[House Hearing, 109 Congress]
[From the U.S. Government Publishing Office]


 
              RURAL VETERANS' ACCESS TO PRIMARY CARE:
                      SUCCESSES AND CHALLENGES

Monday, August 22, 2005

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

	The Subcommittee met, pursuant to call, at 9:06 a.m., at 
Eastern Maine Community College, Room 501, Rangeley Hall, 354 
Hogan Road, Bangor, Maine, Hon. Henry E. Brown, Jr., [Chairman of 
the Subcommittee] Presiding.

	Present:  Representatives Brown and Michaud. 

	Mr. Brown of South Carolina.  Good morning.  My name is Henry 
Brown and I chair the Health Subcommittee of the Veterans 
Committee.  I'm from South Carolina.
	It is a real pleasure to be up in Maine.  This is my first 
stop.  And, you know, I left that 95 degree heat, it just came 
down from a hundred degrees.  So, it's been a real pleasure this 
morning to wake up and enjoy the nice cool temperatures that you 
folks have here.
	It's a real pleasure to be here.  I know Mike Michaud and I 
serve together in Congress, and two years ago we served on the 
Veterans Benefits Subcommittee.  And then I got to be Chairman of 
the Health Subcommittee, and Mike got to be Ranking Member on that 
Subcommittee, so it's been a real good working relationship.  And 
our goal as the chair of the Health Committee is to try and 
improve the health care delivery for veterans.  And we try to do 
some things to get us up with the 21st Century and deal with some 
other issues that we have.
	And we're grateful today to come and listen to you, the 
veterans, and make absolutely sure that this is working; not just 
in South Carolina or in Texas, but in Chicago and also in Maine.
	Rural healthcare is a big issue for us, because, in a state 
like Maine, and even some little areas in South Carolina, where 
accessability to good healthcare is a major concern.
	We also have with us some staff members of the Senate.  And I 
know Mark Kontio is here -- Mark, would you raise your hand -- 
thanks for coming -- from Senator Olympia Snowe's office.  Jon 
Ford from Senator Collins' office.  Matt LaPointe from Thomas 
Allen's office.
	Although the Senators and Congressman Allen were not able to 
come, I'm pleased that Congressman Allen asked us to submit his 
statement in the record, and we will certainly be happy to do 
that.
	[The statement of Thomas Allen appears on p. 33]

	Before delving into the subject of today's hearing, I would 
like to extend my heart-felt thanks to both my staff and Mr. 
Michaud's staff I would like to recognize Jeff Weekly and Dolores 
Dunn from my staff - - Mike, if you would recognize your staff -- 
	Mr. Michaud.  Yes, Linda Bennett, from my staff, as well as 
my staff from the State of Maine, and several are here today.
	I would like to thank them -- and your staff, Chairman Brown 
-- for coordinating this hearing.  I appreciate all of the hard 
work.
	Mr. Brown of South Carolina.  Well, I certainly appreciate 
the hospitality that you've shown, Mike, and your staff since we 
have been here together.  And I look forward to going to Togus 
later today and see the medical facility up there.
	Today we examine how the VA is providing primary care to 
veterans in rural Maine; what challenges the VA confronts in 
providing care for veterans in the state; and what unique and 
innovative measures serve as potential solutions to meet these 
challenges.
	The panels we will hear from today, because of their roles 
inside and outside of VA, will help us better understand the 
current state of play for Mainers and the gaps that have developed 
due to the rural make-up of the state.
	As Chairman, it is my hope that when gaps in treatment or 
clinical care are identified, we put significant effort behind 
developing new and innovative approaches to providing care for 
those who live long distances from VA medical centers or 
community-based outpatient clinics.
	We must remember, however, Maine is not alone when it comes 
to providing rural care to our veterans.  So, the solutions we 
consider as policymakers -- those already in use, or new ideas 
generated as a result of this hearing -- should be exportable to 
other states and localities in the United States, so that all 
eligible and enrolled veterans can benefit.
	I now yield to my good friend, Mike Michaud.
	Mr. Michaud.  Thank you very much, Mr. Chairman.  And once 
again, I want to welcome you, your staff, and staffs from other 
lawmakers.  I welcome you to the State of Maine, and hopefully 
you'll have an enjoyable stay while you are here.  I want to thank 
Eastern Maine Community College for allowing us to use their 
facility here this morning, I really appreciate that.
	I also want to thank all of the veterans who are here today.  
I know a lot of them have traveled great distances to get here, 
several over three hours this morning, so I really appreciate your 
time and effort to come here this morning.
	Mr. Chairman, I want to especially thank you for agreeing to 
hold this hearing in the State of Maine.  And there's another 
hearing in South Carolina next month.
	I know the Chairman and I are definitely united in a 
bipartisan effort to look at taking care of our veterans.  It is a 
high priority for both of us.
	It is a great honor to serve with you, Mr. Chairman, in a 
bipartisan effort over the last three years to make sure that the 
veterans get the services they need.
	I'm also very pleased that the Democrats and Republicans came 
together earlier this year to correct the shortfall that we 
received in the original budget as it relates to veterans.
	That bipartisan effort was put forth in a supplemental 
budget, that the President signed on August 2nd, and we're very 
pleased with the additional funding.
	The budget shortfall definitely hurt the veterans' access to 
care and quality of care; it was put at risk.
	In Maine, the VA had to put a hold on filling many staff 
positions until the new funds were released.
	I must say I am surprised that the VA Central Office was 
caught by surprise by the shortfall in June.  The Bangor Daily 
News had reported back in January that there was a 14 million 
dollar shortfall at the Togus VA Medical Center.
	I hope that we can continue working in a bipartisan manner 
and keep the dialogue open to make sure that we find long-term 
solutions for VA funding.
	I'm fully supportive of mandatory funding.
	If members of Congress, the President and his Cabinet, and 
federal employees are guaranteed healthcare benefits, then I think 
veterans should be guaranteed their healthcare benefits as well.
	As we tackle the underlying flaws that we find in the budget 
process, we also must look at how do we take care of Priority 8 
veterans as well.
	Mr. Chairman, we have a proud tradition here in Maine in 
answering the call to service.  One in six Mainers are veterans.  
And we are very pleased with that.
	We have a new generation of veterans who are risking their 
lives in Iraq and Afghanistan.
	Americans from small rural towns, in your state and mine, 
have taken on more than their share of answering the call to serve 
their country.
	I think it's important to the returning soldiers who need the 
help readjusting once they get back home, that we will provide 
that help.  We'll be looking at the need also for quick access for 
mental health services to prevent the chronic mental health 
problems that we are seeing.
	We must not fail these heroes by ignoring that need.  I look 
forward to hearing from Veterans Integrated Service Network, or 
VISN, 1 Director, Dr. Post; and Togus VAMC Director, Jack Sims -- 
looking forward to their testimony, and the efforts to expand the 
capacity to serve veterans in the state of Maine, which is 
definitely needed.
	I'm also looking forward to hearing from them as well on the 
opening of CBOCs that were proposed under the CARES 
recommendations.
	Veterans need these clinics.  We must move forward to get 
these clinics up and running.  Telemedicine is great.  I believe 
telemedicine is important, but it's not the answer for all of the 
problems that we have.
	We must make sure that we do not forget that, with 
telemedicine, we must have adequate staff -- whether it's 
psychiatrists or eye doctors to meet the demand.  No amount of 
technology will make up that difference.
	I'm also concerned about the way mental health patients are 
being integrated into primary care.  Many veterans suffer from 
depression, post-traumatic stress disorder, and other mental 
health problems.
	There simply are not enough mental health care specialists to 
meet the demand.  We're looking forward to hearing about that 
issue.
	If you look at the statistics, Mr. Chairman, last year VISN 1 
spent only 60 percent of what it did nine years ago 	to treat 
veterans with serious mental illness.
	Also, VISN 1 only had 78 percent of the mental health staff 
that it had back in 1996.
	I am concerned that this means a reduction in the care for 
our veterans.  I'm looking forward to hearing the testimony from 
the VISN 1 Director and Togus VAMC Director Jack Sims.
	I want to thank you both for taking the time to come here 
this morning.
	Thank you.
	Mr. Brown of South Carolina.  Thank you very much, Mike.
	At this time we'll call the first panel to come forward.  Our 
first panel is Dr. Chirico-Post, appointed Director Of the New 
England Healthcare System in 2000.  She oversees a network of 
healthcare centers throughout the six New England states.
	Mr. John Sims has served as the Director of the VA Medical 
Center for 15 years.  His leadership has been instrumental in 
helping veterans in rural Maine access a broad range of medical 
services.
	And let's start with you, Doctor.


