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[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]

                WOMEN, RURAL, AND SPECIAL NEEDS VETERANS

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

                             FIELD HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                             APRIL 21, 2008
                   FIELD HEARING HELD IN SANFORD, ME

                               __________

                           Serial No. 110-84

                               __________

       Printed for the use of the Committee on Veterans' Affairs

                   U.S. GOVERNMENT PRINTING OFFICE
43-050                      WASHINGTON : 2009
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                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South     HENRY E. BROWN, Jr., South 
Dakota                               Carolina
HARRY E. MITCHELL, Arizona           JEFF MILLER, Florida
JOHN J. HALL, New York               JOHN BOOZMAN, Arkansas
PHIL HARE, Illinois                  GINNY BROWN-WAITE, Florida
MICHAEL F. DOYLE, Pennsylvania       MICHAEL R. TURNER, Ohio
SHELLEY BERKLEY, Nevada              BRIAN P. BILBRAY, California
JOHN T. SALAZAR, Colorado            DOUG LAMBORN, Colorado
CIRO D. RODRIGUEZ, Texas             GUS M. BILIRAKIS, Florida
JOE DONNELLY, Indiana                VERN BUCHANAN, Florida
JERRY McNERNEY, California           VACANT
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota

                   Malcom A. Shorter, Staff Director

                                 ______

                         SUBCOMMITTEE ON HEALTH

                  MICHAEL H. MICHAUD, Maine, Chairman

CORRINE BROWN, Florida               JEFF MILLER, Florida, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
PHIL HARE, Illinois                  JERRY MORAN, Kansas
MICHAEL F. DOYLE, Pennsylvania       HENRY E. BROWN, Jr., South 
SHELLEY BERKLEY, Nevada              Carolina
JOHN T. SALAZAR, Colorado            VACANT

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.

                            C O N T E N T S

                               __________

                             April 21, 2008

                                                                   Page
Women, Rural, and Special Needs Veterans.........................     1

                           OPENING STATEMENTS

Chairman Michael H. Michaud......................................     1
    Prepared statement of Chairman Michaud.......................    42
Hon. Jeff Miller, Ranking Republican Member......................     2
Hon. Thomas H. Allen.............................................     3

                               WITNESSES

U.S. Department of Veterans Affairs, Brian G. Stiller, Center 
  Director, Togus Veterans Affairs Medical Center, Veterans 
  Health Administration..........................................    35
    Prepared statement of Mr. Stiller............................    62

                                 ______

American Legion, Department of Maine, Donald A. Simoneau, Past 
  Commander, and Member National Legislative Council.............    22
    Prepared statement of Mr. Simoneau...........................    53
Disabled American Veterans, Department of Maine, Joseph E. 
  Wafford, Supervisory National Service Officer..................    28
    Prepared statement of Mr. Wafford............................    59
Doliber, Dana, Sanford, ME.......................................     5
    Prepared statement of Mr. Doliber............................    42
Hartley, David, Ph.D., MHA, Director, Maine Rural Health Research 
  Center, and Professor, Muskie School of Public Service, 
  University of Southern Maine, Portland, ME.....................    16
    Prepared statement of Dr. Hartley............................    52
Maine, State of, Bureau of Veterans' Services, Augusta, ME, Peter 
  W. Ogden, Director, and Secretary, National Association of 
  State Directors of Veterans Affairs............................    10
    Prepared statement of Mr. Ogden..............................    44
Maine Veterans Coordinating Committee, Waldoboro, ME, Gary I. 
  Laweryson, USMC (Ret.), Chairman, Commander, Military Order of 
  the Purple Heart, State of Maine, Judge Advocate, Marine Corps 
  League, State of Maine, and Aide-de-camp to Governor John 
  Baldacci.......................................................    12
    Prepared statement of Mr. Laweryson..........................    47
Maine Veterans' Homes, Augusta, ME, Kelley J. Kash, Chief 
  Executive Officer..............................................    14
    Prepared statement of Mr. Kash...............................    48
Veterans of Foreign Wars of the United States, Department of 
  Maine, James Bachelder, Commander..............................    23
Vietnam Veterans of America, Maine State Council, John Wallace, 
  President......................................................    26
    Prepared statement of Mr. Wallace............................    56

 
                WOMEN, RURAL, AND SPECIAL NEEDS VETERANS

                              ----------                              

                         MONDAY, APRIL 21, 2008

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                    Washington, DC.

    The Subcommittee met, pursuant to notice, at 10:03 a.m., 
Sanford Town Hall, 919 Main Street, Sanford, Maine, Hon. 
Michael Michaud [Chairman of the Subcommittee] presiding.

    Present: Representatives Michaud and Miller.

    Also present: Representative Allen.

             OPENING STATEMENT OF CHAIRMAN MICHAUD

    Mr. Michaud. I would like to call the Subcommittee to 
order. I would also like to ask unanimous consent for Mr. Allen 
to sit at the dais and to be able to ask witnesses questions. 
If there are no objections, it is so ordered.
    I also would like to thank Sanford, the folks at Sanford 
Town Hall, for allowing us to use their facility today. I 
really appreciate it. Veterans' issues are extremely important, 
and this definitely will give us a venue so we can hear from 
our witnesses today.
    I also would like to recognize in the audience Mike Aube 
who works for Senator Olympia Snowe's office, as well as Bill 
Vail who works for Senator Susan Collins' office, Kara 
Hawthorne, who is the new Director of the Office of Rural 
Health that Congress established a couple years ago, and Dr. 
Patty Hayes who is a Chief Consultant for Women Veterans' 
Health. They are both from Washington, DC. I want to thank both 
of you for coming here today to hear what veterans have to say 
about rural healthcare issues.
    I also would like to recognize Adam Cote who is an Iraq War 
veteran. I don't know if there are any other Iraqi War veterans 
or Afghanistan War veterans here, but I want to thank you and 
all the veterans here in this room for your service to our 
great Nation. I am very pleased to see you here as well. I want 
to thank everyone else who I have not mentioned for coming here 
today to talk about veterans' issues.
    Today, we will examine the U.S. Department of Veterans 
Affairs (VA) programs regarding rural veterans, women veterans 
and other special needs population. I am very happy that it is 
held here in Sanford, Maine, this morning. Sanford is home of a 
long-time veteran advocate, someone who I was honored to call a 
friend, Roger Landry. Roger worked and served in the Maine 
legislature. He worked very diligently in the veterans service 
organization (VSO) community here in Maine, and he was very 
well-liked and respected by all. Roger served his country and 
his community with great pride and honor. Roger died, 
unfortunately, last year. He is sorely missed. I would like to 
dedicate this hearing to Roger Landry in honor of all of his 
hard work with and for our veterans here in Maine and all 
around the country.
    It is appropriate that we are having this hearing in my 
home State of Maine. Maine is a very rural State. Because of 
this, we face many unique challenges in providing healthcare to 
our veterans. Many have to travel long distance for care, 
creating a significant burden for veterans and their families. 
The VA has instituted some innovative programs to provide much 
needed services to our rural veterans, and I look forward to 
hearing from our panels today about their ideas to improve 
access and decrease the travel burden for our veterans living 
in rural communities all across Maine and also all across the 
country.
    At this hearing, we will also hear about women veterans. 
Women make up about 14 percent of the active-duty military; and 
consequently, they are making up more and more of our veteran 
population. Women have some unique healthcare needs. I look 
forward to hearing today about the unique needs of women 
veterans and hearing ideas about how the VA can improve their 
service targeted to women veterans.
    When the United States made a commitment to care for 
veterans, we made the commitment to care for all veterans: 
Male, female, urban, and rural. Today, I hope that we will 
learn how the VA is meeting the needs of these populations, 
what challenges are on the horizon, and what can we do to 
provide services for these veterans in the most cost-effective 
manner.
    I also want to thank Congressman Miller, who is the Ranking 
Member of the Subcommittee on Health of the Committee on 
Veterans' Affairs. Congressman Miller is from Florida. He has 
been a strong advocate for veterans' issues. We deal with the 
healthcare-related veterans' issues in Congress. And I know 
that this is actually a holiday here in Maine and 
Massachusetts, and I know that Mr. Miller has a lot of work in 
his home State that he has to do. We really appreciate him 
taking the time to come here, along with Committee staff, to 
hear what veterans have to say. Indeed, he is a true advocate 
for veterans' issues.
    So, I would turn it over to Mr. Miller for an opening 
statement.
    [The prepared statement of Chairman Michaud appears on
p. 42.]

             OPENING STATEMENT OF HON. JEFF MILLER

    Mr. Miller. Thank you very much, Mr. Chairman. I am, in 
fact, very pleased to be here in your great State of Maine to 
examine how VA is addressing the healthcare needs of women, 
rural needs and special needs veterans. It is appropriate that 
we are here today on Patriots Day because I truly do believe 
that there is no greater patriot than the veteran, a person who 
has worn the uniform in defense of this Nation for all the 
things we stand for. It is great to be here with my friend and 
colleague, Tom Allen. We have had numerous opportunities to do 
things legislatively in Washington. We have traveled together 
as well. It is a great pleasure to be with you here today.
    I know that rural America does have a strong military 
tradition. A lot of people don't think of Florida as being a 
rural State, but actually Maine and Florida are ranked in the 
top 18 in the States in this country that, in fact, have access 
issues. The veterans in my district, which is Pensacola to 
Destin, northwest Florida, my veterans have to travel 3, 3\1/2\ 
hours to get to a hospital. Most people don't think about that 
when they are thinking about the State of Florida because the 
veteran population--I have--I actually have the largest veteran 
population of any Congressional district in the country, and I 
am proud to represent those individuals in Washington, DC. 
Certainly being here today to have a chance to hear from the 
folks from Maine and surrounding areas about how you are being 
dealt with or not being dealt with I think is very important. I 
do have a statement that I would like to have entered into the 
record.
    I would also like to add that the Chairman has continued to 
promise me a taste of Moxie, and I have yet to get it. I 
continue to wait with great anticipation. So, it is a pleasure.
    Mr. Michaud. You definitely will have an opportunity to 
have Moxie. As a matter of fact, I see it coming down the aisle 
right now. And I want you to know that, actually, Moxie is the 
official soft drink here in the State of Maine. So, enjoy.
    [Whereupon Congressman Miller was handed a can of Moxie.]
    Mr. Miller. I like it.
    Mr. Michaud. Well, I am glad you like it. There are plenty 
more.
    It is now my distinct pleasure to introduce my colleague 
from the State of Maine who actually is in this district. I 
appreciate your willingness also, Congressman Allen, to take 
the time out today to hear what people have to say about rural 
veterans' issues, and also thank you for putting forward the 
name for our first witness.
    So, I will turn it over to Mr. Allen.

           OPENING STATEMENT OF HON. THOMAS H. ALLEN

    Mr. Allen. Thank you, Mr. Chairman. It is nice to say those 
words in Mike Michaud's case. Thank you, Mr. Chairman, for 
holding, organizing this hearing, and also for allowing me to 
participate, even though I am not a Member of the Veterans' 
Affairs Committee.
    I do want to welcome Congressman Jeff Miller. It is a real 
pleasure to have him here. He and I were on a trip together to 
Afghanistan and Iraq and Pakistan last August. And you get to 
know people pretty well when you are on a trip like that. And I 
think we both came away with an enormous respect for what the 
young men and women in the armed services are doing over there 
under extraordinarily difficult and challenging circumstances. 
And I just want you all to know, many of you veterans from 
other conflicts, and I see Adam Cote here who is an Iraq 
veteran, many of you from other conflicts that appreciate and 
understand how challenging and difficult the work there really 
is.
    I also want to welcome today's witnesses to the hearing. I 
look forward to their testimony about how we can improve care 
for veterans in Maine and across the country.
    Finally, I want to welcome and express my thanks to all of 
the veterans who are here today. I want to thank you for your 
brave and honorable service to this country. I thank you for 
your service and thank you for being here.
    Maine is home to over 150,000 veterans who have sacrificed 
for our country. I have been honored for the last 12 years to 
represent the veterans in the 1st District of Maine. And I 
pledge to you I will continue my work in Congress to keep the 
promises we have made to those who have defended us past and 
present.
    Today's hearing will focus on the particular needs of women 
veterans, veterans in rural areas and other special 
populations, including veterans with mental health needs. The 
percentage of women serving in the armed forces, their scope of 
responsibility, and their exposure to danger have all grown 
dramatically in recent years. Therefore, we must work even 
harder to ensure that the VA is ready to serve women veterans. 
Women who have served in the military must receive the same 
benefits as their male counterparts, but they also must have 
access to healthcare targeted to their specific needs, 
including gynecological care and mammography, an issue that 
given my wife's illness, I am more aware of than ever before.
    Another important component of care for women veterans is 
the availability of military sexual trauma counseling at Togus' 
Women's Clinic and the VA Vet Centers throughout Maine. Vet 
Centers and community-based outpatient clinics (CBOCs) have 
been extremely important for our rural State. Because of the 
progress of these centers and clinics, most veterans no longer 
have to travel for hours to get the healthcare benefits that 
they have earned, though they still in many cases have to 
travel some distance.
    I am glad that Congress recently increased the mileage rate 
from a meager 11 cents per mile that it was to 28.5 cents per 
mile. The rate is still, as you know, far less than actual 
costs and I am sure we can do better.
    We are extremely proud of the dedicated VA employees here 
in Maine working under the direction of Director Brian Stiller. 
The VA is doing whatever it can to address the healthcare 
requirements of veterans with special needs. The post traumatic 
stress disorder (PTSD) program at Togus has been extremely 
helpful.
    I recently introduced legislation to help veterans applying 
for disability compensation for post traumatic stress disorder. 
The Full Faith in Veterans Act would change the VA standard of 
proof for veterans who suffer from PTSD. The bill creates a 
common sense approach that is long overdue.
    And as you may know, as many of you know, when veterans 
seek treatment and disability benefits for PTSD, they bear the 
burden of proof to establish, first, that they have a diagnosis 
of PTSD; and second, that the PTSD causing event happened 
during their service. To prove the second factor, they must 
produce existing military documentation about the event that 
proves the event happened and that they were present, or they 
have to come up with 2 buddy statements that attest to these 
facts.
    Often, however, particularly in the case of Vietnam vets, 
no records were created at the time that document the event. In 
many cases, moreover, finding a veteran's buddy who was at the 
scene is difficult, and the military services have not been 
especially helpful. This has led to situations where it is 
clear to medical professionals that a veteran's PTSD was caused 
by an event during the individual's service, but the veteran is 
not eligible to receive disability compensation because the 
veteran's military records are inadequate.
    As I have learned from our veterans here in Maine, too many 
of our Nation's heroes are denied benefits because of gaps in 
military documentation that are not their fault. Forcing 
veterans to jump through these hoops to receive compensation 
they had earned while serving their country is simply 
unacceptable. Under my bill, a certified mental health 
professional could make a logical connection between the 
diagnosis of PTSD and the veteran's military service, and a 
service connection must be granted. The bill also directs the 
VA to improve their procedures for evaluating and treating 
PTSD.
    I want, again, to thank Chairman Michaud for cosponsoring 
this legislature with me and working to ensure that this 
legislation gets considered by the full House of 
Representatives for a vote. I want to thank you all for being 
here again today. And, Mr. Chairman, I yield back.
    Almost forgot, but not quite. Dana Doliber----
    Mr. Doliber. Yes, sir.
    Mr. Allen [continuing]. Is one of my constituents. He lives 
here in Sanford. He is a Vietnam veteran. He doesn't need much 
by way of introduction because he is going to tell his story. 
In many ways, I was saying to Dana earlier, he is the poster-
child for the legislation that I have recently introduced about 
PTSD. And in a few minutes, you will understand why.
    Dana, thank you very much for being here.
    Mr. Doliber. Thank you, sir.
    Mr. Allen. You have to turn on the microphone.

        STATEMENT OF DANA DOLIBER, SANFORD, ME (VETERAN)

    Mr. Doliber. First, let me say what an honor and a 
privilege it is to be here to provide this testimony for you.
    In 1971, I filed my first claim with the VA. As PTSD was 
not a known accepted condition at that time, I was denied. In 
1985, at my wife's urging, I began seeing Robert Paige, LCSW, 
for what in a short time was diagnosed by Mr. Paige and Dr. 
John Scammon as PTSD. A claim was again filed with the VA for 
service connected PTSD for service in Vietnam for service from 
1967 to 1968.
    From 1985 to 1992, despite documentation, the VA routinely 
ruled against my claim. The VA did not provide the veteran with 
assistance acquiring records when requested or ruled in the 
veteran's favor providing the benefit of the doubt in favor of 
the veteran or ruled in favor of the veteran without a 
preponderance of the evidence to disprove what the veteran 
provided as evidence. Those 3 of the VA's own regulations were 
not followed in every denial of the veteran's claim.
    The VA's own record was inaccurate in its portrayal of the 
veteran's branch of service, birth date, and personal record 
prior to service. Doctors at the VA routinely diagnosed other 
conditions than PTSD due to their not being given the paperwork 
submitted providing stressors, which would have permitted the 
diagnosis of PTSD, as that is what eventually happened. It 
reached a point that I felt I needed the serial number of the 
round being fired at me to prove my case, a standard that the 
VA seems to not have a problem requiring from many veterans.
    With the submission of documentation of the combat action 
ribbon awarded in 1992, I was granted a percentage rating with 
service connection. From 1992 to the year 2000, the issue of 
clear CUE, or clear and unmistakable error, and retroactivity 
of date of service connection, along with percentage of 
disability was the issue which dealt with the past issues from 
1985 to 1992. In 2000, I was awarded 100 percent PNT, that's 
permanent and total, retroactive to 1985. I agreed to drop the 
CUE case and retroactivity to 1971 as I felt this would drag 
the case out another 10 years. Claims for skin rashes and sores 
and hearing loss were also denied by the VA in much the same 
manner.
    The VA has a choice to either be part of the problem or 
part of the solution. As part of the solution, the VA should 
improve claim processing being mindful to be proactive for the 
veteran, abiding by the laws as passed by Congress as the will 
of the people for the veteran as in the Haas Case, and to be 
proactive regarding veteran medical care. If doctors ask for 
equipment in the rehab of a veteran, provide it. If surgeries 
require rehab for the healing process, provide it.
    The other part of the solution comes from both houses of 
the legislature, not with fancy pro-veteran sounding bills that 
are anti-veteran, such as the Noble Warrior Act or the 
America's Wounded Warrior Act, but proactive veteran 
legislation is what is required. Servicemen and women 
understand and expect that if they need help when they come 
home, that help will be there. America's veterans provided 
the--providing the freedoms that we have deserve no less than 
the full support of the VA and the Congress. The American 
people expect no less than your full support of our veterans. 
We should not disappoint them by a lack of action. Thank you.
    [The prepared statement of Mr. Doliber appears on p. 42.]
    Mr. Michaud. Thank you, Mr. Doliber. I really appreciate 
your willingness to come here today to give your testimony.
    I guess my question is are you currently accessing the VA 
care for your PTSD?
    Mr. Doliber. Yes.
    Mr. Michaud. Do you have trouble getting appointments 
within the VA system to see your provider?
    Mr. Doliber. For other medical problems that are ongoing, 
there seems to be extending waiting periods. If, for instance, 
2 or 3 years ago I fell on the ice and I had a multiple 
compound fracture of my left arm. After getting treated at 
Henrietta D. Goodall Hospital, I was--and having notified the 
VA of the accident and everything like that, I called up the VA 
to request help with their rehab services and the follow-up 
appointment to have somebody from orthopedic to attend to my 
multiple compound fracture of my left arm.
    I was told that I would probably have to wait a month or 2 
for that. The physicians here in town felt that the medical 
help that was needed to be done within a week, not a month or 
2.
    Mr. Michaud. And the services that you have received from 
the VA, do you think that they have been helpful to you?
    Mr. Doliber. What I term the VA medical care is benign 
neglect. They do not--they do not intentionally with malice, I 
believe, do these things. It is just that that's the way their 
system is set up. That's the way that the veteran, when he is 
seeking help, can find himself in a long waiting line.
    It is not beneficial for the veteran who is seeking the aid 
and assistance from the VA for medical conditions or even for 
conditions for PTSD to be put off. Usually, for instance, like 
the PTSD, that's post traumatic stress disorder. That means 
that it has already gone past the point of where it needs to be 
dealt with. The veteran finally has to deal with it. And when 
they seek help from the VA, a lot of times you have to be put 
in a line or there is a waiting situation that has to happen 
because they have to get the doctor there. Sometimes you will 
see a physician assistant. There needs to be more proactive 
work from the VA toward the veteran.
    Mr. Michaud. My last question is whether you have talked to 
other veterans who have the same problem, being put on a 
waiting list?
    Mr. Doliber. Yes, yes. I talked with an Iraqi veteran when 
I was up at the VA about a month and a half ago. And he was 
there for traumatic head injury, and he was in the pay office 
and I was talking with him. And in the middle of the 
conversation with him, he stopped in mid-sentence and it was as 
if the lights were on, but there is nobody home. And he was 
there trying to seek help from the VA. And his wife is beside 
him, she's in tears. They are going financially broke. He is 
not being--he is only 40-percent disabled. That is the rating 
that the VA gave him. That is on the VA. He deserves far more 
attention.
    Mr. Michaud. Thank you. Mr. Miller.
    Mr. Miller. Thank you very much. I appreciate your 
willingness to come forward and testify.
    What did the VA tell you when they said it would take time 
for you to get into rehab? Just that there were no slots?
    Mr. Doliber. They said the earliest that they could--the 
earliest that the appointment could be made for would at least 
be a month, possibly 2. The orthopedic doctor that had set my 
arm and had operated on it said I needed to see a doctor a week 
after that. Okay? I couldn't wait a month. As a result of that, 
I incurred the expense from the orthopedic doctor and all of 
the rehab services after that on my own.
    Mr. Miller. Do you think a solution is a fee-for-service 
type issue, where when you cannot get an appointment within an 
acceptable amount of time you have the ability to continue to 
use the physician that set your arm until you can get into the 
VA system?
    Mr. Doliber. Yes, sir. Yes, I do. Fee-for-service has 
worked very well for a lot of veterans. It has been cut back 
because of lack of funding, because of budget cuts. And if I 
could, I would like to address the budget cuts part of it.
    I had a conversation at one time up at the VA regarding 
budget cuts with the then director, Mr. Sims. And he said that 
the budget cuts are the responsibility of the Congress. And at 
that time, the VA budget and the U.S. Department of Housing and 
Urban Development (HUD) budget were both tied-in at the same 
time when they were being considered. Well, since then, that 
has changed. The HUD budget and the VA budget, from what I 
understand, are 2 different things.
    The problem was that I found out that the VA budget that 
gets submitted to the Congress, the requests, come from the 
directors of the Veterans Administration regional offices. In 
other words, if they are not asking for the increase in 
funding, the Congress has no way of knowing that an individual 
regional office needs that increase in funding. And to my 
knowledge, that is the way it is still being run.
    Mr. Miller. The budget process works where the President or 
the Administration submits a budget to Congress, but we are in 
fact--one of the main things we do is pass appropriation bills. 
So, Congress does have a very large impact. As you said, if the 
information doesn't get to us----
    Mr. Doliber. Right.
    Mr. Miller [continuing]. That is why these field hearings 
are so critical. Sometimes the request is not made and we don't 
know, but we do, in fact, have control of the purse strings----
    Mr. Doliber. Yes, sir.
    Mr. Miller [continuing]. In D.C. What other things, what 
other types of outreach do you think that the VA can use, 
especially in rural areas, to get the word out to those special 
needs veterans or to other groups of veterans?
    Mr. Doliber. Well, the Vet Centers--I have never been to a 
Vet Center. Initially, when I began my PTSD therapy, it was 
being funded by the Vet Center in Portland. I had never gone to 
the Vet Center in Portland, but the Vet Center here in Sanford 
requested the funding from them. That soon was cut because 
their budgets were cut. So, the therapist I was seeing at the 
time began seeing me pro bono, and he saw me for years pro bono 
because the VA would not approve the funding for my therapy.
    Outreach centers need to be there. They do provide a 
helpful service to the veteran, especially in rural 
communities. The funding, again, the 900 pound gorilla in the 
room is money, and that is what it comes down to. Now, the 
American people know that the funding--they want the funding 
for their veterans. They know the veterans need the funding. 
The VA needs to provide the request to the Congress for the 
funding. And to be penny-wise and pound foolish doesn't seem to 
make a whole lot of sense. And the first thing that can be done 
in rural areas is to have the Vet Centers because they do 
provide a needed service.
    Mr. Michaud. Congressman Allen.
    Mr. Allen. Dana, thank you for being here. I just have a 
comment about the funding issues. I sit on the Budget 
Committee, and I did want to make one clarification. Often the 
regional directors will be asking for more money than they 
actually get in the present budget, because the Office 
Management and Budget----
    Mr. Doliber. Right.
    Mr. Allen [continuing]. The presidential operation will 
trim down those requests. And then the regional VA director's 
kind of stuck with the number that they have been given. Maybe 
not the number they asked for privately, but the number that 
they have been given by the Administration.
    But as Representative Miller said, ultimately the decision 
is going to be made in the Congress. And I agree with him that 
the information that we get from our constituents is 
fundamentally important to understanding how we can drive that 
budget, as we did last year, in a much more positive direction.
    I have a question; you indicated that you provided 
documentation to the VA to support your claim of service 
connection for your PTSD over all those years when you were 
trying to get----
    Mr. Doliber. Yes, sir.
    Mr. Allen [continuing]. Trying to get benefits, but there 
were certain gaps in the documentation that led to your claim 
being denied.
    Can you talk a little bit more about what those gaps were, 
what it was you were being told you had to provide but could 
not?
    Mr. Doliber. Well, the main requirement was to provide what 
the VA would term a stressor. Now, a stressor could be handling 
wounded, a stressor could be being shot at or being around 
explosions going off.
    I provided pictures of my ship high-lining wounded from my 
ship to the hospital ships, Repose and Sanctuary. I provided 
documentation from my ship, albeit sketchy, and from the USS 
St. Paul cruiser that we operated with, the USS Newport News, 
another heavy cruiser that we operated with, and the USS 
Collette, another destroyer, where they spell-out in their 
record and their ship's log our receiving counter-battery from 
coastal defense units from North Vietnam and South Vietnam. We 
operated almost up to the Hai Phong Harbor in North Vietnam.
    A lot of the American people believe that our participation 
in Vietnam stopped at the demilitarized zone (DMZ). We were 
routinely--and it wasn't any real big deal for us to be north 
of the DMZ. We received fire from islands off of the DMZ, from 
North Vietnamese, coastal batteries. I am at a loss as to how 
those records could be misrepresented on the ship that I was 
on, and yet to be so complete in the other vessels that we 
operated with.
    Mr. Allen. Did you think at some level was there any chance 
the VA was thinking, well, you were on a ship, you weren't on 
the ground on the shore? Was that a piece of it?
    Mr. Doliber. Well----
    Mr. Allen. Or how would you try to explain it?
    Mr. Doliber. Let me explain it this way. I had a 
conversation with a veteran's service officer at the VA. And he 
was an on-the-ground marine in Vietnam, and more power to him. 
When he heard that I had been onboard ship, he at that time 
would not take my case because in his words, we were on a 
cruise. It was if we were on the Queen Mary.
    This was no Queen Mary. We were--we provided gunfire 
support for the 3rd Marine Division at the Battle of Hue. We 
were anchored in the Perfume--at the mouth of the Perfume 
River. I was in the rangefinder. I was looking through. I was 
watching it. I was providing--I was pressing the button on the 
rangefinder that fired the guns. This is no Queen Mary. They 
don't call them destroyers for nothing, and we did a damn good 
job.
    Mr. Allen. Thank you very much.
    Mr. Doliber. Thank you.
    Mr. Allen. Thank you for your testimony.
    Mr. Michaud. Thank you very much, Dana. Without objection, 
I would ask anything that has been said and for all the written 
testimony to be submitted in full for the record. Hearing none, 
it is so ordered.
    I want to ask the second panel to come on up. While they 
are coming up, I just want to let you know, Dana, that in your 
written testimony you had asked that this Subcommittee be 
assured that there be no retribution against you for your 
testimony today. I assure you that there will not be any 
retribution. I want to thank you once again for coming here 
today.
    Mr. Doliber. Thank you, sir.
    Mr. Michaud. So, if the second panel could come forward. 
While they are coming forward, the second panel is Peter Ogden, 
who is the Director of Bureau of Veterans' Services for the 
State of Maine. We have Gary Laweryson, who is the Chairman of 
the Maine Veterans Coordinating Committee. Kelley Kash, who is 
the Chief Executive Officer of the Maine Veterans' Homes (MVH). 
And David Hartley, who is the Director of the Maine Rural 
Health Research Center. I want to thank all 4 of you for coming 
here today to give your testimony. We look forward to hearing 
your testimony here today.
    We will begin with Mr. Ogden. Please proceed.

