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


 
                  HEARING ON RIGHT-SIZING THE DEPARTMENT OF
                               VETERANS AFFAIRS

                             Thursday, May 11, 2006

House of Representatives,
Committee on Veterans Affairs,
Washington, D.C.





The Committee met, pursuant to call, at 11:26 a.m., in Room 334, Cannon 
House Office Building, Hon. Steve Buyer [Chairman of the committee] 
presiding.


Present: Representatives Buyer, Moran, Brown, Boozman, Brown-Waite, 
Filner, Michaud, and Berkley.


Staff Present: Jeff Weekly, Majority Counsel; David Tucker, Minority 
Counsel; and Jim Lariviere, Staff Director.


The Chairman.  The full Committee of the House Veterans Affairs 
Committee will come to order, May 11, 2006.  We are here today to 
evaluate the requests by the Secretary of Veterans Affairs for 
authorization for several major construction projects and leases which 
will improve, renovate, and/or update patient care facilities at various 
locations.  I'd like to thank all of our panelists today for their 
testimony.  The Department of Veterans Affairs must by law receive 
statutory authorization for all major medical facility construction 
projects and leases that exceed $600,000 per year before it may obligate 
or expend funds.


Secretary Nicholson has requested authorization for $1.6 billion for 
major facility construction projects, and $25 billion for major facility 
leases in fiscal year 2006.  For fiscal year 2007, the Secretary has 
requested authorization for $352 million in major facility construction 
projects and nearly $27 million in major facility leases.


The Secretary's requests include immediate funding authorization to 
ensure the restoration and continuation of care for veterans who had 
depended on VA medical facilities damaged by Hurricane Katrina in 
Biloxi, Mississippi, Gulfport, Mississippi, and New Orleans, Louisiana.  
Those veterans have our support and we commend the men and women of the 
VA and the Gulf for their exemplary work providing uninterrupted care to 
these veterans.


Today we must also look to the long term.  Yesterday the Appropriations 
Committee declined VA's funding request for the replacement medical 
facility in Denver.  The price had originally come in at over $700 
million, and the price tag has now been reduced to $621 million, which 
itself indicates that there is a credibility gap insofar as the facility 
pricing goes, and we're interested in the Administration's testimony.  
For those to whom this is a disappointment and/or a surprise, we must 
all recognize the need for improved facilities in the Denver area, and I 
suggest that all of us have a wake-up call, and a real opportunity 
before us.  It does not have to cost nearly a $1 billion to build a 
world class medical center.  Just last month, the VA's General Andy Love 
and General Heiberg visited the new Clarian Hospital in Indianapolis.  
This is a private sector, leading edge facility.  It's in excess of 170 
beds at a cost of $280 million.  And having been in the facility, when 
you look around it looks like the Four Seasons.  While the core services 
provided by the VA and Clarian differ, as well as some construction 
standards, there appears to be quite a disparity between the private 
sector and the public sector's ability to build state of the art 
facilities at reasonable costs.


If the writing is on the wall we must also have examples of approaches 
that can lead to a sustainable path of quality of care.  We must 
consider the advantages and the virtues offered by a approaches more 
innovative than the status quo process that goes it alone, and misses 
out in opportunities for greater quality and efficiency.


I commend the VA, in particular Dr. Perlin, and Mr. McClain, for seizing 
a great opportunity in Charleston, SC where the VA and the Medical 
University of South Carolina have a unique physical and business 
relationship, and have produced a collaborative report.  In recent 
months, the two made progress on this enhanced collaboration and it will 
yield improved services to veterans.  We now have what is called the 
Charleston Model, and before it could be enacted in Charleston we had 
Katrina.  And it is now proposed to leverage the Charleston Model in the 
Gulf Coast region.


The purpose of the Collaborative Opportunities Steering Group is to 
explore the benefits of collaboration, which could include the 
construction of separate bed towers that share services and some 
equipment while retaining the identity of a Veterans Health System.  
Their April 30th interim report called this sharing ``a very positive 
and exciting prospect that will enhance patient outcomes and 
efficiencies for both institutions.''


Innovation is not limited to examples set by the private sector, or the 
harnessing of collaboration between public and private sectors.  
Government agencies can work with each other to be more efficient.  In a 
sign of progress, a 2002 agreement between the Navy and the VA to share 
facilities in North Chicago is much closer to being fulfilled.  
Collaboration between the VA and the Pentagon, as we have seen, is 
essential for the seamless transition of servicemembers into the VA and 
back again.  We should commend these two agencies for their recent 
progress in developing an interoperable system of the sharing of 
electronic medical records.  Yet, there is still more work to be done.


There is no denying that medicine has undergone a revolution that has 
dramatically boosted its potential, but also the cost and complexity.  
Our response must also therefore be commensurate.  In the face of 
examples such as in Clarian or in Charleston, and now perhaps New 
Orleans, preserving the status quo approach to bricks and mortar should 
be an affront to the much proclaimed excellence of the VA's healthcare 
managers.  The status quo approach to the bricks and mortar is certainly 
not good enough for America's veterans, and we can do better.


At this moment, I would yield to Mr. Filner for any opening comment that 
he would like to make.


Mr. Filner.  I thank you, Mr. Chairman.  Thank you for holding this 
hearing today to examine the major construction projects of the VA, and 
their lease requests, and to hear about the status of the CARES project.


I appreciate that our three colleagues are here,  Congressmen Baker, 
Melancon and Feeney, because they will provide us insight into the 
issues of building in New Orleans and southern Louisiana, and the long 
time need for a VA facility in Central Florida.  As you said, Mr. 
Chairman, I hope this hearing will assist in moving along the provision 
of healthcare facilities for veterans in these states.


I also appreciate the opportunity to hear testimony from the VA and two 
of our Veterans Service Organizations about the status of the CARES 
process.  This can be a very useful tool, if we use it well.  The VA 
should have a comprehensive study of its current infrastructure and its 
future needs, and if used wisely, CARES can help us ensure that veterans 
get the full value of every health dollar that Congress provides.


I was concerned that many construction projects were held up while we 
were waiting, longer than expected I guess, for the CARES report.  I am 
concerned now that plans to accommodate mental healthcare and long term 
care were excluded from the CARES process.  These two areas of service 
are becoming increasingly important.  It has been estimated that at 
least one-third of returning troops have mental health issues.  And 
increased life span is creating long term healthcare needs for our many 
veterans.  The number of veterans ages 75 and older is projected to 
increase from four million to four and a half million by 2010, and the 
number of those over 85 will triple to 1.3 million in the same period.  
So I concur with the testimony of the Veterans of Foreign Wars that 
these services must be evaluated in terms of their facility needs.  
These questions are ones that I will pose to the VA and hope can be 
answered, if not today then very soon.


I am interested in finding out how CARES interacts with the 
Administration's construction request.  What does the VA plan on doing 
to enhance services, and not just close facilities?  Are there any 
criteria for when CARES priorities will be ignored, as they were right 
away for a lower priority project?  Though promises were made regarding 
funding for the CARES process, will the funding indeed be a reality in 
the future?  We want to be certain that the CARES process lives up to 
its mission and does not leave veterans with a series of empty promises.  
I hope that the CARES report and a significant expenditure of resources 
does not end up on a shelf somewhere forgotten.  We must make use of all 
the research and work that has been done and, Mr. Chairman, I thank you 
for holding this important hearing today.


The Chairman.  I thank the gentleman.  Mr. Moran, an opening statement?


Mr. Moran.  No opening statement, Mr. Chairman.


The Chairman.  Thank you.  Mr. Michaud, opening statement?


Mr. Michaud.  Thank you, Mr. Chairman.  I want to thank you as well for 
having this hearing.  I am looking forward to hearing from my three 
colleagues, what you have to say as well as the second panel. I am also 
really interested in the whole CARES process. Dr. Perlin, hopefully you 
will be able to address some of the concerns that we have about the 
inadequate funding.  So, with that Mr. Chairman I yield back.


The Chairman.  Thank you.  Mr. Boozman?  Ms. Berkley, you are recognized 
for an opening statement.


Ms. Berkley.  Thank you, Mr. Chairman.  I want to thank my colleagues 
for being here.  We appreciate the fact that you are going to enlighten 
us regarding projects that probably have particular interest to your 
constituents.  But I want to share my pain, and my constituents' pain 
with you.  So, hopefully we can all work together on a bipartisan basis 
to provide the necessary facilities that our veterans not only deserve 
but that we owe.


As you may know, the CARES report recommended a new Las Vegas VA Medical 
Complex that would be built in my district.  Today, and one of the 
reason I am here, not only to hear about your issues, but to get some 
clarification as to why the completion date has been pushed back from 
2009 to mid-2010, and why the Complex will not be operational until 
2011.  I want to know what the hold up is.  In my district, we build 
five thousand room hotels in 18 months, and they are ready to go, and we 
cannot build a VA facility of 80 beds.  Something is very wrong here.  I 
have got the fastest growing veterans population in the United States.  
It exceeds 200,000 veterans now.  The need for a medical complex exists 
and it exists now.


Currently, my veterans are forced to take a shuttle to numerous clinics 
there are 10 different locations in the Las Vegas valley.  What does 
that mean?  That means that I've got 80 year-old veterans, standing 
there in 110 degrees temperature waiting for a shuttle to take them from 
location to location to have their promised and needed healthcare needs 
met.


My veterans have been promised this facility, the money has been 
partially appropriated.  We have had press conferences with the VA 
Secretary in Southern Nevada, with great hoopla, and great excitement, 
and they are waiting, and waiting, and waiting.  Las Vegas, as I 
mentioned, has the fastest growing veterans population.  We need this 
facility now.  Not 2009.  Certainly not 2011.  I can only imagine what 
the situation is going to be like in 2011 for my veterans.


We simply cannot wait any longer, and I would like to know, as I'm sure 
you would, why this delay, and without any notification to us. So I'm 
still representing to my constituents, my veterans, whenever I meet with 
them, we are online, we are on board, we are going to have this facility 
open in 2009.  I find out I am complicit as a liar to my veterans.  I do 
not like that.  I do not think you guys do, either.


Also, with every passing year the cost of building these facilities 
continues to increase.  We now need an additional $147 million, which 
was promised to be in the 2007 budget.  Low and behold, when the 2007 
Veterans Budget came before this Committee, that $147 million was 
nowhere to be found, with the promise, well, we promised you 2007, now, 
we're going to put it in the budget in 2008.  Now, how do I know that?  
And what am I going to do when I go back home and my veterans ask me 
this question?


It is wrong.  It is wrong at any time.  It is particularly wrong during 
a time of war to treat our veterans in this manner.  When we talk about 
supporting the troops, when we talk about standing up for our soldiers 
and giving them the strength they need to continue to fight and defend 
this nation, then we turn around and do this to our veterans?  It's a 
disgrace.  And not one of us, not any one of the 435 members of us 
should allow this to continue.  It is a shame, it is a disgrace, and 
these people deserve better from us.  And I am anxious to hear your 
testimony.  Thank you very much.


The Chairman.  Thank you, Ms. Berkley.  Chairman Brown, recognized for 
an opening statement.


Mr. Brown of South Carolina.  Thank you, Mr. Chairman.  I would like to 
echo some of your remarks this morning as they relate to the new vision 
for VA and the infrastructure that will be required to meet the future 
veterans' demands for healthcare services.


In my opinion, there are few more important things we can do than engage 
in an earnest discussion about how the Department begins to prepare 
itself for the future.  I am grateful that all of those in attendance 
today will help us better understand what the Department's construction 
priorities are, how they match up with anticipated demands for health 
services, and how we re-engage in the business of building hospitals.


As most of the people in this room know, VA has not constructed a new 
hospital in nearly 15 years.  As a result, a good amount of the 
institutional memory has been lost, and we have to try to reassemble 
processes that will allow us to build appropriately sized facilities 
where they are truly needed, and at the same time be prudent stewards of 
the taxpayers' money.


With that in mind, Mr. Chairman, I have some real concerns about the 
Administration's major construction request.  It would appear that we 
are being asked to provide what I call ``blanket authorizations'' for 
major projects in the absence of any real detailed information about the 
project.  Additionally, the Appropriations Committee has made clear over 
the last several days that they have real concerns about some of those 
projects and the sprawling costs associated with them.  That's the bad 
news.


The good news is that this Committee now has an opportunity to 
reevaluate its traditional thinking, and create new models for 
facilities financing and construction.  In my opinion, some of those 
models should seek to take full advantage of existing and potentially 
collaborative relationships with medical universities and research 
partners, and others might seek to have private or nonprofit 
organizations finance the construction of new facilities.


It is this type of thinking that should energize us all to find new ways 
of providing for our veterans.  The bottom line is that our veterans 
have real needs, and we have the responsibility to identify ways to 
match VA's infrastructure to those needs.  I personally believe a new 
level of creativity is called for, and I look forward to working with my 
colleagues to develop some of these new concepts.


Again, Mr. Chairman, I thank you for assembling this very important 
hearing today, and I look forward to having a frank discussion with our 
witnesses.  With that, I yield back the balance of my time.


The Chairman.  I thank the gentleman.


Before we turn to the first panel, I would like to take a point of 
personal privilege.  And that would be, in a bipartisan fashion, on 
behalf of my Democrat colleagues and staff, and the Republican side and 
the staff, I would like to recognize the Staff Director of the full 
Committee.  Jim Lariviere, would you stand a moment?  To let everyone 
know, we have known Jim Lariviere for 30 years.  He is the only person I 
know here in Washington, D.C. that had ever dropped me for sit-ups as a 
freshman at the Citadel.  Jim has commanded a rifle platoon in Beirut 
and lost a lot of good friends in the Beirut bombing as a Marine, 
commanded a rifle company, and commanded a weapons company. He served 
one year at the White House, and he also commanded the Honors Company.  
When you go to 8th and I, and you go to Iwo --he commanded the Honors 
Company for the Friday evening and Tuesday Parades.  He's commanded the 
3rd Force Recon.  He's been called to active duty twice.  He was 
recalled immediately after September 11th. He was the Operations Officer 
for the Marine Anti-Terrorism Brigade.  Jim Lariviere presently is the 
Assistant Commander of the Division, 4th Marine Division.  He is the 
Assistant Commander, which means he is a full colonel in the Marine 
Corp., and he sits in a one star, a brigadier general's slot.


Jim has been recalled to active duty.  He will be going to Afghanistan, 
and be leaving us soon.  He will be the Advisor to the Operations 
Officer of the Afghan National Army.  And that is a three star position.  
So, you see Jim, you talk to Jim, but you do not know the contributions 
that he has made, not only in the past but also what he is about to do 
for our country.  He will be leaving his wife Jen and four children.  
And they will keep the watch fires burning, but we also, Jim, want you 
to know that we will care for them, and we wish you Godspeed.




(Standing ovation)


The Chairman.  Mr. Michaud?


Mr. Michaud.  Yes, Mr. Chairman, I, too, would like to thank Jim for his 
service.  I have not known Jim nearly as long as you have, Mr. Chairman, 
but I have known him for a little while, particularly his work on the 
House Veterans' Affairs Committee.  And I really appreciate his 
professionalism, his honesty, and his willingness to work hard for the 
Committee.  But also, his commitment to the veterans of this country, 
and his service to our nation.  I want to wish him the very best, and 
Godspeed, and our prayers and our thoughts will be with both him and his 
family.  Thank you, Mr. Chairman.


The Chairman.  Thank you, Mr. Michaud.  We have before us today 
distinguished Members, and one of our Committee, Mr. Richard Baker 
representing Louisiana's 6th Congressional District.  Richard has been a 
stalwart advocate for our nation's veterans, and it is a pleasure to 
have him before our Committee today.  Also testifying is Mr. Charlie 
Melancon, representing Louisiana's 3rd Congressional District.  He 
serves on the Agriculture, Resources and Science Committee and has an 
interest in lowering the healthcare costs.  Our third witness on the 
first panel is Mr. Tom Feeney, representing the 24th District of 
Florida.  Mr. Feeney serves on the Financial Services and Judiciary 
Committee, as well as the Science Committee.