STATEMENTS OF JEANNETTE CHIRICO-POST, M.D., 
	NETWORK DIRECTOR, VA NEW ENGLAND HEALTHCARE
	SYSTEM; AND JOHN H. SIMS, JR., DIRECTOR, TOGUS VA
	MEDICAL CENTER

STATEMENT OF DR. JEANNETTE CHIRICO-POST

	Dr. Chirico-Post.  Good morning.  Mr. Chairman and members of 
the committee, thank you for the opportunity to appear today to 
discuss Rural Veterans Access to Primary Care:  Successes and 
Challenges.
	The New England Healthcare System is comprised of the six 
states in New England as an integrated health care delivery system 
to provide comprehensive quality, innovative care, in a 
compassionate manner to all veterans it serves.
	We serve a population of 240,000 veterans with a total budget 
of over $1.4 billion dollars.  Our eight medical centers operate 
approximately 1900 beds, and we have about 26,000 admissions to 
those beds.
	The network is committed to provide the right care at the 
right time in the right place and at the right course.
	We are committed to the unique healthcare challenges that 
Maine faces.
	We are fortunate to be affiliated with premier medical 
schools in the country, including New England College of 
Osteopathic Medicine.  And we are a leader in research and post-
graduate education.
	I'm pleased today to discuss the many areas in which VA is 
excelling in the state of Maine.  Currently there are no 
significant waiting lists or backlog for new primary care patients 
in Maine.  71.6 percent of new patients are seen within 30 days, 
and 94 percent of the established patients are seen within 30 
days.
	We've had outstanding performance in Maine in high risk, high 
volume areas, such as cancer screening and diabetic care.
	Access is enhanced in New England through a total of 38 
operational community-based outpatient clinics, with the quality 
at the same standard as it is at the medical centers.
	VHA has committed to the expansion of service and the 
transformation of mental health care, and the spectrum of services 
in Maine include both inpatient and outpatient services.
	The network very successfully secured funding recently 
throughout the six states in support of those mental health 
services.
	A grant recently received provides for the expansion of 
services to treat additional areas though substance abuse 
disorders, but not limited in that area.
	We have a number of special programs that were initiated and 
flourished in support of the frail elderly in Maine.  These home 
community-based care programs include other areas such as hospice-
veteran partnerships that exist.
	Telemedicine is a strategy to meet some of the rural 
healthcare needs in the network, including those veterans who need 
special services at a distance.
	The goal is to provide an electronic network capable of 
supporting the veteran patient wherever they live by providing 
innovative means of communication between the patient and the 
healthcare provider on site.
	Care coordination/Home Tele-health programs provide the tools 
to help patients self-manage their care, reducing hospitalizations 
and enabling them to live in the least restrictive environment.
	A recent article from the US News and World Report entitled, 
House Calls, discusses telemedicine and the VA's use of this 
innovative medical tool.
	And I would like to submit a copy of this for the record.
	Advances in telemedicine and technology are included through 
the innovative implementation of My HealtheVet, which will allow 
the veteran access through the Internet for pharmacy refill 
functionality.
	In addition to that, through the technology, we are able to 
establish consultation for our patients and additional referrals 
so the patients do not have to travel long distances.
	We work collaboratively with the Department of Defense to 
insure a seamless transition for our returning service members.  
Our computerized patient record system provides a sharing of data 
in a secure fashion.
	There are other areas in which telemedicine has provided 
enhanced access to the veterans of Maine, including dermatology, 
psychiatry, pathology, cardiac monitoring through 
electrocardiograms.
	VA is committed to ensuring a seamless transition from active 
duty to civilian status for our newest veterans returning from 
conflict in Afghanistan and Iraq.
	To date, over 5,000 veterans are enrolled in the network, 
including over 500 in Maine.  These veterans are primarily seeking 
care through primary care, dental care, and mental health 
services.
	Additionally, we have 18 Vet Centers located throughout the 
network, five in the state of Maine.
	In summary, the VA has implemented numerous innovations to 
meet the rural health care challenges facing our Maine veterans.  
And today's veterans will know, in whatever setting they receive 
their healthcare, that they are receiving the highest quality of 
healthcare from the professionals who provide that care to our 
Nation's veterans.
	Mr. Chairman, that concludes my statement.  I truly 
appreciate the opportunity to share with you how VA New England 
Healthcare System provides quality and compassionate healthcare to 
the veterans of New England.
	Mr. Brown of South Carolina.  Thank you, Dr. Chirico-Post.  
At the conclusion of Mr. Sims' remarks, we'll then have some 
questions.  Thank you.
	[The attachment appears on p. 38]
	[The statement of Dr. Chirico-Post appears on p. 40]

	Mr. Brown of South Carolina.  Mr. Sims?

STATEMENT OF JOHN H. SIMS, JR.

	Mr. Sims.  Mr. Chairman, Congressman Michaud, thank you very 
much for the opportunity to speak to you today about Rural 
Veterans Access to Primary Care in Maine.
	At Togus, as well as throughout the entire health care field, 
there is now a sustained emphasis on outpatient services, an 
emphasis that has significantly reduced hospitalization stays and 
more clearly focuses on outpatient clinics and their available 
services.
	Although we have changed the manner in which we provide our 
care, we continue to provide the same broad range of services and 
high quality care that we have always provided to an ever 
increasing number of Maine veterans.
	During my 15-year tenure as Director of the Togus VA Medical 
Center, there's been a remarkable and sustained shift in the 
delivery of health care services in Maine.  In particular, the VA 
has been progressive in its attempt to provide rural health care 
access.
	Today there are five full-time community-based outpatient 
clinics -- CBOCs -- in Maine, several of which have been expanded 
more than once to meet the increased demand.
	These full-service CBOCs are located in Caribou, Bangor, 
Calais, Rumford and Saco.  And, in addition, we have a part-time 
clinic located in Fort Kent which operates as a satellite of our 
Caribou CBOC.  In addition to primary care, an essential part of 
that primary care at our CBOCs is the provision of preventive 
health services and health promotions as well, in addition to 
disease prevention programs.
	We also have two VA mental health clinics located in Bangor 
and Portland.
	To better serve the Maine veterans, four of these CBOCs were 
recently expanded or relocated, and the remaining CBOC in Calais 
will soon be in its new location.  And we're hopeful that that 
will occur in October of this year.  We're on schedule.
	We've also been able to increase access to mental health 
throughout the state.  The Bangor CBOC has adjacent mental health 
clinic which is fully staffed and operates on a full-time basis.
	Mental health support for our Saco CBOC is provided by the 
newly expanded and relocated mental health clinic in Portland.
	Tele-mental health is in place in Caribou and is planned for 
Calais when that CBOC is relocated later this year.
	Finally, the Rumford CBOC now has an onsite mental health 
clinician one day a week with plans to expand that service when 
additional resources become available.
	One of the most significant changes in VA health care in 
Maine has been the extraordinary increase in the number of 
enrolled veterans selecting VA as their preferred choice for 
health care services.
	In 1999, we had a total enrollment of 19,000 veterans in the 
State of Maine.  2004, the end of last fiscal year, that was up to 
36,000 veterans seeking their care from VA.
	The significant piece then with regards to rural health care 
is that, back in 1999, only one-third of the veterans, were 
getting their care at a CBOC.  In 2004, half of our enrolled 
veterans are now getting their care out in the rural areas.  
Obviously, that shows that the veterans want to get their care 
closer to where they live.
	The Togus Healthcare System has been coordinating very 
closely with the Maine National Guard and various reserve units to 
conduct outreach for the Operation Iraq Freedom/Operation Enduring 
Freedom veterans as they're returning.
	The outreach efforts include healthcare and non- medical 
benefit briefings as well as information on readjustment 
counseling by the Vet Centers.
	Currently, approximately 550 of these veterans have enrolled 
for VA healthcare, and about 80 percent of those are actively 
seeking some type of medical and/or mental health care.
	At this point, the vast majority of veterans have only 
required outpatient health care.
	In May 2004, the CARES Decision identified six additional 
sites of care throughout Maine, that were authorized pending the 
availability of resources and validation with the most current 
data.
	To better meet the needs of the under served veteran 
populations, the majority of these newly authorized sites will be 
located in more rural areas of Maine, which would significantly 
further the attainment of a primary goal of providing veterans 
quality health care closer to their homes.
	Togus will continue to closely monitor implementation of 
these sites of care.
	To date we have about 69 patients receiving various stages of 
adjunctive care through tele-health devices.  Our Home-based 
primary care unit has been using video phone devices for more than 
a year to provide follow-up and on-going care to patients in 
individual and residential home settings.
	Physician assistants and nurses use these devices to review 
medications, look at wounds, complete psychosocial assessments, 
conduct follow-up reviews for medication changes, and determine if 
there have been any other changes or medications have been 
changes.
	To better serve the veterans of Maine, we must continue to 
monitor their needs and find ways to meet the challenges those 
needs present.
	America's veterans have earned the best care we can possibly 
provide, and it's our distinct privilege to provide them with the 
highest levels of customer service.
	We will continue to coordinate closely with Maine's veterans 
and with national and state Veterans Service Organizations, as we 
do our very best to address our veterans' concerns.
	We certainly sincerely appreciate your interest and support 
in helping the VA to successfully accomplish our sacred mission of 
providing world-class care to all those who have so honorably 
served our great country.
	Thank you very much.
	[The statement of Mr. Sims appears on p. 45]

