[Senate Hearing 109-376]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 109-376

        FIELD HEARING ON THE STATE OF VA CARE IN HAWAII: PART I

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED NINTH CONGRESS

                             SECOND SESSION

                               __________

                            JANUARY 10, 2006

                               __________

       Printed for the use of the Committee on Veterans' Affairs


 Available via the World Wide Web: http://www.access.gpo.gov/congress/
                                 senate
                     COMMITTEE ON VETERANS' AFFAIRS

                      Larry Craig, Idaho, Chairman
Arlen Specter, Pennsylvania          Daniel K. Akaka, Ranking Member, 
Kay Bailey Hutchison, Texas              Hawaii
Lindsey O. Graham, South Carolina    John D. Rockefeller IV, West 
Richard Burr, North Carolina             Virginia
John Ensign, Nevada                  James M. Jeffords, (I) Vermont
John Thune, South Dakota             Patty Murray, Washington
Johnny Isakson, Georgia              Barack Obama, Illinois
                                     Ken Salazar, Colorado
                  Lupe Wissel, Majority Staff Director
               D. Noelani Kalipi, Minority Staff Director



                                 ______

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                          WASHINGTON : 2006
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                            C O N T E N T S

                              ----------                              

                            January 10, 2006
                                SENATORS

                                                                   Page
Craig, Hon. Larry, Chairman, U.S. Senator from Idaho.............     1
Akaka, Hon. Daniel K., U.S. Senator from Hawaii..................     3

                               WITNESSES

Evangelista, Rogelio, President, Maui Veterans Council...........     6
    Prepared statement...........................................     9
Helm, Larry, President, Molokai Veterans Caring for Veterans.....    10
    Prepared statement...........................................    12
Kekahuna, Roy W., PhD, District Director, Blinded Veterans 
  Association....................................................    13
    Prepared statement...........................................    15
Obado, Dwight ``Lui,'' Organizer, Lanai Veterans Organization....    16
    Prepared statement...........................................    18
Perlin, Hon. Jonathan A., MD, PhD, Under Secretary for Health, 
  Department of Veterans Affairs, accompanied by Robert Wiebe, 
  MD, VA Network Director, VISN 21, Sierra Pacific Network; James 
  Hastings, MD, Director, VA Pacific Islands Health Care System; 
  and Steven A. MacBride, MD, Chief of Staff, VA Pacific Islands 
  Health Care system.............................................    25
    Prepared statement...........................................    28

                               APPENDIX 1

Prepared statements:

Atwell, Francine.................................................    43
Dickensheet, Don.................................................    42
Newsham, Sgt. Albert A...........................................    43
Ross, Patricia Absher, on behalf of husband, John William Ross, 
  Jr., LCDR, USN, Ret............................................    41

                               APPENDIX 2
                 January 9, 2006--Hawaii Hearing, Kaui

Prepared statements:

Aylward-Bingman, Lynn M., Capt. (NC) USNR (Ret.) member, Veterans 
  Advisory Council to the Veterans Affairs Pacific Islands Health 
  Care System (VISN 21)..........................................    71
Browne, Colette V., professor, University of Hawaii School of 
  Social Work....................................................    69
Cruz, Frank, President Kauai Veterans Council and Chairman for 
  the State Office of Veterans Service Governors Advisory Board..    68
Driskill, Thomas M. Jr., President and Chief Executive Officer, 
  Hawaii Health Systems Corporation..............................    68
Ekstrand, Laurie E., Director, Health Care, U.S. Government 
  Accountability Office..........................................    53
Honjixo, William T...............................................    76
Kawamura, Edward, veteran........................................    51
Perlin, Hon. Jonathan A., MD, PhD, Under Secretary for Health, 
  Department of Veterans Affairs.................................    45
Shaw Robert, National Legislative Chairman, National Association 
  of State Veterans Homes........................................    49
Takamura, Ronald K...............................................    74

 
                   FIELD HEARING ON THE STATE OF VA 
                             CARE IN HAWAII

                              ----------                              


                       TUESDAY, JANUARY 10, 2006

                               U.S. Senate,
                    Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:10 a.m., in 
the J. Walter Cameron Center Auditorium, 95 Mahalani Street, 
Kahului, Hawaii, Hon. Larry Craig (Chairman of the Committee) 
presiding.
    Present: Senators Craig and Akaka.

            OPENING STATEMENT OF HON. LARRY CRAIG, 
                    U.S. SENATOR FROM IDAHO

    Chairman Craig. Good morning, ladies and gentlemen.
    Audience Members. Good morning. Aloha.
    Chairman Craig. Aloha. Thank you very much. It is a 
tremendous pleasure of mine to bring the Senate Committee on 
Veterans' Affairs to Maui, and to have an opportunity to visit 
with many of you today on issues that affect all veterans. I 
say that to receive testimony on the state of VA care here in 
Hawaii and on the neighboring islands of this great State is 
not only an opportunity for me, but an honor.
    As some of you may know, we held hearings yesterday on the 
island of--I always work on these names--Kauai----
    Senator Akaka. Kauai.
    Chairman Craig. Danny corrects me--that focused on VA's 
long-term care programs nationally and here in Hawaii.
    What a beautiful setting for a hearing, I said as we landed 
this morning, and there was a rainbow. Is there always a 
rainbow in Hawaii? I suspect so. Well, I'll tell you. It lifts 
the spirit and the attitude. Rarely do you see a rainbow in 
Washington, DC.
    Yesterday after the hearing, we flew back to Oahu and spent 
the afternoon out at the National Memorial Cemetery of the 
Pacific. What a phenomenal and humbling experience. And, of 
course, at Pearl Harbor. Spent some time, once again, looking 
down into the waters of the Arizona.
    I was truly awestruck when I saw these sights and the 
events that drew our great country into World War II. Of 
course, I was a very small child at that time. In fact, my 
parents would suggest I hadn't even been thought of yet. But I 
must tell you that it is that and your history, the history of 
the people of this great State, that is so long and proud in 
their defense of America's freedoms that you have always met 
the challenge for. Of course, we, both Danny and I, in 
understanding that, recognize our jobs as honoring America's 
heroes.
    I am pleased to be here with my friend, and I say that most 
sincerely, Senator Danny Akaka. Senator Akaka and I came to 
Congress at about the same time. We served in the House 
together for a decade. We came to the Senate in 1990. Now we 
find ourselves as the senior Members of the Veterans' Affairs 
Committee.
    Early on in that relationship, he invited me to Hawaii, and 
of course, I invited him to Idaho. For some strange reason, he 
wanted me to come here in August. I said, you know, we've got 
these roles reversed. You come to Idaho in August. I'll come to 
Hawaii in January or February. It snowed in Idaho yesterday, 
and the skiing there is excellent at this moment. And it's 
obvious why we're here now, and not there. But Danny has been 
to my beautiful State before, and we hope to get him out there 
again.
    Senator Akaka has been vocal in his belief that Hawaii has 
a unique geographic issue that other Members of Congress must 
experience firsthand to understand this great State. I agree 
with my colleague that there is no substitute for personal and 
on-the-ground experience. That's why I'm here at Danny's 
request. And that's why we're spending the time that we are 
with the four hearings. This is the second of four scheduled 
across the State.
    For those in the audience who don't know much about Idaho, 
Idaho and Hawaii are very similar in the sense of geography and 
distance--difficulty of movement. You may have water; we have 
high mountains. And at times, during this time of the year in 
Idaho, it can be very, very difficult to move from one 
community to the other.
    Traveling the length of my State is a 500-mile journey. 
Traveling the width of my State at one point is a near 500-mile 
journey. So, there are great commonalities between our States 
as it relates to the geographic issues. And therefore, how do 
we service and how do we provide service to men and women who 
choose to live, as they have the right to, in small rural 
communities across our States?
    That is an issue here. It is an issue in Idaho. It's why 
we're here to see how we might improve those services, or offer 
different types of services that meet certainly the 
requirements of all of you and all of your needs. Mental health 
treatment is often very difficult to come by, and extensive 
travel, often measured in hundreds of miles, can be required to 
receive complex surgical care.
    I mention this because of our uniqueness as States and our 
relationship as friends. I say to all of you that if all of our 
country's Senators were as kind, as hardworking, and as 
generous as Danny Akaka, the Senate would be an even better 
place to work. I trust that you feel privileged to have him 
serving you in the U.S. Senate because I feel privileged to 
view him as one of my friends.
    So I will turn to Danny now for his opening comments, and 
then he's going to introduce the first panel. We have two 
panels this morning. Our time is limited because we want to get 
on and visit a CBOC and the Vets Center and get out on the 
ground, after testimony and after listening to your concerns 
and responding to some of the questions that we may have coming 
out of our panels' testimony.
    So with that, let me turn the microphone to Senator Akaka.
    Danny.
    [Applause.]

          OPENING STATEMENT OF HON. DANIEL K. AKAKA, 
                    U.S. SENATOR FROM HAWAII

    Senator Akaka. Mahalo. Mahalo nui loa to all of you. And I 
want to say an extra mahalo nui loa to the Chairman for coming 
here to Hawaii to all these hearings. And I want to thank the 
Chairman for his generous remarks this morning.
    I want to tell you that as he mentioned, we've worked 
together for many years. Larry Craig was a great Congressmen 
and is a great Senator. He's inching up in leadership in the 
Senate. So don't be surprised if you see Larry Craig from Idaho 
as one of the leaders of the U.S. Senate one of these days.
    And I really treasure his friendship. I must tell you that 
since he took over and we became leaders of the Veterans' 
Committee, that Committee is moving.
    And I want to tell you that we share many of the same 
ideas. There's no question that we want to do the best we can 
to help the veterans. I think you know that there are limits, 
but we want to do the best we can within the limits to give all 
the services we can to the veterans of our country.
    In Hawaii, we have, as the Chairman mentioned, unique 
issues because of geography and because of our culture. Other 
States have similar problems. This hearing will really help the 
Committee to try to do a job that's great.
    We have the top people here from VA, nationally, as well as 
Statewide, and region-wide, too, here with us to testify. But 
we are all here to try to see what we can do to help the 
veterans. That's our effort here.
    So I'm so glad. I also want you to know that this is the 
first hearing where the Chairman of the Committee has traveled 
to Hawaii in the history of our country.
    [Applause.]
    Senator Akaka. Thanks to the Chairman and our staffs, who 
worked so hard to bring this about. I want to tell you that 
normally the Committee doesn't leave Washington, DC. for 
hearings. We have hearings in Washington. So this is very rare. 
But we are very privileged to have the Committee out here. For 
me, too, I mean, it's kind of a thrill to be able to bring the 
Committee out here to Hawaii.
    As I said, the Chairman has really had a busy schedule, at 
home and in Washington. But I was so glad to have him, as he 
said, suggest it: Hey, if not August, what about January? Oh, 
that's all right with me. You know, whenever it is. And it 
worked out beautifully because I feel great being home in 
Hawaii whenever I can come home. And thanks to the Chairman for 
all of this. And we are privileged and honored that all of you 
have come to testify here and to listen to the testimony about 
the needs of Hawaii's veterans.
    You know, I want to mention--I'm taking long--but I want to 
mention about what the Chairman said about the rainbow. You 
know, the rainbow is very symbolic and important to Hawaii. I 
come from a place on Oahu, and we always have rainbows. I 
remember my mom, my father and mother, would always tell me, 
``The rainbow is here.''
    And it's a kind of symbol that is beautiful. It's spiritual 
in a way because you can't touch it. It's there. It represents 
hope. It's beautiful because it represents all the colors. It's 
good for Hawaii because Hawaii is diverse. It has many, many 
ethnic groups, and each ethnic group is in that rainbow. The 
way I like to put it is that, whatever ethnic person you are, 
it's good to know your tradition. When you do that, your color 
is bright. But your color is better when it's side by side with 
other colors.
    That's why we're here. You know, we harmonize. We work 
together. And that's a rainbow. There's a song that I call the 
rainbow song, but it's really beautiful and it has lots of 
meaning. I'm so glad the Chairman mentioned the rainbow because 
it's significant. And that tells us our hearings are going to 
be the best hearings, and it'll help the Committee do its work. 
There's no question we have and we will, the Chairman and I and 
the Committee, work together on veterans' issues.
    I also want to thank Ernie Matsukawa from the Maui Vets 
Center. Also, Terri Garcia from the Office of Veterans Services 
in Maui, and Naomi Guardado from the J. Walter Cameron Center 
which we are in now, who have been working with my staff to 
coordinate these hearings. We greatly appreciate your hard 
work. So mahalo nui loa for what you have done.
    [Applause.]
    Senator Akaka. My purpose in bringing the Committee to 
Hawaii for field hearings is to find out more about the state 
of VA care in Hawaii. I applaud the efforts of every VA 
employee in Hawaii. I also applaud our officials of the VA who 
have worked hard, in the region as well as nationally. 
Secretary Nicholson is relatively new, but has worked real hard 
in trying to do the best for our veterans across the country. 
There are many things that the VA does well in Hawaii. However, 
there is always room for improvement.
    I want to hear about how we can help VA help Hawaii 
veterans. Today, and over this entire week, the Committee will 
examine the state of VA care in Hawaii. And I'm glad we're here 
on beautiful Maui with representatives from Molokai, and Lanai. 
As such, VA must tailor its strategy to reach all of Hawaii's 
veterans.
    We know that the access for care for those living on what 
we call the neighbor islands--Kauai, Molokai, Lanai, Maui, and 
the Big Island--could be improved. As such, I developed a bill 
that would ensure a greater presence on the islands of Molokai 
and Lanai, which currently lack VA facilities altogether. And 
I'm sure we'll hear about that today.
    A veteran living on either of these remote islands must 
either wait for a VA provider to visit, which is only 9 to 10 
times a year for Molokai and 4 times a year for Lanai, or take 
it upon himself to get on Maui for clinical care, or to Oahu 
for treatment for a more serious condition.
    Filling up the car with a tank of gas and driving across 
the State is obviously not even an option here. Inter-island 
air fare is more than $200, and besides that, we don't have 
bridges between the islands. So veterans have difficulty 
getting reimbursed for these expenses, which also include 
rental cars and hotels. Many veterans who cannot afford these 
costs must choose to forgo care as a result.
    Even when a VA provider finally comes to one of these 
remote islands, they have no tele-medicine equipment--this from 
a Department that is renowned for their computerized medical 
records and technologies. I'm sure all of you know that 
healthcare provided by VA is No. 1 in the Nation by the 
Veterans Administration. That's a fact.
    VA also needs to revamp its beneficiary travel program. 
This benefit is one that is highly valued by many veterans, 
especially those on fixed incomes. Unfortunately, there has not 
been an increase in the benefit for some time. In 2001, VA 
found that the current allowances under this program were not 
sufficient to begin to deal with high gas prices. Yet 4 years 
later, the increase was never put forward.
    We are privileged to have all of our witnesses with us this 
morning. We will hear first from veterans' representatives from 
Maui, Lanai, and Molokai. It is vitally important that you 
share your thoughts with us so that we know how to help VA help 
you and the rest of Hawaii's veterans. VA officials will 
respond to the concerns laid out by the previous panel. That's 
a response not only on the national and regional level, but the 
local level as well, State level, and on our congressional 
level.
    Finally, I want to address the fact that there are many 
veterans who are here today and who want to testify. We want to 
hear from you. And I'm glad to have met some of you before the 
meeting outside, because some of you would have liked to 
testify. But we can't hear everybody. Unfortunately, this is a 
problem, and we cannot accommodate everyone's request.
    However, we are accepting written testimony for the record. 
So you can rest assured that we will read your written 
testimony. If you have brought written testimony with you, 
please give it to the Committee staff who are located in the 
back of the room--they're raising their hands back there.
    But if you do not have a written statement, but would like 
to submit something, our staff is in the back of the room to 
assist you with that also. In addition, the Committee staff is 
joined by VA staff who can respond to the questions, concerns, 
and comments that you raise, and will also be at that table.
    Once again, mahalo nui loa to all of you who are in 
attendance today, and I look forward to hearing from today's 
witnesses.
    Senator Akaka. We welcome the first panel here today. I'm 
sure you're all familiar to the folks here in the tri-island 
County, the three islands: The first one is Rogelio 
Evangelista, who's the--as I call you, just raise your hand--
the President, Maui Veterans Council. Rogelio. I've got to tell 
you, Rogelio was not supposed to be here today. He was supposed 
to have an operation. But he postponed that to be here. Thank 
you very much.
    Also, Larry Helm, the well-known President, Molokai 
Veterans Caring for Veterans.
    Roy Kekahuna, Doctor, District Director, Blinded Veterans 
Association. We're glad to have you, Roy.
    Dwight ``Lui'' Obado, organizer of the Lanai Veterans 
Organization, is here.
    We're delighted to have you folks. We want to hear what you 
have to say. You're welcome to come sit at the table. We're 
delighted to have you folks here. You will testify in the order 
you were introduced. So mahalo nui loa to you, and you can 
begin.

         STATEMENT OF ROGELIO EVANGELISTA, PRESIDENT, 
                     MAUI VETERANS COUNCIL

    Mr. Evangelista. Thank you, Senator. Before we go on, if we 
can have a prayer first. Mario? Are you here? Can you lead us 
in a prayer? And after that, maybe we can have a Pledge of 
Allegiance. Will you stand.
    [Opening prayer and Pledge of Allegiance.]
    Chairman Craig. Please proceed.
    Mr. Evangelista. Mr. Chairman, Larry Craig, Senator Akaka, 
and distinguished Members of the Senate Veterans' Affairs 
Committee, Veterans Administration Pacific Islands Healthcare 
System Director General Hastings and staff, thank you for 
giving me this opportunity to come before you today to discuss 
the state of the VA care in Hawaii, home to more than 110,000 
veterans, and especially for the more than 10,000 veterans 
living in the county of Maui, which comprises the 3 islands of 
Maui, Molokai, and Lanai out of the 8 islands that make up the 
State of Hawaii, which are all separated by the ocean.
    The excellent medical efforts of the Maui CBOC, the 
Community Based Outreach Clinic, with the support of the Spark 
Matsunaga Center on Oahu and the Tripler Army Medical Center, 
have been extraordinary. I would at this time like to take a 
moment to stress the unique nature of healthcare here on Maui, 
Molokai, and Lanai, and to also include Kauai and Hawaii.
    The first, by being on the State Veterans Advisory Board 
for over 9 years and on the VAMROC, which is the Veterans 
Administration Medical and Regional Office Center, Advisory 
Board for over 5 years, and as a disabled veteran, I have 
understood the stress and witness the bureaucracy the veterans 
are faced when receiving healthcare from the Veterans 
Administration.
    They must be able to pass the means test by having limited 
income jointly with their spouse so that if they need to go to 
Oahu or the mainland for specialized care that is not service-
connected, they will be provided airline transportation. And 
this is for any veteran with less than 30 percent disability 
that uses the VA healthcare system as their primary healthcare.
    If the veteran does not qualify on the means test and he or 
she has a disability of less than 30 percent, then the veteran 
must pay their own transportation to go to Oahu or the 
mainland. Veterans on the mainland can drive to the VA 
hospitals and not worry about passing any means test. VA states 
it's cheaper to have the exam or procedure done on Oahu with 
the veteran paying about $145 for a round-trip ticket instead 
of having the veteran see a local provider on the island that 
he or she resides on. Veterans' bills are even being sent to 
collection agencies because the VA takes so long on paying for 
services from outside providers.
    Second, as I look at our aging veteran population, there 
are 100 percent disabled veterans in nursing homes on Maui with 
the families paying over $7,000 per month for their healthcare 
at those nursing homes, plus their medications. It's hard for 
the families to send them to Oahu to the Center for Aging, and 
there will be no family support because they can't fly to Oahu 
every day to see the veteran. Is it possible for VA to do a 
partnership with Hale Makua, a nursing home on the island of 
Maui, for the veterans living on Maui? Why is Hawaii and Alaska 
the last two States that do not have any VA hospital? What 
happened to a Federal mandate that states that there should be 
a VA hospital in each State?
    Third, our CBOCs on all the neighbor islands, even with the 
experienced and dedicated staff, they are underpaid in 
comparisom with the mainland VA staff. And they are also 
overworked. We need more staffing and we need more office space 
on Maui and on the other neighbor islands. On Maui, if the VA 
can buy out the building that CBOC is located in and the vacant 
lot next to the building and look at expanding services with 
more staff we now have volunteers, but they are limited in the 
scope off work that they can perform. And we need more 
specialized equipment, especially for telemedicine.
    There is now one full-time doctor 5 days a week, one part-
time doctor 4 days a week. We need to upgrade our staff to 
provide the best possible care for our veterans. Right now it 
takes so long to get an appointment to see the doctor for 
routine or specialized care. The doctor has to come in from 
Oahu or the mainland.
    In order to provide ongoing care to veterans, first, the 
Government must realize that veterans' healthcare is part of 
the cost of war, and that the Government needs to provide 
enough funding for VA healthcare to all veterans. Second, the 
Veterans Administration, along with the Government, must 
identify and develop programs and use today's technologies to 
help veterans in their daily lives, especially for our disabled 
veterans.
    Combinations of advanced healthcare using new technologies 
will greatly help all of our veterans, and make their 
recoveries possible and the long-term relationship of being 
accepted back into society. I ask you, why is VA funding always 
the lowest priority in our Government, when we, the veterans, 
made our country the greatest Nation in the world?
    Fourth, many of our veterans are suffering from some sort 
of physical or mental disability and would rather alienate 
themselves from anything to do with the Veterans Administration 
due to many contributing factors. All the red tape that they 
must go through to even start to file their claim, something 
that happened over 30 years ago, and it is just being addressed 
today because of the veteran's health status, be it physical or 
mental. And this is all due to different contributing factors 
of the veteran's healthcare.
    Veterans are being informed to get collaborating [sic] 
evidence from other veterans that served with them and might 
know something regarding the veteran's condition or of an 
incident that occurred. Most of the veterans don't know where 
these other veterans are now living, and some of them just 
don't want to get involved. But there are records that the 
military have, so why can't the Veterans Administration get 
those records to collaborate [sic] the veteran's claim?
    Fifth, veterans are now paying $7 co-payment on drugs and 
medication, and the VA is also at this time exploring the idea 
of raising the co-payment on drugs for veterans that are being 
prescribed for non-service-connected medical problems. These 
veterans are on very limited financial support due to their 
physical and mental conditions being attributed to their 
military career in one way or another.
    They answered our Nation's call when they were needed. Why 
can't our Nation now help them in their time of need? I ask and 
plead with you, the Members of the Veterans' Affairs Committee, 
to lobby your constituents and help our Nation's veterans lead 
fruitful and dignified lives.
    Sixth, the vocational rehab program that tried to help 
veterans in training them for a vocation that they can excel in 
is great. But now there are so much restraints being placed on 
being able to qualify, and the approval all now comes from 
Washington, DC and not done here locally like it used to be.
    There is so much paperwork going back and forth, and it 
takes such a long time, sometimes longer than 6 months for 
approval if it does get approved, and by that time the veteran 
has already lost interest and have given up on the system.
    When you apply for vocational rehabilitation, you will need 
specialized and long-term counseling and support from your case 
worker here and not from somebody from Washington that knows 
you only as a number, with no personal knowledge of all your 
special needs as you continue with your studying. And this will 
be due to the type of medications that you are being prescribed 
by the doctor, so the doctors and your case worker need to be 
informed on your physical and mental condition so that you can 
be successful in pursuing your vocational training.
    There are veterans here on Maui that don't even know of 
certain benefits that they may be qualified to apply for due to 
their physical and mental disabilities. Vocational 
rehabilitation is a part of medical. It's due to your physical 
condition.
    Seventh, our veterans now from the Gulf War and those 
returning from Iraq are now at this time being diagnosed with 
illness not yet known. We need to expand our technology to help 
these veterans and their families so they can cope with their 
personal problems.
    By extending our medical staff at our clinics, it won't 
take 2 or 3 months or more for an x-ray, MRI, and other 
specialized tests that need to be done to identify the cause of 
the veteran's illness or his disabling injuries so the veteran 
can be placed in various programs in mental, physical, or 
vocational areas so the veteran can start to lead a fruitful 
and normal life in our society.
    Eighth, single veterans are being discharged from the 
hospital, but still are not able to care for themselves, and 
they can't get any home care since cases are so backlogged, 
they have to go on a waiting period. We need a home care nurse 
here on the island of Maui and Molokai and Lanai.
    And also after hours, if you need to go to emergency and 
use your VA card, about 2 or 3 months later you get a notice 
from the VA that your emergency visit was not covered since it 
was not related to a disability or since the attending 
physician stated that you were OK on the checkup at emergency.
    On behalf of the veterans of the State of Hawaii, 
especially the county of Maui, and all their families, I would 
like to ask all the Members of the Senate Committee on 
Veterans' Affairs, along with the Veterans Administration 
Pacific Islands Healthcare System Director and staff, for their 
support of these men and women who committed a part of their 
lives and well-being to defend and protect our great Nation, 
the United States of America.
    Will the Committee now, along with their constituents, give 
their full support to our veterans and provide a healthcare 
that is second to none and a budget to surpass the costs of 
administering the greatest healthcare to all our veterans.
    Thank you. May God bless America, its people, the armed 
forces, and especially its veterans and their families.
    [Applause.]
    [The prepared statement of Mr. Evangelista follows:]
         Prepared Statement of Rogelio Evangelista, President, 
                         Maui Veterans Council
    Mr. Chairman Larry Craig, Senator Akaka, and distinguished Members 
of the Senate Veterans Affairs Committee, VAPIHCS Director Gen. 
Hastings and Staff, thank you for giving me this opportunity to come 
before you today to discuss the state of VA care in Hawaii, home to 
more than 110,000 veterans and especially for the more than 10,000 
veterans living in the County of Maui, which comprises the three 
islands of Maui, Molokai, and Lanai out of the eight islands that make 
up the State of Hawaii which are all separated by the ocean.
    The excellent medical efforts of the Maui CBOC [Community Based 
Outreach Clinic] with the support of the Spark Matsunaga Center on 
Oahu, and the Tripler Army Medical Center have been extra ordinary. I 
would at this time like to take a moment to stress the unique nature of 
health care here on Maui, Molokai, Lanai, and to also include Kauai, 
and Hawaii.
    First, by being on the State Veterans Advisory Board for over 9 
years and on the VAMROC [Veterans Administration Medical & Regional 
Office Center] Advisory Board for over 5 years and as a Disabled 
Veteran, I have understood the stress and witnessed the bureaucracy 
that Veterans are faced when receiving health care from the Veterans 
Administration. They must be able to pass the Means Test by having 
limited income jointly with their spouse, so that if they need to go to 
Oahu, or the Mainland for specialized care that is not service 
connected, they will be provided airline transportation, and this are 
for any Veteran with less than 30 percent disability that uses the VA 
Health Care System as their Primary Health care. If the Veteran do not 
qualify on the Means Test and he or she has a disability of less than 
30 percent then the Veteran must pay their own transportation to go to 
Oahu, or the mainland. Veterans on the Mainland can drive to the VA 
hospitals and not worry about passing any Means Test. VA states it is 
cheaper to have the exam or procedure done on Oahu with the Veteran 
paying about $145.00 for a round trip ticket, instead of having the 
Veteran see a local provider on the island that he resides on. Veteran 
bills are even being sent to collection agencies because the VA takes 
so long on paying for the services from outside providers.
    Second, as I look at our aging Veteran population, there are 100 
percent disabled veterans in Nursing homes on Maui with the families 
paying over $7,000.00 per month for their health care at those Nursing 
homes plus their medications and its hard for the families to send them 
to Oahu to the Center for Aging and there will be no family support 
because they can't fly to Oahu everyday to see the Veteran. Is it 
possible for the VA to do a partnership with Hale Makua, a Nursing home 
on the Island of Maui for the Veterans living on Maui. Why is Hawaii 
and Alaska the last 2 states that do not have any VA hospital, what 
happened to a Federal mandate that states that there should be a VA 
hospital in each state.
    Third, our CBOC's, on all the neighbor islands, even with the 
experienced and dedicated staff, they are underpaid in comparing with 
the mainland VA staff, and they are also overworked, we need more 
staffing and we need more office space, on Maui, if the VA can buy out 
the building that CBOC is located in and the vacant lot next to the 
building and look at expanding services with more staff, we now have 
volunteers but they are limited in the scope of work that they can 
perform. There is now one full time doctor 5 days a week, one part time 
doctor 4 days a week, we need to upgrade our staff to provide the best 
possible care for our Veterans, right now it takes so long to get an 
appointment to see the doctor, for routine or specialized care, the 
doctor has to come in from Oahu or the mainland. In order to provide 
ongoing care to Veterans, first, the government must realize that 
Veterans health care are part of the cost of war and that the 
government needs to provide enough funding for VA health care to all 
Veterans, second, the Veterans Administration along with the government 
must identify and develop programs and use today technologies to help 
Veterans in their daily lives, especially for our disabled veterans. 
Combinations of advanced health care using new technologies will 
greatly help all of our veterans and make their recoveries possible and 
the long term relationship of being accepted back into society. Why is 
VA funding always the lowest priority in our government, when we the 
Veterans made our country the greatest Nation in the world.
    Fourth, many of our Veterans are suffering from some sort of 
physical or mental disability and would rather alienate themselves from 
anything to do with the Veterans Administration due to many 
contributing factors. All the red tape that they must go through to 
even start to file their claim, something that happened over 30 years 
ago and it is just being addressed today because of the Veterans health 
status, be it physical or mental, Veterans are being informed to get 
collaborating evidence from other Veterans that served with them and 
might know something regarding the Veterans conditions or of an 
incident that occurred. Most of this Veterans don't know where these 
other veterans are now living and some of them just don't want to get 
involved, but there are records that the military have so why can't the 
Veterans Administration get those records to collaborate the Veterans 
claim.
    Fifth, Veterans are now paying $7.00 co-payment on drugs and 
medication and the VA is also at this time exploring the idea of 
raising the co-payment on drugs for Veterans that are being prescribed 
for non-service connected medical problems, and these Veterans are 
living on very limited financial support due to their physical and 
mental conditions being attributed to their military career in one way 
or another. They answered our Nations call when they were needed, why 
can't our Nation now help them in their time of need, I ask and plead 
with you the members of the Veterans Affairs Committee to lobby your 
constituents and help our Nation's Veterans lead fruitful and dignified 
lives.
    Sixth, the Vocational rehabilitation program that try to help 
Veterans in training them for a Vocation that they can excel in is 
great, but now there are so much restraints being placed on being able 
to qualify and the approval all now comes from Washington D.C. and not 
done here locally like it used to be. There is so much paper work going 
back and forth and it takes such a long time sometimes longer than 6 
months for approval if it does get approved and by that time the 
Veteran has already lost interest and have given up on the system. When 
you apply for Vocational rehabilitation you will need specialized and 
long term counseling and support from your case worker here and not 
from somebody from Washington that knows you only as a number with no 
personal knowledge of all your special needs as you continue with your 
studies. There are Veterans here on Maui that don't even know of 
certain benefits that they may be qualified to apply for due to their 
physical and mental disabilities.
    On behalf of the Veterans of the State of Hawaii, especially the 
County of Maui and all their Families, I would like to ask all the 
Members of the Senate Committee on Veterans Affairs, along with the 
VAPIHCS Director and Staff for their support of these men and women who 
committed a part of their lives and well being to defend and protect 
our great Nation, the United States of America. Will the committee now 
along with their constituents give their full support to our Veterans 
and provide a health care that is second to none and a budget to 
surpass the costs of administering the greatest health care to our 
heroes.
    Thank you, may God Bless America, its people, the Armed Forces, and 
especially its Veterans and their Families.

