-500-mile round trip to get a regular blood test 
or basic medical examination and medications. This is a problem we have 
been facing for some time with the WWII Vets; however, the veterans of 
my era, the Korean Conflict, are now approaching the time when they are 
in need of more medical attention. The Viet Nam veterans are 
approaching retirement age and their medical needs are also increasing. 
Present concerns we have now are with our Afghanistan and Iraq 
causalities arriving home daily. The number of wounded, estimated from 
news reports, is 10,000-30,000 needing medical attention from losses 
not seen before in previous wars or conflicts and requiring long-term 
medical attention.
    Colorado has two sparsely populated areas: Northwest and Northeast 
Colorado where veterans must travel at great distances to even get 
basic medical attention such as blood and diabetes tests, medication 
checkups, etc. Northwest and Northeast Colorado need to have medical 
facilities within a few miles to serve the health needs of our 
veterans. At one time there was a Colorado goal of Community Colleges 
and Vocational Education was to have training for employment within a 
30-mile travel distance of every Colorado citizen. Do not Colorado 
veterans deserve the same consideration? Colorado should at least have 
a facility to meet their basic medical needs within 1 hour of their 
home.
    Colorado needs a Community-Based Outreach Clinics (CBOC) System in 
the Northwest and Northeast to meet the veterans' needs. I would ask 
that there be funding to meet the budgetary needs for these facilities.
    At this time I would like to thank you for all of your hard work, 
Senator, for support of all the veterans of Colorado.
              
                                          Darrell Anderson,
                                                   State Commander,
                   Department of Colorado Veterans of Foreign Wars.
                                 ______
                                 
                                                       August 2005.
Hon. Ken Salazar,
225 North 5th St. Suite 511,
Grand Junction, CO 81501.
    Dear Senator Salazar: I am a retired Air Force Lt. Colonel and 
hospital administrator, a volunteer on the town medical board, a 
disabled veteran, and a resident of a rural community. I believe I have 
the knowledge to understand what happens for healthcare for veterans in 
a rural facility. I currently live in Lake City, Colorado, a town with 
about 550 people, close to one-fifth of which are veterans--both male 
and female. Yes we are small but we live a quiet beautiful life with a 
lot of benefits city dwellers do not have, and we also do not have 
things the citizens of a city might enjoy.
    One thing many of us do not have is access to healthcare through 
the veteran's administration and many have no insurance at all. Jobs in 
Lake City are typically seasonal, low paying, and definitely with no 
insurance. So what do they do for healthcare? Nothing or pay as they go 
for care are their options and we all know how expensive healthcare is 
so the second option is unlikely. That leaves doing nothing and I would 
propose that is what most veterans are forced to do. They do nothing, 
of course, until it is too late and then the illness is worse and they 
have to make that trek to Montrose (good luck getting a same day 
appointment) or to Grand Junction to the hospital. There the cost has 
got to be increased because the illness is now worse or the injury more 
severe. It is the same syndrome that exists with any underserved 
population, including Medicare (where the elderly cannot pay the co-
pay).
    I would like to see every Lake City veteran have access to 
healthcare, here in Lake City. We have one of the finest clinic's I 
have ever been associated with and the staff definitely wants everyone 
to receive care. Veterans would be able to not only get care for most 
illnesses or injuries but for preventive care, as well. Prevention is 
the key to any healthcare program.
    I am a very fortunate individual having access to several forms of 
insurance--Medicare (because of my disability), Tricare (for being 
retired Air Force) and the Veteran's Administration. I am proud to say 
I have received the best overall care from the Veteran's 
Administration. This care from the VA includes care received in both 
Lake City and Gunnison. Because of my 100 percent service-connected 
disability I have been afforded the option of care within the civilian 
community on a `fee for service basis.' This care has been extremely 
important in preventing more hospitalizations and illnesses that could 
seriously hamper my overall health.
    I appreciate what I have and want the same for all my fellow 
veterans. Thank you Senator Salazar for caring enough to ask the tough 
questions.
              