	Mr. Brown of South Carolina.  Let me just say, I thank both 
of you for coming today.  Also, let me thank you both for 
addressing the challenges that we have in rural America to find 
the veterans and find some adaptable services, that we are 
committed to support and sort of move away from the institutional 
type of setting in the hospitals we have in place and try to get 
needs and services closer.
	I noticed, Dr. Post, in your testimony you talked about the 
wait time.  I'm just wondering, how is the wait time for 
specialty-type performance?
	Dr. Chirico-Post.  We continue to face significant challenges 
in meeting VHAs own standards in providing specialty services 
within 30 days.
	And throughout the network, there's a variation, if you 
would, in those challenges, primarily depending on the 
availability of specialist.
	We don't have significant delays in neurology -- I happen to 
be a neurologist -- but we do have significant delays in 
gastroenterology, eye care, orthopedic care.
	There are those sub-specialities that are difficult to 
recruit in certain areas.
	We have in place a system whereby there's a prioritization, 
if you would, for the veteran who needs that care, and how that 
care might be rendered.
	If we can not provide the care in a timely fashion in one of 
our institutions, then we seek to do that for that veteran outside 
the VA on a fee basis.
	Mr. Brown of South Carolina.  How about mental health.
	Dr. Chirico-Post.  Let me speak to mental health as well.
	We have an integrated model, if you would, of the delivery of 
services of mental health that run the gamut from simple things 
that may be managed through -- through a primary care office; like 
depression in the early stages can be managed by a primary care 
physician.
	So, those who are seriously mentally ill, they may require 
services of a psychiatrist.  I'm very proud, in New England, that 
one of the standards that VHA uses to measure how well we're doing 
in providing those services, is to look at the percentage of 
mental health care visits in our community-based outpatient 
clinics, where the enrollees total over 1500.  And we do very well 
in that -- in that network.  We're not perfect.  We face 
challenges in several of the areas.
	And, again, I'll go back to the issue of the principal 
resource of the provider being a scarce specialty to get enough 
of.
	From an innovative point of view, what we have done in the 
network is two things.  One is that, you're probably very well 
aware of our computerized patient records.  There's no health care 
organization that has a computerized system like this, so that a 
veteran who is seen in Caribou, Maine, and has consulted with me 
in Massachusetts, I can pull up the record, as well as in 
California.
	That serves as a basis, I think, for coordination continuity, 
especially in referrals.
	That's one thing.
	The other thing that we have done more recently is establish 
direct linkups through telemedicine that Mr. Sims talked briefly 
about, especially between Caribou and Togus.
	When I was chief of staff at Providence, Mr. Sims and I 
established a relationship in dermatology between Providence and 
Togus.
	The challenge that we faced in psychiatry, I think, is the 
gamut of illnesses that the individuals may have when they come to 
seek their care from us.
	So, we attempt to better coordinate that care.  We have other 
resources especially in the state of Maine that we tap into, 
called outreach centers or Vet Centers.
	In all of New England, we have 18, and in Maine we have five.
	Recently there's been separate funding for those Vet Centers.  
VA New England received a number of those in support of that, and 
we have worked very closely with our vet centers in outreach.
	Because, sometimes the veteran doesn't want to come to the 
hospital, and is much more comfortable seeing a comrade at the Vet 
Center, and then can get referred into Togus.
	Mr. Brown of South Carolina.  Do you experience difficulty in 
seeing the transfer between the DOD and the VA as far as their 
medical records.
	Dr. Chirico-Post.  Seamless transition at this time in this 
country is the best it's ever been, I think.
	The VHA has on the ground folks in Department of Defense to 
secure a better coordination of those individuals once they get 
out.
	We have an office in VHA for seamless transition.  I have a 
person in the network, Mr. Sims has a person in the facility, that 
we rely on as the point person for just that issue.
	The electronic medical record is a challenge.  There are some 
incompatibilities that exist right now, but both Department of 
Defense and VHA are committed to enhancing those technical 
challenges that we face to improve the response that might exist 
there.
	We have in the network a standardized system whereby, we go 
out to the reserve units, even before they go to discuss what will 
be available for them when they come back; we do the same thing 
when they come back.
	We have readily accessible to them a specific place that they 
can call at any one of the medical centers when they call in, so 
that we can be there for them.
	Mr. Brown of South Carolina.  I know that Mr. Michaud has 
some questions, too, but let me just ask one further question.
	In the four major services, do you have any opportunities to 
coordinate services, like with the medical universities, in those 
eight regions that you're involved in?
	I know in South Carolina, in our rural areas, we have, like, 
family health clinics for our newer vets.  I'm hearing reports 
that they were recommended that we need more coordination between 
our county governments and state governments and the VAs.
	Do you all have -- 
	Dr. Chirico-Post.  On the network side, we're very fortunate 
to have relationships, whether it's through the state government 
or through the medical schools, and other healthcare partners that 
we can partner with.
	Just here in the state of Maine, we have a wonderful 
relationship with our state veteran homes, from a long-term care 
point of view, where we work in conjunction with them.
	For the last several years, I've been the co- chair of the 
homeless coordinated program through New England.  And that brings 
to the table the state governments -- all of the New England 
states, the chairperson for Veterans' Affairs, for example, of the 
state; the VA, and Social Security, to interact and integrate and 
coordinate resources and services one with the other.
	So, we do try to take advantage of that.
	Mr. Brown of South Carolina.  In South Carolina we are 
looking at -- we also have a VA hospital in the same region or the 
same -- approximately in the same vicinity as a medical university 
hospital.
	We're looking to replace both of those facilities, and move 
the VA hospital closer to the medical university, where so many of 
the offices are located.  And that would help with the cost of the 
testing equipment, it would be a good mix to do that.
	Dr. Chirico-Post.  At the present time, as a consequence of 
the original proposals and recommendations out of the CARES 
process, we're also looking at integrating, if you would, three of 
the facilities in Eastern Massachusetts.  And part of the equation 
of that is the relationship with the schools.  And part of the 
equation is, how do you best utilize that technology?  How do you 
better integrate the research programs?
	VA New England has received -- the largest number of dollars 
from all of the VHA research comes to New England.
	So, we still have a number of those physicians and Ph.D. 
Individuals who do the research and observations, if you would, in 
the VHA.
	But, in addition to that, provide quality care to the 
veterans.
	Mr. Brown of South Carolina.  We also have some outpatient 
clinics, but we have a combination with DOD also, with an air 
force base in Charleston; and so that's another way of sharing.
	Thank you for your patience in answering my questions.  And I 
think Congressman Michaud may have some questions now.
	Mr. Michaud.  Thank you very much, Mr. Chairman.
	Once again, I want to thank you, Dr. Post and Mr. Sims, for 
your testimony.  We enjoyed it.
	Dr. Chirico-Post, I want to congratulate you.  I understand 
that you're going to receive the VHA Recognition Award, so I want 
to congratulate you.
	Dr. Chirico-Post.  Thank you very much.
	Mr. Michaud.  We are here to help you do whatever we can to 
make sure that we take care of the veterans.
	I want to be more specific to the state of Maine.  If you 
look at New England, you can practically fit all of New England 
inside the State of Maine.  Maine's a very large state.  We can 
drive another hour north of here, and that would be the center 
point for the State of Maine.  So, it's a big state.
	I'm concerned that, with this tight budget, that money for 
the clinics that have been recommended under the CARES process, 
and the timing to get those programs up and running.  My concern 
is, whether or not that funding will come out of the existing 
budget of Togus VAMC facility.  I definitely do not agree with 
that.
	The VISN will need additional funding for these clinics.  
With the supplemental budget that was passed, will that help move 
these clinics forward?
	Particularly, when you look at where these clinics are 
located, whether it's Dover-Foxcroft, Lincoln, Houlton, Lewiston-
Auburn area -- a lot of these areas -- I know the VA has been 
working with local healthcare providers to move these clinics 
forward, and this will be great.
	So, my question is, when will they be up and running?
	The second part of that question is, have you estimated the 
cost for each one of these clinics, what it will cost to get them 
up and running?
	Dr. Chirico-Post.  Let me begin to answer that question, and 
some of the specifics of the resources required to open up the 
individual clinics, Mr. Sims may have those specific dollars 
associated with it.
	Let me also thank you for the 1.5 supplemental that we have 
received.  I think that -- I have given my professional career to 
veteran healthcare.
	And to be recognized in that way, to receive the additional 
resources, I think demonstrated that, as good stewards of those 
resources, which I believe we are in the network, and Mr. Sims is 
in the State of Maine, that we will take those resources and do 
what's best for the veteran.
	So, having said that, the supplemental clearly brings us 
closer to the implementation of the recommendation of the CARES 
program.
	We go back in history to the foundation of the CARES program, 
which was to look at the capital assets that we had, and provide 
for enhanced services.  That's what it was.
	And the particular recommendation for -- that affects us and 
in our discussion today was, if you look out from a demographic 
point of view over the next ten and twenty years, you realize that 
the numbers, the sheer numbers that will come to us in VHA, would 
increase.
	And New England, 25 years ago, we might not have said that.  
But, clearly, three years ago, when we started the process for 
CARES, and we keep updating our numbers.
	And as Mr. Sims has said, in Maine, of the six New England 
states, the greatest market penetration is in Maine.  So, on 
average, about 27 percent of our veterans in Maine come to receive 
their care through VHA.
	CARES recognizes, given our definition of urban rural and 
highly rural, that we could -- I would say for the network, 97 
percent of the veterans who seek their care have access to care 
within 30 minutes.  That's not true of Maine.  It's less than 60 
percent.  I think it's 56 or 57 percent.
	So, the recommendations to open the clinics in Lincoln, and 
to speak out to those other areas, that probably will be outreach.
	We originally, in the CARES proposal, started out looking at 
telemedicine throughout Maine.  There were other opportunities.  
CARES was not saying that you have to do it in one way or the 
other.
	I think the network, with the facility, will come forward and 
say, this is what we would like to do.
	So, the first order of business, I think, is to open Lincoln.  
And then after that, to take a look at the other access points, if 
you would, and what's the best way of doing that.
	Clearly, the CARES recommendation came out at the end of -- 
the middle to end of '04.  In '05, the process of protocol we need 
to follow is to go back into headquarters requesting to open it.
	And one of the issues for us was the financial feasibility, 
which we could not do in '05.
	We don't know what the budget's going to be for '06.  Given 
the supplemental that we received in '05, we're fortunate that 
we're able to do a number of new things for the organization.
	A new CAT scan for Maine.  A mobile MRI unit on station in 
Togus at least two days a week.  We would never have been able to 
do that.
	I think the total dollars that came to Mr. Sims out of the 
supplemental was something like 13 million.  And that includes 
both the equipment and the maintenance that's there.
	To get back to your question.  That obviously puts us in a 
better position to be able to put together the papers and the 
protocol, and we have to see what the budget's going to be for 
'06, to move forward in that regard.
	Because, we want the same things that you want, and that's 
better access for the veterans.
	Mr. Michaud.  This may call for Mr. Sims to answer.  That 13 
million, was that FY 05?
	Dr. Chirico-Post.  Yes.
	Mr. Michaud.  Now, that 11 million dollars that was borrowed, 
was that all for Togus, or was that part of VISN 1?
	Dr. Chirico-Post.  Let me deal with the 11 million.
	Before we got the supplemental back in the spring, we 
assessed that we needed 11 million dollars in capital to do what 
we considered high priority safety issues for the organization.
	We never did borrow 11 million, we only borrowed five 
million.  And that was to be paid back with the beginning of the 
next fiscal year.
	So, the 11 million -- and I don't have that figure off the 
top of my head, how much of that were for projects here in Maine, 
but it was a fair share.
	As I look at the budget across the network, the Maine budget 
is that it has increased over certainly the five years that I have 
been network director.  And the apportionment that Maine receives 
in equipment and NRN has always been slightly greater, mostly 
because there's 36,000 veterans for us to take care of, and almost 
1000 employees that we manage in the state of Maine.
	Mr. Michaud.  The centers, Mr. Sims, how soon can they get up 
and running?
	I know, it's the goal to come closer, but I don't know when 
they're going to be up and running, No. 1.
	My next question is, I've been hearing a lot from the 
veterans in the Lewiston-Auburn area, and what are your thoughts 
about a Lewiston-Auburn CBOC?
	Mr. Sims.  First of all, we continue to, in anticipation of 
being able to get these up and running -- we've had ongoing 
discussion in many of the communities already.  They've been 
identified.
	Certainly in Lincoln, with a local facility there.  The CEO, 
we've had discussion about possibly -- about the possibility of 
space, and how we might do that.
	In the Houlton area there's a definite interest on the part 
of veteran groups there to secure a building and have that be 
available for us.
	So, there's ongoing planning in place, so that once the 
resources are available, we can move quickly and get these up in a 
reasonable time.
	Now, once we have that final notification, there are other 
logistics that are required.  Actually getting the equipment, 
getting the furniture in place, and having the space open and 
ready to work in.
	Lewiston-Auburn is an area that I think, certainly now, is a 
large demographic area -- second largest population concentration 
in the state -- and it's far enough away from Togus and our other 
sites that I think that it makes sense for that to be a site for 
us in the future as we get to that point in the planning process.
	Certainly, again, a fair amount of veteran interest in that 
area.  We're working very closely with the various grassroots 
efforts that are in place there to get a suitable site when that 
comes.
	Mr. Michaud.  I see my time's running out, Mr. Chairman.  
But, if I might, Mr. Sims, you testified -- or your testimony 
indicates that 22 percent of the newest veterans enrolled at Togus 
are using mental health services.  
	If this rate continues, will VA be able to provide mental 
health services without increasing the staff level?
	I know Maine has had an increase in funding in the VA.  But, 
when you also look at Maine, 16 percent of our population is 
veterans.  Percentage-wise, we're one of the highest in the 
country.
	Likewise, when you look at those who are actively serving in 
Iraq and Afghanistan, we are way up there in numbers.  We need the 
services.  Being a rural state, that makes it much more 
problematic.
	So, do you think that the mental health resources will be 
there?
	Mr. Sims.  I absolutely do think so.  We just recently added 
two new psychiatrists to our mental health department.
	In fact, one of those just recently came off active duty, and 
had served in Iraq, and so is very well qualified to know some of 
the things that the returning soldiers are facing.
	So, we've added new psychiatrists, other mental health staff.  
We are fully staffed in mental health at this time.
	We have emphasis on the returning veterans, and the issues 
that they're facing, particularly within our PTSD program.
	As Dr. Post mentioned, we have other programs coming online 
at our outbase clinic as well.  And I think we're in a good 
position right now to be able to deal with any of those issues 
that would come up.
	Mr. Michaud.  How is Togus integrating mental health services 
into primary care?
	Mr. Sims.  Again, there is close coordination.  With the 
computerized medical records, the primary care providers can see 
what's being done on the mental health side; and the mental health 
side can see the progress notes from the primary care providers.  
And it's just an integration of the whole services.
	They're located at Togus in close proximity to each other, 
and so consultation as needed between the providers and -- again I 
think, they are very well coordinated, and mental health services 
are in good shape.
	Mr. Michaud.  Would you be able to provide the cost for 
clinics as far as what it would cost to get clinics in Lincoln and 
Dover and all other recommended sites?
	Mr. Sims.  We could provide some preliminary costs.  Again, 
it's going to depend on what the lease cost may be ultimately and, 
you know, the size of the clinic when we finally configure it.  
But, we could come up with some preliminary costs for you.  We 
could get that to you, yes.
	Mr. Michaud.  I would appreciate that.
	[The information appears on p. 112]