Gentlemen, it is a pleasure to welcome the three of you before the 
Committee.  And Mr. Baker, we will start with you.  You are now 
recognized.


STATEMENTS OF HON. RICHARD BAKER, A REPRESENTATIVE IN CONGRESS FROM THE 
STATE OF LOUISIANA; HON. CHARLIE MELANCON, A REPRESENTATIVE IN CONGRESS 
FROM THE STATE OF LOUISIANA; AND HON. TOM FEENEY, A REPRESENTATIVE IN 
CONGRESS FROM THE STATE OF FLORIDA

STATEMENT OF HON. RICHARD BAKER



Mr. Baker.  Thank you, Mr. Chairman.  I appreciate your leadership in 
this matter.  Certainly, provision of care for our nation's veterans is 
of the utmost importance to every Member of the Committee, and of the 
Congress.  In this instance, there is the unique circumstance of the 
natural disaster in Louisiana, Katrina-Rita, they're now lumped as one.  
And the consequences for the provision of service in light of the tragic 
devastation that occurred in our state last year.  Prior to landfall by 
Katrina, the VA facility in Orleans parish served 40,000 patients, with 
1700 employees, with an annual operating budget of $130 million, 
certainly a very significant healthcare provider in our region.


As we move forward, the VA in February of this year issued its own 
report and recommendation with regard to replacement of that facility 
with a shared operational management perspective with Louisiana State 
University.  And on its face, it's certainly something that I think is 
worthy for us to explore to realize savings of joint ownership, of food 
services, laundry, parking facilities, and other operational savings 
that can be accrued from such a joint partnership.  There certainly are 
benefits to be gained from the academic residences that might be 
employed or utilized within the VA system for the provision of care.  
So, at all levels, this recommendation makes great sense.  But as is 
often the case in Louisiana, rarely are things as they seem.  And there 
are concerns that have been raised that I would like to bring to the 
Committee's attention as we move forward.


There is now a June 1 deadline for the subsequent report to be issued 
relative to the change in demographics, and who the facility might 
serve.  There are now about two-thirds of the patient load returning to 
the Orleans area for care.  What is not determined is whether the 
temporary dislocation that has already occurred will become permanent, 
skewing the numbers in the Baton Rouge area above the current capacity 
of facilities that are located there.  I am not suggesting today that 
this is a Baton Rouge effort to take a facility out of Orleans.  Merely 
that we should measure carefully the distribution of the veterans and 
where they might best be served in making this strategic decision as to 
how we rebuild.


There is a second and dramatically more important revelation that I 
think the Committee should be made aware of.  When Katrina struck, 
Governor Blanco created a Louisiana Recovery Authority to be the 
interface between the federal government and the state government in 
overseeing the resolution and rebuilding of Louisiana.  That Recovery 
Authority on its own created a foundation of individuals who collect 
resources, and therefore engage in important studies to assist the 
Authority in making policy judgements going forward.  In a recent 
engagement of Price Waterhouse Cooper, the foundation received a report 
relative to the status of healthcare in Louisiana, and it was very, very 
troubling.  As we begin to speak about an LSU-VA partnership, I think 
it's extremely important for the Members of the Committee and for the 
leadership of the VA to be aware of and understand the implications of 
this important study.


Let me just read one line that struck me most directly.  ``The report 
finds that the charity system,'' that is our publicly operated 
healthcare system, ``is detrimental to the health of all Louisianians, 
and is likely an important reason for the lower system quality, the high 
cost, and lack of public and private sector benefits.''  The report goes 
on at great lengths to describe why the system is at fault.


Why do I bring this to this Committee's attention?  Well, what is now 
being contemplated is an LSU-VA partnership.  LSU is the administrator 
of the charity system.  It would be like entering into a three-way 
partnership for a real estate development, and the third partner is 
bankrupt.  We need to be very careful as we go forward.


Now, this report has, I think, important implications for reform for the 
provision of healthcare going forward.  It is estimated by the report 
that the charity system was underfunded in the last fiscal year by some 
$350 million.  If the VA is entering into a partnership with LSU, we 
would need to be very careful about the supplanting of resources from 
one allocation to offset the losses in another.


I'm going to be much more direct back in my home state and district.  I 
really believe our charity system should be undone.  We are the only 
state that provides care in this fashion.  It is extremely expensive.  
It results in a dual system, for those with money and those without 
resources.  And those without resources are receiving inordinately 
poorer care.  I do not wish to see the implications of irreparable 
injury, certainly extended, may be unintentionally, to the care of our 
veterans.  We have an opportunity here to do something extraordinary.  
We can enter into a partnership using private and public resources, 
leveraging with academia valuable research opportunity, and to raise the 
quality of care to a standard which few have thought possible in our 
state in years past.


Mr. Chairman, I want to be very helpful as we go forward in this.  
Getting care restored to its pre-Katrina level is essential.  But we 
should be very careful to deploy valuable taxpayer resources one time, 
in the most effective manner possible.  And I hope to be helpful to you 
and the Committee as we go forward.


The Chairman.  Thank you very much, Mr. Baker.  Mr. Melancon?


[The statement of Hon. Richard Baker appears on p. 56]




[The attachment appears on p. 115]



The Chairman.  Thank you very much, Mr. Baker.  Mr. Melancon, you are 
now recognized.


STATEMENT OF HON. CHARLIE MELANCON



Mr. Melancon.  Thank you, Chairman Buyer.  Richard, does that mean we go 
on record for National Healthcare?  We're friends.


Mr. Baker.  We used to be friends.


Mr. Melancon.  Yes, we used to be, just until a minute ago.


Mr. Chairman, Ranking Member, and Members of the Committee, I thank you 
for allowing me this opportunity to talk to you about an issue that is 
very important to me, and the citizens of my district: which is 
veterans' healthcare.


As everyone is well aware, after Katrina, the Gulf Coast suffered many 
devastating losses.  The grief felt by the people of the Gulf Coast is 
incomprehensible.  Hurricane Katrina was the worst natural disaster in 
this nation's history, followed by the devastation wrought by Hurricane 
Rita.  South Louisiana has experienced more hardship and more loss in a 
period of mere weeks than most communities, states or regions face in a 
lifetime.  This is evidenced by the fact that nearly nine months after 
Katrina hit, we are struggling day by day to rebuild and recover.  This 
is a long term project for us, because what was lost in Katrina was not 
just structures, but history, memories, culture, communities, and 
perhaps saddest of all, many lives.


But the spirit to return and reclaim our place in the world is strong in 
the hearts of the people of South Louisiana.  And though we are down, we 
are not out, not by a long shot.  During our time of need, Louisiana has 
had many friends who have helped us in innumerable ways in the immediate 
aftermath of the storm, and continuing to this day.


I would like to take this opportunity to thank the VA for its efforts to 
evacuate all of the 241 patients, the 272 employees, and the 342 family 
members from the New Orleans VA Medical Center.  Not only that, but by 
September 7th, 2005, all community-based outpatient clinics in the 
affected areas were operational, and five mobile clinics were sent to 
Louisiana.  The VA's efforts in the aftermath of the storm on behalf of 
the veterans' community were outstanding and will not be forgotten.


However, in this period of rebuilding, some are questioning whether the 
VA Medical Center in New Orleans should be rebuilt.  As a result of the 
immense flooding in New Orleans after Hurricane Katrina, two LSU 
hospitals, Charity and University, which served as vital healthcare 
safety net and only level one trauma center in the area, remain closed 
due to extensive and irreparable damage.  The VA Medical Center in New 
Orleans, which is located a block away from Charity Hospital, suffered a 
similar fate.  In other words, much of the healthcare infrastructure of 
South Louisiana is in ruins, and with limited access to healthcare the 
region's entire recovery is in jeopardy.  That is why the recent 
proposal to build shared facilities for LSU and the VA holds some hope.  
This merger could provide the beds and doctors that the general 
population needs if the city is to have a chance at recovery, as well as 
restoring services to the thousands of area veterans who depend on the 
VA.


And, off script, while I understand and agree in many ways with what Mr. 
Baker says, I think we can work through these problems of 
administration.  


The burden on our veterans since the destruction of the VA in New 
Orleans has been enormous.  Access to care for them has always been an 
issue, particularly for the veterans in my district who have to travel 
long distances for the services they need.  The situation has only been 
made worse in the wake of Katrina and Rita.  And every day my office 
hears from veterans who no longer have a place to go for the care they 
have earned with their service.  Many had to evacuate the area 
altogether and with no operating VA facilities in New Orleans, may not 
ever return.


It's a situation that's not limited to veterans.  Right now thousands of 
families displaced from the Gulf Coast are looking at the recovery 
process and trying to decide whether or not to come home.  Levees are 
being fortified in most areas.  There are a growing number of jobs to be 
had.  Homeowners can now expect to see at least some payment for their 
loss of housing.  And some schools are starting to come online.  A 
tremendous amount of effort has gone into making that simple list 
happen.  But a family asking themselves whether they can move back, has 
to ask the questions, ``Where do I go if I get sick?  What doctor can I 
see if I get hurt?''


The answers to those questions lie in a strong healthcare community.  Of 
key importance is the need to rebuild not just bricks and mortar, but 
the human capital that it takes to delivery quality healthcare.  The 
hospitals in the LSU system were not just providers of care, but were 
also teaching hospitals.  Without these teaching hospitals, there is a 
huge hole in the fabric of medical professionals that are the foundation 
of a strong healthcare community.  The LSU-VA plan gives us an 
opportunity to regenerate this important component.  And again, there 
are ways.


This is an historic partnership for historic times.  From an efficiency 
standpoint, it makes sense.  From a fiscal standpoint, it makes sense.  
And from a moral standpoint, after everything these Gulf veterans have 
experienced and endured with these storms, it makes sense.  I urge the 
Committee to support those efforts to rebuild the healthcare 
infrastructure on the Gulf Coast for our veterans and for the rest of 
our citizens in these affected areas.  Thank you, Mr. Chairman, and 
Members.


[The statement of Hon. Charlie Melancon appears on p. 63]






The Chairman.  Thank you, Mr. Melancon.  Mr. Feeney, you have now been 
recognized.


STATEMENT OF HON. TOM FEENEY



Mr. Feeney.  Mr. Chairman, Members of the Committee, I am really 
delighted to be here, and am very grateful for the Committee's time and 
providing me this opportunity.  The veterans population in the United 
States currently stands at 26,549,704 veterans, give or take.  More than 
1.8 million of those veterans reside in the state of Florida.  Our state 
has the second largest veterans population in the country, with over 
350,000 veterans in the Central Florida area alone.  This does not 
include veterans that like to visit our state, and a lot of veterans 
that winter in our state.  We call them ``snowbirds'' and there are 
snowbirds that served their country admirably, and they need service as 
well.


And yet, Central Florida is the largest metropolitan area in the country 
without a VA medical facility.  Many veterans residing in Central 
Florida average more than two hours travel time to get to a VA hospital 
located in Tampa, Gainesville, or Jacksonville.  That includes veterans 
living in counties like Orange, Seminole, Brevard, Volusia, Osceola, 
Polk, and Lake.  In fact, only 45 percent of veterans in the Orlando 
region are within the VA's access standards for hospital care, meaning 
that 55 percent are not being treated in accordance with the standards.  
Central Florida is the number one destination for combat veterans over 
65 years of age.  It's also the number one area for veterans who have 50 
percent or more service connected disability.  18 percent of our 
veterans have Post-Traumatic Stress Disorder.


There are 128 active veterans organizations in the Central Florida area 
alone.  We have got a number of great American heroes and people that 
served their country ably have been working very, very hard to get a 
veterans hospital for some two decades plus, now.  John Kellat, for 
example, some of the DAV veterans, leaders like Jerry Pierce, Charlie 
Brenner, Dr. Neil Euliano, Charlie Price and George Taylor are all 
friends of mine that have been working very hard for close to two 
decades.  Also Bill Carlson, Earle Denton, and I could name many more.


Orlando and its surrounding area was identified by the VA through 
Capital Asset Realignment for Enhanced Services as an area in need of a 
new VA hospital.  At the same CARES identified the need for a new 
facility in Las Vegas, and I appreciate the gentle lady's frustration 
with the challenges that she has meeting the needs of her constituents.  
The need was both appropriate and warranted in Las Vegas, and they have 
received funding and are scheduled to break ground this year, although I 
guess there are some questions about that schedule which I will be 
paying close attention to.


However, a hospital in Central Florida still remains, at this point, 
just an idea.  Design and planning initiatives have been authorized by 
the VA, and efforts are underway to select a site that best suits the 
needs of the Central Florida veterans community.  Balancing 
accessibility needs of Central Florida's veterans with the long term 
economic impact the hospital will have on the state is essential as we 
look  for ways to leverage funds to maximize investment benefits.


I'm delighted to announce to you that the Florida Board of Governors 
recently approved a proposal for the University of Central Florida to 
build a new medical facility right in the East Orlando area.  As 
Chairman Brown pointed out, there are huge benefits, I think Chairman 
Baker did as well, to co-locating a facility with a medical school.  And 
the fact that you can build them at the same time is an enormous 
opportunity that I hope the Committee and the Site Selection Committee 
will consider.  This will be valuable both to local veterans and the VA, 
as a medical school environment provides insight into innovative and 
cutting edge technology.  We also believe we are going to have all sorts 
of spin off, and collateral biomedical research facilities that will be 
established in our area.


The commitment to ensure that veterans have access to additional 
resources to further enhance the medical services to the VA is an 
important one.  Concerns have arisen from the Central Florida Veterans 
Associations in the area that the Central Florida VA Medical Center may 
not come to fruition in a timely manner.  Again, we have waited over two 
decades, and there is concern that we seem to be falling behind again, 
perhaps.  On May 1 of this year, a public hearing was administered by 
the Orlando VA Hospital Site Selection Committee.  Many veterans accused 
lawmakers throughout the country, including their own from Central 
Florida, of dragging their feet on this very important issue of 
servicing 350,000 unserved veterans.


Veterans in Central Florida have been waiting for nearly three decades 
for a complex that continuously has met with delays.  Mr. Chairman, I 
urge the VA to select the site in a timely manner, so that our growing 
veterans population may finally have appropriate access to a much needed 
hospital.  Again, I am very grateful for the willingness of this 
Committee to have me come and advocate on behalf of 350,000 people that 
have ably served their country.  And we would be grateful for any help 
you can give us in serving these people in return.


[The statement of Hon. Tom Feeney appears on p. 60]






The Chairman.  Thank you very much to my colleagues for your testimony.  
And, let me start with you, Mr. Baker. VISN 16 has been looking closely 
at the demographics issue, and I am glad you bring it to our attention.  
And maybe you can be insightful and helpful here to the Committee on 
what exactly is happening in New Orleans?  I know a lot of the 
population came into your area in Baton Rouge.  Are people going back to 
New Orleans?  Or do they now kind of like where they are, because now 
they have new jobs, and obviously the demographics may be changing Baton 
Rouge.  And this could have an impact on site selection and negotiations 
with LSU, and where we are in working together to build a collaborative 
effort.  If you could enlighten us a little bit more on that?


Mr. Baker.  Thank you, Mr. Chairman.  It is unclear at the moment 
exactly the ramifications of the storm.  I think in Charlie's district 
it is impossible for people to return, simply, in St. Bernard there is 
nothing there yet.  There is no houses, it's not a question of being 
damaged, there is just no structures.  In Orleans Parish, it will vary 
depending on where one was.  The central business district, the French 
Quarter, some areas are relatively and modestly affected.  While other 
areas, the lakefront, Lakeview as it is known, or the Lower Nine, utter 
devastation, and no people are returning.


