[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 II

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED NINTH CONGRESS

                             SECOND SESSION

                               __________

                            JANUARY 11, 2006

                               __________

       Printed for the use of the Committee on Veterans' Affairs


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                                 senate

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                     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 M. 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


                            C O N T E N T S

                              ----------                              

                            JANUARY 11, 2006
                                SENATORS

                                                                   Page
Akaka, Hon. Daniel K., U.S. Senator from Hawaii..................     1
Abercrombie, Hon. Neil, U.S. Representative from Hawaii, 1st 
  District, prepared statement...................................     2
Case, Hon. Ed, U.S. Representative from Hawaii, 2nd District.....     4
    Prepared statement...........................................    10

                               WITNESSES

Daves, William, President, Oahu Veterans Council.................    15
McCloskey, Michael, Member, National Executive Committee, The 
  American Legion, Department of Hawaii..........................    15
    Prepared statement...........................................    16
Hough, Master Chief Petty Officer Gil (Ret.), U.S. Navy; Member, 
  Veterans Advisory Council......................................    18
    Prepared statement...........................................    19
Rienzi, Lieutenant General Thomas (Ret.), Chairman, Veterans 
  Advisory Council...............................................    20
    Prepared statement...........................................    21
Ross, Caz, Veteran Service Officer, The Military Order of the 
  Purple Heart...................................................    21
Cruickshank, Colonel Edward (Ret.), Director, Officer of Veterans 
  Services.......................................................    22
    Prepared statement...........................................    23
Rubens, Diana M., Director, Western Area Office, Veterans 
  Benefits Administration; accompanied by James Carilli, Acting 
  Director, Honolulu Regional Office.............................    31
    Prepared statement...........................................    33
Molnar, Stephen T., M.S.W., Team Leader, Honolulu Vet Center.....    35
    Prepared statement...........................................    38
Gusman, Fred, M.S.W., Chief Operating Officer, Pacific Islands 
  Division, National Center for PTSD.............................    40
    Prepared statement...........................................    41
Wylie, Alfred, Public Relations, Coordinator, Vietnam Veterans of 
  America........................................................    46
    Prepared statement...........................................    48
Shomaker, T. Samuel, M.D., J.D., Interim Dean, John A. Burns 
  School of Medicine, University of Hawaii at Manoa..............    49
    Prepared statement...........................................    50
Kahoano, Haku, 4th-year Medical Student, John A. Burns School of 
  Medicine, University of Hawaii.................................    50
    Prepared statement...........................................    51
Perlin, Hon. Jonathan B., M.D., Ph.D., Under Secretary for 
  Health, Department of Veterans Affairs; accompanied by Robert 
  Wiebe, M.D., VA Network Director, VISN 21, Sierra Pacific 
  Network; James Hastings, M.D., Director, VA Pacific Islands 
  Health Care System; and Steven A. MacBride, M.D., Chief of 
  Staff, VA Pacific Islands Health Care System...................    57
    Prepared statement...........................................    60
Pollock, Major General Gale S., Commander, Tripler Army Medical 
  Center.........................................................    65
    Prepared statement...........................................    67

                                APPENDIX

Combs, Travis, prepared statement................................    75
Giblin, Malcolm M., prepared statement...........................    79
Holi, Wilma, President, Papa Ola Lokahi, prepared statement......    80
Kauhi, Henry, prepared statement.................................    80
Luke, Dr. Stanley, Helping Hands Hawaii, prepared statement......    78
Park, Master Sergeant William C. S. (Ret.), prepared statement...    82
Tsuneyoshi, Randall, prepared statement..........................    85
Turner, Charles H., prepared statement...........................    75
Wessel, Lori and Paul, prepared statement........................    85
Article, Camp McCain Units to Receive Honors.....................    76
Memorandum, Department of VA Regulation..........................    83
News Release, Department of Veterans Affairs.....................    77


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

                              ----------                              


                      WEDNESDAY, JANUARY 11, 2006

                               U.S. Senate,
                    Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:10 a.m., in 
the DAV Hall at Keehi Lagoon, Honolulu, Hawaii, Hon. Daniel 
Akaka presiding.
    Present: Senator Akaka.

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

    Senator Akaka. The hearing of the Veterans' Affairs 
Committee will come to order. Aloha.
    Audience. Aloha.
    Senator Akaka. It's great to be here with you. Normally, 
we're on a stage, but today we're on the same level. I'm 
delighted to be here. I want to welcome all of you to the third 
day of the Senate Committee on Veterans' Affairs field hearings 
in Hawaii.
    It is not often that Senate hearings are held outside 
Washington. For us, it's really great to have this Committee 
hearing here in Hawaii. So let's give the Committee a great 
hand.
    [Applause.]
    Senator Akaka. I'd like to thank Pat Weiland and Fred 
Ballard of the Spark M. Matsunaga VA Ambulatory Care Center as 
well as the Vietnam Veterans of America for their assistance in 
coordinating today's hearing. We greatly appreciate all of your 
hard work.
    Today and over this entire week, the Committee will assess 
VA care in Hawaii. That's the reason most of you are here. Due 
to its geography, Hawaii is unlike any other State in the 
Union. As such, VA must tailor its services to reach all of 
Hawaii's veterans.
    I applaud the efforts of every VA employee in Hawaii. These 
men and women work hard trying to help our veterans. There are 
many things that VA does well. However, there's always room for 
improvement. I want to hear about how we can help VA help 
Hawaii's veterans.
    Many brave young servicemen and women are returning from 
duty in Iraq as we speak. We in Congress work with VA to 
address our newest veterans' needs, along with our oldest. 
Services such as readjustment, transition assistance, PTSD-
related counseling, are at the forefront of our priorities. We 
must continue to ensure a smooth transition of service from DOD 
to VA.
    Sadly, some believe that reducing veterans' compensation 
for PTSD is a good way to save money. I think you remember last 
year VA planned to conduct a review that would have examined 
72,000 claims that were previously awarded compensation over a 
5-year period. Compensation should not be viewed as a welfare 
program. Our veterans have earned their compensation through 
selfless service to their country. I want to say when I 
mentioned that review of 72,000 cases that thankfully, VA set 
aside its plan to conduct the review last year.
    Travel for veterans living on Oahu is relatively 
inexpensive. Traveling from other islands can be costly, and we 
heard, especially in Maui County, how costly it is for them. 
It's costly because of inter-island airfare, which can be over 
$200.
    Veterans often have difficulty getting reimbursed--that's 
another problem--for such expenses. Adding various other travel 
costs, such as rental cars and lodging expenses, and a veteran 
may choose to forgo care rather than pay sizable out-of-pocket 
costs.
    We are privileged to have our witnesses with us this 
morning and to have all of you here present. I must tell you, 
I'm so delighted to have our National VA officials who are here 
with us, and you will hear them, and also our regional 
officials, our State officials here, and all of our veterans 
organizations here as well as families. We look forward to 
being informed so that we can help you have better services.
    We are happy to have our congressional people here. I 
should tell you that Senator Inouye is not able to be here this 
morning, but sends his warmest aloha. Also, Congressman 
Abercrombie was not able to be here, but he has submitted 
testimony for this Committee. We have here two of us. With me 
to testify at this time is our young representative, 
Representative Ed Case.
    [Applause.]
    [The prepared statement of Mr. Abercrombie follows:]

   Prepared Statement of Hon. Neil Abercrombie, U.S. Representative 
                       from Hawaii, 1st District

    Senator Craig and Senator Akaka, thank you for this opportunity to 
discuss with you and the other distinguished Members of the Senate 
Veterans' Affairs Committee my thoughts on both the current status and 
future of Federal veterans programs in Hawaii.
    Before going into specifics, I want to thank all of America's 
veterans, and especially those in Hawaii, for their service to the 
Nation. When the Nation called, they answered ``send me.'' We all 
appreciate the courage and sacrifice of those who leave their friends 
and families behind and go to fight on our behalf.
    Of course, when they get home, the Department of Veterans Affairs 
is responsible for providing our veterans' assistance and healthcare. 
As Members of this Senate Committee, you know how important a mission 
that is. Caring for our veterans is a sacred duty, but it can also be a 
challenge given the size and diversity of needs within the veteran 
population.
    On that note, I'd like to also publicly thank the men and women of 
the Department of Veterans Affairs. They work hard every day with 
limited resources to meet the needs of the Nation's veterans, and I 
don't think they always get the credit they deserve.
    I also want to commend both Senators Craig and Akaka for running 
the Senate Veterans' Affairs Committee in a bipartisan manner. We could 
use some of that spirit of working together to help our veterans in the 
House Veterans' Affairs Committee, but seeing the two of you work so 
well together reminds me that accommodation and compromise are 
possible, and in the end, our veterans will get better service as a 
result.
    As you know, Hawaii has more than 100,000 veterans. In many 
aspects, this large population of veterans shares the same concerns 
that veterans around the country have about VA operations. These 
concerns include improving access to VA healthcare, better and more 
efficient delivery of veterans' benefits, and an overall shortfall in 
VA funding, particularly for VA healthcare.
    I share all of those concerns. Over the past 5 years I have been 
especially troubled by the tone the Bush Administration has 
unfortunately taken regarding veterans' benefits and healthcare. The 
general goal of the Department of Veterans Affairs under its current 
Washington leadership sometimes seems to be to minimize the amount of 
money spent on our veterans, and exclude as many veterans as possible 
from using the VA system created to take care of them.
    This general trend has manifested itself in many ways, as you know 
as Members of this Committee, but let me give a few examples that have 
troubled me. The first is how the Bush Administration chose to deal 
with the long waiting times that many veterans are experiencing trying 
to use or get into the VA healthcare system. Rather than trying to 
improve or expand services to accommodate the increased demand, the 
solutions provided to Congress consisted of both shutting out certain 
veterans and increasing co-payments on veterans already in the system. 
Of course, both of these proposals have met serious opposition in 
Congress, but the very fact that they were offered up as solution says 
a great deal.
    A second example is this past year's controversy regarding a multi-
billion dollar shortfall in VA healthcare funding. While I'm glad that 
the Administration finally owned up to the fact that they needed $1 
billion more healthcare funding in 2005 and $2 billion more in 2006, it 
would have been better for our veterans if the Administration had 
simply been honest in the first place. I just cannot understand why 
these shortfalls were not identified earlier in the budget process.
    I am especially troubled by this trend in under-funding because of 
what it says for the future. The wars in Iraq and Afghanistan are 
producing thousands more future veterans every day. Many of these 
troops are coming back with serious wounds, both physical and mental. 
If the current VA system cannot provide a consistent level of service 
to today's veteran population, how is it going to be able to handle the 
hundreds of thousands of new veterans entering the system over the next 
decade?
    Overall, I would like to see a change in direction from the Bush 
Administration, one that lets our veterans know that they are not 
viewed as ``wards of the state'' who are simply seeking additional 
entitlement spending, but instead that they are valued and honored for 
their service.
    Will improving veterans care be expensive? Of course it will. 
However, I think most Americans would be willing to provide the 
resources if they knew that it would help make sure that our veterans 
get the care and benefits they deserve and have earned. Unfortunately, 
over the past 5 years the Bush Administration has not even asked the 
American people--outside of our military--for any level of sacrifice to 
fund the wars in Iraq or Afghanistan, let alone the increased burden on 
our veterans care system caused by these conflicts. I sincerely hope 
that changes, and soon. We owe our veterans more.
    Looking more at local concerns, it is clear that Hawaii faces many 
issues when it comes to veteran's care, and I'm sure you have heard 
about these at great length during your series of hearings. The unique 
characteristics of Hawaii's geography and population distribution make 
delivering veterans' benefits and care here especially challenging.
    Rather than reiterate those same concerns, all of which are very 
important and need serious attention, I want to focus my testimony 
today on two groups of veterans with whom I have had the privilege of 
working with over the past few years, and on whose behalf I support 
legislation in the House.
    The first group of veterans--many of whom live in Hawaii--are known 
as ``Atomic Veterans'' because of their participation in nuclear 
weapons testing and other nuclear weapon activities.
    These veterans, while small in number, are paying a large price for 
doing their duty and not asking questions when ordered to participate 
in nuclear weapons testing between 1945 and 1965. In short, they did 
what they were told, and while at the time of these tests the military 
did not understand all of the health dangers involved, that does not 
absolve the military, the Congress, or the Nation from providing these 
veterans with the appropriate care and compensation.
    Today, the major barrier faced by veterans seeking care for health 
problems associated with their participation in these atomic activities 
is the ``dose reconstruction'' system. This system, while well-
intentioned, is simply not working. The primary reason for that is that 
it relies upon service records that are either not detailed enough or 
not in existence to ``reconstruct'' how much radiation a veteran was 
exposed to and thus how likely it is that their health problems 
resulted from this service. This is not just my opinion. Both the 
Government Accountability Office and the National Academy of Sciences 
have studied this issue and have concluded that the current dose 
reconstruction methodology does not work due to a lack of appropriate 
records.
    The result of this dysfunctional system is that very few atomic 
veterans are able to get access to the VA healthcare system. The 
National Academy of Sciences 2003 study showed that just 2 percent of 
veterans who went through the ``dose reconstruction'' review had their 
medical conditions validated as ``service connected.'' The other 98 
percent of the approximately 2,500 veterans who had applied for 
service-connected status were told ``too bad.'' While not all claims 
will have merit, I think this approval rating is disgraceful. It is 
clear to me that the current approach to evaluating the service of 
atomic veterans is skewed toward denying them service-related status. 
This must change. These ``Atomic Veterans'' are dying every day from 
diseases caused at least in part by their service in atomic tests and 
other nuclear weapon-related activities.
    To fix this problem I have introduced legislation to eliminate the 
ineffective dose-reconstruction system. My bill, H.R. 2962--The Atomic 
Veterans Relief Act, would still require veterans to prove that they 
participated in an atomic test or served in an atomic occupation area, 
such as Nagasaki, and that they suffer from a radiogenic disease. That 
is, a disease related to exposure to ionizing radiation. This 
legislation would also expand the definition of ``radiation risk-
activity'' to include those veterans who were exposed to ionizing 
radiation from residual contamination at nuclear test sites, which is 
now widely understood to be a serious health risk. This legislation now 
has 40 cosponsors, including Congressman Evans, the senior democrat on 
the House Veterans' Affairs Committee.
    I ask for your support for this much-needed legislation. I think it 
is a basic issue of fairness that the Department of Veterans Affairs 
and the Congress must address. I look forward to working with the 
Committee on this issue in the future, and I will do anything you ask 
of me to help move this legislation forward.
    The second group of veterans whose cause I strongly support is the 
Filipino veterans of World War II that served alongside U.S. military 
forces as members of the Commonwealth Army of the Philippines and the 
Philippine Scouts. As you know, thousands of these veterans who fought 
under our flag in World War II were denied veterans benefits and 
healthcare for decades. While I appreciate the progress in 2003 toward 
getting this group the benefits and care it deserves, I do not believe 
that those incremental steps are where Congress should stop.
    I am a cosponsor of House legislation, The Filipino Veterans Equity 
Act, which would finally erase all the inequities that this group of 
brave veterans has endured. This bill has 67 bipartisan cosponsors in 
the House. The goal of this legislation is full equity for Filipino 
veterans. They fought shoulder to shoulder with their American comrades 
in arms, suffered the same hardships, and sacrificed in the same cause. 
Simple justice demands that we recognize their equal contributions with 
equal veterans benefits.
    As a Member of Congress from Hawaii, I represent a large number of 
these veterans. Many are now in their seventies or eighties, so time is 
running out for the United States Government to finally fulfill the 
promises it made to these veterans during World War II. I look forward 
to working with your Committee in the future to make this legislation a 
reality.
    I want to again thank you for coming to Hawaii and holding these 
hearings. I know that you have many demands on your time, as all 
Members of Congress do, so your willingness to take the time to come 
and hear from Hawaii's veterans is greatly appreciated.

                  STATEMENT OF HON. ED CASE, 
         U.S. REPRESENTATIVE FROM HAWAII, 2ND DISTRICT

    Mr. Case. Thank you very much, Senator. I was young a few 
years ago when I took this job. I'm getting older rapidly.
    [Laughter.]
    Mr. Case. Chairman Craig, Ranking Member Akaka, Members of 
the Senate Veterans' Affairs Committee, guests, especially our 
veterans that are here with us today, good morning to all of 
you. I thank the Committee from the bottom of my heart, on 
behalf of all of Hawaii's people, for joining in addressing 
this most important of issues for our Hawaii and country: how 
we fully and honorably discharge our obligation to our Nation's 
veterans and to those that they leave behind.
    I thank our Hawaii's 120,000 and increasing--as a matter of 
fact, every day that another plane arrives home--increasing 
number of veterans for your service, and for the honor and 
privilege, and I do mean that very sincerely, of representing 
you in your U.S. Congress.
    I thank you for the partnership, Senator Akaka, between our 
congressional delegation and veterans. I think as we look back 
over the last decades and look at a delegation, as it has 
changed, it has still been committed every day to the needs of 
veterans, and we've enjoyed a fantastic relationship with our 
veterans, a partnership, really. It's been a distinct pleasure 
to come into that part of my job.
    I thank you, Senator, personally for your efforts not only 
in bringing this Committee here, but, as the representative of 
the 2nd Congressional District, which I like to define as every 
part of the State of Hawaii except for that small sliver that 
lies in downtown Honolulu, for taking the Committee outside of 
Honolulu. Because of course I think we all know, and we will 
soon see revealed fully and furthermore today, that differences 
between the 1st and 2nd districts do exist. I thank you for 
taking the Committee to the other islands where the needs of 
the veterans communities are sometimes unique, as this 
Committee has already seen.
    Finally, I think it is vital as we start any one of these 
hearings, in this and other hearings and meetings and actions, 
that we pause and remember what we're all about here. We pause 
to remember the joy that we feel in welcoming home our newest 
veterans, including members of the 29th Brigade Combat Team. We 
also pause and remember the great tragedy of the goodbyes that 
we are saying to our best and brightest that won't be coming 
home, people like Sergeant Myla Maravillosa.
    I don't want to take too much time today because I've seen 
the panel and it's a fantastic panel. You have excellent and 
qualified people to inform the Committee. I'm looking forward 
to hearing them as well. I simply want to offer a couple of 
perspectives,
    I offer these perspectives as a Member engaged in a 
difficult and crucial national debate over whether we as a 
country will honor those commitments that I made reference to 
earlier.
    As a Member representing vets individually and collectively 
who have the same concerns as vets elsewhere, as Senator Akaka 
has already mentioned, whether it be student loans and other 
means of advancement; whether it be veterans preferences in 
small business set-asides for Federal procurement 
opportunities, which is a major issue right here; whether it be 
retirement and survivor benefits; or whether it be basic 
healthcare, which I think we all know and realize is really 
where the attention needs to be devoted.
    I also do it, as I mentioned earlier, as a Member 
representing a district that is a rural district, a suburban 
district. In that way, like a lot of other such districts 
throughout the country, we're particularly unique in terms of 
the geographic complications.
    I do it as a Member that has met personally with so many of 
your organizations and individual vets, and finally, as a 
Member like every other Member of Congress, or I hope every 
other Member of Congress, who has a very active casework 
component of the service that they provide, individual casework 
services.
    I can tell you what I think that we all should know and you 
know, and that is, when we talk about individual services, the 
individual connection between our constituents and the Federal 
Government, veterans issues are at the very top of that list. 
So that's a unique and very direct and personal way of 
understanding how our Nation's veterans are being impacted.
    In the big picture, let me first say--and I think we need 
to lay this out because it comes back more and more and 
repeatedly as a theme--that I completely share the legitimate 
concerns of veterans nationally, and many Members of Congress 
over what I think we have to fairly recognize as a lagging 
commitment by our Federal Government to veterans' needs.
    The needs are simply not being kept up with by available 
resources. Despite the efforts of well-meaning, well-
intentioned people, there is an increasing gap between what we 
need to do and what we are doing. That's a national issue. 
We've seen it. I've seen it in my budget committee, where we 
fought major budget battles over the allocation of available 
resources to veterans.
    We have certainly seen it over reports of limitations in 
terms of outreach and the concerns of extending the net too far 
out as we look to the needs of veterans today and down the 
road. We have seen it in shortfalls mid-year in appropriations 
bills, where we've had to come back on major shortfalls and do 
emergency appropriations because the projections of need turned 
out to be dead wrong. We've even seen it in some of the 
procedural aspects of Congress where, for example, 
inexplicably, we stopped doing joint hearings with veterans 
organizations at the outset of this current Congress. I hope 
that changes.
    I don't want to dwell too much on this national debate here 
because this hearing is really about trying to understand what 
our particular challenges are here in Hawaii, other than to 
make this basic observation--and I think this is a truth that 
we have to keep in mind--and that is that we can provide the 
most seamless and complete delivery system of veterans benefits 
throughout Hawaii, solving every single one of the challenges 
and problems logistically and on paper and otherwise that we 
are going to hear about today, have already heard about, and 
will be hearing about.
    Are we going to have that system in place? But if we don't 
have that national commitment, the national resources, we're 
not going to get the job done. So this does start at the 
national level. We need to talk about it locally, but it does 
start nationally.
    Now, let's just turn to Hawaii specifically, some specific 
observations. I hope the witnesses will go into these. I'm sure 
they will. I want to report to you just on what I've observed 
in the last 3 years of representing our veterans community.
    By the way, the veterans community in Hawaii is split 
pretty much evenly between 1st and 2nd Congressional districts, 
60,000 in each. I don't know who has the lead there, but it 
doesn't really matter. I think it's fair to say that each and 
every one of your congressional delegation doesn't distinguish 
on the basis of districts. I'm sure Congressman Abercrombie and 
I certainly don't do that.
    But I will report on some of the observations that I have. 
I want to take off, really, on a veterans survey that I just 
completed. I have for the last 3 years sent out a veterans 
newsletter to the organizations and to the veterans themselves, 
trying to reach out first of all, to try to give you a sense of 
what's happening nationally.
    I have that report here. I have a limited ability to 
distribute it; I can't give it to all the veterans. But the VA 
does give it to me in terms of who is actually getting benefits 
today. So I miss the majority of veterans out there that are 
not actually receiving benefits, but those that are, who are 
those that we're really trying to take care of, are responding, 
are getting my report and are responding to my survey.
    I think that what is coming back in that survey is 
relatively reflective of what I have also felt just through 
casework and talking anecdotally and walking around my 
district. I think the first thing I need to say, and this is 
good news, is that in many areas, veterans do feel relatively 
satisfied with the scope of the services that they are getting.
    This is not a picture in which this is a veterans community 
nor a broader community that believes that the entire system is 
collapsing around us and there's no care being given to our 
veterans. I think it's important for us to recognize both 
individually and institutionally where veterans services are in 
fact being provided, and the information I have and the feeling 
that I have is that what we are talking about is a structure 
that is generally accepted and has generally been committed to 
improvement, but does have problems, challenges, individual 
missed opportunities.
    So the first thing I want to say is something that Senator 
Akaka said as well, and that is, we thank our Federal 
Government. We thank our veterans entities on the Federal level 
for the commitment that they have. We know from the fact that 
the people from Washington are here today that they are 
committed to Hawaii.
    I think we have been blessed here in Hawaii by well-meaning 
and dedicated people in all aspects of the veterans services 
part of our Government, whether it be Federal, State, or local. 
So we say thank you to you, first of all, and thank you for a 
job that is well done in general.
    Let's talk about the problem areas. Clearly, the problem 
areas are isolated in some of the areas that I talked about 
earlier. I think the number one I would note other than 
healthcare would be access to Federal procurement, where I 
certainly have seen a real deficiency. That's not a veterans-
driven issue; that's a Federal procurement-driven issue. We 
simply have to provide those opportunities to our veterans. 
It's a little bit of a complication on the neighbor islands, 
but nothing that is significantly different from urban 
Honolulu.
    Healthcare is clearly, as I said earlier, where we need to 
worry about things. I think there are a couple of areas that 
are of particular note.
    I think access to healthcare throughout Hawaii, and 
especially on the non-Oahu, non-Honolulu--because this applies 
to rural Oahu as well--is a little more spotty, obviously, than 
in downtown Honolulu. That's understandable. You can get to 
medical facilities a little easier here. You have a greater 
diversity and range of medical professionals operating. You 
don't suffer from some of the problems that go beyond the 
veterans issue on the neighbor islands, such as the fact that 
the only ear, nose, and throat specialist in West Hawaii just 
quit and is leaving. So what does that do to the safety net in 
West Hawaii? These are problems throughout the islands other 
than Oahu.
    But it's very clear that one of the things that we have to 
be very vigilant about and work on is just simple availability 
of medical services to our veterans on the islands other than 
Oahu.
    We have had some concerns in terms of consolidation of 
veterans services. In some of the islands, the Committee will 
discover and already knows, the services have in fact been 
consolidated, so it's kind of a one-stop shop. You can come in 
there and get services for your benefits, whether they be 
medical benefits, whether they be clinical benefits, whether 
they be benefits on economic preferences or otherwise. In other 
areas, you frankly have to go clear across town or sometimes 
across island to get them. So I think the concern there is to 
try to effect consolidation for efficiency of delivery, and 
also just to service the customer, who is you.
    In some of the islands, we do not have adequate centers for 
veterans to come together, really, to try to focus on the needs 
of veterans and to provide that camaraderie that is not only 
part of the veterans community, but is particularly important 
to recovery from various of the areas in which veterans still 
suffer. That's been a crucial aspect, I know, for PTSD 
treatment in a number of our committees throughout Hawaii. So 
the adequacy of centers is inconsistent.
    Veterans cemeteries have been a persistent problem, 
especially on some of the neighbor islands. Good, solid efforts 
by Federal, State, and local, county Governments, State 
government, and Federal Government to provide the full range of 
the obligation that we have to provide for the final resting 
place of our veterans and relatives.
    But I think the fact of the matter is that although it's 
relatively available here on Oahu, it is not relatively 
available, at least that simply, on the neighbor islands. So 
one of the bills that I have pending in Congress is a proposal 
to allow for an increase in the burial allowance which is given 
to the State to assume of the responsibility of the Federal 
Government in situations in which a cemetery is not available 
on island.
    Now, if you're in the middle of New Jersey, that might not 
be a problem. But if you're on the island of Hawaii and a 
veteran, you want to be buried on the island of Hawaii, just to 
take an example, or Molokai. So if there's not an availability 
of, or it's too expensive, and you've got to come to another 
island, well, I think that defeats the basic purpose of what 
we're trying to accomplish.
    I think outreach remains a crucial thing for us all to 
focus on. There are veterans out there that are not being 
reached. In general, the veterans that are not being reached 
are the veterans that most need to be reached. I think that's a 
truism. I think that we will find, and the Committee will 
observe and has already observed, that this is true on islands 
such as Molokai, in which I kind of fear that there is just not 
enough penetration, if I can put it that way, into the 
community that needs to be served.
    I think this has nothing to do with the efforts and 
intentions of people that are involved. The veterans councils 
have done a great job of trying to put together consolidated 
outreach efforts with Federal, State, and local Government and 
the veterans groups, and to reach people that need to be 
reached.
    Nonetheless, I think it has not been enough in some areas, 
and I think we all have to focus on a renewed effort to deliver 
to veterans, to take to their doors, in some cases, the 
benefits that the veterans structure does provide and does make 
available to them.
    We can't get caught up in the thinking that because we 
tried, somehow if they're not utilizing it that's their 
problem. It's not. It's our problem. We want to reach these 
veterans. So one of the things that I think we need to do is 
redouble outreach efforts, especially to the more rural and 
remote parts of Hawaii.
    So where does this all leave us? Well, I just give you a 
couple of basic points, Senator Akaka, for consideration by the 
Committee. I think, first of all, I want to reiterate this all 
starts with a national priority to our veterans and a national 
commitment to our veterans and we have to focus there because 
nothing else is going to matter if we don't get that straight.
    It is in danger right now, and we are having this debate as 
we speak, in Washington. It is being fought very hard for the 
veterans by your national veterans organizations, who are doing 
a masterful, great job of advocating. But that's not going to 
be enough. We're all going to have to hang in there.
    Again, the challenges of veterans nationally are the same 
challenges that we have here in Hawaii in a number of areas. 
Healthcare is number one. Access to Federal Government 
contracts I would put number two, and then basic outreach. I 
think that that's important. If I were to say what the three 
priorities are, those would be them.
    We have challenges in Hawaii that affect Hawaii as a rural 
area, just as they affect any other rural area of our country. 
Access to medical care. The application of telemedicine, which 
is an amazing possibility, not possibility, actuality. I 
certainly encourage our National Government to redouble its 
areas in the area of telemedicine.
    That can eliminate distance problems right away, and all 
the issues that we have about getting veterans from Lanai to 
adequate, affordable healthcare on Oahu or Maui. We can do a 
lot of that just by basic telemedicine. We're doing that in 
other areas of health provision in the neighbor islands.
    We have specific challenges for Hawaii as an island State. 
It is not as simple as just jumping in your car and driving 200 
miles down the road, even though that's a problem for many 
veterans. It costs a lot of money to get from Lanai nowadays to 
Tripler or wherever else you might go. We have to accommodate 
that. We're trying to accommodate that. But I think we've got 
work to do.
    Other concerns are a little more individual. I talked about 
the cemetery situation. We have particular personnel issues 
that come up every once in a while in terms of the provision of 
broader veteran services. This is a hard job to provide. 
There's some burnout involved, especially in some parts of it. 
We've got good, solid people that have been doing yeoman's 
service out there. I think you all know somebody like that 
who's in the system right now, who's going above and beyond the 
call.
    But we've got to take care of the personnel that are 
working in the veterans area on behalf of all of our veterans. 
I think we've got to pay attention when those situations arise 
on an isolated basis. Again, I don't think it's something 
that's pervasive. But I do think it's something that has to be 
watched over.
    So those are some overall observations, so overall 
conclusions, some overall recommendations, and certainly some 
overall courses of action that I certainly intend to continue 
to pursue and which I want to pursue with you.
    I thank you again, Senator Akaka, for bringing the 
Committee here, and I thank all the participants here today. We 
all need to return to D.C., as you will next week and as I will 
later in the month, to redouble our efforts on behalf of 
veterans. We're going into a new Federal budget. We're going to 
get the new Federal budget in early February, and I fear for 
what it's going to say about the priorities of veterans. I 
think we're going to have to fight this fight all over again, 
so we've all got to be ready to do it.
    I certainly am there myself, and look forward to working 
with each and all of you. Thank you very much.
    [Applause.]
    [The prepared statement of Mr. Case follows:]

        Prepared Statement of Hon. Ed Case, U.S. Representative 
                       from Hawaii, 2nd District

    I am proud and humbled to represent you and our Hawaii's almost 
120,000 fellow veterans in our U.S. Congress.
    Fully 14 percent of Hawaii's adult population are veterans, one of 
the highest percentages in our Nation. Fully 5 percent of all Hawaii 
citizens 18 to 64 years old are currently serving in our armed forces, 
the highest percentage in our country. These numbers prove what we all 
know: that our Hawaii has been, is and will remain deeply committed to 
contributing to our Nation's defense; and that we must all be 
especially dedicated to meeting our obligations to not only today's 
veterans, but tomorrow's as well.
    In my 2004 Veterans Report last June, I reported that the prior 
108th Congress (2003-2004) was most difficult for our Nation's veterans 
due to concerted efforts within our Federal Government to reduce 
benefits earned by current veterans and to underestimate the needs of 
future veterans. Unfortunately, that trend has continued in the current 
109th Congress (2005-2006), where we have seen great resistance to 
funding especially crucial health needs and to recognizing the special 
needs of our troops returning from Iraq, Afghanistan and elsewhere.
    In this report, I summarize just some of many national veterans 
issues my Congressional colleagues and I have pursued to fully meet our 
country's obligations to you and yours. I also summarize some of my 
efforts in our Hawaii, where I have been especially fortunate to ``talk 
story'' with so many veterans throughout our state. As you well know, 
here at home veterans needs are often different than on the mainland 
(for example, the difficulty in getting from island to island for 
healthcare or of maintaining veterans cemeteries on different islands). 
In addition, I tell you about my congressional office and how we can 
and want to help you, whether veterans-related or otherwise.
    Finally, especially important for me is a quick survey of your 
views and needs as one of our Hawaii's veterans. This is invaluable to 
my continued efforts on your behalf, just as my June 2004 veterans 
survey proved indispensable, and I appreciate your response.
    It is my great privilege to serve you and yours in our Congress. I 
truly look forward to continuing to work with you on not only the needs 
of our veterans, but our other efforts toward a better Hawaii, country 
and world.
    With aloha.