    Senator Akaka. Thank you very much, Rogelio.
    Larry.

STATEMENT OF LARRY HELM, PRESIDENT, MOLOKAI VETERANS CARING FOR 
                            VETERANS

    Mr. Helm. Good morning, fellow veterans. I'd also say a 
special mahalo to our group from Molokai that got up at 4 this 
morning to catch the ferry to come over here for this.
    [Applause.]
    Mr. Helm. Senator Larry Craig, Chairman, Honorable Senator 
Danny Akaka, aloha kakahiaka to you and your staff. Welcome to 
Hawaii nei and to the island Maui. My name is Larry Helm, a 
heavy combat Vietnam veteran. I represent 345 Molokai veterans 
from all wars and conflicts. From the vsn of a Patsy Bird, the 
Molokai Veterans Caring for Veterans Center, Koa Kahiko, which 
means ``strong, wise, ancient warrior,'' formed 4 years ago 
mainly for veterans to have a voice and address concerns on the 
island of Molokai.
    Because we are an island in the Maui County surrounded by 
water, we therefore have been many challenges to get services 
for Molokai veterans. Today, the Veterans Administration is 
doing a lot more for the Molokai veterans. I thank you and ask 
you to please continue. I'm sure that there are a lot of rural 
``Molokais'' throughout this country that face the challenges 
of caring for veterans.
    Molokai has many combat Vietnam veterans that are finally 
getting help. The island has a population of 7,000 residents, 
and has contributed to this country greatly. We have a memorial 
stone in the middle of town naming 10 World War II, 6 Korean, 
and 5 Vietnam veterans who lost their lives for this country. 
There is a wall in Washington, DC with over 58,000 names of my 
brothers and sisters killed in action in country in Vietnam, 
but we do not have a wall for over 100,000 that prematurely 
died from wounds related to combat--Agent Orange, chronic PTSD, 
physical wounds, et cetera. This issue has been sanitized.
    In the last year on Molokai, Koa Kahiko lost 5 Vietnam 
veterans. Spencer Eldridge, 56 years old, died 3 weeks ago. He 
handled Agent Orange on a ship outside the Tonkin Gulf. Three 
of our deceased veterans had just started to receive their 
service-connected disability benefits. The Molokai community 
has over 40 men and women who have served and are serving today 
in Afghanistan and Iraq.
    I speak for past veterans, but essentially for those 
veterans who will return from the Middle East to Molokai. I 
emphasize the importance of continuing and improving the mental 
and physical healthcare they deserve. All service-connected 
claims must be efficiently and hastily processed sooner, not 
later.
    The Molokai veteran community says thank you. The VA has 
certified Dr. Hafermann, a resident of Molokai, to practice on 
Molokai alongside with the medical team from Maui. I'd just 
like Dr. Hafermann to stand up. He's a colonel who used to be 
in charge of Travis Air Force Base.
    [Applause.]
    Mr. Helm. I ask to have more psychological help for our 
veterans on Molokai. It takes 6 months to get an appointment 
with Dr. McNamara, who is the Mother Teresa for the veterans, 
and her time is limited.
    [Applause.]
    Mr. Helm. We need more of her or hire two more Dr. 
McNamaras. Dr. Springer, a psychiatrist, will start this month. 
Mahalo.
    To have an inpatient nurse help for older Molokai veterans.
    We need a mini-honor guard burial service for service-
connected veterans. Every veteran deserves that honor.
    To not repeat the process that led us to lose many of our 
Vietnam veterans' lives, who did not get psychological help 
because of PTSD--suicide, despondence, hopelessness, 
deterioration of their body. In combat, one size does not fit 
all. Why would you want to revisit the studying of PTSD when 
the psychiatric community has studied this scientifically from 
all wars and has agreed that is a serious, permanent disorder 
that affects many veterans. I hope the Government does not 
water down the treatment for this mental disorder because of 
budget restraints, especially for our returning veterans.
    To please continue providing veterans' organizations the 
opportunity to testify for the veterans' affairs. We heard 
Senator [sic] Buyer wanted to stop the VFW, DMV, the American 
Legion, et cetera, from giving testimony. That is absolutely 
not acceptable.
    Starting a national--I suggest starting a national low 
interest credit union and credit card service for service-
connected veterans and all other veterans, it could be a 
profitable and honorable thing to do for the veterans.
    That spouses of 100 percent service-connected veterans 
qualify to receive their husband or wife's benefits 5 years 
rather than 10 years. Many veterans die prematurely and leave 
their spouse empty.
    Senator Craig, Senator Akaka, mahalo for your time and the 
opportunity to testify here this morning, and hope you consider 
all that I have said. In my opinion, veterans are the soul of 
this country. The American people required that it be mandatory 
that the Congress provide whatever budget is needed to care for 
the veterans.
    May Akua bless you and the United States of America. Aloha, 
aloha no.
    [Applause.]
    [The prepared statement of Mr. Helm follows:]
     Prepared Statement of Larry Helm, President, Molokai Veterans 
                          Caring for Veterans
    Aloha Kakahiaka (Good Morning) to you and your staff. Welcome to 
Hawaii nei and to the island of Maui. My name is Larry Helm, a heavy 
combat Vietnam Veteran. I represent 345 Molokai Veterans from all wars 
and conflict. From the vision of Patsy Bird, the Molokai Veterans 
Caring for Veterans Center-Koa Kahiko (strong, wise, ancient warrior) 
formed 4 years ago mainly for Veterans to have a voice and address 
concerns on the island of Molokai.
    Because we are an island in Maui County surrounded by water, there 
have been many challenges to get services for Molokai Veterans. Today 
the Veterans Administration is doing a lot more for the Molokai 
Veterans. I thank you and ask you to please continue. I'm sure that 
there are a lot of rural ``Molokais'' throughout this country that face 
the challenges of caring for the veterans. Molokai has many combat 
Vietnam veterans that are finally getting help. The island has a 
population of 7,000 residents and has contributed to our country 
greatly. We have a memorial stone in the middle of town naming ten 
World War II, six Korean, and five Vietnam Veterans who lost their 
lives for this country.
    There is a wall in Washington DC with over 58,000 names of my 
brothers and sisters killed in action in country in Vietnam but we do 
no have a wall for over 100,000 that prematurely died from wounds 
related to combat i.e. agent orange, chronic PTSD, physical wounds, 
etc. This issue has been sanitized. In the last year on Molokai, Koa 
Kahiko lost five Vietnam veterans. Eldridge Spencer, 56 years old, died 
3 weeks ago from leukemia due to agent orange exposure. Three of the 
deceased veterans had just started to receive their service connected 
disability benefits. The Molokai Community has over 40 men/women who 
have served and are serving today in Afghanistan and Iraq.
    I speak for past Veterans but especially for those veterans who 
will return from the Middle East to Molokai. I emphasize the importance 
of continuing and improving the mental and physical health-care they 
deserve. All service connected claims must be efficiently and hastily 
processed sooner not later.
    The Molokai Veteran Community says ``thank you''. The VA has 
certified Dr. Havelman, a resident of Molokai, to practice on Molokai 
along side the medical team from Maui.
    I ask:
     to have more psychological help for veterans on Molokai. 
It takes 6 months to get an appointment. Dr. McNamara is the Mother 
Theresa for the veterans and her time is limited. We need more of her 
or hire two more Dr. McNamaras. Dr. Springer, the psychiatrist will 
start this month. Mahalo.
     to have inpatient nurse help for older Molokai veterans.
     for a mini honor guard burial service for service 
connected veterans. Every veteran deserves the honor.
     to not repeat the process that led to the loss of many 
Vietnam veteran lives who did not get psychological help because of 
PTSD (suicide, despondence, hopelessness, and deterioration of their 
body). In combat, one size does not fit all. Why would you want to 
revisit the studying of PTSD when the psychiatric community has studied 
this scientifically from all wars and has agreed that PTSD is a serious 
permanent disorder that affects many veterans. I hope the government 
does not water down the treatment for this mental disorder because of 
budget restraints; especially for the returning Veterans.
     To please continue providing Veteran organizations the 
opportunity to testify for veterans affairs. We heard Senator Buyer 
wanted to stop VFW, DMV, etc. from giving testimony. That is absolutely 
not acceptable.

    I suggest:

     starting a national veteran low interest credit union and 
credit card service for connected veterans and other veterans. It could 
be a profitable and honorable thing to do for our veterans.
     that spouses of 100 percent service connected veterans 
qualify to receive their husband/wife veteran benefits 5 years rather 
than 10 years. Many veterans die prematurely and leave their spouse 
empty.
    Mahalo for your time and the opportunity to testify here this 
morning and hope you consider all that I have said. In my opinion, 
Veterans are the soul of this country. The American people require that 
it be mandatory that Congress provide whatever budget is needed to care 
for Veterans. May Akua bless you and the United States of America.
    Aloha, aloha no.

    Senator Akaka. Mahalo. Mahalo, Larry.
    And now we'll hear from Dr. Kekahuna.

 STATEMENT OF ROY W. KEKAHUNA, PhD, DISTRICT DIRECTOR, BLINDED 
                      VETERANS ASSOCIATION

    Dr. Kekahuna. Mr. Chairman and distinguished Members of the 
Committee, thank you for the opportunity to come before you to 
discuss the care of blinded veterans in general, and in 
specific, the needs of the blinded veterans in the State of 
Hawaii.
    By way of introduction, I represent 10 Western States. In 
August, I will represent Hawaii and Alaska. Idaho, Mr. 
Chairman, happens to be one of the States in my District. I 
have 18 regional groups. Hawaii's regional group is currently 
defunct, so that's one of the reasons they asked me to come 
back to Hawaii and put it together.
    Showing my background, I was born and raised here in the 
islands, originally from Molokai. My ancestor was the King of 
Maui; is interred on the island of Maui. His name was Alapai 
Nui in the ancient history of the Hawaiian islands. So there is 
a lot here for me in the State. That's why I'm here today. I 
have been to three blind centers, so I know what the blinded 
veterans of the State of Hawaii really need and deserve. I 
currently live in Las Vegas, and I have been to the Blind 
Center, so I know what the blinded veterans of the State really 
need.
    I would like to take a moment to stress that blindness is a 
catastrophic event in a veteran's life. Immediately, the 
veteran loses his or her independence. The uniqueness of this 
situation is that for the rest of this veteran's life, they 
will need assistance during 25 to 80 percent of their daily 
activities.
    Another unique feature with a good percentage of the 
blinded veterans is that they have dual sensory loss (for 
example, hearing and visual loss). I have both hearing and eye 
problems from my injuries in Vietnam. Besides having vision and 
hearing problems, many of the blinded veterans have dual 
disabilities, such as the loss of use of an arm. I'm sure 
Senator Inouye could talk to that, as well as anybody else.
    To give everybody an idea of what we have to go through in 
our life, if you'll all close your eyes. Keep them closed. 
Reach with your right hand for the left hand of the person next 
to you. Pretty hard to do, isn't it? Well, welcome to my world.
    I use the Veterans Administration healthcare facilities for 
my medical services. Most area's of my medical experiences with 
VA have been favorable. Veterans Administration's care for 
their blinded veterans is behind the curve.
    Veterans Administration in general is behind the curve in 
care for their blinded veterans. Their care for the blinded 
veterans of the State of Hawaii is in the dark ages. I cite 
myself as an example. I came home from Vietnam totally blind. 
There were no low vision services in the local Veterans 
Administration. Today, there is still no low vision services in 
VA, almost 40 years later. Blinded veterans of the State of 
Hawaii are less than stepchildren. I believe that this is 
criminal treatment of Hawaii blinded veterans.
    Currently, the VA in Hawaii provides a part-time Vision 
Impairment Services Team Coordinator, called a VIST. The 
coordinator is responsible for case management of all blind and 
legally blinded veterans. They do not train blinded veterans. 
The VIST coordinator works only 5 percent of her work period on 
blinded veterans. This is inefficient for the workload.
    I'll give you an example because I did some research before 
I got here. There currently 50 veterans in the vision program. 
In the VA, there are 200 blinded veterans registered with eye 
clinic in the State of Hawaii. In the area of high risk, there 
are 700 veterans currently enrolled in the VA Eye Clinic. These 
numbers only reflect the veterans who have come out of the 
woodwork, and realize that they are due these benefits.
    Ho'opono, the State of Hawaii's vocational rehabilitation, 
is the only low vision/blind service currently available to 
veterans. It is VA's responsibility to care for the veterans as 
it promised. The blinded veterans of the State of Hawaii need 
your support to gain equal treatment, which their brother and 
sister veterans of the other 49 States have.
    As an example--some more research--VA outlying clinics are 
not equipped to assist visual impairment. State Rehab for the 
Blind is a 9-month program, where the VA has better programs 
located on the continent. There are no housing facilities to go 
with this. Our island veterans, such as people on Maui, 
Molokai, and Lanai have an expense that is insurmountable just 
to get there. The non-service-connected veterans have no chance 
unless they pay for it out of their pocket presently.
    I applaud the VA and the Department of Defense, DoD, 
partnership that they have here in Hawaii. Together they have 
the makings of a perfect harmony to service the blinded 
veterans. In this opportunity scenario, the Army Medical 
Detachment, AMMED, at Tripler Army Medical Center, TAMC, as 
it's called, can provide a full-time low vision doctor, while 
would provide a full-time VIST/Blind Rehabilitation Outreach 
Specialist, BROS.
    The State of Hawaii's geographical island makeup supports 
the need of a VIST/BROS full-time specialist. The individual 
who operates from this position can provide both casework and 
training for the blinded veteran while on the different 
islands. I would highly recommend the creation of this position 
as soon as possible.
    In the best of times and the best of situations, the 
blinded veteran should attend a VA Blind Rehabilitation Center. 
I notice that we have people here from Palo Alto, California 
who work at the Blind Rehab Center, and I applaud you. I am a 
graduate.
    Ho'opono's program is 9 months long. Anybody on the outer 
islands, on all of the islands, who just have the 
transportation costs, make it almost inaccessible for them to 
attend. Blinded veterans on the island of Oahu currently have a 
place they can go for training. The VA should send other 
blinded veterans to the Blind Rehab Centers, or they should 
have specialists on each and every island to take care of these 
veterans.
    I have experienced the excellent medical services provided 
at TAMC. I have been to four sessions at different Blind 
Rehabilitation Centers and received excellent training. I 
believe that it is important to fund the VA, Department of 
Defense medical facilities, and staff them properly. I don't 
care how good your facility is; if you are not staffed properly 
it will not work.
    On behalf of blinded veterans and their families, the 
people of Hawaii, I thank the Members of this great institution 
for providing us with the funding and resources to take care of 
the finest men and women that I've had the pleasure to 
represent today. Thank you.
    [Applause.]
    [The prepared statement of Mr. Kekahuna follows:]
    Prepared Statement of Roy W. Kekahuna, PhD, District Director, 
                      Blinded Veterans Association
    Mister Chairman and distinguished members of the committee, thank 
you for the opportunity to come before you today to discuss the care of 
blinded veterans in general, and in specific the needs of the blinded 
veterans in the State of Hawaii.
    I would like to take a moment to stress that blindness is a 
catastrophic event in a veterans' life. Immediately the veteran loses 
his or her independence. The uniqueness of this situation is that for 
the rest of those veterans' lives, they will need assistance during 25 
to 85 percent of their daily activities.
    Another unique feature with a good percentage of the blinded 
veterans, is that they have dual sensory loss (for example, hearing and 
vision). Many of the blinded veterans have multiple disabilities (an 
example, loss of limbs).

    A BRIEF DEMONSTRATION OF WHAT A BLIND VETERAN HAS TO GO THROUGH 
                          TO DO A SIMPLE TASK
    I use the Veterans Administration (VA) Health Care Facilities for 
my medical services. Most areas of my medical experiences with VA have 
been favorable; Veterans Administration's care for their blinded 
veterans is behind the curve.
    Veterans Administration in general is behind the curve in care for 
their blinded veterans; their care for the blinded veterans of the 
State of Hawaii is in the dark ages. I cite myself as an example. I 
came home from Vietnam totally blind. There were no low vision services 
at the local Veterans Administration. Today, there is still no low 
vision specialist at the VA. Almost 40 years later, the blinded 
veterans of the State of Hawaii are less than a stepchild. I believe 
that this is criminal treatment of our Hawaii Blinded Veterans.
    Currently the VA in Hawaii provides a part-time Vision Impairment 
Services Team Coordinator (VIST). The coordinator is responsible for 
the case management for all blind and legally blinded veterans. They do 
not train blinded veterans. The VIST coordinator in Hawaii works only 5 
percent of her work period on blinded veterans cases. This is 
inefficient for the caseload.
    Ho'opono, the state of Hawaii's vocational rehabilitation is the 
only low vision/blind service currently available to veterans. It is 
VA's responsibility to care for its veterans as promised. The blinded 
veterans of the State Hawaii need your support to gain equal treatment, 
which their brother and sister blinded veterans of the other 49 States 
receive.
    I applaud the VA and the Department of Defense (DOD) partnership 
that they have here in Hawaii. Together they have the makings for a 
perfect harmony to service the blinded veterans. In this opportune 
scenario the Army Medical Department (AMMED) at Tripler Army Medical 
Center (TAMC) can provide a full time low vision doctor while VA would 
provide a full time VIST/Blind Rehabilitation Outreach Specialist 
(BROS).
    The State of Hawaii's geographical island makeup supports the need 
of a VIST-BROS full time specialist. The individual who operates from 
this position can provide both casework and training for the blinded 
veteran while on the different islands. I would highly recommend the 
creation of this position as soon as possible.
    In the best of times and in the best situation the blinded veteran 
should attend a VA Blind Rehabilitation Centers (BRC). The closest BRC 
for Hawaii's' blinded veterans is Palo Alto, CA. The current 
configuration of the blind services training at Ho'opono only works for 
those veterans residing on the island of Oahu. There are no resident 
facilities for the other island veterans.
    I have experienced the excellent medical services provided at TAMC. 
I have been to four sessions at different BRC's and received excellent 
training. I believe that it is important to fund the VA, DOD Medical 
facilities, and staff them properly to support our current blinded 
veteran population and the next generation of blinded veteran that is 
already here from the conflicts/wars that we fight. This means keeping 
the promise.
    On behalf of the blinded veterans and their families, I thank the 
members of this great institution for providing us with the funding and 
resources to take care of the finest men and women that I have had the 
honor to represent here today.

