    [House Hearing, 110 Congress]
    [From the U.S. Government Publishing Office]

                           LEGISLATIVE HEARING ON
                H.R. 92, H.R. 315, H.R. 339, H.R. 463, H.R. 538
              H.R. 542, H.R. 1426, H.R. 1470, H.R. 1471, H.R. 1527
                     H.R. 1944, AND DISCUSSION DRAFT OF THE
                   ``RURAL VETERANS HEALTHCARE ACT OF 2007''
    =======================================================================

                                    HEARING

                                   before the

                             SUBCOMMITTEE ON HEALTH

                                     of the

                         COMMITTEE ON VETERANS' AFFAIRS
                         U.S. HOUSE OF REPRESENTATIVES

                           ONE HUNDRED TENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                 APRIL 26, 2007

                                   __________

                               Serial No. 110-17

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

                         U.S. GOVERNMENT PRINTING OFFICE

    35-636 PDF                 WASHINGTON DC:  2008
    ---------------------------------------------------------------------
    For sale by the Superintendent of Documents, U.S. Government Printing
    Office  Internet: bookstore.gpo.gov Phone: toll free (866)512-1800
    DC area (202)512-1800  Fax: (202) 512-2250 Mail Stop SSOP,
    Washington, DC 20402-0001

                         COMMITTEE ON VETERANS' AFFAIRS

                        BOB FILNER, California, Chairman

    CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
    VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
    MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
    STEPHANIE HERSETH SANDLIN, South     RICHARD H. BAKER, Louisiana
    Dakota                               HENRY E. BROWN, Jr., South
    HARRY E. MITCHELL, Arizona           Carolina
    JOHN J. HALL, New York               JEFF MILLER, Florida
    PHIL HARE, Illinois                  JOHN BOOZMAN, Arkansas
    MICHAEL F. DOYLE, Pennsylvania       GINNY BROWN-WAITE, Florida
    SHELLEY BERKLEY, Nevada              MICHAEL R. TURNER, Ohio
    JOHN T. SALAZAR, Colorado            BRIAN P. BILBRAY, California
    CIRO D. RODRIGUEZ, Texas             DOUG LAMBORN, Colorado
    JOE DONNELLY, Indiana                GUS M. BILIRAKIS, Florida
    JERRY McNERNEY, California           VERN BUCHANAN, Florida
    ZACHARY T. SPACE, Ohio
    TIMOTHY J. WALZ, Minnesota

                       Malcom A. Shorter, Staff Director

                                     ______

                             SUBCOMMITTEE ON HEALTH

                      MICHAEL H. MICHAUD, Maine, Chairman

    CORRINE BROWN, Florida               JEFF MILLER, Florida, Ranking
    VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
    PHIL HARE, Illinois                  JERRY MORAN, Kansas
    MICHAEL F. DOYLE, Pennsylvania       RICHARD H. BAKER, Louisiana
    SHELLEY BERKLEY, Nevada              HENRY E. BROWN, Jr., South
    JOHN T. SALAZAR, Colorado            Carolina

    Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
    hearing records of the Committee on Veterans' Affairs are also
    published in electronic form. The printed hearing record remains the
    official version. Because electronic submissions are used to prepare
    both printed and electronic versions of the hearing record, the process
    of converting between various electronic formats may introduce
    unintentional errors or omissions. Such occurrences are inherent in the
    current publication process and should diminish as the process is
    further refined.

                                C O N T E N T S

                                   __________

                                 April 26, 2007

                                                                       Page
    Legislative Hearing on H.R. 92, H.R. 315, H.R. 339, H.R. 463,
      H.R. 538, H.R. 542, H.R. 1426, H.R. 1470, H.R. 1471, H.R. 1527,
      H.R. 1944, and Discussion Draft of the ``Rural Veterans
      Healthcare Act of 2007''.......................................     1

                               OPENING STATEMENTS

    Chairman Michael H. Michaud......................................     1
        Prepared statement of Chairman Michaud.......................    45
    Hon. Jeff Miller, Ranking Republican Member......................     2
        Prepared statement of Congressman Miller.....................    45

                                   WITNESSES

    U.S. Department of Veterans Affairs, Gerald M. Cross, M.D.,
      FAAFP, Acting Principal Deputy Under Secretary for Health,
      Veterans Health Administration.................................    38
        Prepared statement of Dr. Cross..............................    94

                                     ______

    Altmire, Hon. Jason, a Representative in Congress from the State
      of Pennsylvania................................................    21
        Prepared statement of Congressman Altmire....................    73
    American Legion, Shannon Middleton, Deputy Director for Health,
      Veterans Affairs and Rehabilitation Commission.................    26
        Prepared statement of Ms. Middleton..........................    74
    American Veterans (AMVETS), Kimo S. Hollingsworth, National
      Legislative Director...........................................    27
        Prepared statement of Mr. Hollingsworth......................    77
    Brown-Waite, Hon. Ginny, a Representative in Congress from the
      State of Florida...............................................     6
        Prepared statement of Congresswoman Brown-Waite..............    47
    Disabled American Veterans, Adrian M. Atizado, Assistant National
      Legislative Director...........................................    28
        Prepared statement of Mr. Atizado............................    79
    Filner, Hon. Bob, Chairman, Full Committee on Veterans' Affairs,
      and a Representative in Congress from the State of California..    24
        Prepared statement of Congressman Filner.....................    74
    Latham, Hon. Tom, a Representative in Congress from the State of
      Iowa...........................................................    19
        Prepared statement of Congressman Latham.....................    72
    Moran, Hon. Jerry, a Representative in Congress from the State of
      Kansas.........................................................    22
    Ortiz, Hon. Solomon P., a Representative in Congress from the
      State of Texas.................................................    10
        Prepared statement of Congressman Ortiz......................    48
    Paralyzed Veterans of America, Carl Blake, National Legislative
      Director.......................................................    30
        Prepared statement of Mr. Blake..............................    84
    Pearce, Hon. Steve, a Representative in Congress from the State
      of New Mexico..................................................     2
        Prepared statement of Congressman Pearce.....................    46
    Rothman, Hon. Steven R., a Representative in Congress from the
      State of New Jersey............................................    14
        Prepared statement of Congressman Rothman....................    71
    Solis, Hon. Hilda L., a Representative in Congress from the State
      of California..................................................    18
    Veterans of Foreign Wars of the United States, Dennis M.
      Cullinan, Director, National Legislative Service...............    32
        Prepared statement of Mr. Cullinan...........................    89
    Vietnam Veterans of America, Richard F. Weidman, Executive
      Director for Policy and Government Affairs.....................    33
        Prepared statement of Mr. Weidman............................    92

                           SUBMISSIONS FOR THE RECORD

    American Academy of Neurology, statement.........................   100
    Brown, Hon. Corrine, a Representative in Congress from the State
      of Florida, statement..........................................   101
    Hinojosa, Hon. Ruben, a Representative in Congress from the State
      of Texas, statement............................................   101

                           LEGISLATIVE HEARING ON
                H.R. 92, H.R. 315, H.R. 339, H.R. 463, H.R. 538
              H.R. 542, H.R. 1426, H.R. 1470, H.R. 1471, H.R. 1527
                     H.R. 1944, AND DISCUSSION DRAFT OF THE
                   ``RURAL VETERANS HEALTHCARE ACT OF 2007''

                                  ----------

                            THURSDAY, APRIL 26, 2007

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

        The Subcommittee met, pursuant to notice, at
    10:02 a.m., in Room 334, Cannon House Office Building, Hon.
    Michael H. Michaud [Chairman of the Subcommittee] presiding.

        Present: Representatives Michaud, Snyder, Hare, Miller,
    Stearns, Moran.

                 OPENING STATEMENT OF CHAIRMAN MICHAUD

        Mr. Michaud. I would like to thank everyone for coming here
    today and I would ask unanimous consent that all written
    statements be made part of the record. Without objection, so
    ordered.
        I also ask unanimous consent that all Members be allowed
    five legislative days to revise and extend their remarks.
    Without objection, so ordered.
        Today's legislative hearing will be the first of many this
    Subcommittee plans on holding to provide Members of Congress,
    veterans, the VA, and other interested parties with the
    opportunity to discuss legislation within the Subcommittee's
    jurisdiction in a clear and orderly process.
        I do not necessarily agree or disagree with the bills
    before us today, but I believe that this is an important
    process that will encourage frank discussions and new ideas. We
    have 11 bills before us and one discussion draft.
        The discussion draft represents some of my ideas to improve
    the quality of care available to our rural veterans and the
    ability to access care, such as establishing mobile vet
    centers, improving information technology and technology
    sharing between the VA and non-VA providers, establishing a
    Rural Veterans Advisory Committee, creating Centers of
    Excellence to encourage research in innovative healthcare to
    address the needs of rural veterans, and encourage more
    healthcare professionals to work in rural areas.
        I look forward to hearing the views of our witnesses and to
    a discussion on this and the other bills before us.
        I also look forward to working with everyone here to
    improve the quality of care available to our veterans.
        [The prepared statement of Chairman Michaud appears on p. 45
    .]
        Mr. Michaud. At this time, I would recognize Ranking Member
    Miller.

                 OPENING STATEMENT OF HON. JEFF MILLER

        Mr. Miller. Thank you, Mr. Chairman, for holding this
    legislative hearing.
        I also want to say thank you to the Members who brought
    these bills before us this morning and to all the witnesses
    that are going to be appearing here today.
        I look forward to engaging in a productive discussion about
    the legislation that will help us provide the best care for our
    veterans, whether it is through contract care or requiring more
    VA medical centers to provide chiropractic services, and I
    yield back.
        [The prepared statement of Congressman Miller appears on
    p. 45.]
        Mr. Michaud. Thank you, Mr. Ranking Member.
        Mr. Hare, do you have an opening statement?
        Mr. Hare. No, Mr. Chairman. I will have some questions
    later though. Thanks.
        Mr. Michaud. Okay. Thank you.
        At this time, I would like to welcome two of our Members
    who are here today to present testimony. I know, Mr. Pearce,
    you have another hearing you need to go to. So why don't we
    start with you?