       SELECTED VETERANS ISSUES IN THE 109TH CONGRESS (2005-2006)

1. Veterans Budget
    By far the most all-encompassing challenge continuing to face all 
current and future veterans nationwide is the ongoing effort in 
Washington, D.C. to limit funding of veterans benefits.
    As you know, the U.S. Department of Veterans Affairs (VA) 
administers promised benefits to eligible veterans, ranging from 
disability compensation and pensions to hospital and medical care. VA 
provides these benefits to veterans through three major operating 
units: the Veterans Health Administration (VHA), the Veterans Benefits 
Administration (VBA) and the National Cemetery Administration (NCA).
    VHA is mainly a direct service provider of primary care, 
specialized care, and related medical and social support services to 
veterans through an integrated health care system. Veterans are 
enrolled in priority groups that determine payments for service and 
non-service connected medical conditions.
    It is veterans healthcare generally and VHA specifically where we 
have seen both the greatest needs for our veterans and the most 
concentrated efforts to curtail funding. The current Administration's 
budget request for fiscal year 2006 (which began on October 1, 2005) 
would have significantly shortfunded adequate veterans health care in 
fiscal year 2006 (as was demonstrated when the VHA ran out of money in 
June and came to Congress for a $1.5 billion supplemental appropriation 
just to get through fiscal year 2005.)
    As a Member of the House Budget Committee, I worked with colleagues 
on both sides of the aisle to craft a fiscal year 2006 budget that 
reined in our country's spiraling debt and deficit while adequately 
funding our Nation's highest priorities, including veterans benefits. 
When the fiscal year 2006 Budget Resolution, setting the overall 
framework for the Federal Government's 2006 fiscal year, failed to do 
this, I voted against it.
    This basic debate continued throughout Congress's consideration of 
H.R. 2528, making actual appropriations for VHA and other military/
veterans programs for fiscal year 2006, with many national veterans 
groups joining us in advocating forcefully for adequate veterans 
funding. In mid-November, Congress approved a final version of this 
bill which funds VHA at more than what the Administration requested but 
less than what is necessary to keep up with true need. Obviously, this 
effort must continue and is, in my mind, the single most important 
veterans issue facing us all.
2. Congressional Consideration of Veterans Issue
    Perhaps what has happened in Congress on veterans issues is not 
surprising given that the basic and time-honored legislative process in 
this area has eroded. Things didn't get off to a good start in the 
current 109th Congress when the Chair of the U.S. House Committee on 
Veterans' Affairs was replaced by House leadership because he was 
viewed as too sympathetic to veterans needs.
    More difficult to understand is the recent announcement by the 
current Committee Chair that the decades-old tradition of conducting 
annual joint hearings of the House and Senate Veterans' Affairs 
committees will be discontinued. These hearings have provided an 
invaluable forum for Congress collectively to review the legislative 
priorities of veterans and military service organizations like AMVETS, 
the American Legion, Disabled American Veterans, Paralyzed Veterans of 
America, and Veterans of Foreign Wars of the United States, and to 
dialog directly with these invaluable representatives of America's 
veterans. I joined many of my colleagues in a letter to the House 
Speaker decrying this decision and urging that it be reversed; at this 
writing that has not occurred.
3. New GI Bill of Rights for the 21st Century Act
    Clearly, in the big picture, we must not only maintain the basic 
fabric of our prior undertakings to our veterans, but also adjust and 
update them to today's and tomorrow's needs. The best overall 
formulation of where we need to go is contained in H.R. 2131, the 
proposed New GI Bill of Rights for the 21st Century Act, which was 
introduced by my colleague, Representative Chet Edwards of Texas. I am 
an original cosponsor of the measure which, to date, has the support of 
171 Members of Congress.
    H.R. 2131 seeks a wide-ranging update in our basic deal with our 
veterans. Among its many provisions, H.R. 2131 would (1) mandate 
adequate funding for veterans medical care, (2) prohibit until the end 
of fiscal year 2006 medication co-payments and imposition of a health 
care system enrollment fee, (3) extend until 2010 Vietnam veterans 
eligibility for readjustment counseling services, (4) collect and 
process data from pre- and post-deployment health assessments, and 
conduct preventive post-deployment intervention, (5) seek early 
detection and treatment of post-traumatic stress disorder (PTSD) for 
returning troops, (6) establish a Department of Defense/Department of 
Veterans Affairs Council on Post-Deployment Mental Health, (7) increase 
survivors' dependency and indemnity compensation (DIC), (8) provide 
certain pay increases and bonuses for active-duty members, (9) expand 
benefits under both active-duty and reserve Montgomery GI Bill 
programs, (10) provide employment assistance for homeless veterans, and 
(11) expand reserve member eligibility under the TRICARE program. This 
bill would also repeal the DIC offset from the Survivor Benefit Plan 
surviving spouse annuities.
4. Concurrent Receipt
    Until 2004, Federal law required that military retired pay be 
reduced by the amount of any VA disability compensation received. For 
many years, some military retirees had sought a change in law to permit 
receipt of all or some of both, and legislation to allow this has been 
introduced during the past several Congresses, frequently with 
cosponsors, including myself, numbering well over half of both the 
House and the Senate. This is known as ``concurrent receipt'' because 
it authorizes the simultaneous receipt of two types of benefits.
    The fiscal year 2003 National Defense Authorization Act (NDAA), 
enacted in 2002, created a benefit known as ``combat-related special 
compensation,'' or CRSC. CRSC provides, for certain seriously disabled 
retirees, a cash benefit financially identical to what concurrent 
receipt would provide them. The fiscal year 2004 NDAA authorized, for 
the first time, actual concurrent receipt, as well as a greatly 
expanded CRSC program. The fiscal year 2005 NDAA further liberalized 
the concurrent receipt rules contained in the fiscal year 2004 NDAA.
    While these initiatives, which I supported, addressed some of this 
longstanding injustice, I asked the House Committee on Government 
Reform to evaluate the extent to which Hawaii veterans in my Second 
District are still affected by the non-concurrent receipt penalty. The 
Committee reported that over 2,100 veterans in our district--and over 
4,500 veterans throughout the state--still lose benefits due to the 
disabled veterans tax.
    There have been a number of bills introduced this Congress seeking 
full concurrent receipt. The one with the greatest support is H.R. 303. 
This bill would (1) allow immediate concurrent receipt, rather than 
phasing it in between now and 2014, and (2) repeal the requirement that 
only military retirees with a 50 percent disability rating can qualify 
for concurrent receipt, allowing it for any retiree with a service-
connected disability.
    I am a cosponsor of this bill. Also, because of current 
leadership's refusal to bring this bill to the floor for a vote, I, 
along with over 200 of my colleagues, have signed a ``discharge 
petition'' which would mandate an up-or-down vote of the full House. As 
it takes a majority of House Members (218) to successfully force such a 
vote under this procedure, we have been working closely with national 
veterans groups toward achieving this goal.
5. Survivor Benefit Plan (SBPI)
    Our country's obligation to its veterans extends to your families. 
However, under previous law, surviving spouses who reach the age of 62 
had their retirement benefits reduced from 55 percent of the deceased 
servicemember's benefit to 35 percent of the deceased servicemember's 
benefit. This unfair reduction--sometimes referred to as the ``widow's 
tax''--caused a substantial hardship on the surviving spouse.
    Prior efforts, in which I joined, to eliminate the penalty were met 
with resistance. However, last year, sensing growing support, 
congressional leadership added a provision to the fiscal year 2005 
defense authorization bill to phaseout the SBP penalty.
    Now, however, the issue, like concurrent receipt, is whether 
surviving spouses receiving survivor benefits should continue to be 
penalized by not being entitled to receive the combined total of such 
benefits and dependent and indemnity compensation (DIC). I and many 
other colleagues believe this is also unfair, and so have introduced 
H.R. 808 to eliminate the military families tax.
6. Equity for Filipino Veterans
    Our Filipino veterans communities both in Hawaii and throughout our 
Nation continue to pursue the critical support needed to restore to our 
Filipino veterans the full benefits unfairly withdrawn by Congress in 
1946. During the 108th Congress, we had partial success when Congress 
passed and the President signed into law H.R. 2297, which I had 
cosponsored, to increase VA benefits for U.S. Filipino WWII veterans 
and allow former Philippine Scouts living in the U.S. to be buried in 
VA cemeteries.
    This long overdue effort must be continued until full justice is 
provided to our now elderly Filipino veterans. To this end, I am a 
cosponsor of H.R. 302, the Filipino Veterans Equity Act, to deem 
certain service performed before July 1, 1946, in the organized 
military forces of the Philippines and the Philippine Scouts, as active 
military service for purposes of eligibility for U.S. veterans 
benefits, and to repeal certain provisions discounting such service as 
qualifying service. We don't have much time left to do the right thing 
here, and we are working toward doing just that.
7. Federal Budget
    There should be no doubt that, in the big picture, the reason for 
the pervasive resistance in D.C. to full and fair funding of existing 
requirements and needs, much less long-denied needs and other 
initiatives necessary to provide basic fairness to our existing and 
soon-to-be veterans and to encourage enlistment in our armed forces, is 
largely the rapid deterioration over the last half-decade in our 
Nation's overall finances. In a nutshell, we have not properly (1) 
balanced revenues and expenses, resulting in the largest annual 
deficits and fastest increases in our Nation's total debt (now over $8 
trillion, up $2 trillion just since I began representing you here in 
2002) in our Nation's history, (2) prioritized spending, and (3) 
addressed ongoing government inefficiency and waste. Until we correct 
these all-encompassing deficiencies, too many here will continue, in 
one form of another, to shortchange our Nation's veterans.

                       SELECTED HAWAII ACTIVITIES

1. Keeping In Touch
    Staying in touch with you and our Hawaii's veterans is essential 
not only to recognizing your invaluable contributions, but to 
representing you in Congress and to assisting with Hawaii-specific 
challenges. I have been fortunate now to join you and speak at many 
Memorial Day, Veterans Day and other ceremonies throughout our state, 
in addition to many other events like the groundbreaking for the new 
Oahu Veterans Center and the annual cleanup at the Kauai Veterans 
Cemetery. I have also spent time just dropping by veterans centers on 
Molokai, Maui and Hawaii Island.
    My Talk Story community meetings district wide have been especially 
invaluable to keeping up on veterans issues, not just nationally but 
locally. I've done 50 in 2005 throughout Hawaii as well as with 
Hawaii's own 29th Brigade Combat Team in Fort Polk, Louisiana and 
Balad, Iraq. From these Talk Stories I learned, for example, of a 
crucial challenge facing Maui's veterans, on which we are working, and 
of the Lanai veterans' request for a U.S. flag flown over our Capitol, 
which I was able to provide.
    My point here is that we can accomplish more together and I can 
focus on your needs better if and as we stay in touch. I am always 
willing to try to work into my schedule a meeting with Hawaii's 
veterans or attendance at an important event, and encourage you to call 
on me for such needs and opportunities.
2. Visiting Our Troops
    Today's active military forces are tomorrow's veterans. Especially 
in this extremely difficult time, when we have hundreds of thousands of 
our own fighting for us overseas, I believe it is crucial for people 
like me to spend time with our troops where they are, not only to show 
our support and solidarity, but to understand and address current and 
future challenges. I've done this through visits throughout our Hawaii 
and overseas. I've now visited our troops in Iraq in 2003 and 2005, and 
in Afghanistan in 2004. My discussions and observations during those 
trips have played a major role in my own thinking on our obligations to 
our current and future veterans, including our guard and reserve 
component.
3. Funding
    Many of our veterans issues in Hawaii involve funding of local 
needs, from cemeteries to centers and other facilities to specific 
programs. My efforts in this area have been to seek financial 
assistance from our Federal Government through existing programs or 
annual congressional allocations, and to support funding requests from 
individual veterans and your organizations and Federal, state and 
county government veterans representatives. As we move into the Federal 
Government's 2006 fiscal year, and look already toward the fiscal year 
2007 congressional appropriations process which starts up in the 
remainder of this year and early next year, I especially need to hear 
from you on specific Hawaii needs so I can assist in the best manner 
available.
4. Benefits Workshops
    Over my last 3 years of representing Hawaii veterans, both 
individually and collectively, it has become increasingly clear that in 
too many instances our veterans are simply not fully aware of their 
benefit and other rights and entitlements under law. I discussed this 
challenge most recently with Dr. James Hastings, the new director of 
the VA's Pacific Health Care System, and will be working with him and 
your other veterans agencies to sponsor a series of outreach benefits 
workshops throughout my district. I am aiming to conduct these 
workshops in the first quarter of 2006, and welcome your input on how 
best to do so and how my office may otherwise assist in educating our 
veterans on the basics of our veterans system.

    Senator Akaka. Mahalo. Mahalo nui loa, Representative Case. 
I thank you very much for what we call in Hawaii mana'o, and it 
starts about veterans here and across the country. Thank you, 
Representative Case, so much for taking the time to be with us 
this morning. Mahalo nui loa. I want to thank him for being 
here.
    I'm pleased also to tell you that we were joined by 
Chairman Larry Craig for the past 2 days. We're very fortunate 
to have him because he has other schedules. But he certainly 
really contributed to the hearings and the success of the 
hearings that we've already had. But he reluctantly had to go 
back to his snowy State because he had other responsibilities 
there.
    I want you to know that this is bipartisan effort. We work 
very closely together and very well together, and look forward 
to continuing to do that to help our veterans here in Hawaii. 
I'm also pleased to announce that the VA at the national level 
and the regional level and the State level on Maui and Kauai 
did make statements that they'll help our veterans on Molokai 
and Lanai as well. I think they have unique problems, too.
    But this has been very fruitful for all of us. I want to 
again mention that it made a difference. I want to thank 
Representative Case. I know he has a busy schedule.
    I also want to mention that in the back of the room, 
uniquely, we have a desk of staff, VA staff as well as our 
staff in the Senate, who are there to help anyone here who has 
a concern or needs some help. You can go back there and talk 
with them.
    In case you have a letter, please present it to them. I 
think you know that letters are very important to us because if 
we do any inquiry, you know, it's a privacy issue that we have 
to be careful of, and receiving a letter from you does take 
care of that for us. I just wanted you to know that they're 
back there. So please feel free to stand and seek that help.
    My purpose in holding these hearings is to find out, as the 
Ranking Member of the Veterans' Affairs Committee, how we can 
help VA provide the best care and services to Hawaii's 
veterans. That's what we're here to do.
    So I'd like to call forward our first--our panel here, 
which is now our second one. William Daves, who's President of 
Oahu Veterans Council. Mike McCloskey, who's a member of the 
National Executive Committee of the American Legion, Department 
of Hawaii. Caz Roswell, service officer, military, awarded the 
Purple Heart. Lieutenant General (Ret.) Tom Rienzi, Veterans 
Advisory Council. Gil Hough, member of the Veterans Advisory 
Council. Colonel (Ret.) Edward Cruickshank, Director, Office of 
Veterans Services.
    We're delighted to have all of you here. I would like to 
ask you to give your testimony in the order that I introduced 
you. So the first will be William Daves, and here's your mike.

             STATEMENT OF WILLIAM DAVES, PRESIDENT,
                     OAHU VETERANS COUNCIL

    Mr. Daves. Thank you and mahalo.
    I want to talk this morning about a program that the VA 
have. It's called CHAMPVA. CHAMPVA is given out to people on 
DIC, and there are no doctors. There are two on Oahu, I think.
    I happen to know of a widow that's getting DIC with two 
children. There are no doctors. There are no pediatricians. I 
can't ask anybody in the VA. They give me the telephone number 
of the place in Denver, and that's as far as you get. That's 
all I wanted to talk about this morning.

  STATEMENT OF MICHAEL McCLOSKEY, MEMBER, NATIONAL EXECUTIVE 
      COMMITTEE, THE AMERICAN LEGION, DEPARTMENT OF HAWAII

    Mr. McCloskey. Good morning. I'd like to thank Congressman 
Case, Senator Akaka, the VA staffers that are here, and of 
course all the wonderful veterans and their families that we've 
got turned out. Mahalo for coming, and aloha. We provided our 
written testimony from the American Legion's perspective. There 
are just a couple of things that I'd like to cover.
    The American Legion's position on medical care for veterans 
is mandatory funding. Mandatory funding is needed so that every 
veteran is adequately taken care of whenever they go to a VA 
clinic. We are at war, ladies and gentlemen. This is not the 
time to be arguing over veterans benefits or trying to nickel 
and dime folks that are shedding their blood and their sweat 
for this country. We simply need mandatory medical care.
    Congressman Case spoke very briefly about the battle that's 
going to come in Congress over funding for the VA. I know that 
the VA sitting over here is going to work hard to get as much 
money as they can to do the best they can for you.
    It's not going to be enough. Right now, only about 20 
percent of the veterans in this State seek and receive VA 
medical care. Many of them do not seek care simply because it's 
so hard to access. As Congressman Case pointed out, 
geographical separation, cost of travel, lack of specialists, 
these all contribute. The bottom line is always money. We rely 
on our congressional delegation, led by Senator Inouye and 
Senator Akaka, to help us with this issue. It is our major 
issue.
    The American Legion also has some major concerns about the 
reassessment of PTSD claims. We are very pleased that those 
claims were not reviewed, the 75,000 cases. We believe that 
would have been counterproductive not only for the VA, but 
extremely harmful to those involved in the process.
    Lastly, I'd like to talk a little bit about readjustment 
counseling. We have a great readjustment counseling service led 
by Steve Molnar here on Oahu. It's not big enough. We need two 
Vet Centers on this island. Ideally, we would have a Vet Center 
located somewhere in Kapolei. Population growth on the leeward 
coast mandates some VA services be placed in that area. I 
believe that that's something we could do.
    The clinics on the outer islands are doing a great job. The 
Vet Centers on the outer islands are doing a great job. But 
they need help. People, some people, do not go to access those 
services because they don't want to wait in line.
    In conclusion, I'd like to say a couple of real good things 
about the VA. The voc rehab program under Ed Gavigan [ph] is 
excellent. They're doing a great job. But he needs help, too. 
The loan guarantee program is also doing an excellent job. They 
just lost one of the best in the business when Tom Sirocca [ph] 
retired last year. But I believe the young lady that they've 
selected to replace Tom is going to do a great job.
    We ask that Senator Akaka and Congressman Case fight hard 
so that we can get the Native Hawaiian program--the Native 
American loan program, thank you--passed and make it permanent. 
That would be really a great deal.
    I see Jim Carilli sitting out here, and most of you know 
Jim. He used to be my boss. There were some at the VA that 
probably thought that the claims process and the workload might 
improve after I retired a year or so ago. Sadly, it didn't. Jim 
needs help. He needs more people to do this very complex 
medical and legal job that he's got. We need to encourage our 
congressional delegation to give these folks all the help they 
can get.
    Thank you very much, Senator Akaka. I appreciate this 
opportunity to speak. We hope that you'll carry this back and 
continue to help our veterans in Hawaii. Mahalo.
    [The prepared statement of Mr. McCloskey follows:]

  Prepared Statement of Michael McCloskey, Member, National Executive 
          Committee, The American Legion, Department of Hawaii

    Senator Akaka, Thank you for the opportunity to participate in this 
forum. Our purpose is to bring to your attention various issues and 
concerns related to the quality and availability of Department of 
Veterans Affairs health care for veterans who reside in Hawai'i.
    As the largest war time veterans organization in the State, we 
believe we are uniquely qualified to speak on these issues.
    1. As National Commander Bock stated in his September 20, 2005 
before a joint session of the Congressional Veterans Affairs 
Committees, there have been recent attempts by some in the 109th 
Congress to create an artificial distinction among veterans; the so-
called ``core constituency'' of veterans eligible for VA Medical Care. 
There have been characterizations of deserving versus undeserving. 
Veterans who Congress granted eligibility for medical care were accused 
of seeking a ``free ride'' and causing ``real'' veterans to wait for 
care. Honorable military service, whether for a single enlistment, a 
30-year career or National Guardsmen and Reservists called to active 
duty for shorter periods due to war time operations is not comparable 
to civilian employment. It is not just another job! Now who answer the 
call to arms are entitled by law to very specific individual legal 
status and entitlements that must not be denigrated regardless of 
whether or not their service involved participation in direct combat 
operations or in support roles. There is no draft or otherwise 
involuntary military service in the United States. We as a Nation rely 
upon the willingness of the population at large to serve. Consequently, 
debate regarding whether or not one group or another is more or less 
deserving is not only hurtful to the individuals concerned but damages 
our ability to recruit and retain capable individuals at a time when we 
most need them. Consider, what would have become of this Country if 
such debate and controversy had existed in some of the most critical 
times in our history, e.g., the Revolution, the Civil War, or World War 
II. It is with this in mind that we support MANDATORY funding of 
medical care for all honorably discharged veterans. This is the minimum 
that should be provided to those who raise their right hands and swear 
to uphold and defend our way of life. Medical care for those who we 
should not be an annual political ballgame with the only losers those 
who shed their blood and sweat to insure the continued existence of our 
Country. It is time to stop balancing the National Budget on the backs 
of those who defend us.
    2. Approximately 110,000 veterans reside in the State of Hawai'i. 
In recent years, this population has been decreasing due to the demise 
of aging World War II and Korea Veterans. However, the current war 
which must be assumed will continue for some years to come will 
undoubtedly keep this number either stable or increasing. Department of 
Veterans Affairs data indicates that only about 20 percent of the 
veteran population receives care from VA medical facilities in Hawai'i. 
Input from our membership indicates that many more would do so but for 
the difficulties veterans experience in getting to and from VA those 
facilities. There are a number of factors that contribute to this 
problem. One of the most significant is the fact that we are an island 
State. One cannot drive from Molokai to O'ahu. In recognition of this 
the Department of Veterans Affairs has established outpatient clinics 
on the major neighbor islands of Hawai'i, Kaua'i, and Mau'i. new 
Clinics have generally provided excellent service to those who are able 
to access them. However, it is our position that too few veterans are 
We to access that care simply because of limited clinic staffing and 
limited dollars in the VA budget. Nearly 75 percent of our veteran 
population resides on the Island of O'ahu. Even on O'ahu which has the 
largest and most sophisticated VA clinic in the State, most veterans do 
not seek VA medical care unless they have no other option. Again, 
limited staffing and limited budget dollars restrict many who need and 
deserve VA care. Put simply, we need more doctors, more nurses, and 
more and better equipped facilities. Now, neighbor island patients are 
often flown to O'ahu for medical care and examinations that cannot be 
conducted locally due to limited or non-existent facilities. Many 
debilitated or aged veterans required to make these trips need the 
assistance of an attendant to travel. The cost of the travel makes this 
a difficult budget issue for the VA but oftentimes, the lack of local 
specialists or simply the prohibitive cost of private sector treatment 
mandates it. Larger, more comprehensive facilities on each major island 
would eradicate this problem. The argument that many veterans have a 
wide range of medical care alternatives outside the VA does not negate 
the Nation's obligation to those who served VA is in effect rationing 
medical care. This rationing causes many aging veterans to pay high 
insurance premiums and to make difficult and ultimately unhealthy 
choices, e.g., do I pay for the medication I need or do I buy food and 
pay my rent? now who served should not be asked to make sacrifices of 
this nature.
    3. Another problem of increasing concern is the lack of adequate 
long-term medical services and facilities in the State. The VA's Center 
for Aging is a 60-bed facility located on the Tripler Army Medical 
Center. It provides excellent service from a highly trained staff of 
dedicated medical professionals. However, it is totally inadequate to 
meet the needs of our aging veteran population. Consequently, it is 
used to care primarily for patients requiring short-term inpatient care 
as in surgery recovery. It is not intended for long-term care. To meet 
the needs of our veterans, similar facilities should be constructed on 
each of the major neighbor islands. In this same regard, a State 
Veterans Hospital intended for long-term care is in the works on the 
Island of Hawai'i at Hilo. This is a great start but again is totally 
inadequate to meet the needs of the aging veteran population of this 
State. Our Congressional Delegation is asked to support the development 
of similar facilities on each of the major neighbor islands.
    4. We have a number of concerns regarding the care and treatment of 
veterans suffering from post traumatic stress disorder (PTSD). The 
number of veterans filing claims for service connection and treatment 
for this condition has risen dramatically over the past 10 years. As we 
are engaged in a global war of unknown duration it is likely that the 
number of these cases will continue to increase. Consequently, the cost 
of compensation and treatment is also likely to escalate. This issue 
and the collateral issue of awarding Individual Unemployability (IU) 
benefits to many veterans disabled by symptoms of PTSD apparently 
prompted the Department of Veterans Affairs last year to begin 
questioning whether some of these claims were appropriate. A review of 
several thousand cases was conducted, and a review of all such cases 
granted was announced. As you can imagine, the impact of this 
announcement on those who suffer from PTSD and rely totally on VA 
compensation as their only income was enormous. Many patients symptoms 
were exacerbated because of fear that VA would stop their compensation 
payments and/or interfere with their ongoing clinical psychiatric care. 
Many of these veterans had fought for years to obtain the benefits and 
it was seen as a setback by not only veterans but mental health care 
professionals as well. Subsequently, the VA announced that the review 
had been canceled and we applaud that decision. However, we have been 
recently advised that another move is being made by VA to perhaps 
restructure the Rating Schedule or to change the criteria for a PTSD 
diagnosis. Obviously, fewer diagnoses of PTSD or fewer grants of 
compensation based on PTSD would save lots of money. This appears to be 
another attempt to balance the budget on the backs of those who served. 
It is a particularly malignant scheme that presumes that lawyers and 
bean counters know more about mental health and the impact of trauma 
than mental health professionals. The DMSN which provides the basis and 
requirements for diagnosis of mental illness is predicated on input 
from the best qualified mental health professionals in the Nation. We 
oppose any effort to restrict or change the application of criteria 
currently established by law for the diagnosis of PTSD or the award of 
compensation benefits based on such diagnosis. We believe that this is 
particularly unconscionable in light of large numbers of troops 
returning from the war zone and in need of help for symptoms of PTSD.
    5. There are currently five Vet Centers in the State. These 
facilities provide outreach efforts for readjustment counseling and 
family counseling for all war time veterans. They have proven to be 
particularly effective and cost efficient. We currently have two on the 
Island of Hawai'i (Hilo and Kailua--Kona), one on Kaua'i, one on Mau'i, 
and one O'ahu. All of these facilities provide excellent and easy to 
access services to literally hundreds of veterans and their families. 
However, the Honolulu office is not adequate to meet the needs of our 
island community. A second facility is needed to meet the increasing 
need and permit easier access from O'ahu communities outside Honolulu 
proper particularly the rapidly growing population of the Leeward 
Coast. We solicit your support in acquiring the necessary funding for 
additional staffing and a new facility somewhere in the Kapolei area.
    6. Until last year, the VA maintained an inpatient facility for 
treatment of PTSD on the Island of Hawai'i. That facility was closed 
with the stated intention of moving it to the Island of O'ahu. The new 
facility has not opened. Put simply, this is an important tool in 
dealing with our growing PTSD patient population. This facility 
combined with our VA mental health clinics and Vet Centers has been an 
extremely effective tool for dealing with what we perceive to be a 
growing problem. Please insure that adequate funding is provided to 
make the new inpatient facility a reality.
    In closing, Senator Akaka, Members of the Commission, and fellow 
veterans, we greatly appreciate this opportunity to present testimony 
regarding VA healthcare in Hawaii. We hope that the information we have 
presented will be valuable and useful to you in making good decisions 
for veterans when you return to Washington. As you can see, the VA in 
Hawai'i has unique problems because of the geographic separation of our 
islands and distance from the continental United States. Our VA 
facilities also face the burden of caring for many veterans who reside 
in Guam, Micronesia, and Samoa. With all this in mind, we hope that 
your actions will reflect the needs of our veterans and provide us with 
the tools to meet the challenges of the 21st Century. On behalf of all 
veterans and especially members of the American Legion Department of 
Hawai'i, we thank you sincerely for allowing us to participate in this 
vital endeavor.

STATEMENT OF MASTER CHIEF PETTY OFFICER GIL HOUGH (RET.), U.S. 
            NAVY; MEMBER, VETERANS ADVISORY COUNCIL

    Master Chief Hough. Senator Akaka, distinguished guests, 
and fellow disabled veterans, good morning and aloha. My name 
is Gil Hough. I'm a retired Master Chief Petty Officer in the 
United States Navy who served 30 years. I am also a member of 
the Pacific Healthcare Advisory Board of the Department of 
Veterans Affairs.
    First, I'd like to say thank you, VA. The VA to me and my 
family have been there for everything we've needed. When I 
first came to Hawaii on my 35th birthday, they gave me a GI 
loan to buy my first house. They paid for me to get an 
associate, bachelor's, and master's degree. They gave me 
veterans preference and disability when I returned, veterans 
preference in hiring so I could become the Director of the U.S. 
Department of Labor here for veterans employment and training.
    They put me in the hospital as a patient. I received 
medicine from them in the mail, direct, very promptly. 
Something I don't want to--well, I will. But my son recently 
passed away in the VA hospital in Portland, and the VA provided 
extraordinary care for him. He was too sick to survive. He's 
also buried at the Willamette National Cemetery in Oregon. So 
I'm going to say that we are a consumer of the VA in my family.
    Is there something wrong with the VA? Well, sure. Somebody 
as large as the VA, there's always going to be problems. I'm 
very pleased that General Hastings was appointed to be the new 
Director because I know with he and General Pollock, they can 
help us maximize our resources and services to provide even 
better services for our veterans.
    I know right now there's a concept of building a joint 
hospital in Great Lakes, Illinois, a Navy/VA joint hospital. 
That would be great. Hawaii is simply one of two States in the 
Nation that doesn't have a VA hospital. Yes, Senator, we need 
more money if we don't have a hospital, so we need better 
services.
    I want to say the Center for Aging is a real class 
organization. Just terrific. I've seen doctors up there cooking 
hamburgers and hot dogs for their patients. It's just great. 
I'd like to see some more beds because we have a lot of 
veterans that are old and need the services, especially on the 
neighbor islands.
    I'm going to just talk about a couple of things. They're 
not real negatives, but they could be fixed. One of them, 
Norbert Enos [ph], our past state commander for the VFW, told 
me that he recently picked up a veteran that came from the 
neighbor islands to bring up to the VA for an EKG test. Well, 
I'm sure that we can give an EKG in Maui. I mean, it's not 
rocket science.
    Another case that was shared with me by a member here in 
this room is a veteran came over from a neighbor island to his 
appointment. He got tied up with the security processing, was 
20 minutes late, and they canceled his appointment. He had to 
make a new appointment and come back 2 months later. Now, that 
is just really not right. We've got to figure out something to 
do to improve that.
    A third item that concerns me is the orthopedic care that 
our veterans get. We have veterans that are very aged, 75, 80 
years old, and we want to send them to Palo Alto for a hip 
replacement or a knee replacement? That's unacceptable. They 
have a hard time getting back on their own.
    We need to figure out here in Hawaii how to get that done. 
I mean, we can do it. We're a great State. We're the 50th 
State. We've got the power and the genius to get all these 
things accomplished.
    My fellow veterans, that's all I have to say, but thank you 
very much.
    [Applause.]
    [The prepared statement of Mr. Hough follows:]

  Prepared Statement of Master Chief Petty Officer Gil Hough (Ret.), 
         United States Navy; Member, Veterans Advisory Council

    I have the distinct honor of residing in Hawaii since February 3, 
1978. I arrived here on that date to serve on the staff of the 
Commander in Chief, United States Pacific Fleet. I retired from the 
United States Navy on July 1, 1989 and made Hawaii our family home.
    The services provided by the Department of Veterans Affairs in 
Hawaii are outstanding. I personally have received benefits/services 
from them to include: home loan guaranty; education benefits; 
disability payments; preference in Federal hiring; hospitalization, 
dental treatment; pharmacy services and general health care. My 
shipmates and I are very proud of them and lucky to have the great 
services that the VA provides us. However, this is mainly because we 
live on Oahu!
    The consolidation of VA services with the United States Army in 
Hawaii (Tripler) was an absolute stroke of genius and provides a 
catalyst for future consolidation of services which will serve to 
maximize and leverage Government funding and services.
    I retired as the Director, Veterans' Employment and Training 
Service, United States Department of Labor on March 31, 2004. I had the 
opportunity to provide services to veterans in the State of Hawaii, 
Guam, and Asia. During my tenure the only negative areas that were 
personally encountered are services to our Neighbor Island veterans by 
all Agencies because services and facilities are limited.
    It would be my fondest wish that you and your colleagues do 
everything in your power to ensure the necessary stream of funding to 
ensure services to veterans on our Neighbor Islands are increased, 
services improved, and new facilities created.
    I know my fellow veterans on our Neighbor Islands will provide you 
with their issues regarding services to them.
    I wish to thank you for your outstanding contribution(s) to our 
great State and Nation. Please continue to do everything possible to 
ensure that our veterans continue to receive that which they so richly 
deserve.