The consequence of this is there are at least a hundred thousand people 
that are new to my congressional district that are in any number of 
housing circumstances, from the infamous FEMA trailer deployment, to 
absorption into whatever available rental market.  Many business owners 
have simply relocated their businesses and bought real estate sight 
unseen and moved the business operation into the region.  From the 
guess-timates that I have heard, it is that they believe a permanent 
dislocation as to veterans will be disproportionately low to the general 
population.  Meaning, they believe that more veterans are likely to stay 
in the Orleans area for services than would be for a customary analysis 
of the business community or any other demographic sector.


However, about a third of the current service area, served in the New 
Orleans area, is likely to be permanently located somewhere in the Baton 
Rouge marketplace.  So there will be, in effect, and I am very anxious 
to see the professional analysis that I hope will be made available 
early June, to help get a better understanding of the potential 
deployment.  But, clearly, it is going to change the market, change it 
for a long time.  And as to the speed of recovery, it is at a snail's 
pace.  Nothing will return to normalcy until we have a significant 
housing inventory for people to live in, and it simply is not happening.  
And the desolation is beyond imaginable scope, even entering into this 
hurricane season.  You know, I would ask everybody's prayers that we be 
spared at least a year before we have to deal with the calamity of even 
a modest storm.


The Chairman.  Well, you have to go back almost 60 years for our federal 
government to have had to face major construction projects.  We have got 
five to six that are in front of us.  It has been 15 years since we have 
built a major facility.  There is a lot of institutional knowledge that 
has left.  And it appears that the priority of all of these, now, is New 
Orleans. And, we are going to have to turn to and rely upon you for your 
counsel, and also your guidance to the VA. They also receive their input 
through the VISN, and through veterans.  We really do not know where 
this is to go.  We are going to have to rely upon you and your counsel.  
This is about not only where they presently are, but what is the 
forecast?


Mr. Baker.  And the fact that it served from Eastern Texas to a great 
number of folks from Mississippi.  This was a regional facility of great 
quality care, I might add, as well.  So replacing it, and the services 
that are now lost, is a very difficult task.  And I just counsel to move 
slowly and get all the professional advice we can get from any source 
before making what will be a very long term decision, and one that we 
cannot easily turn from once the deployment is made.


The Chairman.  Thank you, Mr. Baker.  Mr. Melancon, what is your best 
counsel?  Not only to this Committee, but also, you know, you have got 
VA leadership behind you.


Mr. Melancon.  Thank you, Mr. Buyer.  Down in the bayou it's Melancon, 
up the bayou it's Melancon.


The Chairman.  Melancon?


Mr. Melancon.  Above Baton Rouge it's Melancon.  Here, just call me 
Charlie.  It is a lot easier.


The Chairman.  Melancon, this is de Buyer.  For those who do not know 
me, it is Buyer.


Mr. Melancon. Richard, both of our districts have been impacted, and for 
that matter the entire region has been impacted.  And to tell you where 
anybody has gone is somewhat of a guess.  We have got some approximation 
of numbers, but as far as ethnic groups, or veterans, or who, or, you 
know, income levels, no one knows that number yet.  But I do have a 
place, Richard, if you would like, at the intersection of 55 and I10, 
where we could put it in St. John the Baptist Parish.  I am being 
facetious.  But the need is definitely going to continue.


The frustrations, I guess, and Richard has noted the state and its 
financial problems, are going to continue on for quite a while.  Of 
course, the federal government and its continuing problems, as noted by 
Mr. Filner and Ms. Berkley.....  You know, there is nobody out there 
that has a whole lot of money hanging around.  But we have an obligation 
to all of our veterans that we made to them.  And it goes back long 
before any of us sat in the Congress.


I will support and do whatever it takes to protect our soldiers as long 
as they are at war.  But I think that we need to make sure that we 
expend whatever capital it takes to make sure that when they come back, 
they will have their medical needs and services taken care of, as they 
are fully due.  Thank you, sir.


The Chairman.  My last question, Mr. Feeney.  Have you endorsed a site 
at all, since you are working closely with the Site Selection Group?


Mr. Feeney.  Well, I had not until about two months ago.  And then, in 
conversations with your staff, and with Mr. Brown's staff, we were able 
to determine that there was one site that apparently meets all of the 
criteria for co-location.  And even before the University of Central 
Florida Medical School was approved by the Board of Governors,-this is 
now a done deal and there is funding in the state budget that has been 
passed just two weeks ago- I endorsed the site because of the potential 
and the likelihood of having a co-location.  And that would be Site C, 
which is the Lake Nona Site.


I should say, Chairman Buyer, that there is an ICP site that when 
veterans were asked to testify on the May 1st hearing, virtually all, if 
not all, of the veterans that testified that because of access reasons, 
that that would be their preferred location.  And there were a couple 
questions about that Lake Nona site that I hope that we will take a look 
at and resolve that veterans have raised.  There is a fourth runway of 
the Orlando International Airport which is active right now.  And there 
are questions about things like the sound and noise disturbing veterans 
that have Post-Traumatic Stress Syndrome.  There was also questions 
raised about emergency helicopters, and whether the flight patterns 
would be interrupted.  I think those questions can be resolved as part 
of the site selection process.


And the bottom line is that with respect to the entire Central Florida 
Congressional Delegation, I think including Congresswoman Brown, and all 
of my Republican colleagues, we want a quality site.  And we want it as 
soon as possible.  Where is a lot less important to us if we have the 
best quality site at the earliest possible time.  I think that probably 
sums up 99 percent of the feelings of the people of Central Florida.


The Chairman.  All right.  Thank you, very much.  Mr. Filner?


Mr. Filner.  No questions.


The Chairman.  Mr. Moran?


Mr. Moran.  No questions, sir.


The Chairman.  Mr. Michaud?  Ms. Berkley?  Chairman Brown?  Everybody's 
being really kind to all of you guys.  All right, this panel is excused.  
Thank you very much.  If I could have the second panel, Dr. Jon Perlin, 
Under-Secretary of Health at the Veterans Health Administration.  Dr. 
Perlin's background includes healthcare quality management, health 
information technologies, medical education, and health services 
research.  Dr. Perlin, you are now recognized.


STATEMENTS OF DR. JONATHAN R. PERLIN, UNDER SECRETARY FOR HEALTH, 
VETERANS HEALTH ADMINISTRATION; ACCOMPANIED BY HONORABLE TIM S. MCCLAIN, 
GENERAL COUNSEL, DEPARTMENT OF VETERANS AFFAIRS; ROBERT L. NEARY, JR., 
ACTING CHIEF OF FACILITIES MANAGEMENT OFFICER, VETERANS HEALTH 
ADMINISTRATION

STATEMENT OF DR. JONATHAN PERLIN



Dr. Perlin.  Mr. Chairman, Members of the Committee, good morning.  It 
is a pleasure to join you this morning.  I am joined today by our 
General Counsel, Mr. Tim McClain, Mr. Bob Neary, the acting Chief of 
Facilities Management for VA.


In July of 1999, GAO found that VA was spending $1 million a day on 
unneeded or unused facilities.  In response, VA essentially declared a 
moratorium on new healthcare construction from 2000 to 2004 to develop a 
coherent national plan for modernizing our facilities.  Capital Asset 
Realignment for Enhanced Services, or CARES Program, is that plan.  It 
allows us efficiency in our healthcare operations and to more prudently 
use the funding taxpayers entrust to us.  And it allows us to transform 
an infrastructure created for previous generations of veterans into one 
that provides 21st century care and 21st century technology for 21st 
century veterans.


VA is the owner, tenant and operator of the largest healthcare related 
real estate portfolio in the United States.  The Department also 
maintains facilities for the Veterans Benefits Administration, and most 
of our nation's national cemeteries.  VA's goal is to always use these 
resources efficiently and effectively for the service of veterans.


Former Secretary Anthony Principi released the CARES decision on May 
7th, 2004.  Since that time, 12 construction contracts under CARES have 
been awarded and are underway.  We plan to award an additional 12 
contracts by the end of this fiscal year.  Guided by Secretary 
Nicholson's Blue Ribbon Panel, the construction advisory board which is 
chaired by General Heiberg, this Board offers recommendations for 
contemporary, transparent and accountable approaches to construction.  
These are attributes amplified by our capital investment process.


VA's draft bill to authorize construction for fiscal year 2007 was 
submitted to Congress on April 5th, 2006.  In it, we are asking to re-
authorize 19 previously approved CARES projects.  Also, for six new 
construction authorizations, and approval of eight leases and two 
projects resulting from Hurricane Katrina's devastation.  In particular, 
a replacement facility for our New Orleans VA Medical Center, and the 
expansion of the Biloxi hospital to accommodate the workload from the 
now closed Gulfport campus.   

For fiscal year 2007, the President's budget identifies a total of $714 
million in capital funding.  This includes $399 million for major 
construction projects, two projects of over $7 million in value, and 
$190 million for minor construction for projects under $7 million.  It 
also identifies $85 million in grants for the construction of state 
veterans homes, and $32 million in grants for the construction of state 
veterans cemeteries.


VHA's request for construction funding for medical facilities is $457 
million.  This includes $307 million for major construction projects, 
and $150 million for minor construction.  These resources will be 
devoted to implementing projects identified in our CARES program.  If 
our 2007 budget request is adopted, VA will have received more than $3 
billion to implement CARES to date.


We appreciate Congress' and the President's support as we maximize 
veterans access to the high quality healthcare for which our Department 
is renowned.  Let me highlight one of the projects currently funded 
under CARES, the renovation of our Biloxi VA Medical Center.


Biloxi was damaged during Hurricane Katrina, and its Gulfport division 
was completely destroyed.  The CARES report called for us to collaborate 
with Keesler Air Force Base to meet VA and DOD needs in the area, and to 
transport Gulfport's current patient care services to the Biloxi campus.  
Katrina required us to accelerate the process, and with the $293 million 
emergency supplemental funding we received, we are proceeding rapidly 
with our DOD partners to meet the needs of Gulf Coast veterans, as well 
as servicemembers and their families.


We are also working, as you know, collaboratively with New Orleans to 
bring state of the art medical care back to that city, and to the 
region.  In February we signed an agreement with Louisiana State 
University to work together to develop plans for new medical facilities, 
maximizing efficiencies through sharing.  Together, we hope to create 
sharing agreements that will benefit veterans and all the citizens of 
Louisiana, as well as the American taxpayer.


Mr. Chairman, the $53.4 million in major construction funding, and the 
$25 million in minor construction are resources that this budget 
provides for the National Cemetery Administration will ensure that 
nearly 84 percent of veterans will be served by a burial option in a 
National or State Veterans Cemetery within 75 miles of their residence.  
The National Cemetery Administration is now engaged in its largest 
expansion since the Civil War, and is making all National Cemeteries it 
administers national shrines commemorating veterans' service to our 
nation.


Thank you for your support in fulfilling our mission of service in 
honoring America's veterans.  Thank you.


[The statement of Dr. Jonathan Perlin appears on p. 65]






The Chairman.  Dr. Perlin, while I understand that the core services and 
construction standards themselves in the VA differ somewhat from the 
private sector, how do you explain what seems to be a drastic disparity 
between the cost estimates to construct a new state of the art facility 
for the VA and what is employed in the private sector?


Dr. Perlin.  Thank you, Mr. Chairman, for that question.  I should note 
that VA facilities are built to higher standards in terms of security.  
The hardening of the first two floors is estimated to add about five 
percent to the cost of the facility.


I would, however, suggest that the costs are not different when one 
actually looks at what the VA medical centers typically include.  They 
often include spinal cord injury units, nursing home, and our patient 
population is an older and sicker, less mobile patient population.  
Because of the illnesses, the complexity of the illnesses, and the 
unique services VA offers, as well as facilities which are not just 
hospital bed towers but also include substantial ambulatory services, 
when one actually includes these other factors, as well as the federal 
labor requirements that are part of the construction process, it 
actually turns out that our construction costs are on par with private 
sector construction costs.  I think it is fair to say that all of us are 
reeling from the inflation in not only construction in the United 
States, based in part on the inflation in fuel, in concrete, and in 
steel, with expansion in construction worldwide, but also with a 
hospital boom that is particularly affecting the cost of construction in 
the healthcare industry.


The Chairman.  I have here the two Collaborative Opportunity Steering 
Group reports, one for Charleston, between the Medical University and 
the VA in Charleston.  I also then have your interim report, of April, 
2006, by the Collaborative Opportunity Steering Group for Louisiana, in 
particular the Southeast Louisiana Veterans Healthcare System and LSU.  
I would like for you to share with us what you have learned from this 
process, and where we are going from here.


Dr. Perlin.  Let me first, Mr. Chairman, thank you and Chairman Brown 
for the opportunity to set a stage to really look at how we might 
improve our efficiency, both in terms of capital construction, as well 
as operating efficiency, by sharing and partnership.  We believe that 
the Charleston approach to evaluating potential synergies was so 
successful that we have actually now called it the Charleston Model.  We 
did not anticipate to, but because of the natural disaster, that was 
Katrina, and its tragic circumstances, have applied it very rapidly when 
we looked at the opportunities for those sorts of capital and 
operational synergies in New Orleans.  And, indeed, we discovered that 
where there is an opportunity to collaborate we believe that we can 
reduce the cost to taxpayer, and improve the quality of services by 
creating sharing agreements.  In fact, we believe that there are some 
unique opportunities in New Orleans, Louisiana, and the absence of a 
medical center.


But we are still learning.  What we learned in the New Orleans Model 
will bring us back to the Charleston Model, and will take us to another 
level of granularity as we evaluate potential synergies in that 
environment as well.


The Chairman.  Thank you. Mr. McClain, I want to thank you for your 
efforts.  My last question on the same subject is, do you have anything 
to add, since you personally participated in this process?


Mr. McClain.  No, I think Dr. Perlin has stated it very eloquently.  I 
think the one thing that I learned from it is that the first thing we 
have to do is for both parties to be talking on the same wavelength as 
far as a cost in one facility needs to be based on the same items as a 
cost in the other facility.  And once you get to that level, which took 
us a while in Charleston, but now we have been able to apply in New 
Orleans, then you are able to talk apples to apples.  And it really 
opens up the discussion on both sides.  And the one thing about the 
Charleston Model, especially working with Dr. Greenberg at MUSC, was 
that once you get to that level, both sides open up and are then free to 
talk economics as to what really makes sense in any particular area.  
And I think that that really was helpful to us in talking with LSU and 
getting them and us quickly on the same page.  And that is why we have 
been able to, I think accomplish the interim report in almost record 
time.  And, as I understand it, the final report will be ready on June 
1st.


The Chairman.  Dr. Perlin, Michael Moreland, who is the Director of the 
VA Pittsburgh Healthcare System, is an extraordinary individual, a real 
asset to the VA, and so to the gentleman to your right, for leading 
these two efforts to define something anew,  congratulations.  With 
that, now I yield to Mr. Filner.


Mr. Filner.  Thank you, Mr. Chairman.  I just want to talk a little bit, 
if I might, Dr. Perlin, about the use of this CARES process and your 
prioritizing of projects.  Can you first explain to us how the VA 
develops its annual construction request, and what role will the CARES 
report now play?


Dr. Perlin.  Mr. Filner, thank you for that question.  Let me, if I 
might, start with the role of the CARES report.  As I mentioned in my 
statement, we essentially had a moratorium on new construction for the 
better part of the last half decade.  And the CARES initiative was a 
national inventory of our current physical infrastructure.  And it 
sought to look at whether we were meeting the needs of veterans, and 
whether there was infrastructure that actually was taking resources away 
from serving veterans.  So, it provided a plan, a template, a blueprint 
for 20 years.