    Senator Akaka. Before I call on Lui, I just want to say 
something about what Larry mentioned while he was testifying, 
and that was he said aloha kakahiaka. And for those of you who 
don't know Hawaiian, what he said was good morning. Kakahiaka 
is ``morning.'' Thank you, Larry.
    And now we'll hear from Lui, Lui Obado.

 STATEMENT OF DWIGHT ``LUI'' OBADO, ORGANIZER, LANAI VETERANS 
                          ORGANIZATION

    Mr. Obado. Hello. Thank you, everybody. Thank you for 
attending. I appreciate your calling--bringing Lanai over here. 
Welcome all to Lanai.
    I know the weather in Washington. I was stationed in 
Aberdeen Proving Ground, and I also was stationed in Fort Lee, 
Virginia. I know your weather, and I love being away from it.
    [Laughter.]
    Mr. Obado. So welcome to Lanai. This is a good day to be 
coming to Hawaii. This is a good day to be in Hawaii.
    Now, let me tell you how it is where the rubber meets the 
road. We are the ones--Molokai and Lanai are the ones--that are 
really hurting. OK? Let me tell you about how we're really 
hurting.
    First off, we have post-traumatic syndrome cases in Lanai. 
They affect our wives. Our wives is affected by getting wife 
abuse. And they don't want to come to Lanai because they don't 
have their money reimbursed.
    We make an arrangement. We pay our own arrangement for our 
boat from Lanai to Lahaina. Then from Lahaina, we should catch 
that DAV van. All right? But if we get the DAV van, the DAV van 
supposedly picks us up at Lahaina and bring us to Kahului. But 
the DAV van shows up only 40 percent of the time, and we have 
to wait a whole hour at Lahaina Airport--I mean, Lahaina 
Harbor--for us to make an arrangement and get a taxi if they 
don't show up. The taxi costs us, again, the average of $47 
from Lahaina to Kahului.
    Now, the DAV van driver hang up the keys at 1. If our 
appointment going to keep us after 1, then we've got to go 
through the people again and find a taxi and cost another $47 
from Kahului back to Lahaina, and another $30 from Lahaina to 
Lanai. That's money out of our pockets that we can't claim. 
Right there. And that's [inaudible] to me, but [inaudible] and 
VA. And he gets there all the time. All the time. But it's 
money out of our pockets that we cannot claim.
    And we're VA. We signed the dotted line to join the 
military. When we sign that dotted line, we put our lives on 
the line and we put our families on hold. And when we did that, 
we gave that 100--more than 110 percent. Now we've got to have 
the 110 percent back. We need that.
    In Lanai, it's out of sight, out of mind. I wrote a 
Committee to say, reimburse us for our trip here to make this 
appointment. They said, no. You get a--make a fund-raising to 
support your trip to Maui, and [inaudible] or not. You know, I 
don't understand. You explain that to me. OK? If I am 
[inaudible], then this is the [inaudible] function, then you 
should be reimbursing us for our vote. But money out of our 
pockets.
    I pay the dues for this organization. Money out of my own 
personal pocket for our organization. I don't have money back. 
None. OK? It's a lot of stuff that Lanai people pay out our 
pocket, and we don't have--we can't claim it back. Period.
    Another one we can't claim it back is another health 
insurance, which is TRICARE. The VA clinic over here tells me--
I'm going to give you my experience--tells me that they won't 
service me because I have health insurance. So I use my health 
insurance, which is TRICARE, because I'm a retired military. I 
use the TRICARE, and I get the bill. So I sent the bill to VA. 
VA said, no. You pay your bill.
    All I wanted was a B-12 shot. That's all I wanted. All I 
want is them to bring a syringe to Lanai and use the medication 
that I brought from the mainland and give me a shot. And their 
answer, the VA answer, is no. Use your insurance. And I did, 
and did I claim it? I mean, did I get the money back? No. This 
is where the rubber meets the road.
    Lanai, we all have the problem. The problem is sitting 
right there, too. You see all of us have come. We're all 100 
percent disabled. We're all a Category 1. And for the VA clinic 
to tell us, Category 1 personnel, who is more than 100 percent 
disabled, tell me that they're not going to service me and for 
me to use my insurance? No. My insurance is for my wife and my 
son. I use the VA clinic system.
    And now I come over here and they says, no. We won't 
service you. I'm a Category 1 personnel. What are you doing, 
you know? Don't you know your own regulations? So I am called--
this VA hospital called me a troublemaker. I am not a 
troublemaker. I'm just asking you to read the regulation, 
understand your regulation, and do what you're supposed to be 
doing. That's what I am doing. So I'm a troublemaker. Oh well, 
you know?
    I'm trying to stay on schedule here. I don't want to go 
over. So that's fine. I didn't bring any write-up.
    Anyway, back--oh, I am dyslexic, ADD, and brain-injured. 
So--and I also wear a hearing aid. I don't have it on today 
because I didn't bring my spare with me. So I'm very 
dysfunctional. You see? I got a dysfunctional veteran hat: 
``Leave me alone.''
    [Laughter.]
    Mr. Obado. [Inaudible.] My permanent VA clinic is in 
Vancouver, Washington. When I come to Hawaii, I'm a visitor to 
Hawaii. But I'm helping all the veterans in Lanai because they 
are not getting the care I'm getting from the mainland. OK?
    My care, I get it all from the mainland. And I come over 
here and I see Lanai don't have any kind of care. We have care 
once a month. OK? We have [inaudible] officer, which is Bill, 
come over here once a month. Once a month is not going to cut 
it for Lanai because Lanai, we need the veterans--like Bill, we 
need a veteran to sit down with Bill and do our claim. 
[Inaudible.] Once a month.
    You know, if you live in Maui, just run down to the clinic. 
Make an appointment and run down to the clinic. What's it going 
to cost you? It costs you gas money. That's all. It costs us a 
boat trip, which is $60, a taxi fare, which is $47 one way, and 
they hang up the keys at 1, and then it costs us another $47 
back this way. OK?
    I'm 3 minutes over. Anyway, I want to let you guys know 
that I am the only one in all of Hawaii that [inaudible] the 
United States Army [inaudible]. And that's why I am so eager to 
help the veterans in Lanai to get something what is they 
deserve when they sign that dotted line. Thank you.
    [Applause.]
    [The prepared statement of Mr. Obado follows:]
        Prepared Statement of Dwight ``LUI'' Obado, Organizer, 
                      Lanai Veterans Organization
    We respectfully call to your attention to the seriousness of the 
problem of Veterans medical care in Lanai Hawaii. We wish to emphasize 
the importance of the Veteran's Medical care of one of the most needed 
health benefit and vital to those veterans residing in Lanai.
    Federal policymakers are unaware of the many challenges faced by 
Lanai veterans due to geography of our State. We would need to 
introduce a Bill to provide a new satellite clinics in both health-care 
and mental health service.
    The agency also would have to improve mental health and substance 
abuse services in Lanai. We have a few veterans who are not right in 
their heads because of their war experiences. You would call this 
chronic sickness (PTSD). They have spaced out thoughts and attitudes. 
Even to a point of blacking out and getting an attack. Loosing tempers 
and yelling at their families and friends. One of our Veteran wife had 
to lock her self in the bedroom because her husband was yelling at her 
and stabbing the door with a knife. He is a Korean veterans and a 
Purple Heart recipient. I always have to go to his house when his wife 
calls me when he has his attacks and he always tells me he doesn't know 
what he was doing. He doesn't want to go to Maui for treatment because 
it costs him too much money and he had problems in the past of 
collecting his travel expense back from VA. See VA letter pertaining to 
his case and my travel case. The ``red tape and bureaucracy'' involve 
in obtaining any kind of medical care here in Lanai can be tough and 
frustrating to cope with.
    I can readily appreciate the strain on the Federal budget; 
nevertheless, we ask that you consider giving us your consideration of 
a satellite clinics with both health-care and mental health service.
    On behalf of the veterans' in Lanai Hawaii, We would like to thank 
you for helping us work together to accomplish our goal and what we 
cannot do alone. God Bless the United States of America for the U.S. 
Senate, Committee on Veterans' Affairs to helping us. Please show your 
patriotism and that you care for our veteran's. Please make the 
deference and love the country we veterans' kept free and great.

    Chairman Craig. Lui, thank you very much for your 
testimony. I have a couple of questions, but I want to make a 
couple of observations prior to those questions.
    First and foremost to all of you, we believe your testimony 
to be heartfelt and directed appropriately. Part of the reason 
we're here is to not only understand where there are problems, 
but also to create, where we can, a greater evenness of 
coverage and healthcare access.
    And we also know that there are challenges. We can't have a 
veterans hospital everywhere. In fact, today, quite the 
opposite is happening across the country. Today, with 
technology, we're not building bricks and concrete any more as 
much as we used to. And no one else in the healthcare field is 
because of the use of technology.
    I think, Larry, you mentioned, possibly you, Larry, 
telemedicine as an approach. That is only one of many that are 
allowing healthcare professionals to outreach in ways that 
heretofore have not--we've not been able to do in rural 
environments of the kind that you live in here or that my 
veterans live in Idaho.
    There is no question we are being able to extend healthcare 
in areas where we could not before, or facilitate those who, as 
you said, have to travel by boat. In situations in my State, we 
have people who get in cars and drive 250 and 300 miles to gain 
access to VA healthcare.
    So there are similar kinds of problems, and I think it's 
important that we hear those and that we attempt to resolve, 
where we can, those kinds of difficulties that do exist.
    Let me say this because I am extremely proud of the work 
that has been done over time. There are a variety of illusions, 
and I use that word, illusion, as to what taxpayers and 
Congress are or are not doing for America's veterans.
    But here's a reality: Of all the budgets that I look at, 
the one budget that has consistently had higher rates of 
increase over the last decade, over any other budget, has been 
the veterans' budget. Why? Because of the direct and open and 
obvious commitment that not only the Congress has, but we think 
Congress is reflective of America's concern.
    You watched, I think, with great interest the debate we 
went through this past year. And we nearly doubled the budget 
as it was once proposed. It isn't a partisan issue. President 
Bush proposed a budget. President Clinton proposed different 
budgets. Congress disagreed, and put more money into it. And 
that is consistently the case.
    Over the last decade, we've seen a near-average increase of 
9 percent, on the whole, on an annualized basis, in the 
veterans' healthcare. If you'll notice today's press, 
healthcare costs this year inflated at a lower rate of about 9 
percent.
    We are not able to meet all of the needs or all of the 
perceived needs. We do have to establish priority. We do have 
to look at those who are in greater need and have less means 
within the veterans population to do so.
    It is difficult for most who look at our Government who 
think, well, if you can spend money over there, why can't you 
spend money over here in a different area? Veterans' budgets, 
the VA budget, versus Health and Human Services, versus 
Agriculture, versus Defense, are very clear and separate 
budgets, and they are viewed as that. And they don't commingle.
    And as much as we are--and I believe that to be--Danny and 
I, advocates for veterans, we have advocates there in Congress 
for all other areas of expenditures. And they fight as 
aggressively for their money as we do for your money.
    And as a result, we're about to go through another budget 
cycle. The President will propose a budget. The Congress will 
look at it. This authorizing Committee that Danny and I serve 
on will look at the VA budget very, very closely. We will make 
recommendations to the Budget Committee. The Budget Committee 
will be looking at it. The Budget Committee will then lay out a 
level of expenditure based on what they think is necessary, and 
we will work the process down.
    But there is a bottom line, and I'm very proud of that 
bottom line. That is that VA has been extremely well funded for 
the last decade as it compares to other areas of our 
Government. The only other area that we see larger increases is 
defense, and it's obvious to most of us why that's occurred, 
since 9/11, at least, in the last good number of years.
    So as we work these issues through, and we will continue to 
do so. Not only do we work to get the money, but we also work 
to re-establish priorities or to look at where there are 
greater needs, to see if older services once offered are still 
legitimate, or if we opt to shift money to other areas and 
categories within VA healthcare, to do so.
    Having said all that, Danny mentioned in his opening 
comments something that, again, both he and I are extremely 
proud of. Over the last several years, in numerous write-ups in 
national journals across the country, as a result of an 
analysis of quality care delivery, VA has come out No. 1.
    I think if we think back just a few years, that was not the 
case. VA, when you as a veteran might have had alternative 
healthcare access, might have chosen that over VA. Today, that 
is simply not the case. As a result of us investing in VA 
healthcare and upping its overall quality, we've also 
accelerated the demand. Veterans have looked at it, when 
available, as an option or a selection of first choice in their 
healthcare.
    Those are some of my observations as we work through this, 
that we are very proud of the VA healthcare system. We do 
recognize it as a quality healthcare delivery system. But 
gaining access, gaining service, rural environments, difficult 
geography, all of that complicates. There's no question about 
it.
    And I must say that where it cannot be delivered in one 
location, is delivered in another, in a greater populated area, 
trying to therefore facilitate cost of transportation and 
movement so that veterans can get to those facilities. I don't 
think you can expect in remote environments comprehensive 
levels of care that oftentimes we experience in the more urban 
environments. It is simply a reality, although it's changing 
because of the technologies that are being allowed to us today.
    Let me ask you, Dr. Roy, with your blind--your experience 
as an injured veteran and a blind veteran, you mentioned in 
your testimony that you've been to a number of VA blind 
rehabilitation facilities for training, or BRCs, as they are 
generally residential programs which require long stays away 
from family.
    Dr. Kekahuna. Right.
    Chairman Craig. And I'm sure you would agree that many 
veterans do not want to spend long days away from their 
families. That's a difficulty.
    So the question would be: Do you believe that blind 
rehabilitation outpatient specialists are an adequate 
substitute to a residential program ? Or is the residential 
program of more benefit?
    Dr. Kekahuna. I believe that the outreach program here in 
Hawaii would be most beneficial. In most instances, those 
veterans that can go to the Blind Rehabilitation Center should 
go there because it gives you the opportunity to become who you 
can be, all you can be, all in one place.
    But because of the situation and the geographical location, 
blind outreach specialists would be most beneficial here 
immediately. Getting the veterans then onto the program to go 
forward to the BRC would be the next step because even after 
they get the basic training--at least they can survive at 
home--with the outreach program, then the VA should get them to 
the blind center so that they can get all of the equipment and 
the education that's needed to facilitate their lives.
    I went to Hines in 1968. I went to Palo Alto because, 
through the grace of God and medical science, I've had vision 
back in one eye, and in 1988 I became legally blind again. And 
becoming legally blind, I was able to go to--to Palo Alto 
because they had good computer access to get my PhD. So that's 
why I went to Palo Alto, because at that time, even that was a 
scary place. Let me tell you why.
    [Inaudible]. So by the time I went back to college and 6 
months later, my computer was out of date. It's no longer that 
way, and that's a blessing for the veterans that go there now 
because they get the latest equipment and help them do what 
they need to do for their lives.
    But outreach, yes, by far in this State.
    Chairman Craig. Well, I thank you for that. I will disagree 
with that observation. I think that clearly to gain those 
course skills that you need, you need that clinical/student/
classroom environment that, by the nature of its costs and 
realities, can only be put in certain locations. And we simply 
have to take the veteran to that location instead of expect 
that kind of facility in others.
    Danny, let me turn to you. And again, gentlemen, your 
statements have become a part of the official record of the 
Committee. We thank you for your time and your commitment. Your 
work as advocates of veterans, that's greatly appreciated. 
You've been loudly heard today. Thank you.
    [Applause.]
    Senator Akaka. Thank you very much, Mr. Chairman, for your 
remarks about the system. And I want to tell you that, as I 
mentioned, that working with Larry has been great. We together 
have been looking at better ways to try to service the 
veterans.
    And with your kind of help, with your testimony in Hawaii 
and elsewhere, this will help us do that, as I mentioned in my 
remarks. You can help us to help you. This is what we're trying 
to do here. So Larry and I will continue to work hard on this 
Committee and try to take care of some of the problems that we 
hear, not only in Hawaii but across the country.
    I'd like to ask a question of Mr. Helm, of Larry. In your 
testimony, you state that Molokai's veterans must wait 6 months 
to receive psychiatric care. Can you tell me about some of the 
problems that arise when veterans have to wait so long for 
care?
    Mr. Helm. Senator, we do have a large population of Vietnam 
veterans, and because for many years the VA is finally catching 
up getting these veterans on line to get mental health, there's 
quite a few of them.
    And Dr. McNamara just has so much time. She comes up there 
twice a month now. She used to come up once a month. So to see 
5, 6, 7, 10 patients a day in an 8-hour or how many hours she's 
out on the island--she's got to come back in the afternoon; she 
comes in the morning--there's not enough. So sometimes it 
causes problems. The veterans get impatient. There's, you know, 
some problems at home and stuff like that. But it's been an 
ongoing thing for many years.
    So if we could get Dr. McNamara a little bit more, it 
probably could fill the void. It's, I think, 5 months? If a guy 
goes to you, 3 months to 5 months? Yeah. It's down to 3 months 
now that she's coming twice a month. So if we could get her 
three times a month, that might mean more guys could get the 
help that they need.
    Senator Akaka. Mahalo for your response.
    Mr. Obado, Lui, I was especially concerned to hear that 
veterans may not travel from Lanai to Maui for treatment 
because of what you said and issues they have collecting back 
money from travel reimbursement. And you have covered this 
pretty well.
    My only question to you would be: Do you have an idea on 
how that could be done better?
    Mr. Obado. I think that ideally it would be better to have 
a satellite clinic in Lanai so they can, even through 
television, talk to another veteran doctor, and use our Straub 
Clinic, our doctor in the Straub Clinic, to have a satellite 
clinic, and they can talk to a VA clinic through a satellite.
    We have a doctor, Dr. Gasper. He used to be a doctor to a 
VA clinic. So he knows what it takes to help a veteran. And we 
have one on there. But he can't do it, because now he's a 
doctor for the Straub Clinic. But if he had the camera to talk 
to another veteran doctor, then we can go to the clinic 
ourselves. Instead of coming all the way to Maui, we can go 
straight to the Straub Clinic and the doctor there can just go 
to the television and discuss with another veteran doctor, and 
then that veteran will be helped.
    Senator Akaka. Thank you. Mahalo for your mana'o.
    [Applause.]
    Senator Akaka. Larry, to buildupon Lui's statement, can you 
please explain the obstacles that a veteran must overcome to 
travel from Molokai to Maui for care? I understand that the 
ferry runs during the morning and evening rush hours and 
arrives on the western side of Maui near Lahaina town. So can 
you----
    Mr. Helm. Yes, Senator. We do have a ferry that comes every 
day. We do have Island Air that flies from an airport. And the 
cost of Island Air is $216 round trip for us to come over here 
for care.
    But very difficult sometimes to get the VA to tie in with 
the veterans' timeframe to get a flight and coordinate the 
appointment here. That's been the difficulty [inaudible].
    Paperwork. Sometimes the paperwork did not get in, or the 
VA thought that they are going to Honolulu when he's supposed 
to come to Maui. And there's a lot of mix-ups like that. That 
could be solved if there was a little bit more efficiency there 
for the Molokai vets.
    Also, now that we are having a doctor from on island there, 
and now that we're having or supposedly getting a psychiatrist, 
we also need an outreach counselor. We lost Robert Lewis, so we 
need an outreach counselor to come to Molokai on a regular 
basis. That would help the Molokai veterans a lot. We need a 
lot more, but that would help us a lot.
    We also need about $3 million to build our veterans center.
    [Laughter and applause.]
    Senator Akaka. Mahalo. Mahalo, Larry.
    Dr. Kekahuna, thank you for providing us with that 
demonstration of what a blinded veteran endures to complete 
simple tasks. Can you tell us what you mean exactly by ``low 
vision services''? What does that encompass?
    Dr. Kekahuna. Low vision, in the VA vernacular, is people 
that are not legally blind or blind. But when administering the 
test for the low vision test like I go through, they use a lot 
of different types of equipment, equipment that's needed here 
in the VA in Honolulu, that tests your eyes to see what your 
peripheral vision will be and what your central vision will be. 
It lets, you look deep into the depths of your eyes and how 
clearly you can see.
    I believe that with the equipment and with trained 
personnel, especially at the medical doctor's level, an MD, 
that, you know, it would really help the veterans here.
    Senator Akaka. Thank you. Mahalo.
    Mr. Helm, Larry, I noted in your testimony that you 
expressed the need for support of young returning war veterans. 
Can you tell us what can be done to ease their transition from 
the military to civilian life?
    But before you answer that, let me tell you that one day I 
was on Maui, and this would have been last year, and there was 
a Hawaiian father who was hanging around outside. And so when I 
was ready to leave, he was in a parking lot waiting for me. And 
he wanted to talk to me.
    And he told me the story. He said, you know, my son, before 
he joined the Army, he used to go surfing. He used to go with 
his friends. He was always out of the house. And he said, he 
joined up. He got sent to Iraq when the Iraq War broke out. He 
served in that war. And then following that, he retired and 
came home.
    And he told me, he said, what can you do to help my son? He 
said, I can't even get him to surf. He said, he comes home and 
he sits in the house. And, he said, that's not like him. So he 
told me, visit with your friends. He said, [inaudible]. And 
for, I don't know how many months since then, and he saw me, he 
said, what can I do with my boy? You know, [inaudible].
    And I thought I'd mention that. And I don't know what we 
ought to say. Mahalo.
    Mr. Helm. Yes, Senator. Unfortunately, that's the cost of 
war, that returning young veterans, you're going to have a lot 
of these kind of situations going on. But there is an asset in 
every community in this country that if it was to be malama'd 
or massaged or used, it's the combat veteran that is disabled 
in every place.
    If the VA could put these young guys in touch with these 
veteran organizations or combat veterans, they know the talk. 
They know the walk. They've been there, done that, and they 
could be of great help to these young veterans. That should be 
one way, besides the VA and the mental health department.
    Of course, you need more people in mental health because we 
have a lot of these young guys coming back. But that's an asset 
that this country has, is the Vietnam veteran, combat vets, you 
know, the Korean vets, have been there, have done that, know 
how to respond to these guys and can help them.
    Senator Akaka. Mahalo, Larry.
    Rogelio Evangelista, in your testimony you mentioned that 
although some veterans live on limited financial support, VA 
continues to explore raising the co-payments for drugs 
prescribed for non-service-connected patients. You also 
mentioned that these same veterans may have limited resources 
because of physical or mental conditions that can be attributed 
to their service.
    Can you please elaborate on that?
    Mr. Evangelista. Well, Senator, in regards to that, I have 
seen a lot of veterans suffering from PTSD. And because of 
their physical and mental condition, they work menial jobs and 
they don't last in those jobs long enough to be fruitful and so 
forth. So they end up getting laid off. They end up getting in 
trouble.
    And the part is, if we can look at the veteran himself and 
see how we can retrain him to get, you know, a different type 
of profession other than just the low, menial type of jobs 
like, for example, a computer expert, that part, it's something 
that we can get in regards to this mentality, use it, and we 
can be accepted back into society by that aspect.
    Senator Akaka. Thank you. Mahalo. Thank you very much.
    Before I say mahalo nui loa to this panel, I want to thank 
all the veterans from Molokai, from Lanai, and of course from 
Maui, those who traveled here today. It's not very easy--to 
wake up, to catch the ferry, it's not easy, and I thank you all 
for making such an effort to get here to testify and to be part 
of this hearing.
    So mahalo nui loa, and I'll turn it over to the Chairman.
    Chairman Craig. Well, gentlemen, thank you again for your 
testimony. It's great [inaudible]. Thank you. We'll excuse this 
panel, and ask our second and last panel to come forward, 
please. Thank you very much.
    [Applause.]
    Chairman Craig. All right. Let's get started with the 
second panel. I'm very pleased today that we have--I suspect 
it's a first on this island--the Under Secretary for Health, 
Department of Veterans Affairs. This gentleman that I am about 
to introduce is in charge. It doesn't mean you can blame him 
for everything. But you can blame him for most. How's that?
    [Laughter.]
    Chairman Craig. Let me introduce to you the Honorable 
Jonathan A. Perlin, MD, PhD, Under Secretary for Veterans 
Affairs. He is accompanied by Dr. Robert Wiebe, VA Network 
Director, VISN 21, Sierra Pacific Network. That's the greater 
region of the Pacific area. Dr. James Hastings, Director of VA 
Pacific Islands Health Care Services; and Dr. Steven MacBride, 
Chief of Staff, Honolulu VA Hospital.
    So all four are doctors. I don't know whether that's good 
or bad.
    [Laughter.]
    Chairman Craig. I suspect in this business it's good. If 
they were all four lawyers----
    [Laughter.]
    Chairman Craig. I'll let that speak for itself. Somebody 
said, ``We'd be here longer.'' That's a reasonable observation.
    Well, anyway, we thank these gentlemen very much for 
accompanying us and being with us today. Sitting and listening 
to your concerns is extremely important for those who make the 
system work as well as it does, both from the Washington level 
or from the regional or area level. So we thank you all for 
being here, and I'll turn the testimony over to Dr. Perlin.
    Doctor.
    [Applause.]