STATEMENT OF LIEUTENANT GENERAL THOMAS RIENZI (RET.), CHAIRMAN, 
                   VETERANS ADVISORY COUNCIL

    General Rienzi. Sir, my name is Tom Rienzi. I'm Chairman of 
the Veterans Council here. I take a little bit different view, 
having stumbled around here for the last 50 years. I've been 
Chairman of the Retirement Council, and now the Veterans 
Council. I think I reasonably have seen and know what goes on 
and this is what I have to say.
    As Chairman of the Hawaii Veterans Council for the Pacific 
Ocean area, I state that the veterans/military hospital in 
Tripler, and the CBOCs, the clinics, are the best in the world.
    [Applause.]
    General Rienzi. It serves more than 120,000 vets, as 
Congressman Case said, about 60K in his area and 60K in the 
other congressman's area. It serves these 120,000 in a superior 
manner. I worked there as a chaplain for 22 years, so a 
chaplain knows an awful lot of what goes on in a hospital.
    Additionally, the VA staff, in my opinion--and I'm just a 
dumb little Italian from Philadelphia--the VA staff is well-
organized, capable, to serve our veterans promptly and 
effectively. I didn't say efficiently; I said effectively.
    [Laughter.]
    General Rienzi. I think a thing you should know, with the 
help of Max Cleland, Senator Max Cleland, who was my first 
aide, up on that hill now we have a VA hospital and a military 
hospital in the same place for the old fellows at one end and 
the young fellows at the other end. That's quite an 
accomplishment.
    Finally, if you would look at what we had 2 years ago in 
the outer islands, it was next to nothing. Today, except for 
Molokai, we have a veterans facility, a CBOC, a clinic with a 
nurse or a PTSD person. The only one we've missed so far is 
Molokai, and we'll get there.
    We're a hell of an organization doing a hell of a job. Are 
there mistakes being made? Yes. Are there cases in this room 
here that are awful? Well, I say bring them to me or bring them 
to Dr. Hastings and we'll solve them.
    God bless America, and God bless our veterans.
    [Applause.]
    [The prepared statement of Lieutenant General Rienzi 
follows:]

    Prepared Statement of Lieutenant General Thomas Rienzi (Ret.), 
                  Chairman, Veterans Advisory Council

    As the Chairman of the ``Hawaii VA Council'' for the Pacific Ocean 
area, I state that the VA/military hospitals on Tripler Hill is the 
best in the world. It serves our 100,000 veterans in a superior manner. 
Additionally, the VA staff is well-organized to capably serve our 
veterans promptly and effectively.
    With the help of Secretary Max Cleland, we combined the VA and 
military hospitals to be like one in caring for our personnel.

        STATEMENT OF CAZ ROSS, VETERAN SERVICE OFFICER, 
             THE MILITARY ORDER OF THE PURPLE HEART

    Mr. Ross. Very difficult to follow General Hastings [sic]. 
I really appreciate your sentiment.
    General Rienzi. That's General Rienzi.
    [Laughter.]
    Mr. Ross. That's right. Excuse me. Lieutenant General 
Thomas Patrick Rienzi. Yes, we've talked a lot.
    Chairman Akaka, Senator--Representative Case--I've promoted 
him already--and veterans who are here in attendance as well as 
members of the VA staff and senatorial staff, my name is Caz 
Ross and I'm the Veteran Service Officer for the Military Order 
of the Purple Heart as well as the Veteran Services Coordinator 
with the Office of Veterans Services. I also work with those 
members who are really in the Pacific, those people who are in 
Guam and in American Samoa.
    I'd just like to share just a small bit about of the 
excellent services that we get here on Oahu. We do get the best 
of medical care, and we have in fact had numerous awards that 
show that the VA medical care that we get on here in Oahu is in 
fact fantastic.
    Can we do more? Yes, through telemedicine, Oahu will be the 
center and we'll be able to get more services not only to our 
neighbor island individuals but also to those individuals in 
Guam as well as in American Samoa. It's just taking a lot of 
time, and many of those individuals are extremely frustrated 
with the amount of time that it's taking.
    We also have the same problem in terms of getting more 
medical care to our neighbor island people. That's what we're 
advocating for. We've got a very good system. We just need more 
of that system focused to those individuals in our rural areas, 
whether it be on Oahu or in our neighbor islands such as 
Molokai; Lanai, which we have 300 veterans on; Kalaupapa, where 
we have 5 veterans on. These individuals also need to be able 
to receive adequate medical services.
    A little message in terms of just talking about the 
services that we get from our benefits section. To date, 
service is slow due to the number of FTE not meeting the 
station's needs. I've been asked also to talk about another 
issue, and that issue is what we call 1151. This refers to 
individuals who in fact have medical conditions that become a 
problem because some medical problem occurred while those 
individuals were in a medical facility; a non-VA medical 
facility.
    As long as these individuals go to VA facilities, it's 
fantastic. However, in the State of Hawaii, we only have one VA 
clinic. The vast majority of individuals are sent out, either 
to Palo Alto or someplace else in California, and receive 
medical care.
    When they receive that medical care under the direction of 
the Department of Veterans Affairs in a VA facility, they are 
able to be compensated for any injury that is unintended. For 
example, if somebody loses an arm or a finger because of 
something that happened that's not intended to happen but it 
does, then these individuals are able to claim for a service-
connected disability.
    However, for those individuals who go to Straub, St. 
Francis, or Tripler Medical Center, they are not able to get 
the same type of benefit. They are not protected. We need to 
ensure that the Legislature, meaning the Congress, changes 
1,151, especially Section 38 U.S.C. 1701(3), which states that 
only those facilities under the direct control of the 
Department of Veterans Affairs are eligible to receive this 
type of protection. We need to include all veterans in Hawaii 
who go to non-VA medical facilities and who are not able to 
travel to the mainland, and make them comparable to the 
services that they will get at any other VA facility.
    Another thing that I would like to touch upon is that 
Hawaii is an island State. Everyone here noticed that. But when 
we have consolidation of services in terms of benefits, 
sometimes we lose out.
    Right now, we have a consolidation where we in Hawaii have 
to call to either Muskogee, Oklahoma or to St. Louis or to 
Minneapolis-St. Paul for certain types of benefits. People in 
Hawaii only have a 2-hour window to get in a 1-800 telephone 
call, and it doesn't happen. It's just very difficult in terms 
of accessing these services because the services have been 
consolidated to a mainland facility.
    Part of the solution, of course, is money. We've talked 
about this. We need to have an adequate number of raters here 
in the State of Hawaii so that we can handle ratings for those 
individuals. We don't have to send off so many of our claims to 
the mainland to be worked.
    I want to thank the VA for the services that they do 
provide. I want to thank the healthcare staff particularly 
because you've come a long way from where we first started. VA 
Benefits Staff are struggling, but I know that your people are 
working really hard to make this one of the better units in the 
United States.
    Again, thank you so much for allowing me to testify.
    [Applause.]

   STATEMENT OF COLONEL EDWARD CRUICKSHANK (RET.), DIRECTOR, 
                  OFFICE OF VETERANS SERVICES

    Colonel Cruickshank. Senator Akaka, Members of the Senate 
Committee on Veterans' Affairs, my name is Ed Cruickshank. I'm 
the Director of Veterans Services for the State of Hawaii. 
Based on everything you heard so far, I'm going to change my 
testimony because I just don't want to repeat myself.
    But before I get started, I'd like to recognize the Wessel 
[ph] family back there in the room. They lost their son 
fighting in Iraq. Will the Wessels please stand up? Let's give 
them a hand.
    [Applause.]
    Colonel Cruickshank. Thank you.
    Before I discuss some of the challenges that we all face 
here--and it's primarily because we're an island State--as 
Senator Akaka said, getting the services to our outer islands 
to provide services for veterans is a real problem. Getting the 
services here, we're very lucky. But we need to find ways to 
get services out to the other islands.
    But before I mention the challenges, I want to let all of 
you know, as everyone else has said so far, the VA healthcare 
has been excellent. The way the VA staffs treat their 
veterans--they treat their veterans with dignity and respect, 
and they do everything they possibly can to show the veterans 
they really do care. To you, General Hastings, I'd like to say 
your group and General Pollock do a wonderful job. With our 
returning 2,900 soldiers coming back this week, let me tell 
you, we're going to be counting on you to provide that service 
to them.
    On the island of Oahu, we have 70 percent of the veterans 
here. Two concerns that they have--well, not for those that are 
here but for those that are located on the other islands--is 
what they get assigned to mainland VA medical centers for 
surgical services. For neighbor island veterans, this can be 
very traumatic. They're saying, please let us fly out if at all 
possible from the neighboring islands. Especially since our 
veterans are quite elderly, many times it's a lot easier for 
them to do that.
    The other part that they keep mentioning a lot to me 
continually is on specialty care. I know when I spoke to 
General Hastings on this telemedicine, what is happening and 
what his goals are in the future, being just recently 
appointed, he's mentioned that we've got to get this 
telemedicine to the other islands so that we can take care of 
our veterans. I hope on his behalf, that really will be an 
integral part and something that happens very, very quickly.
    I'd like to just--we're a little bit separate from what we 
said here, and that is I think all of us have to continually 
address the issues of veterans and what care they're getting. 
For all of you here, you know exactly what we're talking about. 
But to you, Senator Akaka, it always comes down to a matter of 
money. If we can get the money or if VA can get the money, they 
can do their job. There's only so much they can do based on the 
amount of money that they have. That becomes the issue.
    So for all of you here, thank you very much for supporting 
the veterans. That completes my testimony, Senator Akaka.
    [The prepared statement of Colonel Cruickshank follows:]

  Prepared Statement of Colonel Edward Cruickshank (Ret.), Director, 
                      Office of Veterans Services

    Chairman Craig, Senator Akaka and Members of the Senate Committee 
on Veterans' Affairs, I am Edward Cruickshank, Director of the Office 
of Veterans Services, this office serves as the single office within 
the State Government responsible for the welfare of Veterans and their 
family members. We act as a liaison between the Governor and veterans 
groups and organizations and serve as an intermediary between the 
Department of Veterans Affairs and Hawaii's veterans. Based upon 
veteran's population estimates as of September 30, 2004, data from the 
Office of the Actuary, Department of Veterans Affairs, there are 
107,310 veterans in Hawaii. The majority or 72 percent live on Oahu, 13 
percent reside on the island of Hawaii, 10 percent live on one of the 
three islands which comprise Maui County, and approximately 5 percent 
live on Kauai. We are an island state located in the middle of the 
Pacific Ocean and Hawaii presents unique challenges for the Department 
of Veterans Affairs.
    Before I discuss some of these challenges, I want to share with you 
comments that my staff and I hear about VA health care very frequently. 
These comments speak to the excellence of VA care, how VA's staff treat 
our veterans with dignity and respect, and that the services rendered 
by the dedicated health care professionals is superior to the care they 
received on the mainland (that is the continental United States). These 
comments are shared with us by local veterans as well as by veterans 
who visit Hawaii and have a need to interact with Spark M. Matsunaga 
Medical staff. When you speak of an organization that supports our 
troops, the VA exemplifies that phrase by supporting our troops at 
home, when they return and after conclusion of their military service. 
I am delighted with the services that VA offers to Hawaii's veterans, 
to include the health care, benefits, and services provided at the 
National Memorial Cemetery of the Pacific; locally known as the 
Punchbowl Cemetery.
    As mentioned earlier Hawaii presents challenges to the VA. We are 
an island state with one large population center on Oahu and 30 percent 
of veterans living on the neighbor islands. Presently many of our 
veterans are referred for surgical services to mainland VA medical 
centers. For neighbor island veterans this can be very traumatic. They 
are booked on flights, sent to a city on the mainland, find the VA 
facility, operated on and sent back to Hawaii. We ask that: those who 
reside on neighbor islands that have direct flights to the mainland be 
offered, at a minimum, return flights that do not require a stop in 
Honolulu but fly directly to their island of residence. Individuals who 
are recovering from surgery are further inconvenienced by a delay in 
route because they were not booked on a direct flight. This delay 
increases the time these individuals endure pain and discomfort. Direct 
booking is available, we ask the VA to make this option a standard.
    Another issue that affects Hawaii and Alaska involves changes that 
were made to 38 U.S.C. 1151, Benefits for persons disabled by treatment 
of vocational rehabilitation. With the change the only facilities 
covered by the law are those over which the Secretary of Veterans 
Affairs has direct jurisdiction or Government Facilities contracted by 
the Secretary. Tripler Army Medical Center and other medical facilities 
in Hawaii, such as Straub, Queens and St Francis do not qualify. This 
means that in the unlikely event that a veteran is disabled or their 
death is caused by hospital care, medical or surgical treatment, or 
examination in any medical facility that VA refers the veteran to in 
Hawaii, he or she will not be covered under 38 U.S.C. 1151. The 
definition as listed in 38 U.S.C. 1701 (3), of who is covered by the 
law should be changed so that veterans in Hawaii are afforded the same 
protection as veterans who receive VA medical care in VA facilities on 
the mainland. Hawaii's veterans must have the same right of redress as 
veterans treated at mainland VA facilities. They too must be able to 
apply for and be granted compensation for injuries and not forced to 
pursue legal action against the facility. Only a modification of the 
law can address this issue. We ask the Committee to consider including 
VA referrals to medical facilities that provide surgical and medical 
treatment in Hawaii and Alaska under 38 U.S.C. 1701(3).
    Hawaii's neighbor islands must be offered the same level of medical 
care and services as veterans located on Oahu. Presently neighbor 
island veterans wait long periods to be scheduled for specialty medical 
care. With the use of Tel-a-medicine, this problem is being addressed, 
never the less, implementation has been slow. Veterans have been known 
to wait several months before they see a specialist. We can and must do 
better in supporting these veterans. Additionally, VA should consider 
contracting dental care on the neighbor islands. With rising airline 
fairs, contract dentist may save veterans time and the VA much needed 
dollars that can be reallocated to other needed medical services, such 
as orthopedic or mental health services.
    As you are aware, Hawaii will be receiving thousands of its 
returning National Guardsmen and Reservist. As Director of the Office 
of Veterans Services and a Vietnam combat veteran I want these 
returning military members to be able to access medical and benefit 
services in a timely manner. We ask that VA Health and Benefits 
Administration be adequately staffed to provide medical care and 
benefit services to all veterans who make Hawaii their home. I know 
this involves dollars, however, as an organization that supports our 
veterans, we must acquire funds to complete the job. We must take care 
of our veterans. We must continue to support our troops, our veterans, 
and our citizens--after all they are our most Patriotic Americans.
    I thank the Committee for this opportunity to speak on this matter 
and I will respond to any questions that you may have.

    Senator Akaka. Thank you. Thank you very much for your 
testimony. We just heard from our VSOs, and I have some 
questions for you.
    This first question is to the whole group. I'm very 
concerned about VA's inquiry to post-traumatic stress disorder 
claims, and I mentioned that. I personally saw the level of 
aggravation that this review caused our veterans, and I heard 
from you, many of you from Hawaii.
    I ask all the members, and we'll go down the line again, 
members of the panel, whether you're familiar with the PTSD 
review that was recently called off by the Department of 
Veterans Affairs, and for you to tell me about the impact the 
review had on you and any fellow members that you may be in 
contact with.
    Let's begin with William Daves.
    Mr. Daves. I'm also a service officer for the Fleet Reserve 
Association, and I help veterans with their claims. It would 
have had a deep impact on all of us service officers because it 
put the claims process back a ways.
    Right now I think most of the claims are done within 200 
days or less. If they had to review all of those cases, it 
would have put the claims that are now going into the mill 
back. We don't need that, sir.
    Mr. McCloskey. Thank you, Senator. I'm a little bit more of 
a unique bird here than most of you. I actually did the job of 
doing claims at the VA for many years. My boss will sit up here 
and tell you how bad or how good I was.
    But I can tell you that if I was sitting in my old job as a 
decision review officer and I was faced with these reviews, it 
would be a nightmare. It would be an absolute nightmare because 
I know that almost every one of these cases we would lose 
subsequently in court. It would be all done for naught. The VA 
generally does a very good job rating cases. If they're given 
the facts, they're going to rate the case properly in most 
cases.
    My big problem with this, though, really, is the impact 
that it had on every veteran who suffers from PTSD in this 
country. When that word went out, I got literally hundreds of 
phone calls in my capacity as an American Legion service 
officer. I had people coming to my office: What are they doing 
to me? I won't be able to feed my family. I won't be able to do 
this. I won't be able to make my mortgage payments.
    I left concerned. But then I got real concerned when mental 
health care professionals that work for the VA, and I won't 
name them, started calling me saying, Hey, what's going on? Do 
you know anything about this? Because my patients are coming in 
really freaked out.
    Then, slowly, people started coming in to me saying, You 
know, if this happens, what do I do? It tripled my workload for 
about 3 months. I'm sure that it created nightmares for many of 
the folks over here at the VA also.
    To me, especially during a time of war, Senator Akaka, it 
is absolutely unconscionable that we would try to do something 
like this. I'm a Vietnam veteran. My father was a World War II 
veteran. I have a son who's a combat infantryman in the 100th 
Battalion. He's coming home this week. If they treated me like 
that, I can imagine how I would feel, or some member of my 
family.
    We appreciate whatever pressure you put on the VA. I know 
it wasn't the folks sitting here that were trying to do it. It 
was some bean-counter in Washington that was trying to save 
some money. It's sad, and it hurt, and we can't let it happen 
again. Thank you very much.
    [Applause.]
    Master Chief Hough. I concur with my good friend there, 
Mike McCloskey. These are traumatized war veterans. These 
people, men and women who served our country, did their very 
best for us. We rated them and adjudicated their claim. The VA 
Inspector General did not find any fraud. So if there's any 
fault, it lies with the system itself.
    Perhaps the internal controls of the VA in the rating of 
compensation needs to be strengthened at the national level. 
But it's certainly not the fault of our veteran. Our veteran 
got the rating, and to take somebody away from somebody, as 
Mike said, would cause not only an emotional breakdown, but 
human tragedy. We just don't want to see that.
    There's another thing that I'm little concerned with, 
Senator, is that there's a study the VA has a big panel going 
on now for a year studying compensation. One of the 
recommendations was to give a lump sum payment to those 
veterans with a lesser degree of disability, such as 10 to 30 
percent.
    This too is unconscionable because as we know, as we grow 
older we're going to have problems. This is essentially saying, 
hey, here's a wad of money, and don't come back and bother us.
    I know that the veterans organizations are adamantly 
opposed to this, and I hope that you could do your best for us 
to make sure that our veterans are treated with the dignity and 
respect they deserve for their efforts. Thank you.
    [Applause.]
    Colonel Cruickshank. I'm just going to simply say I'm glad 
that issue is not being readdressed again. I go along with Mike 
that it's been done. Let's just move on.
    Mr. Ross. I have two perspectives on that. The first one is 
that really it's not over. The Institute of Medicine, as we 
know, has been contracted by the Department of Veterans 
Affairs--not the people sitting here, their bosses--to go ahead 
and look at the vet condition of post-traumatic stress disorder 
and determine whether or not that particular definition that is 
medically looked at right now as the standard--because it's in 
the Diagnostic and Statistical Manual No. IV-R--and determine 
whether or not they should have a new definition for our 
veterans so that we can in fact not grant so many of these 
benefits.
    Now, we're talking money here. This is the problem. We're 
talking money. We don't talk money when I ask you--because many 
of us were--asked to go off to fight in a war. We were picked 
up and they said, now, of course, it's very different because 
you get a chance to volunteer. But I'm holding up where I 
wasn't asked. It was a question of saying, when are you going 
to go fight or join the military? Because it's coming up and 
your draft number is coming up and you need to go in sooner or 
later.
    Now the question is that since we never talk about, when we 
start these wars, how much it's going to cost, we do start 
talking about what is it costing us now that we've started it.
    Well, it's going to cost us some damages. We've got people 
who come back with broken arms, shot arms, damages not only to 
their physical self but also to their bodies. Why is it that 
because someone who has a mangled hand that is so evident for 
everybody to see should be treated so much differently from an 
individual who has a mangled brain and because it's not so 
noticeable?
    I have another question for people who are considering 
this. We have individuals in the military who have come from 
all walks of life. Some of them have been choirboys. Some of 
them have served in the church. Then we sent them off to war. 
They've seen the horrors of war, and then they come home and 
they have post-traumatic stress disorder.
    What kind of country would we have if we could send our 
people off and have them see the horrors of war and come back 
and have no problems? Wouldn't we be a little bit more 
concerned with those kinds of individuals because of what they 
have done and seen, and now are able to just walk off and have 
no feelings or emotions about what they saw?
    I say that we are in fact extremely lucky to have a country 
that's concerned about those individuals that we ask to do our 
bidding, and that we need to in fact continue what the VA says: 
Care for him or her who has borne the battle. Thank you very 
much.
    [Applause.]
    General Rienzi. Tom Rienzi again. I served in eight wars in 
37 years in the Army, and no shell-shock. It's been around, and 
we're going to have a lot more of it. I don't think, Senator 
Akaka, that what we all talked about, and Secretary Nicholson 
talked about and before him--I don't think we--I have not seen 
any strategic plan or major plan that's going to care for these 
many, many, many, many people that will have the head problems.
    I think we can all know here that because of these shell-
shocked--and that's a better term for me--coming back, we're 
going to have a lot of problems. So we need the money. But the 
VA should be prepared for an awful lot of head problems.
    May I suggest that somehow, in your strategic plans, you 
think it through better than just this group here because I 
don't think you have. Not that you're indifferent to it or not 
that--but it's going to be one hell of a big problem for these 
shell-shocked folks that are coming back. I hope we can put it 
in your strategic plans how to care for this head problem, 
which is a big one.
    Thank you very much, Senator Akaka. Thank you.
    [Applause.]
    Senator Akaka. Thank you very much, General. I want to 
thank this panel for their mana'o and their responses. I want 
to say at this point that the VA did withdraw the review that 
we're all talking about, and it has made such a big difference. 
But I wanted to know how our folks felt about that, and you've 
heard them do that.
    My next question to all of you again, in order, is what are 
some of the unique problems that veterans face in Hawaii? There 
are so many different ways.
    I want to thank the panel for mentioning how well they feel 
the VA is doing. They are, you know, trying their best to do it 
whatever limits they have. But they are serving our veterans.
    I'd like to hear from you about what unique problems 
veterans face in Hawaii. Second part--where do you see room for 
improvement, for improvement in services for veterans? So I 
don't want you to tell me only your problems, but also to tell 
me how we can fix it. We look forward to that.
    Mr. Daves. I think the VA needs to have more people, more 
raters, more DROs, more veterans in positions that understand 
what veterans go through in battle and et cetera. That's 
exactly what we need, is more people.
    Mr. McCloskey. Thank you, Senator Akaka. To mention a 
unique problem, we have a couple. Our geographical separation, 
of course, from the mainland and the separation of our islands 
and how our veteran population is spread out are rather unique.
    I think somebody mentioned a guy in Utah may have to drive 
200 miles. But most folks can get that 200 miles. Even if 
you're pretty old, you can usually get your kids or somebody to 
drive you. You can't drive to Molokai from here. You just can't 
do that. It's a real problem. Money will help.
    Another unique problem we have here, I believe, and I think 
most of the VA folks that work here will agree, it's very 
difficult for us to access specialists. Specialist care for 
veterans themselves, specialists to do specialist exams that 
are required for certain cases that are before the Board and 
the DROs. It boils down again, I think, to money and time.
    When we ask these doctors to do this, especially for an 
exam for a claim, typically that doctor has to spend a couple 
of hours reviewing a case, then do an examination, provide a 
report to the VA--in a timely basis, by the way, I might add--
but the VA doesn't pay them very much for this. I'm trying to--
off the top of my head, $150, I think we used to pay the 
specialist for an exam. That may have gone up some. That is one 
of our big problems, I think, here.
    If we had a better way of handling specialists--maybe it's 
getting our own specialists here to do these things. I remember 
we had big cardiovascular problems, cardiovascular examination 
problems, ophthalmologists. Some of these may have been helped 
in the last year or resolved in the last year or so because I 
know we've added some specialties in the clinic. But I'm 
certain that it's still a problem.
    Bill Daves brought up the issue of CHAMPVA. I don't think 
again we really understood what he was talking about. CHAMPVA 
is a program that the VA has that's intended for indigent 
people who are DIC recipients. These are men or women who are 
receiving dependency indemnity compensation benefits. They have 
no other access to healthcare through any other source.
    So the CHAMPVA provides them a system kind of similar to 
TRICARE to get their medical care. Here in Hawaii, we have, 
that I know of, two doctors and no pediatricians. There are a 
number of people here in Hawaii who are eligible for this 
program.
    If they're eligible for CHAMPVA, they cannot get QUEST. So 
it really locks those people out. I know it's not a large 
population. We're only talking about maybe a dozen people, 20 
people, on Oahu. But for those 10 or 20 people, this is a major 
problem because they can't get medical care for their children 
and they can't get medical care for themselves on a timely 
basis. I think, again, this is a matter of how much are we 
willing to pay these doctors to get involved with the CHAMPVA 
program.
    That's all I have, Senator. Again, thank you very much.
    Master Chief Hough. Senator Akaka, it's my feeling that 
Hawaii and Alaska are being penalized because we don't have a 
full-scale Department of Veterans Affairs hospital here. I saw 
the workings of a VA hospital when my son was in Oregon, and 
they are teamed with the Oregon Health Sciences University, and 
it's amazing to see the resources available and the teamwork.
    I know we're teamed with the Army. But again, if we team up 
a lot with the Army, then that means that probably retirees and 
soldiers are going to be penalized because there's not room for 
everything.
    We simply need a steady stream of funding to come up with 
innovative new ways to provide the healthcare that our veterans 
need here in the State. If you look at this State and compare 
it to like Wyoming or Vermont, they have a full-scale VA 
hospital. But we don't, and Alaska doesn't.
    I think that if anybody was to make an analysis of the 
money spent in Hawaii on VA projects as opposed to some of 
these other States, you will see that we're not getting our 
fair share. Thank you very much.
    Colonel Cruickshank. You know, we're going around the panel 
but we all feel the same way. For me, again, it's the 
geographical distance, the specialty care. I know for my 
office, to get off the track a little bit, my office has been 
inundated with veterans because VA can't take care of the 
workload.
    Because of that, I'm going to the Legislature this year to 
request for another counselor for my office to better service 
our veterans. When our troops return, and they'll be coming 
back this week, it's not going to be a matter of overtime to 
service them. What we're going to do is to ensure that our 
troops are serviced properly.
    Our additional counselor will be flying to the neighbor 
islands whenever the counselor on that island is out of the 
office on sick or vacation leave.
    When the 100th Battalion returns and gets ready to fly back 
to American Samoa, Guam and Saipan, we are going to make sure 
we fully service them before they leave for their homes.
    Mr. Ross. Thank you very much, Senator Akaka. Unique 
problems. One of the unique problems that we have in Hawaii is 
that we have cultural differences. We kind of talk in America 
about cultural differences. Since I'm the only guy up here who 
looks different, I can talk about this.
    [Laughter.]
    Mr. Ross. Everybody in America is not the same. That means 
when we start sitting around and talking to the psychologist 
about things like post-traumatic stress disorder, that's really 
good for those individuals that grew up in a culture that 
allows you to talk about mental health problems.
    In Hawaii, we have many cultures that do not talk about 
mental health problems. What happens? Those individuals are 
short-shifted because someone says, ``Well, how do you feel 
about that?'' The therapists looks at them straight in their 
eyes and the person kind of puts their head down because that's 
culturally correct in their culture. Of course, someone else 
misinterprets it, and the guy says, ``I'm all right.''
    They're not all right, and they're telling you that by 
their body language, which shows that they're not all right. 
But we have a talk culture. So those individuals who receive 
mental health care do in fact have an extra barrier because of 
the cultural differences that exist.
    Another thing, is the access. When we have individuals who 
are located on a neighbor island, in rural areas, who cannot 
receive the same quality of care, we do have access problems. 
We need to address that, and I'm happy that the VA is spending 
a lot of money on telemed and other kinds of things to address 
that.
    We also need, you know, additional staffing to make sure 
that those individuals who are rating the cases that come 
through our VA facilities here are culturally sensitive to what 
they're rating. When we send cases off to other places and they 
read and they see what the person is saying, or, even worse, 
when they look at the transcript and they can't read the 
transcript because the guy's speaking pidgin, we really do have 
an issue.
    We need to make sure that we do have people in Hawaii--
because we all grew up speaking pidgin--who can understand some 
of the differences that we have and be willing to address those 
differences through appropriate care. Thank you.
    [Applause.]
    General Rienzi. I'll just take up the specific, and I hope 
you write a note, Senator Akaka. Two years ago, there weren't 
any clinics at all on the outer islands for veterans. Through a 
big fight--or not fight, lots of hard work--we now have CBOCs, 
clinics, except Molokai. Probably some of the biggest PTSD 
problems are on Molokai.
    I would hope you'd write a note there: Molokai CBOC clinic 
within--by 1907. I mean, some of the worst problems are there. 
The rules sort of keep us from getting there, and they have to 
go Lanai or Maui or come over here. We should get a storefront 
and a nurse, and we have one doctor there that we've been able 
to hire that does it out of his office. But Molokai needs some 
specific help. I hope you write down: Molokai CBOC. Thank you 
very much.
    [Applause.]
    Senator Akaka. Thank you. I want to thank all of you for 
your input. That was my final question. I have other questions 
for this panel, but I'm going to submit the questions for the 
record to all of you.
    I want to thank you for your testimonies here. You have 
highlighted, as we wanted, some key issues that we will look at 
with VA. I especially appreciate the insight provided regarding 
the need to address culture because culture in Hawaii in 
particular is very, very important. This is why I'm so happy 
that we're paying attention to culture in Hawaii in trying to 
help our veterans here.
    General Rienzi, we're working on a satellite clinic for 
Molokai and Lanai. Thank you very much.
    [Applause.]
    Senator Akaka. We are working on that, and we hear you, all 
of you. I thank you again so much. I thank you for your 
testimony today. Thank you.
    I'd like to call up the next panel. Diana M. Rubens, 
Director, Western Area Office, Veterans Benefits 
Administration. She will be accompanied by James Carilli, 
Acting Director of the Honolulu regional office. Stephen 
Molnar, M.S.W., Team Leader, Honolulu Vet Center.
    Fred Gusman, M.S.W., Chief Operating Officer, Pacific 
Islands Division, National Center for PTSD. Alfred Wylie, 
Public Relations Coordinator, Vietnam Veterans of America. T. 
Samuel Shomaker, M.D., J.D., Interim Dean, John A. Burns School 
of Medicine, University of Hawaii at Manoa. Dr. Shomaker will 
be accompanied by Haku Kahoano, a 4th-year medical student at 
the John A. Burns School of Medicine, University of Hawaii.
    I look forward to your testimony on some of these issues 
that are pressing for all of us. So I'd like to begin this 
panel with Diana Rubens.