Now, I should let you know, while this is a schematic, we pay attention 
to world events.  And it serves a template, absent any sorts of seismic 
shifts.  We believe it is a good template for where veterans are, and it 
identifies some very pressing needs that are expressed in our 2007 
budget request, and in the CARES projects for new construction that are 
put forward.  Let me ask Mr. Bob Neary to talk about the annual process 
of prioritizing construction activities.


Mr. Filner.  Did you use ``seismic shifts'' metaphorically, or did_


Dr. Perlin.  Well, sir, I certainly hope so.


Mr. Filner.  Me, too.


Mr. Neary.  Thank you.  We in VA have a state of the art capital 
planning process that has been developing over the past several years.  
It relies on linking our strategic benefits delivery goals to the 
infrastructure needs to support those goals.  Some of the guiding 
principles, first of all, on the prioritization of projects relates to 
their sound business and economic principles; promoting a one VA vision; 
the linkage of not only the Veterans Health Administration, but the 
Veterans Benefits Administration and the National Cemetery Program; 
alignment with the VA's strategic goals as established by the Secretary 
and the Secretary's key staff; and also supporting any Presidential 
management agenda items.


Projects are all submitted, and the major construction programs submit 
what is referred to as an Office of Management Budget 300 Application.  
A detailed description of the project and the economics of the project 
are prioritized, and then the budgets are established based on the 
priorities that arrive from that process.  There are, of course, 
instances where for one or another reason, primarily patient safety or 
employee safety, might suggest that a project be moved up on the list.  
Or, there are some projects that are more complicated and take longer to 
plan for, and they might not be proposed in total consistency with the 
priorities.  But other than that, we are proud that we stay strictly 
with our priorities as they are established in the process.


Mr. Filner.  Let me just, since I am not sure that I understood 
everything you said, ask you specifically.  Now, you had in your fiscal 
year 2007 request a project in Columbia, Missouri, that had a priority 
in CARES of 21, or 21 on the list.  Why was that chosen ahead of others 
with higher priorities?  Is that policy clearly stated somewhere, or is 
that just what you decided?


Dr. Perlin.  Mr. Filner, I can take that, because I, in fact, bear some 
of the responsibility for the priority of that issue.  As Mr. Neary 
said, the prioritization of projects is based on first, our service 
mission to veterans, second, making sure any special needs of veterans 
are met, and of nearly equal weight, and actually a mathematical process 
is used, is life safety.  In fact, a change circumstance occurred at 
Columbia, and the operating room is having electrical failure and has 
some infrastructural failures, that presents immediate life safety 
issues, as well as limts the capacity to continue to serve veterans in 
that OR.


Mr. Filner.  Why did the CARES process not take that into account?


Dr. Perlin.  I think the CARES process reviewed things, but there were 
some failures of the infrastructure that became evident that needed to 
be addressed, and addressed immediately.


Mr. Filner.  Okay.


Dr. Perlin.  While the CARES process is a blueprint, this is a fairly 
fine point on that, and one that you would expect us to pay attention to 
in real time.


Mr. Filner.  It is just sort of frustrating, and I think it needs 
further explanation, probably in the documents. We have been told for a 
long time that CARES is going to be an all-encompassing kind of thing, 
and we have to hold off capital investments until it is finished.  Then 
it appears that there are projects that do not appear in the top ten, or 
even top 20, right after the plan is finished.  So, you are going to 
build up a frustration, or a sense that, ``Why did we go through all 
this?'' if you continue to do that.  Do you think that is a worry that 
we should have?  


Dr. Perlin.  As I said, the CARES is a template, and this was a new 
circumstance, or a change in circumstance, that affected a particular 
operating suite with the patient care at risk there.  And it needed 
immediate attention.  Our goal is to be as accountable, transparent, as 
we possibly can, and I do appreciate the opportunity to discuss this 
particular circumstance.


Mr. Filner.  Thank you.


The Chairman.  I thank the gentleman.  Mr. Moran?


Mr. Moran.  No questions, sir.


The Chairman.  Thank you.  Mr. Michaud, you are recognized for 
questions.


Mr. Michaud.  Thank you, Mr. Chairman.  In the essence of time, I will 
narrow it down to one question.  Dr. Perlin, the VA has promised many in 
Congress an increase in community-based outpatient clinics, assuring us 
of an aggressive program to build these facilities.  How many of these 
proposed clinics does the VA plan to build, activate or keep open within 
the next three years?


Dr. Perlin.  Thank you, Mr. Michaud.  Thank you for your support of the 
community-based outpatient clinics as one of the best ways to provide 
outreach services to veterans.  In fact, in our appropriations, or 
budget hearings, the Secretary testified that in 2006 and 2007 that 
there will be a total of 58 community-based outpatient clinics under 
consideration in terms of developing operating plans.  We will get those 
plans from each of the networks, and go over those.  Ultimately, it will 
be up to and including that number of clinics.  There may be reasons 
additional clinics would be brought forward.  I would be unprepared to 
talk about years out beyond that in terms of the specific number of 
CBOC's.


Mr. Michaud.  I have a follow-up question.  But what do you do, when the 
VISN personnel will not submit a plan.  For instance, VISN 1, there is 
only one CBOC that is proposed.  However, they will not even submit a 
plan for VA to consider because they have no money to deal with it.


Dr. Perlin.  Sir, you are absolutely correct that the funding for the 
Community-based Outpatient Clinics comes from operating dollars.  Their 
goal is to bring on the clinics not only in terms of what the operating 
dollars support, but also in terms of the ability to recruit and match 
the infrastructure to the patient needs.  So they prioritize clinics 
over time.  And I actually, along with my senior team, track the 
workload.  And we know that, in particular, in Maine that there is an 
opportunity for one clinic that is coming up this year, and addresses 
one of the areas where there are workload issues that are not up to our 
standards.  The other areas actually are within standard, but we 
recognize the need for introducing those clinics over time.


Again, the CARES plan was a 20-year plan.  And, in fact, it identified 
156 clinics.  I think the Secretary has testified to this body that 58 
are really under consideration in this year and 2007 alone.  So, pretty 
substantial progress.


Mr. Michaud.  In the essence of time, Mr. Chairman, I will submit the 
rest of my questions in writing, because I know we do have to go vote.


The Chairman.  I thank the gentleman.  Well, Mr. Michaud, there is 
nothing more important than this hearing, than this panel.  So, we have 
got a 15 minute vote, and then a five, and we are going to come back.  
They are going to have to wait.  I apologize, but we are going to have 
to come back.  So, I will recognize you again, and then I will go to Mr. 
Brown.  Is that fair?


Mr. Michaud.  Okay.  That is fair.  Thank you, Mr. Chairman.


Mr. Brown of South Carolina.  Thank you, Mr. Chairman.  Dr. Perlin, 
following up on the Collaborative Opportunity Steering Group process in 
Charleston, several operational issues still remain unresolved.  When 
can we expect the COSG 2 to be established to keep the Charleston 
collaboration going?


Dr. Perlin.  Let me first, Mr. Brown, thank you very much for your 
endorsement of the approach, looking at Charleston, looking at New 
Orleans.  It is a good template, and as I mentioned, we learned a lot in 
Charleston, and we also learned in Louisiana.  So I will be returning 
and asking a group to come together this month to, again, look at 
another level of granularity on Charleston.


Mr. Brown of South Carolina.  One further question, do you agree that 
public/private partnerships can be a catalyst for modernization and 
development of a new and improved service for veterans.  You support 
that idea, do you not?


Dr. Perlin.  Mr. Chairman Brown, we do support the opportunity for 
collaborations.  We believe that there are opportunities where there are 
synergies, win-win's.  As our General Counsel mentioned, that the 
ability to use models such as the Charleston Model to understand the 
cost basis of activities for each partner, the opportunity to provide 
services to one another, to support capital infrastructure, all improve 
the opportunity to serve veterans and not only reduce the capital costs, 
but reduce the operating costs every time.


Mr. Brown of South Carolina.  Thank you, and I will wait until the next 
session.


Dr. Perlin.  Thank you, sir.


The Chairman.  Ms. Berkley.


Ms. Berkley.  Mr. Chairman, thank you very much.  Dr. Perlin, thank you 
very much for being here.  I am going to dispense with the niceties 
because I have got some very specific questions and I need some very 
specific answers.  When are we breaking ground on the Las Vegas complex?


Dr. Perlin.  Let me ask our Chief of Facilities Management to_


Ms. Berkley.  And please do not tell me sometime later in 2006.  We have 
been saying that for months.  It is now later in 2006.  When are we 
doing this?


Mr. Neary.  We are scheduled to break ground in Las Vegas on the first 
phase of construction in August, 2006.


Ms. Berkley.  You will let me know the exact date of that as soon as you 
know it?


Mr. Neary.  Yes, ma'am.


Ms. Berkley.  All right, number two.  When is your estimated time of 
completion?


Mr. Neary.  We anticipate, the current schedule to complete the entire 
project in August of 2010.


Ms. Berkley.  Now why is that a year later than was originally 
anticipated?


Mr. Neary.  When the design of this project began with two really 
nationally recognized healthcare architectural firms, they felt that the 
design schedule we had established was far too aggressive to be 
reasonably accomplished.  They felt the design would take longer.  And 
that is the primary contributor, really the only contributor.


Ms. Berkley.  So we have no design yet?


Mr. Neary.  We have completed the first phase of design, which is called 
schematic design.


Ms. Berkley.  Yeah, how many phases do we have in design?


Mr. Neary.  There are three phases in design: schematic design, design 
development, and then the preparation of the construction documents.


Ms. Berkley.  So where is the difficulty, in which phase?  If one is 
done, is it number two or number three that is causing us the delay?


Mr. Neary.  They felt that in each phase of the design our schedule was 
too aggressive.


Ms. Berkley.  In what way?  I would like to know what way that is going 
to be.  I know how quickly buildings can go up in Las Vegas.  I want to 
know why this one is too aggressive and ambitious.


Mr. Neary.  Not the construction, I do not think they felt construction 
was aggressive, but the design itself.  In their view_


Ms. Berkley.  I would like to know exactly what it is, if you do not 
mind finding out from them and letting me know.  And here is another 
question.  Why is it going to take an extra year?  I understand that 
completion is 2010, but we are not going to be operational until 2011.  
Why the lag?


Mr. Neary.  I think the reference to 2011, I assume, relates to the 
fiscal year.


Ms. Berkley.  Can you find that out, too?


Mr. Neary.  The building, when completed in August, should be able to be 
occupied within the next two to three months after that.


Ms. Berkley.  I would think so.  I just attended an opening, a viewing 
of a hospital in Pahrump, Nevada.  It was completed, they did the tours, 
they disinfected it, and they opened it up, and it is taking care of 
patients.  I need that hospital and complex open.  We need it now, and 
now we know we have got another year delay.  And, is the $147 million, 
and I guarantee knowing the cost of construction is skyrocketing that is 
going to go up before this is completed.  Will that money be in the 2008 
budget?  It was promised for the 2007, it was not in there.  Secretary 
Nicholson sat right where you are, Dr. Perlin, and assured me in a not 
so pleasant conversation that this would be in the 2008 budget.  Will it 
be?


Dr. Perlin.  Well, let me just say, we have $259 million in the bank to 
support this project.


Ms. Berkley.  I know, that is what I keep telling my veterans.


Dr. Perlin.  Obviously, we are not going to start a project and not 
complete it.  We want to get this project open.  As you know, we have to 
bring our budget forward through the Office of Management and Budget, 
and the President's budget is ultimately published, and I would not 
preempt that.  But it would be entirely, entirely illogical to assume 
that we would make a nearly $260 million investment and not follow 
through in a timely opening.


Ms. Berkley.  That is not my question.  My question is, will the $147 
million be in the 2008 budget as promised by the VA Secretary as he sat 
in that very seat?


Dr. Perlin.  I would have to defer to the Secretary's testimony.


Ms. Berkley.  Then the answer is, ``yes?''


Dr. Perlin.  I do not recall the specifics of_


Ms. Berkley.  I recall it very well.


The Chairman.  Ms. Berkley?


Ms. Berkley.  Yes, sir?


The Chairman.  We have about five minutes for our vote?


Ms. Berkley.  Yes, and it takes about five minutes to get there.  I 
thank you gentleman.  I am very serious about this.  We need this 
facility.  Thank you.


The Chairman.  We are going to recess for about 15 minutes, and return.  
The Committee stands in recess.


[Whereupon, at 12:38 p.m., the Committee recessed, to reconvene at 1:05 
p.m., the same day.]


The Chairman.  The hearing will come back to order.  Dr. Perlin, I want 
to ask a question regarding the Denver facility.  And, perhaps, Mr. 
Neary, you can be helpful to us.  As you are aware, the House Committee 
on Appropriations completed their Mark for fiscal year 2007, the 
Military Quality of Life Appropriations Bill.  The bill does not include 
any funding for a replacement medical facility in Denver, because of the 
large cost, which has doubled the previous estimates.  So, what we have 
is an appropriations bill ahead of our authorization bill, but we want 
to take this issue up and address it.  And I am curious about the 
Administration's reaction to this, and whether or not you have 
recommendations on how we should proceed in the authorization bill, so 
that the Appropriators get a signal that this is something that they can 
get their arms around.


Dr. Perlin.  Mr. Chairman, thank you very much for the question focusing 
on Denver.  This is a project that is tremendously important.  It is 
part of the CARES decisions.  It is also a project that received initial 
funding of $25 million in fiscal year 2004, I believe.  It is an 
Administration priority.  There is an infrastructure that needs 
improvements, and in the spirit of the same sort of opportunities for 
synergy if offers, the ability to provide ready sub-specialists that are 
university-based and opportunity for a geographic proximity to where 
University of Colorado is moving.  And for both capital opportunities as 
well as operational efficiencies and improvements in care, we believe 
that the new site for Denver is particularly important and would like 
your authorization to proceed, certainly in obtaining land for this new 
facility.


The Chairman.  When you propose to obtain the land, are you proposing 
that we take Denver and break it up incrementally?


Dr. Perlin.  Mr. Chairman, I know that you have expressed, and the 
Committee has expressed, some concern about the cost of the project, and 
does really want to compel in us transparency, accountability and 
efficiency in the stewardship of the resources.  And we welcome your 
oversight at any point in the process, but do recognize, as you have 
recognized to us, that delay leads to cost increases, inflation.


The Chairman.  So, at a minimum in our authorization bill, we should 
authorize you to do the land acquisition.  Do you know at approximately 
what cost, or is this something you need to get back to us on?  Mr. 
Neary?


Mr. Neary.  Mr. Chairman, there are multiple parcels involved.  I 
believe there are four parcels involved.  The largest coming from the 
Fitzsimons Redevelopment Authority.  It is estimated that three of the 
four parcels will cost $25 million, and the fourth parcel contains a 
recently completed new office building, which we expect we could 
purchase for $30 million and integrate that into our plan.  It would 
lessen the need for construction of new space.  And so, in total $55 
million.


The Chairman.  Now, tell me whether I am accurate or not.  You want us, 
the federal government, to spend $25 million for land that we had given 
away?  Is that right, Mr. Neary?  We, the federal government, gave away 
this land to the locals, and they in turn are going to charge us $25 
million.  Is that about accurate?


Dr. Perlin.  Mr. Chairman, I might ask our General Counsel, who has been 
following this process to look at the history.


The Chairman.  I do not blame you.


Mr. McClain.  Sir, you are right.  There was a BRAC process that 
occurred in 1995.  Fitzsimons was part of the BRAC.  It was put up and 
made available under the BRAC process for federal agencies, and so I 
cannot say that it was ever specifically offered to VA but it certainly 
was made available to federal agencies to express interest in this 
property.  VA did not express interest at that time.  Department of 
Education actually acquired some of the property, on which the 
University is located, and Children's Hospital.  And the rest of the 
property went to the Fitzsimons Redevelopment Authority, who paid a 
price, not a very high price, but paid a price for the property.  And 
they now control the property, and that is who we are trying to purchase 
it from.