 STATEMENT OF THE HONORABLE JONATHAN A. PERLIN, MD, PhD, UNDER 
     SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS, 
ACCOMPANIED BY ROBERT WIEBE, MD, VA NETWORK DIRECTOR, VISN 21, 
   SIERRA PACIFIC NETWORK; JAMES HASTINGS, MD, DIRECTOR, VA 
PACIFIC ISLANDS HEALTH CARE SYSTEM; AND STEVEN A. MacBRIDE, MD, 
     CHIEF OF STAFF, VA PACIFIC ISLANDS HEALTH CARE SYSTEM

    Dr. Perlin. Aloha, Chairman Craig, Senator Akaka. Mahalo 
nui loa for the opportunity to be here with you all today to 
provide testimony, and especially for the opportunity to hear 
from the men and women of this great State and the veterans who 
do in fact use VA for what Chairman Craig and you, with your 
fine support and advocacy, have helped to shape as the world's 
best healthcare.
    I appreciate the opportunity to hear about ways in which we 
can improve healthcare here in Maui and on Lanai and on 
Molokai. And I think today that you will be pleased to hear of 
a number of improvements that will in fact go a long way toward 
addressing some of the issues that have been brought to our 
attention.
    It doesn't mean that we'll solve all issues today, but it 
does mean that I think you will be very pleased to hear some of 
the progress, and I think I heard in your testimony what I 
experienced this morning when I had the great honor and 
privilege of visiting the CBOC here at Maui.
    What I saw this morning were a team of dedicated healthcare 
professionals, staff also, from the Veterans Benefits 
Administration who not only were technically excellent in their 
delivery of healthcare services, but in fact, were absolutely 
passionate and compassionate and really creative in the 
delivery of those services to individuals that they felt were 
nothing less than family, part of the community.
    There were two doctors, a nurse practitioner. Everyone 
knows the psychologist, Captain McNamara. In fact, a 
psychiatrist will soon be joining the team who's also well-
known to the residents and veterans of Maui and Molokai and 
Lanai, Dr. Springer.
    And so in that vein, sir, I'm very pleased to be able to 
report that the VA finds exceptional service to veterans of 
Maui County through our VA Pacific healthcare system, which is 
part of the Sierra Pacific Network, one of our 21 Veterans 
Integrated Service Networks or VISNs.
    We're proud to tell you that last year more than 80 percent 
of our patients at the Maui Outpatient Clinic in fact rated 
their care as, overall, very good or excellent. We made 
investments in this clinic 3 years ago, spending more than 
$200,000 to renovate this clinic into really one of the very 
nicest.
    The clinic staffing complement, as mentioned, includes a 
full-time primary care physician, a part-time family practice 
physician. It will include a psychiatrist shortly, the 
psychologist I mentioned, a nurse practitioner. And we need to 
extend these services to veterans with specialty care by 
clinicians who actually rotate to the clinic, such as my 
colleague, who is not only director of the VA Pacific Islands 
Healthcare Care System, Dr. James Hastings, but also a 
cardiologist who is well-known to both the patients and staff, 
who comes to deliver cardiac care services at this particular 
clinic.
    To further serve the veterans of Maui County, we regularly 
send VA staff not only from Honolulu, but also as far away as 
California to bring in the most specialized expertise in all 
areas. And if veterans services are not available here, then we 
will make care available in the community, pay for care, in 
places like Maui Memorial Hospital or in fact Tripler Medical 
Center as well.
    The facts are that last year we spent nearly $3.4 million 
for non-VA care in the private sector to residents of Maui. I'm 
also pleased to note that Maui Clinic has--in fact, very 
shortly--plans for new patients, and it's very rare that 
patients ever wait more than 30 days for their first 
appointment.
    Senators, the Islands of Molokai and Lanai are also, as all 
know here, a part of our Maui County service area. And I 
understand and heard loudly this morning that you've asked us 
to improve services to those islands. Our staff do visit from 
Maui, and while we don't operate formal outpatient clinics 
there, we do provide service to an area which does have a 
number of veterans.
    The island of Molokai, approximately 260 square miles in 
area, is home to 144 veterans among its population of 649 
veterans who use VA for care. We currently send a primary care 
physician to Molokai once a month, a nurse practitioner once a 
month, a psychologist twice a month, and we lease space in the 
community to provide these services.
    In addition, we spent more than $250,000 last year to 
purchase care in the community for eligible veterans living in 
Molokai at places such as Molokai General Hospital. And we are 
absolutely thrilled to welcome Dr. Hafermann, a retired Air 
Force physician, to really be part of the VA community in 
extending continuity of care on Molokai, supported by what 
we'll discuss later, I'm sure, increased tele-health services.
    I want to thank Senator Akaka for his help in helping to 
bring Dr. Hafermann to VA as part of our community, and for his 
support with Chairman Craig of veterans and VA in general. I 
think it's really important that all here understand the degree 
of passion and advocacy and courage that you, sir, Senator 
Akaka and Chairman Craig, show not only for all veterans, but 
in support of the Department of Veterans Affairs providing 
services.
    VA is working to establish additional tele-health 
capabilities on Molokai, and has designated our presence there 
as an outreach clinic. This allows us to establish an 
electronic link between Molokai and Maui so that electronic 
health records will also support the clinical care on Molokai.
    The island of Lanai is approximately 140 square miles, and 
VA estimates that the veteran population on the island is 229, 
of whom 34 veterans use VA for healthcare or used VA for 
healthcare last year. Similarly, we send a nurse practitioner 
from the Maui CBOC to Lanai every few months to provide needed 
primary care services. I believe this can be enhanced in part 
through care in the community, and last year we spent $35,000 
paying for care for veterans in the community, mostly for 
services through Lanai Community Hospital.
    Now, on Lanai, we are not planning to activate a formal 
community-based outpatient clinic. Instead, we are looking at 
other options to improve access. We're talking with the Hawaii 
Health Systems Corporation, the Native Hawaiian Health System, 
and local providers to potentially establish a federally 
Qualified Health Center.
    Since healthcare is currently limited to residents of 
Lanai--for example, there are no mental health services on the 
entire island--we're very excited about the possibilities that 
this offers to improve healthcare, not just for veterans, but 
for all residents of the island.
    We're also looking at the feasibility of establishing tele-
health capabilities on Lanai, and are considering developing 
contracts with other clinicians to provide care for veterans, 
much like we're doing on Molokai.
    And so in conclusion, with the support of Congress, but in 
particular with your leadership, Chairman Craig, Ranking Member 
Akaka, VA is providing unprecedented levels of healthcare 
services to veterans residing in Maui County, and we look 
forward to augmenting those with not only new staff such as Dr. 
Hafermann, but additional tele-health capabilities, and look 
forward to discussing some of the issues that were raised this 
morning. Mahalo nui loa.
    [Applause.]
    [The Prepared statement of Dr. Perlin follows:]
Prepared Statement of Hon. Jonathan A. Perlin, MD, PhD, Under Secretary 
               for Health, Department of Veterans Affairs
    Mr. Chairman and Members of the Committee, mahalo nui loa for the 
opportunity to appear before you today to discuss the state of VA care 
in Hawaii. It is a privilege to be here on Maui--the Valley Isle--to 
speak and answer questions about issues important to veterans residing 
in Hawaii.
    First, Mr. Chairman, I would like to thank you for your outstanding 
leadership and advocacy on behalf of our Nation's veterans. During your 
tenure as Chairman of this Committee, you have clearly demonstrated 
your commitment to veterans by acting decisively to ensure the needs of 
veterans are met. In addition, I appreciate your interest in and 
support of the Department of Veterans Affairs (VA).
    I also would like to express my appreciation and respect for 
Senator Akaka, Ranking Member of this Committee. Along with his 
colleague, Senator Inouye, Senator Akaka has done so much for the 
veterans residing in Hawaii and other islands in the Pacific region. As 
I will highlight later, his vision, guidance and assistance have 
directly led to an unprecedented level of health care services for 
veterans, construction of state-of-the-art facilities in Honolulu and 
remarkable improvements in access to health care services for veterans 
residing on neighbor islands, including Maui.
    Today, I will briefly review the VA Sierra Pacific Network that 
includes Hawaii and the Pacific region; provide an overview of the VA 
Pacific Islands Health Care System (VAPIHCS) and the VA clinic here in 
Maui; highlight issues of particular interest to veterans residing in 
Maui County, including VA services on the nearby islands of Molokai and 
Lanai and access to specialty care; and address any questions posed by 
Members of the Committee.

                  VA SIERRA PACIFIC NETWORK (VISN 21)
    The VA Sierra Pacific Network (Veterans Integrated Service Network 
[VISN] 21) is one of 21 integrated health care networks in the Veterans 
Health Administration (VHA). The VA Sierra Pacific Network provides 
services to veterans residing in Hawaii and the Pacific Basin 
(including the Philippines, Guam, American Samoa and Commonwealth of 
the Northern Marianas Islands), northern Nevada and central/northern 
California. There are an estimated 1.25 million veterans living within 
the boundaries of the VA Sierra Pacific Network.
    The VA Sierra Pacific Network includes six major health care 
systems based in Honolulu, HI; Palo Alto, CA; San Francisco, CA; 
Sacramento, CA; Fresno, CA and Reno, NV. Dr. Robert Wiebe serves as 
director and oversees clinical and administrative operations throughout 
the Network. In Fiscal Year 2005 (FY05), the Network provided services 
to 227,000 veterans. There were about 2.8 million clinic stops and 
24,000 inpatient admissions. . The cumulative full-time employment 
equivalents (FTEE) level was 8,200 and the operating budget was about 
$1.3 billion, which is an increase of $378 million since 2001.
    The VA Sierra Pacific Network is remarkable in several ways. In 
fiscal year 2005, the Network was the only VISN in VHA to meet the 
performance targets for all six Clinical Interventions that directly 
address adherence to evidence-based clinical practice. The Network 
hosts 11 (out of 65) VHA Centers of Excellence--the most in VHA. The VA 
Sierra Pacific Network also has the highest funded research programs in 
VHA. Finally, VISN 21 operates one of four Polytrauma units that are 
dedicated to addressing the clinical needs of the most severely wounded 
Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans.

            VA PACIFIC ISLANDS HEALTH CARE SYSTEM (VAPIHCS)
    As noted above, VAPIHCS is one of six major health care systems in 
VISN 21. VAPIHCS is unique in several important aspects: its vast 
catchment area covering 2.6 million square-miles (including Hawaii, 
Guam, American Samoa and Commonwealth of the Northern Marianas); island 
topography and the challenges to access it creates; richness of the 
culture of Pacific Islanders; and the ethnic diversity of patients and 
staff. In fiscal year 2005, there were an estimated 113,000 veterans 
living in Hawaii (9 percent of Network total).
    VAPIHCS provides care in six locations: Ambulatory Care Center 
(ACC) and Center for Aging (CFA) on the campus of the Tripler Army 
Medical Center (AMC) in Honolulu; and community-based outpatient 
clinics (CBOCs) in Lihue (Kauai), Kahului (Maui), Kailua-Kona (Hawaii), 
Hilo (Hawaii) and Agana (Guam). VAPIHCS also sends clinicians and 
support staff from these locations to provide services on Lanai, 
Molokai and American Samoa. The inpatient post-traumatic stress 
disorder (PTSD) unit formerly in Hilo is in the process of relocating 
to Honolulu. In addition to VAPIHCS, VHA operates five Readjustment 
Counseling Centers (Vet Centers) in Honolulu, Lihue, Wailuku, Kailua-
Kona and Hilo that provide counseling, psychosocial support and 
outreach.
    Dr. James Hastings was recently appointed Director, VAPIHCS. Dr. 
Hastings has impressive credentials, including tenure as Chair, 
Department of Medicine, John A. Burns School of Medicine, University of 
Hawaii, and Commanding General at Walter Reed AMC and Tripler AMC. I am 
excited about the possibilities that his tenure as Director at VAPIHCS 
brings.
    In fiscal year 2005, VAPIHCS provided services to 18,300 veterans 
in Hawaii (8 percent of Network total). There were 194,000 clinic stops 
in Hawaii during fiscal year 2005 (7 percent of Network total), an 
increase of 36 percent since fiscal year 2000. The cumulative FTEE for 
the health care system was 478 employees. The budget for VAPIHCS 
(including General Purpose, Specific Purpose and Medical Care Cost 
Funds [MCCF]) has increased from $53 million in fiscal year 1999 to 
$102 million in fiscal year 2005 (about 8 percent of Network total). In 
addition, VISN 21 provided over $20 million in supplemental funds to 
VAPIHCS over the past two Fiscal Years to ensure VAPIHCS met its 
financial obligations.
    VAPIHCS provides or contracts for a comprehensive array of health 
care services. VAPIHCS directly provides primary care, including 
preventive services and health screenings, and mental health services 
at all locations. Selected specialty services are also currently 
provided at the Honolulu campus and to a lesser extent, at CBOCs. 
VAPIHCS recently hired specialists in gero-psychiatry, 
gastroenterology, ophthalmology and radiology. VAPIHCS is actively 
recruiting additional specialists in cardiology, orthopedic surgery and 
urology. Inpatient long-term care is available at the 60-bed Center for 
Aging. Inpatient mental health services are provided by VA staff on a 
20-bed ward within Tripler AMC and at the 16-bed PTSD Residential 
Rehabilitation Program (PRRP) that was formerly in Hilo (now relocating 
to Honolulu). VAPIHCS contracts for care with DoD (at Tripler AMC and 
Guam Naval Hospital) and community facilities for inpatient medical-
surgical care.
    The current constellation of VA facilities and services represents 
a remarkable transformation over the past several years. Previously, 
the VAPIHCS (formerly known as the VA Medical and Regional Office 
Center [VAMROC] Honolulu) operated primary care and mental health 
clinics based in the Prince Kuhio Federal Building in downtown Honolulu 
and CBOCs on the neighbor islands that were staffed primarily with 
nurse practitioners. Senator Akaka and his colleagues in Congress 
approved $83 million in Major Construction funds to build a state-of-
the-art ambulatory care center and nursing home care unit on the 
Tripler AMC campus and these facilities were activated in 2000 and 
1997, respectively. VISN 21 allocated nearly $17 million from FY98-FY00 
to activate these projects. VISN 21 also provided dedicated funds 
(e.g., $2 million in fiscal year 2001) to enhance care on the neighbor 
islands by expanding/renovating clinic space and adding additional 
staff to ensure there are primary care physicians and psychiatrists at 
all CBOCs.

                               MAUI CBOC
    VA operates a CBOC, located in Kahului (203 Ho'ohana, Suite 303, 
Kahului, HI, 96732). In fiscal year 2002, VAPIHCS spent $208,000 to 
renovate the clinic. The Maui Vet Center is located in nearby Wailuku.
    The veterans treated at the Maui CBOC appear to be very satisfied 
with their care. For example, a Vietnam veteran recently remarked, ``I 
chose VA when I had opportunities to use other health care. My medical 
care from the Maui CBOC has been superb in every respect. There is 
genuine concern for my health and well-being and I could not hope for 
better care.'' With comments like this, it is not surprising that in 
fiscal year 2005, VAPIHCS achieved an exceptional level of performance 
in the national VHA measure of outpatient satisfaction with over 80 
percent of patients rating their overall care as ``very good'' or 
``excellent.''
    The Maui CBOC serves an estimated island veteran population in 
fiscal year 2005 of 10,787. In fiscal year 2005, 2,769 veterans were 
enrolled for care and 1,464 veterans received care (``users'') at the 
Maui CBOC. The market penetrations for enrollees and ``users'' are 26 
percent and 14 percent, respectively, and compare favorably with rates 
within VISN 21 and VHA.
    The current authorized full-time employment equivalents (FTEE) 
level is 12.4, including a full-time primary care physician, part-time 
family practice physician, psychiatrist, psychologist and nurse 
practitioner. With this staff, the Maui CBOC provides a broad range of 
primary care and mental health services. In addition, VAPIHCS provides 
specialty care services at the clinic by sending VA staff from Honolulu 
and other VA facilities in California. Services provided by clinicians 
traveling to Maui include cardiology, geriatrics, nephrology, 
neurology, optometry, orthopedics, rheumatology and urology. If 
veterans need services not available at the clinic, VAPIHCS arranges 
and pays for care in the local community (e.g., Maui Memorial 
Hospital), Honolulu (including Tripler AMC) or VA facilities in 
California. In fiscal year 2005, VA spent nearly $3.4 million for non-
VA care in the private sector (i.e., not including costs at other VA or 
DoD facilities) for residents of Maui.
    In fiscal year 2005, the Maui CBOC recorded 9,135 clinic stops, 
representing a 41 percent increase from fiscal year 2000 (i.e., 6,499 
stops). The clinic has short waiting times for new patients with very 
few veterans waiting more than 30 days for their first primary care 
appointment.

                             SPECIAL ISSUES
    The islands of Molokai and Lanai are part of Maui County. Although 
VA provides limited services on these islands by VA staff visiting from 
Maui, VA does not operate formal CBOCs in these locations. Veterans and 
their advocates have asked VA to increase services in these underserved 
areas.
    Molokai. The area of the island of Molokai is approximately 260 
square miles. VA estimates the veteran population to be 649. In fiscal 
year 2005, 202 veterans were enrolled for VA care and 144 veterans 
received VA services. VA currently sends a primary care physician to 
Molokai once a month, a nurse practitioner once a month and a 
psychologist twice a month. VA leases space in the community to provide 
these services. In addition, VA purchased non-VA care in the community 
(e.g., Molokai General Hospital) for eligible veterans residing in 
Molokai (e.g., $254 thousand in fiscal year 2005). Veterans residing in 
Molokai also are seen at DoD and VA facilities in other locations.
    In fiscal year 2005, VHA formally designated the VA presence in 
Maui as an outreach clinic. This allowed VAPIHCS to establish an 
electronic link between the outreach clinic in Molokai and the Maui 
CBOC so that the VA electronic medical record can be used in Molokai. 
At present, due to the relatively small number of veterans residing in 
Molokai, VA does not plan to establish a formal CBOC in Molokai. 
However, VA does plan to improve access to health care services on the 
island.
    Based on information provided by Senator Akaka and his staff, VA 
has identified a former Air Force physician (i.e., Dr. Hafermann) who 
resides in Molokai and is interested in providing medical care to 
veterans on a part-time basis. VAPIHCS recently credentialed and 
privileged this physician and is working with him to establish a 
regular clinic schedule in early 2006. VA is also working to establish 
telehealth capabilities from Molokai. VA will place an order for 
telehealth equipment and is working to identify the location for the 
telehealth activities. VA will also explore the possibility of sharing 
telehealth capabilities with non-VA providers in exchange for local 
services for veterans.
    Lanai. The island of Lanai is approximately 140 square-miles. VA 
estimates the veteran population to be 229. In fiscal year 2005, 57 
veterans were enrolled for VA care and 34 veterans received VA 
services. VA currently sends a nurse practitioner from the Maui CBOC to 
Lanai every couple of months to provide needed primary care services. 
In addition, VA purchased non-VA care in the community (e.g., Lanai 
Community Hospital) for eligible veterans residing in Lanai (e.g., $35 
thousand in fiscal year 2005). Veterans residing in Lanai also are seen 
at DoD and VA facilities in other locations.
    Due to the small number of veterans residing in Lanai, VA does not 
plan to activate a formal CBOC. Instead, VA is exploring other options 
to improve access. VA is talking with the Hawaii Health Systems 
Corporation (HHSC), Native Hawaiian Health System and local providers 
(i.e., Straub Clinic) to potentially establish a federally Qualified 
Health Center (FQHC). Since health care is limited to all residents of 
Lanai (e.g., there are no mental health services in Lanai), a FQHC 
offers exciting possibilities. VA is also exploring the feasibility of 
establishing telehealth capabilities in Lanai. Finally, VA will also 
consider establishing a contract with local clinicians to provide care 
for veterans, based on the availability of resources and local 
interest.
    Specialty services. The size of the veteran population and number 
of VA patients limit the feasibility of having a large cadre of medical 
and surgical specialists based in the Maui CBOC. Nonetheless, VA 
recognizes that some veterans in Maui County have needs that go beyond 
primary care and mental health. As I noted earlier, VA sends 
specialists from Honolulu and California to the clinic on a regular 
basis. Services provided by clinicians traveling to Maui include 
cardiology, geriatrics, nephrology, neurology, optometry, orthopedics, 
rheumatology and urology. VAPIHCS also refers patients to the local 
community for care at VA expense (when eligibility criteria are met) 
and transports (also at VA expense when eligibility criteria are met) 
patients to the VA facility in Honolulu.
    VAPIHCS is utilizing telehealth technology to expand access to 
specialty care (e.g., dermatology). VAPIHCS estimates that telehealth 
services are provided more than 15 hours per week at the Maui CBOC. As 
additional specialists are hired at the VA facility based in Honolulu, 
these clinicians will be able to travel to Maui County and further 
utilize telehealth technologies. For the past several years, veterans 
in Maui have been invited to participate in research studies designed 
to test if telehealth could be used effectively to extend mental health 
services (e.g., treatment for PTSD) to a culturally diverse population. 
The willingness of Maui veterans to participate reflects their trust in 
VAPIHCS, Maui Vet Center and VHA National Center for PTSD.
    As noted before, VAPIHCS staff occasionally refers patients to VA 
facilities in California. Access to other VA facilities was especially 
important to a veteran who wrote, ``The veteran's health center in Kona 
[Kailua-Kona CBOC] has not only helped me get my prescription drugs at 
a lower cost, but last year they helped me go to the Western Blind 
Rehabilitation Center in Palo Alto to learn how to cope with my 
blindness. For the first time in many years, I have confidence to do 
things I never thought I could do without sight.''

                               CONCLUSION
    In summary, with the support of Senator Akaka and other Members of 
Congress, VA is providing an unprecedented level of health care 
services to veterans residing in Hawaii and the Pacific Region. VA now 
has state-of-the-art facilities and enhanced services in Honolulu, as 
well as robust staffing on the neighbor islands and has expanded or 
renovated clinics in many locations. VA is bringing more specialists on 
board and preparing for the newest generation of veterans-those who 
bravely served in southwest Asia.
    VAPIHCS still faces several challenges, in part due to the 
topography of its catchment area. VAPIHCS will meet these challenges by 
utilizing telehealth technologies, sharing specialists, developing new 
delivery models and opening new clinics as demographics suggest and 
resources allow. I am proud of the improvements in VA services in 
Hawaii, but recognize that our job is not done.
    Again, Mr. Chairman and other Members of the Committee, mahalo nui 
loa for the opportunity to testify at this hearing. I would be 
delighted to address any questions you may have for me or other members 
of the panel.