 STATEMENT OF DIANA M. RUBENS, DIRECTOR, WESTERN AREA OFFICE, 
               VETERANS BENEFITS ADMINISTRATION; 
        ACCOMPANIED BY JAMES CARILLI, ACTING DIRECTOR, 
                    HONOLULU REGIONAL OFFICE

    Ms. Rubens. Thank you, Senator Akaka. I appreciate the 
participation of all the veterans and the service organizations 
today, and the opportunity to appear here on behalf of the 
Veterans Benefits Administration to provide you some 
information on the response to the needs of veterans returning 
from Operation Enduring Freedom and Operation Iraqi Freedom. I 
am accompanied today by Mr. Jim Carilli, the Acting Director of 
the Honolulu regional office.
    Veterans returning from Iraq and Afghanistan are eligible 
for an array of benefits offered through VBA. These include 
disability compensation and related benefits; educational and 
training benefits; vocational rehabilitation and employment 
benefits and services; home loan guarantees; life insurance; 
burial benefits; and the dependents and survivor benefits.
    The VA Honolulu regional office serves an estimated veteran 
population of more than 107,000 veterans in the State of 
Hawaii. Of the 21,842 veterans, surviving spouses, and 
surviving children who receive VA benefits each month, 16,754 
are service-disabled veterans. In addition, the regional office 
effectively participates in numerous outreach activities to 
inform and assist returning servicemembers who are soon to be 
released from active duty.
    For those separating servicemembers, the Honolulu regional 
office Veterans Service Center has a designated Military 
Services coordinator who performed many of the outreach 
functions to those returning servicemembers.
    The service coordinator conducts regular briefings covering 
the full range of VA benefits as part of the military 
Transition Assistance Program at various military installations 
in Hawaii. A Veterans Service Representative is also outbased 
in Guam to provide those same TAP briefings there.
    Each month there are 4 TAP briefings at Schofield, 3 at 
Pearl Harbor, 2 to 3 at the Marine Base in Hawaii, and once a 
month at Hickam, Anderson Air Force Base in Guam, and the Guam 
Naval Station. There's also a briefing every 3 months at the 
Coast Guard facility at Sand Island, Hawaii.
    In addition, the military service coordinator conducts 
briefings for members of the Army or Navy being discharged for 
medical disabilities. This briefings, which are part of the 
Physical Evaluation Board orientations, are conducted three or 
four times each month at Pearl Harbor Naval Regional Medical 
Center and at the Tripler Army Medical Center.
    During the past fiscal year, in 2005, the Honolulu regional 
office conducted 219 separate briefings, reaching over 4,500 
active duty servicemembers and spouses in Hawaii and Guam. A 
total of 623 servicemembers were interviewed following these 
briefings for personnel information. Activity was especially 
heavy during this past January through June of 2005, when a 
large contingent of the 25th Infantry Division returned from 
deployment. Already in fiscal year 2006, the Honolulu regional 
office has conducted 48 military briefings for over 1,200 
servicemembers and conducted 98 post-briefing interviews with 
active duty servicemembers.
    For our National Guard and Reserve members, the regional 
office here provides the veteran benefits briefings to those as 
part of the Army Deployment Cycle Support program to reorient 
servicemembers returning from Iraq and Afghanistan. All 
attendees receive a copy of our pamphlet, ``A Summary of VA 
Benefits,'' as well as a VA Health Care and Benefit Information 
for Veterans wallet card.
    Briefings are scheduled on demand based on the dates of 
return of the various units. The Honolulu regional office 
anticipates conducting numerous briefings in January and 
February of this year when an estimated 2,100 servicemembers 
are expected to return to Hawaii.
    In addition, Veteran Service Center staff provide 
individual case management for our seriously disabled OIF/OEF 
veterans. The Honolulu regional office receives periodic 
referrals from Tripler social workers about the seriously 
disabled OIF/OEF servicemembers and assists with the 
appropriate applications. Acting Director Carilli personally 
meets with all the OIF/OEF soldiers who visit the regional 
office to assure them that VA will provide them the best 
possible service. Each month, the Honolulu regional office 
follows up by calling each servicemember to ensure that their 
claims are being processed expeditiously.
    Additionally, the regional office gets immediate 
information about returning disabled soldiers who are likely to 
be eligible for compensation or other benefits, and the veteran 
service staff either visit these servicemembers at the 
Deployment Health Center or during medical hold or medical 
board briefings.
    Our Vocational Rehabilitation and Employment Division at 
the regional office works closely with the Tripler Army Medical 
Center inpatients, National Guard members, and Reservists to 
make sure the patients receive information about the vocational 
rehabilitation and employment program. When appropriate, they 
also refer patients to the Honolulu regional office for 
assistance with their disability claims.
    The Tripler Army Medical Center has created a special 
Deployment Health Center to assist returning Reservists and 
Guard members. It is staffed by professional treatment 
providers and caregivers, as well as a VA Employment specialist 
from the Honolulu regional office. The VA Employment specialist 
sees 3 or 4 servicemembers a week at the Deployment Health 
Center and makes referrals accordingly. Some recuperating 
soldiers have been referred to the local Disabled Veteran 
Outreach Program for employment briefings as part of the 
Department of Labor ReaLifelines Program.
    The VR&E program provides ongoing monthly briefings at 
Disabled Transition Assistance Program sessions at Pearl Harbor 
Naval Base and Schofield Army Barracks.
    The VA's liaison to the Department of Labor's Disabled 
Veteran Outreach Program, who is co-located in the regional 
office VR&E Division, regularly meets with all medical hold 
servicemembers and special services liaisons to provide job-
finding assistance.
    The Schofield Barracks Army Base established a Soldier and 
Family Assistance Center to provide one-stop service for 
returning servicemembers and their families. Our VR&E 
personnel, along with VA Mental Health Clinic personnel, 
participate in this program.
    Our home loan guarantees activities here in Hawaii. With 
the increasing activation of those Reservists and National 
Guard, these servicemembers are becoming eligible for VA home 
loans faster and in greater numbers than they would have had 
they not been activated. Instead of the time-in-service 
requirements of 6 years as a member of the Reserves or National 
Guard, these active duty personnel and veterans become eligible 
for benefits under the Loan Guaranty and Native American Direct 
Loan programs after having 90 days or more of active wartime 
service. As a result, VBA anticipates there will be an increase 
in eligible veterans applying for VA loan guaranty benefits 
through both the Loan Guaranty Program and the Native American 
Direct Loan Program.
    Further, as a result of Public Law 108-454, veterans will 
be eligible for VA guaranteed loans equal to the Freddie Mac 
conforming loan limit. As of January 1, 2006, that rate 
increased to $625,500 for the high cost areas such as Hawaii 
and Guam. We anticipate that this will make VA guaranteed home 
loans much more attractive to the veterans here.
    Moreover, assuming that pending legislation is passed 
making the Native American Direct Loan Program permanent, the 
very important housing benefit will be continued for many 
returning minority veterans in Hawaii and the Pacific U.S. 
Territories.
    Ranking Member Akaka, I hope this testimony has given you 
and the Members of the Committee a better understanding of the 
benefits, services, and outreach that VA is providing to 
veterans of the OIF/OEF conflicts. I assure you that the 
Honolulu regional office is ready and eager to serve the men 
and women coming home to Hawaii and the Pacific.
    This concludes my testimony. Mr. Carilli and I will be 
pleased to answer any questions you might have.
    [The prepared statement of Ms. Rubens follows:]

 Prepared Statement of Diana M. Rubens, Director, Western Area Office, 
                    Veterans Benefits Administration

    Senator Akaka, I appreciate this opportunity to testify today on 
the Veterans Benefits Administration's (VBA) response to the needs of 
veterans returning from Operation Enduring Freedom and Operation Iraqi 
Freedom (OEF/OIF). I am accompanied today by James Carilli, Acting 
Director of the Honolulu Regional Office.
    Veterans returning from Iraq and Afghanistan are eligible for a 
full array of benefits offered through VBA. These include:
     Disability Compensation and Related Benefits;
     Education and Training Benefits;
     Vocational Rehabilitation and Employment Benefits and 
Services;
     Home Loan Guaranties;
     Life Insurance;
     Burial Benefits; and
     Dependents' and Survivors' Benefits.
    The VA Honolulu Regional Office serves an estimated veteran 
population of more than 107,000 veterans in the State of Hawaii. Of the 
21,842 veterans, surviving spouses, and surviving children who receive 
VA benefits each month, 16,754 are service-disabled veterans. In 
addition, the Regional Office effectively participates in numerous 
outreach activities to inform and assist returning servicemembers who 
are soon to be released from active duty.

                       SEPARATING SERVICEMEMBERS

    The Honolulu RO's Veterans Service Center has a designated Military 
Services Coordinator (MSC) who performs many of the outreach functions 
provided to returning servicemembers. The Military Services Coordinator 
conducts regular briefings covering the full range of VA benefits as 
part of the military Transition Assistance Program (TAP) at various 
military installations in Hawaii. A Veterans Service Representative is 
also outbased in Guam to provide TAP briefings there. Each month there 
are four TAP briefings at Schofield Barracks; three at Pearl Harbor 
Naval Base; two or three at Marine Base Hawaii; and one a month at 
Hickam Air Force Base in Hawaii, Anderson Air Force Base in Guam, and 
Guam Naval Station. There is also a briefing every 3 months at the 
Coast Guard facility at Sand Island, Hawaii. In addition, the military 
service coordinator conducts briefings for members of the Army or Navy 
being discharged for medical disabilities. These briefings, which are 
part of the Physical Evaluation Board orientations, are conducted three 
or four times each month at Pearl Harbor Naval Regional Medical Center 
and Tripler Army Medical Center.
    During fiscal year 2005, the Honolulu Regional Office conducted 219 
separate briefings reaching over 4,500 active duty members and spouses, 
in Hawaii and Guam. A total of 623 servicemembers were interviewed 
following these briefings. Activity was especially heavy during January 
through June 2005, when a large contingent of the 25th Infantry 
Division returned from deployment. Already in fiscal year 2006, the 
Honolulu Regional Office conducted 32 military briefings for 845 
servicemembers and conducted 98 post-briefing interviews with active 
duty servicemembers.

               MEMBERS OF THE NATIONAL GUARD AND RESERVES

    Honolulu's Veterans Service Center staff provide VA benefit 
briefings to National Guard members and Reservists, as part of the Army 
Deployment Cycle Support program to reorient servicemembers returning 
from Iraq and Afghanistan. All attendees receive a copy of the VA 
pamphlet, A Summary of VA Benefits, as well as the VA Health Care and 
Benefit Information for Veterans Wallet Card. Briefings are scheduled 
on demand based upon the dates of return of the various units. The 
Honolulu Regional Office anticipates conducting numerous briefings in 
January and February 2006 when an estimated 2,100 servicemembers are 
expected to return to Hawaii.
    In addition, Veteran Service Center staff provides individual case 
management for seriously disabled OEF/OIF veterans. The Honolulu 
Regional Office receives periodic referrals from Tripler Army Medical 
Center social workers about seriously disabled OEF/OIF servicemembers. 
The Military Services Coordinator provides a comprehensive briefing on 
VA benefits and assists with appropriate applications. Acting Director 
Carilli personally meets with all OEF/OIF soldiers who visit the 
Regional Office to assure them that VA will provide them the best 
possible service. Each month, the Honolulu Regional Office follows up 
by calling each servicemember to ensure them that their claims are 
being processed expeditiously.
    In addition, the Regional Office gets immediate information about 
returning disabled soldiers who are likely to be eligible for VA 
compensation or other benefits. Veteran Service Center staff either 
visit these servicemembers at the Deployment Health Center or during 
``Medical Hold'' or ``Medical Board'' briefings.

           VOCATIONAL REHABILITATION & EMPLOYMENT ACTIVITIES

    The Vocational Rehabilitation and Employment (VR&E) Division at the 
Honolulu Regional Office is working closely with Tripler Medical Army 
Center inpatients, National Guard members, and Reservists to make sure 
patients receive information about the Vocational Rehabilitation and 
Employment Program. When appropriate, they also refer patients to the 
Honolulu Regional Office for assistance with their disability claims.
    The Tripler Army Medical Center has created a special Deployment 
Health Center to assist returning Reservists and National Guard 
members. It is staffed by professional treatment providers and 
caregivers, as well as a VA Employment Specialist from the Honolulu 
Regional Office. The VA Employment Specialist sees three or four 
servicemembers a week at the Deployment Health Center and makes 
referrals accordingly. Some recuperating soldiers have been referred to 
the local Disabled Veteran Outreach Program (DVOP) for employment 
briefings as part of the Department of Labor's Recovery & Employment 
Assistance Lifelines (ReaLifelines) Program.
    The VR&E Division provides ongoing monthly briefings at Disabled 
Transition Assistance Program (DTAP) sessions at Pearl Harbor Naval 
Base and Schofield Army Barracks.
    VA's liaison to the Department of Labor's Disabled Veteran Outreach 
Program, who is co-located in the Regional Office VR&E Division, 
regularly meets with all ``Medical Hold'' servicemembers and special 
services liaisons to provide job finding assistance.
    The Schofield Barracks Army Base established a Solider and Family 
Assistance Center to provide one-stop service for returning 
servicemembers and their families. VR&E personnel, along with VA Mental 
Health clinic personnel, participate in this program.

                     HOME LOAN GUARANTY ACTIVITIES

    With the increasing activation of Reservists and National Guard, 
these servicemembers are becoming eligible for VA home loan benefits 
faster and in greater numbers than they would have had they not been 
activated. Instead of the time-in-service requirement of 6 years as a 
member of the Reserves or National Guard, these active duty personnel 
and veterans become eligible for benefits under the Loan Guaranty and 
Native American Veteran Direct Loan Programs after having 90 days or 
more of active wartime service. As a result, VBA anticipates that there 
will be an increase in eligible veterans applying for VA loan guaranty 
benefits through both the Loan Guaranty Program and Native American 
Direct Loan Program.
    Further, as a result of P.L. 108-454, veterans will be eligible for 
VA guaranteed loans equal to the Freddie Mac conforming loan limit. As 
of January 1, 2006, that rate increased to $625,500 for high cost areas 
such as Hawaii and Guam. VA anticipates that this will make VA 
guaranteed home loans much more attractive to veterans.
    Ranking Member Akaka, I hope this testimony has given you and the 
Members of the Committee a better understanding of the benefits, 
services, and outreach that VA is providing to veterans of the OEF/OIF 
conflicts. I assure you that the Honolulu Regional Office is ready and 
eager to serve the men and women coming home to Hawaii and the Pacific. 
This concludes my testimony. Mr. Carilli and I will be pleased to 
answer any questions you might have.

    Senator Akaka. Thank you very much.
    Stephen Molnar.

 STATEMENT OF STEPHEN T. MOLNAR, M.S.W., TEAM LEADER, HONOLULU 
                           VET CENTER

    Mr. Molnar. Aloha, Senator Akaka, fellow veterans, 
families. It is an honor to have this opportunity today to 
testify at these important congressional hearings on ``The 
State of VA Care in Hawaii.'' I still vividly recall when I had 
testified before you at the Senate Veterans' Affairs Committee 
hearings in Washington, DC back in 1993 to address the concerns 
about VA mental health programs.
    As a result of those hearings, much changed in Hawaii. 
Public Law 104-262 was passed in 1996, thereby expanding 
eligibility for Vet Centers and authorizing the extension of 
readjustment counseling to all combat veterans and their 
families. This landmark legislation made it possible for combat 
veterans and their families to receive free counseling in 
convenient locations at 207 Vet Centers nationwide.
    More importantly, though, it helped to eliminate the stigma 
that is often associated with seeking help for mental health 
care. This law was a critical step toward the development of 
seamless and comprehensive care for our returning war veterans 
and their families.
    At Vet Centers, veterans receive counseling for war-related 
issues, including post-traumatic stress disorder, in a 
comfortable community-based setting that is confidential, 
private, and, as I've said, without stigma or embarrassment. 
The law authorized the Vet Centers to provide family therapy as 
a core component of readjustment counseling.
    As provided at Vet Centers, family counseling is available 
as necessary in connection with any psychological, social, or 
other military-related readjustment problem, whether service-
connected or not. As a special authority in the law, veterans 
eligibility for readjustment counseling is determined solely by 
military service in a combat theater and does not require the 
veteran to go through any enrollment procedure.
    Additionally, providing family services at Vet Centers is 
not time-limited but rather is available as necessary for the 
veteran's readjustment throughout the life of the veteran. The 
veteran's family members are included in the counseling process 
as necessary to address the whole range of family adjustment 
issues stemming from the military experience and post-military 
readjustment.
    Early intervention by way of outreach and preventive family 
counseling services help returning veterans stabilize their 
post-military family and work lives, thereby reducing the risk 
of subsequently developing more chronic forms of PTSD and 
associated family problems.
    As you know, Senator, I am one of the original hire in the 
Vet Center program. For over 25 years, I have had the honor and 
unique privilege of serving Hawaii's combat veterans and their 
families in the sometimes difficult readjustment process. The 
Honolulu Vet Center has served over 10,000 veterans and their 
families since opening in 1980. Our clients range in ages from 
19 to 90, and reflect that diversity that distinguishes Hawaii 
from any other place in the world.
    In addition to readjustment counseling for combat-related 
issues, the Vet Center provides assessment and counseling for 
PTSD, sexual trauma, family counseling, and employment. We 
provide services and referral to homeless veterans and do 
extensive outreach, education, and networking to ensure that 
veterans have access to comprehensive care and assistance 
within their community.
    In 2003, the Secretary directed that Vet Centers be the 
focal point for delivery of bereavement counseling to families 
who lost a servicemember while on active duty. To date, we have 
provided 11 families with bereavement counseling and support. 
As you can imagine, these have been amongst our most difficult 
cases. The pain of these families often runs deep. However, I 
know that our efforts have made a difference.
    With the anticipated return of soldiers from Iraq and 
Afghanistan and the recent hiring of our OIF/OEF outreach 
worker, we expect our proportion of OIF/OEF clients to rise 
accordingly.
    I would like at this point just to introduce our OIF/OEF 
counselor, Matthew Handelsford [ph]. He's in the back there.
    [Applause.]
    Mr. Molnar. He served in Iraq and he also served in Kosovo. 
We brought him on in November, and we're happy that he is back 
to outreaching and working with our returning soldiers.
    While all clients are offered individual counseling at the 
Vet Center, we also provide group counseling. Group counseling 
is important. It's extremely effective therapeutically as well 
as it's an efficient way to deliver services. At present, we 
offer 10 different groups. Many of our groups are held in the 
evenings to better accommodate our veterans and their families.
    As you know, Senator, Vet Centers are community-based 
counseling centers with a small core staff of only three or 
four employees. At the Honolulu Vet Center, we have four full-
time staff: myself, the team leader; two counselors; and an 
office manager. In addition, we have a part-time sexual trauma 
social worker.
    As I mentioned, in November we hired our recently returned 
Iraqi veteran to serve as our outreach specialist. His role 
will be to be the bridge, the conduct, for our returned OIF/OEF 
veterans and their access not only to Vet Centers but the VA 
and other community resources. In addition, we have augmented 
our Vet Center with a comprehensive employment program courtesy 
of the State of Hawaii Department of Labor Disabled Veteran 
Outreach Program. We have a full-time DVOP onsite. He provides 
veterans with immediate access to a full range of computerized 
job listings and placement services that are geared to the 
needs of our veterans.
    I am deeply proud of our dedicated and committed staff, 
Senator. Through their efforts in serving Hawaii's veterans, 
our Vet Center has received both local and national 
recognition, and two of our counselors have been awarded the VA 
Secretary's prestigious ``Hands and Heart'' award for what they 
have done with veterans. I have no doubt that the staff will 
continue to provide the same level of dedication and commitment 
to ensuring that our returning OIF and OEF veterans receive the 
best possible care and support.
    As you know, the 1996 legislation which I referred to 
expanded eligibility from a single group of war veterans to now 
all war zone veterans. This has resulted in a significant 
increase in eligible veterans without increased staffing. 
However, I'm glad to say recently VHA authorized 100 additional 
outreach specialists like Matthew, themselves veterans of OIF/
OEF, to enhance the Vet Center program's ability to extend 
timely services to this new era of war veterans.
    The dedication and can do attitude of the Vet Center staff 
will continue to ensure that combat veterans of all wars 
receive complete and comprehensive care and services. 
Similarly, the recent addition of bereavement services required 
a deep commitment of the staff to ensure that families were 
provided with immediate and sensitive assistance as well as a 
full range of comprehensive services and care, which the staff 
undertook willingly.
    The additional number of veterans who we anticipate may 
reside in Hawaii after discharge from OIF/OEF service will add 
to the Vet Center's demand. As a result, the role of the Vet 
Center will likely continue to be significant in providing for 
their readjustment needs.
    In closing, I would like to again thank you, Senator, for 
this opportunity to be able to address those issues facing 
Hawaii's veterans, particularly those who have served in 
combat, as well as those still deployed in combat. Your 
willingness to identify the problems facing our veterans and 
their families, and your commitment to finding appropriate 
solutions, is deeply appreciated by all here.
    Senator Akaka, this concludes my statement. I'll be glad to 
answer any questions that you may have. Thank you.
    [The prepared statement of Mr. Molnar follows:]

     Prepared Statement of Stephen T. Molnar, M.S.W., Team Leader, 
                          Honolulu Vet Center

    Aloha Senator Akaka and other Members of Congress. It is an honor 
to have this opportunity today to testify at these important 
congressional hearings on ``The State of VA Care in Hawaii.'' I still 
vividly recall when I had testified before you at the Senate Veterans' 
Affairs Committee hearings in Washington, DC in 1993 to address 
concerns about ``VA Mental Health Programs.'' As a result of those 
hearings, Public Law 104-262 was passed in 1996, thereby expanding 
eligibility for Vet Centers and authorizing the extension of 
readjustment counseling to all combat veterans and their families. This 
landmark legislation made it possible for combat veterans, and their 
families, to receive free counseling in convenient locations at 207 Vet 
Centers nationwide. More importantly though, it helped to eliminate the 
stigma often associated with mental health care. Public Law 104-262 was 
a critical step toward the development of seamless and comprehensive 
care for our returned war veterans.
    At Vet Centers, veterans receive counseling for war-related issues, 
including Post-traumatic Stress Disorder (PTSD), in a comfortable 
community-based setting that is confidential, private, and without 
stigma or embarrassment. The law authorized the Vet Centers to provide 
family therapy as a core component of readjustment counseling. As 
provided at Vet Centers, family counseling is available as necessary in 
connection with any psychological, social, or other military-related 
readjustment problem, whether service-connected or not. As a special 
authority in the law, veterans eligibility for readjustment counseling 
is determined by military service in a combat theater and does not 
require the veteran to go through the enrollment procedure. 
Additionally, providing family services at Vet Centers is not time 
limited, but rather available as necessary for the veteran's 
readjustment throughout the life of the veteran. Veterans' family 
members are included in the counseling process as necessary to address 
the whole range of family adjustment issues stemming from the veteran's 
military experience and post-military readjustment. Early intervention 
via outreach and preventive family counseling services help returning 
veterans stabilize their post-military family and work lives, thereby 
reducing the risk of subsequently developing more chronic forms of PTSD 
and associated family problems.
    As you know Senator, I am one of the original hires in the Vet 
Center program. For over 25 years, I have had the opportunity and 
unique privilege of serving Hawaii's combat veterans, and their 
families, in the sometime difficult readjustment process. The Honolulu 
Vet Center has served over 10,000 veterans and their families since 
opening in 1980. Our clients range in ages from 19 to 90 and reflect 
the diversity that distinguishes Hawaii from any other place in the 
world. For example, 47 percent of our caseload is composed of Asian 
Pacific Islander veterans and a full two-thirds of our caseload lists 
their ethnicity as ``other than Caucasian.''
    In addition to readjustment counseling for combat-related issues, 
the Honolulu Vet Center provides assessment and counseling for PTSD, 
sexual trauma, family counseling and employment. The Vet Center 
provides services and referral to homeless veterans and does extensive 
outreach, education and networking to ensure that veterans have access 
to comprehensive care and assistance within their community. In 2003, 
the Secretary directed that Vet Centers be the focal point for delivery 
of bereavement counseling to families who lost a servicemember while on 
active duty. To date, we have provided 11 families with bereavement 
counseling and support. As you can imagine, these have been amongst our 
most difficult cases. The pain of these families runs deep. However, I 
know that our efforts have made a difference.
    Our most recent annual workload data reflects that we have served 
628 unique veterans, recorded 5,500 visits and opened 250 new cases. At 
present, the approximate breakdown of new clients who have served in a 
combat theater are 40 percent for Vietnam, 30 percent for WWII, 15 
percent for OIF/OEF and 15 percent for Other Combat Ops. With the 
anticipated return of soldiers from Iraq and Afghanistan, and the 
recent hiring of our OIF/OEF outreach worker, we expect our proportion 
of OIF/OEF clients to rise accordingly.
    While all clients are offered individual counseling, we also 
provide group counseling. Group counseling is an extremely effective 
therapeutic modality as well as an efficient one. At present, the 
Honolulu Vet Center offers 10 different groups. These include groups 
focusing on combat, sexual trauma, bereavement, family members, life 
skills, meditation, and POWs. Many of these groups are held in the 
evenings to better accommodate our veterans and their families.
    As you know Senator, Vet Centers are community-based counseling 
centers with a small core staff of 3 or 4 employees. At the Honolulu 
Vet Center, we have four full-time staff: a team leader, two counselors 
(a social worker and psychologist) and an office manager. In addition, 
we have a part-time sexual trauma social worker. In November we hired a 
recently returned Iraqi veteran to serve as our outreach worker. His 
role is to be the bridge for our returned OIF/OEF veterans and their 
access to Vet Centers, the VA and other community resources. In 
addition, we have augmented our Vet Center with a comprehensive 
employment program through the State of Hawaii Department of Labor 
Disabled Veteran Outreach Program (DVOP). A full-time DVOP counselor 
out stationed onsite provides veterans with immediate access to a full-
range of computerized job listings and placement services geared to the 
needs of veterans.
    I am deeply proud of our dedicated and committed staff, Senator. 
Through their efforts in serving Hawaii's veterans, the Honolulu Vet 
Center has received both local and national recognition. Two of our 
counselors have been awarded the VA Secretary's prestigious ``Hands and 
Heart Award'' that is presented annually to an employee involved in 
direct patient care who does the most to exercise professional 
expertise, to provide emotional support, help and guidance to patients. 
I have no doubt that the staff will continue to provide the same level 
of dedication and commitment to ensuring that our returning OIF/OEF 
veterans receive the best possible care and support.
    As you know, the 1996 legislation (Public Law 104-262) expanded 
eligibility from a single group of war veterans (Vietnam) to all war 
zone veterans. This resulted in a significant increase in eligible 
veterans without increasing staffing, and, recently, VHA authorized 100 
additional outreach specialists, themselves veterans of OEF/OIF, to 
enhance the Vet Center program's ability to extend timely services to 
this new era of war veterans. The dedication and can do attitude of the 
Vet Center staff ensured that combat veterans of all wars received 
complete and comprehensive care and services. Similarly, the recent 
addition of bereavement services required a deep commitment of the 
staff to ensure that families were provided with immediate and 
sensitive assistance as well as a full-range of comprehensive services 
and care which the staff undertook willingly in a professional and 
compassionate manner. As already noted, with the increased success of 
our OIF/OEF outreach worker, we anticipate added demands will be placed 
upon our current counseling staff.
    The additional number of veterans who we anticipate may reside in 
Hawaii after discharge from their OIF/OEF service will add to the Vet 
Center's demand. As a result, the role of the Vet Center will likely 
continue to be significant in providing for their readjustment needs.
    In closing, I would like to thank you for this opportunity, Senator 
Akaka, to be able to address those issues facing Hawaii's veterans; 
particularly those who have served in combat, as well as those still 
deployed in combat areas. Your willingness to identify the problems 
facing our veterans, and your commitment to finding appropriate 
solutions is deeply appreciated.
    Senator Akaka, this concludes my statement. I will be glad to 
answer any questions that you or other Members of the Committee may 
have.

    Senator Akaka. Thank you very much.
    Mr. Gusman.

       STATEMENT OF FRED GUSMAN, M.S.W., CHIEF OPERATING 
      OFFICER, PACIFIC ISLANDS DIVISION, NATIONAL CENTER 
                            FOR PTSD

    Mr. Gusman. Thank you, Senator Akaka.
    Mr. Chairman, Senator Akaka, distinguished Members of the 
Senate Veterans' Affairs Committee, thank you for providing me 
the opportunity to come before you today to share with you 
insights and lessons learned from three decades of working with 
veterans and active duty personnel from all areas, and more 
recently those serving in OIF and OEF.
    I am the Chief Operating Officer of the VA's National 
Center for PTSD, Pacific Islands Division, Hawaii, and the 
Director of the National Center for PTSD's Education Division 
in Palo Alto, California. It has been my privilege as a 
clinician, a clinical program developer, and a veteran to be 
part of the VA's primary effort to understand and treat combat-
related stress and other medical and psychological co-
morbidities affecting the men and women who have bravely served 
in our country's military. I have submitted my written 
testimony for the record.
    I would like to now highlight some of the lessons learned 
from providing treatment to veterans who suffer from combat-
related stress, and share with you some examples of how 
education can play an integral part in supporting the VA's 
mission to provide the best quality care to our Nation's 
veterans.
    The VA is very familiar treating combat veterans from prior 
wars. As a result, the VA has been instrumental in developing a 
variety of therapies, assessment measures, treatment models, 
educational tools, and research related to combat-related 
stress and PTSD.
    However, our servicemembers fighting in the wars in Iraq 
and Afghanistan present other unique factors that we need to 
incorporate into our current knowledge base. For example, their 
age range is 18 to 60 years. Women are a sizable segment of the 
force. Many more servicemembers are married with children.
    In addition, a majority of the men and women in today's 
military have grown up in an age of great technological 
advances. This data would suggest that the current fighting 
force may be very different demographically from previous 
combat cohorts. As such, it may be necessary to deliver 
existing treatments using innovative formats that are easily 
accessible for both VA and DOD healthcare providers as well as 
the new warrior veterans and their families.
    An example of such innovation is the VA's National Center 
for PTSD's Iraq War Clinicians Guide. Originally developed for 
VA providers, the guide was later revised by the National 
Center and the Army in order to make this information more 
relevant and user-friendly to military providers. In order to 
maximize accessibility, the guide was then distributed via CD-
ROM and the internet.
    The Marine Corps is also currently working with the 
National Center for PTSD to tailor a guide for the Navy and the 
Marine Corps personnel. This is another example of using 
technology that has been recent in application of tele-mental 
health care for the treatment of combat stress and PTSD by VA 
providers located in Honolulu and to neighboring islands.
    The VA's National Center for PTSD's mission continued not 
only to develop a state-of-the-art in clinical treatments, but 
also to employ innovative platforms to widely disseminate and 
deliver their care. I think that for the VA in particular, 
providers education is a critical tool that can be employed to 
help bridge the gap between servicemembers in need and 
providers who can assess and address these needs.
    In order to best serve our new warriors, we must further 
develop and provide ongoing state-of-the-art training and 
continuing education to VA personnel. This is a critical call 
because approximately 40 percent of the VA providers are nearly 
retirement age in this decade. This translates into current 
personnel who need to be updated with training specific to this 
new cohort and, perhaps even more importantly, new hires that 
will new to the VA, new to veterans, and certainly new to the 
provisions of services to our men and women of today's 
military.
    It is possible that the future educational clinical 
treatment materials can be made available via files easily 
downloadable onto handheld devices such as iPods or MP3 players 
as a technology familiar to many of the new warriors. An 
example would be an Iraq veteran who receives an audio file on 
stress management to listen to on his MP3 player as part of the 
veteran's ongoing self-care program.
    This type of innovative approach would make education 
materials available 24 hours a day, 7 days a week, to augment 
the existing therapies and be made widely accessible to 
treatment providers, veterans, soldiers, and their families.
    In summary, I believe that the VA and the VA's National 
Center for PTSD have provided outstanding clinical care for 
veterans from previous wars as well from current conflicts in 
Iraq and Afghanistan. We look forward to continuing to 
collaborate with the Department of Defense as well as other 
Federal, State, and local community agencies to care for our 
veterans.
    A fine example of this type of collaboration is the 
conference, Senator Akaka, that you have so willingly 
cosponsored last year and this year. The conference title, 
``Stress, Violence and Trauma: Providing Resiliency in Hawaii 
2006.'' This is an example of collaboration between the VA, the 
State, and the community at large, and your office, and other 
supporters. It's a great example of how we can bridge the gap 
for our many returnees.
    Senator Akaka, that concludes the remarks that I have 
today. Thank you.
    [Applause.]
    [The prepared statement of Mr. Gusman follows:]

  Prepared Statement of Fred Gusman, M.S.W., Chief Operating Officer, 
           Pacific Islands Division, National Center for PTSD

    Thank you, Mr. Chairman and Members of the Committee. I wish to 
applaud the efforts by Members of the Congress and the Department of 
Veterans Affairs (VA) to address the healthcare needs of those service 
Members currently engaged in combat operations. Moreover, recent 
legislation to support additional mental health care programs 
throughout VA demonstrates leadership's support for quality care for 
the men and women who bravely serve in the United States military.
    Thank you for the opportunity to appear before you today to discuss 
the role of the Department of Veterans Affairs and the National Center 
for Post-traumatic Stress Disorder (NCPTSD) in meeting the mental 
health care needs of veterans and servicemembers returning from 
Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF). VA 
has performed a tremendous service to our country's soldiers and 
veterans through outreach programs designed to provide unprecedented 
access to care for those who have served.
    My testimony today will focus on a number of topics, including (1) 
comparisons between veterans from previous combat and peacekeeping 
missions and the current cohort of OIF/OEF veterans; (2) lessons 
learned from working with veterans from these previous combat and 
peacekeeping missions; (3) an overview of collaborative educational and 
clinical initiatives between NCPTSD and DoD to support OIF/OEF 
servicemembers, veterans and their families; and efforts to provide 
education and training to the mental health community located on the 
Hawaiian Islands concerning stress, violence and traumatic stress. (4) 
anticipation of educational and clinical training needs to augment VA/
DOD seamless transition process.

      I. COMPARISONS BETWEEN VIETNAM VETERANS AND OIF/OEF VETERANS

    During the last 30 plus years, VA and the National Center for PTSD 
have performed an outstanding service to this country's veterans by 
developing the best possible assessment and treatment protocols for 
combat related Post-traumatic Stress Disorder (PTSD). VA has provided 
outstanding and quality healthcare to thousands of veterans who bravely 
served their country in overseas wars for their emotional and 
psychological difficulties. As a result of this long standing 
commitment, accurate assessment tools and evidenced-based guidelines 
are now readily available for VA and DoD providers. As we move forward 
in this tradition to provide quality healthcare to our Nation's 
servicemembers and veterans, we need to recognize the importance to 
update and refine VA's models of care in order to best serve the next 
generation of American Veterans.
    Most of what we know about the effects of traumatic stress, we 
learned from veterans from previous wars and peacekeeping missions 
(e.g., Vietnam, Somalia). We now face both a great challenge and 
opportunity as we translate our knowledge and clinical expertise, 
learned over the past 30 years, into evidenced based treatment for this 
current cohort of OIF/OEF veterans. We must appreciate both the 
differences and similarities between the previous generations of 
warriors with those serving in today's military.