  STATEMENTS OF PETER W. OGDEN, DIRECTOR, BUREAU OF VETERANS' 
SERVICES, STATE OF MAINE, AUGUSTA, ME, AND SECRETARY, NATIONAL 
  ASSOCIATION OF STATE DIRECTORS OF VETERANS AFFAIRS; GARY I. 
 LAWERYSON, USMC (RET.), CHAIRMAN, MAINE VETERANS COORDINATING 
  COMMITTEE, WALDOBORO, ME, COMMANDER, MILITARY ORDER OF THE 
  PURPLE HEART, STATE OF MAINE, JUDGE ADVOCATE, MARINE CORPS 
   LEAGUE, STATE OF MAINE, AND AIDE-DE-CAMP TO GOVERNOR JOHN 
   BALDACCI; KELLEY J. KASH, CHIEF EXECUTIVE OFFICER, MAINE 
 VETERANS' HOMES, AUGUSTA, ME; AND DAVID HARTLEY, PH.D., MHA, 
 DIRECTOR, MAINE RURAL HEALTH RESEARCH CENTER, AND PROFESSOR, 
MUSKIE SCHOOL OF PUBLIC SERVICE, UNIVERSITY OF SOUTHERN MAINE, 
                          PORTLAND, ME

                  STATEMENT OF PETER W. OGDEN

    Mr. Ogden. Chairman Michaud, Congressman Miller, 
Congressman Allen, thank you for this opportunity to speak 
today on 3 extremely important issues for Maine's veterans: 
Access to rural healthcare, women's issues----
    Mr. Michaud. Excuse me, sir. Is your microphone on?
    Mr. Ogden. The light's on. Okay. Should we start over? 
Okay.
    Chairman Michaud, Congressman Miller and Congressman Allen, 
thank you for the opportunity to speak today on 3 extremely 
important issues for Maine veterans: Access to rural 
healthcare, women veterans, and outreach to veterans for 
benefits. My testimony today comes from 3 perspectives: The 
Director of the Bureau of Maine Veterans' Services, the 
Secretary of the National Association of State Directors of 
Veterans' Affairs, and as a disabled combat veteran who uses 
the VA healthcare system in Maine.
    I will begin with some facts that are key to understanding 
Maine and its veterans. First, in 2000, Maine had the largest 
per capita veteran population in the Nation and is still at 
number 2.
    Second, Togus Medical Center is the oldest VA hospital in 
the Nation.
    Third, Maine's aging veteran population is geographically 
dispersed across a large land area. Veterans living in northern 
Maine can drive 5 to 6 hours and up to 260 miles to reach the 
one VA Medical Center at Togus.
    Fourth, 65 percent of our veterans are age 55 or older. 
This percentage should reach about 70 percent between 2020 and 
2025, and these are the veterans that are most likely to need 
and use the VA healthcare system.
    Fifth, 73 percent of our veteran population served during a 
wartime, which means they have more benefits available to them.
    Last, we have over 52,000 or 36 percent of our veterans 
enrolled in the VA healthcare system, and about 38,500 who 
actively use the VA healthcare in Maine.
    A lot of my speech will talk about the Capital Asset 
Realignment for Enhanced Services (CARES) program. The CARES 
market plan, the Far North Market--and Maine is unique because 
Maine as a State has its own market identified by the CARES 
plan--developed by Veterans Integrated Services Network (VISN) 
1 recognized Maine's unique geographic characteristics, limited 
transportation infrastructure, and rural nature.
    The CARES Commission Report made several points about 
access to VA healthcare in Maine, the Far North Market, that 
are relevant to this hearing. Less than 60 percent of our 
enrolled veterans are currently within the VA's access 
standards for hospital care. Inpatient medicine workload is 
projected to increase 209 percent by 2012. Only 59 percent of 
the veterans residing in this largely rural area are within the 
CARES plan guidelines are set for access to primary care. VISN 
1 proposed only 5 new CBOCs, Community-Based Outpatient 
Clinics, all of them in Maine. In short, to improve rural 
access for veterans to VA healthcare in Maine and the Nation, 
implement CARES in Maine and in other rural States, and 
implement it as soon as possible.
    Any conversation about aging veterans and access to 
healthcare should include the importance of State Veterans' 
Home Programs and the service they provide to our veterans. 
Maine is fortunate to have Maine Veterans' Homes with their 6 
facilities spread across the State providing excellent care at 
the most reasonable cost. It is important that Congress 
continue to fund the State Veterans' Home Construction Program 
until each State has the capacity to provide long-term care to 
its veterans.
    Maine has over 10,000 women veterans with less than 1,800 
using the VA healthcare system. Quality or availability of 
types of care for women veterans does not seem to be as much of 
an issue as the access and outreach to those women veterans to 
know about their benefits. Approximately 40 percent of the 
women veterans using the VA healthcare system receive it at the 
CBOCs. So, access at the local area is important. The addition 
of the new CBOC in the Lewiston/Auburn area and the access 
points in Houlton, Dover-Foxcroft and in Farmington will allow 
more women veterans to receive care closer to home and this 
will increase the usage numbers for all of our veterans.
    While growth has occurred in VA healthcare due to improved 
access to CBOCs, many areas of Maine and the country are still 
shortchanged due to the geographic and due to the veterans' 
lack of information and awareness of their benefits. VA and 
State Departments of Veterans Affairs must reduce this inequity 
by reaching out to the veterans regarding their rights and 
entitlements. Maine and the National Association of State 
Directors of Veterans Affairs support the implementation of a 
grant program that would allow the VA to partner with the State 
Department of Veterans Affairs to perform outreach at the local 
level.
    There is no excuse to veterans not receiving benefits to 
which they are entitled simply because they are unaware of 
those benefits. I would encourage the Committee to support S. 
1314, the ``Veterans Outreach Act of 2007,'' to help us with 
that.
    State governments are the Nation's second largest provider 
of services to veterans next to the VA, and this role will 
continue to grow. We believe it is essential for Congress to 
understand this role and ensure we have the resources to carry 
out our responsibilities. The States partner very closely with 
the Federal Department of Veterans Affairs in order to best 
serve our veterans. And as partners, we need to continuously 
strive to be more efficient in delivering those services.
    As I finish my testimony rather rapidly, I would like to 
once again thank you for the opportunity to speak to you today 
and thank you on behalf of Maine's veterans and the Nation's 
veterans for all you are doing to ensure they receive the 
proper healthcare and the benefits they have earned through 
their service to the Nation. Thank you.
    [The prepared statement of Mr. Ogden appears on p. 44.]
    Mr. Michaud. Thank you very much. Mr. Laweryson.

                 STATEMENT OF GARY I. LAWERYSON

    Mr. Laweryson. Congressman Michaud, Congressman Miller, 
Congressman Allen, the Maine Veterans Coordinating Committee 
wants to thank you for allowing us to testify again. Our 
organization is made up of 14 different groups that do their 
best to work for all the veterans in the State of Maine.
    As I testified on August 1st, 2005, on the CARES program, 
and you will see a lot of this overlaps everybody else, it has 
been 2\1/2\ years and we have opened 1 clinic, Houlton, 
possibly in June. And in that interim time period, there's been 
a CBOC opened down in Connecticut, which wasn't even on the 
table at that time. The rural veterans are not getting the care 
that they deserve or need.
    At that time, we discussed the cost of fuel, the cost of 
living up here in Maine. And since that time, I bet it has 
tripled. The gas is out of sight, the fuel oil is out of sight. 
These people are working on a fixed income. They are not able 
to travel. And when they do go down to Togus, there is a cost 
share on the travel pay, they lose half of it, and it is 
already putting a tremendous burden on them as it is. I think 
we need to look at that again.
    With Operation Iraqi Freedom/Operation Enduring Freedom 
(OIF/OEF) troops coming back, and they have been extended 
through a 5-year term with the VA. And I think that boots out 
after they redeploy again, which is another issue. The older 
veterans aren't getting the word that they can get in there. 
So, they don't come down because OIF/OEF has a first run on 
this or their assumption is that they do.
    We discussed communications last time with the VA getting 
out the proper word to clear up the fog. That hasn't happened 
yet. We need to get more of the VA out into local communities 
putting out these town meetings to pull these rural veterans 
in. While Maine is a rural State, there is a subsection of 
rural up there, and you will speak with Mr. Rural later. That 
is where a large majority of your veterans are, especially your 
combat veterans. They like to be out and about away from the 
hustle and the bustle. We need to find out what's taking so 
long for VISN to get our other clinics open. And we need to get 
that moving, especially in the rural areas first.
    The VA and Togus, we support, as we did back then. The past 
director, Jack Sims, was doing a great job with what he had. 
The new director has got a challenge and we are going to hold 
his feet to the fire, but he is doing a great job. We have a 
meeting with the Coordinating Committee once a month. He is 
there, he is an integral part of this. We get the word, we pass 
the word. And if there's any issues, we take it up and deal 
with them, not in a public meeting place but a private matter. 
Very effective, and Mr. Stiller is very receptive to that. We 
are lucky to have him.
    We have done something in Maine that the other States 
haven't done yet, and that is called ``Operation I Served.'' We 
put that package together. It has been very effective. And we 
are putting it out now in doctors' offices, waiting rooms of 
hospitals because the veterans do get that. They are allowed to 
call in. We have worked with the Bureau of Veterans Services in 
Maine, publish this, update it every year or so. It is a 
tremendous tool, and we just need to get more of that out in 
the public. And that goes along with what my brother, Pete, was 
talking about that that would be a tremendous, tremendous way 
to get this information out and if we can get the VA onboard 
and do more town meetings in the rural areas.
    Women veterans. They are combat veterans. A veteran's a 
veteran. They have special needs. There's special needs 
veterans out there with amputations and traumatic brain 
injuries. There is no difference. They are veterans, and they 
should have first-care priority to any area, and that's the 
rural areas. Now, if we can't get them in out there, we could 
temporarily take care of them with fee services until we can 
get them down to the master hospital at Togus. Getting short on 
time here.
    And the Coordinating Committee's opinion is still that VA 
should be a full-service hospital. We should not have to run 
down to Boston. It is counterproductive and it is not in the 
best interest of the veterans or their families. It wasn't 
before, and it especially isn't now with the cost of 
transportation and fuel.
    We appreciate what you are doing for our veterans. We 
continue to look forward to working with you. And we will hold 
your feet to the fire to keep up the good work. Thank you.
    [The prepared statement of Mr. Laweryson appears on p. 47.]
    Mr. Michaud. Thank you. Mr. Kash.

                  STATEMENT OF KELLEY J. KASH

    Mr. Kash. Mr. Chairman and Members of the Committee, thank 
you for the opportunity to testify this morning.
    I am the Chief Executive Officer of the Maine Veterans' 
Home. MVH operates 6 long-term care nursing facilities 
providing 640 skilled nursing, long-term nursing, and 
domiciliary beds. The facilities are relatively small, each in 
size, 30 to 150 beds each. This allows them to be located 
throughout the State of Maine, allowing greater ease of access 
to our facilities by veterans living in the most rural parts of 
Maine.
    MVH is part of a vital national system of State Veterans' 
Homes. The State Veterans' Homes system is the largest provider 
of long-term care to our Nation's veterans and provides 52 
percent of the VA's total long-term care workload at well below 
the cost of care in a VA facility for civilian contract 
providers. The State Veterans' Homes provide long-term medical 
services at a cost to the VA of only $71.00 per day, compared 
to approximately $225.00 per day to the VA for the placement of 
a veteran at a contract nursing home, or over $560.00 per day 
in its own VA facilities. As such, the State Veterans' Homes 
play an irreplaceable role in assuring that eligible veterans 
receive benefits, services, and quality long-term healthcare 
that they have rightfully earned by their service and sacrifice 
for our country.
    Traditionally, State Veterans' Homes residents have been 
primarily male. However, more and more women are being admitted 
to State Veterans' Homes as veterans themselves reflecting the 
large and increasing numbers of women who have served in the 
military since the Korean war and before.
    While our experiences in the Gulf War and present conflicts 
have given tremendous attention to post traumatic stress 
disorder, the reality and effects of PTSD have been present in 
every conflict. State Veterans' Homes provide a common culture, 
reassuring surrounding, greater appreciation, and understanding 
of the veterans' experiences and issues; however, much more can 
be learned in treating PTSD in general.
    We feel strongly that the State Veterans' Homes should play 
a major role in meeting the many rehabilitative care needs for 
veterans and that we should be treated as a resource integrated 
more fully with the VA long-term care program. Here is one 
example of how the VA can partner with the State Veterans' 
Homes.
    The State of Maine enacted legislation earlier this month 
to establish a veterans' campus at Bangor, Maine. The concept 
is to create a one-stop shop for veterans to receive most of 
their healthcare and social service needs. The proposed project 
will locate a new, larger, and more capable VA community-based 
outpatient clinic next to the MVH Bangor facility. Other 
veteran service organizations will be co-located at the campus, 
bringing a wide range of veteran services to a single campus, 
making it more efficient and convenient for veterans, families, 
and the various agencies that serve veterans' healthcare and 
social service needs.
    The Bangor Veterans' Campus is a pioneering effort and it 
is the first of its kind in the Nation. It should receive 
special interest in our Nation's Capitol. The VA should 
streamline its awards process and its success should be 
replicated throughout the Nation.
    The VA chronically has been slow to implement enacted 
legislation. Legislation directing the VA to pay the full cost 
of care for veterans with service-connected disabilities rated 
70 percent or greater and to provide veterans with service-
connected disabilities rated 50 percent or greater with 
prescription medications while residing in State Homes has yet 
to be implemented by the VA, even though Federal law required 
these provisions to take effect by March 2007. The result has 
been tremendous confusion and frustration for the many 
thousands of veterans who are waiting for these services and 
for the State Veterans' Homes which will be required eventually 
to provide these services.
    Regarding VA grant funding, the administration has proposed 
cutting State Veterans' Home construction matching grant 
funding by almost 50 percent from $165 million in fiscal year 
2008 to $85 million in fiscal year 2009. The backlog of 
construction projects to repair, rehabilitate, expand, and 
build new State Veterans' Homes is now approaching $1 billion. 
Over $200 million of this backlog are life-safety projects.
    In conclusion, I will quickly reiterate the issues facing 
the State Veterans' Homes. First, thank you for your continued 
support in the VA per diem payment to the State Veterans' 
Homes. The loss or reduction of the VA per diem would place 
Homes in an untenable financial position and could lead to the 
closure of many State Homes, ultimately impacting our aging 
veterans.
    Second, we believe Congress must increase funding for 
construction grants to State Veterans' Homes to at least $200 
million to address the growing backlog of projects.
    Third, we believe Congress must require the VA to 
promulgate long-overdue regulations to strengthen State 
Veterans' Homes and the veterans they serve.
    Finally, we believe that the State Veterans' Homes can play 
a more substantial role in meeting the long-term care needs of 
veterans. We support the national trends toward de-
institutionalization and the provision of long-term care in the 
most independent and cost-effective setting. We would be 
pleased to work with the Committee and the VA to explore 
options to develop pilot programs, such as the proposed Bangor 
Veterans' Campus, providing innovative care and for more 
closely integrating the State Veterans' Homes program into the 
VA's overall healthcare system for our veterans.
    Thank you for the opportunity to address you today, and 
thank you for your commitment to long-term care for veterans 
and for your support of the State Veterans' Homes as a central 
component of that care.
    [The prepared statement of Mr. Kash appears on p. 48.]
    Mr. Michaud. Thank you very much, Mr. Kash.
    Dr. Hartley.

