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43–050 2009

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 

( 


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COMMITTEE ON VETERANS’ AFFAIRS 

BOB FILNER, California, Chairman 

CORRINE BROWN, Florida 

VIC SNYDER, Arkansas 

MICHAEL H. MICHAUD, Maine 

STEPHANIE HERSETH SANDLIN, South 

Dakota 

HARRY E. MITCHELL, Arizona 

JOHN J. HALL, New York 

PHIL HARE, Illinois 

MICHAEL F. DOYLE, Pennsylvania 

SHELLEY BERKLEY, Nevada 

JOHN T. SALAZAR, Colorado 

CIRO D. RODRIGUEZ, Texas 

JOE DONNELLY, Indiana 

JERRY MCNERNEY, California 

ZACHARY T. SPACE, Ohio 

TIMOTHY J. WALZ, Minnesota 

STEVE BUYER, Indiana, Ranking 

CLIFF STEARNS, Florida 

JERRY MORAN, Kansas 

HENRY E. BROWN, JR., South Carolina 

JEFF MILLER, Florida 

JOHN BOOZMAN, Arkansas 

GINNY BROWN-WAITE, Florida 

MICHAEL R. TURNER, Ohio 

BRIAN P. BILBRAY, California 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida 

VERN BUCHANAN, Florida 

VACANT 

MALCOM A. SHORTER, Staff Director 

SUBCOMMITTEE ON HEALTH 

MICHAEL H. MICHAUD, Maine, Chairman 

CORRINE BROWN, Florida 

VIC SNYDER, Arkansas 

PHIL HARE, Illinois 

MICHAEL F. DOYLE, Pennsylvania 

SHELLEY BERKLEY, Nevada 

JOHN T. SALAZAR, Colorado 

JEFF MILLER, Florida, Ranking 

CLIFF STEARNS, Florida 

JERRY MORAN, Kansas 

HENRY E. BROWN, JR., South Carolina 

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. 


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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 


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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 


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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 healthcarerelated 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 


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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, 31⁄2 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. 


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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 


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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 


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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 antiveteran, 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. 


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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 

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opment (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 


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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-theground 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. 


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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 AssociaVerDate Nov 24 2008 23:53 Feb 10, 2009 Jkt 043050 PO 00000 Frm 00014 Fmt 6633 Sfmt 6633 E:\HR\OC\43050.XXX 43050

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tion 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 


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the Lewiston/Auburn area and the access points in Houlton, DoverFoxcroft 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 21⁄2

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. 


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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. 


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[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 longterm 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. 


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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. 


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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 nonVA 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, 


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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. 


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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 


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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 feefor-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 


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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. 


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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? 


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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, 


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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 


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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 


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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? 


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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 parttime 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 


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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 feebasis care, in which the VA contracts its services out to a thirdparty 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 


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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 satVerDate Nov 24 2008 23:53 Feb 10, 2009 Jkt 043050 PO 00000 Frm 00032 Fmt 6633 Sfmt 6633 E:\HR\OC\43050.XXX 43050

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ellite 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 


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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 DoverFoxcroft 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. 


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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 earVerDate Nov 24 2008 23:53 Feb 10, 2009 Jkt 043050 PO 00000 Frm 00035 Fmt 6633 Sfmt 6633 E:\HR\OC\43050.XXX 43050

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lier 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 feefor-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. 


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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 


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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. § 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 lifethreatening 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 


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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. 


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In addition to the Medical Center and its outlying clinics, we further provide care in rural and residential settings using homebased 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 inhome 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 


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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 numVerDate Nov 24 2008 23:53 Feb 10, 2009 Jkt 043050 PO 00000 Frm 00041 Fmt 6633 Sfmt 6633 E:\HR\OC\43050.XXX 43050

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ber 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 probVerDate Nov 24 2008 23:53 Feb 10, 2009 Jkt 043050 PO 00000 Frm 00042 Fmt 6633 Sfmt 6633 E:\HR\OC\43050.XXX 43050

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lems 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. 


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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 genderspecifics 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 


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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 gogetter. 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.] 


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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. 

f 

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. 


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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 


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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. 

f 

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 


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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. 3 CARES Commission Report, Chapter 5 VISN Recommendations, Page 5-15. 

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. 

6 CARES Commission Report, Chapter 5 VISN Recommendations, Page 5-18, 19. 

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. 

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

‘‘. . . 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

‘‘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

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. 

Year Veteran 

Population* Veterans > 55 Percent of Veteran Population 

2007 144,007 93,780 65 percent 

2010 138,551 91,200 66 percent 

2015 129,091 86,700 68 percent 


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Year Veteran 

Population* Veterans > 55 Percent of Veteran Population 

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. 


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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. 

f 

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 


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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. 

f 

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 curVerDate Nov 24 2008 23:53 Feb 10, 2009 Jkt 043050 PO 00000 Frm 00052 Fmt 6604 Sfmt 6621 E:\HR\OC\43050.XXX 43050

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rently 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. § 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. § 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. 


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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 longterm 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. 


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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 serviceconnected 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. 

f 


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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 


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America has been repeatedly identified as one of the topmost issues facing Statelevel 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. 

f 

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. 


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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. 


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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 


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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. 

f 

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 communitybased 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 proVerDate Nov 24 2008 00:43 Feb 11, 2009 Jkt 043050 PO 00000 Frm 00060 Fmt 6604 Sfmt 6621 E:\HR\OC\43050.XXX 43050

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viding 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 longdistance 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. 


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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 No- vember 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 cooccurring 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 genderspecific 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 


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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. 

f 

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 


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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 communitybased 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. 


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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 


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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. 

f 

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 CommunityBased 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 


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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. 


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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. 

Æ 


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