           PAST PERSPECTIVES: THE VETERANS OF THE VIETNAM WAR

    Veterans of the Vietnam era cohort were a relatively homogeneous 
group: largely young males between the ages of 18-22 years old, single, 
drafted-active duty, and therefore in the relatively early stages of 
life development, and education, work, and career goals. Typically, 
they served a single 12-13 month deployment in country. Unlike those 
veterans of prior wars, those who returned from Vietnam faced a 
divided, and at times, hostile public. Unlike the experience of 
veterans of prior wars, few large scale homecoming ceremonies were 
offered to show support. In fact, veterans were often publicly scorned 
and society's negative stereotyping/stigmatizing often foretold a 
difficult and problematic readjustment/reintegration into society.
    At first, a small percentage of Vietnam veterans accessed VA care. 
This may have been due, in part, to the lack of knowledge about the 
effects of combat stress on psychological adjustment following military 
service. Also, these veterans returned to a hostile and divided U.S. 
public who cast blame on the veterans as well as the government for the 
war. At that time, veterans may have avoided VA due to a fear of being 
labeled ``crazy'' or ``mentally imbalanced.''

    CURRENT PERSPECTIVES: VETERANS/RETURNEES OF THE OPERATION IRAQI 
              FREEDOM/OPERATION ENDURING FREEDOM (OIF/OEF)

    Veterans and returnees of OIF/OEF and the Global War on Terror 
(GWOT) often return to supportive communities who express appreciation 
for their sacrifices--despite political divisions in our country about 
the meaning and purpose of these wars. The age range of these 
combatants is 18-60 years. Many servicemembers are married with 
children. Most of the Reserve and National Guard have jobs and careers 
at home. Currently, women constitute a significant segment of the 
combined forces approximately 10 percent, many of whom serve in 
leadership roles. Unlike those who served in previous combat theaters, 
those deployed in OIF/OEF are likely to have experienced deployments 
lasting longer than 12-13 months and significant numbers may have 
experienced repeated deployments.
    In terms of assessment, diagnosis, and treatment, the field of PTSD 
is no longer in its infancy. We now have a body of knowledge that is 
replete with a variety of theories, assessment measures, treatment 
models, practical interventions, educational tools, and research 
findings in physiological, medical, psychological, and behavioral 
domains. Studies suggest that the great majority of current returnees, 
like those veterans of prior wars, experience the normal range of post-
deployment adjustment reactions. Similarly, a smaller percentage 
develops PTSD as a result of their combat experiences. A recent study 
(Hoge, et al., 2004) in a sample of Army and Marines (n = 3,671) who 
served in Iraq and Afghanistan, indicates that post-deployment, 
approximately 12 percent met criteria for PTSD. Pre-deployment 
assessment found the rates for PTSD were very similar to those of the 
general population: 5 percent and 3-4 percent respectively. 
Collectively, 17 percent met criteria for PTSD, Depression, or 
Generalized Anxiety Disorder (GAD). Of those whose responses were 
positive for a mental disorder, 38-45 percent were actually interested 
in receiving help and 23-40 percent actually received help.

  II. LESSONS LEARNED FROM RESEARCH AND TREATMENT OF PREVIOUS VETERANS

    Important lessons from clinical research and treatment 
interventions to thousands of veterans in the past 30 years provide us 
with a solid foundation of treatment experience that should enable us 
to respond appropriately and effectively to the needs of veterans and 
servicemembers from OIF/OEF. Through our work with active duty, 
National Guard and military reserve units, we have learned to integrate 
such experience with recent scientific and clinical advances in the 
field. The following are lessons learned to be considered for OIF/OEF 
servicemembers and veterans:
    1. Greater implementation of early intervention strategies for 
servicemembers recently exposed to highly stressful events provides an 
opportunity to apply primary prevention to offset the psychological 
trauma of combat operations. The importance of early intervention 
strategies, such as psycho-education to servicemembers, veterans, and 
families, can not be over-emphasized. Early intervention may provide 
the best opportunity to prevent more chronic forms of PTSD in the 
months and years following combat operations.
    2. Associated with early intervention strategies is the concept of 
``stage of transition.'' We now recognize that many individuals who 
experience traumatic stress go through a normal transitional period 
which may be marked by mild clinical features (e.g., insomnia, 
sadness). However, it is important to recognize that this phase is an 
absolutely normal response to loss or stress. We encourage providers 
not to immediately label these responses with psychiatric labels. In 
addition, we recommend to providers to watch for potential ``red 
flags'' such as substance abuse, anger, concentration deficits, which 
may be signs that the individual requires additional professional 
interventions.
    3. Further, we have been promoting a population-based approach to 
screening for combat stress within the military and VA. Both agencies 
are now routinely using the NCPTSD Primary Care PTSD Screen. This 
screen is a brief, four-item tool that can accurately and efficiently 
identify individuals who warrant further assessment for possible PTSD. 
In addition, NCPTSD has produced many gold-standard assessment 
instruments, such as the Clinicians Administered PTSD Scale (CAPS).
    4. We have learned that in addition to addressing issues of 
traumatic stress, that it is important to address resilience and 
growth. Instead of a narrow focus on PTSD symptoms and related 
difficulties, we have promoted resilience, or ``psychological armor'' 
to both active duty and veterans from OIF/OEF. This approach has the 
effect of increasing positive, active coping and maintaining one's life 
goals and plans both during and after military experience.
    5. Veterans and servicemembers do not always seek out behavioral 
health care, even when they suffer from combat stress/PTSD or other 
psychiatric conditions. For example, many veterans will seek mental 
healthcare from their primary care providers. In response, we now 
provide greater education to primary care providers about the effects 
of combat stress on the physical and psychological status of their 
patients. Further, we now provide more onsite mental health staff in 
primary care settings in order to address these psychological issues, 
such as combat stress/PTSD, within the medical setting and during the 
primary care appointment.
    6. Veterans from each combat era develop a unique lexicon, or 
language to describe their own unique combat experiences. In addition 
to appreciating the unique aspects of their war zone experiences, it is 
also important that clinicians learn the lexicon that veterans speak to 
describe these experiences. By having a shared language, clinicians can 
deliver treatment interventions that more accurately capture the 
veterans experience.
    7. Polytrauma and blast related injuries are complex medical 
conditions that require focused, coordinated and comprehensive medical 
interventions. These conditions may consist of trauma to the head, 
eyes, ears, and spinal cord, as well as multiple injuries to internal 
organs, musculoskeletal and connective tissue systems. Closely related 
to the physical injuries are potential mental health conditions, such 
as posttraumatic stress disorder (PTSD), major depression, and anxiety 
disorders, which may interact with the physical injury to decrease 
overall health status and adherence to medical regimens. Such complex 
medical injuries require coordination with mental health to treat the 
psychological wounds associated with these physical injuries.

   III. OVERVIEW OF COLLABORATIVE EDUCATIONAL AND CLINICAL RESEARCH 
                   INITIATIVES BETWEEN NCPTSD AND DOD

    The National Center for PTSD is a consortium composed of the 
following seven divisions: Executive, Women's Health Sciences, 
Behavioral Science, Clinical Neurosciences, Evaluation, Education, and 
Pacific Islands. Our world renowned website is www.ncptsd.va.gov. I 
would like to highlight some of the National Center's recent 
educational and clinical research initiatives. For clarity of 
discussion, I have divided these into two main groups: (i) those that 
are primarily the purview of personnel of the NCPTSD Education, VA Palo 
Alto Healthcare System and the Pacific Islands Divisions (VAPIHCS), and 
(ii) those related to the entire NCPTSD consortium.

           NCPTSD EDUCATION AND THE PACIFIC ISLANDS DIVISIONS

    NCPTSD personnel have been engaged in multiple collaborative 
educational and clinical research activities with the Department of 
Defense.
    In January 2005, the Navy Bureau of Medicine (BUMED) asked NCPTSD/
VAPAHCS staff to coordinate a leadership summit of Navy, Marine and VA 
leadership in Southern California. The summit was attended by military 
and VA mental health, medicine, and chaplains, and line officers from 
Marine Corp Headquarters, BUMED, Camp Pendleton, Camp Lejuene, San 
Diego Naval Hospital, National Center for PTSD, and VA Central Office. 
The focus of the meeting was coordination between services, across 
hospital settings, and transition to VA treatment facilities. In May 
2005, the NCPTSD organized a 2-day combat stress clinical training 
program for Navy and Marine mental health and primary care military 
staff located throughout the western states (i.e., Camp Pendleton, 
Naval Hospital San Diego, Miramar Air Station, Twenty-nine Palms).
    In June 2005, based on trainings provided to staff at Camp 
Pendleton, Marine Corp Headquarters requested that NCPTSD/VAPAHCS staff 
provide clinical training related to identification and interventions 
for combat related stress to all Marine Corp Community Services (MCCS) 
staff at major Marine Corp bases in the U.S.
    NCPTSD/VAPAHCS has created an internet web-based clinical training 
curriculum entitled PTSD 101. The goal is to provide enhanced training 
for all VA and DoD field clinicians who provide services to veterans, 
reservists, and active duty returnees with PTSD, adjustment disorders, 
or other combat stress reactions. This web-based curriculum of over 20 
courses provides practitioners with a convenient, practical, and user-
friendly means to access a range of continuing education materials that 
focus on the diagnosis, assessment, and treatment for PTSD and other 
combat stress reactions. This new web-based curriculum will allow 
practitioners to access training materials 24-hours a day/7 days a 
week, from any computer terminal.
    Since the Congressional mandate for VA/NCPTSD includes developing 
and providing education and trainings about cultural issues affecting 
the Pacific Islands, I sought out partnerships with leadership from 
community mental health agencies and DoD. Further, VA/NCPTSD reached 
out to partner with local, state, and private agencies to provide 
educational and clinical trainings about combat stress/PTSD.
    One outcome of partnering with the larger communities on the 
islands has been the establishment of what will become an annual 
conference entitled ``Stress, Violence, and Trauma: Promoting Hawaii's 
Resilience.'' This conference is organized by a planning committee 
comprised of a consortium of multiple Federal, state and local 
governmental and non-profit agencies. Also, after Senator Akaka's staff 
learned about the conference, they expressed enthusiastic support and 
joined the planning efforts. Our first conference was held in April 
2005 and was attended by a very receptive audience of over 250 people. 
Our next conference is being held January 11 and 12, 2006 at the Hale 
Koa Hotel. (A description of the conference, at which the Under 
Secretary for Veterans Health Administration, Dr. Jonathan Perlin, will 
be presenting, is located at our website at (http://
stressconference.com/). This educational event has increased the 
visibility for the Pacific Island Division. This collaboration has 
already had many positive outcomes as we have provided important 
clinical trainings for both Army and Marines in Hawaii who have been 
deployed and redeployed from Iraq and Afghanistan. We want to take the 
opportunity to thank Senator Akaka and his staff for their support to 
make this annual conference a success.
    Staff from NCPTSD's Pacific Island Division (VAPIHCS) collaborates 
closely with the Army personnel stationed at Schofield Barracks' 
Soldier Assistance Center and the Family Assistance Center. NCPTSD 
staff consult the Directors of the Solider Assistance Center and the 
Director of the Family Assistance Center who oversee the collection of 
needs assessment/clinical intake data for soldiers who screen positive 
for combat-related stress. In 2004, we provided a series of monthly 
trainings to DoD mental health providers at the Soldier Assistance 
Center on treatment for OIF/OEF returnees suffering from combat stress. 
Since that time, we have continued to provide ongoing trainings for 
newly hired therapists and residents on evidenced based treatment 
guidelines for the treatment of PTSD, assessment of combat stress-
related disorders, early intervention for combat stress, intervention 
for sexual assault, and alcohol abuse treatment. Additionally, NCPTSD 
staff members co-lead group educational interventions with military 
personnel at the Soldier Assistance Center for returnees and their 
spouses.
    In February 2005, members of the NCPTSD Educational and Clinical 
Laboratory (VAPAHCS) and Pacific Island Divisions (VAPIHCS) provided a 
5-day conference at Tripler Army Medical Center and Schofield Barracks 
titled ``War-Zone Related Issues for Active Duty Personnel: Pre-, Post-
, and Redeployment.'' Audience members were over 100 Tri-service mental 
health professionals, including Family Service Workers, Social Workers, 
Psychiatrists, Psychologists, Chaplains, and Primary Care Providers. 
Members of the NCPTSD/VAPIHCS and U.S. Army, Schofield Barracks also 
developed a ``Building Resilience Coping Skills Group,'' with a manual 
and workbook that address post-deployment stressors uniquely reported 
by OIF/OEF returnees. Tri-service military providers were trained in 
implementing the group intervention, and several groups have been 
successfully conducted at Schofield Barracks and at Pearl Harbor.
    Personnel from the NCPTSD (VAPAHCS/VAPIHCS) were requested to 
provide a series of outreach and educational trainings to the 3,000 
deploying members of the Hawaii's 29th Infantry Brigade (National 
Guard) and their families in March 2005. We conducted lectures 
addressing the impact of deployment stress upon families, and provided 
educational materials, created by the NCPTSD, that were specifically 
geared to their needs. The National Guard has requested that VA/NCPTSD 
provide follow-up educational trainings to families prior to their 
spouses return and again upon the servicemember's return in March 2006.
    Similarly, the Marine Corps requested ongoing educational trainings 
to spouses of the 800 returning Marines at Kaneohe Marine Base. Members 
of the VA/NCPTSD are also conducting presentations that address 
deployment and post-deployment stress on families and provide 
accompanying VA/NCPTSD educational materials specifically geared to 
families.

               VA/DOD EDUCATION AND THE NCPTSD CONSORTIUM

    Due to the successful collaboration to create an Army version of 
the Iraq War Clinician's Guide, a Marine Corps version is also 
currently being created. The Marine Corps version is a collaboration 
between USMC/VAPAHCS/VAPIHCS and will provide the most current relevant 
clinical information about combat stress and PTSD for both military and 
VA personnel.
    Returning from the War Zone: A Guide for Military Personnel: This 
pamphlet was created to assist active duty, National Guard, military 
reserve, and veteran military servicemembers to positively cope with 
adjustment during their transition back to civilian life. Returning 
from the War Zone: A Guide for Families of Military Personnel: This 
pamphlet was created to help military families understand and assist 
their loved ones following a homecoming.

  IV. RECOMMENDATIONS FOR EDUCATIONAL AND CLINICAL TRAINING NEEDS TO 
                       AUGMENT VA/DOD HEALTHCARE

    In the months and years ahead, VA nationwide and VA/NCPTSD will 
continue to serve as a tremendous resource for servicemembers and 
veterans. VA's task is to continually refine and improve the processes 
of care in order to apply evidenced-based treatment models for those 
servicemembers injured or psychologically affected during combat 
operations. Further, the collective goal of the VA and DoD healthcare 
is to support and facilitate the seamless transition and reintegration 
of the veteran into his or her family, work, and community settings. 
VA/NCPTSD is well positioned to support this mission.
    Here are four suggested recommendations for continued enhancements 
to quality care within VA system:
Implementation of Innovative Treatment Delivery Systems
    Compared to the Vietnam era veterans, the current cohort of 
veterans display a wider diversity in age, racial, cultural, and 
educational backgrounds. They tend to be more comfortable using 
advanced technology. Many in the current generation of warriors have 
grown up with instant access technology, such as the internet, digital 
imagery and communication and other electronically advanced public and 
military technologies. These servicemembers and veterans may be more 
comfortable with technology than any other previous generation of 
warriors and veterans. Thus developing innovative treatment delivery 
systems employing technology based systems (internet-based, virtual 
reality) may provide a relevant platform that suits these individuals' 
preferences for treatment. VA/NCPTSD's Pacific Islands Division 
continues to promote PTSD telemental health as a way of providing 
specialty PTSD services to veterans residing in remote locations. In 
addition, NCPTSD provides ongoing education and supervision to national 
programs interested in developing PTSD telemental health for current 
veterans and returning OIF/OEF veterans.
Continued Education and Clinical Training for VA Providers
    Many treatment providers in VA have tremendous expertise working 
with older generations of veterans. According to VA estimates, 40 
percent of these providers will be nearing retirement age in the next 5 
years. We can expect a new influx of younger treatment providers to 
enter VA's workforce during this time as well. These younger treatment 
providers will not share the first hand knowledge of lessons learned 
from the work over the past 30 years.
    For these reasons, education and clinical training have become the 
primary foundation to support the mission and goals of VA and DoD 
health care. In order to best serve the unique health care needs of the 
OIF/OEF veterans, a wide educational net must be cast to clinical 
service providers, including mental health and primary care providers. 
In addition, veterans will seek out health care from spiritual leaders 
or others in the community. Education and clinical training will play 
an integral role in determining whether a veteran's combat stress 
reactions resolve early, or develop into a more chronic form of PTSD.
    In summary, continued education and training are important 
foundations as VA continues to provide quality care to veterans from 
OIF/OEF, as well as previous wars. Further, it is imperative that the 
VA continues to develop innovative strategies to disseminate education 
not only to the veterans who come to VA but also the veterans who will 
access other community based healthcare. VA's NCPTSD is uniquely 
positioned, as VA's leader in the field of combat-related stress, to 
support VA to meet this objective. The VA/NCPTSD is staffed with highly 
talented clinicians, researchers, and educators who are devoted to 
development and dissemination of empirically based treatment protocols, 
assessment instruments, and guidelines for addressing combat stress and 
PTSD.

    Senator Akaka. Thank you very much. I just want to say 
we'll include your full testimony in the record.
    Mr. Wylie.

   STATEMENT OF ALFRED WYLIE, PUBLIC RELATIONS, COORDINATOR, 
                  VIETNAM VETERANS OF AMERICA

    Mr. Wylie. Senator, thanks. I've been asked to speak about 
my experience with veterans with PTSD and my own experience 
with PTSD.
    First, I wish to clarify that PTSD is essentially an 
emotional wound that is just as crippling as physical wounds, 
especially in personal and social relationships. In fact, there 
is neurological damage from the traumatizing events of war.
    This damage is exemplified by the veteran who hits the 
ground when he hears a car backfire 30 years after the stressor 
occurred. What happens to those of us who are emotionally 
wounded is that certain stimuli will trigger a flashback that 
is in essence a short circuit or a hardwired response that will 
be with the veteran until death.
    This hardwiring of our neural circuits will never be 
resolved. It is with us for the rest of our life. We can be 
improved in our emotional reaction to these specific triggering 
stimuli. The reduction of our emotional reactions is a long-
term process called psychotherapy.
    The issue of psychotherapy is a double one. First, there is 
the emotionally wounded veteran, and then there are those who 
develop secondary PTSD, which is primarily the children of the 
veteran. This issue of secondary PTSD can be resolved if the 
veteran is treated prior to the conception of the children.
    This issue of veterans can be resolved by the VA developing 
procedures to identify those veterans with PTSD at the time of 
discharge and then integrating them into a mandatory therapy 
program immediately upon separation. This would save the 
Government an enormous amount of money in costs of future 
treatment and care.
    The Government needs to truly understand that intensive 
psychotherapy programs such as the VA intensive program in 
Hilo, Hawaii and its follow-up procedures are effective for the 
older veteran and would be doubly effective for the newly 
released veterans with PTSD.
    Again, I must emphasize that this neurological hardwiring 
from the chronic death threats will never go away. But with 
psychotherapy that focuses on processing the repressed death 
threat emotions, the veteran's experiences will diminish in 
time.
    Going through the shakes of fear and letting out the tears 
of grief are necessary for the healing process. Unfortunately, 
the veteran with PTSD is usually unconscious of his emotional 
wounds since the environment that caused them required that he 
or she numb out to such feelings. This numbing-out process to 
emotional feelings is a natural process that occurs in humans 
and non-human primates as well as numerous mammals exposed to 
high levels of stress.
    So here we have veterans fresh from the high stress zone 
who can be treated of for his emotional wounds in a immediate 
manner, or they can be released into society where they will 
become a liability for many years. Most veterans don't become 
conscious of the actual cause of their disability until they 
are older, when they can no longer produce enough epinephrine, 
which is also known as adrenalin, to suppress the emotions.
    Depending on the individual veteran, this occurs around 45 
to 65 years of age. This, by no means, means that the veteran 
is symptom-free, but just that he will start having reality 
level flashbacks when he can no longer produce enough adrenalin 
to suppress conscious memory of traumatic events and lifestyle.
    The second issue concerning veterans is the secondary PTSD 
they cause their children. Being a parent who has caused 
emotional wounding to my own children from my own PTSD, I speak 
with authority on the subject as well as speaking for other 
veteran fathers. Please get us into therapy before we have our 
children.
    Of course, there is the moral issue of the Government's 
responsibility to its emotionally wounded veterans. However, 
after 65 years of life, I conclude that the real moral issue is 
money. Therefore, from this point of view, it is much more 
cost-effective for the Government to provide emotional therapy 
soon after separation from service, thus avoiding the cost to 
the social system of years of veterans who are emotionally 
wounded and the subsequent burden to the social welfare system 
involving their families.
    Secondarily, getting the young emotionally wounded veteran 
into emotional therapy will prevent a generational cost 
inasmuch as the emotionally wounded veteran produces 
emotionally wounded children.
    In conclusion, the Government in the long run will save 
money if veterans with PTSD are identified and entered into 
emotional third-party programs upon separation from service. 
Another benefit of entering young veterans into therapy soon 
after separation is stopping the secondary PTSD that develops 
in children of PTSD parents, which in turn becomes an economic 
drain to society.
    [The prepared statement of Mr. Wylie follows:]

   Prepared Statement of Alfred Wylie, Public Relations Coordinator, 
                      Vietnam Veterans of America

    I have been asked to speak to you about my experience with veterans 
who have PTSD.
    First I wish to clarify that PTSD is in essence emotional wounds 
that are just as crippling as physical wounds, especially in personal 
and social relationships. In fact there is neurological damage from the 
traumatizing events of war. This damage is exemplified by the veteran 
who hits the ground when he hears a car backfire 30 years after the 
stressor occurred. What happens to those of us who are emotionally 
wounded is that certain stimuli will trigger a flash back that is in 
essence a short circuit or a hardwired response that will be with the 
veteran unto death. This hard wiring of our neural circuits will never 
be resolved. It is with those of us who have PTSD for life. What can be 
improved is our emotional reaction to these specific triggering 
stimuli. The reduction of our emotional reactions is a long term 
process called psychotherapy.
    The issue of psychotherapy is a double one. First, there is the 
emotionally wounded veteran and then there are those who develop 
secondary PTSD which is primarily the children of the veteran.
    The issue of secondary PTSD can be resolved if the veteran him/
herself is treated prior to the conception of the children.
    The issue of the veteran can be resolved by the VA developing 
procedures to identify those veterans with PTSD at the time of 
discharge and then integrating them into a mandatory therapy program 
immediately upon separation. This would save the government an enormous 
amount of money in costs of future treatments and care.
    The government needs to truly understand that intensive 
psychotherapy programs such as the VA intensive program in Hilo, Hawaii 
and its follow up procedures are effective for the older veterans and 
would be double effective for newly released veterans with PTSD.
    Again, I must emphasis that the neurological hardwiring from the 
chronic death threats will never go away. But with psychotherapy that 
focuses on processing the repressed death threats the emotions the 
veteran experiences will diminish in time. Going through the shakes of 
fear and letting out the tears of grief are necessary for the healing 
process. Unfortunately, the veteran with PTSD is usually unconscious of 
his emotional wounds since the environment that caused them required 
that he/she numb out to such feelings. This numbing out process to 
emotional feeling is a natural process that occurs in human and non 
human primates as well as numerous mammals exposed to high levels of 
stress.
    So here we have a veteran fresh from the high stress zone who can 
be taken care for his emotional wounds (PTSD) in an immediate manner or 
he can be released into society where he will become a liability for 
many years. Most veterans don't become conscious of the actual cause of 
their disability until they are older when they can no longer produce 
enough ephiphrine (adreline) to suppress the emotions. Depending on the 
individual veteran this occurs around 45-65 years old. This by no 
means, means that the veteran is symptom free but just that he will 
start having reality level flash backs when he can no longer produce 
enough adreline to suppress conscious memory of traumatic events and 
lifestyle.
    The second issue concerning veterans is the secondary PTSD they 
cause their children. Being a parent who has caused emotional wounding 
to my own children from my own emotional wounds (PTSD) I speak with 
authority on the subject as well as speaking for other veteran fathers. 
Please get us into therapy before we have our children.
    Of course there is the moral issue of the government's 
responsibility to its emotionally wounded veterans. However, after 65 
years of life I conclude that the real moral issue is money. Therefore, 
from this point it is much more cost effective for government to 
provide emotional therapy soon after separation from service thus 
avoiding the cost to the social system of years of veterans who are 
emotionally wounded and the subsequent burden to the social welfare 
system. Secondarily, getting the young emotionally wounded veteran into 
emotional therapy will prevent generational cost in as much as the 
emotionally wounded veteran produces emotionally wounded children.
    In conclusion the government in the long run will save money if 
veterans with PTSD are identified and entered into emotional therapy 
programs upon separation from service. Another benefit of entering 
young veterans into therapy soon after separation is stopping the 
secondary PTSD that develops in children of PTSD parents, which in turn 
become an economic drain on the economy.

    Senator Akaka. Thank you. Thank you very much, Mr. Wylie.
    Dr. Shomaker.

STATEMENT OF T. SAMUEL SHOMAKER, M.D., J.D., INTERIM DEAN, JOHN 
   A. BURNS SCHOOL OF MEDICINE, UNIVERSITY OF HAWAII AT MANOA

    Dr. Shomaker. Good morning, everyone. I want to thank 
Senators Craig and Akaka and the Committee staff for holding 
these important and historic hearings here in Hawaii. I 
particularly want to thank Senator Akaka for his longstanding 
support of the School of Medicine. We're proud to count several 
members of his immediate family amongst our graduates, 
including a son, a grandson, and a nephew, I believe.
    I also want to take a moment, as an ordinary citizen, to 
thank all the veterans in the audience for the service that you 
render us. I am deeply grateful, and I think we all owe you a 
debt of gratitude. Thank you very much for all you've done for 
our country.
    [Applause.]
    Dr. Shomaker. I'm joined today by Haku Kahoano, who's a 
4th-year medical student. You'll hear from him in just a 
second.
    The John A. Burns School of Medicine is the only medical 
school in the State. We provide a culturally appropriate 
medical education program for the State's citizens. Our 
partnership with the VA dates back over many years. We share a 
common mission of clinical care, medical education, and 
biomedical research.
    We're very, very excited with the appointment of Dr. 
Hastings, who's a former Chair of the Department of Internal 
Medicine at our school, as the VA Director here. We feel that 
that will open up all sorts of new partnership opportunities 
for us.
    Our partnership in medical education is already very 
strong. Twenty-six members of the VA medical staff have faculty 
appointments at the John A. Burns School of Medicine, and they 
teach our students and residents at the Spark Matsunaga Center, 
which is an active teaching site for the John A. Burns School 
of Medicine.
    The VA also funds 16 residency training slots in residency 
programs in specialties like geriatrics, internal medicine, and 
psychiatry. We also have a very strong and burgeoning 
partnership in biomedical research in areas like dementia, 
movement disorders, kidney disease, and telemedicine. So we're 
excited about developing that partnership further. We're very 
supportive of the VA's commitment to funding education and 
research programs.
    I'm joined today by Haku Kahoano, who's a perfect example 
of the partnership that we have at the VA. He is both a future 
physician and a future veteran. He's a member of the United 
States Army. He's just been accepted to do his residency at 
Tripler, and recently completed a clinical rotation at the VA. 
So I'd like Haku to say a few words today.
    [The prepared statement of Mr. Shomaker follows:]

  Prepared Statement of T. Samuel Shomaker, M.D., J.D., Interim Dean, 
    John A. Burns School of Medicine, University of Hawaii at Manoa

    Chairman Craig, Senator Akaka, and Members of the Committee on 
Veterans' Affairs, thank you for this opportunity to testify on the 
relationship between the VA and the University of Hawaii's John A. 
Burns School of Medicine. I am Sam Shomaker, currently serving as 
interim Dean, and I am accompanied by a 4th-year medical student, Haku 
Kahoano.
    I am pleased to report that our Medical School enjoys a very strong 
relationship with the VA in Hawaii--one that is mutually beneficial to 
our state's veterans and medical education programs. Residents in 
Hawaii enjoy the longest average life span of any state in the Nation. 
For that reason, our Medical School has developed especially strong 
programs in geriatric medicine.
    The Hawaii VA hosts medical residents in internal medicine, 
transitional, psychiatry and geriatric psychiatry programs. At any 
given time, there are about 16 medical residents and fellows serving in 
VA facilities here.
    Areas of active collaboration between our Medical School and VA 
include dementia, movement disorders, aging, kidney disease, 
epidemiology, and telemedicine. More than two dozen members of the VA 
staff hold appointments as faculty of the John A. Burns School of 
Medicine.
    As Hawaii's only medical school, we bear a special responsibility 
to prepare students to meet the health needs of our residents--among 
them our aging military veterans. At this time I would like to 
introduce one of our students who is both a future physician and a 
future veteran--Lt. Haku Kahoano is a member of the U.S. Army and a 
4th-year medical student.

 STATEMENT OF HAKU KAHOANO, 4TH-YEAR MEDICAL STUDENT, JOHN A. 
         BURNS SCHOOL OF MEDICINE, UNIVERSITY OF HAWAII

    Mr. Kahoano. Thank you, Dean Shomaker. Aloha, Senator 
Akaka, Committee Members, and veterans.
    I'm a lifelong resident of Hawaii and will graduate from 
the John A. Burns School of Medicine this May. You've heard 
Dean Shomaker describe the many ways the VA helps our medical 
school fulfill its mission in creating fully functioning 
residents and primary care physicians.
    I might also add that as the baby boomers enter their 
senior years, they can be expected to once again redefine the 
needs of society, redefine the needs of the VA. The need to 
create a cadre of physicians who will be able to address issues 
like polypharmacy, loss of cognitive and physical function, 
dementia, delirium, assisted living, long-term care, palliative 
management, has never been greater.
    In addition to its nationally recognized geriatric 
fellowship, John A. Burns School of Medicine now requires all 
4th-year students to undergo a monthlong geriatric elective. 
JABSOM offers this program in partnership with the VA and 
provides tutelage of attending physicians with expertise in 
geriatrics. Students gain invaluable firsthand exposure to the 
care of geriatric ex-military members, both in the long-term 
care and outpatient arenas.
    I am one of the fortunate members of the class of 2006 to 
benefit from this program, and I come before you to day to 
attest to the truly valuable lessons learned from my geriatric 
experience at the VA. My 4th-year geriatric elective ambulatory 
block was conducted at the VA's Spark M. Matsunaga Clinic 
located on the grounds of Tripler Army Medical Center.
    It is said that the saving grace of medicine is repetition. 
If that is true, then continuity should be seen as an integral 
part of any sound medical education. During my internal 
medicine rotations at Tripler, I had the distinct privilege of 
servicing veterans that I would later see during my outpatient 
geriatric experience. I can honestly say that it is difficult 
to forget a given pathology or a mix of pathologies when you 
see them in the same patient over and over again.
    Case in point: I recall the 87-year-old Mr. H, who was 
admitted to Tripler's inpatient medicine wards for management 
of his ural sepsis and concomitant aspiration pneumonia. He was 
a pleasantly demented gentleman who had suffered a stroke 2 
years prior that left him with significant left-sided weakness 
and an inability to take food orally.
    During his inpatient stay, I learned a great deal about the 
management of ural sepsis and aspiration pneumonia, all of 
which came in very handy when, 3 weeks later, I saw the same 
gentleman again, this time in the outpatient setting. Already 
familiar with the patient's history and the pertinent issues, I 
was able to quickly generate a management plan for Mr. H's new 
onset shortness of breath and cough.
    I was also able to get social work involved to help set up 
some respite time for the patient's care provider. Both the 
patient and his caregiver also seemed to appreciate dealing 
with a familiar face, a face who had already put in the time to 
learn their story and earn their trust.
    Continuity of care in the clinical arena is a win-win 
situation for everyone involved. Through its alliance with the 
VA, the Tripler Army Medical Center, and the various private 
healthcare institutions in the State of Hawaii, the John A. 
Burns School of Medicine works hard to provide for its students 
experiences rich with this kind of continuity.
    In closing, gentlemen, every VA patient who is cared for 
here in the State of Hawaii is yet another patient whom JABSOM 
students can interact with, service, and learn from. Every 
patient that is sent away to another State for healthcare 
becomes another lost opportunity for our physicians-to-be.
    Senator Akaka, Committee Members, veterans, good people. I 
thank you for giving me the opportunity to discuss the 
tremendous relationship enjoyed by the VA and the John A. Burns 
School of Medicine. Aloha kakahiaka.
    [Applause.]
    [The prepared statement of Mr. Kahoano follows:]

  Prepared Testimony by Haku Kahoano, 4th-Year Student, John A. Burns 
                           School of Medicine

    Chairman Craig, Senator Akaka and other Committee Members, my name 
is Haku Kahoano and I am a lifelong resident of Hawaii as well as a 
graduate of the University of Hawaii. I had the privilege of playing on 
the UH football team from 1987 to 1991 and received an MBA in 1996.
    I am on track to graduate from the John A. Burns School of Medicine 
(JABSOM) next year, and I have accepted a residency in internal 
medicine at the Tripler Army Medical Center.
    You've heard Dean Shomaker describe the many ways the VA helps our 
Medical School fulfill its mission to create fully functional residents 
and primary care physicians.
    Allow me to add that there is a national health care crisis on the 
horizon; The reality of the baby-boomers turning 80 and the need to 
create physicians who are ``geriatric'' savvy. As the baby-boomers 
enter this demographic they can be expected to once again redefine the 
needs of society. The need to create a cadre of physicians who will be 
able to address issues like (polypharmacy, loss of cognitive and 
physical function, dementia, delirium, assisted living, long term care, 
palliative management, etc.) has never been greater.
    In addition to its nationally recognized geriatric fellowship, 
JABSOM now requires all 4th-year students to undergo a month-long 
geriatric elective. JABSOM offers this program in partnership with the 
VA, and provides tutelage of attending physicians with expertise in 
geriatrics. Students gain invaluable first-hand exposure to the care of 
geriatric ex-military members both in the long term care and outpatient 
arenas.
    I am one of the fortunate members of the Class of 2006 to benefit 
from this program, and I come before you today to attest, to the truly 
valuable lessons learned from my geriatric experience at the VA.
    My 4th-year geriatric elective ambulatory block (outpatient clinic) 
was conducted at the VA's Spark Matsunaga Clinic located on the grounds 
of Tripler Army Medical Center. Senators, thank you for giving me the 
opportunity to discuss the tremendous relationship enjoyed by the VA 
and Hawaii's medical school, from a medical student's perspective.