	Mr. Brown of South Carolina.  Thanks Mike.  Let me follow up 
along with that same line of questioning.  I think you proposed 
five new clinics in -- I think you said 2000, and your patient 
load was, like, what, 19,000; and I think in 2004 you had like 
36,000.
	Do you anticipate by adding these new health centers that 
those numbers will go up, or do you think those numbers will be 
just shifted around to the new locations?
	Mr. Sims.  We will do some shifting around, clearly that's 
our intent for some of these.  But, we know from past experience 
that when we open up these outbase clinics, that there will be new 
enrollments as well.
	And we've had some projections in some areas.  And in 
Lincoln, for example, we're expecting maybe as many as 400 new 
enrollments initially, and then probably some growth from there.
	But, certainly, there will be some new growth.  As we put 
these CBOCs out in the rural areas, as Dr. Post mentioned, the 
market penetration greatly expands and grows in those areas 
because, when it's there, they come.
	Mr. Brown of South Carolina.  Are you finding that the 
veterans are citizens of Maine, or are they migrating from some 
other regions in the United States.
	Mr. Sims.  Mostly it's Maine citizens, but certainly we get a 
wide variety.  And we're here to take care of the veterans of the 
United States of America, and we do that.
	Mr. Brown of South Carolina.  I represent the coast of South 
Carolina and it's getting to be a destination of choice for 
retirees.  In fact, I think it would be a good connector if we 
could spend winters in Myrtle Beach and summers up here.
	Let me ask you one other question.  Do you have an idea of 
how much you're spending for fee services now?
	Dr. Chirico-Post.  The network spends over 70 million dollars 
in fee services.
	Mr. Brown of South Carolina.  And how much of that is in 
Maine.
	Dr. Chirico-Post.  About 20.
	Mr. Sims.  Probably about 20 million dollars, yes.  It's a 
significant amount here in Maine -- 
	Mr. Brown of South Carolina.  Do you see that that is costing 
VA health centers more money?
	Mr. Sims.  That again is our expectation, as we put these 
places closer to where the veterans live, because they'll get 
their healthcare from us rather than the fee -- 
	Mr. Brown of South Carolina.  You understand that this is a 
cost saving -- 
	Mr. Sims.  Absolutely.
	Mr. Brown of South Carolina.  Let me ask you just one other 
question and then we'll move on to the next panel.  Do you have 
facility specific data in terms of the numbers seeking enrollment 
solely for the purposes of ordering or refilling prescriptions.
	Mr. Sims.  I'm not sure that we do, quite frankly.  It's been 
significant, but I think it's tapered off some recently, so -- 
	If we have it, I'll get it.
	Mr. Brown of South Carolina.  Let me ask another question 
then to follow up on that.
	I know, I think, in order to get a prescription filled or 
refilled, you must see your doctor.
	Mr. Sims.  Correct.
	Mr. Brown of South Carolina.  How do you feel about filling 
the local doctor's prescriptions; would that help the patient load 
some.
	Mr. Sims.  Well -- 
	Mr. Brown of South Carolina.  I know that, as a policy, that 
may be something that you'd want to take a look at, but I'm just 
curious to have you address that.
	Mr. Sims.  Well, the VA was established as a healthcare 
provider, not a pharmacy.  And so, certainly anything that would 
deviate from that would require legislation to allow that sort of 
thing to happen.
	And I think that would be the response.  But, there certainly 
is a significant amount of co-managed care that does go on in the 
VA system, where some veterans prefer to stick with their local 
provider, and then come to the VA because of the prescription 
benefit.
	I think that as we open up additional sites of care, if we're 
closer to where the veteran actually resides, that they'll be more 
apt to go to VA care initially, and not seek out their local 
provider.
	I know we have a significant number of veterans who, once 
they do come to VA, find out how good the care is, how wide the 
variety of care is, and have transferred their care entirely to 
VA.  So -- 
	Dr. Chirico-Post.  A final comment that I will make on that, 
VHA, through its extensive performance measurements system has 
demonstrated both on the inpatient and outpatient side of the 
house that we are a leader in quality, a benchmark for other 
healthcare organizations.
	A recent study in preparation for this that I looked at was 
to compare -- the joint commission publishes a performance through 
ORECS and in Togus -- Togus is above other healthcare 
organizations in those inpatient performances.
	That didn't happen by accident, it's by coordinating the 
care.
	And for those of us who provide that care -- I think there 
has to be a different policy decision to support the prescription 
only in the VHA.
	We don't have that policy yet.
	Mr. Brown of South Carolina.  Right.  And we've established 
that.  I was just curious to know how you might feel about that.
	I know you said that your mission is to take care of these 
veterans and, you know, prescriptions are part of their healthcare 
too.  I don't know why they would separate that, but I was 
wondering if you would just have a response to that.
	Thank you all.  Mike, do you want to -- 
	Mr. Michaud.  Yes.  Mr. Chairman, I have, actually, several 
more questions, and I would request permission to submit the 
questions for the record so we could get the response from Dr. 
Post and Mr. Sims.
	As well as I want to thank you both for coming today.  And I 
definitely encourage Mr. Sims to try to get those numbers to us, 
and really work hard with the hospitals out there in the 
community.  I know they're real anxious to do whatever they can to 
make sure that they can work with the VA to get the clinics up and 
running, because we definitely do need them.
	Mr. Brown of South Carolina.  Thank you very much.  Let's 
move up our next panel.
	Our second panel is Don Simoneau, Vice Commander of the 
Department of Maine American Legion; Mr. Gary Laweryson, Chairman 
of the Maine Veterans Coordinating Committee; and Mr. Roger 
Lessard, President, of Local 2610 of the American Federation of 
Government Employees.  And Mr. Lessard has been an employee of the 
VA for over 20 years.
	And we welcome you guys and we'll ask Mr. Lessard to begin.