             STATEMENT OF DAVID HARTLEY, PH.D., MHA

    Mr. Hartley. Well, thank you. Mr. Chairman, Mr. Allen, Mr. 
Miller, thank you for the opportunity to testify before this 
Committee. My testimony is based on my 12 years as a manager of 
substance abuse treatment programs in rural areas, and 15 years 
as a rural health researcher with a focus on access to mental 
health services in rural America. I would like to make 4 points 
in my testimony.
    First, as you know, many veterans are returning from OEF 
and OIF with mental health issues including PTSD, depression, 
and traumatic brain injuries (TBI). A recent report from the 
RAND Center for Military Health Policy Research refers to these 
as the invisible wounds of war and reports that 31 percent of 
servicemen deployed since 2001 have reported symptoms of one or 
more of these injuries. This report I have here with me, it is 
very long. It just came out a few days ago, and I highly 
recommend it. What is not mentioned in the RAND Report is the 
significant portion of these combat vets who are from rural 
areas, nearly half are recent recruits.
    My second point. The Veterans' Healthcare System has unique 
expertise and resources to devote to the healing of these 
injuries. In recent--excuse me. The VA also has an integrated 
health information network. I am sorry, my notes are out of 
order. I am going to have to switch to my other notes. Excuse 
me. (Pause.) In recent years, the VA has opened more community-
based outpatient clinics, or CBOCs, to make their expertise and 
these resources available to veterans who live at significant 
distances from VA medical centers. We now have 6 CBOCs in 
Maine.
    The VA also has an integrated health information network in 
the Nation, the best in the Nation, with evidence-based, 
patient-centered performance measures and a monitoring system 
to assure that all patients receive high quality care. That 
system gets very good outcomes for those veterans who receive 
care from VA clinics and from CBOCs and from contract 
providers.
    There are several reasons why a veteran in need of help 
might not seek care at one of these facilities. While CBOCs 
have improved access in many rural areas, there remain vast 
remote areas in our most rural States, including Maine, where 
VA facilities are out of reach. Also, some veterans prefer to 
seek care from a non-VA system provider for a variety of 
reasons. This RAND report found that only half of those with 
these injuries actually seek help for them.
    My third point. The Federal Government, through the Health 
Services and Resource Administration, has created several 
programs to attract providers to under-served areas to support 
them. These include federally qualified health centers, 
critical access hospitals, and rural health clinics. Some rural 
areas are also served by community mental health centers. Most 
of these programs exist in areas that are designated as under-
served. While many of these programs are focused on primary 
care, it is common in rural areas to seek mental health 
services from primary care sites.
    We have the technology and the expertise to help these 
rural sites provide care to rural veterans that is of the same 
high quality that urban vets receive. This can be done through 
telehealth, through the VistA information system which is now 
available to non-VA providers, through direct and clinical 
consultation between the expert clinicians in VA medical 
centers and rural providers, and through the placement of VA 
providers in these non-VA rural sites, creating veterans' 
access points. Such cooperation between VA and non-VA providers 
must be encouraged.
    My final point. To facilitate collaboration between Health 
Resources and Services Administration (HRSA) and the VA, this 
Committee should encourage HRSA's Office of Rural Health Policy 
and the VA's new Office of Rural Health to collaborate on 
demonstrations and on interagency research bringing HRSA's 
Rural Health Research Center and the VA's researchers together 
to explore options for improving access to high quality care 
for rural vets.
    Thank you. I will be happy to answer your questions.
    And I would like to add that I am accompanied today by my 
colleague, Dr. David Lambert, who is also an expert in rural 
mental health. Thank you.
    [The prepared statement of Mr. Hartley appears on p. 52.]
    Mr. Michaud. Thank you very much, Dr. Hartley.
    Once again, I would like to thank the 4 panelists here.
    Mr. Laweryson, you had mentioned the CARES process and 
CBOCs, and we are very much familiar with that whole process. 
We keep that book, I know I do, right on my desk in Washington 
to keep updated on how much progress we are making.
    Former Secretary of the VA, Tony Principi said in order to 
move forward in the CARES process, that they would need about a 
billion dollars a year. That has not happened, unfortunately. 
However, I think that if you listened to all the comments made 
here thus far today, as well as in Washington, relating to 
rural healthcare issues and access to healthcare, I think the 
CARES process would actually quite frankly solve a lot of 
problems with access points in rural areas.
    My question is it is an expensive process. Part of that 
expense is establishing some major hospitals that could cost 
$500 million to establish compared to a $50 million dollar CBOC 
or access clinic.
    What would you recommend? Should the Subcommittee focus on 
some of the lower-cost access points and put off maybe for a 
year or whatever some of the higher dollar figure major 
hospitals?
    Mr. Laweryson. I think that hits it right on the head, sir. 
It is--it is like a triage in the battlefield. You get the 
veterans in. If they dictate that they have to go to further 
treatment, then we can move them down to a larger CBOC. For 
instance, we have Bangor. That is on the outreach of 50, 60 
miles north of Togus. I think the problem there is that if we 
can get Togus up to speed, then these veterans don't have to 
travel even further south 2 or 3 hours into Boston, and that is 
from the lower section of the State.
    But on the rural as an overall picture, if you have your 
access sites out there, you are going to find more veterans 
getting into them. And once they are diagnosed and triaged, for 
lack of a better word, then you can get them into the system 
and they will feel more comfortable with it. But to do that, we 
have to communicate to them that this is open, it is a great 
system, because for years they haven't been getting that word.
    Mr. Michaud. I am relieved to hear that answer because 
actually later this week, Wednesday, I believe, our Committee 
will be marking up a construction bill, and we have language in 
there that will actually direct the VA to focus on exactly what 
we were just talking about.
    My other question, you had also mentioned the gas 
reimbursement. As you heard earlier and you all know, we 
increased the mileage to 28.5 cents. However, the VA did put on 
a waiver or increased the waiver. When the Secretary was before 
us in the hearing to the full Committee of Veterans' Affairs, 
he said that the deduction is being waived.
    Are you finding that to be true for your members?
    Mr. Laweryson. No. I was told that it hadn't been waived. 
And it is--we really appreciate the 28 cents, you know, the 
increase to that. But when the gas goes up 28 cents in a day, 
that is--if they could take that waiver off, that would be 
really beneficial to a lot of them.
    Mr. Michaud. So that deduction has not been waived?
    Mr. Laweryson. At the last meeting, it hadn't been. We 
brought it up and was told it hadn't been.
    Mr. Michaud. Okay, because the Secretary had told the 
Committee that it was.
    Mr. Hartley, you had mentioned I think in your testimony 
that you suggested the VA should establish a Rural Behavioral 
Health Research Institute. What specific research questions 
would you like to see the institute address?
    Mr. Hartley. I think the most pressing question right now 
is this fact that 50 percent of the folks who have these 
symptoms aren't seeking care for it. I think there is a whole 
variety of reasons why that must be the case. It is not just 
about geographic access. I think there are other reasons. I 
don't think we know the answers to those questions. This RAND 
report asks some of those questions and begins to point the 
direction, but that would be my first question.
    Mr. Michaud. You also mentioned that you are an expert in 
rural behavioral health. How would you assess the VA's current 
system ability to meet the behavioral health needs for rural 
veterans? Do you think they are meeting all those needs?
    Mr. Hartley. Well, clearly they can't meet all those needs 
in the most rural areas. And as a matter of fact, this isn't a 
problem that faces only the VA, it faces our entire healthcare 
system. Mental health needs and substance abuse needs in rural 
areas are frequently cited as the most acute need in the most 
rural areas by people all across the spectrum. So, it is true, 
they are not meeting those needs.
    I think what we need to do is pool our resources that are 
out there that have been created through these Federal programs 
to do the best job we can to meet as many people's needs as we 
can.
    Mr. Michaud. What are some of the specific things you think 
the VA can do to improve the access to rural veterans?
    Mr. Hartley. Well, as I suggested here, I think they--and I 
like this idea of triage, of figuring out how to make a first 
point of contact, a first point of access where we can get 
folks in the door. And this may address some of those reasons 
for that 50 percent who aren't seeking care. So creating what 
we call the ``no wrong door'' approach, which means wherever 
you show up, there will be somebody there who will say, yes, 
you have this problem and, yes, you are eligible for these 
benefits, let me help you.
    Mr. Michaud. My last question, Mr. Kash, is do you have any 
programs specifically for women veterans?
    Mr. Kash. No, sir, not specifically. Although, we are 
seeing more and more women and we are becoming much more adept 
at handling them. Normal nursing home, a civilian, is 75 
percent women, where it is about 25 percent or less in our 
homes because of the nature of the veterans. But we are getting 
much more adept at how we handle women.
    Mr. Michaud. Mr. Miller.
    Mr. Miller. Thank you, Mr. Chairman. For the record, I do 
believe the Secretary sent a letter out clarifying that he did, 
in fact, misspeak during our hearing in regards to the waiver, 
and he is, in fact, looking at expanding and doing research. I 
think we all support the waiver that he did in fact speak of.
    Mr. Kash, you talked about the veterans' campus in Bangor. 
Could you elaborate a little bit on the benefits? I think it is 
a great idea. How did it come about and what are the options 
that we are looking for?
    Mr. Kash. It came about a year and a half ago. A group, 
including several players in the legislature in the veterans' 
organizations. The CBOC at Bangor right now is about half the 
size that it needs to be. The veteran population there is 
growing and getting big, so they knew they had to replace the 
CBOC and they knew their lease was coming up due. So, a new one 
needed to be built. This was an idea, the Dorothea Dix 
Psychiatric Center up there is a large campus, and we are right 
next to it, we are part of it. And we thought here is a great 
opportunity to locate it nearer to where it is now, bringing a 
large area to build its clinic.
    And then also other ventures that we are looking at doing 
up there, along with Veterans' Housing Coalition of Maine, is 
establishing housing, low-cost housing for homeless or needy 
veterans. And what we would also like to do for MVH is look 
into hospice, building a fixed hospice facility. So, here we 
have a bunch of ventures we would like to do to improve our 
services to the veterans, and we know that we can co-locate 
them all on one campus. We think that it will obviously be much 
more convenient for the families and the veterans themselves, 
but also the many service organizations that work together to 
provide those services. We saw it as a win-win opportunity.
    So, the State of Maine took the initiative to go ahead and 
research it, to put it into action, to have a rather robust 
Committee look at it and make sure all the stakeholders are in 
agreement with it, and then to go ahead and pass legislation 
that will in fact deed land over to MVH to help facilitate the 
building and construction of that.
    Mr. Miller. Thank you. Mr. Laweryson, do you support the 
fee-for-service concept if veterans have no other options 
available, in particular rural veterans?
    Mr. Laweryson. I think the fee-for-service is great if it 
is an emergency and it is also great for those veterans that 
suffer from head colds, rashes, coughs, headaches, or for 
glasses. But your other, you know, major surgeries and stuff 
that can be done that are not emergency, they need to get to 
the VA hospital because the turnaround time on healing, because 
it is in a veteran's community, it is cut in half. These 
veterans, they love being around each other. And that is an 
important part of the system, that is why we have the VA 
hospital, especially the combat veterans.
    But, yeah, on a case-by-case, if they don't need to be 
running down from Caribou or Presque Isle or Clayton Lake to 
get some cough syrup or something, that would be fantastic. You 
know, or if it was an emergency surgery, compound fracture, get 
it over here, get it taken care of right here locally. It is 
done, and the family unit is there to help with the healing 
process.
    Mr. Miller. I only ask that question because we do get 
pretty good push-back from the VSOs out there with regards to--
and I understand part of the argument and the desire not to 
berate the healthcare that is being provided now by allowing 
veterans to, quote, ``flee the system,'' if you will. But we 
are all trying to find a way to get at access problems, even in 
the short-term, and it may be that fee-for-services is the way 
to go.
    I don't know how we establish the severity of an issue, 
obviously, because there are a lot of people that will go to a 
doc in the box, if you will, for a minor issue rather than go 
to the hospital. I just wanted to see what your reaction was.
    I am going to go ahead and yield my time over to Mr. Allen 
so he can continue to ask questions.
    Mr. Michaud. Mr. Allen.
    Mr. Allen. Thank you. Thank you all for your testimony. I 
had a couple of questions for Peter Ogden.
    In your testimony, you say there are more than 10,000 women 
veterans in the State of Maine, but only 1,800--less than 1,800 
receive their healthcare from the VA. You mentioned lack of 
access, lack of outreach as likely reasons for that number 
being as low as it is, or at least I think that is what you are 
saying.
    So, I guess I am curious about what you think the limits 
are of your current outreach efforts, and really are there 
places that you think more could be done? I guess the first 
question is do we have a problem here or not?
    Mr. Ogden. Yes, we have a problem. Actually, outreach--I 
think part of our problem is I know about my World War II 
veterans, Korean war veterans that we are wrestling to bring 
into the VA system now. It is like the women veterans. They are 
there, we know they are there. We know--we can tell what 
counties they are in, but we haven't been able to reach to them 
and say, you have some benefits, please come use them.
    And I think it has a lot to do with the female veterans 
that come back, the younger ones get married, they have 
families or those things. They kind of get drawn into other 
things. And because the access is not convenient for them to 
the women's clinic at Togus or any of the CBOCs that we have 
available to go to them, I think they kind of do other things 
in the process. I really believe that having the CBOCs, the 
access points out there, will bring more women veterans into 
the system.
    And the other part is for us to reach out. And as a State, 
we struggle with how do we reach out to veterans. That is part 
of my job is outreach and working with the VA to be able to say 
to every one of those women veterans that here's the benefits 
available to you, here's what we need to do, please come see 
us. I write letters to every DD-214 that comes into my office. 
There's about 1,500, 1,800 this last year. I send letters to 
every one of those people saying, here's your benefits, if you 
have a question, come call to us.
    Well, we still need to keep community outreach. A lot of 
those are young women veterans, and we have a lot of other 
veterans here. It is a problem with us. I think outreach would 
bring the veterans in, not just the women, but the other 
veterans. And to bring them in, we need the access points to 
bring them into because I think one of the things that we need 
to do is--because access points will give us primary 
healthcare.
    And if we get primary healthcare in a preventive medicine 
kind of timeframe, we will reduce the cost and severity of 
those things when the veteran shows up down at Togus later on. 
If we can get them in sooner and take care of their healthcare 
and be preventative about what we are doing with those things, 
it will reduce the total healthcare costs because when they 
show up--if we haven't done that, they are going to show up 
with a more severe problem than needs to be, I think.
    Mr. Allen. Is there a way to use other women's groups to 
reach women veterans? Part of the question is, should you be 
thinking about outreach to the women veterans any different 
than you do with men?
    Mr. Ogden. Well, the State of Maine has a Commission for 
Women Veterans. They work under my kind of control as a 
commission established by women veterans. There is no funding 
for the women veterans. I try to help them. I do the 
newsletters for them, we send them out and they work with us to 
try to outreach. It is about having some money to travel, 
having some money to have town hall meetings and those kind of 
things. These women are all volunteers. They don't get paid for 
anything they do, but they do travel around, they do work with 
those things.
    Maine just has now--we have a great chapter of the WAVES 
National that are mostly World War II female veterans. We have 
now the Vietnam--actually, the Women Veterans of America just 
started a chapter in Maine. That is going to be helpful, I 
think, to gather the women into the process. But it is about 
outreach, and you need to have female veterans reaching out to 
female veterans.
    Mr. Allen. My other question is for Kelley Kash. In your 
written testimony, you said that the VA recently estimated 
nationally that nursing care beds in the State homes are 87 
percent occupied, but that many of the State veterans' homes 
nationally have occupancy rates near 100 percent and some have 
long waiting lists. In Maine, I understand it is around 97 
percent.
    Mr. Kash. Yes, sir.
    Mr. Allen. Is that right? What do you think is going to 
happen? Has that number been stable? Is it likely to increase? 
Are we at risk of having longer lines, or do you think that, 
you know, you have been adding beds at a pace that will be able 
to take care of the potential influx in the population?
    Mr. Kash. There are 155,000 veterans in the State of Maine, 
plus their families. And on average, about 5 percent of the 
aging population will require nursing home care. So you can see 
that that number is really askew. I think what is going to 
happen is even though we are legally constrained to 640 beds, 
we could easily grow and still not have enough room to provide 
all the services. So, the VA is going to have to look at other 
mechanisms to do that.
    But the short answer to your question, I think we could use 
a lot more beds.
    Mr. Allen. Do you think you are likely to have waiting 
lists in the future? Do you have waiting lists now?
    Mr. Kash. Yes, we do. We have waiting lists right now, and 
a lot of those are family members who would like to get in as 
well. I think that we could address immediate needs in areas 
like York County. But then there are about 40 percent of folks, 
their primary reason for choosing a nursing home is convenience 
of location. And there aren't too many locations that are 
convenient in Maine. So, if we could deploy more homes, we 
could certainly, I think, fill those beds.
    Mr. Allen. Thank you. I yield back.
    Mr. Michaud. Thank you. Once again, I would like to thank 
the 4 panelists for your testimony this morning. I look forward 
to working with you as we move forward in dealing with these 
issues. Thank you very much.
    Next, panel 3 includes Joe Wafford, who is the Supervisory 
National Service Officer for the Department of Maine Disabled 
American Veterans (DAV); Donald Simoneau, who is a past 
Department of Maine Commander for the American Legion; John 
Wallace, the Maine State Council President for the Vietnam 
Veterans of America (VVA); and James Bachelder, who is the 
Maine Department Commander for the Veterans of Foreign Wars 
(VFW) of the United States. I want to thank all of you for 
coming here today. I look forward to hearing your testimony.
    We will start with Mr. Simoneau.

STATEMENTS OF DONALD A. SIMONEAU, PAST COMMANDER, DEPARTMENT OF 
   MAINE, AND MEMBER, NATIONAL LEGISLATIVE COUNCIL, AMERICAN 
   LEGION; JAMES BACHELDER, COMMANDER, DEPARTMENT OF MAINE, 
 VETERANS OF FOREIGN WARS OF THE UNITED STATES; JOHN WALLACE, 
 PRESIDENT, MAINE STATE COUNCIL, VIETNAM VETERANS OF AMERICA; 
 AND JOSEPH E. WAFFORD, SUPERVISORY NATIONAL SERVICE OFFICER, 
        DEPARTMENT OF MAINE, DISABLED AMERICAN VETERANS

                STATEMENT OF DONALD A. SIMONEAU

    Mr. Simoneau. Mr. Chairman, that has a nice ring to it, 
Congressman Miller, Congressman Allen, I thank you for the 
opportunity to present the American Legion's views on women, 
special needs, and rural veterans. The American Legion commends 
the Subcommittee for holding a hearing to discuss this vitally 
important issue.
    According to the VA research, women make up approximately 
15 percent of the active force serving in all branches of the 
military, and the State of Maine has approximately 9,396 women 
veterans. Research has shown that women veterans encounter 3 
large barriers when trying to access healthcare through the VA 
system: The lack of knowledge of the VA health administration 
services, unaware of the eligibility for healthcare benefits, 
and the perception that the VA caters to male veterans.
    The American Legion recommends that once women veterans' 
needs are identified, the VA develop and implement policies to 
address these deficiencies in a timely manner and conduct an 
extensive outreach campaign to ensure that this special 
population of those who served and those who served them are 
aware of the enhancements in the healthcare services.
    Special needs veterans. The American Legion is very 
concerned about the needs of all veterans, but we must reassure 
that special needs veterans do not slip through the cracks: The 
chronically mentally ill, the major affective disorders, post 
traumatic stress disorder, traumatic brain injuries, the frail, 
the elderly, those veterans 65 years of age or older with 
chronic health problems, and we must always be on-watch for the 
homeless veteran.
    Recently, in my own hometown, a young man who served 2 
tours in Iraq, found that he could not handle what he dealt 
with, and he took his own life. And it was a great loss to the 
community, a great loss to the Nation. He is one of those that 
slipped through the cracks. We cannot allow that.
    The American Legion believes veterans, many of whom are 
elderly and infirm, are isolated from regular preventative 
medical attention they need and they deserve. The VA's ability 
to provide treatment and rehabilitation to rural veterans who 
suffer the ongoing wars in Iraq and Afghanistan will continue 
to challenge the system. The American Legion believes CBOCs 
that serve as a vital element of the VA's healthcare delivery 
system in States such as Maine, veterans face extremely long 
drives, shortage of healthcare providers, and bad weather.
    The American Legion urges Congress to adequately fund 
CBOCs, construction and maintenance. The VA must enhance 
existing partnerships with communities and other Federal 
agencies to help alleviate the barriers that exist such as the 
high cost of contracted care in the rural setting. Lastly, the 
American Legion urges Congress to provide adequate funding to 
the VA to accommodate the modernization of all VA structures.
    Mr. Chairman, I thank you for giving the American Legion 
this opportunity to present its views on such important issues. 
You can see a much more in-depth report in my printed report 
which I have submitted. I thank you for my time.
    [The prepared statement of Mr. Simoneau appears on p. 53.]
    Mr. Michaud. Thank you very much, Mr. Simoneau.
    Mr. Bachelder.

                  STATEMENT OF JAMES BACHELDER

    Mr. Bachelder. Mr. Chairman, Congressman Miller, and 
Congressman Allen, I want to thank you for being here today.
    I would like to start by saying that we did have a 
communication problem due to the fact that Rosemary Lane is 
very sick. But I want to thank you for waiving the need to have 
my testimony ahead of time. I am going to record it and I will 
get it to Jim Pineau at Congressman Allen's office for the 
Committee.
    Mr. Michaud. Thank you.
    Mr. Bachelder. As the Commander of the Veterans of Foreign 
Wars in the State of Maine, a Board Member of the Veterans' 
Housing Coalition, Co-Chairman of the Southern Maine Veterans' 
Memorial Cemetery Association, the Chairman of the Sanford 
Veterans' Memorial Committee, the host of the Sanford veterans' 
cable access program which both Congressman Michaud and 
Congressman Allen have been to in the past and we hope to have 
you in the future, a driver of the Disabled American van in 
Sanford for Togus for 5 years, and a disabled veteran due to 
combat in Vietnam, I would like to put some light on some 
issues that we found in the VA healthcare.
    Transportation. If you are not service-connected, you have 
to deal with the Disabled American Veterans' van system which 
is made up of volunteers. And due to health restriction of 
drivers, sometimes it is hard to have people drive the van. So 
in this area, in Sanford, if you need to go for a Tuesday 
appointment, you need to take a van ride on Monday. You need to 
spend the night at Togus. The VA will give you food and 
housing. You would have your appointment for 15 or 30 minutes 
on Tuesday, and you have to stay at Togus hospital Tuesday 
night and take the van back on Wednesday.
    The VA healthcare has the best electronic records, and in 
those records are flags where the Mental Health Department can 
put in information about the patient, about the needs, about 
the concerns. And with research, I have talked with the 
computer department, I have talked with the schedulers, and 
those flags should be used so that the people that need to use 
the DAV van, when they make an appointment, they will know that 
these people should be able to get a ride on Monday and have 
the appointment before noontime and be able to return on the 
same day. And it would reduce the cost of housing and feeding 
these veterans, but we have not been able to get the Mental 
Health to allow these flags to be used for transportation 
reasons.
    And when we have the van that needs to go to Boston, and 
somebody has to get there from up in Caribou, they have to come 
down the day before. They have to take the van to Boston. They 
have to have their procedure done. They have to take the van 
back to Togus. They have to spend the night in Togus and wait 
until there is a van to take them back to Caribou. So, the 
transportation issue is something that as veterans you know 
about, but we need Congress to understand. That if we have the 
communication in the records, then we can key-in to the 
transportation system and these veterans can be serviced in 1-
day service.
    Appointments. I just had a Ryan Lilly come down who is the 
Associate Director of the Medical Center. And when he came 
down, we talked about some letters that I received.
    I had an appointment for May 30th. I received a letter that 
it was canceled because the doctor wasn't going to be 
available, so it was moved to the 7th of May. Then I received a 
letter that the 7th was canceled, it was moved to the 8th. Then 
I received a letter saying that the 8th was canceled, it was 
moved to the 9th. The letter canceling the 7th and the 8th and 
the 8th and the 9th were written on the same day.
    When I talked with Mr. Lilly, he said when you have a 
change in your appointment, the healthcare should be calling 
you to find out if you are available for the day that they are 
going to give you an appointment. That wasn't being done. And 
when he did get it taken care of, the employees did not have a 
very good attitude when they call up and try to arrange an 
appointment with you. And I just don't see that the veteran who 
is trying to get healthcare and isn't being cared for properly 
should have a bad attitude from an employee when they are being 
told to do their job properly. I did get to see a doctor, and 
that's been taken care of.
    I do have another issue, and I am using myself as an 
example because of the fact that I can speak of what I know. 
But I do work as a service officer in the VFW here in Sanford, 
and I know that I am not the only person that has these issues. 
But I do have another appointment I called on, and it takes 2 
months to get the appointment. And it would be nice if we could 
find a way to get these appointments quicker than 2 months.
    Also, I was driving up to Togus 1 day, and I called up just 
to make sure that they understood I was on my way. And when I 
got to Brunswick they said, oh, don't bother coming, the 
doctor's not available. I have gone up to Togus at other times, 
the doctor wasn't available, and all of the people were coming 
in for their appointments and they were never notified that 
this doctor wasn't available and they continued to go to Togus. 
And it is not a one-time deal. This happens often, that they 
have too few of doctors, they have so many veterans, and an 
emergency comes up and the doctor has to be taken away. But 
nobody picks up the phone to try and call these veterans and 
tell them not to come.
    The question about post traumatic stress and traumatic 
brain injury. Peter Ogden was just testifying from the Bureau 
of Maine Veteran Services. And his chapter had a meeting with 
all of the State commanders and with other people about making 
sure that we are servicing our National Guard, our Reserve, and 
any of the military that are coming back.
    And in that meeting, it was stated that traumatic brain 
injury and post traumatic stress have the same symptoms. It is 
very difficult to try and find out what the cause is for the 
veteran. But it has also been found out that the post traumatic 
stress disorder therapy can be devastating to an individual 
with traumatic brain injury. So if you try to resolve the wrong 
issue not knowing, you could actually be putting the veteran's 
life in danger.
    With the assessment of post traumatic stress disorder in 
relationship to this bill which Congressman Allen has created, 
if you have an analysis from a social worker, it can be 
overturned by a VA psychiatrist and you can lose your claim. 
The Vet Centers that are created by the VA are all staffed by 
social workers. If you go to a VA hospital for healthcare, you 
see a social worker. So the assessment that you have can be 
overturned by the psychiatrist that is now doing your 
competence evaluation.
    So, how can individuals get an assessment that will be 
accepted by the regional office if the psychiatrist has the 
power to negate the assessment that you have gone through over 
months or years? And that's a question that has been brought 
up, and I think that it needs to be looked at. And I understand 
that part of your bill may even address that.
    Mr. Michaud. Well, thank you very much, sir. I really 
appreciate it. And if you want to submit your written remarks 
for the record, we will definitely include them.
    And please give Rosemary Lane our best, our prayers and 
thoughts are with her as well.
    Mr. Bachelder. Thank you very much.
    Mr. Michaud. Mr. Wallace.

                   STATEMENT OF JOHN WALLACE

    Mr. Wallace. Mr. Chairman, Ranking Member Miller, and 
distinguished Members of the Subcommittee, my guests, my name 
is John Wallace. I am a combat veteran who is presently Vietnam 
Veterans of America State Council President. I serve on Maine's 
BigMac and MiniMac since their inception, and that's for more 
than 20 years. I am also on the Network Communications Council. 
I also serve on the Veterans Coordinating Committee, the 
Caribou Veterans Cemetery Committee, the Maine Veterans' Home 
Liaison Committee in Caribou, and I participate in the 
Commanders Call with the Governor and National Guard General.
    Mr. Chairman, the Maine Department of Veterans' Affairs is 
located in Togus, 6 miles east of Augusta. Opened in 1866, 
Togus was the first national home for disabled volunteer 
soldiers. This VA Medical Center provides medical, surgical, 
psychiatry and nursing home care. The VA operates community-
based outpatient clinics in Bangor, Calais, Caribou, Rumford, 
and Saco to provide better access for veterans living in rural 
areas. In 2007, they opened a part-time clinic in Lincoln. 
There is also a Mental Health Clinic located in Portland.
    More than 1,400 active-duty servicemembers and veterans of 
the Global War on Terror have sought VA healthcare in Maine. 
Many veterans from the conflicts of Iraq and Afghanistan have 
visited VA counseling centers in Bangor, Caribou, Lewiston, 
Portland, and Springvale. These community-based Vet Centers are 
an important resource for the veterans who, once home, often 
seek out fellow veterans for help transitioning back to 
civilian life. Over 6 million veterans live in rural areas 
across America, and most fall below the poverty line. They 
travel hours to get to the nearest VA medical facilities.
    At a hearing of the Subcommittee on Health, Mr. Chairman, 
you pointed out that although 20 percent of the Nation's 
populace lives in rural areas, 40 percent of the veterans 
returning from deployment in Afghanistan and Iraq live in rural 
areas. This leads to a significant challenge maintaining core 
healthcare services. The average distance for rural veterans to 
access care is 63 miles according to the National Rural Health 
Association.
    The difficulty in accessing healthcare is a significant 
problem for many Maine veterans. Although Togus is almost 
centrally located in Augusta, the State's geographic expanse 
makes it a problem for many veterans to use the hospital as a 
primary care provider. In 2004, the Government Commission 
expressed concern that only 59 percent of Maine's veterans were 
living within the geographical guidelines for access to care 
which ranged from 60 minutes for urban areas and 120 for very 
rural areas.
    Of Maine's 6 CBOCs, with 2 more planned under CARES, the 
closet CBOC is around 80 miles from its hub, the furthest is 
260. For primary care, this is okay. But for specialty care 
services, veterans have to travel to Togus or Boston. The 
distance a veteran may have to travel is more than 300 miles, 
which is clearly outside the 75-mile radius established by the 
VA. To make matters worse, most rural medical care providers, 
weary of the paperwork and long delays involved in the Federal 
benefits system, often do not accept TRICARE.
    There is evidence that the VA has known for some time about 
the need to focus more on rural care. In 2004, the study of 
750,000 veterans found that those living in rural healthcare 
areas tended to have seriously high--more seriously high health 
costly problems than their urban counterparts. Perhaps the VA 
could reach a lot of veterans who live in rural Maine by 
expanding the use of fee-basis care, in which the VA contracts 
its services out to a third-party provider. Certainly, issues 
involved in providing rural healthcare must be addressed by the 
VA's new Office of Rural Healthcare, which has been slow to get 
started.
    Mr. Chairman, we are in an emergency situation in Maine, 
and VVA is seeking your help in Congress to expedite the 
provision stated in lower P.L. 109-61. Otherwise, our disabled 
veterans, both young and old, would be forced to continue the 
long-distance travel for care and treatment to the nearest VA 
Medical Center, clinic, or hospital.
    We pioneered the first rural, or rural-rural VA clinic as I 
like to call it, in Maine. We started out 1 day a week, and 
quickly went to 7. Excuse me, not 7, 5 days with 3 providers, 
staff, 2 mental health providers currently on, and telemental 
health being given access to. This covers an area bigger than 
the State of Rhode Island and Connecticut put together. We, the 
veterans, had to fight every step of the way for this. In the 
beginning, we were told this would never happen. We proved them 
wrong.
    If you travel into the farm towns of any State in this 
union, you will see lots of veterans who need help and are 
having difficulty finding it. Should we lose veterans who 
protected this Nation so honorably because our government is 
unwilling to look past politics? I think not.
    Women veterans' healthcare issues have come a long way, 
basically, in the last 15 years. There are 2 bills before 
Congress, 1 in the Senate, 1 in the House. The Senate version 
addresses the women veterans program manager issue, the House 
doesn't. At present, under the VA guidelines, they have 20 
hours a week to work on that besides doing what they were 
actually hired for in the other position. This needs to be 
changed to a full-time position so that they can take care of 
our women veterans.
    I will briefly discuss the rest of it. Mental healthcare 
issues with the women veterans. There is a big problem there 
because inpatient care for them, they are basically in with the 
men and it is hard for women to talk about military sexual 
trauma, spousal abuse, et cetera, and feel comfortable. The VA 
needs to get a lot more gender-oriented when it comes to women, 
especially with the mental healthcare problems. When you take 
PTSD and military sexual trauma, they have very few, if any, 
clinicians--can't pronounce it--any qualified medical people 
that handle it that can handle both at the same time because it 
is a concurrent treatment. So, they do have a special problem 
there.
    In the last 15 years, the VA, especially here in Maine, has 
come a hell of a long way with the Women Veterans' Clinic and 
their issues, regular veterans and their issues, but their 
hands are tied and they have been tied because of funding. 
They'd do a lot more with the buck they get, but they need the 
funding to be able to take care of these rural issues. And if 
they do not have sufficient funding there when the government 
year begins, and not 3 to 6 months later when Congress finally 
gets off its duffs and votes for a budget, you won't overcome 
any of these problems.
    In closing, I would like to thank you, and I am open to any 
questions.
    [The prepared statement of Mr. Wallace appears on p. 56.]
    Mr. Michaud. Thank you very much, Mr. Wallace.
    Mr. Wafford.