     STATEMENT OF HON. STEVE PEARCE, A REPRESENTATIVE IN CONGRESS
                      FROM THE STATE OF NEW MEXICO

        Mr. Pearce. Thank you, Mr. Chairman.
        I would like to thank Chairman Filner, Ranking Member
    Buyer, Subcommittee on Health Chairman Michaud, and Ranking
    Member Miller for the opportunity to discuss this issue that is
    critical to the veterans of the State of New Mexico.
        Today I am asking for you and the Members of the Veterans'
    Affairs Committee to consider my legislation, House Resolution
    315, the ``Help Establish Access To Local Timely Healthcare For
    Your Healthy Vets Act.''
        In New Mexico's rural communities, many of our veterans are
    deprived of accessible medical facilities and face the high
    cost of gasoline to travel and to obtain care. My legislation
    would require the Secretary of Veterans' Affairs to contract
    with local doctors and hospitals on a case-by-case basis to
    provide medical services including primary care for those
    veterans who live far away from the Veterans Affairs medical
    facilities.
        This would expand the capability of our local health
    providers in southern New Mexico to provide more convenient,
    efficient medical services for veterans who live in areas that
    are far away from established VA facilities.
        Currently veterans residing in southeast New Mexico must
    drive between four and six hundred miles round trip to receive
    care at New Mexico's only VA hospital located in Albuquerque,
    New Mexico.
        Just for example, it is 305 miles from my front door to
    Albuquerque. Now, you might think I live at the end of the
    Earth, but it is actually 40 miles further south to Jal, New
    Mexico. So those people have an even longer drive.
        I consistently hear stories from my constituents about the
    detrimental impact this long-distance drive has on their
    ability to access timely care and overall health.
        One Marine veteran amputee began having uncontrollable
    drainage from his good foot and was making two to three trips a
    week to the Albuquerque VA hospital. This equates to 18 hours
    of drive time a week. After 4 months, he finally lost his foot.
        Several local civilian healthcare experts feel the
    unfortunate travel marathon contributed to the failure to save
    his foot.
        Another 87-year-old Bataan veteran developed a serious
    bladder infection and was directed to make the 6-hour, round-
    trip drive along with his 85-year-old wife. Halfway through his
    treatments, prostate cancer was found and additional trips had
    to be made for chemotherapy. After 7 months of trips, he died
    and his wife's health was seriously damaged after the strain of
    such long-distance care.
        My father is in his eighties. He is a veteran and I will
    guarantee you he is not able to make a 5-hour drive one way.
        Today I know that you will hear from several National
    Veteran Service Organizations who may not support my bill and
    others under consideration today. That is because many of these
    groups have committed themselves to the goal of keeping VA
    dollars inside the VA. I understand this concept and believe at
    first glance it sounds like a commonsense approach to VA
    budgeting.
        But following this logic, the only way to get more
    localized access to care for veterans in my district would be
    to build new facilities in areas closer to their homes. I
    believe there is a need for a full-service veterans' health
    center in south New Mexico and would love to see that come to
    fruition.
        However, I am realistic as are the veterans living in rural
    New Mexico. With the tight budgetary constraints that our
    Nation faces and the smaller population in States like New
    Mexico, that idea is much easier said than done.
        This is a reality veterans living in rural areas have been
    forced to accept. Since that solution is not realistic at this
    time, we must work to find other solutions to this problem that
    is hurting our veterans with every 6- to 8-hour, round-trip
    journey to the hospital.
        Unfortunately, the idea of expanded contracting authority
    raises flags with certain Veteran Service Organizations that
    see it as a step toward privatization. Yet, if they understand
    what is going on, we are spending dollars for gasoline and
    mileage and we are not paying it for the healthcare for our
    veterans.
        I will tell you that the Federal Government and the VA are
    not adequately living up to their commitment in serving my
    constituents in the rural parts of New Mexico.
        John Taylor, life member of the Military Order of the
    Purple Heart and life member of Disabled American Veterans,
    lives in Roswell, New Mexico, which is approximately 200 miles
    away from Albuquerque. In a letter John wrote to me, rural
    veterans in New Mexico are dying and losing body parts because
    of a 6-hour, round-trip drive to the nearest VA hospital in
    this State.
        Our VSO legislative representatives from the DAV have no
    experience or do not live in contact with this issue as they
    are from large urban areas with massive facilities and
    infrastructure for support. The classic response to invitations
    requesting visits to our rural areas has historically been we
    will try. But it takes time to get there and we have a very
    busy schedule.
        I submit the same time that is an inconvenience to
    executives is the same time that is killing my fellow veterans
    or at least causing serious exacerbation of their medical
    problems.
        U.S. Army retired Lieutenant Colonel Charlie Revie, a
    member of the Uniformed Services Disabled Retirees, noted that
    the drive from Las Cruces to our only major VA facilities is a
    250-mile, one-way trip.
        The notion that providing contracted care to veterans
    through local doctors at non-VA hospitals is somehow a way to
    finagle them out of caring for them is absurd. Under my
    legislation, the VA will clearly still pay for the care of
    veterans obtained at non-VA hospitals.
        Veterans in my district and across rural America have been
    hearing politicians talk about increasing access for years. It
    is simply imperative that Congress take these issues seriously.
        Mr. Chairman, I will submit the rest of my statement, but I
    do appreciate the opportunity to come and testify before you
    today and yield back the balance of my time.
        [The prepared statement of Congressman Pearce appears on
    p. 46.]
        Mr. Michaud. Thank you, Mr. Pearce. Rural healthcare for
    our veterans is very important to me, coming from the great
    State of Maine. I appreciate your testimony.
        Mr. Miller.
        Mr. Miller. I may have missed it in your comments, and it
    may be in the text of the legislation, but do you define
    geographically inaccessible?
        Mr. Pearce. Would you state the question again, Mr. Miller?
        Mr. Miller. Do you define geographically inaccessible? How
    do you define that in your legislation?
        Mr. Pearce. The definition, I think, is over 120 or 150
    miles. I will have to check on that. But, yes, we do have a
    definition.
        Mr. Miller. Okay. Very good.
        Thank you, Mr. Chairman.
        Mr. Michaud. Mr. Hare, any questions?
        Mr. Hare. Congressman Pearce, just a quick question. In
    terms of the total number of veterans that are having a
    difficult time getting to--you mentioned the long drives and
    things of that nature. Is there an estimate of how many folks,
    how many veterans in your district, in your State are having
    this problem?
        Mr. Pearce. Oh, Mr. Hare, I would guess that it is probably
    in the 20,000 range. In other words, most of the veterans in
    the southern district are a long way from a hospital. And the
    VA hospital in Albuquerque serves also Texas, so it reaches to
    the extremity.
        Some of the places in the second district are within an
    hour or two, but most are at least 3 hours one way. The rest
    are 4 to 5 hours one way. Again, my home is 5 hours one way
    from the time I leave the front door. So it is probably in the
    20,000 range. And we are just simply requesting that the
    Secretary consider on a case-by-case basis that people be
    allowed to get some care. We have had veterans talk about
    driving to Albuquerque 5 hours away one way, 5 hours back to
    take a blood test. And when they got there, they were told I am
    sorry, that has been rescheduled. These are the sorts of
    problems that the people who come from large metropolitan areas
    just are not familiar with.
        I will tell you that we have had a significant improvement
    in the relationship with the veterans hospital administrator.
    He has actually not this past Saturday, but about two Saturdays
    ago came and met with me and local veterans in Roswell. That is
    still 120 miles north of my hometown and still 40 miles from
    the southern edge of our district.
        And keep in mind, I am on one side and there is another
    side. He was about 7 hours from the sites that are equivalent
    to us on the other side, New Mexico Square. Albuquerque is
    about two-thirds through the middle. So when he was over here
    with us, he is 7 hours from those people over here.
        But at least he is coming down. We could never get the
    former administrator of the hospital to do that. So we are
    having some discussion, but he needs the flexibility to allow
    these people to go to local providers to do commonsense things.
        Mr. Hare. Well, my district is very rural too. And one of
    the things we have done, and I was just wondering if you have
    any of these, we have three veterans' outpatient clinics
    because, for example, we have people who have to go from
    Quincy, Illinois, to St. Louis or drive to Iowa City which was,
    you know, a tremendous hardship on them and people getting in
    vans and taking them to get prescriptions or a blood test or
    something.
        Are there any VA outpatient clinics in your district?
        Mr. Pearce. We do have clinics. And I will tell you that
    the clinic in Artesia, New Mexico, has a big sign that says we
    are not an emergency facility, meaning if you have an emergency
    go somewhere else. That is extraordinarily disruptive.
        So sometimes they do those things like the blood tests.
    Sometimes they do immunizations. Sometimes they say, no, we are
    too busy, you have got to go to Albuquerque.
        Mr. Hare. So you had a veteran drive 5 hours----
        Mr. Pearce. Yes.
        Mr. Hare [continuing]. For a scheduled blood test only to
    find out that----
        Mr. Pearce. Absolutely.
        Mr. Hare [continuing]. They canceled it and you had to
    drive--so 10 hours for absolutely nothing?
        Mr. Pearce. Yes. And that is one of the things that we had
    the VA hospital administrator, he said he would commit that if
    they are going to start cancelling people's appointments, they
    would at least do it the day before or 2 days before.
        Some of these people have to go on their own money. There
    is no hotel compensation allowed and they have to go on their
    own money. And they may leave a day and a half early because
    the drive is so hard.
        I will tell you that I suffer from varicose veins and they
    have recently gone in because I had this pooling of blood
    problem. And the worst thing you can do is drive with that
    situation. And to be describing this Marine veteran that was
    having to drive 5 hours with a foot that is leaking is to me
    the worst thing that you could do. And, sure enough, he ends up
    losing his foot.
        They tell me sitting on the airplane, though it is 9 hours
    for me to commute home from here to Washington, they tell me
    the worst thing I can do is sit in the airplane and, yet, that
    was the prescription for him.
        Mr. Hare. Thank you, Congressman.
        Mr. Michaud. Mr. Stearns, any questions?
        Mr. Stearns. No.
        Mr. Michaud. Dr. Snyder.
        Mr. Snyder. No.
        Mr. Michaud. Now I am pleased to recognize an honorable
    Member of this Committee, Mrs. Ginny Brown-Waite.
        Once again, Mr. Pearce, thank you very much.
        Mr. Pearce. Thank you, Mr. Chairman. You have been very
    gracious.
        Mr. Michaud. Thank you.