                                                     Erin T. Cavit.
                                 ______
                                 
                            Steamboat Mental Health Center,
                                             Steamboat Springs, CO.
    Dear Senator Salazar: I am writing on behalf of Colorado West 
Regional Mental Health Centers and the veterans living in the northwest 
of Colorado. I am the Frontier Division Director with Colorado West 
RMHC and am responsible for the community mental health services in 
four rural counties; Routt, Moffat, Rio Blanco, and Jackson. There are 
veteran residents in each of these counties and the population of 
veterans is growing.
    Access to mental health services for veterans as part of their 
veteran's benefits has always been difficult. Sufferers have to travel 
to Grand Junction to receive care at the VA Medical Center and its 
related clinics, or travel to the Front Range. This travel is not only 
difficult, especially during winter months, but impedes best practices 
care if they want to have care covered by their benefits.
    Several members of the veteran's community have expressed to me a 
desire to receive mental health care in this area either from the 
Veterans Administration or have an agreement to have the care provided 
locally by local providers. This letter is to offer strong support for 
this concept of local care. Colorado West RMHC has offices in each of 
the counties listed above and has psychiatrists and therapists with the 
training to help these veterans with most of their mental health needs. 
With the type and variety of mental health care available locally it 
does not seem appropriate that veterans should have to travel as much 
as 200 miles to receive mental health care.
    I encourage the VA to consider a model in which veterans can 
receive the mental health care they need locally by utilizing the local 
providers who understand both mental issues and the community in which 
the veterans live.
    I am unable to attend your meeting on August 16 in grand Junction 
(I am hosting meeting on grass roots political efforts for our mental 
health services in Colorado with the Mental-Health Association of 
Colorado), however I hope you will take this letter as a declaration of 
support ad willingness to provide services locally to the veterans 
residing in the Frontier Division of Colorado West RMHC.
              
                                                Tom Gangel,
                                                 Division Director,
                         Colorado West Regional Mental Health, Inc.
                                 ______
                                 
                               Yampa Valley Medical Center,
                                                    August 1, 2005.
Hon. Ken Salazar,
U.S. Senate,
Washington, DC.
    Dear Senator Salazar: I am writing this letter on behalf of Yampa 
Valley Medical Center and the veterans residing in northwest Colorado. 
For many years, veterans living in our portion of the State have not 
had easy access to physicians or hospitals providing services as part 
of their veterans' benefits. Most must make the significant drive to 
Grand Junction to receive care at the VA Medical Center and its related 
clinics, or to the Front Range. This significant travel is quite 
disruptive to the veteran, their families and their employers when they 
must seek care to be covered as part of their veterans benefits.
    As I am the CEO at Yampa Valley Medical Center, I know there has 
been an interest on the part of area veterans to have a Veterans 
Administration presence, or arrangement in this area, to allow for care 
to be provided locally. This letter is to offer strong support to this 
concept. In Steamboat Springs, all primary care and specialty 
physicians are independent practitioners. Yampa Valley Medical Center 
does not employ nor operate any physician clinics. YVMC does, however, 
offer extensive diagnostic services and the broad array of services 
that can be provided by our 55 members of the medical staff that 
address more than 25 different specialties. With this type of local 
capabilities, it seems inappropriate not to be able to provide 
healthcare services to our veterans locally.
    Yampa Valley Medical Center has been on record with former 
Representative McGinness and Senators Nighthorse Campbell and Allard in 
being willing to work with the Veterans Administration to enter into 
contractual arrangements to provide service. This commitment and 
interest continues. Additionally, while I cannot speak for them 
individually, I am confident that the members of the medical community 
in Steamboat Springs would be interested in working with the VA to 
develop relationships that allow for the existing medical community to 
provide services to those veterans in our area. The medical community 
of Steamboat Springs serves not only our community, but serves as a 
regional resource center for the five counties of northwestern 
Colorado.
    It is my understanding that the standard model utilized by VA when 
it establishes outreach clinics is to create a clinic environment and 
provide direct staffing to that clinic with VA physicians. I would 
encourage the VA to consider an alternative model utilizing the 
existing physicians and diagnostic services within the community rather 
than duplicating services already in existence.
    I am sorry. I am unable to attend your meeting to discuss this 
topic on August 16th; however, I hope you will take this letter in the 
spirit of interest and cooperation in working with the Veterans 
Administration to bring services closer to the homes of our veterans.
            Sincerely,
                                             Karl B. Gills,
                                           Chief Executive Officer.
                                 ______
                                 