                 STATEMENT OF JOSEPH E. WAFFORD

    Mr. Wafford. Good morning, Mr. Chairman, Congressman Miller 
and Congressman Allen. The DAV would like to thank you for 
inviting us to today's field hearing of the Subcommittee. DAV 
is a national veterans service organization representing 1.3 
million members and is dedicated to rebuilding the lives of 
disabled veterans and their families.
    The topics before the Subcommittee--women, rural and 
special needs veterans--are of acute interest to DAV both in 
Maine and nationwide. With the adult population of 970,0000, 
Maine is home to 155,000 veterans who constitute 16 percent of 
our adult population, among the highest proportions in the 
State, in any State. In regard, we urge the Subcommittee to 
swiftly consider and approve H.R. 4107, the ``Women Veterans 
Health Care Improvement Act,'' offered by Representative 
Herseth Sandlin and Brown-Waite, 2 Members of your Committee.
    We are seeing a large number of rural veterans, both men 
and women, coming home from these wars with severe injuries and 
illnesses as we see today. Therefore, we are pleased that the 
Subcommittee is turning its attention to these issues, and urge 
you to maintain a strong focus.
    As you know, VA operates a major regional medical center in 
Togus. It opened in 1866, and Togus is the first national home 
for disabled volunteer soldiers. Today, Maine's only VA Medical 
Center plays a major role in the community and State, providing 
medical, surgical, psychiatric and nursing home care. It is 
also a civilian employer, significant in Augusta.
    The VA also operates community-based outpatient centers 
which have been attested to many times today. Mr. Chairman, as 
you know, the VA had planned to open a CBOC in Dover-Foxcroft, 
but those plans were shelved due to an insufficient veteran 
population base to support a full-time clinic.
    The DAV believes that area still needs the VA's attention 
as it is very rural. And we highly recommend that Togus provide 
a satellite van or a portable physician office to serve 
veterans in that area. And once the veterans in the Dover-
Foxcroft area become aware that the VA has established a 
healthcare presence for them, even on a part-time basis, this 
may help justify a full-time clinic at a later date in that 
community. And then that will allow the portability of the van 
to travel to other areas, other rural areas to provide service, 
and leave Dover-Foxcroft as a storefront operation, per se. We 
appreciate the Subcommittee making that recommendation to the 
VA.
    According to VA, in 2006, latest information available, 
inpatient admissions to the VA healthcare facilities in Maine 
totaled 1,696, while outpatient visits reached 325,000. Also, 
17,474 veterans 65-years of age or older that received 
healthcare from the VA in 2006.
    Mr. Chairman, in Maine, more than 1,400 active-duty 
servicemembers and veterans of the Global War on Terrorism have 
sought healthcare here. Many veterans from the conflicts in 
Iraq and Afghanistan have visited our Vet Centers throughout 
the State.
    The State of Maine operates 6 veterans homes, as you have 
heard earlier. One difficulty, however, that concerns us in the 
State homes, they do not provide a rehabilitation or 
convalescence capability. Given to our elderly population that 
needs these State homes, could offer veterans a greater new 
service if they embrace a rehab/convalescence mission in 
partnership with the Togus VA Medical Center. Many veterans 
that are in inpatient care at Togus live in Bangor or Caribou 
and other communities at a great distance.
    In general, the current law limits the VA in contracting 
private healthcare services, entrances providing necessary, the 
VA facilities do not have the capability. And we feel that fee 
services and contracting are a good way to go. But beyond these 
limits, there is no general authority, though, in the law to 
support a VA--a broad VA contracting for an oversight, which 
needs to be addressed.
    We believe the best course for most enrolled veterans in 
healthcare is to provide continuity of care in facilities under 
the direct jurisdiction of the Secretary of Veterans Affairs. 
And aside from these concerns, we know the VA's contract 
workloads have grown significantly.
    The VA must ensure that the distance of travel be addressed 
because it does provide hardships in the face of consideration 
in the VA policy. VA must fully support the right of rural 
veterans to healthcare and insist that funding for additional 
rural care and outreach is appropriated for that purpose. 
Mobile Vet Centers should be established, or at least on a 
pilot basis, to provide outreach and counseling.
    Recognizing that in areas of particularly sparse veteran 
population, the absence of VA facilities, the Office of Rural 
Health should sponsor and establish demonstrated projects with 
available providers of mental health and other health provided 
services to veterans, taking care to observe and protect the 
VA's role as coordinator of care.
    Again, Mr. Chairman, most of this is provided in my legal 
or written testimony, and most of these recommendations are 
clearly applicable to our State. On behalf of The Independent 
Budget, we hope that the Subcommittee will address these 
recommendations in oversight and further legislation, if 
needed, to ensure that they are implemented. Rural veterans, 
whether in the State of Maine or elsewhere, deserve access to 
quality VA healthcare, despite obvious changes and challenges 
we face in providing it.
    Mr. Chairman, this concludes my testimony and I will be 
pleased to consider your questions on these important topics.
    [The prepared statement of Mr. Wafford appears on p. 59.]
    Mr. Michaud. Thank you very much.
    Once again, I would like to thank all 4 of our panelists, 
not only for your testimony here today, but also for your 
service to this great Nation of ours.
    I have a couple of questions I know some of you mentioned 
the CARES process. You wanted the Committee to move forward on 
the Dover-Foxcroft facility. Actually, we did pass a piece of 
legislation that required the VA to submit a business plan for 
the Lewiston/Auburn CBOC, the Houlton facility, as well as the 
Dover-Foxcroft facility within 180 days after the enactment of 
the legislation. The whole facility, I am sure the Togus 
director will probably talk about that, is moving forward. The 
Lewiston/Auburn CBOC, actually that's down in the central 
office in the VA, and they are looking at that as well as--I 
haven't heard anything about the Dover-Foxcroft facility.
    As you know, we have a lot of issues before our Committee. 
The CARES process is part of it, dealing with women's 
healthcare issues, dealing with the Montgomery GI Bill, dealing 
with the traumatic brain injury, post traumatic stress 
disorder, just so many issues that we have to deal with and 
such a short time to deal with them.
    I guess my question would be to each of you, if we had to 
focus on the top priority that is a must for Congress to pass 
this year, what would that top priority be for your different 
organizations?
    We will start over here.
    Mr. Wafford. Under rural healthcare, probably the satellite 
van should be a significant push because that will enable to 
touch more veterans. Similar, the DAV has a mobile service 
office to provide outreach to veterans that don't have the 
access or capability of coming to us, we go to them. And I 
think the VA should probably do the same, sir. Thank you.
    Mr. Michaud. Mr. Wallace.
    Mr. Wallace. The speciality care to the clinics that are 
already in place, specifically orthopedics and dermatology. We, 
the Vietnam veterans, are now the older generation, and those 
seem to be the needs as we get older.
    Mr. Bachelder. Medical staff, because if you don't have the 
medical staff, then you can't have the appointments. And I 
think that is one of the biggest problems we have here in 
Maine, trying to find professionals to come in and take the 
positions so that the appointments can be set.
    Mr. Simoneau. I still believe that it comes down to the 
CBOCs. We need to have the community-based outreach. We need 
those veterans to be able to go locally and get the help they 
need, whether it is in a time of crisis or whether it is in a 
time of just a checkup. But they need to know that locally they 
can turn someplace. And if we cannot fund these CBOCs, then we 
need to find a way to fund it so that these veterans can get 
the help they need urgently at that moment they need help, not 
to be told, well come see me in 3 weeks or 6 months.
    So whether it is a CBOC or whether we loosen up some way of 
funding for local doctors to help these people, we have to do 
this. We have to get the help to the veterans immediately, not 
postpone it.
    Mr. Michaud. As you well know, we have heard a lot about 
rural areas and providing healthcare, and some of your 
organizations support more contracting out. When you look at 
the healthcare shortage we have here in Maine and all across 
the country, there is a healthcare shortage. There are not 
enough providers, whether they are Federal, State or private 
facilities.
    Are there any concerns that your organizations would have 
as far as dealing with non-VA providers treating veterans, or 
is it only under certain circumstances should they contract 
out? I know some of you addressed that earlier, but if we can 
actually have each one of you address that.
    Mr. Wafford. Yes, sir. I do believe fee service is a needed 
item and a plus for the VA. I do believe in cost control, 
monitoring. VISN 1 had a problem at one time, they over-
contracted. So, it can be used and it should be used on a case-
by-case basis, depending upon the individual's needs and the 
availability of the services.
    As you know, Maine has no medical school. We have no 
``ologies'' or ``ologists'' available to us on a rotating basis 
in this State. We have to go out-of-State. And that creates a 
very tough time for the director to get qualified individuals 
to provide healthcare at Togus. So, I do believe the fee-basis 
is a way to go to help alleviate the backlog.
    Mr. Michaud. Mr. Wallace.
    Mr. Wallace. I believe fee-based--whoops. I believe fee-
basis is a way to go, but there have to be some limit put on 
it. There has to be a proven track record. You can't just fee-
basis out to every doctor out there. Most of our clinics are 
near a local rural community hospital. Maybe fee-basis with 
that hospital, at least those doctors will have a proven track 
record.
    But the VA, if we do go that way, would also have to open 
up our medical records to those doctors so that unnecessary 
medical tests don't have to be repeated again, and those 
doctors will have a complete history of the veteran and not 
have to take it again. And also, the biggest problem with fee 
services in the civilian part of it is a lot of the civilian 
doctors don't understand the type of sicknesses we have, 
whether it be mental or physical. So, they have to be educated 
in that, and that is part of the thing the VA would have to do.
    Mr. Michaud. Mr. Bachelder?
    Mr. Bachelder. A couple years back, we had a problem with 
the urology because they had a piece of equipment that needed 
to be calibrated. It was so old that the manufacturer said that 
the equipment shouldn't be calibrated, it should be replaced. 
The cost of sending the veterans out to have that service done 
outside was 4 times as much as it would cost to replace the 
equipment. With the help of Bill Vail, who is here today, his 
name was mentioned earlier through Susan Collins' office, it 
was brought to the attention, the equipment was purchased, and 
we saved some money.
    So fee-for-service is something that we need to help that 
veteran out in the middle of the countryside to get taken care 
of immediately, but we need to not disassemble the VA 
healthcare. We need to not take the funding necessary to make 
sure that the healthcare runs right because everybody is going 
to the local doctor and not being seen through the VA 
healthcare. It is a system that we have throughout the whole 
country. We need to fix it, not disassemble it. But fee-for-
services does have the necessary time period where the veteran 
needs to be cared for.
    Mr. Simoneau. Once again, CBOCs, fee-for-services. I think 
Mr. Bachelder made a very poignant point, and that is if we 
take all the money we use and we spend it on fees for other 
doctors, we are taking away from the VA system and the VA 
hospital that is a vital part of that network. We can't do that 
in order to do the fee-for-service, because we still have needs 
at that hospital that are way beyond anything that local 
doctors would have knowledge to or knowledge of.
    So fees for service for the certain items, absolutely. For 
emergency items, absolutely. But we have to be very careful on 
how we use it, when we use it, and where it goes.
    Mr. Michaud. Thank you. Mr. Miller?
    Mr. Miller. Thank you, Mr. Chairman. I understand not 
wanting to take money away from the VA system, but in a 
particular area such as Maine, it is so expensive to build a 
community-based outpatient clinic, and I am a big proponent of 
those. VA at one time was very central in their thought, they 
wanted everything to go to huge medical centers, and we are 
doing what we can to try to change that process within the VA 
program.
    I think we just have to be very careful as we are looking 
at how to provide these services that we spend what little 
dollars are there as wisely as we possibly can. The dollars are 
there in Washington to do the job. You know, we are spending 
money on things that many of you in here, and both sides have 
done it in the past, where we probably should be spending money 
on them in our Federal role. We have needs right here in our 
own country that need to be done.
    Mr. Wallace, I am particularly interested to talk about the 
rural--rural healthcare. The mental healthcare that is being 
provided, the telemental health, how are veterans taking to 
that? There are a lot of people out there who have kind of 
shied away from that, and they don't want to do these things 
via the telephone, they don't want to do it via the Internet, 
they don't--you know, they feel like they have to be sitting 
right across from somebody.
    How is that being received by the veteran population?
    Mr. Wallace. Well, I've got extensive knowledge on that. A 
little over 4 years ago when they pioneered it up in Caribou, 
the 2 social workers that were handling it retired suddenly. 
So, I volunteered and I took it over for almost 2 years. In 
that 2 years time, 3 veterans didn't like it, the rest did. And 
when the VA upgraded the equipment they had there so you 
actually sit in front of a wider TV screen that's crystal 
clear, you get the impression you are there with the doctor.
    And the fact that they don't have to travel 250-plus miles 
to get there. Basically, the way that I can explain that, the 
veteran was traveling to Togus to see a psychiatrist, all 
uptight and wound up. Spent 20 minutes with the psychiatrist, 
got calmed down. And then got all uptight and wound up to 
travel home 250 miles. It was defeating its purpose. Now the 
longest they travel in Aroostook County is about 60 miles.
    Now, in the beginning when the VA went to the CARES and 
they said 30 miles or 30 minutes, at the VISN level meeting at 
the BigMac, I said that don't apply to Maine. More like 60 
miles, 60 minutes would fall in for us. Our road system doesn't 
go in a straight line. The VA figures things out from Togus, 
say, to Madawaska using the road going up there. But in the 
wintertime, they don't travel Route 11. They take the longer 
way around. Also, they take the longer way around in the spring 
and the fall so they don't lose their life hitting a moose or a 
deer.
    Mr. Miller. If you need help thinning out the moose and 
deer herd, I volunteer.
    Mr. Wallace. Well, there's over 100 of them dead along 95 
now because they are out there eating.
    Mr. Miller. Mr. Wallace, I have also found in my 24 hours 
here that even your straight roads aren't straight.
    I yield to my colleague, Mr. Allen.
    Mr. Michaud. And Mr. Miller and the staff had a great 
opportunity to see what the potholes were like as well.
    Mr. Wallace. Do you really like that Moxie? Because I 
don't.
    [Congressman Miller held up and crushed the empty Moxie 
can.]
    Mr. Bachelder. Mr. Chairman, the one thing that I wanted to 
also comment on was that the travel pay, when I went up to 
Togus a week ago, the deductible was increased also. I 
appreciate your looking into it.
    Mr. Michaud. Yes, and that's one thing. I know the 
Secretary told the Committee that it is waived, and Mr. Miller 
had mentioned that there was a letter or a memo saying that the 
Secretary misspoke. Actually, we haven't seen that memo, so we 
will definitely want to look at that memo. That was not the 
intent.
    Mr. Wafford. Yes, sir. It is waived on a case-by-case basis 
is what came down from the national headquarters, sir.
    Mr. Michaud. Mr. Allen?
    Mr. Allen. Thank you, Mr. Chairman. I have just one 
question for all of you.
    What do you hear about traumatic brain injury or PTSD from 
the members of your organizations? I mean, can you just give us 
a flavor of problems you may see, just a fairly concise 
statement about what it is you are hearing these days about 
those 2 kinds of injuries.
    Mr. Wafford. Yes, sir.
    Mr. Allen. You know, what we need to do about them.
    Mr. Wafford. The DAV, we have done--we have partnered with 
a lot of other organizations on these issues. We also feel that 
they are so intertwined at times, they cannot be separated. And 
with the rating system designed like it is, it is a 10 percent 
rating under Diagnostic Code 8517. So, that limits the amount 
that a veteran may be rated unless it is rated under the 
residuals of a traumatic brain injury.
    We need to look at the rating schedule. We need to--we need 
to separate it out. I understand about pyramiding where you 
cannot rate a condition on top of a condition if it is in the 
same area. But TBI is definitely intertwined with this, and we 
need to re-look at the rating schedule on that.
    I just had a young man call me from Walter Reed last week. 
He came home to Sabattus on Tuesday. He has been in Walter Reed 
for the last 10 months. He is waiting on his Medical Evaluation 
Board (MEB) to be finalized. So this young man's coming home 
for the help under the Wounded Warrior program. He will be 
getting some treatment at Brunswick Naval Air Station, but they 
are very limited. So he will have a problem with this traumatic 
brain injury getting services through Togus because he is not 
discharged.
    Mr. Allen. I think he is the young man I saw at Walter 
Reed.
    Mr. Wafford. It may have been, sir, because he did say he 
was in touch with our Congressional, and I advised him to come 
and see me this week.
    But he is a very good case to base the TBI on where he has 
had treatment and we are trying to get him converted over. He 
hasn't been totally discharged yet. We need to do the 
continuity of care. But when the VA gets to rate this young 
man's case, you know, he deserves more than 10 percent under 
that diagnostic code. And so, yeah, we do. And they look under 
that diagnostic code, PTSD is one of the things that are listed 
in there. We need to break it down, we need to upgrade 38 
C.F.R. Sec. 4.71. Thank you.
    Mr. Allen. Mr. Wallace?
    Mr. Wallace. At the last BigMac meeting in Bedford, Mass., 
they gave us a thing on traumatic brain injury and what the VA 
is doing now. They asked them I believe it was 3 or 4 
questions, and if they can answer yes to those 3 or 4 
questions, they are then treated for traumatic brain injury 
instead of PTSD. The biggest thing I remember when they said 
that, I asked them--I said, then what are you doing about those 
Vietnam veterans because I can answer yes to all those 
questions. Does that mean I have been misdiagnosed all these 
years? They've got a long way to go.
    Mr. Allen. Jim?
    Mr. Bachelder. The VFW, along with all these other 
organizations, if you read their magazines, they are very 
concerned about traumatic brain injury. The post traumatic 
stress disorder is life-threatening to the individual if 
suicide is an active symptom. Traumatic brain injury is life-
threatening just in itself because if it is not diagnosed, the 
brain can have problems, swelling. It could be caused from 
other things, of actual bone material that has broken from 
these bombs that we have that is causing it.
    So, it is a major concern that the Department of Defense 
has not built a clinic, is not examining these individuals to 
find out that they have a medical problem, they are not being 
diagnosed, it can end their life. And we need the Department of 
Defense to take responsibility to make sure that these 
individuals that have been through these roadside bombs, that--
and it could be from not just that, it can be just from being 
in an explosion from a grenade or a missile that came by you 
that could cause a brain injury that will end your life when 
you come back home. And where is the responsibility for the 
military to care for these individuals before they are being 
released?
    Mr. Simoneau. Traumatic brain injury is something new. It 
is something that we have dealt with for years, but we haven't 
seen in the proportions that we are today. Traumatic brain 
injury/PTSD are 2 separate items, but they are linked. We need 
to make sure that the VA and the Department of Defense take a 
very close look at this because this traumatic brain injury is 
something that is just hiding behind that person, and we never 
know where that is going to be. We need to step forward. We 
need to make sure that these young men and these young ladies 
that are dealing with this are taken very good care of.
    It is hard to admit, anybody, that they need help. It is 
hard for any of those soldiers to say I have had some things 
happen to me. But if you look at the past record, whether it is 
a Vietnam veteran or whether it is a World War II veteran, or 
anybody else, when they come home they want to go on with life. 
They don't want to say, I've got a problem. We have to reach 
out. We have to make guidelines that they fit and guidelines 
that work for it, and I believe that's a way to start. Thank 
you.
    Mr. Allen. Thank you. I yield back, Mr. Chairman.
    Mr. Michaud. Thank you. Once again, I would like to thank 
all 4 of you for your testimony this morning and thank you for 
your service to this great Nation of ours. Thank you.
    Our last panel is Brian Stiller, who is the Center Director 
for Togus Medical Center, the Department of Veterans Affairs. I 
want to thank you, Mr. Stiller, for coming here this morning. I 
look forward to your testimony. I know you have only been at 
the VA for a year or a little less, so welcome to Maine.

STATEMENT OF BRIAN G. STILLER, CENTER DIRECTOR, TOGUS VETERANS 
 AFFAIRS MEDICAL CENTER, VETERANS HEALTH ADMINISTRATION, U.S. 
                 DEPARTMENT OF VETERANS AFFAIRS

    Mr. Stiller. Thank you, Mr. Chairman, and Members of the 
Subcommittee. Can you hear me? Is this on? There we go. Thank 
you very much.
    On behalf of the employees and the volunteers at the Togus 
VA Medical Center and its outlying clinics, I thank you for the 
opportunity to discuss the care and services we provide Maine 
veterans. I will focus my remarks today on our ongoing efforts 
to improve access to care in a largely rural setting with an 
emphasis on meeting mental health and women veteran healthcare 
needs.
    It is important to recognize that since 1999, we have grown 
from 19,000 veterans to 52,000 enrollees, with 38,000 of those 
enrollees accessing our VA healthcare system. Today, those 
veterans receive their care at Togus and 6 community-based 
outpatient clinics. These clinics are located in Bangor, 
Caribou, Lincoln, Calais, Rumford, Saco, and a part-time access 
point in Fort Kent. The new Bangor clinic plans include 
physical therapy, dental, optometry, radiology, part-time 
limited specialty services, as well as compensation and pension 
rating exams.
    In addition to the Medical Center and its outlying clinics, 
we further provide care in rural and residential settings using 
home-based primary care. We have home-based primary care teams 
operating out of Togus in Portland. The home-based primary care 
teams provide primary care, nursing, social work services to 
the veterans with complex chronic diseases who are seeking to 
maintain an independent living situation. New home-based 
primary care teams are authorized for Caribou and Lincoln, and 
recruitment for these new positions is ongoing.
    Togus leadership is working on the newest approaches to 
improving access as exemplified by the establishment of the VA 
Office of Rural Healthcare. We are working with the Office of 
Rural Healthcare to identify and address the needs and 
challenges of providing healthcare in rural areas. The Office 
of Rural Healthcare is leveraging rural health expertise from 
public and private sectors and is working on several rural 
health initiatives.
    While recognizing our efforts to expand rural healthcare 
access, we also need to further improve and expand access to 
qualified healthcare professionals. Working with community 
educators and healthcare providers, Togus is recommitted to 
enhancing existing affiliations with State and national medical 
educational facilities, as well as establishing new 
affiliations. In October of 2008, we plan to host a ``Medical 
Education and Research'' symposium for medical education, 
healthcare and research organizations.
    At Togus, we are using technology to improve access for 
rural veterans as well. We are currently providing 150 veterans 
with adjunct care via home telehealth. Staff use these devices 
to review medication, assess wounds, complete psychosocial 
assessments, and conduct follow-up reviews for medication 
changes. These devices provide timely, accurate data to provide 
healthcare while minimizing veteran travel.
    Togus continues to be a leader in healthcare by identifying 
and employing new technologies. Maine recently received a $25 
million dollar Federal grant to develop telemedicine services 
throughout New England. Togus is coordinating with other Maine 
healthcare organizations to determine how best to further 
deploy and utilize this healthcare technology.
    I would like to proudly share with you some of our 
accomplishments and successes in mental healthcare. Through the 
VA Mental Health Initiative process, during the period of 
fiscal year 2004 to fiscal year 2007, our mental health staff 
grew from 54 to 74, an increase of 39 percent. With additional 
staffing, we are able to provide better access to veterans and 
develop new programs in the areas of treatment.
    Care for veterans in rural Maine improved with all our 
northern CBOCs having telepsychiatry connectivity and many 
having in-home videophone connections. All Maine CBOCs have an 
on-site specialized mental health provider, and mental health 
clinics are located in Bangor and Portland. We strive to 
provide intensive specialized mental healthcare and residential 
support for veterans in rural areas, particularly homeless 
veterans, those in extended PTSD treatment, and those with 
substance abuse problems.
    To better serve OIF/OEF combat veterans, Togus reorganized 
its PTSD program into a 1-week intensive outpatient program. 
This program utilizes a new evidence-based treatment that 
focuses on the needs of new veterans who have careers, 
families, and cannot attend a longer program. It provides a 
basis for follow-up care as necessary. This program is well-
received with very favorable feedback. Moreover, 2 programs 
have already been conducted solely for women veterans to 
appropriately support their needs.
    Women comprise about 14 percent of the active duty, Guard 
and Reserve forces with approximately 1,700 Maine women 
veterans receiving VA healthcare. Togus' women's clinic 
provides primary care, gynecology, and mental health services. 
Maternity care is provided via fee-basis by a community 
provider of the veteran's choice. Mammography is provided via 
fee-basis at any FDA approved site.
    The VA has 2 performance measures which are specific to 
women's healthcare: Breast cancer screening and cervical cancer 
screening. In both of these measures, Togus exceeded the 
national benchmark. Veterans are surveyed with a clinical 
reminder regarding military sexual trauma and treatment 
services are available through Togus, CBOCs, Vet Centers and 
fee-basis as appropriate.
    We have plans to purchase additional equipment to expand 
care for women veterans this year. VISN 1 is evaluating women's 
healthcare educational and equipment needs at CBOCs with the 
goal of providing increased access to routine gender-specific 
healthcare. Togus has a dedicated women veterans program 
manager. And to enhance their outreach efforts, Togus hosts an 
annual Women Veterans Information Fair and hosts Women Veterans 
of America meetings.
    Mr. Chairman, as you know, I am relatively new to Maine. 
But as I have shared before, I remain impressed with the work 
being accomplished by the veterans organizations, the Maine 
National Guard, and other State programs. I look forward to 
continuing our work with them to better serve Maine.
    Mr. Chairman, we must continue to closely monitor and meet 
the needs of Maine veterans. Our veterans have earned the right 
to the best care available, and it is our privilege to provide 
them with that care. We appreciate your interest and support in 
helping VA to successfully accomplish our mission of providing 
world-class care to all of those who have so honorably served 
our great country.
    Thank you.
    [The prepared statement of Mr. Stiller appears on p. 62.]
    Mr. Michaud. Thank you very much, Mr. Stiller, for your 
testimony.
    We appreciate all the work that you are doing and have done 
for our veterans both at your previous job and here at Togus.
    I know Mr. Miller has a flight that he has to catch, so I 
will recognize him first for questions.
    Mr. Miller. Thank you, Mr. Chairman. I actually have a 
quick stop at Portsmouth first, the Naval Shipyard, and then on 
to the airport. So, if I do step out, it is not because I 
didn't want to stay through the entire hearing. I thank you for 
the invitation.
    Mr. Wafford, from DAV, expressed concern about the CBOC not 
being constructed in Dover-Foxcroft. What are you doing in 
regards to access to healthcare for people in that general 
vicinity now?
    Mr. Stiller. Currently, Mr. Congressman, we have put forth 
a series of plans which would include Farmington as well as a 
number of other areas, as well as Lewiston-Auburn (LA), and 
that gets into the circumference area.
    And one of the other things that we are looking at is we 
have recently applied for a grant, and we are waiting to know 
if we have been approved, to go to a mobile clinic. What we 
want to do, as we have had success in the past with mobile 
clinics, is use the storefront approach coupled with that 
mobile clinic to address the needs of the veterans in that 
area.
    Mr. Miller. I know one of the biggest needs in rural 
healthcare is recruiting physicians and healthcare 
professionals into the area. Do you find the same problems 
here? What are you doing or what is the VA doing, I guess, to 
help overcome these obstacles?
    Mr. Stiller. Well, I think larger--I can't speak to VA 
other than from my experience in VA, and that obviously the 
recent pay changes, Physician Pay Acts have helped 
significantly.
    What we have done locally is we have actually employed a 
Title 38, if you will, headhunter recruiters I call them. And 
we also have 2 contracts now since my arrival that address the 
challenges of recruiting the specialty care providers.
    I think it is incumbent on us in the State of Maine, as far 
as the Veterans Healthcare System, to educate the future 
students. So, affiliations is going to be a huge piece of this. 
I have been quoted as saying, ``We want our medical center and 
CBOCs crawling with students.'' Obviously, it is part of our 
mission, and I think we have great opportunities to bring those 
future healthcare providers in and entice them into the 
practice of rural healthcare.
    Mr. Miller. I think you said, you talked about having 
students all over the campuses. One thing that the statistics 
do show is when medical students come to an area to do their 
residency and do some of their original practice work, they 
stay there.
    Mr. Stiller. Yes.
    Mr. Miller. That is something that I know Maine will want 
to look forward to as well.
    You've got an opportunity to take a shot at any one of us 
up here. Is there anything that Congress can do? I mean, 
obviously everybody is saying give more money, appropriate more 
money, but from the standpoint of outreach, what else can we do 
to help you reach out to the veteran population?
    Mr. Stiller. Sir, I think that is an awesome question 
because right now our big stress, at least in the State of 
Maine, is we have a great relationship with the National Guard 
and getting to these young men and women who are coming home. 
We are there when they muster out and when they return from 
deployment.
    Where we run into difficulties is with the Reservists. The 
young men and women who come home with the Reserve, we do not 
have one central contact that we can go to to find out when 
these units return to their drilling areas. So, if we had one 
central contact for the State of Maine, and it may be the same 
in other parts of the country, that would be extremely 
beneficial.
    Mr. Miller. Thank you.
    Mr. Michaud. Mr. Stiller, just to follow-up on that.
    Mr. Stiller. Yes, sir.
    Mr. Michaud. We heard a lot this morning about the CARES 
process and how that would actually help with a lot of the 
problems that we have been hearing about veterans getting 
access to the care that they need, and you mentioned Dover-
Foxcroft, Bangor.
    Where does Togus, the remaining clinic that was recommended 
in the CARES process, how far along are you with moving that 
process forward?
    Mr. Stiller. Right now, sir, as you know, we have submitted 
the LA, and it is in headquarters, and I believe it is going 
across the street to the Office of Management and Budget, as I 
understand. We are in the process, the first step of seeking a 
contractor for the Bangor replacement clinic. As I said, we are 
in a 2-step process for, first, applying for the grant, if you 
will, for the mobile clinic. But then the storefront for Dover-
Foxcroft will be separate. The other ones are still in the 
planning stage and have not been submitted up the ladder, if 
you will.
    Mr. Michaud. You have heard earlier as well, it is very 
important for the different VISNs to move forward projects that 
they need, and ultimately it is up to Congress to provide the 
adequate funding.
    How do you go about the process of moving up to the VISN 
level? Will you be able to get everything you need here for 
Maine to take care of our veterans, or is there push-back from 
the VISN 1 level?
    Mr. Stiller. No, sir. Actually, VISN 1 has been extremely 
helpful in helping us complete the financing, complete the 
business plans because of the technical acumen that is needed 
to complete these plans. So, they have been very successful and 
there has been no dropping off, if you will, and repeating 
them.
    Mr. Michaud. Is the VA/Togus looking at expanding specialty 
services and inpatient services at Togus to a full tertiary 
care facility for our veterans?
    Mr. Stiller. I know that we have opportunities to continue 
to expand specialty care within Togus. I think what we have to 
balance is the number of surgeries. I am not a medical 
professional, but in my training there is a certain amount, a 
certain number you want to hit for proficiency. We are trying 
to take care of all of the key ones such as urology, neurology, 
and then the more specialized services are better accomplished 
in Boston or Maine Medical or wherever we can purchase it.
    Mr. Michaud. Would you provide to the Subcommittee how many 
veterans you are moving to or shipping to Boston for services 
at a later date?
    Mr. Stiller. Yeah, I can get you the exact number, sir. I 
don't have that on the top of my head.
    Mr. Michaud. And what type of services that they are going 
to Boston for.
    Mr. Stiller. If I could, I would like to get you the exact 
pieces of that. I don't have that with me.
    Mr. Michaud. No problem.