STATEMENTS OF ROGER LESSARD, PRESIDENT, AFGE LO-
	CAL 2610; DON SIMONEAU, VICE COMMANDER, THE 
	DEPARTMENT OF MAINE AMERICAN LEGION; AND GARY
	Laweryson, CHAIRMAN, MAINE VETERANS COORDINAT-
	ING COMMITTEE 

STATEMENT OF ROGER LESSARD

	Mr. Lessard.  Thank you, Mr. Chairman.  It's my pleasure to 
be here today.  Of course, I represent approximately 800 VA 
employees in professional and nonprofessional positions at the VA 
facilities affiliated with Togus; also including the Bangor, 
Calais and Caribou community clinics.
	Rural healthcare markets face significant challenges as 
compared to urban markets, including a limited number of 
specialists, less access to expensive technologies, and a less 
affluent patient population.
	At the same time, rural Americans are disproportionately 
represented in the military.  Thus, it is no surprise that a 
disparity in healthcare exists between veterans living in rural 
areas and their urban and suburban counterparts.
	A recent study by public health experts found that veterans 
living in rural areas experience a lower health-related quality of 
life.  As a result, the veterans' health care costs are estimated 
to be as high as 11 percent greater in rural areas.
	Here in Maine, we are very familiar with these healthcare 
challenges.  Maine ranks fourth in the nation when it comes to the 
share of veterans living in rural areas.
	Togus VA Director Jack Sims testified before the CARES 
Commission two years ago that only 59 percent of the enrollees 
have access to primary care services within the CARES travel time 
criteria, and only 52 percent have access to acute hospital care.
	The Togus VAMC has experienced a dramatic growth in demand 
for services over the last four years.  We average between 300 to 
400 new enrollees per month.
	Similarly, our community based outpatient clinics have 
experienced tremendous increases in demand in the past few years.  
As a result, our veterans are forced to wait longer for needed 
medical care.
	For example, there is currently a four-month wait for 
ultrasounds in radiology, as well as a wait list for cardiology, 
urology, and other specialty care.
	The CARES Commission warned the VA of this likely surge in 
demand in its February 2004 Report to Secretary.  Specifically, 
the Commission recommended the addition of five CBOCs in Maine, 
including one in Lincoln.
	However, due to lack of funding, and contrary to the CARES 
Commission's recommendations, no new CBOCs have opened up to serve 
Maine's veterans more promptly and closer to home.
	If and when we area able to open additional CBOCs, we will 
not be able to adequately staff them given the current hiring 
freeze.
	Since the start of this year, we have only been able to hire 
one new employee for every two we lost.  If the freeze continues, 
our only alternative will be to take staff away from another 
CBOCs, causing shortages and delays there instead.
	Lack of funding and cuts in FTEs also affect our ability to 
deliver timely care in other ways.  We have been forced by budget 
cuts to delay the implementation of important innovations such as 
our nurse case management system.
	Also, we had to delay needed capital improvements and medical 
equipment purchases, including a much needed MRI machine as 
discussed below.
	Despite years of short staffing, I am proud to represent a 
staff that has been continuously dedicated to the caring of our 
veterans.  At the same time, I also have to care about our 
dedicated employees who become ill and stressed because of 
mandated overtime.  Prolonged overtime and other pressures also 
are causing more or our older staff members to take early 
retirement, which further adds to the staffing problem.
	These staff shortages have forced us to hire agency staff -- 
an unsatisfactory stopgap measure which ends up costing the 
taxpayer more, while affecting the quality and safety of the 
medical care we provide to our veterans.
	The veterans in our state need new facilities and more staff 
to meet their medical needs.  Additional CBOCs will allow us to 
provide more timely care and reduce the long distances that many 
veterans have to drive to see a doctor.
	We will not help the rural veteran -- what will not help the 
rural veteran is an increased use of costly fee basis services.
	Another VISN recently estimated that fee basis care costs 35 
percent more than care provided by a VA facility.  One must also 
consider the difference in quality in care delivered by an outside 
provider who lacks the training and resources available within the 
VA.
	Finally, veterans and taxpayers in Maine will benefit from 
the acquisition of an MRI machine at Togus.
	Currently, we have to pay high prices to outside providers 
because we do not have our own MRI or PET Scan machines, diverting 
scarce health care dollars from other needs.
	If we had our own MRI machine, we could save close to a 
million dollars a year, even after including the cost of the 
purchase.  In addition, our veterans would be able to get their 
screenings in- house.
	This has changed, by the way, because now we are proposing to 
get an MRI machine and PET Scan in Togus.
	We are grateful for the recent good news that the current 
shortfall in VA health care dollars has been partially addressed 
through supplemental funding.  These additional dollars will 
enable us to undertake some of the capital improvements that we 
had to delay.
	In the long term, there should be a better way to provide 
reliable funding for the medical needs of returning soldiers and 
other veterans.
	Every budget cycle, our dedicated staff as well as the 
veterans we serve are left wondering whether there will be enough 
funding for hospital beds and doctor visits.
	Uncertain funding also takes a toll on our ability to plan 
for the long-term needs of current and future veterans.
	Thank you again for the opportunity to testify on behalf of 
the Maine veterans and thank you also for holding this hearing in 
Maine.
	We at Togus will continue to provide the best care for our 
veterans.  I am proud and grateful that as elected officials that 
you have recognized how this shortfall has hurt veterans and that 
measures are needed to rectify the problems that have resulted.
	I pray that our veterans will never again have to experience 
these problems in accessing health care.
	Thank you.
	Mr. Brown of South Carolina.  Thank you, Mr. Lessard.  And 
thank you for your service. 
	[The statement of Mr. Lessard appears on p. 51]