                                           Hinsdale County,
                                                    August 1, 2005.
    Hon. Ken Salazar: As the Hinsdale County Veterans Service Officer 
in Lake City, Colorado, I wish to express my views concerning veterans' 
health care in rural communities. I greatly appreciate this opportunity 
to do so.
    For years I have been an advocate of allowing veterans who reside 
in rural areas to access healthcare in their own communities.
    The fairly recent opening of the VA clinic in Montrose reduced the 
travel distance for veterans' healthcare, but the more than 200-mile 
round trip to access healthcare in Montrose remains a burden for 
Hinsdale County veterans. My main concern is that the trip is 
hazardous, especially in winter and more so for our elderly veterans.
    The distance problem is compounded for our working veterans. The 4-
hour plus travel time usually means a full day of work lost for a 15 
minute or so appointment. It could turn into an overnight stay if 
required to travel to Grand.
    Residents take pride in the excellent facilities and staff at the 
Lake City Area Medical Center. It is located in town within walking 
distance of most that use it. Although veterans pay taxes to maintain 
the facility, they are not able to use it while taking advantage of 
their VA benefits.
    On a personal note, I am a disabled veteran. Prior to the opening 
of the Montrose clinic, I was able to have routine checkups and 
prescription renewals done at the Lake City Area Medical Center for my 
service-connected disabilities. This was done under the Fee-Basis, or 
Non-VA Care program. I am no longer able to take advantage of this 
program and must travel to Montrose or Grand Junction if necessary. As 
a disabled veteran I am eligible to receive reimbursement for travel, 
meals and lodging for service-connected healthcare. I would love to 
have these payments be used for office visits at the local medical 
center.
    Thank you for this opportunity to express my views on behalf of 
Hinsdale County veterans.
            Sincerely,
                                             Paul G. Olson,
                          Hinsdale County Veterans Service Officer.
                                 ______
                                 
                                                   August 17, 2005.
Hon. Ken Salazar,
U.S. Senate,
Washington, DC.
    Dear Senator Salazar: The most effective contribution to the health 
of our veterans would be to make VA medical contracts available at 
local hospitals and clinics in rural areas.
    Perhaps the greatest hardship upon these veterans is the necessary 
travel for medical care in these rural areas.
    The current transportation arrangements are of benefit to many 
veterans, but do not include their spouses or support persons who are 
an important part of their health-care support team. Many times the 
people have to take unpaid leave from their jobs in order to travel 
with their spouses to VA hospitals and clinics for critical or routine 
care. These, in addition to the rising transportation costs at present, 
are a definite hardship for those whose income is already stretched to 
the limit Being able to access health care locally would be the most 
important veterans benefit to come out of this session of Congress. 
Please continue to work toward this goal on behalf of all of us in 
Western Colorado as well as other rural areas.
    We are very fortunate to have you and John Salazar representing 
Colorado in Washington.
            Best regards,
                                         T.A. Ottman, USMC,
                                                   Korean Conflict.
                                 ______
                                 
                                    Department of Colorado,
                                        Denver, CO, August 8, 2005.
    Dear Senator Salazar: I am writing on behalf of all veterans who 
have answered their Country's Call and served honorably in the armed 
forces. When we entered the service we were not given assignments based 
on where we had previously lived, but rather based on the needs of the 
service. We all were subject to being placed in harms way and served 
where ordered.
    While serving, and when we left the service, we were all told that 
there would be health care available to us for the rest of our lives 
through the Veteran's Administration. There was no mention of 
limitations based on where we chose to live.
    At the present time there is great disparity in the quantity and 
quality of health care a veteran can receive based solely on where the 
veteran lives. Only our elected Senators and Congressmen can bring 
about the equality we fought for.
    You can do this by passing legislation which will require the 
Veteran's Administration to contract with local health care providers 
to provide Community-Based Outpatient Clinics whenever a veteran must 
travel more than 100 miles round trip to a Veteran's Administration 
Medical Facility. (In medicine there is a ``Golden Hour'' rule which 
states that if a patient receives definitive medical care within 1 hour 
of an emergency, the patient's chances of a successful outcome are much 
greater than if there is more than an hour delay in obtaining medical 
treatment.) Great travel distances to a VA Medical Facility deprive 
many veterans of this level of care.
    The American Legion, Department of Colorado, and all veterans 
living more than 100 miles from a VA Medical Facility applaud your 
efforts and will support the intent of the legislation you have 
proposed in Senate Bill 1191.
    This legislation, as presently proposed, will fill a need to permit 
us to continue to provide veterans with a way to get to a VA Medical 
Facility and to obtain the care they earned with their service to our 
nation. We believe this is a temporary solution to a permanent problem.
              
                                              Gar Williams,
                                     Department Jr. Vice Commander.
                                 ______
                                 
                                     The Memorial Hospital,
                                   Craig, Colorado, August 8, 2005.
Mr. Gar Williams, Vice-Commander,
Colorado American Legion Post,
Craig, CO.
    Dear Mr. Williams: The Memorial Hospital has previously established 
its position as being supportive of facilitating a community-based 
outreach clinic in support of local veterans. This topic came up a few 
years ago and the Administrator of the Hospital at that time agreed to 
sit down with the Veterans Administration officials to discuss and 
negotiate an arrangement that would enable local Veterans to receive 
primary care in our community. At that time, no one from the VA ever 
approached the Hospital to have the necessary conversation. On behalf 
of the Hospital, I am again extending the offer to discuss this 
possibility with the VA.
            Sincerely Yours,
                                                Sue Lyster,
                                          Chair, Board of Trustees.
  

                                  
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