    [The information from VA follows:]

           Question: How many patients are being sent to Boston VAMC 
        and Massachusetts General from Togus VAMC? (VHA)
           Response: In FY 2007, 37,796 patients received healthcare 
        services at the Togus VAMC. During this same time period, Togus 
        VAMC sent 1,096 patients to the Boston VAMC. Togus VAMC does 
        not refer patients to Massachusetts General Hospital.
           Question: What types of services are being provided via fee 
        basis at these hospitals (Boston VAMC and Massachusetts 
        General)?
           Response: Togus VAMC fee bases out gastroenterology, 
        urology, cardiology and audiology to Maine Medical and Eastern 
        Maine Medical Center. Patients are also referred to Boston VAMC 
        as clinically appropriate. Togus does not fee out or refer 
        patients to Massachusetts General.

    Mr. Michaud. And my last question is, can you tell me what 
the hardest female medical service is for your agency to 
provide rural healthcare needs for our female veterans?
    Mr. Stiller. I think that it would be the specialized care, 
and not any different than the private industry and that 
gender-specific specialized care. I have Dr. Hayes in the 
audience. She may be better able to speak to the specifics. The 
specifics, well, for the gender-specifics as you get further 
into rural America, it does get difficult.
    Mr. Michaud. One more issue, actually. We just established 
the Office of Rural Health. How closely have you been able to 
work with the Office of Rural Health, and have they been 
responsive? Should we look at additional help in that office in 
your opinion?
    Mr. Stiller. They have been really responsive. Sir, just 
anecdotally off to the side, after we had talked about--after 
you had visited the Medical Center and we had talked about the 
importance of reaching rural veterans, I had the luck of going 
to a training class and meeting Kara Hawthorne, the new 
director, and approached her. At the same time, your letter hit 
her office. So, we have begun a good dialog and we continue 
to--in fact, we are going to meet today to talk about some 
interesting things that we are going to try to accomplish.
    Mr. Michaud. Mr. Stiller, thank you very much. Mr. Allen?
    Mr. Allen. Thank you, Mr. Chairman. Thank you, Mr. Stiller, 
for the good work you are doing, and I was very impressed when 
I was last up there.
    How many counselors do you have doing military sexual 
trauma issues?
    Mr. Stiller. We have one major military sexual trauma 
coordinator who then, as I understand it, we provide the 
specialized training to the primary care physicians and the 
mental health providers to cover it. And so, like, in the CBOCs 
to be in the position to provide the services that the veterans 
would need.
    Mr. Allen. And is it one person?
    Mr. Stiller. One person initially coordinates it, and then 
there is a training template and there is an intensive training 
program.
    Mr. Allen. And she does the training of the physicians who 
provide the care?
    Mr. Stiller. As I understand it, sir, yes.
    Mr. Allen. Okay, thank you. Lots of people sat at that 
table today and testified. Was there anything that you heard 
that you need or want to respond to to shed more light on, or 
was there anything that struck you in terms of the testimony 
that you wanted to comment on?
    Mr. Stiller. I was pleased by the testimony. The one thing 
I am curious to continue to work on is that's the access. 
Access is critical. But the challenges we face in rural 
healthcare is availability, the specialty doctors. And I think 
the best way for us to address that is through bringing more 
education programs and affiliations into the VA Medical Center 
at Togus, and we will see significant improvement in the areas 
of access.
    But compared to where we were 3 years ago, which was some 
of the time lines, I am not quite sure that they would find 
that same experience. We do have some areas where we certainly 
will improve. But overall, it has been looking pretty promising 
in my opinion.
    Mr. Allen. Well, all I want to say on that conclusion is, I 
remember what it was like when I was first elected, and let's 
just say relations between Togus and the VSOs were stormy. And 
I understand that the funding was inadequate and we were being 
squeezed, both at the Federal level and by the VISN. And a lot 
has changed.
    Mr. Stiller. Thank you, sir.
    Mr. Allen. Thank you very much for your testimony, and I 
would like to thank everyone else as well.
    Mr. Stiller. Thank you, sir, for your support.
    Mr. Michaud. Once again, Mr. Stiller, I want to thank you 
for your service to the country, but also thank you very much 
for what you are doing at Togus. I know you have only been 
there a short while, but from what I have seen so far, you are 
definitely a go-getter. You think outside the box. And as I 
told the Secretary at the beginning, your performance has been 
great.
    As you heard testimony as well from the VSOs here this 
morning, there is still work that has to be done with access 
issues. Part of it you can do. I think part of it has to be on 
Congress to make sure that we do provide the adequate funding 
for VA healthcare, but also make sure that it is in a timely 
manner. That is our job, and we will do the best job that we 
can. We will continue to work with you and your staff, and we 
want to thank your staff as well for all the hard work that 
they do.
    Once again, I want to thank Congressman Miller for his time 
and willingness to have a Congressional hearing here in Maine. 
I hope that you enjoyed your Moxie. We have some more available 
for you for your flight back to Florida.
    I also want to thank Congressman Allen for his time and 
effort to come out this morning, and especially for the 
audience. We look very much forward to working with each and 
every one of you, especially the Office of Rural Health in 
dealing with issues for access. I want to thank Kara for your 
time coming up here as well. Hopefully you heard a lot from our 
veterans here today, and look forward to working with you and 
Mr. Stiller to make sure that every veteran has the opportunity 
to access good, quality healthcare when they need that 
healthcare.
    So, once again, thank you everyone. This hearing is 
adjourned.
    [Whereupon, at 12:27 p.m., the Subcommittee was adjourned.]

 
                            A P P E N D I X

                              ----------                              

             Prepared Statement of Hon. Michael H. Michaud,
                    Chairman, Subcommittee on Health
    The Subcommittee on Health will come to order. I would like to 
thank everyone for coming today.
    Today, we will examine the Department of Veterans Affairs programs 
regarding rural veterans, women veterans, and other special needs 
populations.
    I am very happy to be here in Sanford, Maine, this morning. Sanford 
is the home of longtime veteran advocate, and someone who I was honored 
to call a friend, Roger Landry. Roger worked in the legislature and in 
the VSO community here in Maine and was very well liked and respected 
by all. Roger served his country and his community with great pride and 
honor. Roger died last year and he is sorely missed. I would like to 
dedicate this hearing to Roger Landry in honor of his work with and for 
veterans.
    It is appropriate that we are having this hearing in my home State 
of Maine this morning. Maine is a very rural State and because of this 
we face many unique challenges in providing health care to our 
veterans. Many have to travel long distances for care, creating a 
significant burden for veterans and their families.
    The VA has instituted some innovative programs to provide much 
needed services to rural veterans. I look forward to hearing from our 
panel today about their ideas to improve access and decrease the travel 
burden for our veterans living in rural communities across the United 
States.
    At this hearing, we will also hear about women veterans. Women make 
up about 14 percent of active duty military, and consequently they are 
making up more and more of our veteran population. Women have some 
unique health needs. I look forward to hearing today about the unique 
needs of women veterans and to hear ideas about how the VA can improve 
their services targeted at women.
    When the United States made a commitment to care for veterans, we 
made the commitment to care for all veterans--male and female, urban 
and rural. Today, I hope that we will learn how VA is meeting the needs 
of these populations, what challenges are on the horizon and what we 
can do to provide these veterans with the best possible care available.

                                 
       Prepared Statement of Dana Doliber, Sanford, ME (Veteran)
    In 1971 in an attempt to address increasingly debilitating mental 
health circumstances I sought assistance from the VA at Togus VA 
Hospital. While there I filed a claim for what was termed then as a 
``nervous condition''. Associated with the ``nervous condition'' was a 
record of poly substance drug abuse. The emphasis that the VA chose to 
take was to emphasize the poly substance drug abuse as the cause of the 
``nervous condition'' which they were incorrect as the poly substance 
drug abuse was an attempt at self-medication on my part to try to deal 
with my so called ``nervous condition'' as it was called as there was 
no terminology of PTSD at the time and interestingly enough while at 
Togus VA the emphasis on treatment besides group and individual 
psychiatric therapy was drug therapy with Thorazine, Elavil and a host 
of other mood altering drugs. My claim was denied. In 1985 after losing 
my first marriage and coming close to losing my second marriage, at the 
pleading of my second and present wife, many jobs and the loss of many, 
if not all friends and abject social isolation, recently being laid-off 
from my job and trying to work at the Navy Yard at Kittery, Maine, in 
the apprentice program, my depression reached an unbearable point where 
on the urgent request of my wife I sought help from a counseling 
service in Sanford and began seeing Mr. Robert Paige, LCSW.
    I was diagnosed with PTSD at that time and upon seeing Dr. John 
Scammon, Psychiatrist at the counseling service, who concurred with Mr. 
Paige's diagnosis. Upon seeking assistance from the State of Maine 
Veterans Service Representative, Mr. Campbell Colton, a claim was filed 
with the VA at Togus VA Regional Center. Subsequent claims for medical 
conditions, all service connected, were filed in later years. From 1985 
to 1992 claim after claim was denied. I provided documentation, ships' 
logs from my ship, USS Richard S. Edwards (DD950), USS Newport News 
(cruiser), USS Saint Paul (cruiser), USS Collette (destroyer) that not 
only detailed firing on coastal defenses, gunfire support missions, 
harassment and interdiction fire but of receiving fire from various 
units of the enemy both from Vietnam but also islands off of the coast 
of Vietnam and north of the DMZ. Letters from shipmates (buddy letters) 
were also provided that corroborated my previous testimony. Photographs 
were provided showing wounded being high-lined to hospital ships such 
as Repose and Sanctuary. Because the ships log was incomplete and 
inaccurate the VA used that as a basis for denying my claim. I had to 
further provide a stressor was the VA primary qualifier.
    It reached a point that I felt that unless I had the serial number 
of the round going past that I would never win. There was even one 
occasion in the process that the VA paperwork reflected that I was in 
the Army in 1971 with a previous record of being in trouble with the 
law and trouble in school while being born on July 3, 1952. The 
opposite was the true story, I was born in July 3, 1947, was in the 
Navy and had no problems with the law or school. This was all in one 
document. Even though my brother had no claim filed with the VA, the VA 
had my brother and I mixed up. This dual portrayal was not designed to 
help my claim but to cast doubt on the validity of what the evidence 
was. On one occasion I had an interview with a Psychiatrist because the 
VA failed to provide him with stressor documentation I had already 
provided made an other than PTSD diagnosis but after the documentation 
was provided a panel of Psychiatrists, a diagnosis of PTSD was reached.
    From 1992 to the year 2000 the claim was pursued for increased 
rating and retroactivity. The decision for that was reached in December 
2000. This was agreed upon as a result of my agreeing to not pursue my 
claim of CUE (clear and unmistakable error) that were a result of the 
VA Togus previous rulings being thoroughly vacated by the BVA in 
Washington and the Federal Appeals Court for the VA. During this claim 
process and evidence gathering process I requested assistance from the 
VA in acquiring evidence. It is my understanding that if the veteran 
request side from the VA in seeking records the VA is supposed to help. 
This assistance was not forthcoming. As I understand it the VA also 
gives the veteran the ``benefit of the doubt'' and that if the VA 
cannot provide a preponderance of evidence to counter the veteran's 
claim then they must rule in the veteran's favor. This didn't happen. 
Only when I found out from a shipmate that we had been awarded the 
Combat Action Ribbon did the VA relent. From that point on it was a 
matter of my filing claim after claim for percentage increases and 
retroactivity. During that time I felt it was necessary to retain 
counsel but in 1998 due to changes provided by legislation provided by 
Congress the VA regs created a situation where I had to give up counsel 
and after a time I asked the AMVETS for their assistance.
    It needs to be noted that during the time between 1985-2000 in 
pursuing my claim I received help from Senators Cohen and Mitchell and 
Representative Tom Allen, Mr. Robert Paige LCSW (counselor) and 
contacted to provide information Judge Greene, United States Court of 
Veterans Appeals, Attorney General of the United States Janet Reno, 
Richard B. Standefer, Vice Chairman Dept. of Veterans Affairs Board of 
Veterans Affairs and sought confirmation of ships' activity from the 
Republic of Vietnam office at the UN. When I was finally awarded the 
100 percent P&T for chronic and severe PTSD I lost the percentages that 
I had for medical disabilities previously awarded and the disability 
for hearing loss was removed from my medical record I just recently 
learned after seeking again treatment for sores and skin rashes that I 
associate with Agent Orange exposure that I filed a claim for in 1991.
    The VA acknowledges Chloracne and Acne form disease as indications 
of Agent Orange exposure but blue water Navy isn't acknowledged by the 
VA as being exposed to chemical agents while offshore. I would have 
thought that the VA could make the leap from ``sores and skin rashes'' 
to Chloracne and Acne form disease. Apparently they can't. In their 
most recent action in that regard titled: VA Adjudication Procedures 
Manual, M21-1; Rescission of Manual M21-1 Provisions Related To 
Exposure to Herbicides Based on Receipt of the Vietnam Service Medal an 
interesting item the VA uses to discount blue water NAVY from being 
exposed is that because chemical agents used as herbicides when heated 
as on board ship to desalinate seawater for drinking, cooking, showers 
becomes concentrated much more than when diluted in seawater. The VA 
position is that it doesn't know if ships used desalinators while at 
sea to convert sea water to fresh. This borders on ludicrous. There are 
ships systems that require fresh water, people require freshwater. The 
ship I was on operated in I Corps and north of the DMZ. I was there in 
1967-'68. I Corp was one of the heaviest sprayed areas in Vietnam. The 
years of the heaviest spraying for I Corps is 1966-'69. My ship was 
anchored in DaNang harbor and on one occasion went up river that is 
mentioned in the ship's log. The conclusion I would draw from this is 
that we were subject to exposure to chemical herbicide agents.
    The VA has several areas it could improve: 1) Claim processing with 
and for the veteran; 2) Abiding by the law as passed by the Congress, 
is: the HAAS case be Proactive FOR Veterans; 3) Medical: There are 100 
percent Disabled veterans that doctors have asked for tools from the VA 
Togus to help with medical conditions that are being withheld. Veterans 
that should receive the gold standard in medical care whether having 
heart surgery or colon cancer surgery or treatment for peripheral 
neuropathy, traumatic brain injury whether in West Roxbury, Togus VA 
Hospital or whereever. Be more proactive in the VA medical care of its 
veterans with regard to budget requirements. Provide counseling, in-
house--to veterans just after surgery for rehab services. My own 
brother recently had colon cancer surgery and was sent home 5 days 
later instead of going to a rehab facility. While at home the following 
day with coughing and sneezing and throwing up, all his stitches broke 
and his guts came out. After being taken to a hospital after being 
stabilized he was operated on again twice. Once to debride and remove 
the guts to clean and put them back and a couple of days later to close 
the wound leaving a space for the wound to heal from the inside out. He 
is scared to death of going back to Togus VA but tomorrow morning the 
18 of April he is going. He was told that if he didn't go to the VA 
hospital the VA would not pay for his hospital care. He also is 100 
percent disabled.
    It is my hope that by providing this testimony that it in some way 
it helps. Either the VA can provide some relief to its veterans or the 
ironclad legislation necessary to compel the VA to do what is necessary 
for veterans should be forthcoming. The VA history regarding Agent 
Orange and the HAAS case is yet another example of the VA shirking 
their responsibility to the veteran. Add to this the attempt of the VA, 
at present time, to reinterpret the DSM IV protocol for PTSD to the 
benefit of the VA and not the veteran demonstrates a level of hubris 
that is amazing. The 900 lb. gorilla in the room that may prevent any 
good coming from this is money or rather, the lack of it. America's 
veterans providing the freedoms that we have deserve no less than the 
full support of the VA. The American people understand the need to 
support our veteran population. Servicemen and women understand and 
expect that if they need help when they come home the help will be 
there. We should not disappoint them by a lack of action. The one thing 
I ask from this Committee at this time is their assurance there will be 
no retribution against me or my family by the VA regarding my 
testimony. I submit as well a copy of suggested legislation designed to 
address Agent Orange legislation for blue water Navy.
    Thank You.

                                 
            Prepared Statement of Peter W. Ogden, Director,
       Bureau of Veterans' Services, State of Maine, Augusta, ME,
                 and Secretary, National Association of
                   State Directors of Veterans Affars
    Chairman Michaud, Congressman Miller, Congressman Allen and 
distinguished members of the committee, thank you for this opportunity 
to speak today on three extremely important issues for Maine's 
veterans; access to healthcare, women veterans, and outreach to 
veterans on their benefits. My testimony today comes from three 
prospectives: as the Director of the Bureau of Maine Veterans' 
Services, the Secretary of the National Association of State Directors 
of Veterans Affairs (NASDVA), and as a disabled combat veteran who uses 
the VA healthcare system in Maine.
    We greatly appreciate the leadership of Chairmen Akaka and Filner, 
Ranking Members Craig and Buyer and the entire membership of the Senate 
and House Veterans' Affairs Committees for their past and continued 
support of our veterans and the VA. Because of the War on Terror, we 
are now serving a new generation of veterans while we are struggling to 
bring our elderly WW II and Korean war veterans into the VA system. The 
new veterans are going to need our help as they return to civilian life 
while our elderly veterans need primary and long-term healthcare. We 
believe there will be an increased demand for certain benefits and 
services and the overall level of healthcare funding must meet that 
demand while continuing to serve those veterans already under VA care.
    Maine is a unique State in several ways: In 2000 Maine had the 
largest per capita veteran population in the Nation and is still at 
number two or three; the Togus Medical Center is the oldest VA hospital 
in the Nation; and Maine's aging veteran population is geographically 
dispersed across a large land area. We have a saying in Maine, ``ya 
can't get there from here,'' while you can get to the one VA Medical 
Center at Togus from about anywhere in Maine it can take you five to 
six hours to travel up to 260 miles to reach Togus.
    Maine presently has the distinction of being the oldest State in 
the Nation with a median age of 40.6 years old. \1\ When you look at 
the age of Maine's veterans you will find that 65 percent or 93,780 
veterans are aged 55 and older. \2\ These are the veterans that are 
most likely to need and use the VA healthcare system. Access for 
Maine's aging veterans is of extreme importance.
---------------------------------------------------------------------------
    \1\ Churchill, Chris. Maine: The gray State, Maine now has highest 
median age in the U.S., Kennebec Journal, March 11, 2005. Page A-1.
    \2\ Numbers were taken from the Veterans Administration's 
Demographics Program VetPop2007 for the year ending September 2007.
---------------------------------------------------------------------------
    Any conversation about aging veterans and access to healthcare 
should include the importance of the State Veterans Homes program and 
the services they provide to our veterans in long-term, residential, 
skilled, dementia and respite care. Maine is fortunate that we have the 
Maine Veterans Homes with their six facilities spread across the State 
that provide the best care at the most reasonable cost. While Maine has 
the maximum number of beds available by VA demographics standards, many 
other States do not and Congress should continue to fund the State 
Veterans Home Construction Program until they have the capacity to 
provide long-term care to their veterans.
    Maine's aging veteran population coupled with our rural geography 
presents problems to elderly veterans trying to access VA healthcare 
especially in Maine's severe winter months. Maine has a limited 
transportation infrastructure and this compounds the access issue. The 
CARES market plan (Far North Market) developed in VISN 1 recognized 
Maine's unique geographic characteristics, limited transportation 
infrastructure and rural nature. The resulting CARES Commission Report 
made several points about access to VA healthcare in Maine (Far North 
Market) that are relevant to this hearing.
    ``In the Far North and North Markets, less than 60 percent of 
enrolled veterans are currently within the VA's access standards for 
hospital care. The CARES standard is 60 minutes for urban areas; 90 
minutes in rural areas; and 120 minutes in highly rural areas. 
Inpatient medicine workload is projected to increase . . . The Far 
North Market has the largest projected increase, with 209 percent over 
baseline by FY 2012.'' \3\
---------------------------------------------------------------------------
    \3\ CARES Commission Report, Chapter 5 VISN Recommendations, Page 
5-15.
---------------------------------------------------------------------------
    ``. . . the Far North Market is currently below the standard for 
access to primary care. Currently only 59 percent of the veterans 
residing in this largely rural area are within the CARES guidelines set 
for access to primary care services.'' \4\ The CARES definition for 
``Access to Primary Care'' is ``70 percent of veterans in urban and 
rural communities must be within 30 minutes of primary care; for highly 
rural areas, this requirement is within 60 miles.'' \5\
---------------------------------------------------------------------------
    \4\ CARES Commission Report, Chapter 5 VISN Recommendations, Page 
5-18.
    \5\ CARES Commission Report, Appendix A, Glossary of Acronyms and 
Definitions, Page A-3.
---------------------------------------------------------------------------
    ``The VISN had proposed five new CBOCs, (Community Based Outpatient 
Clinics) all in the Far North Market. These new CBOCs would be located 
across Maine in order to improve access to care and thus address 
current deficiencies in access in this market. . . . These CBOCs are 
also crucial to the VISN's plan to expand inpatient capacity at Togus, 
by reclaiming old inpatient space that has been converted to outpatient 
services.'' \6\
---------------------------------------------------------------------------
    \6\ CARES Commission Report, Chapter 5 VISN Recommendations, Page 
5-18, 19.
---------------------------------------------------------------------------
    The following table shows the aging of Maine's veteran population 
over the next 25 years. As you can see we will continue to have the 
majority of our veteran population over age 55 for many years to come.