    Chairman Craig. Thank you very much, Dr. Perlin. You 
mentioned in your testimony that VA does send a primary care 
physician and a nurse practitioner to Molokai once per month, 
and a psychologist to the island twice per month, to provide 
service to veterans who reside there.
    What kind of service does the traveling staff generally 
provide? Is there an advance schedule of their travel published 
so that all veterans on the island know of the staff's 
impending arrival?
    Dr. Perlin. Thank you, Chairman Craig, for the question. In 
fact, I asked that question this morning when we had the chance 
to visit the Maui CBOC. In fact, the nurse practitioner and the 
primary care physician provide just that, general medical care. 
They make appropriate referrals where that is necessary.
    Captain McNamara, the psychologist, provides individual 
psychotherapy and support services, outreach counseling, across 
the range of mental health diagnoses. Again, she also makes 
appropriate referrals. I know, as was alluded to here, she also 
looks forward to Dr. Springer coming back to the Maui CBOC to 
be part of the mental health team.
    We realize that that is one way of extending our outreach, 
is to provide the services with physicians, psychologists, who 
travel. But we also look forward to extending the reach of 
telehealth as one of the important ways to help provide 
additional support.
    We do publish a schedule annually of the times that the 
medical team is there. But one of the other things that we also 
discussed that the clinic does is that they send a letter 
individually to each patient to just reaffirm particular 
appointment times.
    Chairman Craig. Well, thank you. One of the gentlemen who 
testified on the first panel mentioned that there were some 
difficulties experienced by some of his friends in obtaining 
quick and accurate travel reimbursement from VA for his visit 
to--I think this was to Honolulu for services.
    Can you or someone else on the panel here give me an idea 
of what the process of beneficiary travel reimbursement is 
like, and what turnaround time there is on these claims?
    Dr. Perlin. Let me just note that, in fact, the backlog of 
claims has been worked down so that once the claim is received, 
it should be less than 30 days. But let me ask Dr. MacBride to 
elaborate on the current process.
    Dr. MacBride. Thank you very much. Thank you, Dr. Perlin.
    Patients who have had authorization for travel then have 
the opportunity to submit travel claims for reimbursement. 
Typically, we receive those requests for reimbursement anywhere 
from 6 to 8 weeks after the travel has occurred, sometimes 
sooner.
    From that point on, it takes us about 30 days in 
processing. As Dr. Perlin mentioned, we did have a backlog for 
a while in our claims processing. So once we are in receipt of 
completed claim with a receipt, we are able to refund the 
veteran within 30 days.
    Chairman Craig. Dr. MacBride, if you would explain to me, 
and maybe to the audience, what designates--I believe you used 
the word certified travel--or authorized travel. Yes. How is 
that established?
    Dr. MacBride. Well, travel for veterans that is going to be 
reimbursed by the VA is authorized ahead of time. Typically, 
our travel benefits include travel for service-connected 
conditions.
    Chairman Craig. So in other words, that's known in advance 
by the veteran who's traveling to seek services, whether he or 
she has been authorized----
    Dr. MacBride. That's correct.
    Chairman T4raig [Continuing]. To receive reimbursement?
    Dr. MacBride. That's correct, sir.
    Chairman Craig. Dr. Perlin, you mentioned in your testimony 
that VA purchased approximately $250,000 worth of care and 
services from Molokai General Hospital for veterans residing 
there.
    What criteria governs the decision to purchase care locally 
on the island as opposed to having veterans travel to other 
places for care, and are those standards for Hawaii any 
different than any of the other States?
    Dr. Perlin. Mr. Chairman, that is a great question. And in 
fact, there's absolutely no difference in the way that one 
makes a purchase or provides service decision or [inaudible] 
decision. It comes down to this. If the veteran has an 
emergency situation, and those are emergencies to a reasonable 
person--someone who has chest pain--then we buy those services.
    You know, when there is some time there, we really do 
appreciate when the veteran calls to make sure that we can 
coordinate services as well as possible. These are small 
communities. Doctors and nurses and psychologists and others 
know each other. So that if there's an urgent situation or 
emergency, we will purchase those services.
    We won't purchase the services, A, if they're not available 
because they're not available of the island of Molokai, for 
example, itself; or when in fact we know that it's not an 
emergency or urgent situation, and we not only have the 
services, but by virtue of the electronic health record and the 
continuity and quality that both you and Senator Akaka alluded 
to, we can provide those services within VA. So emergency or 
urgent, we purchase otherwise services that we would provide 
ourselves.
    Senator Akaka. Dr. Hastings and Dr. MacBride, as you know, 
last year I introduced legislation to formalize what VA is 
already doing on Molokai and to increase access to VA care.
    I understand that VA sent a team to Molokai to review 
certain options. Will you please describe those options? Have 
there been any attempts to coordinate with Mr. Helm's group, 
Molokai Veterans Caring for Veterans, as they have identified 
land to build a center for veterans on the island that could 
potentially house a part-time clinic or, at the very least, 
space to house tele-ealth equipment? Please make your remarks 
on this.
    Dr. Hastings. Senator, Dr. MacBride is part of that group. 
So I've asked him to respond to your question.
    Senator Akaka. Dr. MacBride?
    Dr. MacBride. Thank you, Dr. Hastings. Thank you, Senator 
Akaka. I want to thank also Mr. Larry Helm and Mr. Manny Garcia 
and Dr. Dave Hafermann and several other Molokai veterans who 
not only joined us on that day, but provided us with some very 
interesting insights into care and conditions on Molokai that 
helped us enormously.
    As was mentioned earlier, for a number of years now staff 
from the Maui CBOC have been traveling to Molokai to provide 
services in a rural health clinic located on the grounds of 
Molokai General Hospital. I think that it's worth mentioning--
some of them haven't been mentioned today--a person who really 
went forward first was Kathy Haas, CNS who at the time was our 
nurse practitioner in the CBOC in Maui and now coordinates the 
management of all of our CBOCS.
    [Applause.]
    Dr. MacBride. And then in addition, we have heard so many 
nice things said about Kathy McNamara, Dr. Jim Santoro, Rita 
Webb, and previously, Dr. Richard Rose, the psychiatrist.
    There on Molokai, what we did in fiscal year 2005, as Dr. 
Perlin testified, was to designate our presence at the Rural 
Health Clinic as an outreach of the Maui CBOC, an outreach 
clinic. With that official designation in VA, it allowed us to 
provide the electronic links to establish connectivity to the 
VA electronic patient record.
    This is extremely important because, in fact, this is 
really the lifeblood of our care, to be able to have the 
electronic record throughout VA so that the record is present 
wherever veterans travel. Veterans don't travel with the 
record. With that established, we have now gone forward, and 
Dr. Dave Hafermann, who was introduced earlier, a retired Air 
Force internist/pulmonologist--that's a lung specialist--will 
begin seeing veteran patients in the Rural Health Clinic using 
our electronic record in February of this year.
    In addition, VA, with its partnerships with Queen's Medical 
Center and the administration of Molokai General Hospital, will 
be using tele-health equipment that is in existence at the 
Molokai General Hospital. Further, we will augmenting that 
equipment with VA tele-health equipment.
    Now, it's fortunate that the Molokai General Hospital is 
linked to the State Tele-health Access Network, the STAN. That 
allows us to have the broadband that is necessary to do tele-
health transmissions.
    We were fortunate that day to review several other options 
and availabilities, and meet several of the physicians on the 
island. There is a federally Qualified Health Center in 
Kaunakakai, and there is Hui Malama with the Native Hawaiian 
Health Care System. We plan to work more closely with the 
Native Hawaiian Health Care System because they are expert at 
providing education for chronic diseases. We, in addition, are 
expert at providing tele-mental health for mental health 
services in general.
    So, in addition to our traveling people to Molokai, we 
intend to work with our new physician, Dr. Hafermann, 
physicians in the community hopefully by contract, and to 
augment services using telehealth.
    I also want to thank Larry Helms and Manny Garcia and Dr. 
Dave Hafermann for their service to veterans, and not only 
through the insights they provided to VA leadership, but also 
in showing us their plans for the veterans center. Our mission, 
of course, is to provide healthcare services to the 144 
veterans who Dr. Perlin mentioned have enrolled for care with 
us and are actively receiving VA services. We look forward to 
working closely with Mr. Helm and Mr. Garcia and the Koa Kahiko 
to explore and establish the best possible options for enhanced 
care for Molokai's veterans.
    Senator Akaka. Thank you very much for that response, Dr. 
MacBride.
    Dr. Perlin, your testimony indicates that VA does not plan 
to activate a formal clinic on Lanai. Can you explain some 
other ways that VA can improve access to care for veterans on 
Lanai? I am especially interested in hearing more about a 
federally Qualified Health Center that could benefit all 
veterans on Lanai.
    Dr. Perlin. Thank you, Senator Akaka, for that question. As 
with Molokai, the ability to improve services for the residents 
of that island occurs through more regularly scheduled visits 
and additional visits of staff, better coordination with the 
local providers in the community, and the use of telehealth, 
which we're exploring.
    All that said, I'm very excited, as well of its acceptance 
for a federally Qualified Health Center, and I would again ask 
to turn the microphone back to Dr. MacBride to elaborate on 
that discussion.
    Dr. MacBride. Well, thank you, Dr. Perlin. And before I 
forget, I would like to take the opportunity to thank you, 
Senator Craig, for coming all the way out to Hawaii in January, 
and Senator Akaka, for your remarkable leadership and 
assistance here with veterans here and the VA.
    The VA is very fortunate again on the island of Lanai to 
have discovered recently that we have the opportunity to work 
together with partners and friends. Mr. Tom Driskill, who 
testified yesterday in Kauai and who is the CEO for the Hawaii 
Health Systems Corporation, and Mr. Ray Vera from Straub Clinic 
and Hospital, recently discussed with us the opportunity to 
collaborate together.
    On Lanai, the hospital is administered by Hawaii Health 
Systems Corporation, and they have the outpatient building in 
which Straub Clinic houses two physicians who practice medicine 
and also do emergency services at the hospital.
    There is a plan, with VA in collaboration, to apply for a 
federally Qualified Health Clinic and to add much-needed 
women's services to the island--and I think Mr. Obado testified 
to the importance of having services for women as well--and 
also to partner with Native Hawaiian Health Care System in 
their remarkable ability to provide education for chronic 
diseases.
    We very much want to partner with these individuals 
amenities. We want to be able work with physicians onsite who 
can see our VA patients and take care of VA patients in the 
event of an emergency. But we also want to augment mental 
health services in which VA is so outstanding. So we intend to 
provide tele-mental health services for patients of this 
consortium with whom we work. In addition, our partners have 
spoken with us about the possibility of supplementing some of 
the specialty care, and we will study that as well.
    Senator Akaka. Thank you very much for your response, Dr. 
MacBride.
    Dr. Wiebe, I have concerns about the Maui clinic and other 
clinics around Hawaii restricting specific healthcare services 
such as home care, based upon disabilities status rather than 
clinical need. I am glad that VA is reviewing this situation. I 
know they are.
    I need a commitment from you that when these restrictions 
are lifted, that new dollars will flow from the network to 
Hawaii to cover these costs. But we'd like to hear your 
thoughts about this.
    Dr. Wiebe. Thank you, Senator Akaka. As you know, the 
Pacific Islands Health Care System is one of six healthcare 
systems that comprise the VA Sierra Pacific Network. One of my 
responsibilities as network director is to make an allocation 
to each facility at the beginning of each fiscal year.
    Since I have been network director and have had the 
privilege of doing so since 1998, budget at the VA Pacific 
Island Health Care System has increased from approximately $53 
million to, last year, about $105 million. The portion of that 
budget that is allocated by my office to Hawaii, has increased 
over this period of time by 85 percent, while the network 
budget, as a whole, has increased about 70 percent.
    I expect that the budget here in Hawaii for fiscal year 
2006--that allocation has not been made yet--that the 
allocation will be higher than the previous year. In general, 
we do not allocate money for individual programs, but instead 
rely on each individual medical center and healthcare system to 
make those choices based upon what they know the local 
conditions and the local needs to be.
    You're absolutely correct in that we were, here, 
incorrectly and inappropriately restricting care. That since 
has been corrected, and I fully expect that additional 
resources will be spent on non-institutional care specifically 
in the home healthcare programs.
    Senator Akaka. Thank you very much, Dr. Wiebe, for your 
response.
    Dr. Perlin, vision impairment, as you heard from Dr. 
Kekahuna, services provided veterans are below par in Hawaii, 
and he compared some services he received on the mainland.
    What can be done to improve this situation?
    Dr. Perlin. Well, thank you, Senator Akaka, for that 
question on care for veterans with blindness or low vision. I 
need to tell you that this is not a theoretical question for 
me. My grandfather was a blinded veteran, and something I feel 
very passionately about. This is also not the first opportunity 
that I've had the privilege of meeting Dr. Kekahuna or some of 
his colleagues.
    I think the opportunities to improve care here in Hawaii 
are not significantly different than some of the opportunities 
to advance for the care for veterans with blindness and low 
vision. There are really two things that I think we need to 
think about in caring for veterans with blindness or low 
vision.
    First is the proximity, but the second is the mode in which 
the veteran acquired blindness. The veteran who experienced the 
immediate, traumatic loss of vision is one circumstance. The 
other circumstance is one that's becoming all too prevalent 
today: Older veterans, or even some veterans who aren't all 
that old, who have the ravages of diabetes or macular 
degeneration.
    And in fact, for the veteran who's had a sudden and 
catastrophic loss of vision, a very intensive inpatient setting 
which has a great deal of experience, such as in a Blind Rehab 
Center, is really the best way to reorient them to higher 
function, given the trauma of recent blindness.
    I'm pleased that Dr. Kekahuna had such a good experience at 
the Western Blind Rehabilitation Center, which is one of 10 
national referral centers for veterans that are scattered 
around the country. We just opened a brand-new Blind Rehab 
Center at Hines where Dr. Kekahuna has also experienced their 
care. This is a shining example of the promise of the Cares 
program and the best we can offer veterans. It is a premier 
facility anywhere in the world.
    That doesn't answer the mail, though, for the veteran who 
has the gradual loss of vision and needs some support in his or 
her community. In fact, Ms. Cynthia Yosuda is dual-hatted right 
now. She is the visual impairment coordinator, and she in fact 
needs to be given more time to provide services and outreach.
    This is one of the areas where I think we can improve care 
here in Hawaii, which is to provide that dedicated time and 
those important services. I've become aware that there are some 
equipment needs that are actually fairly modest, and we can 
provide that as well.
    The optometrists do travel, not only to Maui, but Kona and 
Hilo and Kauai as well. And we do hope to coordinate with the 
wonderful program that is here in the State that provides 
services for all residents of the State. But that's not enough. 
We're also hiring an ophthalmologist who will begin to make 
rounds, and I'm pleased to report that that individual will be 
part of the team here in VA Pacific Islands Health Care Systems 
in 60 days.
    Finally, sir, I think one of the best ways to address 
blindness is to prevent it. I couldn't be more proud of the 
high-quality care provided by VA in terms of treating diabetes 
so well and preventing the really horrific complications, such 
as loss of vision.
    Senator Akaka. Thank you very much, Dr. Perlin, for that 
response. And I noted in your testimony that VA is working to 
establish telehealth capabilities on Molokai. Do you have an 
idea about the timeframe on that?
    Dr. Perlin. We look forward to seeing the telehealth in 
operation in April. And I'm also pleased to report that VISN 21 
and the VA Pacific Islands Healthcare System applied for some 
funding for telehealth and its support of tele-mental health--
and I'm pleased to share a little bit before the announcement, 
but I want to thank Chairman Craig and Senator Akaka for their 
support of the mental health initiatives to make this 
possible--$200,000 to support personnel to operate that 
equipment in such areas as tele-mental health.
    Senator Akaka. Thank you. I have two more questions, Dr. 
Perlin.
    VA in Hawaii falls under the Sierra Pacific Health Care 
Network, which includes some very large tertiary facilities in 
California. Given the competing demands for resources, how do 
you believe VA Hawaii is faring?
    Dr. Perlin. Well, Senator, I think Dr. Wiebe mentioned that 
the budgets for the VA Pacific Islands Health Care System 
increased from $53 million to nearly $105 million over this 
last 5-year period, roughly doubling. And so it's fairly clear 
to me that Dr. Wiebe, in making allocation decisions, 
understands and appreciates the needs for services here in 
Hawaii and neighbor islands.
    I think the budget is good. As both you and Chairman Craig 
and Secretary Nicholson challenge us, our goal is to make sure 
that those resources go as far as possible in treating as many 
veterans as possible, as well as possible.
    Senator Akaka. Thank you. And my final question is one 
about long-term care needs. Testimony given at yesterday's 
hearing on Kauai pointed to the significant gaps in long-term 
care services provided to Hawaii's veterans due to the 
geography of our State.
    What is the VA doing to meet long-term care needs on Maui 
and throughout all of Hawaii, both in terms of nursing home 
care and home-based care?
    Dr. Perlin. We appreciate the opportunity to discuss the 
long-term care. And clearly there are here some veterans who 
are not safe or don't have social support and need 
institutional long-term care.
    I recall your support and that of this Committee for 
building the Center for Aging on the Tripler campus, and it's 
really a remarkable institution. It provides care for up to 60 
veterans. And I know that it's been running very full, 56 
veterans on average.
    I'm very, very excited, again, about the leadership that's 
been shown in the State of Hawaii to build the new State 
Veterans Home in Hilo. This is a very exciting proposition. 
It's a partnership with the State. VA provides two-thirds of 
the funding for up to $20 million, and we look forward to this 
facility opening in the spring of 2007, again providing 95 
additional beds.
    VA contracts for care in a couple of other community 
nursing homes. We do have some challenges in terms of the 
institutional care in that any of facilities either don't meet 
VA's life safety standards, which we consider absolutely 
critical, or they haven't been willing to contract with us.
    We really hope to get Dr. Michael Carrithers, who was here 
yesterday and is the Associate Chief of Staff of the Pacific 
Islands Health Care Systems for Geriatric and Extended Care, 
together with Mr. Driskill, to see what sorts of discussions 
might bear.
    Turning to the non-institutional care, this is really such 
an important area. It's an area where we've had to preserve not 
only community relationships but, as in the case of so many 
World War II veterans, spousal relationships of 50 or 60 years.
    The use of technologies that allow us to make sure that the 
veteran is doing OK, that their breathing is OK, that their 
weight is OK, that their blood sugar is OK, that they're taking 
their medicines, that they're not hungry, are technologies that 
are not science fiction. They're technologies that we use 
today.
    They're technologies that preserve that spousal and 
community relationship under technologies which also extend the 
dollars. And I'm very proud of the tremendous increases that 
are being shown here in Hawaii, which not only offer all of the 
social advantages, but also transcend and get beyond the 
barrier of that great ocean that separates the islands.
    Senator Akaka. Thank you so much for your response. I want 
to especially thank Dr. Hastings and Dr. MacBride for 
responding to my repeated, really repeated requests for 
addressing access to care, and those issues on Maui and on 
Molokai and Lanai. I really am happy to have learned of your 
efforts to include access to care for rural veterans as well.
    I appreciate Dr. Perlin's and Dr. Wiebe's response to these 
needs as well. I also thank Cathy Haas and Dr. McNamara for 
what you do every day to help the veterans of Maui County. And 
I want to thank this panel very much for coming to Hawaii and 
responding as you have to our questions here. That without 
question will make a huge difference for all veterans in 
Hawaii.
    I also want to remind you that we have a table in the back 
of the room where we have staff, both from the VA, as well as 
our staff, who are there to take any questions or concerns that 
you may have. Remember that if you're wanting to testify and we 
don't have it on the agenda, you are welcome to give us a 
statement or arrange to give a statement to us. And we'll be 
glad to direct it.
    So again, I want to say thank you so much to this 
distinguished panel that's before us. Also, before I quit here, 
I want to say mahalo nui loa to Lupe Wissel, who sits on this 
side of the Chairman, and to Noe Kalipi, who sits on this side, 
on my side. I also want to thank the Committee staff, Kim 
Lipsky, Dahlia Melendrez, and Alex Sardegna, who organized this 
morning's hearing. Thank you so much because it really went 
well.
    And mahalo nui loa for making this a great hearing, Mr. 
Chairman.
    Chairman Craig. Well, Danny, thank you very much.
    Ladies and gentlemen, my fellow citizens, I am here today 
and the Committee is here today because of Danny Akaka. He is a 
gentleman and a soft-spoken person, but one of the loudest 
advocates you have in Washington, DC.
    [Applause.]
    Chairman Craig. And you watched a classic case this morning 
of Senator Akaka working with this panel to get them to assure 
you and him that the services he has consistently requested for 
you are being looked at and/or are en route toward being 
supplied. That role he plays on behalf of all of you in the 
State of Hawaii is a very active one, and I congratulate Danny 
for his advocacy.
    Let me also mention one of you in your testimony of the 
first panel. You referred to him as a Senator. He is not. He is 
a Congressman, Congressman Buyer, who is Chairman of the 
Veterans Affairs Committee in the House. He's been in a bit of 
controversy of late in discussing how he would handle what had 
been traditional hearings by the service organizations who come 
to Washington annually to advocate on your behalf, but also to 
examine the budgets as proposed by the administrations and the 
Veterans Administration itself as it relates to its adequacy.
    He and I disagree as to how those hearings ought to be 
held. Please understand me very directly: All veterans service 
organizations will be heard. We will hold those hearings on the 
Senate side. Other hearings will be held on the House side. But 
rest assured, all veterans service organizations who come to 
Washington to testify before the appropriate authorizing 
Committee--that's this Committee--will be heard in complete 
forum as to the record they want to build.
    [Applause.]
    Chairman Craig. Let me also thank this panel, Dr. Perlin 
and his associates, for being here, for the work they do. I've 
had the privilege of getting to know these gentlemen, work very 
closely with Dr. Perlin and of course Robert Wiebe, and I'm 
getting to know these other gentlemen. And they live their 
profession on a day-to-day basis. They are without question 
your greatest advocates.
    While there may be times when they make tough choices, 
that's also their job as it relates to how resources get 
allocated and where resources go. They live with you on a day-
to-day basis. They are committed as no other professionals I 
have ever met as to the services they provide and the 
responsibilities they've undertaken with the titles of the 
positions that they hold. I honor them for that. They should be 
recognized for that quality of work.
    Let me also recognize, as Danny did, Lupe Whistle, who's 
the staff director for the Veterans' Affairs Committee to my 
immediate right; Billy Cahill in the back, an associate who, 
between us all, keep these folks on their toes; because the 
relationship of Government is a lot of oversight and checks and 
balances. That's the character of our system and why it works, 
frankly, as well as it does.
    The administrative side, the legislative side, the 
policymaking side, the budget-shaping side. That's Danny's 
responsibility. That's my responsibility. The administrative 
side is to take that policy and the resources and bring it to 
the ground to provide the services for us to oversight and to 
view and to correct or adjust as time goes on and the 
situations occur, and as you react to us, as you should in a 
representative republic, in the way you have with your presence 
here today.
    We thank you all very much for coming out and spending your 
morning and early afternoon with us. And again, Danny, let me 
thank you for inviting me and the Committee to your great 
State.
    [Applause.]
    Senator Akaka. Mahalo. Mahalo nui loa, Mr. Chairman. Larry 
and I, as you can tell, work very well together. And many of 
our successes in the Committee are due to him. And so he has 
done well for the veterans across the country.
    But I want to particularly thank him for sacrificing the 
few days that he has to come to Hawaii and join us with this 
hearing. He has made a huge difference. And I want to thank him 
for his generous remarks and wish him a safe trip, and his 
staff also, when they finally go back to Washington, DC. Larry, 
I can't thank you enough for helping us out here. Mahalo.
    [Applause.]
    Chairman Craig. Thank you. The Committee will stand 
adjourned.
    [Whereupon, at 12:28 p.m., the Committee was adjourned.]

                      A  P  P  E  N  D  I  X    1

                              ----------                              

  Prepared Statement of Patricia Absher Ross on Behalf of Her Husband 
                John William Ross, Jr., LCDR, USN, Ret.
    I, Patricia Ross, am a Veteran of the United States Cadet Nurse 
Corps, sworn into service March, 1944. I received tuition, maintenance, 
textbooks, Summer and Winter uniforms and stipends, and signed to stay 
in essential nursing until the war crisis was over. I was released from 
that commitment in March, 1947, the nursing shortage declared over.
    We are registered and included in the Women Veterans' Memorial, 
Arlington National Cemetery, Washington D.C., the only Congressionally 
mandated memorial to honor all military women-all wars--all grades--all 
periods of time from the Revolutionary War to present day and beyond. 
It is with that service background that I rise to speak-up for my 
husband, John Ross, and thank you for allowing me the opportunity and 
honor to do so.
    Specifically, I would like to address the issue of the inequity of 
access to care for the many underserved veterans needing care, in Maui 
County so they can be supported and be with family and friends, at a 
critical, frightening, stressful time in their lives.
    John has numerous health problems that require Specialists' care 
and monitoring. We have chosen to pay for Kaiser Permanente Senior 
Advantage program and use them as our primary care. Because of 
moderately severe Dementia and being blind, John must stay in familiar 
surroundings to avoid panic and air travel is not for him. What we seek 
from the Veterans Health Care System, is help with expenses for 
Intermediate Day Care and Long-term Care, when it will be needed at 
home, here on the Island of Maui, where we have been for 29 years.
    Medical expenses have been very high this year, with needing to 
have full time care for John' while his wife was hospitalized with four 
cardiac surgeries, (February to mid-July). John cannot be left alone. 
This was an unplanned expense for an exhausted wife, Caregiver!
    Nearly 300, Disabled Veterans in Maui County face similar problems.