The Chairman.  Okay, help me so that I can explain to the taxpayers why 
it is a good deal.  Spending $25 million on property that we just gave 
to somebody does not feel good.


Mr. McClain.  This is property that the FRA had originally designed to 
utilize as a tax base.  They were going to have a convention hotel on 
it, I understand.  Our greatest desire was to be close to our affiliate, 
the University of Colorado Health Sciences Center.  This whole thing 
precipitated when the University decided to move the Fitzsimons.  They 
are located, of course, right across the street from us in downtown, on 
Colorado Avenue.  But when they moved, that created a problem for us.  
And we needed to accelerate our plans to stay with our affiliate.


In fact, they were originally going to complete the move to Fitzsimons, 
I believe it was 2011.  And now they have accelerated their plans, and 
they are going to complete the move by next year, by 2007.  And, so we 
have a rather old hospital in downtown that is landlocked, and we wanted 
to be on Fitzsimons.  And this is one of the last remaining properties 
on Fitzsimons that we could negotiate for.  And so I think the good deal 
for the veterans and for the American taxpayer is that we are going to 
build a state of the art facility very close to our affiliate, and in 
very close proximity to other major medical facilities, such as 
Children's Hospital.


The Chairman.  So, you are saying that I should not view this as a shake 
down by the University of the VA?


Mr. McClain.  This is not the University property, Mr. Chairman.


The Chairman.  Well, the Redevelopment Authority.


Mr. McClain.  This is the Fitzsimons Redevelopment Authority.


The Chairman.  You know, a lot of people would love to have a VA 
Hospital be placed on their land.  In fact, they would also almost give 
you the land, because of the values which we bring, and all the other 
synergies, and things that could happen, Dr. Perlin, as you described.  
So I am trying to get there.  Am I viewing this wrong?  Is the 
Redevelopment Authority seeing this as an opportunity to milk the 
federal government for some money?


Mr. McClain.  No, sir, I do not believe.  And I have been involved in 
some of the negotiations, and I do not view it that way.  They certainly 
want to get value for their property, because they took control of it, 
they have it, they paid a certain amount for it, and they want to get 
value for it.


The Chairman.  How much did they pay for all of this land?


Mr. McClain.  Sir, I will have to get back to you on that.  As to how 
many acres it was after Department of Education took their chunk, and 
the exact purchase price, I do not have that.


The Chairman.  All right, let me ask this question:  with regard to 
where your present facility is and the University, this affiliation, how 
far do the doctors travel today between hospitals?


Mr. McClain.  Across the street.


The Chairman.  Today?


Mr. McClain.  Today.  Or do you mean the new hospital that they have?


The Chairman.  Right now, the present VA compared to where the 
University is.


Mr. McClain.  When they complete their move to Fitzsimons, in other 
words, sir?  I believe it's in the neighborhood of 15 miles.


The Chairman.  Fifteen miles.  Let me ask you, is the University 
Hospital the only game in town?


Mr. McClain.  Not the only game in town, but we have an established 
affiliation with that hospital in Denver.


The Chairman.  And if you let Denver know that you are willing to breach 
or sever that relationship because the Redevelopment Authority is 
gouging the taxpayer for money on property that we had already given 
back to them, is there another relationship that we could establish with 
someone else?  I do not know, I am just asking.


Mr. McClain.  And I think that that is a very, very fair question, and 
one that I know was looked into.  And I would like to get back to you on 
that, if I could, as to what other opportunities there are available.  I 
know it has been looked at, and the choice was to be on Fitzsimons, that 
would be our first choice.  But I know that there were other options 
that were considered, and I would like to get back to you on what they 
were.


The Chairman.  Well, the number one priority is either maintaining or 
increasing the quality of care for our veterans in Denver, and access.  
At the same time, being cognizant, or using your word, Dr. Perlin, being 
the good steward.  And it just does not feel good to me, I just want to 
let you know that.  Something does not feel right, here.


Dr. Perlin.  Mr. Chairman?


The Chairman.  Yes.


Dr. Perlin.  As you know, we currently have the opportunity to express 
interest in parcels of land under this current BRAC.  And we are making 
known interest in 11 sites, seven Army, two Air Force, two Navy.  
Unfortunately, I agree with some of the feelings around what might have 
been available, but there was a timing problem after, of course, the 
mid-90's BRAC, it was '95, and would that the conditions were that we 
could have expressed interest then.


The University is not the only game in town.  It is the game that offers 
certain specialty services, and certain sorts of synergies for sub-
specialties, as well as the opportunity to share workload through the 
use of fellows and trainees in an educational experience.  So there are 
desirable attributes.  The ability, for instance, if we need half of the 
very sub, sub-specialist's time, to be able to go from one facility to 
the other, when we really do not need the full time of the person, is 
simply unlikely for an individual who has to travel that sort of 
distance.  If it is across the street, if it is a couple miles, it is 
really feasible to share, particularly for procedural specialties.  For 
the others, it really becomes more difficult.


So, I agree with the sentiment.  I appreciate your passion for the 
stewardship of resources.  We do feel that the efficiencies that would 
be derived over the longer haul, operating efficiencies, make this a 
worthwhile investment.


The Chairman.  All right.  Puerto Rico, are you personally comfortable 
with spending nearly $300 million on renovations in San Juan, Puerto 
Rico considering we are talking about a facility that is already nearly 
50 years old?


Dr. Perlin.  The situation in Puerto Rico, Mr. Chairman, presents some 
unique challenges.  It is a facility that is very convenient for 
veterans.  It is on the light rail system.  It is a facility where 
substantial renovations have already been made.  Improvements in the 
nursing home, and minor construction projects, and parking garage 
improvements to outpatient clinic.  It is a facility, also, that has 
seismic challenges, and we need to make seismic corrections to Building 
No. 1, about $145.2 million, as well as create a new bed tower.  And the 
investment would be in the order of $230 million.  At the end of the 
day, we would have an improved, functional facility, but you are right, 
the basic infrastructure would be 50 years old.  It is one that raises 
that question, what are alternatives?  And it is one that we explore.


The challenge in that particular environment is that we have an 
immediate need and immediate occupancy requirements.  And whatever the 
choice, we need to continue to care for veterans whether we invest it in 
this current facility, or seek to create a new one.


The Chairman.  Gentlemen, have you seen the private/public business 
proposal as it relates to construction for a new medical facility in 
Puerto Rico?  You have not?


Dr. Perlin.  We have not seen it.  We have heard that there is interest.


The Chairman.  The delegate of Puerto Rico, a colleague of ours here, is 
interested in that.  If you will note, also in the Appropriations 
Committee Mark under Puerto Rico, they are also asking that you begin to 
look at that a little bit further.  I would, well, you need to look at 
it a little bit further, but we sent Committee staff down to Puerto Rico 
to examine the facility.  And we want to work with you as to whether it 
would make any sense to consider the San Juan, Puerto Rico as a pilot 
site for the public/private partnership project.  Given the substantial 
facility deficiencies that the Department is proposing to address with 
very expensive renovations that in the end will fall short of the 
capacity needed to handle the workload.  So, we would like to work with 
you on the Puerto Rico sight, on the authorization, all right?


Dr. Perlin.  Thank you, Mr. Chairman, we would be pleased to explore it.


The Chairman.  With regard to Mr. Baker's testimony, do you have any 
comment on his testimony?


Dr. Perlin.  We appreciate the Congressman's testimony, and do recognize 
that there is a deluge of, perhaps the wrong word, or quite a sizable 
population shifts up to the Baton Rouge area.  As Congressman Baker 
testified, the New Orleans Medical Center was a Referral Center serving 
veterans from Mississippi to Texas.  I think it is important to note 
that even if Orleans and St. Bernard Parish were not to repopulate, the 
environment would still support the need, very much support the need, 
for a Referral Hospital for Veterans regionally.


The opportunity to partner, again, for all the reasons we discussed, 
introduces certain synergies.  The Congressman made certain points 
regarding a report about the concerns of the Charity Hospital system.  
In fact, one of the reasons that LSU is interested in partnership with 
VA is because they have seen the transformation in VA from really 
serving as a safety net to becoming a prevention net.  The great thing 
about that transformation is it not only provides individuals with 
better care, it is also far more efficient.  So they would hope to take 
a page from our play book in the way that care is delivered.


So on the basis of population, and the basis of synergy, and the belief 
that their philosophical interest in VA is because they want to model 
the way that VA now approaches care; health promotion and disease 
prevention, as opposed to a safety net.  We view this as an important 
opportunity for improving service to veterans, and for them to improve 
service to their Louisiana patients.


The Chairman.  Now, regarding the VISN and you, I do not know so I am 
asking this. You are investigating the demographics, the trends, as to 
where to properly go, where to build a collaborative site?  You're 
already doing a demographic study at LSU saying, ``Well, come to our 
site. Come on back downtown."  Tell us what's happening here.


Dr. Perlin.  Yes, sir.  We've been working with actuaries to try to 
understand what the demographic shifts are, and not only in New Orleans 
but in the state of Louisiana, what the impacts are in terms of 
projected workload for a VA medical center in that region.  In fact, 
even if St. Bernard Parish and Orleans Parish were not to repopulate, 
there is still absolutely a sizeable workload that is regionally based.  
In fact, the three new clinics, at Slidell, Hammond and La Place, which 
ring the New Orleans city area proper, but are part of the surrounding 
community, are extremely busy already, as is, in fairness, the clinic up 
in Baton Rouge.  So there is already the workload to support to support 
a referral hospital.  And even if, again, St. Bernard and Orleans were 
not to repopulate, the growth projections for the region, and the 
surrounding parishes of New Orleans proper, is very substantial.  So it 
would seem to be appropriately placed.


The Chairman.  Well, can I throw this to you?  Let us go to your 
testimony, ``appropriately placed,'' and let me
just ask this question.  There is an emotional desire to rebuild New 
Orleans.  If our goal is to increase quality and access, and we want to 
build up the levies, and even if we are to build a VA facility that 
would protect itself against a Category 4 storm or above, we could still 
find ourselves, the VA, as an island.  So we would still have an access 
problem.  Veterans would have to go somewhere else.  I know that there 
are some that are saying, ``Well, if you are going to build this 
facility, or a collaborative effort, move to the population trends in 
Slidell or others.''  Are we caught between this emotion to build New 
Orleans, yet we find ourselves compounded in a problem we have just gone 
through?  Or are we to go where the population trends are, whereby we do 
not have a repeat?


Dr. Perlin.  Mr. Chairman, I think every feeling American is sympathetic 
to the plight of the individuals of New Orleans, but I hope we will make 
our decision on the basis of good business and transparent analysis of 
the demographics.  With that in mind, you raise a very fair point.  
Which is, okay, what would the risk be even for a hardened facility in 
that location?  One permutation, because this is a question that, I can 
assure you, I asked and the Secretary asked, is how could you prevent, 
if the city were, heaven forbid, to flood again, how could you prevent 
the facility from becoming an island?  In point of fact, above sea level 
is the expressway, and one permutation that has been proposed is to 
actually have an exit ramp built directly to these facility sites so 
that in fact there were elevated access to these facilities.  One plot 
of land happens to be very proximate to that expressway.  But a very 
fair question, for all of the reasons that you suggest.


The Chairman.  I remember, when I was serving on the Katrina Commission, 
gosh, please do not ask me where I got this.  This is one of those 
things that you just kind of remember.  That areas that had some 
devastation by hurricane, 30 percent do not come back.  Then they slowly 
trickle back, over time, and a decade later, they will return.  So, take 
Hugo, for example.  It took 10 years for them to come back, and then for 
the population to explode.  Homestead, 50 percent.  And, so this 
demographic and trend analysis will be pretty important.  Mr. Michaud?


Mr. Michaud.  Thank you very much, Mr. Chairman.  I would like to follow 
up on where I left off previously. Dr. Perlin,  since I have been here I 
have heard a lot about, the CARES process, that it is all encompassing 
and that we need it to hold off capital investments until it is 
completed.  And we heard the Chairman talk about buying some land back 
that we gave away with a significant amount of dollars, and a lot of 
these other expenditures.  I guess, how much is the Department still 
interested in the CARES planning?  I am really having concerns because 
it is an all-encompassing plan.  Granted, things might be a little 
different than when the plan originally came out, and I can understand 
that.


However, in all of VISN 1, there is one CBOC recommended and four 
outreach clinics.  VISN 1 hasn't got the capability financially to even 
submit a business plan for the CBOC.  So, if you have a VISN, and this 
is the same VISN that actually had to borrow money to make ends meet 
because they did not have the financial resources.  So, if the CARES 
plan says, yes, a CBOC and four outreach clinics are important, granted 
it has to be a priority.  But what I am seeing is now, when you look at 
some of the capital construction funds, other projects are jumping over 
another priority.  I am just concerned that the Department is not 
maintaining, the CARES process as a top priority.  Comments?


Dr. Perlin.  Yes, thank you, sir, for the question.  I want to tease 
apart two aspects.  In terms of the CARES process, I think that is the 
major blueprint for the major capital infrastructural investments, and 
we have requests for authorization and reauthorizations in the 
Authorization Bill that the Department submitted.  And so that really is 
a template.  In terms of the Community-based Outpatient Clinics, the 
CARES plan, as you have alluded, also noted the need for 156.  The CARES 
plan is a 20-year plan.  I think it is pretty compelling that the VA has 
had a 350 percent increase in points of access over, nearly the past 
decade in terms of opening new clinics.  I know that we make decisions, 
and I really want to stress this, not just on the basis of what is in 
the operating budget, but what is the immediate operational need.


This is why, as we have discussed, the Lincoln Outreach Clinic is 
prioritized, but we recognize that there will be growth in other areas, 
and the network will bring them on.  So I think it is important to 
recognize that dollars are important, but so are the operational needs 
will drive the timing of requests for particular clinics.  And I will 
track not only the individual clinics, but the workload at each of the 
facilities that the clinic would be in the catchman area of.  And I know 
that there are some in Maine, in particular, and you have my commitment 
to watch those.


Mr. Michaud.  I appreciate that.  And I will be watching it very closely 
myself.  Because you could have some VISN's, who have identified need 
and are entitled to a CBOC, and has the money to actually submit their 
business plan, but that CBOC might not be a higher priority than other 
VISN's that cannot even submit a business plan because of lack of 
funding.  And things do change, particularly when you look at different 
regions, and what is happening over in Iraq and Afghanistan creating 
more veterans.  And that is my concern.  VISN's who are inadequately 
funded in the first place will fall further and further behind in 
opening CBOCS and outreach clinics because of the lack of the resource.


My second question deals with a GAO report that just came out.  In light 
of the GAO report that came out on the collaboration in Denver and in 
Charleston,  have you changed or modified the Charleston Model, based on 
the GAO recommendations.


Dr. Perlin.  Thank you for the question.  I am going to ask Mr. Neary to 
provide comment on that.


Mr. Michaud.  Thank you.


Mr. Neary.  I think one of the things that we learned in Charleston is 
that we did not bring enough architectural support to the thinking that 
was going on in the group.  So, in New Orleans we have added that 
component.  We have the architectural firm of Leo Daly, a noted 
healthcare architectural firm, working with the Mike Moreland planning 
team to assist them in any way they can.


Mr. Michaud. Thank you.  Okay, and my last question deals with_


The Chairman.  Will the gentleman yield on this for a second?


Mr. Michaud.  Yes.