------------------------------------------------------------------------
                      Veteran                        Percent of Veteran
       Year         Population*    Veterans > 55         Population
------------------------------------------------------------------------
2007                   144,007            93,780             65 percent
------------------------------------------------------------------------
2010                   138,551            91,200             66 percent
------------------------------------------------------------------------
2015                   129,091            86,700             68 percent
------------------------------------------------------------------------
2020                   115,506            80,925             70 percent
------------------------------------------------------------------------
2025                   104,650            73,047             70 percent
------------------------------------------------------------------------
2030                    94,582            63,633             67 percent
------------------------------------------------------------------------

         * Based on projections from VA Demographics Program VetPop2007

    Rural access to VA healthcare in Maine will greatly improve if and 
when the CARES Plan is fully implemented. Even if fully implemented in 
Maine today, we will still face challenges as the CARES Plan only 
addresses 70 percent of the veteran population which means that 30 
percent or 43,202 veterans (2007 numbers) will still be outside of the 
CARES standard for healthcare access. New initiatives by the VA such 
as: home-based healthcare, telemedicine, tele-mental health, will help 
alleviate the access to care for these veterans.
    While we would like to see additional Vet Centers in Maine to 
provide the necessary readjustment counseling to the large number of 
returning combat veterans to the State, we applaud VA's efforts to 
reach out to these individuals by establishing access points for mental 
health counseling outside of the Vet Centers.
    The Veterans Administration at Togus does a remarkable job of 
taking care of Maine's veterans with their limited resources. I will be 
the first to tell you, we do have problems that arise occasionally but 
in my time as State Director they been extremely responsive to 
resolving issues that have been identified to them.
    The recent influx of new veterans from Iraq and Afghanistan are 
being serviced well by Togus but this does have an impact on how they 
can take care of the older veterans that we are identifying and 
enrolling in the VA healthcare system. While the VA staffing continues 
to grow, it still takes a long time to credential employees and this 
does have an impact at the delivery of services level. In Maine we will 
continue seeing an increasing number of our aging veterans enrolling 
and seeking assistance from the VA. Currently we have over 52,000 or 36 
percent of our veterans enrolled with about 38,500 who actively use the 
VA healthcare system in Maine.
    Continued development of CBOCs has greatly improved veterans' 
access to VA healthcare. A shining example is the Lincoln clinic that 
opened last year and is providing primary care to more than 800 
veterans. We continue to encourage rapid deployment of new priority 
clinics/access points over the next few years with the corresponding 
budget support to the corresponding VA Medical Centers. VA needs to 
quickly develop these additional clinics, to include mental health 
services. We support VA contracting-out some specialty care to private-
sector facilities where or when access is difficult. CBOCs provide 
better access, leading to better preventive care, which better serves 
our veterans.
    In short, to improve rural access for veterans to VA healthcare in 
Maine and the Nation, implement CARES in Maine and other States and 
implement it sooner than later.
    According to the VA's demographics program VetPop2007 Maine has 
over 10,000 women veterans with less than 1,800 using VA healthcare. 
Quality or availability of types of care for women veterans does not 
seem to be as much of an issue as access and outreach. Approximately 40 
percent of the women veterans using VA healthcare receive it at the 
CBOCs. The addition of new CBOC in the Lewiston/Auburn area and the 
access points in Houlton, Dover-Foxcroft, and Farmington will allow 
more women veterans to receive care closer to home and this will 
increase usage numbers.
    While growth has occurred in VA healthcare due to improved access 
to CBOCs, many areas of Maine and the country are still short-changed 
due to geography and/or due to veterans' lack of information and 
awareness of their benefits. VA and State Departments of Veterans 
Affairs must reduce this inequity by reaching out to veterans regarding 
their rights and entitlements. Maine and NASDVA support implementation 
of a grant program that would allow VA to partner with the State 
Department of Veterans Affairs to perform outreach at the local level. 
There is no excuse for veterans not receiving benefits to which they're 
entitled simply because they are unaware of those benefits. I would 
encourage the Committee to support S.R. 1314, Veterans Outreach Act of 
2007.
    As the Nation's second largest provider of services to Veterans, 
State governments' role continues to grow. We believe it is essential 
for Congress to understand this role and ensure we have the resources 
to carry out our responsibilities. The States partner very closely with 
the Federal Department of Veterans Affairs in order to best serve our 
veterans and as partners, we are continuously striving to be more 
efficient in delivering services to veterans.
    As I finish my testimony I would like to once again thank you for 
the opportunity to speak to you today and thank you on behalf of 
Maine's and the Nation's veterans for all you are doing to ensure they 
receive the proper healthcare and benefits they have earned through 
their service to the Nation.
    Thank you.

                                 
    Prepared Statement of Gary I. Laweryson, USMC (Ret.), Chairman,
         Maine Veterans Coordinating Committee, Waldoboro, ME,
     Commander, Military Order of the Purple Heart, State of Maine,
        Judge Advocate, Marine Corps League, State of Maine, and
                 Aide-de-camp to Governor John Baldacci
                 MAINE VETERANS COORDINATING COMMITTEE
  Military Order of the Purple Heart * AMVETS * Marine Corps League *
       Disabled American Veterans * Korean War Veterans * WAVES *
    Vietnam Veterans of America * Women Veterans of America * 40/8 *
   Jewish War Veterans *York County Veterans * Paralyzed Veterans of
    America * American Legion Aux * Disabled American Veterans Aux *
    Honorable Congressmen:
    Thank you for allowing me to testify on behalf of the Maine 
Veterans Coordinating Committee. Our organization is comprised of the 
above veterans service organizations and represents a united voice 
working for all veterans of Maine.
    As I testified on August 1, 2005, the VA's Capitol Assets 
Realignment Enhanced Services (CARES) studied access to Maine's rural 
veteran population and concluded more Community Based Outpatient 
Clinics (CBOC's) were needed along Maine's north-south corridor and 
western Maine. These CBOC's would provide Maine's rural veterans 
increased access to the VA's outpatient and specialty cares.
    Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) allows 
the National Guard and Reserve troops to access the VA system for 5 
years after return from OIF/OEF. As these current arenas of combat 
continue, treatment of Traumatic Brain Injury, PTSD, amputations, 
multiple injuries and illnesses, as well as, the added numbers of women 
combat veterans further strains an already challenged VA system, 
especially in the rural areas. High fuel prices and loss of jobs in the 
rural areas have impacted the need for increased rural access to the 
CBOC's as many of these veterans are now seeking care through the VA 
for the first time.
    CBOC's within Maine are filled to capacity and need additional 
space and providers to be able to continue to provide the quality care 
Maine's veterans expect and demand.
    CARES studies demonstrated Maine is greater in area and veteran 
population than the entire VISN 1 area. With the new OIF/OEF veterans, 
Maine's veteran population has swelled from the projected 154,000 in 
2004 to an estimated additional 5000 veterans eligible for care in the 
VA system.
    Communication of the varied VA services available to all Maine 
veterans is imperative, especially to the OIF/OEF veterans. Through the 
efforts of the Maine Veterans Coordinating Committee and its subsidiary 
organizations, Togus VAMROC enrolled 500-700 new veterans each month 
from 2003--2005. While this trend has slowed, Togus continues to enroll 
new veterans each month. Many of Maine's National Guard and Reserve 
components returning from Iraq and Afghanistan are returning with 
illnesses and injuries requiring VA care, thus increasing the need for 
improved access to the VA system.
    Due to Maine's unique geographical size and the rising cost of gas, 
it is difficult for Maine's rural veterans to travel to Togus and in 
some instances, the existing CBOC's. Maine has no mass transit system. 
Maine's veterans rely on the DAV shuttle bus for transport to Togus and 
the CBOC's. However, in the northern counties, there is only one bus 
available. Many of Maine's rural veterans are on a fixed income or 
unemployed and unable to afford transportation to the nearest CBOC or 
Togus. These veterans cannot afford health insurance or access to local 
healthcare.
    The Maine Veterans Coordinating Committee believes Togus should be 
expanded to become a full service VA Regional Medical Center, 
independent of Boston. Maine's rural veterans must now travel several 
hours one way to obtain care at Togus or a CBOC. To require Maine's 
veterans to travel an additional three to 8 hours to Boston to receive 
tertiary care is unacceptable. Maine has one of the top Cardiac Surgery 
Centers in the Nation and leads the Nation in long term care and end of 
life care provided to our veterans. Sending Maine's veterans to Boston 
removes the family and local veteran support systems needed to effect 
recovery.
    The majority of the Nation is urban or metro and growth has slowed. 
Rural Maine has demonstrated a sustained growth and will continue this 
trend.
    During my 2005 testimony, the Maine Veterans Coordinating Committee 
urged the VA to open lines of communication to all veterans, not just 
in Maine. Historically, veterans have not felt the VA was user friendly 
and as a result, many older veterans and those serving on active duty 
have failed to avail themselves of the quality care provided by the VA 
system. This has not improved.
    In Maine, the veterans have banded together to educate our veterans 
on the many services available to them. ``Operation I Served'' is a 
joint project initiated to provide information on VA services, 
educational benefits, tax relief, financial assistance, housing 
assistance, long term care and end of life care available to Maine's 
veterans, their spouses and families. Maine has the leading long term 
care system in the Nation through the Maine Veterans Homes. ``Operation 
I Served'' has been requested and shared with many other States.
    On behalf of the Maine Veterans Coordinating Committee and the 
Maine veterans we represent, thank you for allowing me this opportunity 
to testify. The Maine Veterans Coordinating Committee looks forward to 
continuing to work with Congress to enable the VA to provide quality 
care to all veterans.
    Respectfully submitted.

                                 
     Prepared Statement of Kelley J. Kash, Chief Executive Officer,
                   Maine Veterans' Homes, Augusta, ME
    Mr. Chairman and Members of the Committee, thank you for the 
opportunity to testify today on behalf of the Maine Veterans' Homes 
(``MVH'') on the topic of ``Women, Rural, and Special Needs Veterans,'' 
including the extremely important issue of continued access by veterans 
to quality long-term nursing care.
    I am the Chief Executive Officer of MVH. MVH is a public body 
corporate created by the State of Maine to provide long-term nursing 
care to Maine veterans. MVH operates long-term nursing care facilities 
for veterans at Augusta, Bangor, Caribou, Scarborough, South Paris, and 
Machias, Maine. In the aggregate, MVH currently operates 640 skilled 
nursing, long-term nursing, and domiciliary beds for Maine veterans. We 
are very proud of the quality long-term care nursing services that we 
provide to Maine veterans.
    Also, as one of the most successful State Veterans Homes systems in 
the Nation, MVH provides a crucial portion of the healthcare continuum 
for Maine veterans. Our facilities are each relatively small in size, 
30 to 150 beds each, and this allows them to be located throughout the 
State of Maine, allowing greater ease of access to our facilities by 
veterans living in the most rural parts of Maine. In the future, we 
hope to develop additional in-patient and out-patient services at all 
of our six locations in order to offer rural Maine veterans greater 
access to all of the services that the Maine Veterans' Homes, the Maine 
Bureau of Veterans Services, and the United States Department of 
Veterans Affairs provide.
    MVH is part of a vital national system of State Veterans Homes. The 
State Veterans Homes system is the largest provider of long-term care 
to our Nation's veterans. As such, the State Veterans Homes play an 
irreplaceable role in assuring that eligible veterans receive the 
benefits, services, and quality long-term healthcare that they have 
rightfully earned by their service and sacrifice to our country. We 
greatly appreciate this Committee's commitment to the long-term care 
needs of veterans, your understanding of the indispensable function 
that State Veterans Homes perform, and your strong support for our 
programs.
    We especially appreciate the past support of this Committee in 
providing funding to assure per diem payments by the Department of 
Veterans Affairs to veterans who are residents in our State Homes. 
Adequate funding is absolutely key to providing top quality long-term 
care and access at affordable costs for our veterans. In addition, we 
greatly appreciate your efforts to provide more funding for VA 
construction grants to provide new, expanded, and more capable long-
term care services and facilities to veterans.
    The Maine Veterans' Homes is a leader in this national system of 
State Veterans Homes and a leader in the National Association of State 
Veterans Homes (``NASVH''). The membership of NASVH consists of the 
administrators and staff of State-operated veterans homes throughout 
the United States. NASVH members currently operate 132 veterans homes 
in 49 States and the Commonwealth of Puerto Rico. These homes provide 
over 28,000 nursing home and domiciliary beds for veterans and their 
dependents. These beds represent about 52 percent of the long-term care 
workload for the VA, while consuming just 12 percent of the VA's long-
term care budget.
    We work closely with the VA, State governments, the National 
Association of State Directors of Veterans Affairs, veterans service 
organizations, and other entities dedicated to the long-term care of 
our veterans. Our goal is to ensure that the level of care and services 
provided by State Veterans Homes meet or exceed the highest standards 
available.
Role of the State Veterans Homes
    State Veterans Homes first began serving veterans after the Civil 
War. Faced with a large number of soldiers and sailors in critical need 
of long-term care, several States established veterans homes to care 
for those who served in the military.
    In 1888, Congress first authorized federal grants-in-aid to States 
that maintained homes in which American soldiers and sailors received 
long-term care. At the time, the payments amounted to about 30 cents 
per resident per day. In the years since, Congress has made several 
major revisions to the State Veterans Homes program to expand the base 
of payments to include nursing home, domiciliary, and adult day health 
care.
    For nearly half a century, State Veterans Homes have operated under 
a program administered by the VA which supports the Homes through 
construction grants and per diem payments. Both the VA construction 
grants and the VA per diem payments are essential components of this 
support. Each State Veterans Home must meet stringent VA-prescribed 
standards of care, which exceed standards mandated by federal and state 
governments for other long-term care facilities. The VA conducts annual 
inspections to assure that these standards are met and to assure the 
proper disbursement of funds. Together, the VA and the State Homes 
represent a very effective and financially efficient federal-state 
partnership in the service of our veterans.
    VA per diem payments to State Homes are authorized by 38 U.S.C. 
Sec. 1741-1743. Congress intended to assist the States in providing for 
the higher level of care and treatment required for eligible veterans 
residing in State Veterans Homes. As you know, the per diem rates are 
established by the VA annually and may not exceed 50 percent of the 
cost of care. They are currently $71.42 per day for nursing home care, 
$64.13 per day for adult day healthcare, and $33.01 per day for 
domiciliary care. Our State Veterans Homes cannot operate without the 
per diem payments from the VA.
    Construction grants are authorized by 38 U.S.C. Sec. 8131-8137. The 
objective of such grants is to assist the States in constructing or 
acquiring State Veterans Home facilities. Construction grants are also 
utilized to renovate existing facilities and to assure continuing 
compliance with life safety and building codes. Construction grants 
made by the VA may not exceed 65 percent of the estimated cost of 
construction or renovation of facilities, including the provision of 
initial equipment for any project. State funding covers at least 35 
percent of the cost. Our program cannot meet our veterans' needs 
without an adequate level of construction grant funding.
    In recent years, State Veterans Homes have experienced a period of 
controlled growth--the result of increasing numbers of elderly veterans 
who have reached that point in life when long-term care is needed. In 
fact, we face the largest aging veterans population in our Nation's 
history. From 2000 to 2010, the number of veterans aged 85 and older is 
expected to triple from 422,000 to 1.3 million. If the State Veterans 
Homes program is to fill even a part of this unmet need for long-term 
care beds in certain States, and to respond to the increase in the 
number of veterans eligible for such care nationally, it is critical 
that the State Veterans Home construction grant program be sustained.
    Traditionally, State Veterans Homes residents have been primarily 
male, as the VA per diem and construction grant requirements mandate 
that at least 75 percent of residents at any time be veterans. However, 
more and more women veterans are being admitted to State Veterans Homes 
as veterans themselves, reflecting the large and increasing numbers of 
women who have served in the military since the Korean war.
    While our experiences in the Gulf War and present conflicts have 
given tremendous attention to post traumatic stress disorder 
(``PTSD''), the reality and effects of PTSD have been present in every 
conflict. While State Veterans Homes provide a common culture, 
reassuring surrounding, appreciation, and understanding of the 
veterans' experiences and issues, more can be learned and provided in 
treating PTSD in general.
    The State Veterans Home program now provides about 52 percent of 
the VA's total long-term care workload. The VA recently estimated 
nationally that nursing care beds in the State Homes are 87 percent 
occupied. MVH beds are approximately 97 percent occupied. Many of the 
State Veterans Homes nationally have occupancy rates near 100 percent, 
and some have long waiting lists. The State Veterans Homes provide 
long-term medical services to frail, elderly veterans at a cost to the 
VA of only $71 per day, well below the cost of care in a VA nursing 
home, which exceeds $560 per day.
    Although there are no national admission requirements for the State 
Veterans Homes, there are State-by-State medical requirements for 
admission. Generally, a State will demand a medical certification 
confirming significant deficits in activities of daily living (an 
assessment of basic living functions) that require 24-hour nursing 
care. Moreover, no per diem is paid by the VA unless and until a VA 
official certifies that nursing home care is required. Veterans 
qualifying for long-term nursing care at a State Veterans Home are 
almost always chronically ill and elderly, and many are afflicted with 
mental health conditions.
State Veterans Homes as a VA Resource
    The State Veterans Homes should play a major role in meeting these 
requirements and be treated as a resource integrated more fully with 
the VA long-term care program. We have proposed that our beds be 
counted toward the VA's overall long-term care census. Doing so would 
allow the VA to meet its long-term care bed requirements. A nursing 
home bed in a State Veterans Home is a very cost-effective alternative 
to a nursing home bed in a VA-operated facility. Congress's goal should 
be to provide long-term care to veterans in a manner that expands the 
VA's capacity to provide services, while paying the lowest available 
per capita cost for each eligible veteran. Including State Veterans 
Homes nursing beds in the mandated VA long-term care totals could allow 
the VA to meet its legislative mandate, shift some of its maintenance 
care and other specialty services to the State Veterans Homes, and 
ultimately increase the capacity of the VA to provide greater short-
stay, highly specialized rehabilitative care.
    This goal can be accomplished by the State Homes at substantially 
less cost to taxpayers than other alternatives. The average daily cost 
of care for a veteran at a long-term care facility run directly by the 
VA has been calculated nationally to be $563.45 per day. The cost of 
care is $225.30 per day to the VA for the placement of a veteran at a 
contract nursing home, which is not required to meet more stringent 
State Veterans Home standards. The same daily cost to the VA to provide 
outstanding quality long-term care at a State Veterans Home is far less 
-- only $71.42 per day for nursing care.
    This substantially lower daily cost to the VA of the State Veterans 
Homes compared to other available long-term care alternatives led the 
VA Office of Inspector General to conclude in a 1999 report: ``the SVH 
[State Veterans Home] program provides an economical alternative to 
Contract Nursing Home (CNH) placements, and VAMC [VA Medical Center] 
Nursing Home Care Unit (NHCU) care'' (emphasis added). In this same 
report, the VA Office of Inspector General went on to say:

         A growing portion of the aging and infirm veteran population 
        requires domiciliary and nursing home care. The SVH [State 
        Veterans Home] option has become increasingly necessary in the 
        era of VAMC [VA Medical Center] downsizing and the increasing 
        need to discharge long-term care patients to community based 
        facilities. VA's contribution to SVH per diem rates, which does 
        not exceed 50 percent of the cost to treat patients, is 
        significantly less than the cost of care in VA and community 
        facilities.

    In another example of how the VA can partner with State Veterans 
Homes, the State of Maine enacted legislation earlier this month to 
establish a veterans' campus at Bangor, Maine. The concept is to create 
a one-stop shop for veterans to receive most of their healthcare and 
social services needs. The proposed project will locate a new, larger, 
and more capable VA community-based outpatient clinic next to the MVH 
Bangor facility. Other veteran service organizations will be colocated 
at the campus, bringing a wide range of veteran services to a single 
campus and making it more efficient and convenient for veterans, 
families, the State Bureau of Veterans Affairs, VA, and various 
agencies and veterans service organizations that serve veterans' 
healthcare and social service needs. The Bangor Veterans Campus is a 
pioneering effort and the first of its kind in the Nation. Its success 
should be replicated throughout the Nation.
Status of VA Regulations
    In our opinion, the VA chronically has been slow to implement 
enacted legislation. Section 211 of Pub. L. No. 109-461 authorized the 
VA to directly place and pay the full cost of care for veterans with 
service-connected disabilities rated 70 percent or greater, or for 
veterans who need nursing home care as a result of their service-
connected disabilities. The same legislation authorized the VA to 
provide veterans with service-connected disabilities rated 50 percent 
or greater with prescription medications while residing in State Homes. 
Federal law required these provisions to take effect by March 22, 2007, 
yet we are still waiting for the VA regulations with no forecasted date 
of implementation. The result has been tremendous confusion and 
frustration for the many thousands of veterans who are waiting for 
these services, and for the State Veterans Homes, which will be 
required eventually to provide these services.
    Section 201 of Pub. L. No. 108-422 authorized the VA to pay up to 
50 percent of the cost for State Veterans Homes to implement an 
employee incentive scholarship to recruit and retain nurses. While the 
VA announced that its regulations and implementation instructions will 
be completed this summer, Federal law required the VA to begin making 
payments to States no later than June 1, 2005 -- 3 years ago!
VA Construction Grant Program
    Under current law, there are strict limits and standards for 
funding the construction and renovation of State Veterans Homes. The 
system is working very well under the provisions of the Millennium 
Bill, which establishes priorities for funding according to life/
safety, great need, significant need, and limited need.
    Moreover, under the requirements of the Millennium Bill, the VA 
prescribes strict limits on the maximum number of State Veterans Home 
nursing beds that may be funded by construction grants. This is based 
on projected demand for the year 2009, which determines which States 
have the greatest need for additional beds. This process assures that 
additional State Veterans Home beds are built only in those States that 
have the greatest unmet need for such beds.
    However, the Administration has proposed cutting State Veteran Home 
construction matching-grant funding by almost 50 percent, from $165 
million in FY 2008 down to $85 million for FY 2009. The backlog of 
construction projects to repair, rehabilitate, expand, and build new 
State Veterans Homes is now approaching $1 billion. Over $200 million 
of this backlog are life-safety projects. These are critical and 
immediate needs. Moreover, habitually under funding these projects puts 
the State Veterans Homes and their veteran residents at risk.
Conclusion
    Thank you for your commitment to long-term care for veterans and 
for your support of the State Veterans Homes as a central component of 
that care. In conclusion, I will reiterate the key issues facing the 
State Veterans Homes.
    First, thank you for your continued support of the VA per diem 
payment to the State Veterans Homes. The loss or reduction of the VA 
per diem would place Homes in an untenable financial position and could 
lead to the closure of many State Homes, ultimately impacting our aging 
veterans severely.
    Second, we believe Congress must increase funding for construction 
grants to State Veterans Homes to at least $200 million to address the 
growing backlog of projects. Inadequate or delayed funding will 
continue to grow the nearly $1 billion backlog that now exists, 
including over $200 million in life-safety projects.
    Third, we believe Congress must require the VA to promulgate long-
overdue regulations to strengthen State Veterans Homes and the veterans 
they serve. In particular, increased payment for nursing home care and 
the provision of prescription medication in State Veterans Homes for 
veterans with service-connected disabilities of 70 percent or greater 
and 50 percent or greater, respectively, have been delayed indefinitely 
by the VA.
    Fourth, we believe that the State Veterans Homes can play a more 
substantial role in meeting the long-term care needs of veterans. NASVH 
recognizes and supports the national trend toward 
deinstitutionalization and the provision of long-term care in the most 
independent and cost-effective setting. In a letter to VA Secretary 
Nicholson dated April 5, 2005, NASVH proposed that we explore together 
creative ways to provide a true continuum of care to our veterans, both 
rural and urban, in State Veterans Homes and in the community. We would 
be pleased to work with the Committee and the VA to explore options for 
developing pilot programs, such as the proposed Bangor Veterans Campus, 
for providing innovative care and for more closely integrating the 
State Veterans Homes program into the VA's overall healthcare system 
for veterans.