       STATEMENT OF HON. GINNY BROWN-WAITE, A REPRESENTATIVE IN
                   CONGRESS FROM THE STATE OF FLORIDA

        Ms. Brown-Waite. Thank you, Mr. Chairman, and thank you,
    Ranking Member and the Members who care enough to attend. I
    know that many people have simultaneous hearings going on that
    they also have to be to as I do, so I will be leaving after the
    testimony.
        I appreciate the opportunity to testify on House Resolution
    92, the ``Veterans Timely Access To Healthcare Act.'' When I
    first came to Congress in 2003, I introduced this measure after
    hearing of the long wait times facing some veterans in need of
    healthcare.
        We recently checked with the VA and the VA is saying that
    96 percent of the patients seeking primary care can get an
    appointment within 30 days. I think that every Member of
    Congress, if they were polled, knows that they are hearing
    otherwise. I do not know where the VA is getting their figures
    from, but we hear otherwise.
        The stories that many of us have heard about these delays
    are unacceptable. The holdups can worsen the veteran's health
    and pose a greater financial hardship on everyone involved. In
    some situations, these waits can be the difference between life
    and death.
        Events in Iraq and Afghanistan also remind us of the urgent
    matter at hand. With thousands of soldiers returning from the
    front lines, many will require immediate healthcare. VA medical
    facilities face a difficult task. Unless Congress takes action,
    wait times will only grow.
        My legislation would help ensure that our Nation's veterans
    receive timely healthcare. For veterans seeking primary care
    from the VA, the bill would establish a 30-day timeframe as the
    standard for access to medical services. This standard would
    cover from the time the individual schedules a visit until they
    actually see a medical provider. In the event this standard is
    unachievable, the VA would have authorization to contract for
    care from a private provider.
        At the same time, my bill also grants the VA some
    flexibility in meeting the standard. For those facilities in
    geographic areas that have a 90-percent or greater rate of
    complying with this requirement, the contracting provisions
    would not be necessary.
        Finally, Mr. Chairman, this legislation would establish
    comprehensive reporting requirements on wait times for
    individuals seeking care at VA medical facilities.
        As Members of Congress, we have an extraordinary
    responsibility to veterans. These brave men and women answered
    the call in our time of need and it is only fitting that we
    take care of them at their time of need.
        I look forward to working with my colleagues on the
    critical issue of wait times, and I would be happy to take any
    questions regarding the legislation.
        When I first got elected, I contacted all of the clinics in
    my area and asked what the wait times were. It did not jive
    with what I was being told by veterans. I then said I want you
    to tell me the real wait times that they have.
        Mr. Chairman, I am embarrassed to tell you that there was a
    big difference between their quick and dirty analysis and the
    true wait times that the veterans had to wait for the primary
    care.
        This is unacceptable, and because we have stayed on top of
    it, those numbers are somewhat within the acceptable range, but
    still not where they should be. Everybody in Congress wants to
    make sure that our veterans are taken care of and timely access
    to healthcare is very important.
        And with that, I yield back the balance of my time.
        [The prepared statement of Congresswoman Brown-Waite
    appears on p. 47.]
        Mr. Michaud. Thank you very much, Ms. Brown-Waite.
        Mr. Miller.
        Mr. Miller. To my colleague from Florida, I think you have
    already answered the question, do you have any confidence in
    VA's numbers in regards to wait times?
        Ms. Brown-Waite. No, sir, I do not. I honestly do not. I
    question it and every Member of Congress who hears from their
    veterans has to also question it. I know you have a large
    number of veterans and that you are very much on top of their
    needs as we all are. That is not what we hear.
        I am known as the nag in the 5th District. And I am fine
    with that because unless you nag the VA and let them know that
    you track those numbers, they do get out of control. And also
    they play games. They will schedule an appointment within ``30
    days'' and on the 25th day perhaps cancel it. So it is not
    really an appointment within 30 days. So we need to constantly
    question their numbers.
        Mr. Miller. You also talk in your legislation about
    requiring that veterans be referred to private physicians. What
    about the instance of the veteran that says he is willing to
    wait and go ahead and go through the system as normal? It does
    not preclude them from continuing on through VA?
        Ms. Brown-Waite. If they are willing to wait, they
    certainly would have that flexibility.
        Mr. Miller. That is all, Mr. Chairman.
        Mr. Michaud. Mr. Hare.
        Mr. Hare. I was just interested in where the VSOs are
    coming down on the legislation and if you could tell me why,
    from your perspective, there is opposition to the bill.
        Ms. Brown-Waite. Most of the VSOs that represent the
    veterans up here want to make sure that all the healthcare
    resides within the VA. And that certainly is their job.
    However, I think each of us when we go back home hear different
    from the veterans who want a much more timely access.
        Historically the VSOs have always wanted to contain the
    healthcare only within the VA system. And in a perfect world,
    that would be the ideal because of continuity of care. But we
    also do not want the veteran waiting inordinate amounts of time
    and the VA playing games with the wait times.
        Mr. Hare. Could you give me an example or two of what you
    have seen in terms of wait times. I know you mentioned a little
    bit about it, but maybe from in your district because, as you
    said, when we go back and we hear from the veterans, I just
    wondered if you had an instance or two that you could----
        Ms. Brown-Waite. Certainly. Mr. Chairman, if I may respond.
    I have had veterans tell me exactly this situation that I just
    described of, yes, they had an appointment within 30 days, but
    on the 21st or the 25th day, VA called to reschedule it 30 days
    later. That is not timely access and that is not serving the
    veterans.
        Certainly the VA clinics, and we are fortunate we have many
    in Florida, the VA clinics do all that they can, but they are
    also having trouble hiring for positions that are open. They do
    not have enough doctors. They do not have enough of the nurses
    and the medical technicians there.
        We are expanding clinics regularly, but people are still
    having trouble with the primary care access.
        Mr. Hare. Thank you very much.
        Mr. Michaud. Mr. Stearns.
        Mr. Stearns. Yeah. Thank you, Mr. Chairman.
        My colleague from Florida has been a leader on this ever
    since she came to Congress and I commend her for it and for
    particularly in an informal basis to try and understand the
    facts.
        Ginny, you had indicated that it takes 30 days, that that
    is the question. But have you looked at once a person gets the
    appointment and then has to come back sometimes and it is not
    just the first appointment that takes a long time, it is coming
    back for the second and third? And I heard complaints that they
    can get within the 30 days, but then when they come to get the
    referral sometimes takes longer. And I just wonder if you had
    any experience on that.
        Ms. Brown-Waite. Mr. Stearns, it depends whether or not the
    second appointment is for specialty care. I know that there is
    a much longer wait for specialty care. I recently heard from a
    veteran seeking dermatology care and that was an inordinate
    amount of time that he had to wait.
        As you all know in Florida, dermatologists are, even in the
    private sector, there is a long wait for the dermatology
    appointment. But very often they will get that first
    appointment and then there is a delay in the followup
    appointment. So, yes, I am hearing that as are other Members of
    Congress.
        Mr. Stearns. Yes. That is what I hear that some complain,
    well, okay, I can get into the front door, but I cannot get any
    response beyond that.
        I do not know. I heard you talk about your informal
    investigation. What did you find was the real time when you
    talked to these veterans themselves? What have they been
    telling you? Like some of my veterans have told me well beyond
    45, 50 days.
        Ms. Brown-Waite. Oh, absolutely. I hear well beyond that,
    as much as 2 months and longer that they are waiting. And that
    is just not acceptable and, yet, the VA tell us that overall 96
    percent are being seen within that 30-day period. I guess it is
    in, you know, dog years that they are counting it because it is
    not 30 days in human days.
        Mr. Stearns. Just your option you talked about, about the
    referral of veterans to private physicians if a network fails
    to meet the standards of access. I guess the question is, is
    your intention not to give an individual veteran the option of
    waiting to receive it or just, in other words, the veteran
    could decide, okay, I will wait 45, 50 days or is it a mandate
    that he has to go to a private physician?
        Ms. Brown-Waite. No, sir. Obviously the veteran could wait
    for the VA care if that is their choice.
        Mr. Stearns. Yeah. Mr. Chairman, I think it is important to
    point out that the legislation is not a mandate to go private,
    but giving the veteran the choice which is what I think
    ultimately the veteran wants to have.
        And I thank you.
        Mr. Michaud. Thank you.
        Dr. Snyder, any questions?
        Mr. Snyder. Thank you, Mr. Chairman.
        I did not realize we had such Florida domination of the
    Veterans Committee until this very moment.
        Ms. Brown-Waite, I guess just two comments or questions,
    and I like what you said about nagging. I think that is what we
    all do sometimes on different issues. And I think it is really
    important that we all do that.
        The concern I have about this bill and some of the other
    bills is there is no new source of funds in this bill and if we
    pass any kind of language that requires the VA to hit this mark
    or we have to pull money out of our system, that money is going
    to be pulled from some place. And if you magnify that all over
    the country or at some point, then they say, well, we need to
    lay off a primary care doctor because we got to pay these bills
    down the road.
        And it seems like we dealt with this a few years ago and I
    think there was a decision made that trying to find healthcare
    in the private sector because we do not like what is going on
    in the VA system that we love so much, at some point, it leads
    into a spiral of funding problems for the underlying system.
        How do you respond to that? I mean, I applaud you. I mean,
    this is kind of a sophisticated form of nagging you are doing
    here this morning. I think it sends a message that we, I agree
    with you 100 percent, we need to be working on these problems.
    But how do you respond to that criticism that we have heard
    through the years and which I have agreed with, by the way?
        Ms. Brown-Waite. Dr. Snyder, as you know, we have increased
    funding. This is my fifth year here and we have increased
    veterans' funding for healthcare substantially during that
    time. It has been over 40 percent in those 5 years that the
    funding has been increased.
        We need to continue to increase that funding. No, this bill
    itself does not have a pricetag attached to it. That would be
    certainly part of the appropriations process.
        Mr. Snyder. Yeah, which I think has some problems.
        Then the other, there is this other issue, too, which I
    think the VA system, as we all know, gets accolades for things
    that it does better than the private sector, but I was nagging
    one of my employees not long ago about I thought he had a
    dermatological thing he needed to have checked out and he
    finally succumbed to my verbal pressures. And it was like it
    was going to be almost, I think, like 2 months before he could
    get in. I said that is not acceptable. So then he was calling
    around and he finally did find somebody.
        But the standard at a private community on some of these
    specialty things is not all that great either for getting in.
    But thank you.
        Thank you, Mr. Chairman.
        Mr. Michaud. Thank you, Dr. Snyder.
        And, once again, thank you, Ms. Brown-Waite for your
    testimony.
        Ms. Brown-Waite. Thank you, Mr. Chairman.
        Mr. Michaud. Next on is Mr. Ortiz. I want to thank you for
    coming here today as well and to present your legislation.