                             BRIEF HISTORY
    John entered service in the U.S. Navy on March 31, 1941 and was 
honorably discharged on July 31, 1961. He served in the Navy as a 
career Engineering Officer (EDO) for over 20 years. He was classified 
as 100 percent, service-connected disabled effective February 26, 2002, 
based on diagnosed Asbestosis some years ago, as John developed a 
malignant lesion in his lung.

------------------------------------------------------------------------
              Cause                     Problem       Medical Monitoring
------------------------------------------------------------------------
Ship repair, inspection,          Lung cancer.......  Pulmonary
 construction, mothballing                             specialist
 constant exposure to asbestos.
Dry-docked radioactive Ships at   Skin Cancers,       Dermatologist
 SFNaval Shipyard from atomic      colon cancer.      Surgeon/Oncologist
 tests at Bikini Atoll, 1948.
Numerous head injuries Normal     Normal pressure,    Neurologist to
 Pressure Starting with 2 falls    hydrocephalus.      monitor shunt
 down Hydrocephalus Darkened                           placed in brain.
 submarine Hatches.
Knee deterioration  2..  Knee Replacements   Orthopedic checks
                                   (2).
Vision: Aging...................  Blindness due to    Ophthalmologist,
                                   Ophthalmologist,    checks
                                   Q2mos.
Prostate problems...............  Elevated psa (28).  Urologist
------------------------------------------------------------------------

    The cost for the medical care was covered by the Kaiser Insurance 
we have held for many years and will keep as our Primary Care.
        difficulties encountered with maui veterans health care
    Full access for Veterans to have VA Health Care on Maui, Lanai and 
Molokai, and provisions for intermediate and long term care, at home or 
in facilities ON ISLAND does not exist. Numerous agencies and qualified 
medical personnel are present and could provide much of the care if the 
VA would contract with them.
    John's greatest fear expressed to the VA Gerontologists on 12/15/
05, was what would happen to him if something happened to his wife, 
first! The doctors assured him that he would be taken care of, but in 
HONOLULU.
    It is hard to accept that John would be sent off island, away from 
his home, friends, and familiar surroundings to a more confusing, 
unfamiliar place, blind, with mobility problems, worried about his wife 
of 58 years and no way to keep in touch. He is very frightened.
    Reasons given for not contracting on each island vary from:
    (1) Excessive pages of redundant paper work required by the VA
    (2) The VA is slow in paying and the care facilities cannot carry 
the debt.
    (3) The Veterans are not organized to demand change.
    (4) The Veterans are considered a ``sub-group'' among the numerous 
health Agencies planning long-term care for Seniors and Disabled.
    There re over 13,000 veterans in Maui County.
    (5) Permission needed from the VA to participate and there is a 
lack of funds.
    (6) ``SPEND DOWN your assets and apply for MEDICAID, as that system 
is being used and in place and easier to administer.

                           INTERMEDIATE CARE
    A plea for VA to contract with Maui Adult Day Care Center. John has 
found an incentive to do more than stay in his recliner despairing over 
his loss of vision. He attends MADCC 5 days a week where he has found 
new friends, activities, exercise and new interests. It is a safe 
environment where his self-worth has been restored as he helps others. 
``Health'' is more than physical rehabilitation, the mental, emotional 
social and psychological aspect is so important and present at MADCC. 
John has found a second home. MADCC have centers in Kahului, Lahaina, 
and Hana . Add ``Health'' to their name.
    In conclusion:
    Maui County's service members serving in Iraq and elsewhere are 
contacted and made aware of their Veteran Rights. Included is the Dept. 
of the Army's (DS3) disabled Soldiers Support System for the severely 
disabled. Soldiers include Reservists and National Guard and their 
families. Support is offered throughout notification, treatment and 
eventual return to home station and home destination. It is the home 
destination segment we should be concerned with. How and where will 
these veterans fit into the health care systems of the outer islands?
    Where will the funds come from to support on or islands, the VA 
Health Care that is available only on Oahu? You should not provide for 
the outer islands at the expense of care on Oahu, but you must find 
ways to provide better VA Health Care in Maui County. WE PLEAD FOR 
COMPASSIONATE SOLUTIONS!
    Mahalo for listening and for your caring.
                 Prepared Statement of Don Dickensheet
    Howzit from the island of Lanai and yesterday I got a copy of a 
letter from Mr. Obado about a hearing well please allow me to throw my 
2 cents in if I may as my name is Don Dickensheet and I have lived on 
Lanai since retiring from the Navy after 21 years in 1992 and let me 
first tell you that the only thing you can do successfully on Lanai 
when it comes to medical is die! Almost everything else you have to go 
to Honolulu for, don't get me wrong those of us who live here realize 
this and the pleasure we gain from living on this island outweighs a 
lot of the alternatives.
    In August of 2000 I like Mr. Obado suffered a cerebral aneurysm and 
have since then been stumbling along and in this day of the internet I 
don't feel I should have to sell my home here and move to some squalid 
apartment in San Diego to get my benefits, as we here on Lanai realize 
we are ALWAYS on the low end of the pecking order as they have vans in 
Honolulu to whisk all the guys living in the bushes on Nimitz highway 
up to the Sparky VA center to dry out for a few weeks most folks here 
just give up after awhile and I can understand their frustration 
getting up at 0 dark thirty to dial 1-800 numbers and talk to machine 
during normal working hours in DC. After my aneurysm I started thinking 
now that my life was ruined. Why had this happened and it took me 3 
years to prove to the VA that it was service connected because unknown 
to me the whole time I was on active duty I was growing a brain tumor 
which they failed to detect as it caused a hearing loss in my left ear 
and they never bothered to fully investigate the cause on my retirement 
physical so with only Bill Station to help me once a month I got busy 
and it took 3 years but I got it done and am now in the process of 
trying to get a grant to have a new bathroom made as when I first came 
home from the hospital I spent out of my own pocket for grab bars a new 
toilet etc. only to find out later on that the VA will provide it. To 
this date, we are still working on this and all I ever seem to get is 
forms requesting more forms? My rating decision has already been made 
and I don't know what the hang up is but since I refuse to play the 
Press 1 for English and press 2 to listen to goofy music game I guess 
it will take me another 3 years at least to get what I am entitled to. 
My heart goes out to the old timers here whose families would have to 
play these games when they pass away to get them buried here in our 
veterans cemetery.
    We NEED a central place here on Lanai where vets can go and 
actually speak to a human being who knows how to get their benefits. 
For example, I would like to see someone get hold of NALCO in Honolulu 
and see if regular logistic flights could be scheduled to all islands 
utilizing the C-12 aircraft which Navy pilots utilize while on shore 
duty to maintain flight quals and instead of flying in circles around 
the runway doing touch and goes how about flying to Molokai, Lanai Maui 
and the Big Island to pick up vets for their appointments in Honolulu 
saving the $200 plus. There are many ways that already exist within the 
system to accommodate us and in my case being retired military it 
really burnt me up to HAVE to spend $400 to go re-new my wife's ID card 
in Honolulu bet Dan doesn't do this? Also let me get back to the 
retired thing we military retirees give up a lot to live on outer 
islands as we don't get to buy cheap gas, food, and clothing and we all 
know this when we make the decision to live where we do but it really 
smarts when we cant even get the basic entitlements which we were 
promised and there are probably less than a dozen military retirees on 
this island but each one of us has to do something different to try to 
get our benefits as we know so much more how the system works than 
those vets who only were in for one hitch, they earned these benefits 
many paid with their own blood and to act as if they don't exist 
because they chose to live in a place that doesn't fit in the required 
block, example one form I use to get repaid my co-payments for 
Medication has DO NOT USE PO BOX on it for address guess the bean 
counters don't know that zip code 96763 is PO BOX ONLY I think I got 
that through their heads by telling them to dial 1-800- ASK-USPS its 
stupid stuff like this that cause delays for months! I for one would 
like to get all Vets on the same page here so we can get what we 
earned.
                 Prepared Statement of Francine Atwell
    I am the wife of a disabled vet and I have recently become disabled 
myself, due in part to my husband's severing PTSD.
    The VA provides very little support to veterans' families. On Maui, 
there is a women's/spouse group primarily focused on understanding our 
veterans PTSD but it is not enough, even though the meeting has been a 
very good start.
    First families pay the high-test emotional price sometimes even 
higher than veterans themselves for the veteran's injuries and illness. 
We need more help to withstand the stress that comes with long-term 
conditions.
    Second, the families are true first responders to our veterans.
    Given the opportunities to lean assertive training/communications 
skills or anger management techniques not for ourselves and for our 
vets. We can deal with our vets more effectively and as caregivers 
reinforce VA care.
    Supporting the families supports the vet in very cost effective 
way. Group meeting and classes are very expensive compared to the costs 
of hospital treatment and the effects of abuse and violence which is 
very real to many of us.
              Prepared Statement oF Sgt. Albert A. Newsham
    I want to know why the thousands of combat veterans are not 
permitted to collect ``combat related special compensation.'' I was 
forced to retired from the Army because of my wounds. I spent my time 
in combat. I spent 2 and half years in Army hospitals and I am 100 
percent disabled.
    Let's be fair, we did what you asked us to do. We went when you 
said Vietnam and our country needed us. Now it is time for you to step 
up and do the correct and honorable thing. Show us you can keep your 
word. Pass the legislation so men and women like me can receive the 
compensation we earned with our blood and tears and honor.

                        A  P  E  N  D  I  X    2

                              ----------                              


                 January 9, 2006--Hawaii Hearing, Kauai

 Prepared Statement of Jonathan A. Perlin, MD, PHD, MSHA, FACP, Under 
          Secretary for Health Department of Veterans Affairs
    Mr. Chairman and Members of the Committee, mahalo nui loa for the 
opportunity to appear before you today to discuss the state of VA care 
in Hawaii. It is a privilege to be here on Kauai--the Garden Isle--to 
speak and answer questions about issues important to veterans residing 
in Hawaii.
    First, Mr. Chairman, I would like to thank you for your outstanding 
leadership and advocacy on behalf of our Nation's veterans. During your 
tenure as Chairman of this Committee, you have clearly demonstrated 
your commitment to veterans by acting decisively to ensure the needs of 
veterans are met. In addition, I appreciate your interest in and 
support of the Department of Veterans Affairs (VA).
    I also would like to express my appreciation and respect for 
Senator Akaka, Ranking Member of this Committee. Along with his 
colleague, Senator Inouye, Senator Akaka has done so much for the 
veterans residing in Hawaii and other islands in the Pacific region. As 
I will highlight later, his vision, guidance and assistance have 
directly led to an unprecedented level of health care services for 
veterans, construction of state-of-the-art facilities in Honolulu and 
remarkable improvements in access to health care services for veterans 
residing on neighbor islands, including Kauai.
    Today, I will briefly review the VA Sierra Pacific Network that 
includes Hawaii and the Pacific region; provide an overview of the VA 
Pacific Islands Health Care System (VAPIHCS) and the VA clinic here in 
Kauai; highlight issues of particular interest to veterans residing in 
Kauai, including the availability of long-term care services, specialty 
care and access to the VA clinic from the west side of Kauai; and 
address any questions posed by Members of the Committee.

                  VA SIERRA PACIFIC NETWORK (VISN 21)
    The VA Sierra Pacific Network (Veterans Integrated Service Network 
[VISN] 21) is one of 21 integrated health care networks in the Veterans 
Health Administration (VHA). The VA Sierra Pacific Network provides 
services to veterans residing in Hawaii and the Pacific Basin 
(including the Philippines, Guam, American Samoa and Commonwealth of 
the Northern Marianas Islands), northern Nevada and central/northern 
California. There are an estimated 1.25 million veterans living within 
the boundaries of the VA Sierra Pacific Network.
    The VA Sierra Pacific Network includes six major health care 
systems based in Honolulu, HI; Palo Alto, CA; San Francisco, CA; 
Sacramento, CA; Fresno, CA and Reno, NV. Dr. Robert Wiebe serves as 
director and oversees clinical and administrative operations throughout 
the Network. In Fiscal Year 2005 (FY05), the Network provided services 
to 227,000 veterans. There were about 2.8 million clinic stops and 
24,000 inpatient admissions. The cumulative full-time employment 
equivalents (FTEE) level was 8,200 and the operating budget was about 
$1.3 billion, which is an increase of $378 million since 2001.
    The VA Sierra Pacific Network is remarkable in several ways. In 
fiscal year 2005, the Network was the only VISN in VHA to meet the 
performance targets for all six Clinical Interventions that directly 
address adherence to evidence-based clinical practice. The Network 
hosts 11 (out of 65) VHA Centers of Excellence-the most in VHA. The VA 
Sierra Pacific Network also has the highest funded research programs in 
VHA. Finally, VISN 21 operates one of four Polytrauma units that are 
dedicated to addressing the clinical needs of the most severely wounded 
Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans.

            VA PACIFIC ISLANDS HEALTH CARE SYSTEM (VAPIHCS)
    As noted above, VAPIHCS is one of six major health care systems in 
VISN 21. VAPIHCS is unique in several important aspects: its vast 
catchment area covering 2.6 million square-miles (including Hawaii, 
Guam, American Samoa and Commonwealth of the Northern Marianas); island 
topography and the challenges to access it creates; richness of the 
culture of Pacific Islanders; and the ethnic diversity of patients and 
staff. In fiscal year 2005, there were an estimated 113,000 veterans 
living in Hawaii (9 percent of Network total).
    VAPIHCS provides care in six locations: Ambulatory Care Center 
(ACC) and Center for Aging (CFA) on the campus of the Tripler Army 
Medical Center (AMC) in Honolulu; and community-based outpatient 
clinics (CBOCs) in Lihue (Kauai), Kahului (Maui), Kailua-Kona (Hawaii), 
Hilo (Hawaii) and Agana (Guam). VAPIHCS also sends clinicians and 
support staff from these locations to provide services on Lanai, 
Molokai and American Samoa. The inpatient post-traumatic stress 
disorder (PTSD) unit formerly in Hilo is in the process of relocating 
to Honolulu. In addition to VAPIHCS, VHA operates five Readjustment 
Counseling Centers (Vet Centers) in Honolulu, Lihue, Wailuku, Kailua-
Kona and Hilo that provide counseling, psychosocial support and 
outreach.
    Dr. James Hastings was recently appointed Director, VAPIHCS. Dr. 
Hastings has impressive credentials, including tenure as Chair, 
Department of Medicine, John A. Burns School of Medicine, University of 
Hawaii, and Commanding General at Walter Reed AMC and Tripler AMC. I am 
excited about the possibilities that his tenure as Director at VAPIHCS 
brings.
    In fiscal year 2005, VAPIHCS provided services to 18,300 veterans 
in Hawaii (8 percent of Network total). There were 194,000 clinic stops 
in Hawaii during fiscal year 2005 (7 percent of Network total), an 
increase of 36 percent since fiscal year 00. The cumulative FTEE for 
the health care system was 478 employees. The budget for VAPIHCS 
(including General Purpose, Specific Purpose and Medical Care Cost 
Funds [MCCF]) has increased from $53 million in fiscal year 1999 to 
$102 million in fiscal year 2005 (about 8 percent of Network total). In 
addition, VISN 21 provided over $20 million in supplemental funds to 
VAPIHCS over the past two Fiscal Years to ensure VAPIHCS met its 
financial obligations.
    VAPIHCS provides or contracts for a comprehensive array of health 
care services. VAPIHCS directly provides primary care, including 
preventive services and health screenings, and mental health services 
at all locations. Selected specialty services are also currently 
provided at the Honolulu campus and to a lesser extent, at CBOCs. 
VAPIHCS recently hired specialists in gero-psychiatry, 
gastroenterology, ophthalmology and radiology. VAPIHCS is actively 
recruiting additional specialists in cardiology, orthopedic surgery and 
urology. Inpatient long-term care is available at the 60-bed Center for 
Aging. Inpatient mental health services are provided by VA staff on a 
20-bed ward within Tripler AMC and at the 16-bed PTSD Residential 
Rehabilitation Program (PRRP) that was formerly in Hilo (now relocating 
to Honolulu). VAPIHCS contracts for care with DoD (at Tripler AMC and 
Guam Naval Hospital) and community facilities for inpatient medical-
surgical care.
    The current constellation of VA facilities and services represents 
a remarkable transformation over the past several years. Previously, 
the VAPIHCS (formerly known as the VA Medical and Regional Office 
Center [VAMROC] Honolulu) operated primary care and mental health 
clinics based in the Prince Kuhio Federal Building in downtown Honolulu 
and CBOCs on the neighbor islands that were staffed primarily with 
nurse practitioners. Senator Akaka and his colleagues in Congress 
approved $83 million in Major Construction funds to build a state-of-
the-art ambulatory care center and nursing home care unit on the 
Tripler AMC campus and these facilities were activated in 2000 and 
1997, respectively. VISN 21 allocated nearly $17 million from FY98-FY00 
to activate these projects. VISN 21 also provided dedicated funds 
(e.g., $2 million in fiscal year 2001) to enhance care on the neighbor 
islands by expanding/renovating clinic space and adding additional 
staff to ensure there are primary care physicians and psychiatrists at 
all CBOCs.

                               KAUAI CBOC
    VA operates a community-based outpatient clinic (CBOC), located in 
Lihue (3-3367 Kuhio Highway, Suite 200, Lihue, HI, 96766-1061). In 
fiscal year 2003, VAPIHCS spent $470,000 to renovate the clinic. The 
Kauai Vet Center is co-located with the clinic in Lihue.
    CBOCs, like the one here in Kauai, play a crucial role in the care 
of veterans in Hawaii. Since they are located in small communities, 
CBOCs have the feel of an old-fashioned doctor's office. Patients get 
to know their caregivers (in ways not possible in a large medical 
center) and clinic staff gets to know their patients, including their 
friends, military stories and even their grandchildren's names. Staff 
at the Kauai CBOC sees its role as not just caregiver, but also as an 
active participant in the local community. On its own time, staff 
participates in community events like Veterans Day, Fourth of July 
celebrations and December holiday festivities.
    The Kauai CBOC serves an estimated island veteran population in 
fiscal year 2005 of 5,420. In fiscal year 2005, 1,518 veterans were 
enrolled for care and 1,016 veterans received care (``users'') at the 
Kauai CBOC. The market penetrations for enrollees and ``users'' are 28 
percent and 18 percent, respectively, and compare favorably with rates 
within VISN 21 and VHA.
    The current authorized full-time employment equivalents (FTEE) 
level is 9.0, including a full-time primary care physician, 
psychiatrist and nurse practitioner, and all positions are filled. With 
this staff, the Kauai CBOC provides a broad range of primary care and 
mental health services. In addition, VAPIHCS provides specialty care 
services at the clinic by sending VA staff from Honolulu and other VA 
facilities in California. Services provided by clinicians traveling to 
Kauai include cardiology, nephrology, neurology, optometry, 
orthopedics, rheumatology and urology. If veterans need services not 
available at the clinic, VAPIHCS arranges and pays for care in the 
local community (e.g., Wilcox Hospital), Honolulu (including Tripler 
AMC) or VA facilities in California. In fiscal year 2005, VA spent more 
than $2.1 million for non-VA care in the private sector (i.e., not 
including costs at other VA or DoD facilities) for residents of Kauai.
    In fiscal year 2005, the Kauai CBOC recorded 6,024 clinic stops, 
representing a 35 percent increase from fiscal year 2000 (i.e., 4,457 
stops). The clinic has short waiting times for new patients with very 
few veterans waiting more than 30 days for their first primary care 
appointment.

                             SPECIAL ISSUES
    Long-term care. As a group, the veteran population is aging. 
Consequently, long-term care (LTC) services are a very important 
component of the continuum of care provided by VA. VA provides both 
inpatient LTC (i.e., institutional care) and non-institutional care 
(NIC). VA's approach to LTC is to provide extended care services in the 
least restrictive setting that is appropriate for the clinical 
condition of the veteran and his/her personal circumstances.
    As an alternative to inpatient LTC, VA has developed and fostered a 
variety of NIC programs. NIC includes Adult Day Health Care (ADHC), 
Contract Adult Day Health Care (CADHC), Home-based Primary Care (HBPC), 
Contract Home Health Care (CHHC), Homemaker/Home Health Aid (H/HHA), 
Home Hospice, Home Respite, Geriatric Evaluation and Management (GEM) 
Program and Spinal Cord Injury (SCI) Home Program. Secretary Nicholson 
and his predecessors authorized the expansion of VA's NIC services. The 
capacity of these programs has grown rapidly since fiscal year 1998 and 
VA is expecting a further increase of 18 percent in fiscal year 2006.
    This trend is also present in Hawaii. In fiscal year 2005, VAPIHCS 
recorded a NIC ADC of 108 patients, representing an increase of 38 
percent compared to fiscal year 2004 (i.e., NIC ADC 78.2 patients). In 
some locations in Hawaii, VA directly provides NIC services. In other 
venues, including Kauai, VA contracts for these services. The following 
table displays trend in VAPIHCS obligations for LTC services in the 
community.

                 Trend in Non-VA Expenditures at VAPIHCS
                                 [$000]
------------------------------------------------------------------------
                                                        Change  FY 2002-
   FY 2002       FY 2003       FY 2004       FY 2005         FY 2005
------------------------------------------------------------------------
                       Comunity nursing home (CNH)
------------------------------------------------------------------------
      $93          $280          $661        $1,047              442%
------------------------------------------------------------------------
                      Non-institutional care (NIC)
------------------------------------------------------------------------
      $97          $126          $191          $716              638%
------------------------------------------------------------------------

    The decision to ``make or buy'' is based on the clinical need for 
and availability of these services in the local community. These 
decisions are re-evaluated based on changes in workload and 
availability of resources. As an example, VAPIHCS currently operates 
HBPC programs in the Big Island (i.e., at its CBOCs in Hilo and Kailua-
Kona, but not in Kauai or Maui. VAPIHCS is currently reassessing the 
feasibility of adding staff at its CBOCs here in Kauai and Maui to 
provide HBPC.
    At the request of Senator Akaka, the Office of Inspector General 
recently began a review of access to NIC in VHA. Although its findings 
and recommendations are not yet available, I am already taking actions 
in Hawaii to ensure clinical and eligibility criteria are correctly 
applied. As an example, VAPIHCS had been inappropriately restricting H/
HHA services to veterans meeting the eligibility requirements for 
mandatory inpatient LTC as set forth in the Veterans Millennium Health 
Care and Benefits Act (Millennium Act), Public Law 106-117 (1999). 
These local eligibility restrictions have been rescinded.
    Nursing home care is reserved for situations in which the veteran 
can no longer safely be cared for at home. VA is committed to providing 
nursing home care to all veterans for whom such care is mandated by the 
Millennium Act (i.e., 70 percent or more service-connected rating or 
requiring nursing home care because of a service-connected disability). 
VA will continue to provide long-term maintenance care to other 
veterans on a discretionary basis as resources permit. VA provides 
inpatient LTC services directly in its nursing home care facilities, 
pays for nursing home care in communities and supports State Veterans 
Homes (with construction funds and per diem reimbursements).
    As noted earlier, VAPIHCS operates a long-term care inpatient unit 
in Honolulu. Recently, this 60-bed unit operates close to its capacity 
(e.g., in fiscal year 2005, the average daily census [ADC] was 56 
patients). VA has contracts with and places veterans in two community 
nursing home care units in Oahu. In fiscal year 2005, VAPIHCS spent 
more than $1 million in community nursing home (CNH) care-nearly 
quadruple the amount spent in fiscal year 2003 (i.e., $280 thousand). 
VAPIHCS is interested in expanding its CNH program, but unfortunately, 
the other community facilities (including those on Neighbor Islands) 
VAPIHCS has contacted do not meet VA's life and safety codes or are 
unwilling to fulfill the requirements of VA's CNH contract.
    VA is also providing funding and working with the State of Hawaii 
to build and activate the first State Veterans Home in Hawaii. The 95-
bed nursing home facility will be built in Hilo at the site of the 
former Hilo Hospital on the Hilo Medical Center Campus. The cost 
estimate for the project is $31 million and VA is contributing 65 
percent (i.e., $20 million).
    Specialty services. The size of the veteran population and number 
of VA patients limit the feasibility of having a large cadre of medical 
and surgical specialists based in the Kauai CBOC. Nonetheless, VA 
recognizes that some veterans in Kauai have needs that go beyond 
primary care and mental health. As I noted earlier, VA sends 
specialists from Honolulu and California to the clinic on a regular 
basis. Services provided by clinicians traveling to Kauai include 
cardiology, nephrology, neurology, optometry, orthopedics, rheumatology 
and urology. VAPIHCS also refers patients to the local community for 
care at VA expense (when eligibility criteria are met) and transports 
(also at VA expense when eligibility criteria are met) patients to the 
VA facility in Honolulu.
    VAPIHCS is utilizing telehealth technology to expand access to 
specialty care (e.g., dermatology). VAPIHCS estimates that telehealth 
services are provided more than 10 hours per week at the Kauai CBOC. As 
additional specialists are hired at the VA facility based in Honolulu, 
these clinicians will be able to travel to Kauai and further utilize 
telehealth technologies.
    West Kauai. Although Kauai is a relatively small island (i.e., 550 
square-miles), transportation on the island can be problematic. As an 
example, the driving time from the west side of Kauai to the VA clinic 
can be up to an hour. VAPIHCS estimates approximately 190 existing 
patients (i.e., ``current users'') live on the west side of Kauai. 
Consequently, it is not practical to establish a new clinic on the west 
side or rotate staff from the existing clinic. Instead, VA will work 
with community organizations, such as veterans' service organizations, 
and local government to enhance transportation options for veterans.