The Chairman.  I just want to share with you, if the focus is on 
communication, is what the GAO is saying, the history here is, with 
regard to the Denver facility, the hope was that was where the 
collaboration was going to be.  But it did not work out.  There was real 
conflict in personalities between a VISN Director and the University 
Hospital Director.  And the architectural firm that did that, tried to 
do the Charleston Model, which really would have been the Denver Model, 
had it worked.  Four years ago, I met with Charleston, and everybody 
wanted to run off and build their own facilities everywhere.  And so 
Henry Brown, four or five years ago, we met with them and encouraged 
them to hire the architectural firm that did the planning in Denver, and 
did it in Charleston.


And so we asked the GAO to come in and look at Denver.  What were the 
lessons learned, why did it fail?  Because some of the same input was 
given for Charleston, and to assess some of the, what, failings?  So we 
could figure out how to improve it, and they really wanted to focus on 
communications.  But I wanted to share with the gentleman sort of the 
history of that.  I yield back.


Mr. Michaud.  I appreciate that very much, Mr. Chairman.  My last 
question, it seems that collaborative opportunities for the VA will 
increase, particularly with what happened in the Gulf Region, because of 
disasters.  In the environment of constrained funding, how can the VA 
deal with the construction issues caused by disasters as well as move 
forward on the CARES process?  Because clearly we have to take care of 
the hospitals damaged disasters by but that is going to have an effect 
on the CARES process.


Dr. Perlin.  Thank you, Mr. Michaud, for that question.  I think it is 
important to say that our first mission is the care of veterans, the 
ability to improve the care of veterans, the ability to serve veterans 
is really what we hope to serve through any sort of collaborative 
activity, and that alone.


Second, you have asked the question about how we prepare for disasters.  
This is one of the great advantages of being a national system.  We are 
operational.  We deal with the care of patients day in and day out, and 
because of that we have relationships with suppliers.  We also have a 
system which also has a very systematic approach to readiness, and we 
exercise that.


So, in point of fact, our infrastructure while in the shared 
environments with others is one that can actually be supported, 
bolstered by the national organization providing supplies, providing 
personnel, and providing resources in times of disaster.  It is hard to 
believe, but come June 1 we again face the prospect of hurricane season, 
and some of the preparatory activity includes such things as beginning 
to stockpile certain supplies, rather than having our usual just in time 
inventory.  But, we will continue to have a very systematic approach, it 
will be exercised to approach the specter not only of local emergency 
but of regional and even national emergencies.


The Chairman.  Mrs. Brown?


Mrs. Brown-Waite.  Thank you, Mr. Chairman.  Just one second, thirty 
seconds about me.  I represent most of Florida.  I have Jacksonville, 
Orlando, Gainesville, I have a lot of veterans in my area, and I have 
got to tell you I want to say, I want to associate myself with the 
remarks of, I understand, Congressman Feeney came in here earlier.  I 
have represented the area for 14 years.  It has been a fight on this 
hospital for over 25 years.  And the people that have lost have been the 
veterans in the Orlando, you know, Central Florida area.   




Secretary Brown did come in and helped us a great deal when they 
recommended closing the Naval Training Center, and the Department of 
Defense gave it to the veterans and we in Congress got the money to 
renovate it.  And it has been a good deal up until this point.  We 
really need a hospital in that area.  And I guess my first question is, 
once you are close to making a decision then where are we with the 
request for the funds, that is my first question.


Dr. Perlin.  Yes, ma'am.  Let me start by thanking you for your support 
of the Orlando facility.  We are very excited about this finally coming 
to a decision point.  As you may know, there was a site team that went 
down on May 2nd and 3rd, I believe those were the dates, and evaluated 
the contending sites.  There are some that, for many of the reasons 
discussed today, appear to be favorable.  But the Secretary will have 
the opportunity to review those data, and I believe begin to make a 
preliminary decision within the next few weeks.


Mrs. Brown-Waite.  Okay.


Dr. Perlin.  And that is something that I very much look forward to, I'm 
sure, as you do.


Mrs. Brown-Waite.  I want to make sure my statement is included in the 
record, Mr. Chairman, pertaining to my written comments in the record, 
because it pertains to the Orlando facility.


The Chairman.  You would like to submit a statement into the record?


Mrs. Brown-Waite.  Yes, sir.


The Chairman.  Yes, hearing no objections, so ordered.


Mrs. Brown-Waite.  Now, we have a situation in Jacksonville that I have 
scheduled a meeting with the VA on Monday, and I am going to ask you a 
national question, but first of all you have got to get your local 
situation taken care of.  So my first question is, it pertains to 
Jacksonville.


I do not know whether you know, but I met 30 minutes ago with the 
President of the University of Florida who is over Shands Hospital.  Two 
weeks ago I met with the Mayor of Jacksonville, and I met with the VA, 
and now I am putting all those same people in a room on Monday at 3:00, 
because I do not know what you do when failure is not an option.  And we 
have been working, the city and Shands, they had a facility that they 
have torn down, and they moved an agency that was in there that has been 
a great disturbance to the community.  And everybody thought we were 
moving forward, and then I heard it was some problem about the parking 
garage, or something.  So I met with the mayor, they are willing to 
resolve it.  So I do not really know the problem, but I hope everybody 
gets their notes together, and when we come together Monday, when we get 
out of that room this will be resolved and we will be moving forward.


Dr. Perlin.  Well, Congresswomen, thank you very much for your support 
of us, and in particular bringing people together on Monday.  I think 
this will be very helpful.  As you know, we are very committed to the 
increasing outpatient presence needed in Jacksonville.  The Deputy 
Secretary himself has been down there to really affirm VA's commitment 
to serving veterans in that area, and we appreciate the relationship 
with Shands.


I would be less than forthright if I did not acknowledge that there has 
been some wrestling over the number of parking spaces.  I believe some 
of that has to do with city code, and I think that can be easily 
resolved, and I think some of it has to do with capacity of some 
buildings.  And I would appreciate your help very much on Monday on 
bringing parties together such that we can provide the necessary parking 
for veterans, and get on with this activity.


Mrs. Brown-Waite.  Okay, and can you just give me an update on the 
cemetery in that area, also?


Dr. Perlin.  If I might, I would refer to Mr. Bill Jayne of the National 
Cemetery Administration.


Mrs. Brown-Waite.  Yes, sir.


Mr. Jayne.  Yes, ma'am, we just finished the environmental assessment 
for three properties that we are looking at, potential sites for the 
National Cemetery in Jacksonville that was authorized by Public Law 108-
109.  And we are reviewing the comments and we will be preparing a 
recommendation to the Secretary to make the final decision in the next 
couple of months.  The process will probably take about that long, but 
it is going along well, and we feel like we have got some good potential 
sites.  They are all located roughly north of the airport there in 
Jacksonville.


Mrs. Brown-Waite.  Well, good.  My question is, do you all have this, I 
know that in order to expedite the time, that you all have some kind of 
a model that you all use, that you are using all over the country?


Mr. Jayne.  What we try to do to expedite the provision of service is 
that we will divide the first phase of construction into what we call a 
Phase 1A and Phase 1B.  And the Phase 1A will be intended to prepare 
some of the site, a small portion of the site, for burials as soon as 
possible.  And we will rely to some degree there on temporary 
facilities, such as a temporary office, temporary maintenance facility, 
that will be replaced during Phase 1B with permanent facilities.  But 
the idea is to bite off, if you will, a small workable chunk and design 
that in so that when the entire Phase 1 is done, it will meld into the 
rest of the cemetery.  It will not look like it is part of something, a 
different project.


Mrs. Brown-Waite.  How long for each phase?


Mr. Jayne.  We hope to be able to finish that Phase 1A by late 2008, 
early 2009.


Mrs. Brown-Waite.  And final completion?


Mr. Jayne.  Final completion would be about a year later, of Phase 1.


Mrs. Brown-Waite.  Of Phase 1?


Mr. Jayne.  Right.  And that would be, the Phase 1A would be open, 
available to veterans and their families in late 2008, early 2009, and 
about a year later we would be able to finish the rest of Phase 1, that 
is the permanent buildings and so forth.


Mrs. Brown-Waite.  Okay, thank you very much.  On the national system, I 
just returned from New Orleans I guess about a month ago.  And I met 
with the Army Corp. and wanted a status report as far as where we was as 
far as the levies is concerned.  But my concern goes to, it is not just 
New Orleans.  I mean, like you said, I live in Florida.  The hurricane 
season is coming, and it is not just coming to New Orleans, but Florida.  
And the national system, my understanding was that part of the problem 
was the veterans, if they are displaced, and many were displaced after 
the hurricane.  But, are we plugged in so that no matter where a veteran 
goes, you can pull up his records?  Is that straight now?


Dr. Perlin.  Yes, ma'am.  Let me assure you that as we use our 
electronic health record, you can actually go to a function called 
remote data view, and see their medical conditions, refill 
prescriptions, also a function called VistaWeb.  And we would certainly 
want to put in also back-up communications.  And in fact, we are in the 
process of establishing, and we appreciate the help of our Office of 
Information and Technology, establishing satellite uplinks so that in 
the event there is not communication on, ground based fiber and cable, 
we can actually use high band width satellites to communicate between 
facilities.


Mrs. Brown-Waite.  So we will be able to assist the veterans no matter 
where this takes place?


Dr. Perlin.  Yes, ma'am, absolutely.


Mrs. Brown-Waite.  Well, that is good.  I want to thank the Chairman for 
what he did as far as the communications, making sure that we put that 
system in place, and we held up the money a little bit until we could 
really get a system that would serve the veterans.  So, thank you, and 
thank you for the time.




The Chairman.  Thank you very much.  I have just a few more questions.  
This is an authorization for a lot of money, so I know this is a long 
hearing, and I thank you for the patience of the American Legion and the 
VFW.  We are going to get to you.


As I go down the list, you also are asking for $189 million in 
Pittsburgh, Pennsylvania.  So, let us turn to our buddy, Mr. Moreland.  
What is he doing?


Dr. Perlin.  Sir, in Pittsburgh, Pennsylvania, it is actually an 
opportunity to improve service to veterans while improving efficiency.  
Pittsburgh has been operating virtually as three campuses, and in this 
area we will be able to consolidate down to two.  And the University 
Drive campus, actually bring much of the workload to that facility, and 
also supports a second facility with improved residential treatment.  
Bring the management and the overhead of three facilities into two, 
improved access, improved facilities, improved technology, improved 
efficiency.  So we appreciate the investment and realizing the promise 
of the CARES program.


The Chairman.  What is Mike Moreland doing there with regard to 
collaboration, if any?


Dr. Perlin.  Mr. Moreland is doing tremendous things in terms of 
collaboration.  This is really a great example where, in collaboration 
with the University of Pittsburgh Medical Center, they share certain 
specialties.  In other areas, they actually use some of our services, 
that makes it a long term win-win partnership.  And in other areas, Mr. 
Moreland's entrepreneurial approach has created a template that allows 
for leadership in programs that are extremely complex, like transplant 
surgery.  And that facility is really an extremely well managed 
facility, as you would expect from Mr. Moreland, but one that benefits 
both from internally efficient operations as well as good collaborative 
relationships.


The Chairman.  All right, as a Committee we have the challenge here in 
front of us.  Earlier I had mentioned, it has been decades since the VA 
has found itself with this many major construction projects in front of 
it.  The list goes on and on, with a lot of the consolidation of 
clinical and administrative functions, and outpatient clinics, 
ambulatory care, expansion of spinal care, seismic corrections, ward 
upgrades, electrical systems, bed renovations, I mean, the list goes on.  
But we have a challenge here in front of us.  So I feel no differently 
from how the Appropriations Committee must have felt.


You submit a request for us for $675 million for New Orleans, Louisiana.  
Appropriators put in an emergency supplemental in excess of $550 
million, subject to an authorization to expire on June 30th.  So, we as 
a Committee do not know where you want to go, and we need good counsel 
from you to us.


We also have the Biloxi facility.  And I know you just met with Mr. 
Taylor of Mississippi, and I know that he would love to keep the 
Gulfport facility, but I had to explain to him also, and I know you were 
very candid with him, about the realities, and to follow CARES, and that 
we are going to upgrade Biloxi.  And I do not have a problem with that 
at all.


But New Orleans, break this one out a little better for us.  I mean, 
because I feel conflicted inside a little bit, just where I am with 
Denver.  So, give me your best shot.


Dr. Perlin.  Mr. Chairman, it is not possible at this moment to tell you 
exactly what corner, what intersection in New Orleans this facility will 
be located.  What we can tell you is that for reasons that have 
convinced the Secretary, convinced me, we have the opportunity to 
improve efficiency and restore services to veterans with a facility in 
New Orleans proper.


We appreciate the discussion and the responsible oversight provided by 
you and the Committee in asking the question, ``What if?''  And that is 
something we take very seriously, having weathered Katrina as a hospital 
that was in a flooded area.  The ability to assure access is something 
that is absolutely paramount.  The ability for a facility to be hardened 
and withstand damage is absolutely paramount.  And given that the 
demographics from actuaries demonstrate that there is still a population 
basis, even if Orleans and St. Bernard were not to repopulate, that 
would support the need for a tertiary referral center, now and in the 
future, our request is for authorization for a facility in New Orleans 
proper.


The Chairman.  And if we were to do this in New Orleans, authorize it 
subject to the collaboration between you and LSU, do you have a problem 
with that?


Dr. Perlin.  Mr. Chairman, we believe that the collaboration will offer 
efficiencies.  Not only do we not have a problem, we look forward to not 
only approving care, but improving efficiency and the stewardship of 
resources.


The Chairman.  And increasing the quality at the same time.


Dr. Perlin.  Yes, sir.


The Chairman.  All right.  Mr. McClain and Mr. Neary, I know that there 
are some outstanding leases out there, and that we have got to get this 
authorization of the leases.  Mr. McClain, our present liability, could 
you address that right now?  I mean, we are in a present liability 
because of not having gotten this authorization done, so can you help 
explain about time being of the essence?


Mr. McClain.  Many of the leases will run out, as I understand it, at 
the end of the fiscal year.  So, unless we have authorization to reenter 
into those leases, or extend them, we are probably going to be paying 
more afterwards when we do get the authorization.  We will be paying 
market rates or whatever the market rate will be at that point.


The Chairman.  These are contract penalties?


Mr. McClain.  Yes, sir.  So I believe that that is the case.  I defer 
actually to Mr. Neary.


The Chairman.  Do we have any leases right now that have expired, which 
were in penalty?


Mr. Neary.  No, Mr. Chairman, we do not.  The leases for which we are 
requesting authorization in a couple of instances are new facilities, we 
do not have anything existing.  As Mr. McClain said, the sooner we get 
authorization the sooner we can proceed to a contract and lock in that 
market rate.  As we talked earlier, building costs are growing.  And so, 
the sooner the better.


The other leases are in situations where we are in an existing facility, 
the leases will be expiring.  We will, if needed, attempt to work with 
that lessor to enter into an extension of the lease while we get 
authorization, and then acquire the new facility.


So the only additional liability I believe we have at this point is, as 
Mr. McClain said, as the market increases, the sooner we can lock in the 
better.


The Chairman.  Thank you, very much.  These penalties would be 
approximately what over an annualized basis, per facility, would you 
know that? Someone I think had informed me one time it was around 
$100,000, is that right?  Over a year, is that about accurate?


Mr. Neary.  I think maybe penalty is not exactly the right word used.  
When we go and extend the lease, the lessor will obviously want to 
increase our rental rate to current market.  And some of these are 
clinics that have been in existence 20 years, so we are paying a darn 
good rate now.


The Chairman.  I guess I am calling it a penalty only in that if we do 
not get our job done on time, you have got to pay more money.  That is a 
penalty to the taxpayer.


Mr. Neary.  Correct.


The Chairman.  I stand corrected.  The $377,700,000 you are asking for 
on the Orlando facility, can you break this out for us?


Mr. Neary.  Our working number currently for the site is $30 million.  
So the design and construction costs we have presently estimated $347 
million.