        STATEMENT OF HON. SOLOMON P. ORTIZ, A REPRESENTATIVE IN
                    CONGRESS FROM THE STATE OF TEXAS

        Mr. Ortiz. Thank you, Mr. Chairman, Ranking Member, and
    Members of the Committee, for this opportunity to speak to you
    on behalf of south Texas veterans and help this Subcommittee
    understand the urgent need for a veterans' hospital for the men
    and women who fought for us.
        We have this map before you because I will be addressing
    the Rio Grande Valley. The valley is way at the bottom with a
    population of close to 600,000 people, but the nearest hospital
    is about 6 hours away.
        I would like to echo what my good friend, Mr. Pearce,
    testified to about the distance. Here with me today are the
    Veterans Alliance of the Rio Grande Valley so you can see the
    faces of the south Texans affected by the lack of a hospital.
        The Rio Grande Valley is the southern-most tip of my
    district. And these young men fought bravely for us in
    different wars, from the Korean War to the Vietnam War, and
    some of them still fighting the Iraqi and Afghanistan War.
        Here with me today is Jose Maria Vasquez, Ruben Cordova,
    Max Belmarez, Polo Uresti, Frank Albiar, and Mr. Felix
    Rodriguez. They wanted to be here today to put a face to the
    problem that we face in south Texas.
        My legislation gives the government flexibility in
    establishing a way to deal with hospital services in south
    Texas, but the only real solution, my friends, and I know you
    understand this problem, is a hospital.
        Most of the clinics that we have do not have any inpatient
    care. All they do is have outpatient care. We did try to
    contract out, but 10 beds is not sufficient. The bottom line is
    veterans' inpatient healthcare must be available where the
    veterans reside, not several hours away.
        Part of the healing process is for the family to be able to
    be close to their loved ones who are recuperating from wounds.
    Now we are beginning to see wounds that we did not see before
    because our young men and women are surviving this war because
    they have body armor and better equipment.
        These guys have fought, bled, sacrificed for this Nation.
    They need something that belongs to them, a hospital that gives
    them the care that they need where they reside.
        And we know that the VA plays the numbers game, but the
    numbers do not reflect the need, particularly in the Rio Grande
    Valley.
        When the VA commissioned the CARES study, they recognized
    the far south area of south Texas was in need of acute,
    inpatient care. They decided to meet this demand through
    contracting and leasing beds with the local hospitals, an
    approach that we tried but simply did not work.
        Veterans are still traveling in large numbers to San
    Antonio for care. And for many who are treated for emergencies
    at area hospitals, the bills go unpaid.
        Before, you can imagine this, these young men went and
    fought a war thinking that we as a government were going to
    take care of their problems. Now they have a five and a half
    hour drive, and do not even have vans. They do not have an
    ambulance. They have to get volunteers, my friends, to drive
    them for five and a half hours to the nearest VA hospital which
    is in San Antonio.
        Some of the Second World War veterans are bedridden and no
    ambulance to drive them and are dependent on volunteers to
    drive them. They have a van. How in the world can you see the
    Second World War veteran on a van when he is bedridden? Some of
    them just simply do not go to the hospital anymore or to the
    clinics that we have.
        Many of the veterans are so disgusted by the level of VA
    healthcare that they just simply do not sign up anymore. They
    have given up.
        You have heard me describe the conditions of south Texas
    veterans today, but they want to show you experience of
    veterans themselves, veterans who shed blood for our Nation.
        What I have done and what they wanted to do was give you
    testimonies, and it is a stack this high, of some of the
    sacrifices that they have gone through to go five and a half
    hours to get a 15-minute checkup because the locals do not have
    the equipment, because the locals just cannot do it. They go up
    there for 15 minutes. They drive five and a half hours. Then
    they come back another five and a half hours' drive.
        Some of them, the older people are having prostate
    problems, in the eighties. They go there just to see that their
    appointment was canceled. Then they have to drive back again,
    and they say come back in 6 months.
        This is just something that I cannot understand. You know,
    we can find money to go fight a war, into the billions of
    dollars, but for some reason we cannot find enough money to
    take care of the promises that we made.
        I am a veteran. I served. We must give them what they
    fought for. And Vic and I, you know, we served, Congressman
    Snyder and Jeff Miller. This is something that we do every day.
    We talk about readiness, about military, about personnel, and
    about funding into the billions of dollars.
        I am afraid that what we are doing today is going to have a
    huge impact if we do not try to resolve some of these problems
    on retention and recruitment.
        I was at a fair that we had for veterans and I see this
    older man on crutches with his two young grandsons. And as I
    was talking to him, he says do you think I am going to
    recommend for my grandsons to go join the military when you
    look at my condition and they have not been able to take care
    of me?
        This is why we need something to address the needs of our
    soldiers, people who have fought, people who have bled, many
    have died, have never come back.
        We just had a recent young man come back from Iraq. He was
    shot in the back. His spinal cord is gone. He cannot walk
    anymore. He says I remember when I was in Iraq and I saw those
    young men lose their legs and I felt sorry for them, you know,
    and I still do. But you know what? Those young men who lost
    their legs can walk because of prostheses. There are a lot of
    us coming back with spinal injuries with our legs, but we
    cannot walk.
        When he was coming out of anesthesia, my friends, he was
    fighting. He thought they were taking him prisoner. We need
    competent people, trauma care, who understand what they are
    faced with. And this is something that we do not have.
        I have a large testimony, but I know that time is limited.
    Look at my legislation. I will leave with you some letters that
    you can read about the sacrifices that they go through.
        Thank you so much for listening to us. Hopefully you will
    take a look at my bill, and I will give you the testimony that
    the veterans and some petitions because this is something. I
    have been in Congress 25 years. I have been fighting for a
    hospital for the last 24 years.
        What they have done in the past is to consolidate some of
    the clinics, shut down some hospitals, and now we are getting
    more and more soldiers coming back with different wounds from
    Iraq and we need to take care of that.
        Thank you so much.
        [The prepared statement of Congressman Ortiz appears on p.
    48. The petition submitted by Congressman Ortiz is being
    retained in the Committee files.]
        Mr. Michaud. Thank you, Mr. Ortiz. And do you have a copy
    of that map, so we can have it for the record?
        Mr. Ortiz. We do. We are going to pass you a copy of the
    map with the testimonials of several of the veterans.
        Mr. Michaud. Okay. Great. I appreciate it.
        And it is my understanding that under the Capital Asset
    Realignment for Enhanced Services (CARES) process there is no
    hospital, but we will check with VA to make sure.
        Mr. Miller.
        Mr. Miller. Solomon, I assume that the closest DoD facility
    to south Texas is Corpus Christi. Is there a Navy hospital
    there at the Naval Air Station?
        Mr. Ortiz. We had a Naval hospital. It was shut down. And
    sometime back, I testified before the VA Appropriations
    Subcommittee. They came down and they looked at the hospital.
    Again, the lack of funding. And then they came down and they
    said this hospital is obsolete, you know, does not conform to
    the American Association Guidelines. So we do not have a
    facility.
        Another problem that we have is the influx, you know, we
    have a lot of winter tourists, veterans that live in the area
    for 4 to 6 months, they are vets who need treatment, about
    20,000. We have about 140,000 people, soldiers who have served
    in the military. We do not have a facility. We tried
    contracting out with the local hospitals.
        One young man was having a cardiac arrest and he called his
    people at the VA, who say go to the hospital, go to the nearest
    hospital. He did. Then he got a bill for $10,000 that he still
    has not been able to pay.
        These are the problems that we face on an everyday basis.
    There is not a hospital. It is all outpatient care.
        Mr. Miller. You said that the contracting side was not
    working. Is it not working in regards to them being able to get
    the care? Is the breakdown just in paying for the bills? Where
    is the breakdown?
        Mr. Ortiz. It is both, because when you have 140,000
    eligible people and you only have about 10 beds, you know,
    either they are full, they cannot take anybody, or if they take
    somebody else, they do not have room, then they charge the
    patient coming in.
        So this is why the system, we tried it before, it is not
    working. And when I meet with a veteran, they say, you know,
    when I enlisted, they told me that they were going to take care
    of my health and now I am back and I have to wait 6 months for
    an appointment. I cannot get inpatient care. It is all
    outpatient care.
        Mr. Michaud. Mr. Hare.
        Mr. Hare. Congressman, let me just say thank you for two
    things. One, first and foremost, for introducing this
    legislation. You know, you were absolutely right. I was
    listening to your testimony and the amounts of money that we
    spend, you know, $11 million an hour on this war and, yet, I
    sat at this Committee and I keep hearing people say how are we
    going to afford this. And my answer has always been the
    question is not can we afford, the question is how can we
    afford not to do this.
        So, Congressman, I would be honored to be a cosponsor of
    this bill. I think it is something that your veterans need and
    you have been a champion for veterans. And so I just want you
    to know that.
        And we will find the money. We have got it. You know, and I
    said before maybe we ought to take it out of Paris Hilton's tax
    break. I do not know. But we will get it.
        But let me just suggest this to you, too, or thank you for
    this too. I thank you for taking the time to come in. Lane
    Evans is my predecessor as you know. And I want to thank you
    for coming in helping us complete the Hero Street Memorial with
    your help.
        And for those of you who do not know what that is, that is
    a Hispanic area in my district, one street where five young men
    gave their lives in World War II.
        And thanks to you, Congressman, that memorial is now
    finished. And I want to, on behalf of the people of Hero
    Street, I have not had a chance to thank you yet, but I want to
    thank you for doing that.
        And, again, thank you for introducing the legislation and I
    will do everything I can on my end to help you with it. And,
    you know, you are right. When you bring veterans in and you put
    a face on it, you know, I think it is a wonderful thing to do
    because sometimes we look at charts and numbers, but we are
    talking about people here.
        And from my perspective, I cannot think of anything more
    important to do than to support this bill. So thank you for
    taking the time.
        Mr. Ortiz. Thank you so much for your comments. Thank you,
    sir.
        Mr. Michaud. Dr. Snyder.
        Mr. Snyder. I have no questions.
        Mr. Michaud. Well, once again, thank you very much, Mr.
    Ortiz, for bringing the legislation forward.
        Mr. Ortiz. Thank you so much.
        Mr. Michaud. The last panelist for this panel is Mr.
    Rothman.

       STATEMENT OF HON. STEVEN R. ROTHMAN, A REPRESENTATIVE IN
                 CONGRESS FROM THE STATE OF NEW JERSEY

        Mr. Rothman. Thank you, Mr. Chairman.
        Ranking Member, Members of the Committee, thank you for
    having me here today.
        I am here to testify today about the moral responsibility
    and national security obligation of the Federal Government to
    honor its commitment to all veterans, namely the commitment to
    provide them with quality, affordable healthcare.
        It is a moral responsibility because the American
    Government makes a promise to every veteran. We say that you
    volunteer to put your life on the line for freedom, because you
    are willing to sacrifice yourself for the good of all
    Americans, because of this courage, we will take care of you
    when you leave the service.
        We do not make that promise with our fingers crossed. We do
    not tack on fine print or attach a bunch of strings to the
    promise. We make that promise freely because our veterans gave
    freely of themselves in the service.
        It is a national security obligation because without
    question, the morale of a young soldier, I believe, is
    seriously hurt when he meets a 35-, 45-, 55-year-old veteran,
    combat veteran who is battling cancer or who had a heart attack
    but had no health insurance and was banned by his government
    from getting healthcare through the VA. It is outrageous.
        As a representative for more than 156,000 veterans, I have
    heard story after story from veterans in Bergen, Hudson, and
    Passaic counties of New Jersey who tell me that their
    government has broken its promise to them. That is because in
    January of 2003, the Bush Administration decided to cut costs
    by telling veterans designated as Priority 8 that they are
    banned from enrolling in the VA health system and will no
    longer have access to VA hospitals, clinics, or medications.
        The Administration defended its decision by saying that
    Priority 8 veterans make too much money to be worth the added
    expense to the system. Just so you know, the amount of money
    they said was too much was anything over $26,902. I say that
    Priority 8 is wrong and that the Bush Administration has the
    wrong priorities.
        We made a promise to those men and women to take care of
    them and there is absolutely no justification for breaking our
    word. Those veterans often live in areas where the cost of
    living more than eats up the $26,902 of income that the Bush
    Administration seems to think is so great.
        In Bergen County, New Jersey, we have the second highest
    concentration of veterans in the State of New Jersey and the
    largest number of Priority 8 veterans. There are 73,000
    Priority 8 veterans in New Jersey alone, 273,000 Priority 8
    veterans throughout the country, 273,000 veterans who have been
    told they make too much money making $26,902.
        So an example, if you served in combat in Iraq or
    Afghanistan for a number of years, three, four deployments,
    five deployments and thank God you come home without any
    physical injuries, 5 years later you get cancer, you cannot use
    the VA if you make more than 26,000 bucks. In my district, the
    number is a little bit higher, but it is certainly not enough
    to cover the costs of healthcare.
        Turned away, 273,000 veterans turned away from the VA. What
    is the message we are sending to our soldiers? We are saying
    that even though the government made this promise, even though
    all Americans believe that this is the case that if we serve,
    we are going to be taken care of, that is not the case. It is a
    lie.
        The President may promise to love veterans and love people
    in the Armed Forces, but that is not what he is doing. He had
    this Congress or he had his Administration come forth with a
    plan that has cut 273,000 veterans from healthcare through the
    VA. We need to keep our promises to our veterans.
        Mr. Chairman, Mr. Ranking Member, and Members of the
    Committee, again, we did not make those promises with our
    fingers crossed or our hands behind our back. They deserve this
    healthcare.
        And one of my colleagues was asking where we get the money.
    In my book, I think the way most Americans feel is this is an
    obligation, this is a promise we made. It is a moral imperative
    that we live up to our promise to those who put their lives on
    the line for us. It is a national disgrace, a national
    dishonor.
        Where should we get the money? Well, you know, if you have
    a lot of different needs, you take care of the most urgent need
    and the promise to those who did the most, that would fall into
    this category. And if, my goodness, because the health of the
    veterans' healthcare system cannot take care of all of its
    veterans because this Administration will not provide the
    money, then maybe we ought to rethink our healthcare system.
    Oh, my goodness.
        The first thing we need to do, though, is live up to our
    promises to our veterans and take care of them if they get sick
    when they come home.
        Thank you, Mr. Chairman, Mr. Ranking Member, Members of the
    Committee.
        [The prepared statement of Congressman Rothman appears on
    p. 71.]
        Mr. Michaud. Thank you very much for your testimony.
        Mr. Miller.
        Mr. Miller. Thank you very much for your testimony, and I
    think we all agree that there are many things that we can work
    on and do better. Certainly the VA system gets that from this
    Committee and Subcommittee all the time.
        Are you aware, Mr. Rothman, that an Operation Iraqi
    Freedom/Operation Enduring Freedom (OIF/OEF) combat veteran
    can, when they come home, get 2 years of healthcare, so they do
    have that. I do not know if there is a lie being perpetrated on
    those veterans at all, and I do not think that is what you were
    trying to characterize, but----
        Mr. Rothman. Thank you for the clarification. But with
    regards to those veterans whose service preceded Iraq and
    Afghanistan, if they get a heart attack, if they get cancer and
    they do not qualify for Medicare because they are too young,
    they are under the age, they are in their thirties or forties
    or fifties, they are out of luck. They do not get any
    healthcare. And that is a lot of folks, 273,000 in the United
    States.
        Mr. Miller. I concur. Again there is an issue, but I think
    a lot of times while we are at war, we use current stories
    about veterans as they are returning home and there is a clear
    distinction in regards to their ability.
        Mr. Rothman. I accept that distinction and I appreciate
    that.
        Mr. Miller. Thank you for your testimony, Steve.
        Mr. Michaud. Mr. Hare.
        Mr. Hare. I would just concur with you. I mean, a promise
    made to veterans is a promise that we have to keep and for the
    life of me I continue to shake my head because even if we did
    not care about the health of the veteran, which should be first
    and foremost, I do not know how we are going to recruit other
    people to go in when they see the kind of treatment, or lack
    thereof, that we are giving to the current veterans.
        I really applaud you for doing this because I do not care
    what category you are, it just seems to me if you served this
    country, you are honorably discharged, this country makes a
    promise, and, as you said Congressman, we did not make it with
    fingers crossed or wink and a nod. We made the promise. So if
    we are going to make it to veterans we have to keep it. And for
    those two hundred and how much? I am sorry.
        Mr. Rothman. Two seventy-three.
        Mr. Hare. Two hundred and seventy-three thousand veterans,
    I mean, what does that say for the service that they have given
    to this country?
        Mr. Rothman. If I may, Mr. Chairman.
        Mr. Michaud. Absolutely.
        Mr. Rothman. There are a lot of our service men and women
    who are not in combat as defined under the law that my friend
    from Florida referred to. Nonetheless they are in harm's way.
    There are terrorists who would seek to blow up any
    servicemember in uniform or out of uniform. And so there is a
    justified distinction in those who served in combat, but I
    think every veteran deserves the right to, especially after 9/
    11, to, and before, to get this kind of care.
        And by the way, if you ask yourself is this not so sad and
    shocking for veterans, is it not sad and shocking for an
    industrialized nation, the richest in the world, if one of the
    people that served in the military gets a heart attack or
    cancer and they cannot afford health insurance, they are going
    to suffer in the United States of America?
        Mr. Hare. I just want to say, Congressman, you know, when
    people are sworn in to any branch of the service, they swear
    that they are going to protect this country and they do. And
    once they are discharged, I think we have a moral obligation to
    protect them.
        And for the life of me, I do not know why the
    Administration decided they were going to do this unless it was
    a cost-saving factor and even if that was the excuse, that is
    about as lame as it gets. So I think we have to restore this. I
    think your bill does that.
        And, again, I think, and I know one of the Members on the
    other side, what do you want to do, do you want to cover
    everybody? The answer is, yes, I do. And I think it is
    something that is terribly important.
        And, again, this Committee, and I love this Committee a
    great deal, we have been able to do some wonderful things. We
    have a great Chairman, great Subcommittee Chairman, great
    Members, and I think we finally decided that enough already. We
    have put the brakes on this.
        And I look forward to working with you on this because I
    think it is a moral obligation that we have as a country.
        I yield back.
        Mr. Rothman. Thank you. I hope you will consider my bill,
    Mr. Chairman, Mr. Ranking Member. I appreciate your service for
    all of the veterans. We need to do more and to find the money
    to do it.
        Mr. Michaud. Thank you very much, Mr. Rothman, for your
    testimony.
        And since there are no further questions, I would ask that
    the next panel come up.
        We will be having votes shortly, so what we will do is have
    the next panel give their testimony before we ask questions.
    Keep in mind that we do have votes, and we have two more panels
    after this panel.
        I would ask unanimous consent that Chairman Filner be
    invited to sit at the dais for the Subcommittee hearing today.
    Hearing no objection, so ordered.
        I would like to welcome the second panel with us here this
    morning. And what we will do is start with Congresswoman Solis
    and move down the line.
        Congresswoman.