	Mr. Brown of South Carolina.  At the conclusion of all three 
of these presentations, we'll have some questions.

STATEMENT OF DON SIMONEAU

	Mr. Simoneau.  Chairman Brown, Congressman Michaud, I thank 
you for the opportunity to testify before you today on behalf of 
the American Legion, Department of Maine, regarding Access to 
Primary Care for Rural Veterans in the State of Maine.
	According to the 2000 Census, many rural and non- 
metropolitan counties across the nation had the highest 
concentrations of veterans in the civilian population aged 18 and 
over from 1990 to 2000.
	The State of Maine has the fourth highest proportion of 
veterans living in rural areas in the nation at 15.9 percent.  
Studies have further shown that veterans who live in rural areas 
are in poorer health than their urban counterparts.
	And I present to you an article from the American Journal of 
Public Health, October 2004, to go on record to show that article 
and that study.
	The Capital Asset Realignment for Enhanced Services, CARES 
Commission, report released February 2004 specifically mentioned 
the Far North Market, which is Maine.
	Only 59 percent of the veterans in Maine are presently within 
the CARES own guidelines, to access primary care services.
	The subsequent CARES decision released in May 2004 identified 
156 priority community based outpatient clinics, six of which are 
slated for Maine.
	CBOCs were designed to bring health care closer to the 
veteran, and that means in the community where the veteran 
resides.
	After a long, hard fought battle the final commission report 
and the CARES decision decided that, indeed, VISN1, and more 
importantly, Maine, needed these CBOCs to provide adequate primary 
care access to a mostly rural population.
	The CARES decision of May 2004 directed that VISN begin 
immediate preparation of proposals for development of CBOCs for 
that same year.  However, upon inquiry to the Veterans 
Administration Central Office, the American Legion has learned 
that business plans have not been submitted or revalidated during 
2005, and are not anticipated until the final 2006 budget 
allocations are distributed and reviewed by VISNs.
	The CBOCs of VISN 1 listed in the CARES decision are all 
designated for the State of Maine.  The American Legion does not 
understand this delay.  Nearly two years will have passed in 
preparing the proposals.
	Additionally, establishing a CBOC is not a not a short 
process, and now the timeline has been considerably pushed back.  
The VA can ill afford a time lapse as lengthy as two years when it 
comes to providing health care to our rural veterans.
	The nation is in the midst of a war on terror, and delaying 
the delivery of quality health care is not in the best interest of 
any veteran.
	Of special note is the provision of mental health services 
within the CBOC setting.  Mental health specialists within the VA 
all agree that CBOC should provide mental health services; 
however, they do not.
	The committee on care of veterans with serious mental 
illness, has been monitoring this issue for years and has 
advocated in their annual report to Under Secretary of Health that 
CBOCs need to provide mental health services.
	It has been reported that up to 30 percent of the returning 
veterans from Operations Enduring and Iraqi Freedom will have 
mental health problems to include post-traumatic stress disorder.
	In 2005, Togus reported approximately 365 Operations Enduring 
Freedom and Iraqi Freedom veterans enrolled for healthcare with 
approximately 260 actively seeking medical and or mental health 
services.
	While the VA does not believe returning veterans will have a 
major impact on Togus, they are continuing to monitor it.
	The American Legion cautions the Togus facility on their 
optimistic view of returning veterans and their impact on the 
system.
	Let us not forget that the returning veteran suffers from 
multiple physical and mental wounds and is resource intensive to 
treat.  Those that put their life on the line so that we may enjoy 
our carefree lifestyles deserve nothing but the best, and we can 
not deny them their deserve treatment.
	What is of growing concern to the American Legion is the 
increasing number of veterans who are put on electronic wait 
lists.  For example, in medical specialities, if a veteran is a 
service-connected at 50 to 100 percent, priority group 1, you can 
usually be seen within 30 to 45 days.  However, if you are not in 
that priority group, you can wait up to year for specialties such 
as ophthalmology or orthopedics.
	The VA budget woes are well documented, and the American 
Legion has played a key role in bringing these shortfalls to the 
forefront.
	The American Legion has advocated for assured funding to 
ensure shortfalls such as that experienced by the VA this year 
does not happen in the future.
	Again, I thank you for the opportunity -- for giving the 
American Legion this opportunity to express our views for the 
Department of Maine.  We look forward to our continued work with 
Congress on these important issues.
	Thank you, sir.
	[Applause.] 

	[The statement of Mr. Simoneau appears on p. 55]
	[The attachment appears on p. 59]

	Mr. Brown of South Carolina.  I would also like to thank Mr. 
Simoneau for the help you put in for locating graves of the 
departed veterans.
	And I was just curious as I read that last night, that 
there's an initiative in other states and other regions to do a 
similar thing.
	Mr. Simoneau.  When I started that a few years ago, it was a 
local thing, because my Post said that we need to make sure that 
we flag the veterans.
	And now I'm getting phone calls from all over the country.  I 
mean, I've had people from Ohio and Florida contact me and say, 
how did you start this, and, you know, where do you go from there.  
So --  Thank you, sir.
	Mr. Brown of South Carolina.  Okay.  Mr. Laweryson.

STATEMENT OF GARY LAWERYSON

	Mr. Laweryson.  Chairman Brown, Congressman Michaud, we 
appreciate testifying on behalf of the Maine Veterans Coordinating 
Committee.  We represent 14 organizations and speak as a united 
voice for the veterans of Maine.
	The VA CARES program, short for Capital Asset Realignment 
Enhanced Services, studied the access to Maine's rural veteran 
population and concluded more Community Based Outpatient Clinics -
- CBOCs -- were needed along Maine's North-South corridor and 
Western Maine.
	These CBOCs would provide a greater number of Maine's rural 
veterans the much need access to quality outpatient and specialty 
care.
	Every CBOC site within Maine is filled to capacity and are in 
need of expansion to be able to continue to provide the quality 
care Maine's veterans have come to expect.  The CARES study shows 
Maine is greater in area and rural veteran population than the 
other entire VISN 1 areas.
	In 2004, the VA's computer projections were 154,000 veterans 
in Maine that were eligible for care in the VA system.
	These projections did not take into account the veterans who 
move to Maine's rural areas to escape the fast life, nor Maine's 
growing retired veteran population.
	Through the efforts of the Maine Veterans Coordinating 
Committee and its subsidiary organizations, Togus VAMROC enrolled 
500-700 new veterans each month for over two years.
	Although this trend has slowed, Togus continues to enroll new 
veterans each month.
	Now that Maine's National Guard and Reserve components are 
returning from Afghanistan and Iraq, many with wounds and 
illnesses requiring VA care, the need for access will again 
increase.
	Maine's current VA system is stretched to the breaking point, 
and it is imperative that new CBOCs are made available to provide 
timely access to the services.
	Due to Maine's unique geographical size, it is difficult for 
many of Maine's veterans to travel to the existing sites.  Maine 
has no mass transit system.  Maine's veterans rely on the DAV 
shuttle bus for transport to Togus and the CBOCs.
	However, in the northern counties, there is only one bus 
available.  Many of Maine's rural veterans are on a limited, fixed 
income and are unable to afford transportation to Togus or the 
nearest CBOC.  Nor can these veterans afford health insurance or 
access to local care.
	The Maine Veterans Coordinating Committee believes Togus 
should be expanded to become a full service VA Regional Medical 
Center, independent of Boston.  Maine's rural veterans must now 
travel several hours one way to obtain care at Togus or a CBOC.
	To require Maine's veterans to travel three to eight hours 
more to Boston for tertiary care is unacceptable.  Maine has one 
of the top rated Cardiac Surgery Centers in the nation, and is 
leading the nation in long-term care and end-of-life care provided 
to our veterans.
	Sending Maine's veterans to Boston removes the family and 
local veteran support system sorely needed to effect recovery of 
its veterans.
	While the majority of the nation is urban or metro, and have 
showed a slower growth, rural Maine has demonstrated a sustained 
growth pattern and will continue this trend.
	Lastly, the Maine Veterans Coordinating Committee would urge 
the VA to open lines of communications to all veterans, not just 
in Maine.  In the past, the veterans have not felt the VA was user 
friendly.  As a result, many older veterans and those serving on 
active duty have failed to avail themselves of the quality care 
provided by the current VA system.
	In Maine, the veterans are banding together to educate our 
veterans on the many services available to them.  Operation I 
Served is a joint project initiated to provide information to 
Maine's veterans, their spouses and families on services through 
the VA system, educational benefits, tax relief, financial 
assistance, employment assistance, housing assistance, and long-
term-care options through the VA and Maine's Veterans Homes 
systems.
	Our program has received requests and been supplied to many 
other states.
	Again, on behalf of the Maine Veterans Coordinating Committee 
and the Maine veterans we represent, thank you for allowing us the 
opportunity to speak to you.
	The Maine Veterans Coordinating Committee looks forward to 
continuing to work with Congress to enable the VA to provide 
quality services to all veterans.
	[Applause.]