The Chairman.  So, your request to us is not 377 it is 347?


Mr. Neary.  No, we would need authorization for the total of 377.  We 
require authorization_


The Chairman.  How much is the land, approximately?


Mr. Neary.  Our working number is $30 million.


The Chairman.  Your working number, but as of right now_


Mr. Neary.  We are looking at six sites.  As Dr. Perlin said, we will 
soon in the next few weeks be shortening that number up.  We will then 
engage in real estate due diligence, seeking appraisals of the sites, 
begin negotiating with the landowner.


The Chairman.  Obviously that is all being done before you announce.


Mr. Neary.  I'm sorry?  One of the requirements_


The Chairman.  If I were a landowner I would love for you to announce 
that you are coming to buy my property.


Mr. Neary.  We are required to follow_


The Chairman.  Right?  They are only going to put the price up.


Mr. Neary.  Well, the good thing for us is we have choices.  There are a 
number of competing sites.


The Chairman.  Yes?


Dr. Perlin.  Mr. Chairman, you are exactly right.  We would caution, we 
do not want to bid against ourselves.


The Chairman.  Yes, do not tell us, right?


Dr. Perlin.  Exactly.


The Chairman.  Mr. McClain, you go out there and you negotiate, and then 
you can tell us.


Dr. Perlin.  Exactly.


The Chairman.  All right.  I'm good.  Are you good with that, Mr. 
Michaud?  Going down this list, Mr. Michaud, do you have anything 
further on any of these sites?  I think we have covered them.  The only 
thing I have would be this, and it is a follow-up from the conversation 
we had had.


At some point in time, and from my conversation with General Love, is 
this idea of when the Secretary and your team have put together the time 
lines of this construction so you can begin to overlay and utilize this 
institutional knowledge, these time lines when you set them will be very 
helpful to us.  And it is helpful also to OMB, because over this next 
decade, building these six facilities, we have not been here before.  
And as you lay that out to OMB, lay it out to us, and the appropriators, 
and the Senate, so everybody has confidence in your plan and in your 
number, and we all can proceed.  For the veterans service organizations 
you have used, the word transparency, getting their input from the 
localities so that the national leadership of the organizations 
understand how it is going, and the time line.   

When that happens, then you calm the emotion of a Ms. Berkley.  Right?  
I mean, you calm the emotions of others.  And we want to work with you 
to do that.  Do you have anything that you would like to add?


Dr. Perlin.  No, sir.  We agree with you in terms of that, and in fact 
do have Gantt charts on play out layout, and we commit to being more 
transparent about making those very public so you are with us as we 
progress through these important constructions.


As well, I would simply note again that General Heiberg's advice and the 
Construction Advisory Board_


The Chairman.  Hold on, just a second.  Would you be willing to submit 
that for the record?  Your chart?


Dr. Perlin.  Absolutely, yes, sir.


The Chairman.  All right, how do you identify your document?


Dr. Perlin.  This is a Gantt chart on the construction timetable for Las 
Vegas.


The Chairman.  The document shall be entered into the record, so 
ordered.  Please, I'm sorry.


Dr. Perlin.  I would simply conclude by saying that the Construction 
Advisory Board, that blue ribbon panel that the Secretary chartered, 
that really compels us to use the most contemporary, transparent and 
accountable approaches.  We know how important that is, not only to the 
Committee, but to the taxpayer.  We owe taxpayers and veterans that.


The Chairman.  All right, thank you very much, gentlemen for your -- 
yes?


Dr. Perlin.  If I might, sir, before we leave, it would be remiss if on 
behalf of our colleagues at the Department of Veterans Affairs we did 
not join you in expressing our admiration and appreciation for the 
service of Jim Lariviere.  I would just like to really acknowledge his 
tremendous leadership and service.


The Chairman.  Thank you.  I will make sure he sees that.  Thank you, 
gentlemen for you testimony.  You are now excused.  Third panel, please 
come forward.


Mr. Salazar, I ask that the opening statement of Mr. Salazar shall be 
offered to be entered into the record.  Hearing no objections, so 
ordered.

[No statement was submitted.]


The Chairman.  Our final panel will receive the endurance award.  I've 
got a couple like energy bars here, if you need them.  Are you okay?  
You operate well on an empty stomach?


Mr. Cullinan.  So far, so good, Mr. Chairman.


The Chairman.  I do apologize to you.  You have been here since 10:30, 
but you also have been able to sit there and take in some very valuable 
testimony.  Not only from our members, in particular our two members 
from the New Orleans/Baton Rouge area, and Mr. Feeney of Orlando.  I 
mean, you get your input from your membership, but it is kind of 
interesting to listen from their perspective.  At the same time, we have 
huge challenges in front of us on how we get this construction done and 
know what the plan is, and how we get it into the budgets. 




So, thank you very much for enduring, but you were able to listen to all 
of this testimony.


Representing the American Legion is Cathleen Wiblemo, a U.S. Army 
Veteran, and she is the Deputy Director for the Veterans Affairs and 
Rehabilitation Commission of the American Legion.  And our final witness 
on this panel, Dennis Cullinan, is the Director of the National 
Legislative Services for the Veterans of Foreign Wars.  Dennis was 
discharged from the United States Navy in 1970.  Ms Wiblemo I did not 
say when you were discharged.  That is because I am a gentleman.


Ms. Wiblemo.  Oh, thank you.  Thank you.


The Chairman.  Ms. Wiblemo, you are now recognized.


STATEMENTS OF CATHLEEN C. WIBLEMO, DEPUTY DIRECTOR, VETERANS AFFAIRS AND 
REHABILITATION COMMISSION, THE AMERICAN LEGION; ACCOMPANIED BY DENNIS 
CULLINAN, DIRECTOR NATIONAL LEGISLATIVE SERVICE, VETERANS OF FOREIGN 
WARS

STATEMENT OF CATHLEEN C. WIBLEMO



Ms. Wiblemo.  Good afternoon Mr. Chairman, and Members of the Committee.  
Thank you for the invitation to present the American Legion's views on 
the Rightsizing of the Department of Veterans Affairs.  The American 
Legion has a keen interest in this very important process.  My oral 
remarks will be brief, but I ask that my written testimony be submitted 
in its entirety for the record.


The Chairman.  Hearing no objections, it is so ordered.


Ms. Wiblemo.  From the beginning of the CARES process, the American 
Legion has taken an active role.  We have formed an advisory committee 
made up of volunteer legionnaires to look at facility assessment and 
possible use or reuse of reported vacant space.  We appointed a 
volunteer legionnaire in every VISN to report on the local concerns on 
legionnaires regarding CARES.  These volunteers also testified before 
the CARES Commission during the Commission Site Visits in 2003.  We have 
sent a representative to every Local Advisory Panel meeting that has 
been held to date.  If and when Stage 2 starts and the LAPS resume, rest 
assured that we will be present.  It is frustrating that we have tried 
since November to find out the status of the LAPS and have been 
unsuccessful.  We even called all the LAP points of contact that were 
given to us, and they were as much in the dark as we were.


The American Legion would like to emphasize that stakeholder input has 
been a key component in the CARES process.  The LAPS were set up to 
ensure continued stakeholder input.  Veterans across the country were 
astonished to hear that after seven months of dormancy, and complete 
lack of communication with stakeholders, major realignment decisions in 
16 of the CARES affected communities are soon to be made by the 
Secretary of VA.


The American Legion has conducted site visits to every medical center in 
the VA Healthcare System across America as part of our System Task Force 
mandate.  We have recently visited Las Vegas, Denver and New Orleans.  
We have seen first hand the state of VA healthcare at these sites.


The CARES decision was meant to be used as a blueprint, a guideline, a 
method of developing the tools necessary to shape the VA healthcare 
system into the future.  Congress tasked VA to come up with a plan, and 
they did.  For many years, construction dollars were hard to come by 
awaiting the outcome of the CARES process.  What we would like to see is 
a more pronounced sense of urgency to implement decisions that have 
already been made, and get quality, accessible healthcare to veterans in 
specific areas that the CARES determined are not only high priority but 
urgent and critical.


It is time to move forward and fund major and minor construction 
throughout the VA healthcare system to catch up for the years when 
capital improvement projects were frozen awaiting the CARES plan, along 
with the years since CARES when funding has fallen short of the well-
defined need.


CARES was triggered by a GAO report in 1999 that showed VA was spending 
millions of dollars a year on unused space.  Solving that problem guided 
CARES from beginning to end.  Seven years later, this costly problem of 
inefficiency not only remains but has grown bigger.  Former VA Secretary 
Principi warned that one of the biggest threats to CARES was ``paralysis 
by analysis.''  It is the plan Congress asked for.  It is a plan that 
envisions the right size for VA healthcare and veterans deserve that.  
Thank you, and I look forward to your questions.


[The statement of Ms. Cathleen C. Wiblemo appears on p. 78]




  

Mr. Chairman.  Thank you very much.  Mr. Cullinan?


STATEMENT OF DENNIS CULLINAN



Mr. Cullinan.  Thank you very much, Mr. Chairman.  On behalf of the men 
and women of the Veterans of Foreign Wars of the United States, and our 
Ladies Auxiliary, I want to thank you for inviting us to participate in 
today's most important and revealing hearing.


As you know, the VFW handles the construction portion, and independent 
budget, and I will continue in that vein.


The Chairman.  Does the gentleman have a written statement?


Mr. Cullinan.  I would ask that our written statement be made a part of 
the record.


The Chairman.  Hearing no objection, it is so ordered.


Mr. Cullinan.  To begin, I would say that the VFW and the IBVSO's 
continue to be supportive of sharing of collaborative ventures, you 
know, when they benefit both the veteran and indeed the community.  We 
are, of course, concerned that VA maintain, it continue to protect VA's 
identity as a provider of care and service_


The Chairman.  Mr. Cullinan, may I ask a question?


Mr. Cullinan.  Yes, sir.


The Chairman.  Just for a point of clarity, your testimony here today, 
is it on behalf of the VFW, or is it also as the_


Mr. Cullinan.  We are representing the IBVSO's as well.


The Chairman.  Okay.


Mr. Cullinan.  So, IB.


The Chairman.  Very good.


Mr. Cullinan.  IB.


The Chairman.  All right, thank you.  So you are representing both here 
today, the Independent Budget and the VFW?


Mr. Cullinan.  Well, the VFW is part of the Independent Budget, and we 
handle the construction portion.


The Chairman.  I just want to make sure it is clear.  You are here 
providing testimony, what hat are you wearing?


Mr. Cullinan.  The IB.


The Chairman.  Thank you.


Mr. Cullinan.  You are welcome, sir.  Some of the things that you are 
emphasizing here today, also pertain mightily, as far as we are 
concerned, with respect to collaborative ventures.  It has to do with 
things like access.  The facility has to be located somewhere where a 
veteran can get to it.  Accessibility, we have talked about this before.  
If a facility happens to be, say, situated on a military base, you know, 
is the security too daunting for veterans to get in there.  And what you 
really emphasize is the issue of quality.  That is very, very important.  
In a sharing arrangement, we want to ensure that veterans will get 
quality care.  That is a key issue with us.


We are, of course, and we testified to this extent before, with respect 
to funding of the Gulf Region.  In past testimony, we have indicated 
that the money has to come not only just through the VA's construction 
budget, but through other sources as well, and we are very pleased to 
see that there is money in the emergency supplemental for both Biloxi 
and New Orleans.  But, with respect to New Orleans, I believe we share a 
concern with you that VA not be put in a position where it is acting 
prematurely with respect to building a new facility down in New Orleans.  
We have got to look at the demographics.  There are safety issues of 
concern.  Your image earlier of a VA medical facility as an island was 
pretty impressive and pretty daunting as well.


So these are things that have to be looked at.  We are concerned that 
there may be a tendency to want VA to sort of lead the way, and that may 
not be in veterans' best interests, and that is where we are coming from 
on this issue.


I also have to say that Mr. Baker's testimony earlier was troubling 
indeed.  I mean, usually when we are talking about, both with respect to 
New Orleans and sharing arrangements in general, usually when we are 
talking about a collaboration between a medical school and a VA 
facility, our biggest concern generally is that the VA not get pushed 
around, and everything not sort of work in the medical school's favor.  
It would seem here, from what Mr. Baker was indicating, is that it could 
be a situation where VA could end up as a form of cash cow for a 
facility, and I do not know this, but for a healthcare system that is in 
jeopardy, that is in trouble.  That is troubling to us.  I cannot say 
how accurate of an assessment that is.  I am sure Mr. Baker understands 
it very well, and it is something that we would ask for you to look at.


You know our general budget number.  I am not going to review those 
again.  I would say, in earlier testimony we talked about the situation 
of non-recurring maintenance.  As you know, that is not funded under 
budget.  It is part of the healthcare funding.  That sets a form of 
competition between providing care to veterans and keeping up with 
essential maintenance projects.  The other issue there is that it is 
funded via VERA, which may be the best way going to fund medical care, 
but it can misdirect dollars with respect to construction.  You can have 
an old facility that costs a whole lot of money to maintain, and not 
have very many veterans using it.  If the decision is to keep that thing 
running, then it has got to be properly funded.


Another area, we are pleased to note that the VA is going forward with 
some seismic corrections.  However, it is indicated some 890 VA 
facilities are at significant risk.  We have to move forward with this.  
And we continue to support an architectural master plan.


I have a little note to myself here.  It says, ``Delays cost money.''  
This is a point we have made in earlier testimony, and then today it was 
revealed that there are now 14 projects which are not going to go 
forward in a timely basis.  That costs a lot of money.  It also means 
that veterans are denied, or are not getting, the care that these 
facilities should be providing.  We have court support extending the 
authority to 2009 to provide it, but, again, this is a case where we are 
not doing the right thing by veterans and we are not doing the right 
thing by the taxpayer.  And that is a concern.  We are worried system-
wide.  You can have the best plan in the world, but if money is not 
there to pay for it, what happens next?  So, and this was brought up in 
Senate testimony about a month ago.  What do we do with CARES?  What 
happens if the money is simply not there to pay for it?  And there will 
be a time where the IB will ask to look at this, and say, ``Need we do 
something else?''  If the money is not there to pay for it, what do we 
do?  And we, all of us, the American people, the veterans' community, 
have invested a lot of time, energy, money into this thing.  It would be 
a shame to see it squandered.


The last thing I would like to say here, Mr. Chairman, is that we very 
much appreciate your urging total transparency in the process, in the 
construction process.  I mean, this is a situation we have not had to 
contend with for years and years with respect to building VA facilities, 
figuring out where they have to go.  It is essential that the local 
veterans be involved in the process.  And that concludes my testimony.  
Thank you.


[The statement of Mr. Dennis Cullinan appears on p. 74]






The Chairman.  Yes, I definitely agree with your last statement.  When 
we first began this issue on collaboration, a step beyond personnel to 
facilities, there was confusion at the local level as to what was going 
on.  And then the mysteries and the boogie men started to appear.  And 
you know what?  It goes back to the communication.  And it was very good 
that Mr. Michaud was present, because he also gave some good counsel to 
everyone to, wait a minute, let us make sure that everybody gets 
included in the process.  One of the district Legion individuals was 
present, but the state commander did not know.  And then you had your 
own intra-politics going on within your own groups.  Whoa.  But 
communication I think is beginning to work itself out, and I appreciate 
your final testimony on that point.


Let me turn to Ms. Wiblemo of the American Legion.  In your written 
statement, on page four, if you have it in front of you, if not let me 
just read this to you, with regard to this Charleston Model that is 
being leveraged, now in New Orleans.  So under your paragraph regarding 
New Orleans, in the second paragraph, you said for the American Legion, 
you ``support the relationships that the VA enjoys with the medical 
school.  However, we remain adamant that the VA health system retain its 
own identity.''  Carry that forward.  What do you mean?