    STATEMENT OF HON. HILDA L. SOLIS, A REPRESENTATIVE IN CONGRESS
                      FROM THE STATE OF CALIFORNIA

        Ms. Solis. Thank you very much, Mr. Chairman, Ranking
    Member Miller, for holding this very important hearing.
        I feel real privileged with this opportunity to present, I
    think, a case that has not been stated very clearly here in the
    Congress and it is with respect to a bill that I have
    introduced, Culturally Competent Veterans' Care, House
    Resolution 542.
        The bill requires that the Department of Veterans Affairs
    conduct a thorough assessment identifying non-English languages
    that are likely to be encountered and ensure that such services
    are available in both English and a language in which a veteran
    is proficient.
        And as you will see by the posterboard here, these are
    servicemen that have actually come from the district, served in
    Afghanistan or Iraq. Unfortunately, they did not come home.
    There are 14, so some are missing. But if you can see their
    faces, you can tell that they are predominantly of Latino
    background.
        One of the cases that came to my attention when the war
    began was one of our fellow soldiers who had fallen. I went to
    visit the family. The mother was not proficient in English. The
    son was about 20 years old, passed away, was killed in Iraq.
    And the mother had no idea about the information that the
    military was relaying to her. We tried to get them an
    interpreter.
        What they ended up doing was actually getting another
    service officer, about 18, 19 years of age, to try to interpret
    what choices the family had in terms of burial services and
    life insurance and everything else, all the details that you
    would think somebody would be proficient and competent in.
        When I came to realize that, I saw a serious gap, but it
    kept repeating itself. And so different families that I would
    encounter in my district in LA, and this is typical of the
    southwest where you see a large concentration of Hispanic
    communities serving our military, you are finding these
    households, whether it is the family itself or the soldier, who
    is proficient in another language, which is in this case, I am
    arguing, Spanish, but it could be Asian, it could be Filipino,
    it could be Asian-Pacific Islander, because we have those
    individuals, too, serving in combat.
        And what I am finding is that upon calling the VA to ask
    them about services that could be provided in their language so
    that there is less resistance and more understanding and
    sensitivity in applying for services through the VA, that that
    should be a part of what the VA does.
        Well, apparently what they do is they receive grants and
    they decide what languages they want to provide information.
    And in many cases, I do not think a booklet or a piece of paper
    goes far enough. We need to have staff out there. And you
    cannot rely on another soldier who might be misinterpreting
    information, who is not trained properly to give that
    information to a family member, to a spouse, or to the soldier,
    him or her self. And we have encountered this situation
    multiple times.
        Upon inquiring with the VA, they said, well, we do not have
    enough staff available. We know that there are guidelines that
    we are supposed to be abiding by, they say, and, yet, in most
    of their facilities, I am told that only 43 percent of the
    entire VA services it is supposed to be providing the service
    is actually being applied.
        So I have a serious, serious concern and that is why I have
    introduced the bill. I think it goes a long way and I would
    just ask for your consideration and support.
        In addition, while you may see male members here, I have
    met several times with many of our recruits in our district and
    there is a large Latino population as well. And there are
    special circumstances there where women also need to be treated
    differently with respect to service-related benefits that they
    may have.
        So I think that that is something that we have to keep in
    mind as well, and I will gladly work with the Committee and
    hope that you may somehow incorporate our efforts here, if not
    possibly see the bill come through your Committee.
        But I thank you for the opportunity to be here this
    morning.
        Mr. Michaud. Thank you very much for your testimony.
        Mr. Latham.

    STATEMENT OF HON. TOM LATHAM, A REPRESENTATIVE IN CONGRESS FROM
                           THE STATE OF IOWA

        Mr. Latham. I thank the Chairman and the Ranking Members,
    Members of the Subcommittee.
        I am honored to have the opportunity to testify before you
    today regarding House Resolution 1426 which is the ``Veterans'
    Access to Local Healthcare Options and Resources Act,'' also
    known as the ``VALOR Act.''
        I introduced this legislation in response to a growing
    concern expressed by veterans in my district regarding access
    to VA healthcare. Veterans who live in rural parts of my
    district must travel long distances to VA medical facilities to
    receive the healthcare that was promised to them.
        Oftentimes they have to wait for months to get an
    appointment. They are frequently forced to give up a full day
    sometimes in fragile condition to travel for healthcare.
        Despite the remarkable improvement in the quality of VA
    healthcare during the past decade, the fact remains that not
    all America's veterans have equal access to these services.
        One example of this inequity is the story of a Vietnam Army
    veteran from Fort Dodge, Iowa. He is a recipient of the Bronze
    Star and is service disabled. And he estimates that he has made
    the 4-hour round trip from Fort Dodge to the VA medical
    facility in Des Moines more than 100 times in the past 3 years.
    Because he cannot drive, he relies like most veterans on a
    shuttle graciously provided by one of the Veteran Service
    Organizations which takes up to 10 or more veterans to Des
    Moines at a time.
        Since they have to wait for the last appointment to return,
    the trip takes an entire day, sometimes starting at 5 a.m. and
    returning late in the evening.
        Countless similar cases have been reported to me by
    veterans in my district. This situation leads me to ask the
    question, can we really say that we are providing top-quality
    care for our veterans when so many have limited access to it?
        Out of nearly 8 million veterans enrolled in the VA
    healthcare system last year, only 5 million veterans actually
    receive VA healthcare. Recent reports show that the VA
    healthcare system continues to match or outrank private-sector
    healthcare in overall quality and consumer satisfaction.
        Out-of-pocket costs are extremely low, in particular for
    service-connected veterans, so why are less than two-thirds of
    the veterans enrolled in the system actually using it? I
    believe that access problems account for a great deal of this
    disparity. For millions of veterans, VA healthcare is simply
    not readily accessible, and again especially in rural areas.
        VA-funded research conducted by Dr. William Weeks and his
    colleagues from the VA Outcomes Group highlights the urgent
    need for action to increase healthcare access for our rural
    veterans. This research supports the conclusion that, compared
    to their urban counterparts, rural veterans have a higher
    prevalence of mental and physical problems and the least access
    to the VA healthcare system.
        I am concerned that this disparity will continue to grow
    over time unless we do something now about it. First, rural
    residents are over-represented among veterans. The VA Outcomes
    Group found that 22 percent of veterans are rural compared to
    14 percent among the general population.
        Furthermore, rural veterans are over-represented among
    those serving in Iraq and Afghanistan due to the increased use
    of the National Guard and Reserve units. These units are often
    dispersed in rural areas far from large urban centers or
    concentrations of veterans where VA facilities tend to be
    located.
        As I previously mentioned, rural veterans are already
    likely to experience more health problems. While large numbers
    of these veterans return from combat, the need for VA
    healthcare in rural areas will increase dramatically in the
    coming years.
        The ``VALOR Act'' aims at meeting this need by providing
    veterans with an option, and I will emphasize it is an option,
    they are not mandated to do anything, to receive healthcare
    that they would otherwise be eligible to receive in a VA
    facility at the local hospital or a physician's office.
        To provide this option, the legislation builds on the
    existing VA system for contracting with non-VA providers known
    as fee-basis care. The VA already has specific statutory
    authority to contract with non-VA facilities for medical care,
    but it is subject to way too many restrictions.
        The ``VALOR Act'' would require an expansion of fee-basis
    care to allow greater access to VA-funded healthcare in our
    local communities.
        Under the bill, covered services would include hospital
    care, medical services and rehabilitative services and
    preventative health services that a veteran would be eligible
    to receive at any VA facility. It also clarifies that VA drugs
    can be obtained with prescriptions written by contract
    physicians.
        Mr. Chairman, I see my time is up and I want to submit the
    rest of it for the record. But let me just say this is the
    number one veterans' issue in my district. I hear about this
    all the time. So many of these people are World War II, Korean
    veterans and it is just virtually impossible for them to
    withstand a 5 o'clock in the morning to 8 o'clock, 9 o'clock at
    night situation just to get healthcare.
        And I appreciate the opportunity to testify, and I look
    forward to answering any questions.
        [The prepared statement of Congressman Latham appears on
    p. 72.]
        Mr. Michaud. Thank you very much. I really appreciate it.
        The next is Mr. Altmire who is a freshman Member of
    Congress. I want to thank you for your willingness to become
    very active in veterans' issues and look forward to your
    testimony as well.