	Mr. Brown of South Carolina.  Thank you very much.  And thank 
you for that report.
	[The statement of Mr. Laweryson appears on p. 64]

	Mr. Brown of South Carolina.  We'll continue the questions.
	Mr. Simoneau, while this hearing is focused on primary care, 
do you think there's any utility in using new innovative 
technology such as telemedicine to help fill the current gap of 
specialized services you mentioned in your testimony, like tele-
psychiatry?
	Mr. Simoneau.  Congressman, I guess my own -- my own gut 
instinct is that, if I'm suffering from PTSD, or I'm suffering 
from mental illness, I want to talk to a person.  I don't want to 
sit in front of a telecommunication device and testify in front of 
something that scares the puppy out of me.
	And I believe that a doctor or a therapist immediately for 
that patient needs to be there for that type of service.
	Mr. Brown of South Carolina.  Do you see any line of 
treatment where telemedicine might work, like eye examinations, 
blood sugar checking, and many other different types of diagnostic 
testing situations that you believe it could fit.
	Mr. Simoneau.  I believe there are places that tele-
communication will work.  But I think that we have to be real 
careful in placing what items in front of that type of situation.
	If we're talking about a doctor being able to look at reports 
and do things with telecommunication with a patient that are 
paper-work intensive or such, yes.
	But, when it gets down to an exam, where you're really 
talking about the nuts and bolts of what's going on with the 
patient -- a lot of these people have been through stresses 
already in their lives.
	And to put them under the stress of a television camera I 
think is unfair.  There are places they can be used, I agree.  
But, I think we have to be very careful in picking those areas.
	Mr. Brown of South Carolina.  Mr. Laweryson, your written 
testimony suggested that VA is not notifying younger and older 
veterans of the services available through the VA.  I know there's 
the American Legion and other avenues.
	What type of outreaches would you like to see that aren't 
currently taking place in Maine or other regions of the nation?
	Mr. Laweryson.  Well, sir, I think the VA has to overcome the 
past transgressions.
	What I mean by that is, the communications.  The VA right now 
is user friendly.  From the Vietnam era on, it wasn't user 
friendly.  And that stigma sat there for a long time.  We have 
seen an increase of Vietnam veterans coming, and that's due to the 
fact that this -- we're used to working with the VA on that.  
Communication goes out, and then it's up to the service 
organizations to get the word out, and explain to them that this 
is a user-friendly system now.
	And, as Mr. Sims eluded to, once they get in there they find 
out -- you know, it's like Christmas.  This place is fantastic.
	And then they come back out and spread the word again.  But, 
it's a fact that we need to get that word to them, especially the 
older ones right now with the economy the way it is and the fuel.  
There's tough times ahead in the state of Maine, especially -- an 
hour north or here, either side of 95, is a bit lonely.  There's 
not much out there.
	And a lot of your combat veterans, not just from Maine, but 
from other states, gravitate to this solitude.  There's a great 
number up there that are hiding.
	The 154,000 veterans that we have, and -- we feel it is 
higher -- and our objective or goal is to notify as many of them 
as we can.  That's why we went from 16,000 to 36,000.  And we tend 
to make Jack earn his money up there, get another 10 to 15,000 
enrolled.
	Mr. Brown of South Carolina.  Mr. Simoneau, do you have any 
suggestions of how we might be able to reach the veterans and 
notify them of the services available.
	Mr. Simoneau.  I believe part of our problem in the state of 
Maine is how rural we are.
	You can go an hour from here and not have cell phone 
communication down the street.  You can go across the street and 
not have communication on the Internet.
	There's a lot of people within the state of Maine who don't 
have TV cable.  There's a lot of access issues within the state of 
Maine that are really prevalent to the state of Maine because of 
the type of state we are.
	Reaching those people is a full-time job, and I'm not sure 
how we can better do that.
	The veteran organizations go out there, but you need to 
understand, some of these veterans are really skeptical about a 
veterans organization.  You know, what do they want from me.
	And they're afraid of the VA system.  The VA turned me down 
when I got home from World War II.  I went over to see them and 
they said, sorry, you're okay, go home.  And that veteran in 1946 
went home.
	And now, when he's 80 years old, we try to tell them, you 
know, you need to go to Togus, you need to get some help.
	He looks at me and he says, but they sent me away in 1946.
	And you would be surprised how many veterans that are out 
there that are that way.  And I'm talking 1946, World War II 
veterans.
	But, we can do the same thing with the Korean veterans, and 
we can do the same thing with the Vietnam era veterans, and I'm 
sure down the road with the Iraqi Freedom veterans, we're going to 
have that same issue.
	How do we do that?  I'm not sure.
	We've done local areas where we bring in people from the VA, 
people from the Maine Veteran Services, and we sit down and we ask 
veterans to come to the community to apply for help, to talk to 
people.  Those fair-type systems work very well.
	But, to put them on in a state as rural as Maine is tight 
skating.
	Mr. Brown of South Carolina.  Do you have something like a 
mailing list?  I know the post office gets to everybody, I would 
assume that, even up here -- 
	Do you have up here a mailing list where you have everybody 
recorded?
	Mr. Simoneau.  I believe, under the Freedom of Information 
Act, and all of the other requirements for protecting peoples' 
rights, that's one of the drawbacks of those rights, and that 
protection.
	The names are out there, but we don't have access to them.  
We have access to the 26,000 members of the American Legion here 
in the state of Maine, but we don't have access to the 156,000 
that are actually veterans.
	Mr. Brown of South Carolina.  Okay.  Mr. Michaud.
	Mr. Michaud.  Thank you very much, Mr. Chairman.
	Mr. Laweryson, you talked about the Operation I Serve 
program.  I was really intrigued by that.  And living in the state 
of Maine all my life, I know how rural the state of Maine is, and 
it's problematic particularly when you look at the economic 
hardships which we have had over a number of years with mill 
closings and what have you.
	Currently we're going through the BRAC process and we don't 
know how that's going to end up for bases in Maine.
	In the program, Operation I Serve, how do veterans know about 
that program?  I know it's difficult.  We do have 
telecommunications here, but is there a website, or an 800 number 
that they can call in?  Do you do mailings?
	Can you tell us a little bit more about the program?
	Mr. Laweryson.  The I Serve, we have a website, 
www.mainedvs.org.  They get the information from there.  The 
packets come out in the county where it's most rural up there.
	Every town office gets a copy of this on CD as well as the 
paper one.  And that was done through the coordinating committee.  
We got the funds ourselves, and we got a veteran up there, John 
Wallace, who's working on his own.
	And we've got this as far south as North Carolina now.  I 
retired from the Marine Corps down there.  And when I went down 
there this summer, I dropped it off at the VA transition site at 
Camp Lejeune. 
	We also picked up the VA transitional list, and we're in the 
process of sending them all over the states, which is the major 
military installations.
	[To Chairman Brown.]  South Carolina will get theirs shortly.
	But, the veterans returning from active duty, the ones in 
Maine, we got to let them know.  Because when I decapped, we knew 
nothing about Maine.  I grew up here, but I didn't know what the 
services were.
	And I come back and worked through the system.  So, what we 
did is put down the state commanders and the Maine Veterans 
Coordinating Committee the one with the BBS, and he's sit down and 
come up with a list of phone numbers, points of contact in the 
state, federal level.
	We amend this every three to four months.  We're putting on 
all of the elected officials now.  The governor's on board with 
this.  He made the announcement the 11th of November.  He was 
kicking this off.  He fully supports it.
	We're grass roots.  We're paying for it for ourselves.  It 
isn't costing the state anything.
	But, it's helpful to the state because we're getting the 
veterans in here.  It's a slow process.
	At town meetings I think would be the way to go.
	The VA wasn't allowed to go up and actively enroll because 
they were shut down, because of the waiting list.  Our philosophy 
was, if you could get the numbers then you could justify them 
paying or getting the money to us.  And it works.
	And Jack Sims down there, at VA Togus, is doing a phenomenal 