    Senator Akaka. Mahalo nui loa. Mahalo, Haku Kahoano, and 
Dr. Shomaker.
    Dr. Shomaker, I know you have another event to attend, too, 
so I plan to ask you a question first. I want you to feel free 
to depart after you've answered the question.
    Dr. Shomaker. Thank you, sir. I appreciate it.
    Senator Akaka. Dr. Shomaker, I noted in your testimony that 
you have collaborated with VA on telemedicine issues. What 
advances do you think that VA can make in the area of 
telemedicine in Hawaii?
    Dr. Shomaker. I think it's a wonderful adjunct to providing 
onsite care. There obviously are going to be situations in 
which it's not possible to have a specialist such as a 
cardiologist present at every VA clinic on neighbor islands.
    However, providing access to those services via 
telemedicine is a viable alternative to stationing specialists 
in neighbor island clinics on a regular basis. So I think it's 
a tremendous adjunct to the care that serves the role of 
extending the capabilities of the VA, and it's something that 
is probably well worth the investment.
    Senator Akaka. Thank you for your testimony. I want you to 
know that our Washington level VA folks here, led by Dr. 
Perlin, have been looking forward to the future and the use of 
high tech to get services to veterans. This certainly fits in 
that future.
    So I want to thank you and Haku Kahoano for being here and 
for adding to this, and would wish you well.
    Dr. Shomaker. Thank you, Senator.
    [Applause.]
    Senator Akaka. I have questions for the rest of the panel. 
I would like for each of you to comment on this.
    The spiraling costs of post-traumatic stress disorder have 
intensified a debate in Washington, adding fears of my fellow 
veterans. I believe that this debate is unfounded, as the cost 
of post-traumatic stress disorder should be viewed as a cost of 
war.
    Some have suggested that a veteran's PTSD compensation 
should be reduced if the veteran's decision is deemed to be 
improved. Some have also said that this move would be 
politically courageous.
    My question to each of you, first, on this side, and we'll 
move to my right: Do you believe this to be a wise move?
    Ms. Rubens. Well, the Veterans Benefits Administration is 
in place to enact and administer the laws that have been passed 
by Congress. The issue of cost savings is not one that we, 
quite honestly, trouble ourselves with because we feel as 
though the laws that are on the books are the ones that we are 
here to implement, and we can only make the assumption that you 
put the laws in place in Congress and you will find money to 
ensure that our veterans are being paid the benefits to which 
they are entitled.
    Mr. Molnar. Thank you, Senator. I will try to answer that 
question from a clinical point of view.
    When the decision was made to look at the 72,000 cases, I 
can tell you that, as others who have testified in the panel 
before, there was a great deal of concern about what it meant 
for the veteran we were serving.
    A couple of examples. One is, many of our World War II 
veterans never came forward after the war. They didn't deal 
with their issues of trauma. There are some good reasons for 
that. We didn't even recognize PTSD officially in the 
psychiatric diagnosis until 1980. We didn't have the kind of 
mental health care that we have today. For many cultural 
reasons, people did not want to be identified as a mental 
health provider.
    Nevertheless, after many years, some of them applied for 
compensation. Most of our World War II veterans are in their 
later years, the autumn of their life. Their concern is taking 
care of their families. This was an added stress, an added 
aggravation. They asked me, what do you think is going to 
happen? Do you think I might lose my PTSD, my compensation? 
What will happen to my wife? Those kinds of questions certainly 
came up.
    Clinically, was there an impact on that discussion? Yes.
    Mr. Gusman. Thank you, Senator Akaka. I think I would add 
that I'd like to also speak to that from a clinical 
perspective, that our understanding of now what we term combat-
related stress and post-traumatic stress disorder are really 
different from 30 years ago. There's so much more information.
    I believe it's really important, without any intent to do 
harm, to look at how we do our assessments and how we make 
determinations on what's best for our veterans. I think that 
there was a lot of concern by many, many veterans. I got calls 
from veterans that I had seen, you know, 20 years ago asking me 
what did this really mean.
    I believe that we have to find a happy medium somewhere, 
that we have to work with where science is taking us today. We 
have to look at what the impact is, and in some ways I 
personally--this is not the VA's policy--is that sometimes we 
institutionalize people unintentionally. We create situations 
that allow for a dependency that in many instances is not 
healthy.
    I can personally tell you there are many veterans that come 
to me that say, I want to be in treatment but I don't want to 
have this label. I don't want to be compensated that way. I 
want a job. I want a place to live. I want to be able to raise 
my family in a healthy way.
    So I think that, yes, we need to look at things. But I 
think we need to clear this with the veterans, and we don't do 
this with the intent to do harm, but to look at where science 
today is taking us.
    Senator Akaka. Mr. Gusman, let me ask you a question here. 
Is there a time frame for PTSD symptoms to appear? How long 
does it take for this disorder to reveal itself?
    Mr. Gusman. Well, I'd like to say, as my colleague to the 
right had mentioned, that there really isn't a timeline. You 
try to narrow that down scientifically, and we really haven't 
been able to because what we've seen is that for some people, 
they can come home and manage the stress levels. They 
reintegrate to the community well. But then it might be many 
years later, if they're having a loss in the family, that many 
of the old memories can trigger. Then some of the issues for 
that will come roaring in and overwhelm him.
    I think that what we do know is that we not have tools to 
help people. I think the issue really is about how we deliver 
those tools. How do we make them more accessible and user-
friendly?
    I think some of the things that we're starting to do, and 
including here in Hawaii, is working with the community at 
large because we know many of these veterans do not go to the 
VA, as they don't in most of the country. I believe it's a 
little above 7 percent of veterans who go to the VA on a 
national level.
    So it's important that we share our knowledge with the 
community providers because they interface with the majority of 
veterans more frequently. I think that knowledge is the key 
here. Veterans who understand, as I've had the benefit of 
working with many Marines who are active duty, and what I find 
is that when they have knowledge about what they're feeling and 
experiencing and understand that this is normal, that they do 
much better.
    Senator Akaka. Thank you, Mr. Gusman.
    I want to finish the panel with Mr. Wylie's answer on that 
question that I asked the panel.
    Mr. Wylie. Well, I believe the question was, should 
compensation be lowered for the veteran if he gets better. I 
think for us older veterans, there is nothing that can be done 
for us. We're getting too old. We had years and years of adding 
on pain due to the PTSD. Consequently we have to spend years 
working on emotional healings, whereas the young veteran only 
has to heal with the military trauma once they come out of 
service. They should be able to achieve a better adjustment. 
However, if the Government doesn't accept that responsibility, 
I don't see much progress to be made beyond that.
    Senator Akaka. Thank you very much.
    Mr. Molnar and Mr. Gusman, we have seen in the past that 
substance abuse can become a secondary condition to another 
service-connected condition such as PTSD. How do you feel we 
can prevent our veterans from becoming users of illegal 
substances?
    Mr. Molnar. Well, I think it's also both illegal and legal 
substances when you talk about substance abuse. I can speak to 
that question, Senator, both from a professional perspective 
and also from a personal one. My father was a World War II 
Marine, fought on Saipan and Tinian, was wounded there, and 
struggled most of his life with PTSD. He often went down to the 
VFW Hall and drank with his buddies, and developed an alcohol 
problem over the years.
    I think that quite often, since time immemorial, people 
seek to numb their pain, whether it be physical or whether it 
be emotional. That's not unusual. Our doctors prescribe 
medication when we have pain.
    Many people, though, who are suffering from post-traumatic 
stress symptoms often will not present to the mental health 
clinic. They have fear, whether it be cultural, they have fear 
job-wise, that they do not want to be labeled or stigmatized 
with a mental health issue.
    So they can fall between the cracks. That's why, as a 
number of folks have mentioned, outreach is important. 
Networking is important. Liaison is important. When our OIF/OEF 
person goes out there, Matthew, I want him to do one thing, to 
tell veterans, remember our phone number, 973-VETS. Call us. 
Perhaps if we can't help you, we can put you in touch with 
someone who can.
    Because the important thing is that people have a 
readjustment period where they can begin to talk about these 
issues that they will carry the rest of their lives. The friend 
they lost, the day they lost that friend, the mistake that was 
made, the error, these things will live with them for the rest 
of their lives.
    If we can assist them in that readjustment process, we 
hopefully can minimize issues of substance abuse.
    Senator Akaka. Thank you.
    Mr. Gusman.
    Mr. Gusman. Thank you, Senator. Substance abuse is becoming 
more of a problem, as I understand from my----
    Senator Akaka. Excuse me. Would you please pull up the 
mike?
    Mr. Gusman. Yes. As I said, Senator Akaka, as I understand 
from my DOD colleagues and working with them, that substance 
abuse is becoming more of a problem in the sense that our young 
men and women use this as a way of avoiding having some of the 
recall, some of the flashbacks, as we call them, some of the 
uncomfortableness.
    I think that DOD and the VA is making every effort, and we 
need to continue to do so to do some early intervention in this 
regard. We didn't understand that 30 years ago, and many--by 
the time Vietnam veterans came to the VA, many then had chronic 
substance abuse problems. Then there was a constant debate 
within the VA: Do we treat the substance abuse or do we treat 
the so-called PTSD?
    I think we're not going to go down that road this time, 
thank God, and what we understand is that PTSD does not 
discriminate. It doesn't matter what ethnic group you are, your 
education or background; that if you're exposed to enough 
events, you're going to have some issues to deal with.
    It's only natural that if you're away from home, whether 
it's 7 months or multiple tours of being redeployed, that there 
is going to be some difficulty in transitioning back. You might 
possibly see people using substances of different sorts.
    As Dr. [sic] Molnar just said, it's not only alcohol or 
dugs, but there are other kinds of problems--eating disorders, 
compulsive behavior, spending. I could tell you that when the 
first cadre of Marines came back to Camp Pendleton, the Harley 
dealers heard that these Marines needed to buy Harleys, and 
they just lined up everywhere you can go from San Diego up to 
Camp Pendleton to sell these Harleys. What was that about? 
Well, this is about the rush that many of these Marines felt 
more akin to.
    So there are many different ways that people so-called 
self-medicate. I think it's important for us in the VA and for 
the community healthcare providers that we look for those 
flags, that we don't only look for traditional drugs and 
alcohol but other kinds of behaviors that are addictive.
    Senator Akaka. Mr. Gusman, in your opinion, how can VA 
better help the families of veterans with PTSD cope with the 
situation and take care of our veterans?
    Mr. Gusman. One of the ways actually is happening today, 
Senator, which I mentioned earlier that I'm very happy and 
thankful that you're a supporter of, and that's the community 
conference that's happening at Hale Koa dealing with resiliency 
and stress and bonds in the community.
    These kinds of partnerships with the VA and other State and 
county agencies and nonprofits is essential. I think right now 
one of the things the VA has been doing, and again I'm proud to 
say that we have been part of this, including the Pacific 
Islands Division in Hawaii, is to develop materials that are 
easily accessible to families so that they can get the kind of 
education that they need to understand what their family 
members are dealing with.
    That's the key, I think, you know. When people understand 
what to do, the mystery is taken away and things become sort of 
at least somewhat acceptable. Then the veteran, the returnee, 
doesn't also feel like maybe they're going crazy or something 
when in fact they're not. They're having normal reactions to 
some very terrifying experiences.
    I think that the VA is on the right track right now working 
with families and Vet Centers, doing a lot of that. Groups like 
the National Center's PTSD section are working hand-in-hand 
with employee education in the VA to develop all kinds of 
materials, is the way to go.
    More outreach, sir. That's what we have to do.
    Senator Akaka. Thank you very much, Mr. Gusman.
    I want to thank this panel very much for your testimonies, 
and I'll dismiss you at this time.
    Folks, we have another panel. This is the panel that are at 
the head of our VA. I would like to call them forward at this 
time.
    Dr. Perlin, who's Under Secretary of Health, Department of 
Veterans Affairs; Robert Wiebe, who is the VA Network Director, 
VISN 21, Sierra Pacific Network; James Hastings, Doctor, and 
Director of VA Pacific Islands Health Care System; Steven 
MacBride, Chief of Staff, VA Pacific Islands Health Care 
System; and Major General Gale S. Pollock, Commander, Tripler 
Army Medical Center.
    General Pollock and Dr. Perlin, I appreciate your patience. 
I ask for the witness order to be adjusted today so that I 
could hear from you in response to all that has been shared. I 
greatly value your input and response, and I look forward to 
your testimony.
    I know, hearing from you already, that you're making huge 
efforts to try to deal with the concerns of Hawaii's veterans. 
I want you to know that I'm so grateful to you. Let me step 
back and say I'm grateful to Chairman Larry Craig of this 
Committee who did come out and did add so much to the hearings 
here. He, too, as we work together so well, will be looking 
forward to dealing with these issues.
    So let me ask Dr. Perlin to proceed with your testimony.

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

    Dr. Perlin. Aloha kakahiaka, Senator.
    Senator Akaka. Aloha.
    Dr. Perlin. Mahalo nui loa for the opportunity to appear 
before you today to discuss VA care.
    Senator Akaka. I want to say, Dr. Perlin, in the short time 
that he's been here, see how eloquent he is in Hawaiian? Thank 
you so much.
    [Applause.]
    Dr. Perlin. Mahalo nui loa.
    Senator Akaka.  You're getting better.
    [Laughter.]
    Dr. Perlin. Senator, it's really a delight to be here with 
you. Thank you, Senator Akaka, for your incredible leadership, 
your passion, your advocacy for veterans, and your support of 
VA and Department of Defense, the men and women who support and 
serve America in uniform.
    I'm pleased to be able to discuss with you VA care, 
especially care related to post-traumatic stress disorder. I 
have found care throughout all of the islands of Hawaii, and 
the access to that care. In fact, I've had the opportunity 
these last couple of days to move around the islands--we've had 
some hearings--and to see that care firsthand.
    We've had some good discussions in those hearings. We've 
identified some of the issues that we're working on to make 
improvements to our, in fact, already very robust services for 
veterans in the State. Especially, the area of the greatest 
improvement is extending greater access to veterans on the 
neighbor islands, especially reaching out even more strongly to 
Lanai and Molokai.
    Improving access will take a number of shapes and forms. 
But let me assure you that the care is already very, very 
robust. For example, I'm proud of how [inaudible] CBOCs, such 
as those on Kauai and Molokai. The CBOCs are an element with 
one to two physicians, primary care physicians, one nurse 
practitioner, one psychiatrist, and generally a psychologist, 
with a panel about 1,000 to 1,500 patients. This compares 
favorably to services on the mainland, where one primary care 
provider has a panel of 1,200 patients themselves.
    I realize that there are unique logistical issues. But 
these are the ways that we want to make sure that we transcend 
some of those logistical issues and continue to improve care.
    A number of issues have been identified this morning, and 
we look forward to sharing with you what emerged from some of 
the discussions, the hearings yesterday on Maui and the 
previous day on Kauai. Through hiring additional care 
providers, particularly in specialties that were identified as 
being in short supply--orthopedics and ophthalmology, for 
example.
    Through better scheduling of traveling doctors and nurses 
and psychologists to the neighbor islands to make sure that 
those specialty services are available more regularly and more 
timely. Through the use of advance technologies such as those 
Senator Akaka has championed in terms of telehealth and 
extending the care, and something I've had an opportunity to 
discuss during the questions in even more detail, some of the 
additional advances in telehealth supporting tele-mental health 
and all of the mental health services.
    In fact, which General Hastings later showed, the 
improvements in scheduling of services so when the veteran does 
travel from one of the neighbor islands, that the clinics, that 
services that are needed, are scheduled on the same day.
    But in fact my best observation is that it's not just about 
the quality of care, which is excellent, nor about the access 
to service, but about the compassion with which that care is 
delivered.
    The thing that I learned in listening to the clinics that 
we visited together and the Vet Centers, that it's not just 
about patients. It's about community. It's about family. That 
is absolutely remarkable and as good as if not better than I've 
seen anywhere else in this country. I commend the men of VA 
Pacific Islands Health Care System, who give not only of their 
technical skills but in their hearts in serving individuals who 
are not just their patients but their family.
    Here on Oahu we operate one of the Department's finest and 
most innovative facilities. The Spark M. Matsunaga VA Medical 
Center is located, as I think you all know, on the campus of 
the Tripler Army Medical Center. Care here on the islands is 
provided through our VA Pacific Islands Health Care System, 
which is part of our Sierra Pacific Health Care Network, one of 
our 21 Veterans Integrated Service Networks. Dr. Robert Wiebe 
is the Director of that very, very large network.
    We're joined also today by Dr. James Hastings, who is the 
new Director of the VA Pacific Islands Health Care System and 
also a card-carrying cardiologist who goes around still, 
despite his administrative duties, to the other islands 
providing cardiac care.
    The compassion and the sense of community and family is 
never better exemplified than anyone other than our Chief of 
Staff of that facility, Dr. Steven MacBride, who has, in his 
words and action, shown the absolute love and commitment he 
feels for the veterans that we serve.
    The Medical Center provides primary care services in its 
ambulatory care center. This includes mental health, specialty 
services, radiology, optometry, all in a state-of-the-art 
facility that was dedicated in May 2000. It houses also the 
Center for Aging, which is a 60-bed facility that provides 
outstanding convalescent and end-of-life care, rehabilitation 
services, geriatric, and geripsychiatric assessments for 
veterans, all with the goal, if possible, of improving 
veterans' functions so they can return to their homes and their 
families.
    I have to tell you that I would be remiss if I didn't 
acknowledge Senator Akaka's leadership in securing $83 million 
for the ambulatory care center and for the Center for Aging. 
This clearly is a demonstration of that support and leadership 
and compassion in caring for veterans.
    VA's partnership here with Tripler Army Medical Center is 
one of the largest and most important of all the VA and DOD 
partnerships. I appreciate the great leadership and partnership 
that Major General Gale Pollock, Commander at Tripler Army 
Medical Center, provides. We're pleased also, as I mentioned, 
to welcome the former commander of Tripler Army Medical Center 
as director. I know that these two individuals can form an 
unprecedented level of effectiveness in their partnership in 
serving both servicemembers and their dependents as well as our 
veterans.
    We heard also from Dr. Shomaker, who is the Dean of the 
John A. Burns School of Medicine. That relationship is not only 
so important, but was so well demonstrated by the presence of 
the medical student who will carry the torch on even beyond our 
times caring for the citizens and veterans and servicemembers 
here in Hawaii.
    That partnership provides a number of services, including 
emergency room care and acute medical/surgical inpatient care, 
outpatient specialty care, and ancillary services, and we 
greatly appreciate the leadership that Tripler Army Medical 
Center provides in allowing VA to use those services to provide 
the state-of-the-art care for veterans.
    That care extends. VA and DOD have secured $1.25 billion in 
funding for projects related to such things as computer-aided 
design and manufacturing and prosthetic devices, and for the 
construction of a chronic dialysis center, something that will 
help the servicemembers and veterans, and for the development 
of a chronic pain management program.
    We also work together on a single separation health 
examination for active duty personnel who will be leaving 
military service so they don't have to go through two 
examinations with the same information required.
    One more piece of good news, particularly for the residents 
on Oahu, on that relates to the topic of today's hearing, and 
that's that we're relocating our Post-Traumatic Stress 
Residential Rehabilitation Program from Hilo to here. It's a 
program that provides intensive residential rehabilitation for 
veterans suffering from PTSD.
    The PTSD residential rehab problem was established about 10 
years ago to meet the needs of veterans with chronic post-
traumatic stress disorder who would benefit from a specialized 
residential program. Over the years, approximately 830 
veterans, mostly Vietnam era, have been treated at the center, 
and many of these patients, nearly 75 percent, were not in fact 
from the Big Island but from right here in Oahu.
    Now, clearly the discussion indicates, and we fully expect, 
that there will be veterans of the Global War on Terror with 
PTSD or combat stress reactions. We hope to provide them--plan 
to provide them--with the very best of services at the center 
in the next few years.
    Most of these veterans reside in Oahu, and the best 
treatment for them is outpatient care that integrates their 
formal treatment with the service and support to their families 
and community. Consequently, we're moving that program to 
Honolulu over the next few months.
    PTSD, as we've heard, is a major concern for our Department 
because of the activities and exposures inherent to military 
service. We've found that up to one-third of the veterans 
treated in the VA Pacific Islands Health Care System who are 
provided service for mental health issues also carry a 
diagnosis of PTSD.
    Besides the Residential Rehabilitation Program, we will 
provide a broad spectrum of mental health services on the 
island for veterans with PTSD and all mental health disorders, 
especially outpatient PTSDs that are now provided in Oahu by a 
traumatic stress recovery program, which is interdisciplinary.
    It includes a team of psychiatrists, psychologists, social 
workers, nurses. Readjustment counseling staff from the Vet 
Centers, as you've heard, are also so important. That work, 
that close relationship, extends not just on this island but 
over all of the islands.
    Each of our five community-based outpatient clinics in 
Hawaii are staffed by full-time psychiatrists, and our post-
traumatic stress recovery program helps to provide care for 
those veterans who require a fair level of service.
    In fiscal year 2005, the VA treated 2,006 island veterans 
with PTSD, and we expect that there will be additional veterans 
to care for in the year to come. But we'll meet those needs of 
all island veterans in this important area.
    Senator Akaka, with your help and the help and leadership 
provided by Chairman Craig, who's equally passionate in terms 
of supporting the VA and veterans, and the support of all 
Members of Congress, we feel the VA is providing an 
unprecedented level of care in health services to all veterans 
residing on Oahu and throughout all of Hawaii. Thank you very, 
very much for that, and thank you for the opportunity to 
testify today.
    [Applause.]
    [The prepared statement of Mr. Perlin follows:]

      Prepared Statement of Hon. Jonathan B. Perlin, M.D., Ph.D., 
       Under Secretary for Health, Department of Veterans Affairs

    Senator Akaka, 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 Oahu--The Gathering Place--to speak and answer questions 
about issues important to veterans residing in Hawaii.
    First, I would like to express my appreciation and respect for how 
much you have done, along with your colleague, Senator Inouye, for the 
veterans residing in Hawaii and other islands in the Pacific region. As 
I will highlight later, your 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.
    Also, I would like to commend Chairman Craig for his outstanding 
leadership and advocacy on behalf of our Nation's veterans. During his 
tenure as Chairman of this Committee, he has clearly demonstrated his 
commitment to veterans by acting decisively to ensure the needs of 
veterans are met. In addition, I appreciate his interest in and support 
of the Department of Veterans Affairs (VA).
    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 facilities here 
in Oahu; and highlight issues of particular interest to veterans 
residing in Hawaii, including post-traumatic stress disorder (PTSD), 
VA-Department of Defense (DoD) joint venture in Honolulu and access to 
specialty services.

                  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 (fiscal year 2005), 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 at the Tripler AMC. 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 Center for Aging. 
Inpatient mental health services are provided by VA staff on a 20-bed 
ward within Tripler AMC and at the 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 fiscal 
year 1998 to fiscal year 2000 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.

                            OAHU FACILITIES

    VA operates the Spark M. Matsunaga VA Medical Center in Oahu, 
located on the campus of Tripler AMC at 459 Patterson Road, Honolulu, 
HI, 96815. The medical center primarily consists of the Ambulatory Care 
Center (ACC) and Center for Aging (CFA). Congress appropriated $25.1 
million Major Construction funds during fiscal years 1993-1994 to build 
the CFA; $14.9 million in fiscal year 1995 to construct the parking 
garage; and $43.0 million in fiscal years 1994/1995/1997 to build the 
ACC and renovate the E Wing of Tripler AMC for VA administrative use. 
Veterans Benefits Administration (VBA) is co-located with VHA on this 
campus. The Honolulu Vet Center is located nearby at 1680 Kapiolani 
Boulevard.
    The VA facilities in Oahu serve an estimated island veteran 
population in fiscal year 2005 of 80,118. In fiscal year 2005, 25,222 
veterans were enrolled for care and 12,739 veterans received care 
(``users'') in Oahu. The market penetrations for enrollees and 
``users'' are 31 percent and 16 percent, respectively and compare 
favorably with rates within VISN 21 and VHA.
    The current authorized full-time employment equivalents (FTEE) 
level in Oahu is 425. With this staff, VAPIHCS provides a wide range of 
outpatient services, including primary care, several medical 
subspecialties (e.g., cardiology, gastroenterology, nephrology, 
pulmonary and women's health), mental health and dental care. In 
addition, VAPIHCS provides diagnostic services such as laboratory, 
echocardiography and radiology. As noted earlier, VA staffs a 20-bed 
inpatient mental health unit within Tripler AMC and a 60-bed nursing 
home care unit (i.e., CFA). If veterans need services not available at 
the ACC or CFA, VAPIHCS arranges and pays for care at Tripler AMC, 
local community or VA facilities in California.
    In fiscal year 2005, VA facilities in Oahu recorded about 156,000 
clinic stops, representing a 35 percent increase from fiscal year 2000 
(i.e., 116,000 stops). The clinic has short waiting times for new 
patients with few veterans waiting more than 30 days for their first 
primary care appointment. In fiscal year 2005, the combined average 
daily census (ADC) was 19 in the mental health ward and PRRP (52 
percent occupancy rate) and 56 at the CFA (94 percent occupancy rate). 
VAPIHCS spent about $14.0 million for care at Tripler AMC and another 
$9.2 million for non-VA care in the community for residents in Oahu.

                             SPECIAL ISSUES

    Post-traumatic stress disorder (PTSD). PTSD is a psychiatric 
disorder that can occur after the experience of a life-threatening 
event. This is a major concern for VA because of the activities and 
exposures inherent to military service. PTSD has been observed in 
veterans from all conflicts, including Vietnam and Gulf theaters.
    VA has very active PTSD programs nationally. In fiscal year 2005, a 
significant portion of the $2.4 billion spent on mental health programs 
was used to treat veterans with PTSD. In fiscal year 2006, more than 
$40 million will be earmarked to establish new PTSD and Returning 
Veterans Outreach Education and Care (RVOEC) programs. VA is also 
enhancing staffing levels at many Vet Centers.
    There is a high prevalence of PTSD in veterans served by VAPIHCS 
(e.g., up to one-third of veterans treated in VAPIHCS mental health 
clinics carry the diagnosis of PTSD). Consequently, VAPIHCS provides a 
broad spectrum of mental health services for veterans with PTSD at the 
main facilities here in Honolulu (i.e., ACC and inpatient mental health 
ward in Tripler AMC), neighbor island CBOCs and the PTSD Residential 
Rehabilitation Program (PRRP) now in transition. Specialty outpatient 
PTSD services are provided in Oahu by the Traumatic Stress Recovery 
Program (TSRP), which is an interdisciplinary team of psychiatry, 
psychology, social work, nursing and readjustment counseling staff. The 
TSRP team also collaborates with the Honolulu Vet Center.
    On the neighbor islands, outpatient PTSD services are provided by 
full-time psychiatrists located at all CBOCs. The PRRP has also been 
available to veterans with chronic PTSD who need a higher level of 
care. In fiscal year 2005, VAPIHCS treated 2,006 veterans with PTSD 
throughout the system and provided PTSD care during 8,401 clinic stops. 
This represents increases of 39 percent and 16 percent, respectively, 
compared to fiscal year 2002.
    In addition to VAPIHCS, the VHA National Center for PTSD in 
Honolulu is an important resource for veterans. Mr. Fred Gusman, 
operations officer at the National Center for PTSD, Pacific Islands 
Division, is also testifying today and will highlight the activities of 
the Center, including its collaboration with DoD.
    Although VAPIHCS is currently very active in PTSD treatment, we 
expect additional patients from Operation Iraqi Freedom and Operation 
Enduring Freedom (OIF/OEF) will present to our facilities for 
evaluation of possible mental disorders. VA estimates up to 15,000 
residents of Hawaii have been deployed to Afghanistan and Iraq as 
active duty personnel, Reservists or Hawaii National Guard personnel. 
Major General Lee, Adjutant General, State of Hawaii, Department of 
Defense (DoD), reports there are 2,200 Reservists and National Guard 
serving in Iraq and Afghanistan.
    VAPIHCS estimates that 10-20 percent of OIF/OEF veterans may 
present to its facilities for evaluation of possible PTSD or other 
adjustment disorders. In fiscal year 2005, VAPIHCS evaluated 393 OIF/
OEF veterans and 30 of these patients were diagnosed with PTSD. For 
planning purposes, VAPIHCS projects an increased demand from OIF/OEF 
veterans presenting for care at its mental health clinics in the next 
several years.
    VAPIHCS will meet the needs of our newest veterans. Currently, 
VAPIHCS has 9.0 psychiatry FTEE. This equates to 43 mental health 
physicians per 100,000 unique patients, which is higher than the 
national VHA average (i.e., 35 FTEE per 100,000). VAPIHCS will use 
these and other staff to assist those veterans who have either acute 
PTSD, also known as Acute Stress Disorder (ASD), and chronic PTSD. The 
goals are outreach, early identification, standardized assessment, 
individualized treatment plans and emphasis on recovery.
    To accomplish these goals, VAPIHCS will make several changes in its 
care delivery model, including the relocation of the PRRP unit from 
Hilo to Honolulu. The new outpatient program will be built on the 
successful foundation of the Hilo program. A Vietnam veteran who 
returned from combat with serious physical and emotional wounds, 
graduated from the PRRP last year. ``I had lost 10 years of my life to 
drugs and chaotic living,'' he said. ``Healing takes a long time, but I 
carry note cards as reminders of the most important lessons I learned 
from VA. I'm clean and sober and my wife and I have love and 
happiness.'' The veteran summarized his experience by saying, ``I will 
be eternally indebted to the VA for turning my life around.''
    VAPIHCS is also developing new programs (e.g., VAPIHCS submitted 
several proposals related to the $100 million set aside in fiscal year 
2006 by VHA for new mental health initiatives) and hiring additional 
staff as needed (e.g., Hilo CBOC). In these endeavors, VA will continue 
to closely collaborate with our DoD partners, including Tripler AMC.
    VA-DoD Joint ventures. VAPIHCS participates in one of the largest 
and most complex VA-DoD partnerships. The partnership with Tripler AMC 
accelerated when VA began to move clinical and administrative functions 
from the Prince Kuhio Federal Building to the Tripler AMC campus in 
1997. The co-location of VAPIHCS and Tripler AMC allows functional 
integration and opportunities to provide high quality care to Federal 
beneficiaries residing in Hawaii and the Pacific region. VAPIHCS relies 
on Tripler AMC for emergency room care, acute medical-surgical 
inpatient care (including intensive care unit), outpatient specialty 
care and ancillary services. VAPIHCS also partners with Tripler AMC for 
nutritional services (e.g., inpatient meals at Tripler AMC and CFA), 
housekeeping, security and medical maintenance. In fiscal year 2005, 
VAPIHCS purchased about $14 million of services for veterans at Tripler 
AMC.
    VAPIHCS and Tripler AMC also collaborate in several other important 
endeavors. The joint venture in Honolulu has successfully competed for 
several Joint Incentive Fund (JIF) projects. JIF was established by 
Congress in the National Defense Authorization Act (NDAA) in fiscal 
year 2003 to encourage ongoing collaboration. The VA-DoD joint venture 
in Honolulu has secured $4 million in funding for projects related to 
computer-aided design and manufacturing of prosthetic devices; chronic 
dialysis center; and chronic pain management program. The venture was 
also selected as one of eight formal VA-DoD Joint Venture Demonstration 
Sites and will review budget and financial management systems. We are 
also collaborating on a single separation health examination for active 
duty personnel who will be leaving military service.
    VA appreciates the leadership of Major General (MG) Gale Pollock 
and the responsiveness her staff to VA concerns. The joint venture has 
made great strides in both clinical and administrative areas. 
Admittedly, some systemic barriers still exist, such as conflicting 
mission priorities, lack of computer interoperability, ambiguities 
regarding dual-eligible beneficiaries and differences in financial 
systems. Some of these barriers can be overcome at the local level, but 
many will require a solution at the national level. In any case, I am 
confident that our new Director, Dr. Hastings, and MG Pollock will 
continue the growth and accomplishments of this very important joint 
venture.
    Specialty services. VAPIHCS does not operate its own acute medical-
surgical inpatient unit and has a limited number of specialists on 
staff. Historically, VAPIHCS has relied on its DoD partners and 
community facilities to provide these and specialty outpatient services 
to veterans. Over the past several years, VAPIHCS has significantly 
increased its recruitment of specialists to improve the access and 
continuity of care for veterans. Since fiscal year 2004, VAPIHCS has 
hired physicians in gero-psychiatry, gastroenterology, ophthalmology 
and radiology. VAPIHCS is actively recruiting additional specialists in 
cardiology, orthopedic surgery and urology. VAPIHCS has also hired 
hospitalists to provide care for veterans admitted to Tripler AMC.
    Although these specialists will be based in Oahu, most will travel 
regularly to CBOCs on neighbor islands and will be able to conduct 
telehealth clinics. The topography of the Pacific region makes 
telehealth one of VA's most valuable programs--not only for our older 
veterans from World War II, but also for our newest veterans from Iraq 
and Afghanistan. For example, a veteran came to VAPIHCS after surviving 
severe injuries from a rocket grenade attack in June 2004 that left him 
as a triple amputee (both legs and one arm). The veteran lives in 
Pohnpei, Federated States of Micronesia (FSM). After his return home to 
FSM, VA staff in Hawaii followed him weekly with telehealth visits to 
monitor his progress.