     STATEMENT OF HON. JASON ALTMIRE, A REPRESENTATIVE IN CONGRESS
                     FROM THE STATE OF PENNSYLVANIA

        Mr. Altmire. Thank you, Mr. Chairman, Ranking Member
    Miller, for the opportunity to testify before the Committee
    today.
        My bill, House Resolution 1944, the ``Veterans Traumatic
    Brain Injury Act of 2007,'' is bipartisan. And I introduced
    this legislation to increase the screening and treatment for
    traumatic brain injuries (TBI), for our Nation's veterans.
        TBI is an impending crisis in this country. Our brave
    service men and women are returning from Iraq and Afghanistan
    with TBI at an alarming rate. Of those treated just at Walter
    Reed Army Medical Center, it is estimated that 65 percent have
    been diagnosed with TBI as a primary or co-morbid diagnosis.
    Many now consider TBI to be the signature injury for those
    returning from Iraq and Afghanistan.
        And I am concerned that the VA health system may not be
    properly identifying and treating TBI among our Nation's
    veterans. It is estimated that more than half of all combat
    casualties have associated brain injuries. Most of them include
    mild TBI which is often missed in initial exams as physicians
    attend to other more visible injuries.
        My bill improves the coordination of TBI care for our
    Nation's veterans by requiring the VA to screen veterans for
    symptoms, develop and operate a comprehensive program of long-
    term and post-acute TBI rehabilitation, establish TBI
    transition offices at all polytrauma network sites, and create
    and maintain a veterans' TBI health registry.
        And I do want to take the opportunity to commend the work
    of this Committee and the full Committee under Chairman
    Filner's leadership for the work that has been done in just the
    first 4 months on veterans' healthcare.
        The 110th Congress is taking enormous strides in meeting
    its commitments to veterans. Here in the House, we voted for
    more than $11 billion in increased funding for veterans'
    healthcare and we passed the ``Wounded Warrior Assistance Act''
    to provide for the management of their medical care.
        And I know every Member of this Committee agrees that no
    group should stand ahead of our Nation's veterans when it comes
    time to make Federal funding decisions.
        We owe no greater debt than to our veterans and while we
    have made some progress, more needs to be done. To this end,
    the bipartisan ``Veterans Traumatic Brain Injury Treatment
    Act,'' House Resolution 1944, will allow us to properly screen
    America's returning heros for TBI and improve their treatment.
        I would be happy to answer any questions that you have, and
    I do thank the Committee for allowing me to testify today.
        [The prepared statement of Congressman Altmire appears on
    p. 73.]
        Mr. Michaud. Thank you very much, Mr. Altmire.
        Next is Mr. Moran who is a distinguished Member of this
    Committee.

      STATEMENT OF HON. JERRY MORAN, A REPRESENTATIVE IN CONGRESS
                        FROM THE STATE OF KANSAS

        Mr. Moran. Mr. Chairman, thank you very much. I am pleased
    to be on this side of the table this morning with you and
    Chairman Filner, Ranking Member Miller for the opportunity to
    testify.
        This is a topic that you have heard me speak about in the
    Committee before and it in many ways mirrors the comments of
    Mr. Latham, the gentleman from Iowa. We share the same kind of
    challenges when it comes to a rural district.
        I represent a congressional district that is about the size
    of the State of Illinois. It is almost 60,000 square miles and
    although there are 75 hospitals in my congressional district,
    there are no VA hospitals.
        And so the veterans, just as Mr. Latham described, have
    long distances to travel. We have been successful in bringing
    Community Based Outpatient Clinics (CBOCs) to the congressional
    district and I am very grateful for that, but I am convinced
    there will never be enough construction dollars to justify
    enough new clinics to serve the needs of veterans who live in
    the remote areas of Kansas and really across the country.
        I want to share just a couple of stories with you, again a
    World War II veteran. This letter comes from his wife. My
    husband has been a resident of a long-term care facility for 2
    years and is unable to drive the 65 miles it takes to get a
    physical at the Hayes VA Clinic as is required by the VA to
    receive his prescription drug benefit. They stopped filling his
    prescription medicine.
        Veterans like Ralph gave several years of their lives for
    our country and I feel that he is being treated in a very
    ungrateful way.
        Another example, Hoxie, Kansas, in which the gentleman, the
    elderly veteran needed a new pair of eyeglasses. The veteran
    was told he must travel 4 hours to Wichita to the VA hospital
    to receive his new pair of glasses, a distance of about 260
    miles, yet his hometown has an optometrist who is unable to
    meet his needs because he is not part of the VA.
        This does not make sense to me and I know that it does not
    make sense to many of my colleagues. It is long drives, bad
    weather, limited financial resources and ailments that make it
    very difficult for our veterans to make that trip and,
    therefore, many of them, I would say most forego getting
    treatment.
        It is no wonder that studies highlight the poor health of
    America's rural veterans. It is not right that we penalize
    veterans because of their choices of where they live.
        This legislation, the ``Rural Veterans Access To Care
    Act,'' has the goal of stopping these disparities in access.
    The legislation would give our country's most underserved
    veterans, those who live the farthest from VA facilities the
    choice to receive care closer to home at a local hospital or
    physician's office.
        This legislation requires the VA to coordinate care with
    the Department of Health and Human Services and to contract
    with qualified providers. These rural providers already supply
    healthcare, quality healthcare to America's rural population.
        To further ensure quality standards for the veterans' care,
    the VA should write quality criteria into contracts, monitor
    the service delivery, and put in place mechanisms to share
    healthcare information.
        The legislation would also require the VA to fill
    prescriptions written by outside physicians for eligible
    veterans.
        And I understand there are concerns. Mr. Michaud, I chaired
    this Subcommittee at one point in time and I promoted this
    legislation for a long time. It is not always supported by the
    Veteran Service Organization community. And I understand the
    concerns that are raised about the budgets and that there is a
    fear that if we enhance contracting that our VA hospitals will
    suffer.
        And I believe that it is important that we do both, fund
    the hospitals and CBOCs as well as provide contracting for our
    most rural veterans the outreach that they need.
        This legislation has not been scored, but I believe in
    order to lessen its budgetary impact, we can create criteria
    which the bill does. A veteran must live at least 60 miles from
    a VA primary care facility like a CBOC when seeking such
    outside care or 120 miles from the VA hospital or 240 miles
    from a VA tertiary care facility.
        So we have placed mileage restrictions in this legislation
    to minimize the budgetary impact. These requirements are based
    upon the VA's own care system in which they establish the goals
    for service to veterans and using their criteria of distance
    and time for veterans that they desire to serve.
        Mr. Chairman, I believe that allowing highly rural veterans
    to take advantage of the convenience of an existing rural
    healthcare infrastructure is a commonsense solution to
    providing VA care when it is not otherwise available.
        I am not suggesting we abandon the VA healthcare system, a
    system that has served veterans well and continues to improve,
    but I do request that we put in place practical reforms to
    account for the reality of those who live on the fringes of the
    VA's ability to care for them.
        I ask the Committee's full consideration of this
    legislation and would work with others to supply other ideas
    and suggestions of how it can be improved or altered so that
    our veterans will finally have the access that we have promised
    them years ago.
        Thank you, Mr. Chairman.
        Mr. Michaud. Thank you very much, Mr. Moran, for your
    testimony.
        And the final panelist is our distinguished Chairman of the
    full Committee on Veterans' Affairs, and I would like to thank
    you, Mr. Chairman, for assisting us in having this hearing on
    several pieces of legislation that are important to veterans
    and individual Members of Congress. So thank you, Mr. Chairman.

       STATEMENT OF HON. BOB FILNER, CHAIRMAN, FULL COMMITTEE ON
     VETERANS' AFFAIRS, AND A REPRESENTATIVE IN CONGRESS FROM THE
                          STATE OF CALIFORNIA

        Mr. Filner. Thank you. Mr. Chairman, thank you for your
    leadership. There are a lot of good bills here.
        Mr. Altmire, before you leave, I just want to thank you for
    your leadership on the traumatic brain injury situation. We are
    going to have a national symposium on brain injury and bring in
    a lot of creative and outside ideas about treatment to deal
    with it. And your bill will be there to be considered, so we
    thank you for that.
        And I thank also Mr. Latham and Mr. Moran. We are going to
    address a rural health agenda for our Nation's veterans and we
    look forward to having your bills to look at as we proceed. So
    thank you for your leadership here.
        I have two bills on our agenda today, H.R. 1470 and H.R.
    1471, and I appreciate the opportunity to speak on these bills.
        I think a special opportunity presents itself in that over
    40 percent of the medical problems for returning servicemembers
    from Iraq and Afghanistan are what we call musculoskeletal and
    many can undoubtedly benefit from chiropractic care. As one
    American who has benefited from chiropractic care, I can
    promote it in absolutely good faith.
        H.R. 1470 which was introduced in the last Congress by
    former Congressman Jeb Bradley, who was a Member of this
    Committee from New Hampshire, is called the ``Chiropractic Care
    Available to All Veterans Act.'' It requires that chiropractors
    are phased into the VA with not fewer than 75 medical centers
    by the end of December 2009 and all of our centers by the end
    of 2011.
        House Resolution 1471 is the ``Back Our Veterans Health
    Act,'' which means better access to chiropractors to keep our
    veterans healthy. It requires that veterans have direct access
    to chiropractic care at the VA hospitals and clinics so that
    veterans do not have to go through a general practitioner, or
    gatekeeper, as this doctor is sometimes called.
        We must remember that since the creation of the VA
    healthcare system, the Nation's doctors of chiropractic have
    been kept outside and all but prevented from providing proven,
    cost-effective, and much-needed care to our veterans. So, we
    are grateful that access is becoming greater.
        The support for VA chiropractic care is bipartisan and you
    may recall that the previous Secretary of the VA, Anthony
    Principi, released a policy directive before his departure
    regarding the true and full integration of chiropractic care in
    the VA.
        I hope that Secretary Nicholson will be equally open to
    this and, of course, both Republican and Democratic Members of
    this Committee have supported this bill.
        I have worked very closely with chiropractic patients,
    including our Nation's veterans, on these bills as well as the
    American Chiropractic Association and the World Chiropractic
    Alliance. I see members of both groups here today. Thank you
    for your support and your energy in promoting these important
    concepts.
        Hopefully the VA will do some of this administratively, but
    I think we have to pass this legislation to make sure that
    there is direct access for our Nation's veterans to this proven
    healthcare.
        And I thank the Chairman.
        [The prepared statement of Congressman Filner appears on
    p. 74.]
        Mr. Michaud. Thank you very much, Mr. Chairman.
        Are there any questions of the panelists that are
    remaining?
        Mr. Moran. Mr. Chairman, I would only suppose any Member of
    the Committee should compliment Chairman Filner. It is probably
    the political thing to do, but I appreciate his continued
    effort in regard to chiropractic care.
        I introduced legislation that ultimately became law 3 or 4
    years ago, 5 years ago maybe, in requiring that the VA develop
    a chiropractic care protocol. And it is a slow process by which
    the VA has integrated chiropractic care.
        And I would join with Mr. Filner in trying to encourage
    that to occur and look forward to working with you to see that
    that is accomplished.
        Mr. Filner. Thank you.
        We have passed three important bills in the last 5, 6 years
    and each time, we have gotten more direct because the VA just
    has not cooperated. So we continue to make sure, and we will
    have also oversight to make sure, that it does occur.
        Mr. Moran. Thank you.
        Mr. Michaud. Dr. Snyder.
        Mr. Snyder. Mr. Chairman, I want to ask questions of the
    Members that are not here because I will find that less
    stressful.
        Just a couple comments on Ms. Solis' bill and I have not
    studied the bill, but I am sure my family doctor back down
    here, she is dealing with primarily counseling and mental
    health treatment issues with people who were raised in other
    countries or cultures and so their language skills are
    different than those of us who are native born.
        And I think at first blush, someone may say, well, they are
    veterans, they are in the service, what do we have to do that
    for. Well, just remember that the skills that are required to,
    you know, drive a striker or shoot or go on patrol are a whole
    lot different kind of language skill requirement than the kind
    of language that you need to talk about your relationship with
    your wife, your relationship with your children, what is going
    on with your feelings in terms of the rage that you may feel or
    fears that you may feel. There are just levels, different kinds
    of language skills and different cultural sensitivities.
        Like I said, I do not know if her bill is the answer to
    this and I do not know what the current VA policy is with
    regard to these issues, but I have, you know, worked in refugee
    camps where you try to provide mental health services to people
    that you do not have good language communication with and it is
    a challenge.
        And the second issue is with Mr. Altmire's bill on TBI. We
    have talked about this issue before, but I hope in the mix, we
    will be sure that we are doing a good job of funding all the
    good research opportunities that are out there on traumatic
    brain injury because that is going to be a huge issue as Mr.
    Altmire pointed out.
        Thank you for your indulgence.
        Mr. Michaud. Thank you very much.
        I would like to ask the third panel to please come up. On
    the third panel we have Shannon Middleton, Deputy Director of
    Healthcare for the American Legion; Kimo Hollingsworth,
    Legislative Director for American Veterans; Adrian Atizado,
    Assistant National Legislative Director for DAV; Carl Blake,
    Legislative Director for Paralyzed Veterans of America; Dennis
    Cullinan, Director of the National Legislative Service of VFW;
    and Rick Weidman who is the Executive Director of Vietnam
    Veterans of America.
        And I would like to thank all of you for coming here. I
    look forward to your testimony. Why don't we start with Ms.
    Middleton and I would ask you to try to keep within the time
    limits because we do have to go vote here pretty quickly.
        Ms. Middleton.