                                 
            Prepared Statement of David Hartley, Ph.D., MHA,
           Director, Maine Rural Health Research Center, and
              Professor, Muskie School of Public Service,
               University of Southern Maine, Portland, ME
    Thank you for the opportunity to testify before this Committee. My 
testimony is based on 12 years as a manager of substance abuse 
treatment programs followed by 15 years as a rural health researcher, 
much of which has been focused on access to mental health services in 
rural America. I brought that expertise to bear when I served on the 
Institute of Medicine's Committee on the Future of Rural Health which 
met throughout 2004 and released its report early in 2005: Quality 
through Collaboration: The Future of Rural Health (IoM 2005). Two years 
ago, I testified before this subcommittee in Washington DC, and 
reported that several of the recommendations of the IoM Committee were 
directly relevant to the challenge of delivering high quality health 
care services to rural veterans.
    Since 44 percent of new recruits come from rural places (Tyson 
2005), we are seeing an increase in the numbers of veterans from Iraq 
and Afghanistan who are returning to rural America recovering from 
complex combat-related injuries, both physical and emotional. The 
Veteran's Healthcare System has unique expertise and resources to 
devote to the healing of these injuries. In recent years, the VA has 
opened more community based outpatient clinics or CBOCs to make this 
expertise and these resources available to veterans who live at 
significant distances from VA medical centers. We now have six CBOCs in 
Maine.
    The Department of Veterans Affairs has arguably the best integrated 
health information network in the Nation. It also has extensive, 
evidence-based, patient-centered performance measures and a monitoring 
system to assure that all patients receive high quality, guideline 
concordant care. That system gets good outcomes for those veterans who 
receive care from VA clinics, and from Community-Based Outpatient 
Clinics and contract providers who can meet the VA's high standards of 
care. There are several reasons why a veteran in need of help might not 
seek care at one of these facilities. While CBOCs have improved access 
in many rural areas, there remain vast remote areas in our most rural 
States, including Maine, where VA facilities are still out of reach. 
Also, some veterans prefer to seek care from the non-VA system, for a 
variety of reasons. The significant numbers of veterans whose combat 
experience was with the National Guard are often in this category. 
Citizen soldiers may be more familiar with citizen health care, and 
often do not register for VA benefits. While many veterans prefer to 
receive care from VA providers, others feel just the opposite. Our VA 
healthcare system needs to reach out to our civilian health care system 
to assure that these combat veterans get care consistent with their 
needs, and concordant with the special expertise of the VA healthcare 
system.
    Clearly, one way the VA system can do this is by contracting with 
non-VA providers in rural areas where it is not efficient to open a 
CBOC. The federal government has created several programs to attract 
providers to underserved areas, and to support them. These include 
federally qualified health centers (FQHCs), critical access hospitals, 
and rural health clinics. Some rural areas are also served by community 
mental health centers. These programs were created as a federal 
response to the difficulty of recruiting providers to serve remote 
populations. They exist in areas that have been designated as 
underserved. In many rural areas, hospitals, clinics and health centers 
collaborate in recruiting efforts, often with the help of their state 
office of rural health, or state hospital association. For the VA to 
open a new CBOC in a community that is already served by one or more of 
these entities is inefficient. Rather, I would suggest that we have the 
technology and the expertise to help these rural sites provide care to 
rural veterans that is of the same high quality that urban vets 
receive. This can be done through tele-health, through the VistA 
information system which is now available as open-access software to 
all providers, through direct clinical consultation and supervision 
between expert clinicians in VA medical centers and rural providers, 
and through the placement of VA providers in these non-VA rural sites, 
creating veterans' access points. With these resources at our disposal, 
care provided in a rural site for some of these combat injuries can be 
of the same high quality as that provided in a VA medical center.
    My research has been in the area of rural behavioral health. The 
IoM rural report found that behavioral health needs in rural America 
are not being met, due to a fragmented, under-funded, non-system. Much 
of my research has sought to document the lack of specialty mental 
health services in rural areas, and to discover alternative models for 
delivering such services in the absence of psychiatrists, psychologists 
and psychiatric facilities. The need for mental health services in 
rural

America has been repeatedly identified as one of the topmost issues 
facing State-level officials and policymakers. It now faces the VA 
healthcare system as well.
    Evidence of the need for mental health services among veterans can 
be found in the high rates of combat zone suicide (Army News Service 
2004), post-traumatic stress disorder, often not manifesting until a 
year or more after returning home, and in the VA's recently published 
studies of rural-urban disparities in health-related quality of life, 
both for veterans with psychiatric disorders (Wallace et al. 2006) and 
for veterans in general (Weeks 2004). Lacking specialty mental health 
services, rural people with psychiatric problems have typically sought 
help from their primary care practitioner. Research tells us that such 
care has not always been of the highest quality, and often does not 
follow evidence-based guidelines for conditions such as depression, 
anxiety disorders and children's mental health issues (Rost et al. 
2002). Two specific conditions of veterans now returning from 
Afghanistan and Iraq may not be accurately diagnosed by primary care 
practitioners who are not familiar with these conditions: post-
traumatic stress disorder (PTSD) and traumatic brain injury (TBI). Once 
such disorders are suspected, it may be possible to refer vets to a VA 
specialist, and travel from a rural to an urban area for specialty care 
may simply be the only way to get quality care. In many of our most 
rural States, however, there is no VA TBI program. Moreover, the 
symptoms of PTSD typically affect the whole family, and may lead to 
domestic violence, child abuse, divorce, substance abuse and suicide. 
Here too, the lack of services in rural areas poses a significant 
barrier to effectively addressing these problems.
    My research suggests that creative solutions are needed to meet the 
need for mental health and substance abuse treatment in rural areas. 
Behavioral health research often entails precisely designed trials of 
various clinical interventions, many of which are unlikely to be 
implemented in rural areas. Creative solutions to meet the behavioral 
health needs of rural veterans can be found by establishing a rural 
behavioral health research center charged to explore and evaluate new 
models for delivering care to veterans in remote areas. This can best 
be accomplished through collaboration between a VA medical center and a 
federally funded rural health research center. Such a collaboration 
might be facilitated by the VA Office of Rural Health and the Federal 
Office of Rural Health Policy, in the Health Resources and Services 
Administration, working together.
    As I stated to this subcommittee two years ago, the Veterans 
Administration has an opportunity to take advantage of decades of 
research, policy, and programs serving rural Americans, and combine 
those resources with its own, so as to improve access to quality care 
for rural veterans, and to bring its unique resources for quality 
improvement and information management to rural providers. We can do 
this for our veterans.
References
    Army News Service (2004). Army suicide rate in combat zones 
elevated. March 26, 2004.
    Institute of Medicine, Committee on the Future of Rural Health Care 
(2005) Quality through Collaboration: the Future of Rural Health. 
Washington DC: The National Academies Press.
    Rost K, Fortney J, Fischer E, and Smith J (2002) Use, quality and 
outcomes of care for mental health: The rural perspective. Medical Care 
Research and Review 59(3): 231-265.
    Wallace AE, Weeks WB, Wang, S, et al. (2006) Rural and urban 
disparities in health-related quality of life among veterans with 
psychiatric disorders. Psychiatric Services. 57(6):1-6.
    Tyson, AS (2005) ``Youths in rural U.S. are drawn to military.'' 
Washington Post. November 4, 2005.
    Weeks WB, Kazis LE, Shen Y, et al. (2004) Differences in health-
related quality of life in rural and urban veterans. American Journal 
of Public Health 94:1762-67.

                                 
  Prepared Statement of Donald A. Simoneau, Past Commander, Department
  of Maine, and Member, National Legislative Council, American Legion
    Mr. Chairman and Members of the Subcommittee:
    Thank you for this opportunity to present The American Legion's 
views on women, special needs, and rural veterans. As more eventual 
veterans return from Iraq and Afghanistan, a higher emphasis is being 
placed on the Department of Veterans Affairs (VA) to provide the 
highest quality of care to all veterans who have served our Nation and 
earned the entitlement.
    Within the veteran population, the provision of quality health care 
to women veterans, special needs veterans, and rural veterans has 
proven to be very challenging, given factors such as limited 
availability of skilled care providers and inadequate access to care. 
Other challenges such as miscommunications and misperceptions of 
Veteran Health Administration (VHA) services also continue to impede 
the delivery of quality care to the veteran population. The American 
Legion commends the Subcommittee for holding a hearing to discuss these 
vitally important issues.
Women Veterans
    According to VA research, women make up approximately 15 percent of 
the active force, are serving in all branches of the military, and are 
eligible for assignment in most military occupational specialties 
except for direct combat roles. The increase in the number of women 
serving in the military significantly impacts the services provided by 
the Department of Veterans Affairs (VA). VA also projects that by the 
year 2010, women will comprise well over 10 percent of the veteran 
population, an increase of 6 percent over current figures. The State of 
Maine is comprised of approximately 9,396 of these women veterans.
    Although integrated within the ranks, these women veterans require 
special treatment to ensure they have the best chance of returning to 
good health. Research has shown that female veterans encounter three 
large barriers when trying to access health care through VA. These 
barriers include: lack of knowledge about VHA services; unaware of 
eligibility for health care benefits; and the perception that VA only 
caters to male veterans. During various site visits to VA Medical 
Hospitals, Vet Centers, and Community Based Outpatient Clinics (CBOCs), 
the American Legion met with various managers who stated their greatest 
challenge was accommodating women who suffered from Military Sexual 
Trauma (MST). It is imperative that VA has adequate funding and 
resources, to include staffing, to ensure tools such as private 
entrances are in place, thereby encouraging more women to come forward 
and obtain care.
    The American Legion recommends that once women veterans' needs are 
identified, VA develop and implement policy to address these 
deficiencies in a timely manner and conduct an extensive outreach 
campaign to ensure this special population--and those who serve them--
aware of enhancements in health care services. We also urge Congress to 
also appropriate adequate funding to maintain these enhancements, once 
in place.
Special Needs Veterans
    The American Legion is concerned with the needs of all veterans; to 
add, we must reassure to all that special needs veterans (SNV) don't 
slip through the cracks of the VA health care system. Recently in my 
hometown here in Maine we lost one of these Special Needs Soldiers, who 
served two tours of duty in Iraq but slipped through the cracks, in the 
VA system. This should not have happened, to anyone, especially someone 
who gave so much to us, but it is happening all across the Nation. 
Special Needs Veterans, according to the Diagnostic Statistical Manual 
(DSM) IV, include the chronically mentally ill, which are conditions of 
schizophrenia or major affective disorder including bipolar disorder, 
or Post Traumatic Stress Disorder (PTSD). Many older veterans are 
dealing with PTSD and have for years and are never diagnosed. Many 
returning veterans are dealing with TBI or Traumatic Brain Injury, 
which is one of the newest Special Needs Veterans issues. Special Needs 
Veterans also include the frail elderly or those veterans who are 65 
years of age or older with one or more chronic health problems; and 
limitations in performing one or more activities of daily living. The 
last major group with special needs is the homeless.
    The issue of homelessness affects every category of veteran. The VA 
Advisory Committee on Homeless Veterans 2007 report states the need and 
complexity of issues involving women veterans who become homeless are 
increasingly unexpected.
    The increased risks of homelessness among each of these 
populations, warrant funding for special needs grants. The American 
Legion strongly urges Congress to provide VA with the adequate funding, 
ensuring more grants be put into place to assist those veterans with 
special needs.
    Special Needs Veterans also encounter barriers when trying to 
access health care through VA. These obstacles include: lack of 
knowledge about VHA services, not knowing that they may be eligible for 
health care benefits, and a negative perception of VA.
    The American Legion maintains that VA has a duty to constantly seek 
new ways to bring information to veterans--ALL veterans.
Rural Veterans
    The American Legion believes veterans, many of whom are elderly and 
infirm or unable to travel, are isolated from the regular, preventative 
medical attention they need and deserve. Providing quality health care 
in a rural setting has proven to be challenging with such dilemmas as 
limited availability of skilled care providers and inadequate access to 
care.
    VA's ability to provide treatment and rehabilitation to rural 
veterans who suffer from the ``signature ailments'' of the on-going 
wars in Iraq and Afghanistan (Traumatic blast injuries and combat-
related mental health conditions) will continue to be challenged if it 
lacks the appropriate resources to accommodate new returning and 
existing veterans. According to Title 38, United States Code, section 
1703, VA has the authority to contract for services where they are 
needed.
    Mr. Chairman, with that measure in place, we have to persistently 
ensure funding and resources are available to facilitate the needs of 
veterans who reside in rural locations. We also encourage VA to 
periodically assess the resources in place and match against those who 
have returned. This assessment will determine the future needs of our 
Nation's veterans, to include those who reside outside normal distances 
of the VA Medical Center system.
    The American Legion believes that where there is limited access to 
VA healthcare, it is in the best interest of veterans residing in 
highly rural areas to have local care made available to them. This 
would alleviate the unwarranted hardships rural veterans encounter when 
seeking access to VA health care services. Veterans should not be 
penalized or forced to travel long distances to access quality health 
care because of where they choose to live.
    On October 15, 2004, the VA Office of Inspector General (VAOIG) 
released the ``Evaluation of Department of Veterans Affairs Policies 
and Procedures Addressing the Location of New Offices and Other 
Facilities in Rural Areas.'' This report examined VA's policies and 
procedures to give first priority to locating new offices and other 
facilities in rural areas, as outlined in the Rural Development Act 
(RDA) of 1972.
    The report determined that despite not having formal policies in 
place, VA did make a significant effort to improve access to VA 
services for veterans living in rural areas. The American Legion 
commends VA's efforts, however, we urge the Congress to ensure there 
are an adequate number of resources for veterans, as well as provision 
of adequate funding and care whilst VA is making efforts to accommodate 
the veteran.
    The American Legion believes that CBOCs serve as a vital element of 
VA's health care delivery system when rural veterans are being 
discussed. As is widely known, there is great difficulty serving 
veterans in rural areas. According to the 2000 Census, many rural and 
non-metropolitan counties across the Nation had the highest 
concentrations of veterans in the civilian population aged 18 and over 
from 1990-2000. The State of Maine has the fourth highest proportion of 
veterans living in rural areas in the Nation at 15.9 percent. Studies 
have further shown that veterans who live in rural areas are in poorer 
health than their urban counterparts. In States such as Nevada, 
Nebraska, Iowa, North Dakota, South Dakota, Wyoming, Montana, and 
Maine, veterans face extremely long drives, a shortage of health care 
providers and bad weather. In Maine we are waiting for the funding for 
Lewiston, Dover/Foxcroft, Farmington and Norway/So. Paris CBOCs and 
grateful for the Lincoln CBOC that opened recently. The Veteran 
Integrated Services Networks (VISNs) rely heavily upon these CBOCs to 
close the gaps. The American Legion urges the Congress to adequately 
fund VHA to ensure an adequate number of CBOCs are constructed and 
maintained.
    Although effective, CBOCs are not the only avenue with which VA can 
provide access to quality health care to rural veterans. VA must 
enhance existing partnerships with communities and other federal 
agencies to help alleviate barriers that exist, such as, the high cost 
of contracted care in rural settings. The American Legion believes 
coordinating services with Medicare or other healthcare systems based 
in rural areas is another way to provide quality care.
    In closing, providing quality health care to women veterans, 
special needs veterans, and rural veterans has proven to be very 
challenging, given factors such as limited availability of skilled care 
providers and inadequate access to care. Other challenges such as 
miscommunications and misperceptions of Veteran Health Administration 
(VHA) services also continue to impede the delivery of quality care to 
theses veteran populations.
    The American Legion believes all veterans who are entitled to VHA 
services should receive it in a timely and quality manner. Last The 
American Legion urges the Congress to provide adequate funding to VA to 
accommodate the modernization of all VA structures. The modernization 
of VA structures would readily provide telehealth and telemedicine to 
all veterans who reside in rural areas.
    Again, thank you Mr. Chairman for giving The American Legion this 
opportunity to present its views on such important issues. We look 
forward to working with the Subcommittee to bring an end to the 
disparities that exist in access to quality health care to women 
veterans, special needs veterans, and rural veterans.
    For God and Country.

                                 
             Prepared Statement of John Wallace, President,
            Maine State Council, Vietnam Veterans of America
    Mr. Chairman, Ranking Member Miller, Distinguished Members of this 
Subcommittee, and guests, my name is John W. Wallace. I am a combat 
veteran who is presently Vietnam Veterans of America Maine State 
Council President. I serve on the Maine VHA MiniMac, BigMac, and 
Network Communications Council. I also serve on the Maine Veterans 
Coordinating Committee, the Caribou Veterans Cemetery Committee, the 
Maine Veterans Home Liaison Committee in Caribou and I participate in 
the Commanders Call with the Governor/General.
    Today, I will briefly discuss with you some of the health related 
issues facing veterans in the State of Maine, which is home of more 
than 154,000 veterans and their families.
    Mr. Chairman, the Maine Department of Veterans Affairs Medical 
Center is located in Togus, 6 miles east of Augusta. Opened in 1866, 
Togus was the first national home for disabled volunteer soldiers. This 
VA Medical Center provides medical, surgical, psychiatric, and nursing 
home care. The VA operates community-based outpatient clinics in 
Bangor, Calais, Caribou, Rumford, and Saco to provide better access to 
care for veterans living in rural areas. In 2007, the VA opened a part-
time clinic in Lincoln. There is also a Mental Health Clinic located in 
Portland.
    More than 1,400 active-duty service members and veterans of the 
Global War on Terror have sought VA health care in Maine. Many veterans 
from the conflicts in Iraq and Afghanistan have visited VA counseling 
centers in Bangor, Caribou, Lewiston, Portland, and Springvale. These 
community-based Vet Centers are an important resource for veterans who, 
once home, often seek out fellow veterans for help transitioning back 
to civilian life. Over six million veterans live in rural areas across 
America, and most fall below the poverty line. They travel hours to get 
to the nearest VA medical facilities. At a hearing of the Subcommittee 
on Health, Mr. Chairman, you pointed out that although 20 percent of 
the Nation's populace lives in rural areas, 40 percent of veterans 
returning from deployments in Afghanistan and Iraq live in rural 
communities. This leads to ``significant challenges maintaining `core 
health care services'.'' The average distance for rural veterans to 
access care is 63 miles, according to the National Rural Health 
Association.
    The difficulty of accessing health care is a significant problem 
for many of Maine's veterans. Although Togus is centrally located in 
Augusta, the State's geographic expanse makes it a problem for many 
veterans to use the hospital as their primary health-care provider. In 
a 2004 report, a government commission expressed concern that only 59 
percent of Maine's veterans were living within its geographic 
guidelines for access to care, which ranged from 60 minutes for urban 
areas to 120 for very rural areas.
    Furthermore, research by the National Rural Health Association 
underscores the problem. The association found that about 44 percent of 
service recruits come from rural areas whose population comprises 19 
percent of Americans. The disparity was far less during World War II 
and the Vietnam War.
    Of Maine's six CBOCs with two more planned under CARES, the closest 
CBOC is over 80 miles from its hub and the farthest is 260 miles. For 
primary care this is ok, but for specialty care services veterans have 
to travel to Togus or Boston. The distance a veteran may have to travel 
is more than 300 miles, which is clearly outside the 75-mile radius 
established by the VA. To make matters worse, most rural medical care 
providers, weary of the paperwork and long delays involved in the 
federal benefits system, often do not accept TRICARE, the military 
health insurance for active-duty soldiers and their families. The 
program offers a 180-day transitional benefit for soldiers after 
discharge.
    There is evidence that the VA has known for some time about the 
need to focus more on rural care. A 2004 VA study of 750,000 veterans 
found that those living in rural areas tended to have more serious and 
costly health problems than their urban counterparts. Perhaps the VA 
could reach a lot of the veterans who live in rural Maine by expanding 
the use of fee-basis care, in which the VA contracts its services out 
to a third-party provider. Certainly, the myriad issues involved in 
providing healthcare for rural veterans must be addressed by the VA's 
new Office of Rural Health, which has been slow to get started.
Veterans Health Administration Office of Rural Health
    In accordance with section 212 of the Pubic Law 109-461, VA 
established an Office of Rural Health. The mission of the office is to 
develop policies and identify and disseminate best practices and 
innovations to improve services to veterans who reside in rural areas. 
The law states:

      Section 212c(3) ``To designate in each Veterans 
Integrated Service Network (VISN) an individual who shall consult on 
and coordinate the discharge in such Network of programs and activities 
of the Office for veterans who reside in rural areas of the United 
States.

Public Law 109-461--Sec. 822. Business Plans For Enhanced Access To 
        Outpatient Care In Certain Rural Areas
      (a) Requirement--Not later than 180 days after the date of the 
enactment of this Act, the Secretary of Veterans Affairs shall submit 
to the Committee on Veterans' Affairs of the Senate and the Committee 
on Veterans' Affairs of the House of Representatives a business plan 
for enhanced access to outpatient care (as described in subsection (b)) 
for primary care, mental health care, and specialty care in each of the 
following areas:

       (1)  The Lewiston-Auburn area of Maine.
       (2)  The area of Houlton, Maine.
       (3)  The area of Dover-Foxcroft, Maine.
       (4)  Whiteside County, Illinois.

      (b) Means of Enhanced Access--The means of enhanced access to 
outpatient care to be covered by the business plans under subsection 
(a) are, with respect to each area specified in that subsection, one or 
more of the following:

       (1)  New sites of care.
       (2)  Expansions at existing sites of care.
       (3)  Use of existing authority and policies to contract for care 
where necessary.
       (4)  Increased use of telemedicine.

    Mr. Chairman, we are in an emergency situation in Maine, and VVA is 
seeking your help in Congress to expedite the provision stated in P.L. 
109-461. Otherwise, our disabled veterans'--both young and old--will be 
forced to continue their long-distance travel for care and treatment to 
the nearest VHA Medical Center, clinic, or hospital. We pioneered the 
first rural or rural-rural VA clinic as I like to call it, in the 
country. It covers an area bigger than the States of Connecticut and 
Rhode Island. It sits about 260 miles north of Togus VAMC. We quickly 
went from 1 day a week to 5 days a week with three providers and staff 
treating over three thousand veterans a month. There are also two 
mental health providers on board with telemedicine health 2 days a 
week. This was a great start to the VA's commitment to its veterans. 
But we veterans had to fight for this every step of the way. In the 
beginning we were told this would never happen.
    If you travel into the farm towns of any State in the Union, you 
see lots of veterans who need help and are having difficulty finding 
it. Should we lose veterans who protected this Nation so honorably 
because our government was unwilling to look past politics? I think 
not!
    Since 1982, Vietnam Veterans of America has been a leader in 
championing appropriate and quality health care for all women veterans. 
Additionally, although women veterans are authorized the same benefits, 
services and compensation as their male counterparts, many women do not 
know their rights as veterans, and they do not know how to access VA 
programs. Some concerns remain in the treatment, delivery, and 
monitoring of services to women veterans.
WOMEN VETERAN PROGRAM MANAGERS
    The duties, responsibilities, advocacy, oversight and reporting of 
the VA Women Veteran Program Managers, as defined in their handbook 
(1330.2), are substantial. VVA calls for the VA to provide the Women 
Veteran Program Managers with a minimum of 20 hours per week to 
accomplish the responsibilities of the position. VVA believes that 
these significant duties and responsibilities are essential and should 
not be minimized in light of the collateral duties they usually must 
perform. Further, we believe that while each VISN must designate, 
support, and utilize one of its Medical Center Woman Veteran Program 
Managers as the VISN Women Veteran Program Manager, we believe 
additional time must be allocated for these increased duties and 
responsibilities.
PTSD AND SUBSTANCE ABUSE
    The VA counts PTSD as the most prevalent mental health malady (and 
one of the top illnesses overall) to emerge from the wars in Iraq and 
Afghanistan, but the VA is facing a wave of returning veterans who are 
struggling with memories of a war where it's hard to distinguish 
civilians from enemy fighters and where the threat of suicide attacks 
and roadside bombs hovers over the most routine mission. Moreover, the 
return of so many veterans from Afghanistan and Iraq is squeezing the 
VA's ability to treat yesterdays' soldiers. Top VA officials have said 
that the agency is well-equipped to handle any onslaught of mental 
health issues and that it plans to continue beefing up mental health 
care and access under the administration's budget proposal released in 
mid-February.
    Yet according to a Government Accountability Office (GAO) report 
issued in November 2006, the VA did not spend all of the extra $300 
million budgeted to increase mental health services and failed to keep 
track of how some of the money was used. The VA launched a plan in 2004 
to improve its mental health services for veterans with PTSD and 
substance-abuse problems. To fill gaps in services, the department 
added $100 million for mental health initiatives in 2005 and another 
$200 million in 2006. That money was to be distributed to its regional 
networks of hospitals, medical centers, and clinics for new services. 
But the VA fell short of the spending by $12 million in 2005 and about 
$42 million in fiscal 2006, said the GAO report. It distributed $35 
million in 2005 to its 21 health care networks but did not inform the 
networks the money was supposed to be used for mental health 
initiatives. VA medical centers returned $46 million to headquarters 
because they could not spend the money in FY'06.
    More troubling, however, is the fact that the VA cannot determine 
to what extent about $112 million was spent on mental health services 
improvements or new services in 2006. In September 2006, the VA said 
that it had increased funding for mental health services, hired 100 
more counselors for the Vet Center program, and subsequently was not 
overwhelmed by the rising demand. That money is only a portion of what 
VA spends on mental health. The VA planned to spend about $2 billion on 
mental health services in FY'06. But the additional spending from 
existing funds on what the VA dubbed its Mental Health Care Strategic 
Plan was trumpeted by VA officials as a way to eliminate gaps in recent 
and future mental health.
    Furthermore, VVA believes there is a need for increased VA research 
specifically focused on women veterans' mental health issues. For 
example, as of August 2006 VA data showed that 25,960 of the 69,861 
women separated from the military during fiscal years 2002-06 sought VA 
services. Of this number approximately 35.8 percent requested 
assistance for ``mental disorders'' (i.e., based on VA ICD-9 
categories) of which 21 percent was for PTSD, with older female vets 
showing higher PTSD rates. Also, as of early May 2007, 14.5 percent of 
female OEF/OIF veterans reported having endured military sexual trauma 
(MST). Although all VA medical centers are to have MST clinicians, very 
few clinicians within the VA are prepared to treat co-occurring combat-
induced PTSD and MST. These issues need to be addressed.
    The VA will need to directly identify its ability and capacity to 
address these issues along with providing oversight and accountability 
to the delivery of their services. VVA believes that the VA has twelve 
programs that address PTSD in women veterans, but they are not 
exclusively for MST (some are general PTSD programs) and not all are 
gender-specific programs.
    A concern for the environment of the delivery of services also 
exists in the residential programs of the VA. Most if not all 
residential programs are designed for treatment of mental health 
problems. The veterans of these programs are a very vulnerable 
population. This was particularly brought to our attention in regard to 
women veterans, who, in light of the high incidence of sexual trauma, 
rape, MST, and domestic violence find it difficult, if not impossible, 
to share residential programs with male veterans. They openly discuss 
their concern for a safe treatment setting, especially on units where 
the treatment unit layout does not provide them with a physically 
segregated, secured area. They also discuss the need for gender-
specific group sessions, in light of the nature of some of their 
personal and trauma issues. VVA asks that all residential treatment 
areas be evaluated for the ability to provide this environment; that 
medical center facilities develop cost plans to address this 
accommodation; that these facilities report the findings for 
consideration to their respective VISN and to VA Central Office, Office 
of the Under Secretary for Health.
    This submission points to the need for a well-conceived and well-
implemented long-range plan for healthcare services and delivery for 
our women veterans. To VVA's knowledge no such plan exists. Although 
the VA has taken great strides in the past 15 years toward improvement 
of the quality of care for female veterans, there is always room for 
improvement. While it is fair to say that the quality of care at most 
VA facilities is equal to that of any other medical system in the 
world, it does not help women veterans who cannot access that fine care 
because services aren't available.
    In closing, VVA would like your support of H.R. 4107, Women 
Veterans Health Care Improvement Act, introduced by Rep. Stephanie 
Herseth Sandlin (D-SD) and S. 2799 Women Veterans Health Care 
Improvement Act of 2008, introduced by Senator Patty Murray (D-WA).
    Mr. Chairman and members of the Subcommittee, on behalf of Vietnam 
Veterans of America, and the Veterans in Maine, I thank you for your 
continued hard work and dedication to this issue. I will be happy to 
answer your questions.