Ms. Wiblemo.  Well, a lot of that has to do with the history, South 
Carolina being one of them, MUSC.  And we are adamantly, it is a 
challenge, because I know with the collaborations, and the sharing that 
goes on, and we support sharing and collaborations, and that.  We are 
very afraid that the VA will lose its identity, and lose its unique 
specialty.  It holds a special place in veterans', I mean, obviously, in 
veterans' hearts, but to get_


The Chairman.  Ma'am, have you seen, or read both of these?


Ms. Wiblemo.  Yes, I have.  No, I have not seen the New Orleans one, but 
I have read the MUSC one.


The Chairman.  All right, I will tell you what.  Before you leave here 
today, we will get you a copy of this one.


Ms. Wiblemo.  Thank you.


The Chairman.  Because when you read both of these, I think everyone has 
given the great assurance, and agrees, we want the VA to retain an 
identity.


Ms. Wiblemo.  Right.  And I will tell you, part of the South Carolina 
issue was veterans were not at the table at the time, and they were only 
briefed.


The Chairman.  And early on they got confused because they were going to 
be in the same ward with civilians, and_


Ms. Wiblemo.  There was a lot of confusion.


The Chairman.  That is not going to happen.  That is not what this is 
about.


Ms. Wiblemo.  So, yeah.


The Chairman.  So, if we are in agreement_


Ms. Wiblemo.  That would be_


The Chairman.  Pardon?


Ms. Wiblemo.  That is very important, obviously.  Not just to us, but I 
am sure to a lot of people.


The Chairman.  It is important to me.


Ms. Wiblemo.  Obviously.


The Chairman.  It is important to Mr. Michaud.  It is important to Mr. 
Brown.


Ms. Wiblemo.  Yes.


The Chairman.  So I want you to know that with regard to that statement 
as it appears in your testimony, we in fact all agree.


Ms. Wiblemo.  Great.


The Chairman.  Okay?  So, as they proceed, it is the Charleston Model 
that is being leveraged now to New Orleans, and this one is going to try 
to_


Ms. Wiblemo.  When did the New Orleans one come out?  Was that just this 
month?


The Chairman.  Yes, it just came out.  April 30th.


Ms. Wiblemo.  I have not seen that one.  But I have read the other one.


The Chairman.  Well, you will enjoy this.


Ms. Wiblemo.  Thank you.


The Chairman.  Because Mike Moreland, this is a very sharp individual, 
and he took the best of having gone through this process and leveraged 
it into New Orleans.  And where we are from here, is, that now we need 
to go to Stage 2.  Because this was the heavy lift.  This was the 
identification of all of the no-go categories that must be defined.  And 
once they got defined, then you have to go into the next step.  And that 
is where we are to go, and we are going to move in tandem with both.  
So, it will be important.  If you have any questions, IB, American 
Legion, as this proceeds, please stay in touch with us.  We will be more 
than happy to let you know what we know as we know it.


Ms. Wiblemo.  Thank you.


The Chairman.  Okay.  All right?  Will you make a copy of that right 
now?  We are going to get it to you.  Mr. Michaud, I yield to you, and 
then I have other questions.


Mr. Michaud.  Okay, thank you very much, Mr. Chairman.  I want to thank 
you both for your testimony and willingness to stay as well.  I 
appreciate that very much.  Getting back to, and the reason why I 
mention VISN 1 is that I am familiar with VISN 1 compared to the other 
VISN's.  And I am sure we are not unique in our concerns when you look 
at the whole CARES process.  Do you think that this Committee, or the 
VA, should actually re-look at the whole CARES process?  See if it 
should be changed; what are your thoughts on that?  Because, as you 
heard Dr. Perlin, it is a 20 year plan, and things do change in 20 
years.  They change from year to year.  And priorities do change.  But 
what is your overall thought as far as to make sure that CARES, the plan 
that is put out there, is still valid, you know, next month, next year, 
the year after?


Mr. Cullinan.  Thank you, Mr. Michaud.  I mean, clearly, we do not have 
another 20 years to wait.  I mean, that is what I was afraid of when I 
was listening to Dr. Perlin.  Was it about a month ago the Secretary was 
presented with the CARES report?  Now is the time to look to see if 
something comes of this.  If nothing comes of it, at a certain point, we 
are going to have to say_and I keep saying, I know it is vague to say a 
certain point.  And I do not want to say, and there certainly is not 
agreement within the IB that the time is right now to say, ``Okay, CARES 
ain't working because the money is not there.''  But clearly, you know, 
within the not so distant future, if nothing is coming out of CARES, I 
mean, the construction has been held up for years because of CARES, 
waiting for CARES to emerge.  Well, it is emerging now.  So, let us see 
what comes of it, and let us see if the Congress will fund it.


Ms. Wiblemo.  I suspect, CARES is just a plan to help guide the VA.  It 
will be up to the VA managers and those of us that use the VA system, 
and oversee the VA system, that if it needs to change, or evolve, that 
we are involved in that process.  I imagine that, 10 years from now, 
when technology is advanced even more, and the way that they deliver 
healthcare and where they deliver it is all going to be changed.  It 
will all be changing.  So we have to be open to that type of change that 
might be needed.  And, you know, you could, VA is in genomic medicine 
right now.  You know, they are talking about that.  That is pretty 
futuristic, or it used to be.


So, I think the CARES plan is good for what it was intended to do.  We 
supported the process, and now it is up to VA management to take it and 
put it into place.


Mr. Michaud.  Thank you.  To follow up on your question, you mentioned 
about the VA keeping its identity, which I think is extremely important.  
I hear that a lot from veterans in Maine. And when you look at the CARES 
process, particularly as it relates to rural areas, would either of you 
comment on, as far as a collaborative effort what your thoughts are.  
For instance, it might not be cost effective for the VA to build their 
own outreach clinic or CBOC in the rural area where they can work 
closely with a federally qualified healthcare clinic, or hospital.  Do 
you care to comment on that?  Do you think that is something acceptable 
for your organizations?


Ms. Wiblemo.  Absolutely.  I mean, rural healthcare is its own little 
bit problem, access to rural healthcare, access to quality healthcare.  
And, I mean, we recognize the necessity to contract out to ensure that 
veterans that live in, I'm from South Dakota, you know veterans that 
live in Aberdeen, or out there in the west, you know, they are hundreds 
of miles from a hospital.  And, yeah, sure.  I mean, you have to 
recognize that as something that is needed.  So, we recognize that and 
sure we would support that.


Mr. Cullinan.  Mr. Michaud, we agree with that assessment.  There are 
certain areas, certain parts of the country where that is the only way 
to provide care.  And we do not want veterans denied simply because they 
live in a rural or a remote area.


Ms. Wiblemo.  Could I just add one other thing?  The only thing that we 
have ever, as far as contracting out, the only thing that we have ever 
really said about that, that we do not want it used as a blanket option 
for the VA.  I mean, they need to look at other avenues.  But, certainly 
we understand the need to have to do that.  And in the rural areas.


Mr. Michaud.  Great.  Thank you.  My last question, and Chairman Buyer 
had alluded to it.  When we went down to South Carolina, we saw the bulk 
of the problem, and the reason why there is a lot of concern among 
veterans, is the fact that there was not that communication, they were 
not kept in the loop, so to speak.  And at that time, Dr. Perlin had 
agreed to make sure that they will be kept in the loop from here on out.  
Is that a common practice, that your organizations have seen?  Or is it 
just a rare occurrence where on big projects, whether it is the 
collaboration in South Carolina, or Denver, or the CARES process, where 
your organizations are not kept in the loop.


Mr. Cullinan.  Communication is key.  I would say with the big projects 
our people are brought into the process.  The problem is, a lot of times 
it is just too complicated, it is too technical.  I mean, unless a great 
deal of effort is expended to make it clear.  I mean, they could be 
brought in, but they are not really understanding what is going on, and 
that is a problem.  Of course, that is in part inherent with the problem 
of construction, it is a very technical area.  But I think sometimes, it 
has been better of late.  Some of our people have felt that they have 
been talked down to, but.


Ms. Wiblemo.  With the Chicago CARES Phase 1, the VA really after that, 
because one of the biggest problems with that was there was no buy in 
from the stakeholders from the beginning and they did not even have a 
voice.  So, at the time, when Secretary Principi brought the 
stakeholders in and ensured us a voice, we have not run into that.  I 
was kind of really surprised when I got the e-mail from the Department 
in South Carolina that said this was going on.  Although we knew that 
the collaboration effort had started, because we wrote about it in one 
of our task force reports, that they were looking at that.  This was 
years ago, I mean, 2002, 2003, that they were looking at it, and that it 
was starting.  But I was kind of surprised for him to call and not have 
been kept in the loop.  So I do not think that it is a, I do not think 
it is usually a problem.  I mean, I know at the national level, Dr. 
Perlin and his people, they give us lots of, I mean, we are usually 
overwhelmed with information from them.  But, usually it is not a 
problem.  And South Carolina was probably an anomaly.  That was a huge 
study going on. And they did not know anything about it, so.


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


The Chairman.  Mr. Cullinan, you opened your testimony, and you 
mentioned the word ``quality'' with regard to the collaborative efforts, 
and it is one of the drivers.  It was an idea that I had on how I can 
increase the quality of care, and save money.  Now, how do you do that?  
Think about that.  That is a challenge, right?  And what I learned is 
that too often in this town, and maybe it is even human behavior, it is 
easy to say no.  ``Oh, do not do that.  This is how we always do it, 
this is what we do.  Oh, nah.''


And sometimes, you know, in this town, we will expend 80 percent effort 
to stop something, and 20 percent to do something.  This is an unusual 
town.  But maybe there is some human behavior there.


But what got exciting about this was in those, I told you, those no-go 
areas, you know, and you read that in the report.  It is fascinating to 
put all of these great minds together and say, ``Okay, wow, let us 
explore this.''  And down in Charleston when they testified and said 
that a paradigm had been broken, to think that right now you have the 
tomotherapy, the machine has been purchased, they are building the room 
around it, and two angiographic suites are also included in it.  And 
these are things whereby Dr. Greenberg at MUSC, because of the 
population and economies of scale, they really could not afford to buy.  
And this is equipment not even located in South Carolina or North 
Carolina.  So, when the VA went and said, ``Okay," we are intrigued by 
this effort of collaboration.  And our first effort of building the 
trust was that we will go together.''  The VA is going to purchase this, 
they are going to begin to do this collaborative effort, figure out how 
to do the clinical services, and the legal part, and all the other sides 
of this one, the finances and everything.  It is all going to be 
explored, really, through this.  And when they do this, and the 
treatment of cancer, what have we done?  We have just elevated the 
quality of care that is delivered in South Carolina, or even North 
Carolina.  People will want to go to it.  And so, now all you have to do 
is replicate that with some other things.


But one of the things that is important in all of this, and it was 
important to us in negotiation of this, is priority.  It is our machine, 
we are going to let you use the machine, we are going to get 
reimbursement for it.  But our veterans have priority with regard to 
utilization.  So that goes back to, I think, your testimony about 
identity, you know?  And that is what we want to do.  And I want to take 
the time to be open and honest here with you, and just let you know 
where I am coming from, and where the Committee comes from.  And strike 
me if I am wrong, but Mr. Michaud has been working very well with Mr. 
Brown, in how we proceed forward, and both of them have been working 
very well together to do this.  And as a matter of fact, the only 
caution on this one is before we can even begin to digest it, Katrina 
hits, New Orleans, leverage, you know what I mean, and it is moving.


And so, Mr. Michaud that is where I want to make sure that now that we 
have these two collaborative studies now going, the smartest man on the 
block is Mike Moreland.  The guy that has really done them both, along 
with Mr. McClain.  I mean, that is the guy that now has the 
institutional knowledge of both of these things.  And, not that we want 
to keep a watchful eye, well, maybe that is the thing.  We want to 
figure out, how do we do this in the next stage, and to blend these two 
going forward.  In other words, I do not want to go, ``Okay, we started 
with Charleston, we are going to go to New Orleans, we are going to do 
New Orleans, and then maybe sometime later we will go back to 
Charleston.''  See what I mean?  Let us proceed forward.


And that is why my last question to Dr. Perlin was so important. I did 
not even know they had done that chart.  I had asked them before about 
doing that, graphing it, giving us a time line so that we can know.  
That was the first time, I did not even know that they had already done 
it.


Mr. Cullinan.  We certainly did not know about it, Mr. Chairman.


The Chairman.  Well, I did not either.  Maybe Mr. Michaud knew about 
that.


Mr. Cullinan.  I would have to say that we really appreciate your 
keeping a watchful eye on this.  Because collaborative efforts, we 
think, are a great idea where they work.  But it is something that has 
to be watched, our big fear.


The Chairman.  They do not work everywhere.


Mr. Cullinan.  No, I know.  But generally, some places they will work 
and where they work we support them strongly.  You know, at one point we 
had the specter of the VA healthcare system becoming the federal 
healthcare system, which kind of smacks of something else a little bit, 
too.  But we just do not want to see that happening.  And where there 
are collaborations we want to be sure that they work.  And that issue, 
when you said priority, that veterans remain the top priority.


The Chairman.  And you know what, I think, we are just having an open 
conversation.  What kind of makes some people nervous is that, I do not 
think they want to say, ``Okay, this one is number one, and this one is 
number two, and this one is number three.''  You know, you are going to 
upset Orlando, or do you upset Las Vegas? No, no, we will put it all on 
paper, and we are all working on it, you know?  So they really do not 
like to do the time line thing.  But from our perspective, on the 
authorization, we want to know these time lines.  I just wanted to share 
that with you.


Mr. Michaud, do you have anything else?


I will end where I started.  And that is, the big lift in front of us.  
We have not built a new facility in 15 years.  The last facility was 
built, a behemoth down in Florida with many floors that were not even 
used for patients.  It was built under an old system.  And we provide 
healthcare much differently today.  And so, when you look at the map of 
the United States, we want to continue our valued collaboration with 
medical universities.  We have Las Vegas and Orlando, and the states are 
saying, ``We want to build medical universities.''  So now, UNLV wants 
to bring the medical university in close proximity, to our facility, to 
what we are doing in Las Vegas.  And we think it makes sense to put this 
Orlando facility next to Central Florida, just to let you know.  I do 
not know what they are going to be saying, but where we have been 
sending them, this makes sense.


And then we have, you have heard my comments on Denver, I have read your 
testimony on Denver.  Maybe I have to get over this pit in my stomach, 
because it has already happened.  The federal government gave it away, 
and now we need to figure out where we are going.  But I just do not 
feel good about this one.


We then are left with three others, Charleston, New Orleans, and Puerto 
Rico.


And the last thing I will say about the Puerto Rico that I find is 
interesting is that this private partnership and enhanced use lease with 
the construction of a hospital is worthy of analysis.  Right now, we 
cannot do it.  The law would not permit you to do something like that.  
But it is worthy of looking at it.  How are we going to build six major 
facilities in a short period of time?


So, I am willing to explore different alternatives, how we can do it, 
and do it in a manner whereby we increase the quality and the access.  
And we want to continue to work with you, okay?


Mr. Cullinan.  Thank you very much.


Ms. Wiblemo.  Thank you, Mr. Chairman.


The Chairman.  All right.  Thank you very much.  This panel is excused.  
I ask unanimous consent that the statement on behalf of the Honorable 
Cliff Stearns be submitted into the record.  Hearing no objections, it 
is so ordered.  And I also order that all Members of the Committee may 
have five legislative days to submit statements for the record.  Hearing 
no objections, it is ordered.  The hearing is now concluded.


[No statement for Hon. Cliff Stearns was submitted.]




[The statement of Hon. Jeff Miller appears on p. 55]




[Whereupon, at 2:32 p.m., the Committee was adjourned.]
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