     STATEMENTS OF SHANNON MIDDLETON, DEPUTY DIRECTOR FOR HEALTH,
                  VETERANS AFFAIRS AND REHABILITATION
     COMMISSION, AMERICAN LEGION; KIMO S. HOLLINGSWORTH, NATIONAL
      LEGISLATIVE DIRECTOR, AMERICAN VETERANS (AMVETS); ADRIAN M.
          ATIZADO, ASSISTANT NATIONAL LEG- ISLATIVE DIRECTOR,
     DISABLED AMERICAN VETERANS; CARL BLAKE, NATIONAL LEGISLATIVE
     DIRECTOR, PARALYZED VETERANS OF AMERICA; DENNIS M. CULLINAN,
      DIRECTOR, NATIONAL LEGISLATIVE SERVICE, VETERANS OF FOREIGN
     WARS OF THE UNITED STATES; AND RICHARD F. WEIDMAN, EXECUTIVE
    DIRECTOR FOR POLICY AND GOVERNMENT AFFAIRS, VIETNAM VETERANS OF
                                AMERICA

                     STATEMENT OF SHANNON MIDDLETON

        Ms. Middleton. Mr. Chairman and Members of the
    Subcommittee, thank you for this opportunity to present The
    American Legion's views on several pieces of legislation being
    considered by the Subcommittee.
        Providing quality healthcare in a rural setting has proven
    to be very challenging given the factors such as limited
    ability of skilled care professionals and inadequate access to
    care.
        The American Legion commends the Subcommittee for holding a
    hearing to discuss these very important and timely issues. My
    comments will address just a few of these bills.
        House Resolution 92, the ``Veterans Timely Access to
    Healthcare Act,'' seeks to establish standards of access to
    healthcare provided by the Department of Veterans Affairs. The
    American Legion believes that setting standards for timeliness
    in the delivery of healthcare and requiring VA to report on how
    these standards were executed will provide a realistic
    illustration of the ongoing challenges for rural veterans in
    gaining timely access to care. It will also allow VA and
    lawmakers to determine the best ways to improve timely access
    for rural veterans.
        House Resolution 315, the Help Establish Access to Local
    Timely Healthcare for Your Veterans bill would require that VA
    contract with community healthcare providers to improve access
    to healthcare for veterans in highly rural areas.
        The American Legion believes where there is limited access
    to VA healthcare, it is in the best interest of veterans
    residing in highly rural areas that local care be made
    available to them. This would alleviate the unwarranted
    hardship rural veterans encounter with seeking care.
        House Resolution 463, the ``Honor Our Commitment to
    Veterans Act,'' discussed lifting the healthcare enrollment
    restriction on Priority 8 veterans. The American Legion
    supports removing the healthcare enrollment restriction to
    Priority 8 veterans.
        We believe that it is a more effective method to ensure
    that VA can continue to provide quality healthcare by assuring
    that there is sufficient funding to care for the veterans'
    needs, not limiting access to those who have incomes that fall
    above the means tests thresholds.
        And, finally, House Resolution 1944, ``Veterans Traumatic
    Brain Injury Treatment Act of 2007,'' seeks to have certain
    veterans screened for traumatic brain injuries and discusses
    the creation of a comprehensive program for long-term care and
    rehabilitation that includes residential, community, and home-
    based components.
        The American Legion believes that the provisions in this
    bill are both necessary and timely. Symptoms of traumatic brain
    injury may not be obvious and may be dismissed or may occur
    over time. Screening those who were known to have been
    subjected to blast trauma in theater, even if they have no
    visible physical wounds, would aid in diagnosing injuries more
    quickly and improve the chances of a successful rehabilitation.
        Again, thank you, Mr. Chairman, for giving the American
    Legion this opportunity to present its views on such important
    issues. We look forward to working with the Subcommittee to
    bring an end to the disparities that exist in access to quality
    healthcare in rural areas.
        [The prepared statement of Ms. Middleton appears on p. 74.]
        Mr. Michaud. Thank you very much.
        Mr. Hollingsworth.

                   STATEMENT OF KIMO S. HOLLINGSWORTH

        Mr. Hollingsworth. Mr. Chairman, Members of the
    Subcommittee, I am pleased to appear to offer testimony on
    behalf of American Veterans for the pending legislation.
        The central problem for veterans with regards to the VA
    healthcare system in a timely fashion has generally been
    access. Over the years, VA has become increasingly effective in
    providing timely access, although problems still do remain.
        Regarding the legislation before this Subcommittee, we
    would like to reaffirm our commitment that service-connected
    disabled veterans should have the highest priority healthcare
    and that these services should be of the highest quality. We
    believe VA does provide that service today.
        Many of today's proposals do risk some unintended
    consequences to include quality control, safety, and potential
    adverse impacts on some mandated programs that VA is required
    to keep.
        Overall, the proposals seem to move VA toward higher cost.
    The escalating costs of healthcare in the private sector are
    well documented and, quite frankly, VA is doing a pretty good
    job at keeping healthcare costs down.
        We believe the central question to all of these contract
    proposals is whether or not Members of Congress believe the VA
    healthcare system is a national asset worth preserving or
    abandoning.
        This in turn is reliant upon appropriate levels of funding
    to hire staff, operate facilities, and clinics, and provide
    unique and specialized services. Appropriate levels of funding
    would also allow VA to open outpatient clinics where needed and
    provide other contractual arrangements to provide VA-sanctioned
    healthcare.
        Many of these proposals have some triggering mechanism that
    would mandate the Secretary contract care. These triggering
    mechanisms appear to be a one-time event that authorizes
    veterans to essentially opt out of the system and have VA pick
    up the cost.
        VA was mandated to establish an office of rural healthcare
    within VHA and we would encourage Congress to fully fund the
    office and allow VA to conduct the mandated assessment.
        The issue of nonservice-connected veterans accessing VA
    care is not new and obviously we would support open enrollment
    to the VA healthcare system. If veterans want to use the system
    and they are willing to bring their dollars to receive
    healthcare, we believe they should have that opportunity.
        Very briefly on the capital asset realignment for
    enhancement of services, it was a systemwide process to do an
    assessment of VA infrastructure. In short, with regards to VA
    construction, AMVETS supported the CARES Commission process.
        Regarding legislation on the English language, we believe
    that veterans earn benefits and services and are granted access
    to the system by virtue of qualifying military service. This
    should continue to be the overriding principle when discussing
    veterans' issues.
        And for Congress to pass a law and mandate the Secretary to
    provide these services when, in fact, they are starting to do
    this internally would create division and separation among
    veterans that took an oath to uphold and defend the
    Constitution of the United States in English.
        Mr. Chairman, with regards to chiropractor care, the
    program has been pretty successful at DoD. There was some
    resistance at VA initially getting the program started. We
    would like to see similar results within VA that appeared in
    DoD.
        This concludes my testimony. I will be happy to answer any
    questions.
        [The prepared statement of Mr. Hollingsworth appears on p.
    77.]
        Mr. Michaud. Thank you very much.
        Mr. Atizado.

                     STATEMENT OF ADRIAN M. ATIZADO

        Mr. Atizado. Mr. Chairman, Members of the Subcommittee, on
    behalf of the 1.3 million members of the DAV and its auxiliary,
    I wish to express my appreciation for the opportunity to
    present our views on healthcare legislation before us today.
        As a majority, the bills for consideration seek to address
    access to VA medical care whether it is time or distance that
    it takes a veteran to get to a facility or the time it takes a
    veteran to receive the care when needed.
        The DAV is encouraged with this hearing and the number of
    bills introduced that Congress believes as we do that through
    their extraordinary sacrifices and contributions in military
    service, these veterans have earned the right to VA healthcare
    as a continuing cost of national defense.
        Operating on a limited resource environment, there is a
    cost to improving access to VA care. And in addressing this
    issue, it is incumbent upon us to ensure that VA receives on
    time sufficient funding to plan and meet the growing need of
    enrolled veterans' healthcare including rural veterans' care as
    well as for VA to be held accountable for meeting the need in a
    timely manner.
        Equally important that all of this be done without
    disrupting the delicate balance by the erosion of VA's patient
    resource base and eventually what has been recognized as
    America's best healthcare value.
        For the sake of brevity, I will highlight some measures in
    my oral testimony and refer you to my written statement for
    greater detail on our position and commentary on any of these
    measures.
        DAV opposes both House Resolution 92 and 339. Both contain,
    as my colleague mentioned, a trigger mechanism that would
    require VA to utilize its contracting care authority in the
    provision of medical care. This is in line with our
    organization's opposition to any initiative that would turn VA
    into a primary insurer rather than provider of healthcare to
    veterans.
        In line with this, Mr. Chairman, our concern is this hard
    trigger, using limited resources, particularly without
    appropriate controls to protect from erosion the critical mass
    of VA patient over time as I had mentioned earlier.
        House Resolution 463 would overturn the policy to close
    enrollment and deny access to Priority 8 veterans. DAV believes
    that the manner by which this is accomplished in this bill
    would eliminate accountability over the Secretary's
    responsibility to establish and operate a system of annual
    enrollment for VA healthcare.
        Similarly, DAV opposes ``Rural Veterans Healthcare Act,''
    which would provide veterans access to VA care at the expense
    of worsening VA's financial situation. We urge the confidence
    in the VA healthcare system displayed in this measure to remain
    and be used within the VA healthcare system, not outside, not
    without.
        Veterans' geographic inaccessibility of VA care is a direct
    result of limited VA resources. This bill would not improve
    this financial situation nor does it address the higher cost of
    rural care and in the end would not serve veterans well.
        DAV members support the systemwide availability of
    chiropractic services within the VA as contemplated under House
    Resolution 1470. However, 1471 would establish chiropractic
    services' practitioners on the same level as VA medical doctors
    in the direct provision of primary care services.
        DAV believes access to chiropractic services should be
    provided in consultation with VA primary care providers
    responsible for maintaining the overall health of patients
    assigned to them. Thus, we oppose House Resolution 1471.
        As this Committee is aware, the cost of providing care in
    rural and remote areas is higher than in urban areas. In much
    of our deliberation on this issue, we struggle to find a way to
    fill the indeterminate gap between limited resources and the
    demand for rural healthcare.
        Accordingly, we ask due consideration be given to the cost-
    effectiveness of the mobile vet center program in the draft
    bill titled ``Veterans Rural Healthcare Act.'' This is a
    concern for such a program serving in rural areas and must be
    addressed accordingly.
        Much of the content of this bill is consistent with the
    recommendations on the Independent Budget. Further, we believe
    this measure is a good first step in addressing the healthcare
    needs of rural veterans and a good complementary step to the
    Public Law passed late last year. Therefore, DAV fully supports
    the purposes of this bill.
        Mr. Chairman, much of the content of the ``Veterans
    Traumatic Brain Injury Act of 2007'' is consistent with the
    recommendations of the IB. We have some recommendations in our
    testimony and refer you to them.
        This concludes my testimony, Mr. Chairman. I would be happy
    to answer any questions you may have.
        [The prepared statement of Mr. Atizado appears on p. 79.]
        Mr. Michaud. Thank you.
        We will have to recess at this time so we can get over and
    vote and we will recess until approximately 12:15 according to
    Mr. Tucker.
        [Recess]
        Mr. Michaud. I would like to reconvene the Committee. Sorry
    for the delay. The votes lasted longer than what Mr. Tucker
    originally thought they would last.
        We left off with Carl Blake from Paralyzed Veterans of
    America. Carl.