                                 
     Prepared Statement of Joseph E. Wafford, Supervisory National
    Service Officer, Department of Maine, Disabled American Veterans
    Chairman Michaud and other Members of the Subcommittee:
    Thank you for requesting the testimony of the Disabled American 
Veterans (DAV), Department of Maine, at today's field hearing of the 
Subcommittee. DAV is a national veterans service organization of 1.3 
million members, and is dedicated to rebuilding the lives of disabled 
veterans and their families.
    The topics before the Subcommittee--women, rural and special needs 
veterans--are of acute interest to DAV in Maine and nationwide. Maine, 
with an adult population of 970,000, is home to 155,000 veterans, who 
constitute 16 percent of our adult population, among the highest 
proportion of veterans in any State. Also, with so many members of the 
National Guard and Reserve forces fighting the wars in Iraq and 
Afghanistan, including the Maine National Guard, and with nearly half 
of those serving coming from rural, remote and frontier areas, access 
to Department of Veterans Affairs health care and other VA services in 
rural areas is perhaps VA's most pressing challenge today, and is an 
exceedingly important issue in this State. Within that set of 
challenges, we are encouraging VA to do a better job of addressing the 
needs of women veterans, who are playing such an important role in 
these war deployments, and because of that exposure, are suffering a 
degree of disability and combat-related illnesses that we have never 
seen before in American military expeditions. In that regard, we urge 
the Subcommittee to swiftly consider and approve a bill, H.R. 4107, the 
Women Veterans Health Care Improvement Act, offered by Representatives 
Herseth Sandlin and Brown-Waite, two Members of your Committee. We are 
seeing a large number of rural veterans, both men and women, coming 
home from these wars with severe injuries and illnesses. Therefore, we 
are very pleased that the Subcommittee is turning its attention to 
these issues, and urge that you maintain that strong focus.
    As you know, VA operates a major regional medical center in Togus, 
near Augusta. Opened in 1866, the Togus facility was the first national 
home for disabled volunteer soldiers. Today, Maine's only VA medical 
center plays a major role in the community and State, providing 
medical, surgical, psychiatric and nursing home care. It is also a 
significant employer in the Augusta community.
    VA also operates community-based outpatient clinics (CBOC) in 
Bangor, Calais, Caribou, Rumford and Saco, and there is a part-time 
outpatient clinic in Lincoln. Also the VA's Readjustment Counseling 
Service has established ``Vet Centers'' in Bangor, Lewiston, Caribou, 
Portland and Springvale, and VA provides a mental health clinic in 
Portland. Given the vast distances, severe weather and geographical 
barriers of our beautiful State, coordination of health care and 
patient referrals for subspecialty services are major, continuing 
challenges, both within the VA and in the State's private sector as 
well. In an effort to provide more effective health care to Maine's 
veterans, the Togus Center operates a home tele-health program that 
currently aids 116 veterans, and uses VA's video ``Help Buddy'' system 
to monitor the health status of outpatient veterans who live at a 
distance from the Medical Center.
    Mr. Chairman, as you know, VA had planned to open a CBOC in Dover 
Foxcroft, but those plans were shelved due to an insufficient veteran 
population base to support a full time VA clinic. DAV believes that 
area still needs VA's attention, and we highly recommend that Togus 
provide a ``satellite van'' or a portable physician office to serve 
veterans in that area. Once veterans in the Dover Foxcroft area become 
aware that VA has established a health care presence for them, even on 
a part time basis, this may help justify a full time clinic later on in 
that community. We would appreciate the Subcommittee's making that 
recommendation to the VA.
    According to VA, in 2006 (latest information available), inpatient 
admissions to VA health care facilities in Maine totaled 1,696, while 
outpatient visits reached 325,718. Also, 17,474 veterans 65 years of 
age and older received health care from VA in 2006. VA makes a wide 
range of geriatric, rehabilitation and extended care services available 
and offers expanded programs to meet the growing needs of this elderly 
population. The Togus VA Medical Center offers elderly veterans 
geriatric primary care, geriatric and gero-psychiatric consultations, 
geriatric evaluation, nursing home and dementia care, as well as 
palliative and respite care.
    Mr. Chairman, in Maine, more than 1,400 active duty service members 
and veterans of the Global War on Terror have sought VA health care. 
Many veterans from the conflicts in Iraq and Afghanistan have visited 
Vet Centers. These community-based Vet Centers serve as an important 
resource for veterans who, once home, often seek out fellow veterans 
for advice to help them transition back to civilian life.
    The State of Maine operates six State veterans homes supported by 
VA subsidies. They are located in Augusta (120-bed skilled care and 30-
bed residential care); Bangor (120-bed skilled care); Caribou (40-bed 
skilled care and 30-bed residential care); Scarborough (120-bed skilled 
care and 30-bed residential care); South Paris (62-bed skilled care and 
30-bed residential care) and Machias (30-bed residential care). We are 
very fortunate in Maine to have these homes available to the State's 
war veterans as a continuing source of care and comfort in their 
elderly period. One difficulty, however, that concerns us is that our 
State Homes do not provide a rehabilitation or convalescence 
capability. Given our elderly veteran population's needs, the State 
Homes could offer veterans a great new service if they embraced a 
rehabilitation/convalescence mission in partnership with the Togus 
Medical Center. Many veterans in inpatient care at the Togus VA Center 
live in Bangor, Caribou and other communities at great distance from 
Togus. Following surgery or other invasive care in Togus, if they had a 
local residential provider available to help them with rehabilitation, 
these veterans could be placed closer to home. The State Homes are 
available but do not offer rehabilitation, so often these veterans are 
admitted to community nursing homes at higher cost to the VA. I 
encourage VA to consider exploring such an arrangement with the Maine 
Veterans Homes to see whether such a referral partnership for post-
hospital convalescence is feasible.
    In general, current law limits VA in contracting for private health 
care services to instances in which VA facilities are incapable of 
providing necessary care to a veteran; when VA facilities are 
geographically inaccessible to a veteran for necessary care; when a 
medical emergency prevents a veteran from receiving care in a VA 
facility; to complete an episode of VA care; and, for certain specialty 
examinations to assist VA in adjudicating disability claims. VA also 
has authority to contract for the services in VA facilities of scarce 
medical specialists. Beyond these limits, there is no general authority 
in the law to support any broad VA contracting for populations of 
veterans.
    The Independent Budget (IB) veterans service organizations 
(Disabled American Veterans, Veterans of Foreign Wars of the United 
States, AMVETS and Paralyzed Veterans of America) agree that VA 
contract care for eligible veterans should be used judiciously and only 
in the specific circumstances described above so as not to endanger VA 
facilities' ability to maintain a full range of specialized inpatient 
services for all enrolled veterans. We believe VA must maintain a 
``critical mass'' of capital, human and technical resources to promote 
effective, high quality care for veterans, especially those disabled in 
military service and those with highly sophisticated health problems 
such as blindness, amputations, spinal cord injury or chronic mental 
health problems. We are concerned that in an open environment of mixed 
government and private providers with tight budgets, the contracted 
element (particularly if it were focused on acute and primary care to 
large populations) would inevitably grow over time, and place at risk 
VA's well-recognized qualities as a renowned and comprehensive 
provider. We believe such a distributed program would not only become 
prohibitively expensive, but also could damage VA's health professions 
affiliations--the bedrock of VA quality care.
    We believe the best course for most enrolled veterans in VA health 
care is for VA to provide continuity of care in facilities under the 
direct jurisdiction of the Secretary of Veterans Affairs. For the past 
twenty-five years or more all major veterans service organizations have 
consistently opposed a series of proposals seeking to contract out or 
to ``privatize'' VA health care to non-VA providers on a broad or 
general basis. Specific incidences of such proposals have occurred in 
the States of Maryland, Minnesota, Oregon and Florida. Ultimately, 
these ideas were rejected by Congress or the Federal courts. We believe 
such proposals--ostensibly seeking to expand VA health care services 
into broader areas serving additional veteran populations at less cost, 
or providing health care vouchers enabling veterans to choose private 
providers in lieu of VA programs, in the end only dilute the quality 
and quantity of VA services for all veteran patients. Given the dire 
financial straits VA has experienced over several recent fiscal years, 
this is an important policy to sick and disabled veterans, and to those 
who represent their interests.
    Mr. Chairman, aside from these concerns, we know that VA's contract 
workloads have grown significantly. VA currently spends more than $2 
billion annually on contract health care services, from all sources. 
Unfortunately, VA does not adequately monitor this care, consider its 
relative costs, analyze patient care outcomes, or even establish 
patient satisfaction measures for most veterans under the care of 
contract providers. VA has no systematic process for contract care 
services to ensure the care is safe and delivered by certified, 
licensed, credentialed providers. Also, VA does not monitor continuity 
of contract care or ensure that these veterans are properly referred 
back to the VA health care system following private care. Records of 
veterans' contract care are inadequate in documenting the associated 
pharmaceutical, laboratory, radiology and other key information 
relevant to the episode(s) of care, nor does VA know if the care 
received is consistent with a continuum of VA care.
    Several times the Independent Budget has recommended that VA 
implement a program of community contract care coordination that 
includes integrated clinical and claims information for veterans 
currently cared for by community-based providers. VA is yet to take 
these actions.
    In order to meet the needs of our newest generation of veterans 
with access challenges and special needs, particularly in a State such 
as Maine, it will be crucial for VA to develop an effective care 
coordination model that achieves VA's responsibilities to these 
veterans. Developing an effective care coordination model would improve 
patient care quality, optimize use of VA's limited resources, and 
prevent overpayments when eligible veterans utilize contract community 
care.
    Mr. Chairman, the information expressed above is the basis for the 
IB recommendation on coordination of community care. Based on our 
current knowledge of VA's ongoing demonstration called ``Project HERO 
(Healthcare Effectiveness and Resource Optimization),'' VA is not fully 
employing our recommended model in that demonstration, which has been 
put in place in Veterans Integrated Service Networks (VISNs) 8, 16, 20 
and 23. While this demonstration does not directly affect VA programs 
in the State of Maine, it is of rising concern among veterans and 
organizations that represent them in the States that are a part of this 
demonstration. The Independent Budget veterans organizations are united 
that whatever emerges from that demonstration, we believe as 
representatives of millions of enrolled, sick and disabled veterans, 
that the Veterans Health Administration (VHA) needs to closely 
coordinate with our community any proposed expansion of the Project 
HERO initiative.
    We appreciate the recent change in VA policy on beneficiary travel 
reimbursement, increasing the rate of reimbursement from eleven cents 
per mile to 28.5 cents. This increase, made after over 30 years of 
stagnancy, helped to ease rural veterans' ability to access VA 
facilities for their care. We thank you for supporting that change, and 
for providing the new funding essential to enable VA to adopt the new 
policy. Unfortunately, recent dramatic gasoline price increases have 
wiped out most of that improvement, but we are grateful nevertheless.
    Mr. Chairman, we appreciate your Subcommittee's work in 
establishing the VA Office of Rural Health (ORH) in legislation enacted 
in 2006, Public Law 109-461. Veterans in Maine and elsewhere have high 
expectations for that office to establish creative and effective 
policies in meeting veterans' healthcare needs in rural America. The 
Independent Budget for Fiscal Year 2009 made a series of 
recommendations dealing with the responsibilities of this new office, 
including the following:

      VA must ensure that the distance veterans travel, as well 
as other hardships they face be considered in VA' s policies in 
determining the appropriate location and setting for providing VA 
health care services;
      VA must fully support the right of rural veterans to 
health care and insist that funding for additional rural care and 
outreach be specifically appropriated for this purpose, and not be the 
cause of reduction in highly specialized VA medical programs needed for 
the care of sick and disabled veterans;
      VA should ensure that mandated outreach efforts in rural 
areas required by Public Law 109-461 be closely coordinated with the 
Office of Rural Health;
      Mobile Vet Centers should be established, at least on a 
pilot basis, to provide outreach and counseling for veterans in rural 
and highly rural areas;
      Through its affiliations with schools of health 
professions, VA should develop a policy to help supply health 
professions clinical personnel to rural VA facilities and practitioners 
to rural areas in general. The VHA Office of Academic Affiliations, in 
conjunction with Office of Rural Health, should develop a specific 
initiative aimed at taking advantage of VA's affiliations to meet 
clinical staffing needs in rural VA locations;
      The VA Secretary should use existing authority to 
establish a Rural Veterans Advisory Committee under the Federal 
Advisory Committee Act, to include membership by veterans service 
organizations (including those that offered the Independent Budget). 
Mr. Chairman, we understand the Secretary is now considering taking 
steps to establish this advisory Committee, and we applaud that 
decision;
      Recognizing that in areas of particularly sparse veteran 
population and absence of VA facilities, the Office of Rural Health 
should sponsor and establish demonstration projects with available 
providers of mental health and other health care services for enrolled 
veterans, taking care to observe and protect VA's role as coordinator 
of care. The projects should be reviewed and monitored by the Rural 
Veterans Advisory Committee. Funding should be made available to the 
Office of Rural Health to conduct these demonstration and pilot 
projects outside of VERA, and VA should report the results of these 
projects to the Committees on Veterans' Affairs;
      At highly rural VA CBOCs, VA should establish a staff 
function of rural out reach worker to collaborate with rural and 
frontier non-VA providers to establish referral mechanisms to ease 
referrals by these providers to direct VA health care when available, 
or VA-authorized care by other agencies;
      Rural outreach workers in VA's rural CBOCs should receive 
funding and authority to enable them to purchase and provide public 
transportation vouchers and other mechanisms to promote rural veterans' 
access to VA health care facilities that are distant to their rural 
residences. This travel program should be inaugurated as a pilot 
program, in a small number of facilities. If successful as an effective 
access tool for rural, remote and frontier veterans who need access to 
direct VA care and services, it should be expanded into other rural 
areas; and
      The ORH should seek and coordinate the implementation of 
novel methods and means of communication, including use of the 
worldwide web and other forms of telecommunication and telemetry, to 
connect rural, remote and frontier veterans to VA health care 
facilities, providers, technologies and therapies, including greater 
access to their personal health records, prescription medications, and 
primary and specialty appointments.

    Mr. Chairman, most of these recommendations are clearly applicable 
in our State. On behalf of the Independent Budget, we hope the 
Subcommittee will address these recommendations with oversight and 
further legislation if needed, to ensure they are implemented. Rural 
veterans, whether in the State of Maine or elsewhere, deserve access to 
VA health care, despite the obvious challenges we face in providing it.
    Mr. Chairman, this concludes my testimony, and I will be pleased to 
consider your questions on these important topics.

                                 
        Prepared Statement of Brian G. Stiller, Center Director,
 Togus Veterans Affairs Medical Center, Veterans Health Administration,
                  U.S. Department of Veterans Affairs
    Mr. Chairman and members of the Subcommittee, on behalf of the 1300 
employees and 400 volunteers at the Togus Veterans Affairs Medical 
Center (Togus) in Maine, I thank you for this opportunity to discuss 
the care and services we provide to veterans in Maine.
    Togus has experienced many positive changes in the delivery of 
healthcare services to veterans in Maine. One of the most significant 
changes has been an increase in numbers of enrolled veterans selecting 
Togus as their preferred choice for healthcare services and support. In 
1999, total enrollment for healthcare was 19,000. Currently, 52,000 
veterans are enrolled. Of those enrolled, 38,500 have received 
healthcare services.
    I want to focus my remarks today on three key factors in the 
delivery of healthcare in Maine. First, I will speak on the challenge 
of providing access to care in a largely rural setting. Next, I want to 
share our progress in meeting the demands in the mental health area. 
Finally, I will conclude with remarks on our current efforts in serving 
the expanding female veteran population.
    Community Based Outpatient Clinics. During the last two decades, 
Maine has experienced a remarkable and sustained shift in the delivery 
of healthcare services, particularly access to rural healthcare. Today, 
there are six full-service Community-Based Outpatient Clinics (CBOC) in 
Maine. Five of six CBOCs have expanded more than once to meet increased 
demand. Our CBOCs are located in Bangor, Calais, Caribou, Lincoln, 
Rumford and Saco.
    The new Bangor CBOC includes physical therapy, dental, optometry, 
radiology, part-time and limited specialty services as well as 
Compensation & Pension rating exams. Four of our six CBOCs now offer 
on-site phlebotomy services and all CBOCs have contracted locally for 
X-rays and immediate lab services. To minimize travel, teleretinal 
imaging services are available at Caribou. VA recently changed the 
reimbursement rate from 11 cents to 28.5 cents per mile to help offset 
some of the travel cost.
    CBOCs are an essential part of primary care and they provide 
preventive health services, health promotion and disease prevention 
programs, as well as mental health services. A part-time primary care 
access point is located in Fort Kent. To further provide care in rural 
or residential settings, Home-Based Primary Care (HBPC) teams operate 
out of Togus and Portland. These teams provide primary care and support 
services to veterans requiring short term care, as well as veterans 
seeking to maintain an independent living situation. New HBPC teams are 
authorized for Caribou and Lincoln. Recruitment for these new positions 
is ongoing.
    Rural Health. VA recently instituted the Office of Rural Healthcare 
(ORH) to specifically identify and address the needs and challenges of 
providing healthcare to veterans living in rural areas. ORH is 
leveraging rural health expertise from the public and private sectors 
and is currently working on several initiatives such as the Veterans 
Rural Health Advisory Committee, Veterans Integrated Service Network 
(VISN) Rural Consultant Program and Rural Health Resource Centers. ORH 
recently completed an analysis of outreach clinics and a Mental Health 
and Long Term Care Plan. These initiatives are a few of the additional 
mechanisms to enhance effectiveness and efficiency of healthcare 
delivery to rural areas including Maine.
    Affiliations. Togus continues to enhance existing affiliations with 
State and national medical education facilities as well as establishing 
new affiliations. We see the need to help grow and nurture the medical 
education of students in Maine, to encourage them to stay and to 
practice rural healthcare. To that end, Togus is working with the Maine 
Medical Center (MMC), a private facility in Portland to provide 
clinical positions for Maine medical students attending Tufts 
University for their rotations or residency. Similarly, Togus is 
working with the University of Southern Maine for nurse practitioner 
students and the University of New England for physician assistant and 
pharmacist students. As Husson College institutes its new pharmacist 
program, Togus will offer training opportunities to those students. 
Similar training opportunities are currently available for other 
clinical disciplines such as dental, psychology, social work, and 
nursing. In October 2008, we plan to host a ``Medical Education and 
Research'' symposium for medical education, healthcare and research 
organizations.
    Additional Initiatives. Togus continues to be a leader in health 
care by identifying and employing new technologies such as the latest 
improvements in home healthcare monitoring. Maine recently received a 
$25 million Federal Communications Commission grant to develop 
telemedicine services throughout Maine. Togus is coordinating with 
other Maine healthcare organizations to determine how best to further 
deploy and utilize this healthcare technology.
    Currently, over 150 veterans receive adjunct care via home 
telehealth using a variety of devices. VA staff use these devices to 
review medications, assess wounds, complete psychosocial assessments, 
conduct follow-up reviews for medication changes and determine if there 
are changes in health status when medications are changed. Areas of 
focus are primary care, Spinal Cord Injury, specialty or acute care and 
patients discharged from inpatient medical or mental health units. 
These devices provide timely, accurate data to allow providers to 
provide some healthcare remotely while minimizing veteran travel.
    Mental Health. I'd now like to share with you some of our 
accomplishments and successes in the mental health area. Togus Mental 
Health Service saw sustained growth in the number of unique veterans 
served from 4,230 to 5,854--a 38-percent increase from FY 04 to FY 07. 
Through the VA Mental Health Initiative process, during the same 
period, our mental health staff grew from 54 to 74, an increase of 39 
percent. With additional staffing, we are able to care for the 
increased number of veterans and develop new programs and areas of 
treatment. New services include an opiate substitution (buprenorphine) 
treatment program, a Suicide Prevention program, a recovery program, 
our first Grant and Per Diem homeless facility, an integrated mental 
health and primary care team located in the primary care area at the 
Togus campus, three new clinicians for our Post Traumatic Stress 
Disorder (PTSD) Clinical Team and a vocational rehabilitation staffer 
for a supported employment program. Care for veterans in rural Maine 
improved with all of our northern CBOCs having telemental health 
connectivity and many having in-home video phone connections. All Maine 
CBOCs now have on-site specialized mental health providers. There are 
two VA mental health clinics located in Bangor and Portland.
    To better serve combat veterans returning from Iraq or Afghanistan, 
Togus reorganized its PTSD program into a one week intensive outpatient 
program that uses a new evidenced based treatment approach: Acceptance 
and Commitment Therapy (ACT). With clinical experience in that area, we 
were asked to be consultants to the national roll-out of ACT for VA. 
This program focuses on the needs of new veterans who have careers, 
families and cannot attend a longer program. This program provides the 
basis for follow-on care in another PTSD class and individual or group 
treatment as well as a dual diagnosis treatment. This new program has 
been very well received by Operation Enduring Freedom/Operation Iraqi 
Freedom (OEF/OIF) veterans with favorable feedback. Moreover, two 
programs were conducted solely for women veterans to appropriately 
support their needs.
    We are striving to provide more intensive or specialized mental 
healthcare and residential support for veterans in rural areas, 
particularly veterans who are homeless, who are in extended treatment 
for PTSD, or who have substance abuse problems.
    Partnership with Vet Centers. PTSD treatment is readily available 
at Togus VAMC, six CBOCs, two mental health clinics and all five Vet 
Centers located in Bangor, Caribou, Lewiston, Portland and Sanford. 
Togus works in partnership with the five Vet Centers to provide mental 
health services to combat veterans throughout the State. Maine's Vet 
Centers have outreach locations to provide mental health services to 
more rural locations.
    Special Need Population. Design is nearly complete and construction 
will begin this fall on the relocation and expansion of our 16 bed 
inpatient psychiatry unit. The new unit will have 24 beds, with special 
care areas for geriatric veterans and those more acutely ill. These 
improvements will ensure care is provided in accordance with latest 
industry standards to minimize risk and ensure safety for this 
vulnerable patient population.
    Women Veterans. Women comprise about 14 percent of active duty 
Guard and Reserve forces. The ratio of enrollment for female to male 
veterans has increased over the last decade. In FY 2007, women 
comprised 5.2 percent of all veteran users nationwide and it is 
projected the percentage will increase to 8.1 percent of all veteran 
users by 2011. Approximately 42 percent of OEF/OIF women veterans are 
enrolled for VA healthcare services and 28.5 percent used VA healthcare 
services in 2007. Of these, 78.5 percent were under the age of 40, 
which presents new challenges in addressing their unique healthcare 
needs. In Maine, there are approximately 1700 women veterans receiving 
VA healthcare.
    VA is committed to identifying and meeting the various needs of 
women veterans of all ages and at all levels. Togus' women's clinic 
provides primary care, gynecology and mental health services and a bone 
densitometer to screen for osteoporosis. Maternity care is provided via 
Fee-Basis by a community provider of the veteran's choice. Mammography 
is provided via Fee-Basis at any FDA-approved site near the veteran's 
home. VA has two Performance Measures which are specific to women's 
health: breast cancer screening and cervical cancer screening. In both 
of these measures, Togus exceeded the national benchmark. All veterans 
are surveyed with a clinical reminder regarding Military Sexual Trauma 
and dedicated treatment services are available through Togus and its 
various clinics, Vet Centers or Fee-Basis as appropriate.
    We plan to purchase additional equipment to expand care to women 
veterans this year. VISN 1 primary care is evaluating women's 
healthcare educational and equipment needs at CBOCs with the goal of 
providing increased access to routine healthcare that is gender 
specific. Togus has a dedicated Women Veterans Program Manager (WVPM) 
who is also the Lead MVPM for VISN 1. To enhance outreach efforts, 
Togus hosts an annual Women Veterans Information Fair and provides a 
site for Women Veterans of America meetings.
    Mr. Chairman, to better serve Maine veterans, we must continue to 
closely monitor and meet their needs. America's veterans have earned 
the best care we can possibly provide and it is our privilege to 
provide them with the highest levels of customer service. We appreciate 
your interest and support in helping VA to successfully accomplish our 
mission of providing world-class care to all those who have so 
honorably served our great country.

                                  
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