                               CONCLUSION
    In summary, with the support of Senator Akaka and other Members of 
Congress, VA is providing an unprecedented level of health care 
services to veterans residing in Hawaii and the Pacific Region. VA now 
has state-of-the-art facilities and enhanced services in Honolulu, as 
well as robust staffing on the neighbor islands and has expanded or 
renovated clinics in many locations. VA is bringing more specialists on 
board and preparing for the newest generation of veterans-those who 
bravely served in southwest Asia.
    VAPIHCS still faces several challenges, in part due to the 
topography of its catchment area. VAPIHCS will meet these challenges by 
utilizing telehealth technologies, sharing specialists, developing new 
delivery models and opening new clinics as demographics suggest and 
resources allow. I am proud of the improvements in VA services in 
Hawaii, but recognize that our job is not done.
    Again, Mr. Chairman and other members of the Committee, mahalo nui 
loa for the opportunity to testify at this hearing. I would be 
delighted to address any questions you may have for me or other members 
of the panel.
   Prepared Statement of Robert Shaw, National Legislative Chairman 
              National Association of State Veterans Homes
    Chairman Craig, Senator Akaka and other Distinguished Members:
    Thank you for the opportunity given to me to present the views of 
the National Association of State Veterans Homes before this hearing of 
the Committee on Veterans' Affairs. It is an honor to join you today on 
this beautiful island of Kauai to explore ideas and seek methods to 
better serve Hawaii's aging veterans with long-term care services they 
need and have earned through their service.
    I am presenting testimony today on behalf of the National 
Association of State Veterans Homes (NASVH), an all-volunteer, non-
profit organization founded over a half century ago to promote the 
common interests of State veterans homes and the deserving elderly 
veterans and their families that we serve. The membership of NASVH 
consists of the administrators and senior staffs of State-operated 
veterans homes throughout the United States. Our current membership 
includes 119 homes in 47 States and the Commonwealth of Puerto Rico. We 
provide nursing home care in 114 homes, domiciliary care in 52 of those 
locations, and hospital-type care in five of our homes. Our State homes 
presently provide over 27,500 resident beds for veterans, of which more 
than 21,000 are nursing home beds. I am here today as both the National 
Legislative Chairman of NASVH, an elected position I have held since 
the year 2000, and also as the Administrator of the State Veterans 
Center in Rifle, Colorado, where we provide skilled nursing care to 100 
veterans and family members each day.
    The State home program dates back to the post-Civil War era when 
several States established homes in which to provide domicile, shelter 
and care to homeless, sick and maimed Union soldiers and sailors. In 
1888 Congress first authorized Federal grants-in-aid to States that 
maintained these homes, including a per diem allowance for each veteran 
of twenty-seven cents ($100 per year per veteran). Over the years since 
that time, the State home program has been expanded and refined to 
reflect the improvements in standards of medical practice, including 
the advent of nursing home, domiciliary, adult day health, and other 
specialized geriatric care for veterans. For example, the facility that 
I manage in Colorado now includes a Special Care Unit for Alzheimer's 
and dementia patients, a growing need in this population. There are 
also now two State homes providing adult day health care, and a number 
of others are developing programs in this new discipline and other 
emerging approaches to delivering care in less restrictive settings.
    Today, the State home program is supported in two ways by the 
Federal Government: through per diem subsidy payments that help States 
cover daily costs, and construction grants to keep our homes up-to-date 
and safe for our patients and staffs. Subject to appropriations, VA 
provides construction matching-grant funding for up to 65 percent of 
the cost of constructing or rehabilitating homes, with at least 35 
percent covered by State funding commitments. The per diem program 
provides reimbursement to State homes, currently $63.40 for nursing 
home care, which is about 30 percent of the average cost to the States. 
Section 1741 of Title 38, United States Code, authorizes VA to provide 
a per diem rate of up to 50 percent of the States' average daily cost, 
but VA has not been able to bring the actual rate paid to our homes 
near this statutory cost ceiling.
    Mr. Chairman, as you well know, the last budget debate for fiscal 
year 2006 was a crucial one for the State home program. We want to 
thank this Committee, and especially you, Mr. Chairman and Senator 
Akaka, for the vital role you both played in defending the State home 
program during the budget and appropriations cycle just concluded for 
fiscal year 2006. Thanks to your leadership, as well as tremendous 
support and leadership from Senators Hutchison, Feinstein and others, 
the Administration's proposals to dramatically restrict per diem 
payments to only a small portion of the veterans currently in our 
homes, and to impose a moratorium on further construction funding, were 
soundly rejected. We are grateful that Congress spoke clearly and 
forcefully on theses matters in the Joint Explanatory Statement 
accompanying the Act:

          The conferees do not agree with the proposal contained in the 
        budget to alter the long-term care policies, including a policy 
        of priority care in nursing homes. The conferees have provided 
        with this total appropriation, sufficient resources to maintain 
        a policy of providing long-term care to all veterans, utilizing 
        VA-owned facilities, community nursing homes, State nursing 
        homes, and other non-institutional venues. The conferees expect 
        there to be no change from the policies in existence prior to 
        fiscal year 2005.

    We look forward to working closely with you in this New Year should 
we again face budgetary and legislative challenges during the Second 
Session of the 109th Congress.
    Today, however, we are focusing on how best to provide long term 
care services to Hawaii's veterans who need and deserve this care. As I 
stated previously, 47 States already have at least one state veterans 
home in operation, leaving just three states--Hawaii, Alaska and 
Delaware--which do not. Of course, as you well know, there is a new 95-
bed State veterans' home under construction in Hilo on the Big Island 
scheduled to open later this year that will substantially meet the 
needs of veterans residing on that island. In addition, long-term care 
and transitional rehabilitative services are being provided now on Oahu 
by a VA-operated, 60-bed Center for Aging, located at Tripler Army 
Medical Center. The VA Center for Aging will partially meet Honolulu-
area veterans' long term care needs, but additional resources will 
probably be needed on that island as the elderly Oahu veteran 
population continues to grow.
    There remain, however, significant gaps in long term care services 
to Hawaii's veterans due to the nature and geography of this great 
State. In particular, the Neighbor Islands, with their smaller overall 
veteran populations and physical separation, face a much more difficult 
challenge in trying to meet the needs of their frail, elderly veterans. 
For those living on Kauai, Molokai, Maui and other Neighbor Islands, 
the facilities at Hilo and Oahu simply are not realistic options. The 
question before this panel today is how best to meet these needs given 
the challenges we have identified and the inevitable budgetary 
constraints faced by VA and Congress.
    Under current law, as set forth in Public Law 106-117, the Veterans 
Millennium Health Care and Benefits Act, Congress established specific 
criteria for authorizing construction of new State homes. It is 
possible under VA criteria that Hawaii, in addition to building the new 
home at Hilo, could justify building another State home with about 120 
beds based upon its State-wide veteran population. However, given the 
unique island geography of Hawaii, with vast seas separating islands, 
as well as their rich cultural traditions, it would not be practical to 
expect veterans from close-knit families and communities on one island 
to leave their families and travel great distances to another island 
for long-term care. While the construction of a second State veterans' 
home somewhere in Hawaii might solve one island's problem for aging 
veterans, it would not adequately address their lack of long-term care 
services on other islands.
    For better or for worse, Mr. Chairman, Hawaii is not alone in 
trying to address the challenge of meeting the needs of geographically 
dispersed populations. Other large rural States, including, Alaska, 
Wyoming, Montana and Idaho, among others, face similar problems in 
trying to provide high quality and convenient long term care for 
veterans who live at great distances from larger population centers and 
major VA facilities. As Congress and VA seek to address this problem, 
it could prove beneficial for this Committee to look at how Alaska, our 
largest State, has managed this challenge.
    Over the years, Alaska's State government, Congress and Alaska's 
veterans' organizations have considered numerous proposals for that 
State to seek VA matching grants for the construction of State homes 
for veterans, but no concrete proposal was ever approved by the 
Governor or the State legislature. This is not to suggest that Alaska 
has no facilities serving older veterans in need of long-term care.
    Beginning in 1913 in the city of Sitka, the State of Alaska began 
operating what are called ``Pioneer Homes.'' Today, Alaska operates six 
of these homes providing more than 500 total long term care beds in 
Sitka, Anchorage, Fairbanks, Juneau, Ketchikan and Palmer. These homes 
provide nursing and residential care to ``Alaska Pioneers'' -- any 
Alaska citizen over age 65, in declining health, and in need of 
significant care for activities of daily living. These homes are 
supported by State funds, insurance reimbursements and private 
payments, very similar to the mixed financing arrangements of State 
veterans' homes. Although these homes are not solely reserved for 
veterans, about one-quarter of the residents are veterans of military 
service.
    In the past decade, Alaska's ``Pioneer Homes'' also have become 
licensed assisted living facilities, offering a comprehensive range of 
services to meet the needs of the elderly residents. Professional 
services cover the full range of needed care, including assistance with 
activities of daily living, skilled nursing, and compassionate end-of-
life services. Many Pioneer residents receive a level of service that 
would otherwise be delivered in a hospital, a traditional nursing home, 
a hospice, or in a home-based elder program under a Medicaid waiver 
arrangement Alaska reached with the Center for Medicare and Medicaid 
Services (CMS).
    In May 2004, Congress passed legislation to define the Alaska 
``Pioneer Homes'' as a single State veterans home for purposes of 
establishing eligibility for participation in VA's State home programs. 
Based upon this legislation, Alaska submitted a request for, and was 
approved for, the construction of a 79-bed veterans' domiciliary as a 
new wing to the existing Pioneer Home in Palmer, Alaska. Construction 
of this new wing began this past summer and is expected to be completed 
late this year.
    Similar to Alaska, Hawaii's dispersed veteran population on the 
smaller islands generally cannot justify construction of veterans' 
homes on each island. However, using the Alaska Pioneer Home concept as 
a foundation, it may be feasible to advance legislation deeming a 
similar status to the Hawaii Health Systems Corporation (HHSC)--as one 
``State veterans' home'' for purposes of HHSC's participation in the VA 
State veterans' home programs. The HHSC, a public benefit corporation, 
is an extensive hospital system of 12 facilities on five islands, and 
is the largest health provider in the Neighbor Islands. Under this 
scenario, smaller bed units--perhaps ten to thirty beds each, depending 
on local circumstances--could be justified under existing VA criteria 
in a manner similar to the Alaska model. Such projects could be 
developed as separate facilities within these existing State-owned and 
operated hospitals to accommodate the needs of elder and disabled 
Hawaii veterans in rural and remote locations.
    Mr. Chairman, like you, NASVH is committed to meeting the long-term 
care needs of veterans, whether they live in major metropolitan areas 
or in geographically dispersed areas such as these Neighbor Islands of 
Hawaii. Although Hawaii may not be able to cost-effectively justify the 
establishment of large, stand-alone State veterans' nursing homes on 
each of the Neighbor Islands, other creative solutions such as the 
Pioneer Homes model may be worth pursuing. NASVH stands ready to work 
with you, this Committee, Congress and VA to meet the diverse needs of 
veterans living throughout Hawaii, as well as other veterans living in 
large States such as Alaska, Wyoming, Montana, and Idaho.
    Mr. Chairman, Senator Akaka, and other Members the Committee, once 
again I want to thank you for allowing me to testify here today on 
behalf of the National Association of State Veterans Homes. We look 
forward to working with you and the Congress to strengthen, rather than 
weaken, this foundation of veterans' long-term care. The care provided 
by our member homes is an indispensable, cost-effective, and successful 
element in VA's provision of comprehensive health care. We are grateful 
for your past support and hope that should we see a repetition of the 
misguided budget proposals submitted by the Administration last year, 
that we can again count on your support. Millions of veterans are going 
to need long-term care in the years ahead. We want to be sure that the 
State home program is there to support them.
    Mr. Chairman, this concludes my testimony. I would be pleased to 
answer any questions you may have on this or other topics in which I 
might be helpful to the Committee.
             Prepared Statement of Edward Kawamura, Veteran
    To: Senator Craig, Ranking Member, Senator Akaka, and Members of 
this hearing.
    My name is Edward M. Kawamura. I am a Vietnam Veteran who retired 
from the U.S. Army in 1978. I have been involved with veterans and 
families as Department of Hawaii, Disabled American Veteran Commander, 
Kauai Veteran's Council President, Board Member Office of Veterans 
Services, and current Board member to the VA Advisory Board.
    The services that are provided by our VA are ``No. 1.'' The 
personnel at the Kauai Community Based Outpatient Clinic (CBOC) are the 
best. Their professionalism, dedication, and willingness to help, make 
them the best. Their rating by JACCO reflects their No. 1 rating. I 
applaud all the workers involved at the CBOC and VET Center.
    There are some improvements and visions that I would like to share 
as improvements and new programs for Kauai Veterans. They are as 
follows:
    a. Manpower. More manpower is needed. A Home Healthcare Nurse is 
needed. Our aging population, coupled with problems of getting veterans 
to the medical clinic, mandates the need to provide the care and 
services at the homes. This nurse would help in reducing time now 
serviced by our doctor and nurse practitioner so more veterans can be 
served and reduce scheduling time for appointments. Outreach programs 
are needed, and can be accomplished with more manpower. Increased 
manpower and services are needed also due to the increased veteran 
population returning from the Iraqi War.
    b. Facility. The CBOC has outgrown itself. The size and space for 
the waiting room, screening rooms, prescription vault and conference 
rooms needs to be increased. Parking is another area that needs to be 
increased. Recommendation: A new CBOC be constructed at the Kauai 
Veterans Center site. Parking is adequate and space is available for 
new building. This would make for a ``One-Stop'' veterans operation.
    c. Funding. More funds should be made available for travel as our 
VA has a huge geographic area to cover. All of these travels must be by 
air. Care servers, care givers, and patients are often required to 
travel to provide or receive services.
    d. Kauai Veterans Cemetery. Phase I expansion by the VA doubled the 
size of the cemetery. They did not provide for increase in manpower or 
equipment. This should be a factor included in future plans.
    e. Vision. The vision is that there should be an Old Soldiers Home 
of the Pacific here on Kauai. The aged veterans who have nowhere to go 
should be afforded a place to live out their lives. This is so we can 
accommodate the Pacific Rim veterans to provide for an environment 
similar to their lifestyles. The site location at Sam Mahelona Hospital 
has the ideal view and environmental elements for a good soldier's 
home.
    The Spark M. Matsunaga Medical Center is a perfect example that 
reflects the dedication by our congressional and your committee to our 
fellow veterans. This facility is ``No. 1.''
    I would like to thank each and everyone on your committee for 
taking time to hear our concerns. This is truly the only way to hear 
first hand the needs of our fellow veterans and their families. Thank 
you very much.
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  Prepared Statement of Thomas M. Driskill, Jr., President and Chief 
          Executive Officer Hawaii Health Systems Corporation
    Senator Akaka, and other distinguished Members of this Committee, 
thank you for this opportunity to testify before you in strong support 
of healthcare programs, services, and facilities that serve the 
approximately 118,000 Veterans living in Hawaii. Hawaii Health Systems 
Corporation (HHSC) is grateful for the opportunities to provide high 
quality healthcare services to Veterans at all 12 of our existing 
facilities located on five islands of Hawaii. The more than 3,400 
employees of Hawaii Health Services Corporation take great pride in 
caring for our State's Veterans. Soon, our role in caring for Hawaii's 
Veterans will be expanding to new heights when the 95-bed State 
Veterans Home is opened for operation and occupancy in 2007.
    As Hawaii's Veteran population continues to both grow and age, 
there is an even more critical need for long-term care services such as 
will be available in the state-of-the-art State Veterans Home that 
Hawaii Health Systems Corporation is building in Hilo. This 95-bed 
facility will significantly increase the number of long-term care (LTC) 
beds in east Hawaii and because they are earmarked specifically for 
Veterans and other eligible beneficiaries, we will be measurably 
improving the LTC access and capacity for our Veterans.
    Over the last 8 years, HHSC has enjoyed an outstanding, 
collaborative and very successful working relationship with the 
Department of Veterans Affairs-Hawaii, Washington, D.C., the VA Medical 
& Regional Office Center-Hawaii, the Office of Veterans Services, and 
multiple Veterans organizations across the State. Since 2001, HHSC has 
intensively worked with our VA partners to attain the first ever State 
Veterans Home for Hawaii, and now the fruits of that arduous labor will 
soon pay off with the opening of the State Home.
    We have recently selected and contracted with a nationally 
acclaimed management company to operate the State Home for HHSC. 
Community support both in East Hawaii and across the State for our new 
State Home has been strong and steadfast over the past several years, 
and we anticipate that this support will continue to grow as we get 
closer to opening the State Home. The synergy of a combined Federal and 
State funding of the Home has been the catalyst for making this dream a 
reality. We deeply appreciate Senator Akaka's tremendous support, as 
well as the tremendous support we received from Senator Inouye, 
Representative Abercrombie, Representative Case, Governor Lingle, our 
Hawaii State legislators, and our Hawaii Veterans organizations in 
making this State Home possible for Hawaii's Veterans.
    We would like to ask for one additional element of support from 
this Committee and that is to help ensure that the per diem rate for 
State Veterans Homes is NOT decreased at the Federal level. Decrements 
to the per diem rate of reimbursement to the State Veterans Home will 
have serious adverse financial consequences to the viability and 
sustainability of all State Veterans Home's operations.
    Thank you, Senator Akaka, for the tremendous support you continue 
to give to all of Hawaii's Veterans, and thank you for your sage 
leadership and the warm Aloha that you bring to our great State.
    Mahalo Nui Loa.
  Prepared Statement by Frank Cruz, President Kauai Veterans Counicl 
 Chairman for the State Office of Veterans Service Governors Advisory 
                                 Board
    Chairman Craig, Ranking Member, Senator Akaka, and Members of this 
Hearing: My name is Frank Cruz. I am a Vietnam Veteran and currently 
the President of the Kauai Veterans Council and Chairman for the State 
Office of Veterans Service Governors Advisory Board.
    The 95 bed Long Term Care Facility being build in Hilo is a welcome 
and long awaited project for our veterans living in the State of 
Hawaii. This Facility will help our veterans especially the World War 
II, Korean, Vietnam and our 100 percent disabled veterans here in 
Hawaii a much needed long term care place. However there are some 
question and information that needs to be decimated to all veterans 
wanting to apply for this facility.
    1. What are the criteria for any veterans applying for long term 
care?
    2. What will be the cost for the veteran and their family?
    3. This facility needs professional and trained caretakers, how 
will this facility be able to be self sufficient without putting the 
burden on the veterans staying in this facility?
    The Kauai Community Based Outpatient Clinic (CBOC) has provided top 
notch services to our veterans here on Kauai. There are some areas 
where much needed improvements are needed.
    1. Parking for this clinic is inadequate to accommodate for 
patients having appointment.
    2. How will this clinic be able to handle the influx of veterans 
coming from Iraq and elsewhere?
    3. The medical equipment must be up-graded to current standard.
    4. There is a need for qualified female to handle the needs for our 
women coming from Iraq and elsewhere.
    5. There is a need to increase manpower and services due to the 
increased of veteran population returning form the Gulf war.
    On behalf of the veterans on Kauai, I thank the members of this 
Committee for the time you have taken to listen to the concerns of our 
Island. Your commitment and efforts to our Veteran Community is greatly 
appreciated. Thank you very much.
   Prepared Statement of Colette V. Browne Professor, University of 
                      Hawaii School of Social Work
    Mr. Chairman and Members of the Senate Committee on Veterans 
Affairs:
    Thank you for the opportunity to participate in this hearing on 
long term care in Hawai'i, and the role of the Department of Veterans 
Affairs in providing this care.
    Mr. Chairman, we at the School of Social Work join in welcoming you 
to Hawaii. We appreciate your leadership and your commitment to working 
in a bipartisan manner to better understand how to ensure that the 
needs of older adults, specifically veterans, are met with accessible 
and affordable quality of care. I am professor and Chair of the School 
of Social Work's gerontology program. For more than fifteen years, I 
have served as a gubernatorial appointment to the State's Policy 
Advisory Board for Elderly Affairs. In this capacity, I learned a great 
deal from the older adults in our great State. I also speak to you 
today as the proud daughter of a World War II veteran. I will speak 
specifically about the availability of long-term care services in 
Hawaii.
    Long-term care refers to a range of support services provided in a 
variety of home, community, and institutional settings, and coordinated 
to meet the needs of people of all ages with disabilities or serious or 
chronic illnesses. Examples of these services range from personal 
assistance, transportation, home health, meals, nursing care, case 
management, and adult day care. Although these services are age-
irrelevant, research informs us that the primary consumers are older 
adults. Nationally, nearly 45 million Americans, or one in every six, 
are 60 years of age and over. Most older Americans are healthy, 
contributory members of society. Others, especially those over the age 
of 85 who compose the fastest growing cohort within the aging 
population, have become frail and are dependent on others for care. 
This dramatic shift in our nation's population has clear implications 
for long-term care, in part because older adults have more chronic 
ailments than do younger adults. Older citizens account for almost one-
quarter of hospital days in 2001, have a higher physician and hospital 
utilization rate, use 69 percent of home health services, and represent 
83 percent of nursing home residents.
    Mr. Chairman, Hawaii has one of the Nation's fastest growing aging 
populations. Today, there are 120,000 citizens who are 60 and over, or 
17 percent of our State's population. To put this in perspective, 
between 1970 and 2000, the older adult population increased by 207 
percent while the total population increased by 57 percent. Our life 
expectancy is greater than any other State--an average of 80 years 
compared to the Nation as a whole at 77 years. By 2020, an estimated 
400,000 residents will be over the age of 60, composing 25 percent of 
the State's population.
    To determine what the State's needs are and may be for long-term 
care, researchers estimate that 15 percent of citizens have limitations 
or disabilities that require some form of long term care. In Hawaii, 
this is estimated to be 31,000 people. It is important to note that of 
this population, 82 percent have annual incomes of less than $20,000. 
These are individuals most at-risk of needing public support for long-
term care.
    Similar to her sister States, Hawaii provides for its disabled and 
elderly citizens with a wide array of health and supportive care 
services provided in institutions, health care and social service 
sites, community based programs and in the home. Over the past twenty 
years, numerous reports and studies conducted by public and private 
entities have examined this issue of long term care for Hawaii. A 
review of these reports finds a great deal of agreement that the long 
term care system in general is: complex and fragmented, institutionally 
biased, lacking in its capacity for critical services, limited in its 
efforts to maximize Federal funding for programs for special needs, 
supports and services; limited in its agency awareness; and 
experiencing a shortage of adequately trained professional and direct 
support workers, especially in rural areas of the State.
    Long-term care is not only nursing home beds, although the very 
frail can be found needing this level of care. According to the Health 
Care Association of Hawaii, in 2003 Hawaii had fewer than half the 
national average of long term care beds per 1,000 population aged 65 
and over even though we have the fastest growing population in the 85 
and over group. The State's nursing facility median occupancy was 93.7 
percent. This same report found that Hawai has the most dependent 
nursing facility residents as measured by higher acuity in areas such 
as activities of daily living, mobility and medical support 
requirements. This results in the need for more resources to be 
utilized in these patients' care. Because of this higher acuity level 
of Hawaii's nursing facility resident, the average total nursing hours 
per patient day in Hawaii is 4.57 compared to 3.24 hours per day on the 
mainland.
    To finance existing services, Hawai'i relies on a mix of public and 
private funders and agencies, together with private and family 
resources. This is similar to the rest of the nation. Projecting into 
the future, the Hawaii Health Information Corporation's recent report 
on forecasting long-term care bed days in Hawaii found that Hawaii's 
aging population is and will continue to be a challenge for long term 
care service delivery as baby boomers age. This is because older adults 
are much more likely to require acute care hospitalization, long-term 
care, home care and hospice, placing heavy demands on the Medicare and 
Medicaid programs. This same report found that in both rural and urban 
settings in Hawaii, the increases in health care utilization are for 
age related disorders, such as heart disease, diabetes, cancer and 
stroke. In short, Hawaii 's citizens have the greatest longevity, one 
of the nation's most rapidly aging populations, the most ethnically 
diverse population, and, looking at Hawai'i's most frail--the oldest, 
sickest and most dependent nursing home population in the United 
States.
    Here in Hawaii, the Department of Veterans Affairs (VA) is a key 
government agency that provides services to veterans on all major 
islands. Nationally, the Department of Veterans Affairs is responsible 
for providing Federal benefits to veterans and their families. The most 
visible of all VA benefits and services is health care, providing a 
wide spectrum of medical, surgical, and rehabilitative care.
    Similar to all public and private agencies, the VA is challenged to 
meet the needs of this growing population. Unlike other States, Hawaii 
has two unique characteristics that impact the delivery of care. First, 
Hawaii's island geography compounds challenges related to access and 
utilization of services. As an island State, travel must be by plane or 
boat. Second, our multicultural population is unlike any other State, 
with a mix of 22 percent Caucasian, 22.8 percent Hawaiian, 11.7 percent 
Filipino, 16.4 percent Japanese, 16.3 percent mixed, 3.1 percent 
Chinese, and the category of ``other'' equal to 7.7 percent. 
Preferences, cultural values, and practices all influence health status 
and choice of care. Furthermore, 80 percent of our population resides 
on the island of Oahu, where most of our main government programs are 
provided. The State is challenged to ensure that all of its citizens 
receive equal care. In summary, Hawaii is one of the most ethnically 
diverse States, has one of the fastest growing aging populations in the 
nation, and its unique geography lends itself to specific challenges 
related to access and quality care issues.
    As the Nation grows older, Congress is presented with the needs of 
those who so well have served our nation. In turn, the VA works to meet 
the needs of its constituencies by responding to recent Congressional 
laws and mandates within its budgeted resources. This typically results 
in the prioritization of services. Inpatient rehabilitation, community 
care, respite services, palliative care and nursing home care are some 
of the long-term care services offered to veterans through the VA. On 
our neighbor islands, the VA operates community-based outpatient 
clinics in their attempts to meet needs. Some services, like homemaker 
and adult day care, are provided under the Uniform Health benefit to 
all veterans. Other services, such as nursing home care, are provided 
under the Millennium Law by contracted community institutions to those 
with service-connected disabilities.
    What we have learned is that veterans and non veterans appear to 
want the same thing when it comes to long-term care. A recent AARP 
study found that most adults prefer to receive care in their own home, 
are not confident about being able to pay for nursing home care; feel 
it is important for the government to help pay for long term care 
services, and support being able to decide about the kind of care they 
want to purchase. It is worth pointing out that it is not only the 
needs of veterans that must be considered, but those of their families, 
who have and continue to provide the bulk of long term care. Services 
to support families, then, must be part of our mix of long-term care.
    A critical need in which we at the University see the VA taking a 
key leadership role is the education and training of new professionals 
in geriatrics and gerontology. This is no small task, as the 
recruitment of new professionals continues to be a challenge. The 
Veterans Administration fulfills a critical and valued community need 
in its training of future geriatricians, geriatric psychiatrists, and 
geriatric social workers.
    Mr. Chairman, the problems around long-term care are huge, and 
clearly no one agency can do it alone. Long-term care requires 
collaboration. Throughout the nation, aging networks, health care 
providers and community services are joining together to promote and 
improve the well-being of older adults. A recent report, A Strategic 
Plan: On Achieving Outcomes on Creating a Legacy: Healthy Aging Project 
(2005-2009), a partnership among the Aging Network, Department of 
Health, and public and private agencies here in Hawaii, offered a 
blueprint for improving health of na kupuna--our elders. This report 
recommended that any venture to improve the health of our elders must 
be community driven, inclusive, community-owned, built upon existing 
community assets and infrastructure to ensure long term sustainability, 
and use evidence-based strategies. Ensuring the adequacy of the State's 
infrastructure to provide long-term care requires skilled and 
knowledgeable professionals and paraprofessionals committed to quality 
care. From a university perspective, we remain concerned about meeting 
future long-term care workforce needs. We therefore respectfully 
request Congressional support for the training and education of future 
professionals in medicine, nursing, social work and other related 
fields.
    In closing, a recent Summit on Long-Term Care organized by the 
Hawaii Institute for Public Affairs analyzed previous reports and 
studies, plans and data, and arrived at the following conclusion. The 
need exists to build the political will and gain greater community 
support for the issue of long term care. This hearing can hopefully be 
seen as a concrete step toward building both.
    The VA provides a number of critically important services for our 
veterans. Nonetheless, they face similar challenges that our State and 
private entities face: a growing aging population with increasing 
fiscal restraint. We are all here today because we understand the 
enormous sacrifice that our soldiers and their families make everyday 
to serve their country. The question is: Will the Nation be there for 
our veterans with the necessary long term care services when they need 
us? The mission of the VA is clear. Have we, in turn, provided them 
with the requisite resources to meet this need?
    I thank you for this opportunity to speak with you today, and I am 
happy to answer any questions.