                               CONCLUSION

    In summary, with your support and the support of 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, Senator Akaka, 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.

    Senator Akaka. Thank you very much, Dr. Perlin. I want to 
thank Dr. Perlin, who is Under Secretary for Health for VA. I 
want to tell you that whenever we have high level hearings and 
we have the Secretary of VA at the hearing, usually Dr. Perlin 
is there with him. So we are hearing from a person who is 
really at a high level in VA across the country.
    At this moment, this is a personal break. I'm going to ask 
for about a minute or so, and I'll be right back. I'm going to 
call a recess. I've had the permission from the General. So 
we'll just recess for a couple of minutes. Thank you. I'll be 
back. Please don't leave. We aren't done. We are going to hear 
from the General about Tripler and the partnership that's 
really working out. So we'll see you in a few minutes.
    [Recess.]
    Senator Akaka. The hearing will come to order.
    I'd like to call from testimony of Major General Gale 
Pollock. She's the Commander of Tripler Army Medical Center.

STATEMENT OF MAJOR GENERAL GALE S. POLLOCK, COMMANDER, TRIPLER 
                      ARMY MEDICAL CENTER

    General Pollock. Senator Akaka, aloha and mahalo for the 
opportunity to share information about the collaborative 
relationship and initiatives under the auspices of Department 
of Defense and the Department of Veterans Affairs joint 
ventures here in Hawaii.
    I've submitted my written testimony for the record.
    Senator Akaka. It will be included in the record.
    General Pollock. Thank you, sir.
    As the commanding general at Tripler Army Medical Center, I 
represent the largest military medical treatment facility in 
the entire Pacific basin. Tripler's area of responsibility 
spans more than 52 percent of the earth's surface and provides 
medical support to nearly 400,000 beneficiaries, including 
active duty members of all branches, their eligible families, 
military retirees and their families, veterans, and many 
Pacific island residents.
    In 1991, what leaders initially conceived as a small 
veterans hospital adjacent to our medical center is now a vast 
$20 million sharing agreement spanning inpatient and outpatient 
services and non-medical support such as security, meals, and 
housekeeping. This collaboration has increased patient care at 
both Tripler and for the VA.
    On a daily basis, VA patients represent a large part of our 
workload. For example, during the last month, my average 
hospital census was 131 patients. Approximately 30 percent of 
those patients were veterans. An average 3 of the 12 daily 
admissions from my emergency room are veterans. The VA-operated 
psychiatric ward averages 9 patients each day.
    Over the years, we've hired additional clinical staff to 
accommodate the growing VA workload, forming a reliance on the 
input reimbursement from the VA. While other medical treatment 
facilities may have excess capacity and can accommodate 
additional workload without a need to hire, that is not the 
situation at Tripler. The additional workload requires that we 
add staff.
    While reimbursement is essential to a successful DOD/VA 
partnership, it is not the primary motivation. Veteran access 
to specialized care in Oahu and their satisfaction is improved 
due to our joint venture. Another dimension of caring for the 
veteran is that the illnesses and surgeries associated with 
aging are very relevant to keeping our active duty military 
personnel trained and ready for our battlefield mission.
    We stay competent by caring for acutely ill patients. At 
Tripler, we have a robust graduate medical education program 
spanning 10 different medical specialties and training 220 
residents per year. Our anesthesia nursing graduate program, 
recognized as the number two program in the Nation, also 
depends upon these complex patients. All of our patients, 
graduate health education programs, and our staff benefit from 
serving the veteran population.
    One major recent initiative was already mentioned, and 
that's our joint separation process and examination. The 
separation physical performed while the servicemember is still 
on active duty is convenient for the military member. It 
eliminates duplicative physical exams, and ideally completes 
the disability determination prior to discharge from the active 
duty. This process is very much appreciate by the 
beneficiaries, and is cost-effective for both DOD and the VA.
    Recently, we developed several joint initiative fund 
proposals, and three of them were approved and funded, 
computer-aided design and manufacturing for orthotics and 
prosthetics, a chronic dialysis center, and a pain management 
project. All three of these initiatives will improve access to 
care for our joint beneficiaries and decrease their waiting 
time.
    We continue to explore opportunities and initiatives that 
allow the services and VA to share staffing, ensuring that we 
are both effective fiduciary stewards of the Government's 
resources. In the past month, we've signed two new sharing 
agreements.
    The first agreement relocates the post-traumatic stress 
disorder program from Hilo to Tripler. This facility currently 
provides residential PTSD services to veterans. Once relocated 
to Tripler, the program will also treat military active duty 
members.
    The second agreement is in support of a clinical 
investigation study titled, ``Women's Deployment Stress and 
Health: A Pilot Study.'' The principal investigators are the 
providers from Tripler and the VA. We have also undertaken a 
joint approach in planning our response to a pandemic avian 
flu.
    In terms of DOD/VA joint venture development, we are 
clearly ahead of most other locations in that we are already 
one of the most functionally integrated joint ventures. Instead 
of two freestanding medical centers, we have one emergency 
room, one inpatient medical, surgical, and psychiatric service, 
and essentially one major specialty outpatient service. We have 
integrated our clinical services for psychiatric on-call 
support, hospitalists, nephrology, and psychology services.
    There are still opportunities for continued development of 
our joint venture. There's top DOD leadership support to make 
Tripler a model joint venture site. The two key determinants 
for additional progress are expansion of our patient care 
services and elimination of redundant overhead.
    As with most merger activities, there are barriers that 
impede unfettered, efficient coordination. I believe, though, 
that most of our joint venture barriers are systemic in nature. 
In order to perpetuate sharing between VA and DOD entities, 
national initiatives applicable to all types of sharing must 
continue.
    Information systems require evaluation for applicability 
for sharing, and solutions for any systemic issues must be 
identified and shared expeditiously. We must address and 
resolve all barriers to achieve our ultimate goal--high quality 
care for our beneficiaries in a seamless healthcare system. The 
men and women currently serving in America's military and those 
who have already completed their service to our Nation deserve 
no less.
    Senator, thank you for the opportunity to appear before you 
today and for your support of the military and veterans. I look 
forward to your questions.
    [Applause.]
    [The prepared statement of Major General Pollock follows:]

      Prepared Statement of Major General S. Pollock, Commander, 
                      Tripler Army Medical Center

    Mr. Chairman and distinguished Members of the Committee, thank you 
for the opportunity to share information about the collaborative 
relationship and initiatives under the auspices of the Department of 
Defense (DoD)--Department of Veterans Affairs (VA) Joint Venture in 
Hawaii. As Commanding General, Tripler Army Medical Center (TAMC), I 
represent the largest military medical treatment facility in the entire 
Pacific Basin. TAMC's area of responsibility spans more than 52 percent 
of the entire Earth's surface and provides medical support to nearly 
400,000 beneficiaries, including active duty servicemembers of all 
branches of service; their eligible families; military retirees and 
their families; veterans; and many Pacific Island nation residents.
    In 1991, Under Secretary of the Army and the Deputy Secretary of 
Veterans Affairs approved the basic concept of a Joint Venture for 
Hawaii. What was initially conceived as a small veteran's hospital 
adjunct to the medical center, now is a vast twenty million dollar 
sharing agreement spanning inpatient and outpatient services and non-
medical support, such as security, meals and housekeeping. Beginning in 
1997, the VA began to relocate administrative and health care services 
to the TAMC campus. Construction and renovation to portions of the 
medical center infrastructure have resulted in both new and relocated 
veteran services on the Tripler campus. By 1997, both the parking 
structure and the Center for Aging were completed. In 2000, the 
renovation of the E-Wing of TAMC and the Ambulatory Care Clinic were 
completed and operational. The relocation resulted in increased 
workload for both TAMC and the VA Pacific Islands Healthcare System 
(VAPIHCS).
    A collaborative of this magnitude requires diligent planning and 
oversight. Both the VA and TAMC have dedicated staff to ensure the 
exploration and development of collaborative efforts. On a daily basis, 
VA patients represent a large part of our workload. For example, during 
the last month my hospital census was 131 patients. Approximately 30 
percent of those patients are veterans. Additionally, an average three 
of 12 daily admissions from the emergency room are veterans. The VA 
operated psychiatric ward averages nine psychiatric patients a day.
    Over the years, additional clinical staff has been hired to 
accommodate the growing VA workload, forming a reliance on the 
inpatient reimbursement from the VA. While there are Medical Treatment 
Facilities (MTFs) with excess capacity that can accommodate some 
workload within their minimum staffing requirements without adding 
significantly to their costs, that is not the situation at Tripler.
    While reimbursement is essential to a successful DOD/VA 
partnership, it is not the primary motivation. For the military, caring 
for veterans represents a continuation of the services we provided when 
they were active duty. In fact, when I talk to audiences regarding the 
relationship between the active duty and the veteran populations I say 
the active duty are ``veterans in training''. Our ultimate status will 
be as veterans. Another dimension of caring for the veteran is that the 
illnesses and surgeries associated with aging are very relevant to 
keeping active duty medical personnel trained and ready for our 
battlefield mission. We need to stay competent caring for acutely ill 
patients. At Tripler we have a robust graduate medical education 
program spanning 10 different medical specialties and training 220 
physicians per year. Our graduate medical education occurs in 
Orthopedics, Radiology, Urology, Medicine, Obstetrics & Gynecology, 
Psychiatry, ENT, Pediatrics, Family Practice and General Surgery. We 
have found that these programs benefit from caring for the veterans 
population.
    Our current DoD/VA sharing agreements cover a wide variety of 
patient care services including inpatient care, outpatient specialty 
services and ancillary support. We also partner for facility support 
for housekeeping, security and medical maintenance. I am particularly 
proud that the medical center's Nutrition Care Division prepares all 
the meals and nourishments for the 50-bed VA Center for Aging facility. 
We continuously receive positive feedback on our meals from the VA 
beneficiaries residing there.
    One major initiative is the Cooperative Separation Process/
Examination Memorandum of Understanding (MOU) of June 2005, designed to 
create a coordinated effort between DoD and the VA on Oahu for a single 
separation physical exam through the VA with specialized services 
primarily performed through the MTFs. The separation physical, 
performed while the servicemember is on active duty, is not only 
convenient to the military member, it eliminates duplicative physical 
exams for servicemembers who leave the military and file disability 
claims with the VA. Thus it is cost effective to both the VA and the 
DoD.
    This year, there have been approximately 90 claims filed with 44 
physicals completed. Currently, we are working through some minor 
disconnects with the VA on the process of returning the physical 
paperwork to the proper points of contact as well as the process of 
informing the member of the benefit eligibility and how to receive it. 
TAMC, along with the other MTFs on Oahu are working with the VA to 
refine the process and ensure the physical return of the paperwork 
allowing the active duty servicemember to separate from the military in 
a timely manner.
    Recently several new initiatives have been undertaken under the 
Joint Incentive Program and the Joint Demonstration Project. 
Development of several Joint Incentive Fund proposals totaling $4 
million have been completed and funded including computer-aided design/
computer-aided manufacturing for orthotics and prosthetics, a chronic 
dialysis center for veterans and a joint pain management improvement 
project. All three of these initiatives will improve access to care to 
our joint beneficiaries and decrease wait times. The Hawaii 
Collaborative was also selected as one of eight sites to serve as a 
demonstration project. Our Collaborative proposes to meet the need of 
establishing a structure and process to jointly assess, execute, and 
evaluate improvements in the following: Health Care Forecasting and 
Demand; Referral Management and Fee Authorization; Joint Charge Master 
Based Billing development; and Knowledge and Document Management. The 
collaborative expects to garner benefits from these demonstration 
studies including improved planning and programming for resource 
sharing (e.g. facility construction, joint staffing, joint purchase of 
services in the community, etc); improved budget forecasting; improved 
monitoring of access, workload, and budget execution for the 
Collaborative; improved access to documents for information exchange 
within the Collaborative; improved continuity of patient care; and 
improved fiscal resource management.
    We have also undertaken a joint approach in planning for pandemic 
flu response. We continue to explore opportunities and initiatives that 
allow the Services and VA to share staffing representing effective 
fiduciary stewards of our government resources. In the past month, 
we've signed two new sharing agreements. The first agreement relocates 
the Post Traumatic Stress Disorders (PTSD) Residential Rehabilitation 
Program (PRRP) from Hilo to TAMC. This facility currently provides 
residential PTSD services to veterans with chronic PTSD. However, once 
relocated to TAMC, the PRRP will be able to treat active duty members 
too. The current PRRP program admits patients as a cohort group, and 
provides a 7-week program of integrated treatment, including but not 
limited to PTSD symptom management, communication skills, anger 
management, relaxation training, behavior therapy, trauma focus 
therapy, adjustment counseling, substance abuse and relapse prevention 
treatment, and general health education. The second agreement is in 
support of a Clinical Investigation study titled ``Women's Deployment 
Stress and Health: A Pilot Study''. The principal investigators include 
providers from both TAMC and VAPIHCS. The primary objective of the 
study is to explore the relationship between deployment stress and 
women's health in a population of women returning to Oahu from 
deployment to Iraq or Afghanistan. We have also undertaken a joint 
approach in planning for pandemic flu response. We continue to explore 
opportunities and initiatives that allow the Services and VA to share 
staffing, and remain effective fiduciary stewards of our government 
resources.
    As with most merger type activities, there are barriers that impede 
unfettered, efficient coordination. I believe, however, most of our 
Joint Venture barriers are systemic in nature.
    Despite the barriers we confront, we continue to work together 
diligently to devise local solutions. The Pacific Telehealth & 
Technology Hui is an agency that represents a partnership between TAMC 
and the VA. The DoD/VA Interoperability Project is a healthcare systems 
interchange initiative focused in three distinct areas--Pharmacy Bi-
Directional Data Interchange, Common Data View (Janus) and Laboratory 
Interoperability. The Pharmacy Bi-Directional Data Interchange allows 
providers on both the DoD and VA sides to order and receive 
prescriptions from either information system. The common data view 
presents patient data (demographics, lab, pharmacy, etc) to be viewed 
on a common screen. Finally, the laboratory interoperability allows lab 
orders and results to be communicated between both systems. The common 
goal of these initiatives is to improve patient care by developing 
interfaces to allow the electronic sharing of pertinent patient 
information between the VA, DoD and other clinical data providers.
    In terms of DoD VA/joint venture development, our future is now. We 
are ahead of most localities in that we are already one of the most 
functionally integrated joint ventures. Instead of two freestanding 
medical centers, we have only one emergency room; one inpatient 
medical, surgical, and psychiatric service; and essentially one major 
specialty outpatient service. We have integrated clinical services for 
psychiatric on-call support, hospitalist support, nephrology support 
and psychology services. However, this functional integration is just 
the beginning.
    While we are ahead of most of the other joint venture sites in the 
Nation in developing our sharing agreements and establishing policies 
and procedures, there are still opportunities for continued development 
of our Joint Venture. The two key determinants when developing 
opportunities for improved coordination are expansion of our patient 
care services to care for more patients and elimination of redundant 
overhead. We have worked diligently to develop initiatives for VA 
Chronic Dialysis, shared pain management resources and expanded 
orthotic/prosthetic support to veteran patients through the Joint 
Incentive Fund. However, additional opportunities for improved 
coordination and cooperation are numerous.
    There is local VA and DoD top management support to make Tripler a 
model joint venture site. In this respect, countless hours have been 
invested by both activities to improve our joint venture. In order to 
perpetuate sharing between VA and DoD entities, national initiatives 
applicable to all types of sharing should continue to be developed.
    Information systems are evaluated for applicability to sharing, and 
solutions to systemic issues should be identified and resolved 
expeditiously. We must address and resolve the barriers to achieve our 
ultimate goal--high quality care for our respective beneficiaries in a 
seamless healthcare system.

    Senator Akaka. Thank you. Thank you very much, General 
Pollock, for your testimony. I really appreciate what you're 
doing there for our active duty servicemembers as well as our 
veterans. I want to tell you that with Tripler, we have a great 
model of services there for our active duty servicemembers as 
well as our veteran members, the situation there on the hill.
    I have some questions for this panel. Dr. Perlin, I want to 
commend your efforts to expand the delivery of mental health 
services in fiscal year 2006. I note the excellent way in which 
you are distributing $100 million for mental health services, 
allowing the networks to develop their own creative proposals.
    I wish to call your attention to Hawaii's proposal to meet 
the needs of all veterans residing on remote Pacific islands as 
well. The cornerstone of one enhancement is the use of 
telemedicine capabilities to address existing gaps. Another 
proposed enhancement would improve PTSD and substance abuse 
treatment as well as staffing levels at Hilo on Hawaii, on 
Maui, and Oahu.
    With a relatively minimal investment in equipment and 
staff, we believe we will see tremendous improvements in 
outreach and outcomes with each of these enhancements. I hope 
you find their proposals meritorious.
    Moving on to a related issue, it is my understanding that 
the relocation of the Hilo PRRP has yet to be completed. Dr. 
Perlin, has a suitable location been found on the Tripler 
campus for these much needed services yet? Where are we with 
regards to the relocation and restoration of the service?
    Dr. Perlin. Thank you, Senator Akaka. If I may address the 
two questions first, the telemedicine and the $100 million for 
mental health care, first let me thank Chairman Craig and you 
for your leadership in making $100 million available to make 
sure that mental health needs are not only met, but met in the 
best possible way.
    Part of that, I think you'll find, will help services here 
in Hawaii in some very unique ways. My goal when these $100 
million were distributed were to make sure that those dollars 
got to the very front lines of care. I think in Hawaii, the 
ability to use telemedicine for tele-mental health is a unique 
opportunity to reach veterans across all the neighbor islands.
    What I'd like to do is have Dr. Robert Wiebe, who directs 
our VA Pacific--I'm sorry, the Sierra Pacific Health Care 
Network, VISN 21, describe the proposal that, under his 
leadership, his excellent leadership, aimed for. I think you'll 
find the answer to how those funds are coming right here to 
Hawaii to be very, very satisfactory.
    Dr. Wiebe.
    Dr. Wiebe. Thank you, Dr. Perlin and Senator Akaka. Thanks 
to the generous acts of you and your colleagues in Congress as 
well as the outstanding leadership of Dr. Perlin, VA did indeed 
make $100 million available this year to support the 
implementation of the VA Strategic Health Plan for Mental 
Health.
    Facilities across the country were given the opportunity to 
apply for funds and submit proposals that would describe how 
those funds would be used to directly benefit veterans. The VA 
Pacific Islands Health Care System submitted four such 
proposals that received strong support from the network office 
as well as the program office in VA headquarters, and 
ultimately, the approval of Dr. Perlin.
    All four proposals submitted by the Pacific Islands Health 
Care System are being funded, so there will be more than $1 
million coming directly to Pacific Islands Health Care System 
this year to support improvements in mental health.
    They will come in four areas: Substance abuse; tele-mental 
health; enhancement of mental health services on two neighbor 
island clinics; and also funds for direct support of OIF/OEF 
care, and specifically the creation of an intensive outpatient 
program so that we can serve the veterans returning from Iraq 
and Afghanistan with the full range of adjustment disorders, 
including PTSD.
    As you noted in your question, Senator Akaka, indeed this 
will be a great benefit to the veterans in Hawaii, and I look 
forward to the implementation of those programs later this 
year. Thank you.
    Senator Akaka. Thank you very much, Dr. Wiebe.
    [Applause.]
    Senator Akaka. We've heard from the Director and the 
Regional Director of the VA.
    Dr. Perlin. If I may address your second question, you 
asked about finding a suitable location for the PTSD 
Residential Rehabilitation Program. I'll ask our new director 
of the Matsunaga Medical Center, Dr. James Hastings, to address 
that, along with Dr. MacBride, the Chief of Staff.
    Senator Akaka. Dr. Hastings.
    Dr. Hastings. Thank you very much, Dr. Perlin.
    Senator Akaka, I have come into this system and become 
aware of this changing philosophy of how we are going to 
address the problem of PTSD for our new generation of veterans, 
and this is embodied in the move that we're currently 
undertaking.
    As of, I think, 2 weeks ago, we were able to take 
possession of space in Tripler, which is currently being 
formatted so that we can continue the treatment of our PTSD 
patients, but on this island instead of in Hilo.
    So we have the space. We have moved some of the employees 
over. We are currently in the process of acquiring a few more 
employees. We hope that in the near future, we'll be able to 
begin to open our new class.
    Senator Akaka. Thank you very much.
    Dr. MacBride.
    Dr. MacBride. Thank you, Senator Akaka.
    I would just like to add that because I was there before 
Dr. Hastings joined us, I remember vividly the day that the VA 
asked General Pollock and her staff for help in relocating the 
PRRP, and General Pollock graciously made this a very high 
priority for her staff to help us locate space within Tripler. 
That has, as testified by Dr. Hastings, become a reality. We're 
very grateful again for that partnership with Tripler.
    Senator Akaka, thank you so much for supporting the 
formation of the PRRP initially for us 10 years ago. Now, we 
take the next step forward and move into the 5C-1 unit at 
Tripler--and by the way, I learned on the way over here from 
our ACOS for Mental Health, Dr. David Bernstein, that the 
furniture has now been installed and that we have three staff 
that are busy putting things in place. As General Hastings 
mentioned, we are recruiting new staff.
    But that vision to begin for Hawaii a post-traumatic stress 
residential rehabilitation program was yours, Sir. Again, we 
thank you for that leadership.
    Senator Akaka. Thank you very much. You've just heard from 
Dr. Hastings, who's the Director, and also the Chief of Staff, 
Dr. MacBride, their testimony. I want to thank you folks for 
being here. You've heard what they're trying to do here, and 
it's really great for Hawaii.
    I have a question for General Pollock. In your written 
statement, you mention systemic barriers to joint ventures. 
Could you elaborate and provide examples of these barriers?
    General Pollock. Thank you for that question, sir, because 
it really relates to the needs of the patients. It's very, very 
confusing for the patients when they're dual eligible. They're 
not clear about what their benefit really is and which of us 
it's best to go to receive that benefit. Then as we coordinate 
it, just that additional coordination can be frustrating for 
the patients as we work that. That would be one example, that 
dual eligibility.
    The other that I would talk about is we really need a 
standard methodology throughout DOD and VA for billing and 
reimbursement because I would much rather that we spend our 
staff money on people who can assist the patients and do 
patient education and patient support than have them doing 
stubby pencil pushing pieces of paper back and forth in order 
to accomplish that billing mission. They would be two examples.
    Sir, if you would indulge me for just 1 second, you asked 
the question about the status of the residential treatment 
facility. We've signed together a document that has gone down 
to the installation management activity, Colonel Howard, who's 
down at Schofield Barracks.
    He's promised us that we will have expedited review and 
evaluation. So we'll know exactly where on the campus we'll be 
able to break ground for that new building.
    Senator Akaka. That's great news. Thank you so much for 
that.
    General Pollock, talking about paperwork and all of that, 
how do you handle dual-eligible beneficiaries?
    General Pollock. We spend a significant amount of time 
trying to educate them. Both sides of the building, whether 
they go in to the VA for advice or if they come to us for 
advice, there's a significant amount of time, just because the 
benefits are different. So it's very complex.
    We both have staff that are dedicated to resolving those 
issues, to coordinating that care, to make sure that we're able 
to go as quickly as possible. But one of the other concerns 
that I have as one of the healthcare providers is that when 
they can go from one organization to the other, we have 
concerns about, well, who's really managing their care? Who's 
their primary care manager? How can we ensure that everything 
is in line so they're getting the best care possible?
    So that would be one I would really like see us resolve.
    Senator Akaka. Thank you for your response.
    Dr. Hastings, from your vantage point as the former 
commander and now a director at VA Hawaii, where do you see the 
most opportunities for increased sharing here in Hawaii?
    Dr. Hastings. Senator, I think I want to start off by 
answering that and thanking you and your Committee for all the 
efforts that you have put forward over the years in helping us. 
I've had the opportunity for 30 years to look at how the 
veterans are taken care of at Tripler, and I am absolutely 
astounded at the improved care, quantity of care, in a very 
high performance organization that I see.
    I have to agree with General Pollock in one of the comments 
that she made, that the sharing that is going on today between 
these two organizations, these two very high quality healthcare 
organizations, is as good as it gets anywhere in our country.
    I've heard a lot of the problems of sharing across the 
country, and you have heard some of the examples here. But I 
can tell you from firsthand experience, we're sharing in many, 
many other ways and are running a seamless system in spite of a 
number of frustrations.
    Now, that's not to say that, you know, we're finished. We 
have, I think, a lot of opportunities to develop over the next 
few years. One of the ones that I would mention has been 
addressed today, and that's specialty care.
    A number of years ago, the Veterans Administration in 
Hawaii was not terribly involved with specialty care. The 
philosophy has changed enormously, and we are now getting much 
more involved in specialty care.
    At the same time, Tripler, which has been a tertiary care 
institution with significant specialty care for many years, is 
under significant stress because of the war that we're in. I 
see a significant opportunity for us to augment the specialty 
care that Tripler is providing at this time. I think that's one 
example.
    As was mentioned earlier, the VA has already put in motion 
hiring some sub-specialists who will improve care to our 
veterans on the outer islands, but at the same time will do it 
right here on the Tripler campus.
    I think another example that I would bring out is the same-
day surgery. An opportunity that we have--when I talk to the 
surgeons at Tripler, they're maxed out in their operating room. 
They are stretched as far as they can stretch them. I'm sure 
you've heard problems from our veterans of having to go out 
into the community to get procedures done that we would like to 
have been done at Tripler.
    I think a win-win situation for both the Veterans' 
Administration and for the Department of Defense is to come up 
with some solutions that would increase the availability of 
same-day surgery and, indeed, endoscopy for our veterans. So I 
think this is another area where we clearly can make some very 
significant headway.
    Another area that has struck me as I have been with the VA 
in the past couple of years, and that is we have very well 
developed community-based clinics on the other islands. That 
has been addressed today. These clinics deliver a very high 
quality of care.
    I'm sure that there are members of the active duty and 
dependents who have needs for healthcare and exist on our outer 
islands. The density is not high enough to make it possible for 
General Pollock to provide care. This is an area where we can 
share, we can develop sharing, where we can help out Tripler 
just because we are distributed in a different kind of way.
    These are all areas that I think are areas where working 
together, we can come up with much better access and quality 
and quantity healthcare for both our veterans and our active 
duty personnel and their dependents.
    Senator Akaka. Thank you, Dr. Hastings.
    Before I end the hearing, I want to recognize a special 
person in the audience, Claire Wiebe. Is Claire here? Just 
stand. Claire is in the third grade, up front here, and she is 
attending her first Senate hearing.
    [Applause.]
    Senator Akaka. I'm sure you are proud of your dad. You can 
see how hard he works here.
    I also want to recognize the Committee, the Committee 
staff, who have worked hard over months and during the days 
that we're here at these hearings. They have worked to put 
these hearings together, and it's a tremendous job because I 
see it being done. I want to thank Pat Driscoll, Rob Mann, and 
Kim Lipsky, who were primarily responsible for today's hearing.
    I also want to thank--and again, I want to say I have much 
aloha for Chairman Larry Craig and for what he has been to this 
Committee and what he has done. And it's tremendous.
    And of course, I'm saying that so I can say mahalo to his 
staff, too, who are here. I want you to know Lupe Wissel and 
Billy Cahill are here from Chairman Craig's staff. They've been 
here working with us and are here today.
    I also thank Tom Harvey, who's executive assistant to 
Secretary Nicholson, for joining us here in Hawaii.
    I also want to recognize Michelle Moreno, Ted Pusey, Dahlia 
Melendrez, Alex Sardegna, Donalyn Dela Cruz, and Jim Yoshimura 
on my staff who are here. I want to thank them for all they've 
done.
    Of course, before I forget, Noe Kalipi. We have two staff 
directors. Lupe is Senator Craig's staff director, and Noe is 
my staff director.
    [Applause.]
    Senator Akaka. Finally, I want to thank our veterans in 
Hawaii. I thank God for you for our great country and for all 
of our boys and girls who are in service right now in Iraq and 
Afghanistan and in other places, who are serving to keep our 
country free and with liberty. That's a great effort, and they 
sacrifice themselves for it.
    We're grateful. This is why Larry Craig and I are trying 
our best to help out. VA is also doing it. We all are here, 
trying to help give the best service to our veterans when they 
come off of active duty. But we have ideas, and you'll hear 
about it in the future, and we'll let you know about that. But 
this Committee will continue to strive to do all of these 
things.
    I want to thank the veterans in Hawaii for all you and your 
families have done to make our State and our Nation so great. 
Mahalo nui loa, and aloha.
    [Applause.]
    Senator Akaka. This hearing is adjourned.
    [Whereupon, at 1:03 p.m., the Committee was adjourned.]

                            A P P E N D I X

                              ----------                              

                   Prepared Statement of Travis Combs

    Mahalo, Senator Akaka for bringing the Senate Committee on 
Veterans' Affairs hearings to our DAV Hall recently. I found the 
historic event very interesting and the ecumenical spirit alive and 
well amongst the various veterans groups.
    I look forward to your re-election and thank you and your staff for 
all your support and hard work.