job taking care of our veterans, and he wants to do a better job.  
That's why we're trying to get the veterans in there.
	It's a challenge.  And other states have asked us for it, and 
they're starting to -- I think the key word is you work together.  
All of the veteran organizations have to work together.  Dance on 
the same sheet of music, and we're also building the VAs.
	They get this out to the congressmen's offices and the 
senator's offices, and they're aware of this, because they're 
getting an influx of senior citizen centers, hospitals.
	Get it out there and get it in front of them.  Things are 
getting tight out there, and these people have got to make 
decisions.  Do put heat in the house?  Do I pay for the pills?  
And it's getting to the point where some of their kids bring them 
in to us.
	It works.  The CBOCs are critical.  If they can't travel down 
to Bangor, we've got one in Lincoln, we got one in Houlton -- 
that's the North-South corridor.  And the western corridor goes 
across Route 2 and goes over towards Rumford and that area.  And, 
of course, Lewiston-Auburn is a large city for Maine.
	Mr. Michaud.  And don't forget Dover-Foxcroft.
	Mr. Laweryson.  Well, no, we can't forget that.
	Mr. Michaud.  How would you -- to follow up on that question.
	What I've seen, particularly when Great Northern, where I 
worked for 30 years, shut down and filed bankruptcy, a lot of the 
workers there are veterans.
	How do you convince someone who's working currently -- has 
good health care benefits, do not need them to go to the VA at 
all, how do you convince them to sign up to make sure that they're 
taken care of?  Is there a lot of resistance?
	Mr. Laweryson.  It is and it's due to a lot of rumors up 
there.  And the rumors are rampant.
	You can come out here and say, you know, the VA is the way to 
go.  And someone else is out there saying, you don't want to go to 
VA because -- they'll kill you, and it's slow, the waiting list is 
prenominal.
	Well, in some cases it is and some cases it isn't.  It's the 
education system.  Again, this is part of it.
	Category 8s, there's going to be a wait, Category 7s, there's 
a wait.
	There's a priority list, and the priority list is there for a 
reason.  There's a priority given your treatment for the VA.
	They need to understand this.  Once they're made aware of it, 
and what's available, there's not a problem.  They feel that they 
can go down there and get into this.
	But there are a lot of veterans out there who really need to 
be in there, they're just unaware.
	And we need -- as the veterans that are active now, we have 
to communicate to them, and do so on a level that they will 
understand and are comfortable with, so they you can come to the 
VA and get proper treatment.
	Mr. Michaud.  Mr. Simoneau, in your testimony, you raised 
concerns about electronic waiting lists.  And, actually, I think 
the VA Inspector General came out with a report that says that the 
VA is under-reporting the number of veterans on the list, and that 
they're over-reporting the number of veterans who are receiving 
services within 30 days.
	Can you elaborate more on the problems at Togus and at the 
clinics?
	Mr. Simoneau.  I won't elaborate on numbers, because I guess, 
as you can see, numbers will tell whatever you want to say.
	I'll elaborate on the fact of people that I know of within 
the system.
	And people I knew within the system get very frustrated.  
They think they have an appointment.  They think they're all set, 
and then all of a sudden they're on this list and, oh, by the way, 
your appointment isn't this month, it's not next month.  We'll get 
back to you.
	I get real nervous over electronic wait lists.  I'm just not 
sure -- once again, we're taking a person out of the middle of 
that system.
	Mr. Michaud.  To follow up on that question that's very 
similar, what would you recommend that we would do at the federal 
level, in the sense that there are waiting lists, and the veterans 
are waiting and going for services after retirement?
	Is there something that we could do to help in the short term 
to help veterans? 
	Mr. Simoneau.  I believe that we need to come up with some 
sort of emergency funding for these veterans.  I believe we need 
to come with some sort of pilot program where a veteran who 
applies for assistance in Togus, or Rumford, or Portland, 
wherever, when he applies for assistance, he needs assistance now.  
It's not six months from now.
	But, he's also not eating well, he's not paying the rent 
well, he's not paying the electric bills well.  He has no 
assistance out there to help him get by, until when he gets his 
paperwork done, that says, oh, yes, he's PTSD, a hundred percent, 
he should have been qualified for that two years ago.
	But, there's no safety net out there for him.  When he 
applies for it, from the time he applies until the time he 
actually sees somebody, where the system is kicking in, time goes 
by and the veteran is hanging out there on a thread.
	And those are the veterans that sooner or later run away from 
the system because, well, gee, I can't do that, and I don't know 
where to go.
	So, we need to come up with some sort of safety net, be it an 
emergency-type funding mechanism, or something that can temporally 
get that veteran through a tough time that he finds himself in.  
And there's got to be a way to do that.  And we need to be able to 
sit down and figure that out, because those veterans are walking 
away from the system that they need, but they're afraid they're 
going to starve to death before they get through it.
	Mr. Michaud.  My last question is for Mr. Lessard.
	Since Congress has provided additional funding--and the 
legislation was just signed recently--for the budget short-fall at 
the VA, has Togus started to fill some of the vacancies, or 
started to conduct some of the needed repairs at Togus?
	Mr. Lessard.  Congressman Michaud, not as of yet.  We have 
tried to fill some of the gaps, but they're not fully staffed as 
of yet.  And I'm sure that we will be working on that in the near 
future.
	Mr. Michaud.  Can you give any examples of lack of adequate 
staff?  What are they doing to veterans' access to care?
	Mr. Lessard.  It's delaying some of the clinics, I believe, 
in some of the areas where they're short- staffed.
	It's also causing -- as I mentioned in my testimony, we are 
causing older nurses that would remain for another four or five 
years to retire early, due to the mandated overtime due to the 
short falls in staff.
	It has a great demoralizing effect on the employees.
	Mr. Michaud.  Thank you.
	Mr. Brown of South Carolina.  Okay.  Thank you very much, 
Gentlemen, for your testimony, and for what you do to support our 
veterans.  I know I had the privilege this past Memorial Day to go 
to Normandy and be a guest speaker.  And what a moving experience 
it is.  We saw all those flags, over 9,000, of those Americans who 
never got a chance to come home; a lot of 17- and 18- and 19-year-
old kids.  The price of freedom of this nation is tremendous.
	And I pledge to you, and Mr. Michaud certainly has been 
supportive, as part of the Health Subcommittee, assure you guys 
and you girls that you'll have support up here.
	And it's been a real pleasure for me to come today and be 
part of this session.
	And you can be absolutely sure that we try to find other ways 
to make the problems up here much better, and support the staff 
and the various operations around the nation.
	But, it can't happen unless we have the feedback from folks 
like you.  And we thank you for taking your time in coming and 
being with us today, and the preparations you made to make these 
presentations.
	And I do thank you.  Thank you all for coming and being part 
of this process.
	Mr. Sims, I guess I have one other official thing -- I think 
you have something you wanted to submit for the record, and I'll 
also note that at this time.
	Mr. Michaud.  And I guess you have been reading my mind, Mr. 
Chairman, because we work so closely here, I was going to actually 
mention that Mr. Sims wanted that included for the record.
	And, once again, Mr. Chairman, I want to thank you for taking 
the time to have one of the two hearings that we're having in the 
country as it relates to healthcare for veterans in Maine.  And 
the State of Maine really appreciates that.  And I want to thank 
all of the veteran organizations and veterans that came out this 
morning to be with us.
	Thank you for your testimony, it definitely has been 
enlightening, and we'll be sitting down with the Chairman to move 
forward.
	So, once again, thank you very much.
	Mr. Brown of South Carolina.  This meeting stands adjourned.  
Thank you very much for coming.

	[The statement of Senator Olympia Snowe appears on p. 35]
	[The statement of Ronald W. Brodeur appears on p. 66]
	[The statement of COL Edward L. Chase, USAF (Ret.) appears on 
p. 70]
	[The statement of Roger Landry appears on p. 75]
	[The statement of Timothy J. Politis appears on p. 78]
	[The statement of Peter W. Ogden appears on p. 86]
	[The information appears on p.89]
	[Whereupon, at 10:39 a.m., the Subcommittee was adjourned.]
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