  Prepared Statement by Lynn M. Aylward-Bingman, Capt (NC) USNR (Ret) 
   Member, Veterans Advisory Council to the Veterans Affairs Pacific 
                  Islands Health Care System (VISN 21)
    Chairman Craig, Ranking Member, Senator Akaka, and Members of this 
Hearing: I am Lynn Aylward-Bingman. I am a retired US Navy Nurse Corps 
Captain. Among other duty stations, I served at the Naval Hospital Guam 
in 1968--1969 caring for the air-evaced wounded from Viet Nam. 
Subsequently, while stationed in San Diego, I received my law degree 
and was a trial attorney for 23 years. I became involved with the 
Hawaii Veteran community when I came to Kauai, from California, nearly 
5 years ago. I am proud to represent our veterans as a member of the 
Veterans Advisory Council to the VA Pacific Islands Health Care System. 
In that capacity, my colleagues and I communicate to, and address, 
concerns of our Hawaii veterans with the Director of the VAPIHCS and 
the Regional VISN Director. We also liaison with the individual Island 
Veterans Councils. I am honored to speak on behalf of our veterans, 
particularly the Kauai veterans, at today's hearing, and to express 
some of our concerns with the State of veterans' health care in Hawaii.
    The citizens of Hawaii are the most patriotic and generous people 
I've ever known. This is exemplified by the fact that there are several 
Medal of Honor recipients among our Hawaii veteran community; and by 
the spirit of ``ohana,'' which is particularly strong in our veteran 
community. The ohana spirit is very important given the unique 
disparate and geographic nature of our Islands and the Pacific Region. 
It is far more difficult for our veterans to obtain full health care 
services than it is for our fellow veterans on the Mainland.
    We are very proud of the strides that have been made by the VA in 
Hawaii over the last few years, especially those on the Outer Islands 
such as establishment of Community Based Outpatient Clinics or 
``CBOCs''. Our Kauai CBOC staff are outstanding and do their best to 
provide a high quality of care to our veteran patient community. 
However, they are limited in the care they can provide by limited 
funding. We lack ``on Island'' VA specialists, certain equipment, and 
adequate staffing, among other things. There are three areas of concern 
I would like to address today.

                  SPECIALIZED TREATMENT/SURGICAL CARE
    At present, when a veteran needs specialized care for a cardiac, 
orthopedic, or serious dermatologic condition, for example, one of 
three situations will occur after being evaluated by our CBOC staff. 
The veteran will either: (a) be flown to Honolulu to see a specialist; 
(b) have to wait several months to get an appointment with one of the 
specialists who come to the CBOCs intermittently; or (c) obtain 
authorization to be seen by a local health care provider in the 
community. Telemedicine greatly assists our CBOC staff in evaluating 
some health issues, but does not eliminate the need for the veteran to 
actually be seen and treated by a specialist. Each of the above 
scenarios costs the VA money and, in the first two, also costs the 
veteran valuable time.
    We recognize that it is not practical, nor possible, to have a full 
complement of specialists on each Island to see veterans when needed. 
However, it is also not acceptable to have to wait months, in pain, 
before a veteran is seen by a specialist who only comes to Kauai for a 
single day once every 3 or 4 months. Nor is it acceptable to wait 
several months before the veteran is flown to the Mainland for hip 
replacement surgery.
    When a veteran is flown to the Mainland for surgery, more problems 
are created. First the VA incurs the transportation costs. Second a 
sick or disabled veteran is forced to travel alone to a location where 
he, or she, has no friends nor family support, and undergo, again 
alone, what is frequently serious or even life threatening surgery or 
treatment. Following the surgery or treatment, the veteran then travels 
alone again to return home. He is not followed by his surgeon, nor is 
his post operative care or recovery monitored, or modified if needed, 
by anyone who actually did the surgery. This is far from optimal care 
and, in some instances, would be considered negligent. If post 
operative problems occur, other healthcare providers, who have no first 
hand knowledge of the surgery, are involved in the veteran's care. The 
more providers involved, the greater the chance recovery problems will 
arise. Additionally, it doesn't make good medical sense, or good care, 
to expect a person who has just been through major surgery to travel 
long distances. Just navigating a large airport these days is stressful 
to a healthy person.
    One solution to this problem, and to obviate the VA incurring the 
costs of the local health care provider on a fee basis, is to increase 
and implement more long term arrangements with the local healthcare 
providers on Kauai, and the other Islands. Through the use of Memoranda 
of Understanding (MOU), or other long term contracts, more veterans 
could receive care locally, at a reduced cost to the VA. This would 
also benefit the veteran in that he would not have to leave his home 
Island, or family, for surgeries. It would also improve the overall 
quality of the care rendered as the veteran's progress would be 
monitored by the provider performing the surgery. If adequate 
facilities exist at Tripler, another alternative is for the VA to hire 
board certified specialists who can treat and/or perform surgery on 
veterans as inpatients at Tripler.
    Funding for the VA needs to be significantly increased to meet the 
increased demand for care, not just by our older veterans, but also to 
ensure that good care is available to our service men and women who 
are, and will be, returning from the middle East. We also want to 
ensure that the VA obtains maximum value for the monies budgeted for 
healthcare. MOUs with local providers will help accomplish this goal.

                                STAFFING
    Interrelated with the above is our concern that the CBOCs have 
sufficient staff. Adding another physician would allow for more 
diagnostic evaluations to be done ``in house.'' In turn, some of the 
fee based costs incurred by the VA for referrals to local providers 
would be eliminated or, at least, reduced.
    At present, we still have a need for at least one more clinic 
staff, preferably an LVN or person certified to draw blood. The Kauai 
CBOC does have a part time person who is in the clinic 3 days a week to 
draw blood, and collect other specimens, which are then sent off Island 
for processing. Obviously, this creates a delay in getting results, and 
in treatment when indicated. It also requires a return visit by the 
veteran if they come on a day the ``lab'' person isn't there. Emergency 
laboratory work is done locally on a fee basis. Again, use of an MOU 
would be useful in reducing the costs to the VA.
    The individual who does the tele-medicine support at the CBOC is, 
inaccurately, ``counted'' as Kauai CBOC ``staff;'' but is, in fact, a 
Honolulu staff person who could be recalled at any time. If any one of 
the current staff become ill, or are even on vacation, it creates an 
immediate staff shortage. The Kauai CBOC staff is very devoted to 
providing optimal care to the veterans they serve, and they do an 
excellent job. However, insufficient staff translates into delays for 
patients, and the inability to see more patients.
    One problem with determination of staff needs is that an outdated 
model, based solely on the numbers of patients, is utilized to assess 
physician, nursing, and support staff needs. Our CNP not only sees 
patients and assists our physician. She also is responsible for all the 
patient education, supervision of the staff, dispensing medications, 
doing follow-up phone evaluations and many other duties. However, the 
CBOCs needs for additional nursing personnel are based only on the 
number of patients she sees. All the other hours she expends on the 
care of our veterans, including preventative care through education, 
are not counted. The methods used to evaluate the healthcare needs and, 
hence, determine the amount of funds needed and allocated requires 
immediate revision and updating.
    Of equal import is the long time need for a Home Health nurse. 
Monies for this position were budgeted and approved; but the monies 
were utilized for other health care matters. However, the need for a 
Home Health care nurse still exists. Hawaii, and the Pacific Islands in 
general, have significant numbers of elderly veterans. Many of these 
veterans have reached the age when they can no longer drive or tolerate 
the trip from their homes to the CBOC. The obligation to these aged 
veterans cannot be ignored or forgotten. Once again the inability to 
meet these healthcare needs is due to lack of adequate funding to 
provide these services. Long term care facilities are non existent, but 
greatly needed, for Kauai veterans. Similarly, Kauai's homeless 
veterans are in need of attention. Extension of the O'ahu outreach and 
other programs, even on a part time basis, is needed.

                                FUNDING
    As noted at the outset, VA Pacific Islands Healthcare System 
encompasses a vast, and disparate, geographic area. The very 
composition of the System mandates additional monies be allocated for 
rendering health care, and other, services simply to meet the costs of 
transportation and the necessity of utilizing community resources more 
frequently than a similar Mainland veteran population. Our healthcare 
providers primary goal is to render quality care for our veterans. 
Although some increases have occurred, the VA budget is still seriously 
short of it's needs. Providers are doing the best they can, but cannot 
work miracles . . . with limited staff, resources and equipment, the 
care rendered is also limited.
    On behalf of the veterans we represent, I thank the Members of this 
Committee for the time you have taken to hold these hearings and listen 
to the concerns of our Islands. Your efforts and commitment to our 
Veteran community is greatly appreciated. Mahalo, and Aloha.

                 Prepared Statement of Laurie Makaneole
    I would like to take this opportunity to express my concern 
regarding our returning military personnel from Iraq and Afghanistan. 
Kauai will be having over 100 reservists but in addition we have many 
Kauai people who have also served in the active military and will also 
be returning from Iraq and Afghanistan.
    I have a son who is a Captain out of the Stryker Brigade Combat 
Team from Fort Lewis-Washington--who just recently returned from Iraq. 
I am concerned that these military persons and their families need 
access to Post Traumatic Stress counseling- that is appropriate for 
them. These young people returning are not the same persons who left us 
a year ago--and we all need help with this serious issue.
    I am concerned about their successful re-entry into our world. 
These young persons gave so much of themselves and now need our help to 
assist with a successful re-entry and a good future life. Their 
difficulties are also a spouse and child concern- it affects the entire 
family unit.
    Please provide funds to appropriately educate families and provide 
appropriate treatment for this concern.
                  Prepared Statement of Martin T. Rice
    In the summer of 1966 I joined the U.S. Army and served two tours 
in Vietnam which just so happened to span three successive Tet 
Offensives: 1967 and `68 in Nha Trang, on the central coast, and 1969 
at Long Binh, just outside of Saigon.
    I was told that one of the benefits of joining the service was 
life-long health care coverage. Some administrations have whittled away 
at the promise. It is an alarming trend.
    However, I am grateful for the partial coverage that has been 
provided to me. The Government has admitted and taken responsibility 
for the diabetes and colon cancer that was diagnosed in August of 1999, 
probably as a result of exposure to Agent Orange during one or both of 
those two tours. The emphysema that was simultaneously diagnosed in 
August 1999 is currently not a problem, however, it continues to be 
monitored and is a result of the cheap tobacco products offered to 
young soldiers, such as myself, at PX's. I was able to stop smoking, 
with the help of hypnotherapy, in November 1988, 22 years after 
entering the service. The emphysema appears to be in check. The 
diabetes is likewise under control, thanks to the monitoring by Dr. 
Duvachelle and the Kauai Clinic staff, however, to keep it under 
control requires the attention and time-frame of a part-time job. I 
currently spend about 18 hours a week, including drive time, at the gym 
in order to maintain blood sugar levels. I've found that 6 days a week 
of cardio-vascular exercise coupled with weight training has done the 
trick. I am able to forgo medicine, most days, and of course, I watch 
my diet. I have, over the years, seen the number of per-year visits at 
the Kauai Cluuc, whittled down, due in part to my exercising regimen, 
but also due in part to a heavier patient load carried by the staff.
    Be that as it may, the lasting effects of the Agent Orange-induced 
colon cancer are ever-pervasive. I had what's known as a total 
proctocolonectomy, basically Tripler Army doctors in Honolulu took 
everything ``south'' of the small intestine: the appendix, colon and 
most of the rectum, and reattach the small intestine to what was left 
of the rectum. The procedure was innovative at the time, and required a 
4-month period with a colonectomy bag while the lower third of my small 
intestine was trained to function, somewhat, as a colon.
    I do own my own home-based business, however it requires one day of 
delivery, from Kekaha to Hanalei--a day of complete fasting until the 
deliveries are done. Usually that means from the preceding evening 
until 7pm that day, at the earliest, about 24 hours.
    I'm also lucky to have started this business in 1990, as I've been 
able to adapt it, somewhat, to my current medical condition. Otherwise, 
I would be unemployable, as the absence of the storage capacity that a 
colon provides requires many daily restroom visits. By way of 
measurement, I usually use seven to ten rolls of toilet paper weekly. 
Literally, I know my way around this island from restroom to restroom.
    Additionally, I have not slept more than 4 hours uninterrupted at 
any given time since the April 2000 surgery, due to the need to use the 
restroom at all hours, giving rise to what has been diagnosed as acute 
sleep deprivation.
    I'm not complaining. I know many people have it a lot worse than I. 
I feel lucky to be here, as the cancer surgery, which took place almost 
8 months after diagnosis, again due to the heavy patient load, this 
time at Tripler, came just in time. It became negated as the cancer had 
spread quite dramatically; a total proctocolonectomy became necessary. 
It was luckily performed before the cancer penetrated the outer wall of 
the colon, from which it usually spreads to the liver, a sure death 
sentence.
    I have presented all of the preceding to demonstrate how precarious 
my current situation is. Without the promise of medical help of the 
government, I would not have even limited health coverage. In fact, I 
probably would have been dead already.
    I feel that this promise of limited health care is in further 
jeopardy, for main two reasons. (1) there's a need for increased 
staffing at the local clinic as the load will be increasing due to 
returning servicemembers from Iraq and Afghanistan, and (2) there's the 
ongoing threat that the current administration will cut health services 
to people such as myself as a matter of fact.
    Those who know me, know that I remain active in spite of my 
service-connected diseases. In addition to my main business and the 6 
days-a-week gym workouts, I am starting a second business. I'm also a 
lobbyist at the State legislature for a civil rights organization, I'm 
the current chair of the local Democratic Party and I serve as 
treasurer for a local non-profit.
    My story is but one of a hundred thousand in this small State, and 
one of but millions upon millions nationwide. My dream of public 
service at the State legislature will probably remain just that, due to 
the aftermath of my service-connected diseases as I feel that although 
my country wouldn't abandon me or my health care needs, this 
Administration will.
                Prepared Statement of Ronald K. Takamura
    Mr. Chairman, Senator Akaka and other distinguished members of the 
panel. My name is Ronald K. Takamura. I am a medically retired US Army 
Captain. I am presently involved with the Hawaii Veterans Community and 
especially on affairs concerning the Veterans of Kauai.
    First of all, let me give you a broad insight of just where this 
island stands within the entire United States. Our little island has a 
population count of approximately 54,000 people of which approximately 
5,700 are veterans; this is equal to 10 percent of the population which 
is the highest pro-capita ratio in the entire United States. Our CBOC 
technical staff which consists of only one Doctor, one Nurse 
Practitioner and one Psychologist see and treat approximately 30+ 
patients per day out of a registered count of approximately 1,850 
veterans. With the returning veterans from the Middle-East who will be 
coming home very shortly, our facility will be greatly under-staffed 
and will be very strained to deliver the best care and services to the 
total number of veterans.
    As a proposed remedy to this situation, the following idea is 
presented to you for your consideration:
    A. Facts:
    1. The CBOC and the VA office located at its present location will 
have outgrown its space for which the sum of $ 15,000.00 plus utilities 
is paid for rent on a monthly basis.
    2. There is only adequate parking space for 17 cars including those 
that belong to the staff.
    3. Cost to the VA each time a veteran is sent t Honolulu runs over 
$200.00 per visit for transportation alone.
    4. It takes the veteran approximately 3 hours of travel time to get 
to Honolulu and another 3 hours for him to return.
    5. In addition to the above, the State of Hawaii Office of 
Veterans' Affairs (OVS) pays approximately $1,850.00 rent for the area 
it occupies in the present Veterans Center.
    B. Proposal:
    1. The Kauai Veterans Council has acquired enough additional land 
at the rear of the present center to construct a two or possibly three 
story building in which it would be ideal to house the CBOC, VA Office 
and the OVS Office.
    2. This building would be customized to house an expanded CBOC as 
well as the other offices. By doing so, would create a one-stop 
Veterans Complex with ample parking and technical facilities to better 
serve our veterans in the long run.
    3. The monies paid for rent/utilities would be better utilized as 
the facilities located within this complex will be owned by our 
veterans, and would contribute toward any costs incurred like mortgage, 
etc.
    4. The CBOC would then be expanded to handle a larger technical 
staff as well as up-to-date equipment and programs which would be 
classified a State-of-the-Art.
    5. The cost of flying specialists to Kauai from Oahu would be 
cheaper than flying patients from Kauai to Oahu due to the following 
accepted procedures presently in effect:
    a. Time saved on patient travel time which would be an equivalent 
to approximately 3 hours to and from Oahu for a total of 6 hours.
    b. Each time a patient goes there to Oahu, he is first interviewed 
by interns from the University. The interns then consult with the 
specialist and only after all of this, he gets to see the specialist 
for approximately fifteen minutes if lucky. If the specialist flew over 
to Kauai, there would be no interns and then he would be able to 
service at least three to four times as many veterans for the same 
amount of time.
    c. Transportation for patients would be much simpler with the 
utilization of the DAV Transportation Network and the Kauai Bus 
services.
    d. By increasing the technical staff of the CBOC, i.e. one Doctor, 
one Laboratory Technician, one administrative clerk and one records 
management clerk, much better services could be provided the veterans 
and the waiting periods between appointments would be greatly reduced.
    As for my comments on Long-Term Care Facilities, I personally do 
not think that the operation of one on this island would be 
economically practical. In addition, to have the facility on another 
island would not for practical purposes sufficiently or efficiently 
service our veterans due to travel and other cost restrictions.
    The cost factors to operate such a facility have not been spelled 
out to the veterans in black and white which leaves many loop holes in 
the true benefits that a veteran would gain over the civilian type of 
care facilities now in operation.
    For example, if the administration would only accept the VA 
benefits check, the Social Security check and maybe \1/2\ of the 
retired military pay check, then the veteran may be able to benefit 
some provided that his personal property not be touched. If his 
personal property and assets are included into the cost factor, then I 
contend that there would be no different than the present operating 
Long-Term Care Centers presently in operation and the veteran would 
lose in the long run.
    Judging from the panel members in attendance of his hearing, all of 
the operational bodies would belong to a profit making organization or 
company and would be out there to make money instead of trying to do 
what would be best for the veteran. Therefore, I contend that there 
would be better ways to utilize our monies, such as building a center 
as proposed above.
    Thank you for giving me this opportunity of testifying before this 
Committee.
                Prepared Statement of William T. Honjixo
    A hearing as this is great appreciated by veterans on this island 
of Kauai. IT certainly demonstrates that our nation cares about 
veterans. The caliber of participants and speakers were outstanding and 
impressive. It was not ``eye wash,'' but a serious attempt to solve 
problems facing the veterans here on Kauai and the State of Hawaii. 
Mahalo for your effort and the caring of veterans.