                                 ______
                                 
                Prepared Statement of Charles H. Turner

    I have had claims filed with the VA for nearly 15 years for 
injuries suffered from mustard gas during my service in World War II. 
My first claim was denied on the basis of lack of evidence. I could not 
provide such evidence because the Army conducted a secret operation on 
me and my fellow servicemen while we were on maneuvers in Mississippi. 
We were sprayed with phosgene to test the efficiency of new gas masks 
that were supposedly impervious to any gas the enemy had.
    These new gas masks also were used in field operations while we 
were engaged in qualifying tests for the Expert Infantryman's Badge 
that involved chemical warfare tactics. I qualified and was awarded the 
Badge and a pay boost of $5 a month. I still have that treasured Badge. 
But the Army refuses to admit that I earned it! It has stonewalled my 
application for correction of my Honorable Discharge since 1991 when I 
also filed a VA claim. The VA apparently could not proceed without 
verification of the award and thus I have been frustrated.
    I now feel that I should come forward and disclose something I have 
never revealed before: While I was engaged in preparations for overseas 
duty in Mississippi in 1944 I was detached from my unit--Company I, 
376th Infantry--and assigned to a special unit that was preparing our 
201 Files for shipment. My MOS was as a BARman but because I could type 
I was assigned to the Company Clerk, Cpl. D. Nelson Russ.
    While working at headquarters, I noticed something strange. 
Information about the Expert Infantryman's Badge was being deleted. 
Furthermore, no General Orders had been cut, as was normal procedure. I 
questioned the company clerk and he told me not to worry about it.
    But I did worry about it . . . so much that I secretly began making 
a list of everyone in my company--name, rank, serial number and 
hometown address. I still have that list. I never got a chance to 
complete it.
    I was summarily dismissed from my special assignment and sent back 
to do BAR training.
    I have irrefutable evidence that I received the Expert 
Infantryman's Badge. I submit with this letter an enlarged photo of me 
while I was in Company Formation at Camp McCain, Miss., shortly before 
we went overseas. One can plainly see that I am wearing the Expert 
Infantryman's Badge. I can make the full photo (it shows 200 men) 
available if necessary. Would anyone dare wear such a badge in 
formation unless he earned it? The Army, in attempt to cover up the 
abuses in our training, has done a terrible thing. Most of those 200 
men in the picture are long dead. Even Corporal Russ, our Company 
Clerk, no longer is among the living. Even if I finally win my case, it 
will be a hollow victory.
    But I am determined that the truth shall come out. I want the Army 
to end the charade once and for all. I would hope that in a sense of 
decency it would finally correct my Honorable Discharge to show that I 
received the Expert Infantryman's Badge as well as the other awards 
omitted from the document because I took the word of a clerk at the 
Mustering Out facility at Ft. Dix, N.J., that ``No one wants to hire a 
killer!''
    I have submitted medical evidence to support my latest claim with 
the VA and am awaiting a decision.
    Meantime, I hope I can survive to see this matter to a final 
conclusion. At age 82, fighting cancer and heart trouble, the Diagnosis 
is not good.
                                 ______
                                 

           [From the Memphis Commercial Appeal, July 9, 1944]

                  CAMP McCAIN UNITS TO RECEIVE HONORS

   Expert Infantry Regiment Awards Planned Today--Public Will Attend
    Camp McCain, Miss.--The three infantry regiments of the 94th 
Division will receive the highest award of the Army Ground Forces--that 
of Expert Infantry Regiment--in elaborate ceremonies at the division 
parade grounds Monday morning.
    The event will mark the first award of the Expert Infantry Regiment 
streamer to any regiment in the Army, which at present count is more 
than 8,000,000 troops. The honor of being the first regiment to qualify 
for the streamer goes to the 376th Regiment, commanded by Col. Harold 
H. McClune, who has progressed from a private in World War I to his 
present position.

                          376TH REGIMENT WINS

    Three days after the 376th became the first in the Army to deserve 
the streamer, the 302nd Regiment, commanded by Col. Earl A. Johnson, 
and the 301st, led by Col. Roy N. Hagerty, qualified. The last two 
outfits, however, are still shy of the record set by the 376th, which 
has every company in the regiment qualified for the Expert Infantry 
company streamer.
    This latest recognition is a continuation of a long string of 
honors which have come to the 94th Division, commanded by Maj. Gen. 
Harry J. Malony.
    Among the distinguished general officers who will be present for 
the ceremonies are Maj. Gen. John P. Lucas, who led the Army corps 
which initiated the Anzio beachhead south of Rome and now is commander 
of the Fourth Army, and Maj. Gen. Frank M. Milburn, commander of the 
XXI Corps, of which the 94th is a part. Also ranking officers from the 
Army Ground Forces headquarters in Washington are expected to be on 
hand.

                            MEANS PAY BOOST

    The Expert Infantry awards, created by the War Department to 
partially give the Doughboys credit for the unsung work they do in 
winning wars, require a high degree of efficiency from the soldier in 
every phase of training--from military discipline to bayonet skill to 
chemical warfare.
    A company, battalion or regiment must qualify 65 percent of its 
personnel to be eligible for the award. As further recognition of the 
work of the Doughboy, Congress recently passed a bill granting pay 
raises of $5 per month to holders of the Expert Infantry Badge, which 
means practically an en masse pay raise for the 94th foot troops.
    In the parade Monday Brig. Gen. Louis, division artillery 
commander, will serve as commander of troops, forming the division for 
review by Generals Lucas, Milburn and Malony. The public is invited to 
attend at 10 a.m.

[GRAPHIC] [TIFF OMITTED] T7351.001

      Prepared Statement of Dr. Stanley Luke, Helping Hands Hawaii
    We are writing to you regarding the VA services in the State of 
Hawaii. The focus of the below issues is on gaps and barriers to care 
for the local veterans. Please allow us to review these problems from 
the perspective of a mental health provider in the community.
    1. On Oahu, veterans have much difficulty obtaining an appointment 
at the VA. Our understanding is that the NCQA standard for a Routine 
appointment is 5 working days. The VA system clearly does not meet this 
community standard for Access to care.
    2. There has been a strained relationship between our agency and 
the Mental Health department at the VAMROC. Specifically, we had a VA 
client, S.A., who was denied services at the mental health clinic by 
Drs. Bernstein and Batzer. In my letters to Senators Inouye and Akaka, 
I filed a formal complaint regarding the quality of care problems 
associated with the denial of services for this 100 percent Service 
Connected veteran, who is now deceased.
    3. Regarding PTSD treatment, as a psychologist, I have worked twice 
for the PRRPHilo program, which was closed in December 2005. I 
understand that there is a plan to build an expensive inpatient PTSD 
facility at TAMC. I would recommend that a comprehensive study be 
conducted to determine if this is an efficient and effective manner to 
provide PTSD services to veterans in Hawaii. In general, I believe that 
an intensive outpatient PTSD program and supported housing program 
would be an alternative to inpatient treatment. Such a treatment 
program would be possible for All locations, including the neighbor 
islands.
    4. On Oahu, the C and P process has often been a burden and even a 
traumatic process for the local veterans. They have had to wait for 
their disability evaluations and have been disrespected by some of the 
mental health professionals who have conducted the PTSD evaluations. 
Specifically, I had a veteran express rage and resentment after being 
told that he was a ``faker,'' who was exaggerating his PTSD symptoms.
    5. There has been no on call coverage for mental health services. 
Veterans are simply told to go to the Tripler ER after business hours. 
Psychiatrists are not providing 24-hour coverage for their patients.
    6. We understand that mental health professionals have no office 
space now at the psychiatric unit at Tripler's 3B2. This has affected 
morale and wasted time for the mental health staff assigned to treat 
inpatients.
    7. We also have observed that the staff at the benefits department 
have been burdened by large caseloads. This has affected morale and 
effectiveness in this department. We have noticed burn out and 
conflicts between staff members as well.
    8. Dr. Bernstein, who is chief of mental health services, has not 
been able to answer our questions regarding denial of services for 
veterans. He has even produced a rather flawed policy and procedure 
regarding veterans who are on a Conditional Release from the Hawaii 
State Hospital. In short, we have been told that the State of Hawaii's 
Adult Mental Health Division, not the VA, is responsible for the mental 
health needs of the veterans, even if he/she is 100 percent Service 
Connected for a disability. I am not clear why Dr. Bernstein has not 
addressed this issue regarding dual eligibility for services.
    9. We have not been impressed with the utilization of the 
telemedicine resources. On Oahu, there are rural areas such as the 
Leeward side and North Shore which could benefit from telemedicine. 
There are many homeless veterans in these areas of Oahu, and they could 
benefit from outreach services as well.
    10. There has been a lack of resources in the VA's mental health 
system. For example, there has been no hiring of clinical psychologists 
when replacements are needed. Positions have either been frozen or 
eliminated. No psychologists have been hired to work in Primary Care 
settings. Only a Maui psychologist has been hired for this kind of 
integration of mental health with Primary Care.
    11. There has been no replacement hired for the chief psychologist 
position after Dr. Rodney Torigoe retired many years ago. This has 
weakened the Psychology Service.
    12. In the past, cultural issues have been given both emphasis and 
money to improve VA services. Cultural competence is considered to be 
essential in any health care system, but the local VA has decreased its 
resources for this area. Many of the veterans are Native Hawaiians, and 
it concerns us that the VA has allowed an erosion in the trainings and 
education on cultural competence.
    13. The National Center for PTSD (Pac Center) has located its 
offices in downtown Honolulu. It has been on Bishop Street for many 
years, and veterans have had to go to this location for services and 
also research projects. We recommend an audit of this office location 
to determine if this is efficient and effective. We wonder if the 
National Center office should be located at TAMC rather than in an 
expensive location in downtown.
    14. The VA services have been affected by poor leadership and 
management. In Honolulu, the VA upper management have been insensitive 
to mental health services, usually using money and resources for other 
areas. In addition, there has been poor morale for staff members at 
VAMROC. There has even been infighting between staff at the VA.
    15. The Vet Centers have been extremely busy. They are providing 
mental health services with a small staff model. Therefore, we 
recommend that the Vet Centers hire additional staff to improve their 
capacity for services.
    16. Finally, we have been concerned about the lack of outreach 
services to veterans on Oahu. Generally the mental health services have 
been office or facility based, rather than community based. 
Essentially, veterans have avoided going to the VA because mental 
health outreach services have not attempted to engage them. They also 
perceive the services to be poor in quality. Thus, other health systems 
in Oahu have had to provide mental health services for veterans. For 
example, they have opted out and gone to private sector providers or 
even state-funded programs to receive their care.
                                 ______
                                 
                Prepared Statement of Malcolm M. Giblin

    Thank you for taking the time to update the veterans on the state 
of VA care in Hawaii.
    The status of coordination health care resource between the 
Department of Veterans Affairs (DVA) and the Department of Defense 
(Tripler Army Medical Center) (TAMC) delivery of adequate medical care 
is grossly inadequate.
    I want to express the fact that the DVA lack a strong commitment to 
support the activities and deliberation of health care. Collaboration 
between the VA and DOD has to be improved in order to provide adequate 
services to our veterans. For example, the DVA prefers to send veterans 
to Palo Alto, California for surgery when the same services are 
available at Tripler Army Medical Center. We desperately need to 
improve coordination between the two departments in order to achieve 
enhanced and much needed benefits for our deserving veteran population.
    It is important to note that the VA and DOD leadership in Hawaii 
has not worked jointly for several years to address improvement or 
expansion of health care to our veterans.
    I recently had a conversation with an Orthopedic Surgeon at Tripler 
Army Medical Center. He informed me that the DVA prefers to fly a 
patient to Palo Alto for surgical procedures. The surgery is performed 
and then the patient is flown back to Hawaii. The primary doctor is in 
Palo Alto and the patient is in Hawaii. The same procedure could have 
been performed at TAMC with the doctor located here in Hawaii, instead 
of the mainland. Follow-up treatment can be performed locally. 
Additionally, the DVA prefers to farm the veteran out to local doctors 
for specialty care vs. using TAMC.
    A new Orthopedic Surgeon will be assigned to DVA at TAMC in the 
near future. What is the value of a surgeon who will not have operation 
room privileges at Tripler? Between the two, we need to explore 
collaboration to improve delivery of care at patient level. The VA 
Leadership needs to explore the potential of sharing with TAMC. As a 
matter of fact, health care officials need to declare that health care 
is local. Therefore making facility-level between coordination the VA 
efforts extremely important, in order to improve health care delivery 
to our beneficiary collaboration and Tripler.
    In addition, under TRICARE, the nature of interagency sharing 
health care has shifted from direct sharing of Federal Complicated 
partners to VA, primarily functioning in a subcontractor role and 
making sharing even more complex and complicated.
    In conclusion, I believe that in order to improve ``The State of 
Health Care in Hawaii'', the VA and TAMC need to work at all levels to 
expand and improve our sharing relationship. In addition to those 
specifically issues discussed, we need to continue to ensure that both 
our departments work together as effectively as possible.

                   Prepared Statement of Henry Kauhi

Subject: Assistance With the Following Pertinent Veteran Benefits and 
Health Related Issues:

    (1) Priority: Direct Hawaiian Home Lands to allow my 71-year-old 
mom to reinstate her lease of 40-plus years, so that the Regional VA 
Office can assist me in completing my VA Home Mortgage Loan to a 
Veteran who currently is collecting 100 percent Social Security 
Benefits and at least 50 percent total VA Disability Benefits which has 
been in appeals for over 6 years and demands closure;
    (2) To Assist me and future Veterans Who are still in the Appeals 
Stage by either expediting or having a process that is more easy to 
understand and easier for the Veteran to follow as currently it seems 
that we are locked in many red tape issues or/and catch 22 issues;
    (3) Currently I received a diagnosis and half treatment for the 
following conditions:
    (a) Thyroid Cancer Glands surgery performed late August 2005 by Dr. 
Francis, Tripler Medical Personnel and have yet to perform the follow 
up Iodine Treatment to ensure total removal of all cancerous cells;
    (b) Received confirmation by Dr. Bahrenberg of same facility that I 
have Multiple My Loma, another Cancerous Diagnosis in late Sept. 2005 
which has resulted in current treatment making my body weak, and 
susceptible to current Pneumonia Conditions and also in dealing with my 
current service connected injuries which are pain to the middle lower 
back and also PTSD, which Social Security has recognized, however VA 
has yet to acknowledge that is connected regardless of currently being 
treated by my Prim Nakatsu and also Dr. Wong from Psychiatry at the 
Clinic at Tripler.
    (4) I have maxed out the Voc. Rehab Program (to include Completing 
Independent Living);
    (5) My current health requirement is an assistant immediately, as 
my mom is currently helping but have health limitations of her own, and 
I have been bed ridden for over 2 weeks!
    (6) In addition, I could use a way to get around, like a bed that 
can assist me to stand and also one of those carts that can transport 
me to and from shopping as I have been unable to work since 1997.

                                 ______
                                 
      Prepared Statement of Wilma Holi, President, Papa Ola Lokahi

    Good morning Chairman Craig and Members of the U.S. Senate 
Committee on Veterans' Affairs and a special Aloha to Senator Akaka, 
Ranking Member. Papa Ola Lokahi (POL) wishes to express its deep 
gratitude to Senator Akaka for bringing the Committee to Hawai'i to 
review ``The State of VA Care in Hawai'i.'' My name is Wilma Holi, 
president of Papa Ola Lokahi.
    Papa Ola Lokahi is the Native Hawaiian Health Board that was 
established in 1988 to plan and implement programs, coordinate projects 
and programs, define policy, and educate about and advocate for the 
improved health and wellbeing of Native Hawaiians. This was done in 
conjunction with the U.S. Congress establishing its policy ``to raise 
the health status of Native Hawaiians to the highest possible level and 
to provide existing Native Hawaiian health care programs with all the 
resources necessary to effectuate this policy (P.L. 100-579/P.L. 102-
396).
    Native Hawaiians have served in the military services of the United 
States almost from the very beginning of the Nation. Young Prince 
George Kaumuali'i enlisted in the U.S. Navy and fought in the War of 
1812 in the Mediterranean. In following conflicts including the 
American Civil War, the Spanish-American War, World Wars I and II, 
Korea, Vietnam, Iraq, and now Afghanistan and again Iraq, Native 
Hawaiians have continued to serve and serve with distinction. As a side 
note, a number of Native Hawaiians have also served historically in the 
military services of other countries including England and Canada.
    Current U.S. Census data indicate that there are about 30,000 
Native Hawaiian and Pacific Islander veterans in the United States. A 
large proportion of this number is resident in Hawaii; thus, the great 
importance of the local VA offices.
    In 1997, when the VA released the results of the Hawaii's late 
Senator Spark Matsunaga-initiated study on the impacts of exposure to 
war zones on Native Hawaiian and Asian veterans, it became clear that 
along with American Indians and Alaska Natives, Native Hawaiians have 
borne a higher burden of battle-related stress and trauma. More than 
one in two Native Hawaiian veterans experienced war-related trauma in 
Vietnam. The report goes on . . . Upon returning home after one or more 
tours in Vietnam many Native Hawaiian veterans struggle with extremely 
severe problems that neither they nor their families, friends, or 
communities know how to understand or cope with: depression, shame, 
guilt, isolation and emotional emptiness, alienation, unable to relax, 
addiction. One in three Native Hawaiians have full or partial PTSD 
currently . . . More than one in two Native Hawaiians have had full or 
partial PTSD sometime since Vietnam.
    With conflicts in the 1990s in Iraq and now ongoing conflicts in 
Iraq and Afghanistan, and with Reserve and National Guard units being 
heavily utilized along with regular military and the particularly 
brutal nature of the current warfare, these PTSD episodes will only 
greatly increase. An additional factor in these conflicts is the full 
participation of women now integrated with formally almost all male 
forces.
    Native Hawaiians have been actively engaged with the Hawai'i Office 
of the VA (Veterans Affairs) for more than 10 years.
    In 1993, the Office of Hawaiian Affairs under Babette Galang and 
working with Native Hawaiian kupuna (elders) developed for VA staff 
statewide a cultural sensitivity program entitled ``Project 
Ho'olauna''. POL became involved with health and wellness issues 
surrounding Native Hawaiian veterans shortly thereafter. It actively 
participated with the Department of Veterans Affairs and Director Barry 
Raff in the holding of its landmark Symposium on Healing Alternatives 
in October 1995, ``An Interdisciplinary Orientation to Healing from 
Native Hawaiian, Native American, and Asian Perspectives.''
    Later, in March 1998, with Director David Burge and Thomas 
Kaulukukui, POL hosted a special section in its Native Hawaiian Health 
Summit on the health and wellness issues and concerns of Native 
Hawaiian veterans. Later, in 1999, both Director Burge and Mr. 
Kaulukukui were part of a POL team that visited the Navajo Nation to 
discuss with its veteran leadership how it was dealing with PTSD and 
other health issues surrounding Navajo veterans.
    Also, in 1999 Federal legislation established the Hawai'i Federal 
Healthcare Partnership which brought together Hawaii's federally 
designated health entities--the Native Hawaiian Health Care Systems and 
Papa Ola Lokahi and the community health centers and the Hawai'i 
Primary Care Association--with the VA and TAMC (Tripler Army Medical 
Center) to focus on collaborative efforts around Native Hawaiian 
health. This partnership has developed into an increasingly effective 
mechanism to address Native Hawaiian health concerns including those of 
Hawaii's veterans.
    In 2001, POL initiated with the VA a symposium for VA personnel and 
for others working with Native Hawaiian veterans. Noted psychologist 
Dr. Kekuni Minton presented a number of sessions on cultural trauma and 
its impacts. Also in 2003 and 2004, POL provided Native Hawaiian 
cultural competency sessions for VA and TAMC professional staff. These 
sessions clearly indicated the importance sensitivity to culture is in 
treating Native peoples.
    Most recently in 2005, POL launched an effort with Dr. Bud Cook of 
Ka Maluhia Learning Center to begin to develop a program for Native 
Hawaiians, their families, and others which would look at building on 
the strengths of the Hawaiian culture to help mitigate veteran health 
and wellness issues. Work is just beginning on this initiative but it 
hopefully will enhance the work of the VA as well as bring together 
those entities working in the Hawaiian community in health such as the 
Native Hawaiian Health Care Systems to better address the on-going 
needs of our returning Native Hawaiian veterans-men and women-from the 
Afghanistan and Iraq theatres.
    Despite these efforts, there is so much more to be accomplished as 
the needs of many Native Hawaiian veterans remain unaddressed. Reports 
of Hawaiian veterans living in caves and in rural forested areas 
continue to be heard. Health care access for them and their families is 
non-existent. Somehow we need to find ways of reaching out to these 
`lost warriors.' This remains our challenge for the future.
    Finally, before making the following recommendations, POL would 
like to acknowledge the appointment of Dr. Hastings as the new VA 
Director. POL looks forward to continuing to work with him and his 
staff. POL makes the following recommendations for your Committee's 
consideration:
    1. Good health is integral to wellness and in the Hawaiian context, 
it incorporates mind, body, and spirit. POL strongly recommends that VA 
programs need to be mindful of and support cultural approaches which 
enhance wellness as well as address physical health needs;
    2. Native organizations have an important role to play in the 
healing process for Native peoples. POL recommends that the VA work 
closely with and collaborate with such groups as the now being 
chartered National American Indian Veterans, Inc.; the Native Hawaiian 
Health Care Systems; the Hawai'i Federal Healthcare Partnership and 
others to include sharing resources and expertise to better address the 
health and wellness issues of Native Hawaiian veterans and others;
    3. Culture serves as the foundation for healing for Native peoples. 
POL strongly recommends that the VA incorporate cultural competency 
sessions for its professional staff working with Native Hawaiian 
veterans;
    4. The concept of `place' has great significance in Native Hawaiian 
culture as it does in American Indian and Alaska Native cultures. POL 
recommends that the VA study this concept as a means to enhancing its 
ability to provide services to Native Hawaiians; and
    5. Finally, on-going research into the needs and concerns of 
current Native Hawaiian veterans returning from war zones is crucial to 
saving lives. POL strongly recommends that the VA increase its research 
capacity to investigate what the health and wellness issues are for 
returning Native Hawaiian men and women veterans from today's war 
zones. It is hoped that many of these studies could be undertaken by 
Native Hawaiian health researchers themselves.
    Thank you for giving POL an opportunity to provide testimony on 
this important issue.
                                 ______
                                 
   Prepared Statement of William C. S. Park, Retired Master Sergeant

    Mr. Chairman and Members of the U.S. Senate Committee on Veterans' 
Affairs:
    I offer all honor and respect to the Great Spirit who brings us 
together today, to the spirits of this sacred land, the sky above, the 
earth below, the streams which run to the sea and the sea itself. I pay 
all honor and respect to our ancestors who watch over us, to the kupuna 
who have passed, to the kupuna who yet live to guide us with their 
wisdom; and to the chiefs, dignitaries, Senators, and other leaders 
present, to the Department of Veterans Affairs, its Chair, to all 
veterans and to all others present.
    I thank you for taking the time to be here today and providing us 
the opportunity to discuss with you our concerns regarding veterans 
care here in Hawaii.
    I am a disabled veteran employed with a non-profit organization 
that works with adult mental health clients and the homeless, many of 
which are disabled veterans. Through my position, I am not only a 
witness to the care disabled veterans receive (or don't receive), I am 
also faced with the challenge of helping them to find ways to overcome 
all the obstacles that are placed before them.
    Through the teachings of our elders and Papa Auwae, we were taught 
that Hawaiian tradition and culture believed that warriors returning 
from battle needed to be ``re-born''. Special rituals were performed to 
help the warriors through this process. In today's society, we also 
must address and meet our warrior's needs.
    Although it appears that this Committee is addressing many issues 
that directly affect veterans care, it doesn't seem as if the long-
standing, underlying issues are getting the attention they should. I 
would like to stress that as a veteran receiving care at the VA and 
working with veterans, my complaint does not lie with staff. I have 
nothing but great respect and gratitude for the doctors and staff at 
the VA. They are committed and dedicated to the veterans and their 
care. They are also overworked, intimidated by management, and 
disillusioned with leadership at all levels. It is a ripple affect and 
it starts at the top with poor leadership, low staff morale, distrust 
of management by staff, no open door policies, no adequate resolution 
of complaints, misuse of VA funds, but most important, a severe lack of 
care for veterans.
    Here locally, the VA has what it terms a ``hands off'' policy. This 
means that when a veteran is incarcerated or becomes a patient at one 
of the State's facilities, the VA considers him/her a ``ward of the 
State'', and thereby relinquishes all contact, communication and care 
of the veteran. (Enclosed is a Facility Policy Memorandum No. 136-01-
030.) Although this policy does provide for a possible collaboration of 
a veteran's care once deemed to be a ward of the State or other 
government agencies, the local VA does not participate in such 
agreements for the care and well-being of the veteran. Working with 
these types of clients, living in the State of Hawaii, and given the 
lack of care provided by the VA, it seems only logical that at some 
point in time, a veteran will likely require the services of the State.
    It has been my experience that when this happens there is 
absolutely no communication between the doctors and/or staff at the VA, 
the detention facilities, or the hospitals. I personally know of 
veterans who have for one reason or another (whether it be difficulty 
in getting appointments with VA doctors, lack of transportation, lack 
of understanding, misinterpretation of procedures, among a few) have 
failed to take their medications and in an attempt to seek help, ended 
up being referred to a State Agency. It is a well known fact among the 
veterans requiring mental health care, that the VA has NO case 
management services for its veterans. NONE. When a veteran is in a 
mental health crisis and calls the VA for help, they are told to call 
the State Access line. I ask you, when you are in a health crisis, do 
you want to talk with a stranger who knows absolutely nothing of you or 
your circumstances, and who has no access to your files and records to 
refer to if you are unable to communicate your needs to them? And the 
story gets even better, because the veteran is the pawn, the State's 
hands are tied, and the VA has an uncooperative and uncommunicative 
spirit.
    What is a veteran's alternative then? He/she seeks services on a 
fee basis which is approved by the VA. Unfortunately, more often than 
not, the vendor fails to get paid by the VA and the veteran receives 
the bill. Unable to pay the bill, it ends up with a collection agency. 
Now the veteran faces an additional challenge, when all he/she wanted 
and deserved was to get the care they are entitled to, a small 
compensation for the great sacrifice they have made in service of our 
country.
    I implore you, each of you on this Committee, to listen well to all 
that is being said, not only today, but at all of your meetings with 
the public.
    Go beyond what leadership and management are telling you.
    Listen carefully to staff who care and are brave enough to speak 
regarding their needs and concerns, and please, please pay heed to what 
the veterans themselves are telling you.
    He `onipa'a ka `oia'i'o. Truth is not changeable.
    I firmly believe that the brave warriors of this country deserve 
the best health care services its government has to offer.
    In closing, I once again thank you for holding these meetings and 
giving us the opportunity to voice our concerns. My thanks to you who 
cared enough to be here today, to those who were instrumental in 
arranging these meetings, and to you, the Committee, for seeking to 
ensure better care for veterans.
    My heartfelt thanks to each and every veteran throughout this 
Nation, who have served our country so well. May the Great Spirit that 
watches over all, bless and keep each of us.
                                 ______
                                 
 Department of VA Regulation--Department of Veterans Affairs Medical & 
Regional Office Center, Honolulu, HI 96819, Facility Policy Memorandum, 
                   No. 136-01-030, September 30, 2001

EXCLUSION FROM TREATMENT OF VETERANS WHO ARE ALSO WARDS OF THE STATE OF 
                   HAWAII OR OTHER GOVERNMENT AGENCY

1. Purpose
    To establish policy and procedures that expressly exclude hospital 
and outpatient care for a veteran who is a patient or inmate in an 
institution of another government agency.
2. Policy
    (a) In October 1999, VA promulgated regulations, establishing the 
enrollment system and a medical benefits package describing the 
services VA furnishes to veterans enrolled in the VA health care 
system. In developing the benefits package, VHA decided to change its 
long standing policy and expressly exclude from the benefits package, 
by regulation, hospital and outpatient care for a veteran who is a 
patient or inmate in. an institution of another government agency if 
that agency has a duty to give the care or service.
    (b) Under the Eight Amendment, a State or local government has a 
duty to provide adequate medical care and services to those whom it has 
incarcerated. To be adequate, the care must be reasonably designed to 
meet the routine and emergency health care needs of prisoners, 
including medical treatment for physical ills, dental care and mental 
health care. The medical care also must be at a level reasonably 
commensurate with modern medical science and of a quality acceptable 
within prudent professional standards. That standard arguably applies 
to virtually all care that VA might furnish to a veteran.
    (c) Emergency services will be provided to stabilize any veteran 
brought in. However, inpatient treatment will be considered only on a 
case-by-case basis.
3. Definitions
    (a) 38 U.S.C., 1710(g). In 1986, Congress amended 38 U.S.C., 1710 
(formerly 610) providing that VA ``shall'' furnish certain veterans 
with hospital care. To ensure that State and local officials did not 
use the new statute to argue that VA must provide care for incarcerated 
veterans, Congress added language providing that the statute does not 
require VA to furnish care to a veteran to whom another agency of 
Federal, State, or local government has a duty under law to provide 
care in an institution of such government. Subsection (g) does not 
prohibit VA from caring for incarcerated veterans, thus from 1986 until 
late 1999, VA did provide such care. Rather, subsection (g) provides VA 
with legal authority for refusing to furnish such care to incarcerated 
veterans if it so chooses. VA did just that when it chose to exclude 
care for incarcerated veterans in the regulations establishing the 
benefits package, as discussed above.
    (b) Sharing Agreement: The policy on providing care to incarcerated 
veterans does not prohibit VA facilities from entering into sharing 
agreements with prison or other state officials to furnish care to 
incarcerated veterans.
    (c) Ward of the State: Any person who is forensically committed to 
an institution or is under conditional release. Patients on parole or 
probation are not considered wards of the state.
    (d) Conditional release: A person who is forensically committed by 
the State of Hawaii Courts, but who is allowed community treatment 
based on their meeting a specific set of conditions approved by the 
court. These patients are considered active patients in Hawaii State 
Hospital (HSH) or other institution and are still a ``ward of the 
State''. A violation of any condition is considered grounds for 
revocation of the release.
    (e) Voluntary vs. Involuntary: Voluntary assumes treatment that is 
with explicit permission of the patient, involuntary assumes legal 
involvement. There are involuntary admissions, which are based on 
medical opinion of danger to self or other while awaiting court ruling.
4. Procedure
    (a) All patients meeting the ward of the state criteria are 
excluded from obtaining VA hospital or outpatient care.
    (b) The VA reserves the right to enter or not enter into sharing 
agreements with other government agencies for the provision of care to 
veterans who are wards of the state.
    (c) All patients on probation or parole are expected to have signed 
release of information agreements with the Hawaii State agency (either 
parole or probation officer, or HSH) and the VA, to afford free 
communication between the treating clinicians and the State officials.
    (d) Treatment, other than emergency care, will not be provided when 
it is required as a result of a breach in conditions of release. 
Subject to signed releases of information, the VA will notify the 
proper State officials, such as parole officers or HSH staff, to assume 
their responsibility in care of the patient.
    (e) Voluntary treatment as an inpatient or outpatient may be 
provided within VA or TAMC facilities for decompensation due to the 
veteran's medical or psychiatric illness. VA will not be responsible 
for care in other facilities.
    (f) Involuntary inpatient or outpatient treatment will not be 
provided unless part of sharing agreement or if patient arrives at VA 
facility in need of emergent care. If a decision is made not to provide 
inpatient or outpatient care or treatment to a ward of the State, the 
appropriate State officials will be notified to act on the legal 
conditions.
5. Responsibilities
    Compliance with this policy is the responsibility of all VA 
clinical staff. The ACOS of Mental Health Service, the Chief of the 
inpatient service, Fee Service, or attending physician is responsible 
for contacting the appropriate authorities.
6. Reference
    (a) Title 38 U.S. Code Section 1710(g)
7. Rescission
    Facility Policy Memorandum No. 116-99-001, dated July 30, 1999.
8. Attachments
    None.
9. Review Dates
    September 30, 2002 and September 30, 2003.
10. Re-issue Date
    September 30, 2004.
11. Follow-up Responsibility
    Chief, Health Administration Service, H. David Burge, Director.
                                 ______
                                 
                Prepared Statement of Randall Tsuneyoshi

    1. Health Care is excellent when you get it.
    2. It took 18 months to get an Agent Orange review.
    3. Takes 6 months to get an appointment.
    4. Why does VA send out letter requesting proof that a veteran 
served in RUN, when the DD 214 clearly states they were there.
    5. VA staff is overworked and under budgeted.
    6. VA benefits should be tied in with the annual Defense Budget. A 
quarter of the budget should be for Vet care.
    7. It takes 1 Combat Tour (we months) to develop PTSD. VA care 
should be funded of the level of 24 hours x 365 days = minimum time 
required for mental health care.
    8. On Agent Orange diseases: Why does VA not used EPA Standards on 
Chemical affects. Agent Orange problems take years to affect the 
veteran. A CIB or Purple Heart is not the only justification for 
disability.
                                 ______
                                 
               Prepared Statement of Lori and Paul Wessel

    The support, therapy and guidance that they continue to provide for 
us (and our sons) have been excellent and very helpful throughout this 
awfully painful time in our lives. Bereavement Counseling provided by 
those who are knowledgeable about the military as well as being trained 
as counselors makes a difference. Sitting in the waiting area has also 
allowed me to witness first hand what they (the center, facilities and 
staff) provide to the veterans who walk in for information, support, 
advise and the work info center is a great asset and well utilized. 
We've seen vets come in for a bite of respite.
    As non-military, without access to the VA benefits or really, 
information, this center has proven to be a life saver for us in 
dealing with the loss of our son.
  

                                  
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