                        STATEMENT OF CARL BLAKE

        Mr. Blake. Mr. Chairman, thank you for the opportunity to
    testify today. It seems ironic that in the face of some
    criticism about the care being provided in VA facilities that
    demand has never been higher.
        House Resolution 92 would establish standards of access to
    care within the VA healthcare system. Access is indeed a
    critical concern of PVA as with the other organizations. The
    number of veterans enrolled in the VA is approaching 8 million
    and the number of unique users is nearly 6 million.
    Unfortunately, funding for VA healthcare has not kept pace with
    the growing demand. Furthermore, Congress has failed to live up
    to its responsibility to provide adequate resources in a timely
    manner. As long as VA continues to receive funding months into
    its fiscal year, it will never be able to properly plan to meet
    this demand. To that end, access standards without sufficient
    funding provided by the start of the fiscal year are standards
    in name only.
        PVA is concerned that contracting healthcare services to
    private facilities when access standards are not met is not an
    appropriate enforcement mechanism for ensuring access to care.
    In fact, it may actually serve as a disincentive to achieve
    timely access for veterans seeking care.
        We do think that these access standards are important, but
    we believe that the answer to providing timely care is in
    providing sufficient funding in the first place in order to
    negate the impetus driving healthcare rationing.
        Because House Resolution 315 and House Resolution 1527
    principally address the same issue, I will outline our concerns
    with these proposed bills together.
        PVA is fully aware of the challenges the VA faces every day
    to provide timely access to quality care for veterans who live
    in rural areas. However, we are concerned that in addressing
    the problem of access for these veterans, the long-term
    viability of the VA healthcare system may be threatened.
        The services provided by VA, particularly specialized
    services like spinal cord injury care, are unmatched in the
    private sector. If a large pool of veterans is sent into the
    private sector for healthcare, the diversity of services and
    expertise in different fields is placed in jeopardy.
        Ultimately PVA has serious concern about the provisions of
    this legislation that would give VA additional leverage to
    broaden contracting out of healthcare services to veterans in
    geographically remote or rural areas thereby leading to
    privatization.
        Privatization is simply a means for the Federal Government
    to shift its responsibility of caring for the men and women who
    have served and sacrificed.
        Current law limits VA in contracting for private healthcare
    services to instances in which VA facilities are incapable of
    providing necessary care, when VA facilities are geographically
    inaccessible to a veteran for necessary care, when medical
    emergency prevents a veteran from receiving care in a VA
    facility, or to complete an episode of VA care, and for certain
    specialty examinations.
        The VA could better meet the demands of rural veterans
    through more judicious application of its fee-for-service
    program. Due to the concerns that I have outlined and included
    in my written statement, PVA cannot support House Resolution
    315 or House Resolution 1527.
        PVA fully supports House Resolution 463. The provisions of
    this legislation are in accordance with the recommendations of
    the Independent Budget. However, we must emphasize that if this
    policy is overturned, additional adequate funding must be
    provided to meet this new demand. It would make no sense to
    make this change without providing that funding.
        PVA finds it difficult to comprehend the rationale for
    establishing a precedent for veterans in the VA healthcare
    system to leave the system and seek services elsewhere as House
    Resolution 1426 would do. While this legislation may be well-
    intentioned, the potential unintended consequences far outweigh
    any benefit that this bill might provide.
        There would almost certainly be a diminution of established
    quality, safety, and continuity of VA care of veterans if they
    were to leave the system.
        While as a consequence of enactment of this bill some
    service-connected veterans might seek care in the private
    sector as a matter of personal convenience, they would lose the
    many safeguards built into the VA system through its patient
    safety program, evidence-based medicine, electronic medical
    records, and medication verification program.
        These unique VA features culminate in the highest-quality
    care available public or private. Also these safeguards that
    are generally not available in private-sector systems would
    equate to diminished oversight and coordination of care and
    ultimately may result in lower quality care for those who
    deserve it most.
        Mr. Chairman, we recognize that the challenges the VA faces
    in the healthcare arena are difficult. However, we must
    reiterate that the VA will struggle to meet the ever-growing
    demand of veterans, particularly rural veterans, as long as it
    does not receive adequate resources in a timely manner.
        It is unreasonable and, frankly, unacceptable to place
    expectations on the VA to meet certain types of demand if it is
    not given the resources and tools necessary.
        I look forward to working with the Subcommittee to develop
    workable solutions that will allow veterans to get the best
    quality care available.
        Mr. Chairman, I would like to thank you again for the
    opportunity to testify, and I would be happy to answer any
    questions that you might have.
        [The prepared statement of Mr. Blake appears on p. 84.]
        Mr. Michaud. Thank you very much, Mr. Blake.
        Mr. Cullinan.

                    STATEMENT OF DENNIS M. CULLINAN

        Mr. Cullinan. Thank you very much, Mr. Chairman. On behalf
    of the men and women of the Veterans of Foreign Wars and
    auxiliaries, I want to thank you for including us in today's
    most important discussion.
        First under discussion today was House Resolution 92, the
    ``Veterans Timely Access to Healthcare Act.'' The VFW strongly
    supports the intent of this legislation, but we do have
    concerns about the contracting aspect as well as the adverse
    impact on overall VA funding.
        Next under discussion is House Resolution 315, the
    ``HEALTHY Vets Act.'' Again, the VFW supports the intent of
    this bill. We would express our concern, however, with the
    potential for over-use of contracting care as we did with House
    Resolution 92. But there are certainly areas where its use is
    proper.
        We must be mindful, though, of a demonstration project VA
    is currently undergoing, Project HERO, Healthcare Effectiveness
    through Resources Optimization. We have been supportive of the
    Project HERO's aims and think it would be wise to see how
    effective this demonstration project is and what lessons can be
    learned from it before making a sweeping legislative change.
        Next under discussion is House Resolution 339. Again the
    VFW supports the intent of this legislation, which is similar
    to House Resolution 92, in that it establishes standards of
    care for veterans waiting to receive care from VA.
        Next I will address House Resolution 463. The VFW strongly
    supports this legislation which would end the 4-year freeze on
    the enrollment of Category 8 veterans. We also urge that
    Congress keep in mind that this would have to be properly
    funded.
        Next the VFW will discuss House Resolution 542. The VFW
    supports this bill which would make mental health services
    available for veterans with limited English proficiency. There
    can be no other area where clear communication is so important
    as with respect to the provision of mental health services.
        Next I will address House Resolution 538. This bill calls
    for a study to determine whether contract care, construction of
    a VA medical facility, or sharing agreement with defense
    facility would fill the needs of veterans residing in far south
    Texas.
        Current VFW Resolution 661 which was adopted by the voting
    delegates of our last national convention calls for a medical
    center in this region.
        Next I will address House Resolution 1426. The VFW opposed
    this legislation which would allow any veteran to elect to
    receive contracted care whenever and wherever they choose. We
    have strong concerns about the viability of the VA healthcare
    system should this be enacted. Although this bill intends to
    expand coverage available to veterans, we believe it would only
    dilute the quality and quantity of service provided to new and
    existing veterans into the future.
        Next under discussion is House Resolution 1470, the
    ``Chiropractic Care Available to All Veterans Act.'' The VFW
    supports this bill.
        Next under discussion is House Resolution 1471. The VFW
    opposes this legislation which would allow veterans to receive
    direct access to chiropractic services. It is important to
    remember that no other VA healthcare specialty allows for
    direct access to patients.
        Next under discussion is House Resolution 1527. We also
    support the intent of this legislation, which, like House
    Resolution 315 as discussed, allows for contracting of care to
    veterans in rural areas. Again, we urge that the Committee
    consider the results of Project HERO before going further with
    this bill.
        Also under discussion is House Resolution 1944. The VFW
    offers our strong support for this legislation which would
    require VA to implement screening programs for traumatic brain
    injuries which is the signature disability of this particular
    conflict, something with consequences going far into the
    future.
        Last under discussion is the draft bill, the ``Rural
    Veterans Healthcare Act.'' The VFW supports this bill which
    would make changes and improvements to the availability of
    veterans' rural healthcare. With over 44 percent of returning
    servicemembers living in rural areas access problems are all to
    clear and need to be addressed. We are happy to support this
    bill.
        Mr. Chairman, this concludes my testimony.
        [The prepared statement of Mr. Cullinan appears on p. 89.]
        Mr. Michaud. Thank you very much.
        Mr. Weidman.

                    STATEMENT OF RICHARD F. WEIDMAN

        Mr. Weidman. Mr. Chairman, Vietnam Veterans of America
    thanks you for this opportunity to present our views here
    today.
        Quite a number of these bills that are under consideration
    really revolve around a funding issue and only point up the
    need for assured funding that is predictable, that is adequate
    to meet all the needs of veterans.
        And I am sure you are familiar with this. The partnership,
    sir, which nine organizations including the six represented at
    this table have agreed upon and urge that the 110th Congress
    move to address this chronic problem and to do so before the
    end of the first session because it would obviate the need for
    many of these well-intentioned bills that just nibble around
    the edges.
        In regard to the Priority 8 veterans, in January of 2003,
    the Executive Directors, and I am that for VVA, of the six
    organizations represented before you met with Secretary
    Principi and the then Under Secretary for Health and were told
    that they were going to limit, because of the short-term
    funding problem, we are going to temporarily suspend enrollment
    of Category 8's on the basis that it was a temporary
    suspension. We backed them at great political cost, I might
    add, within our organizations.
        Five weeks later, I was in a briefing on the so-called
    CARES procedure and they flipped up a slide. I said stop, go
    back. The slide before projected 20 years out was a still
    freezing out Category 8 veterans. I said how did we go from a
    1-year, temporary freeze to a permanent barment of veterans who
    are not indigent.
        We resented that. I can assure you that I asked who
    authorized this and ended up on the 10th floor of VA saying I
    do not know how we can trust you all again because you sold us
    a pig in a poke. And this is not right. It is not right to do
    this on a permanent basis.
        If, in fact, you all asked for enough money to serve the
    veterans whom you are legally obligated to serve correctly and
    they do not give it to you, shame on the Congress. But if you
    continue not to ask for that money, then shame on you. And it
    is time once again to address the funding issue.
        Similarly to that, if I may suggest, and this also goes
    along with, VVA strongly supports the TBI bill, the screening
    bill, and at the same time would encourage you to add in that a
    requirement that as they are in the process now of redesigning
    the automated patient treatment record that VA be required,
    since they do not seem to be able to do it on their own, be
    required to take a complete military history and include it in
    the automated patient treatment record based on branch of
    service, when did you serve, where did you serve, what was your
    military occupational specialty, and what actually happened to
    you. And based on the answers to those five questions to
    automatically screen for things like traumatic brain injury as
    one example along with many other things such as post-traumatic
    stress disorder (PTSD). And it would be high time to do that.
        Doing the look-back and the proper training on TBI
    throughout VA is absolutely essential. I would bring to the
    Committee's attention that 17 percent of the active-duty troops
    serving at Fort Carson in a survey that was completed 2 weeks
    ago done by the Army that were diagnosed, most of these people
    were not diagnosed as TBI; 17 percent of those active-duty
    troops who had been in Iraq were screened and found to have
    traumatic brain injury of one degree or another.
        This is a huge problem. It is going to be a huge problem
    that unfortunately is moving from the military medical system,
    and not being adequately addressed there, into the VA
    healthcare system. And VA needs to do its part and urge that
    Mr. Snyder and those folks on Armed Services ensure that
    military medical system carries more of its load.
        On a number of the other bills, rural access to veterans
    and building a hospital in south Texas, VVA strongly favors
    that. It is a need that goes back very far and these veterans
    have been underserved for many, many years, and urge that the
    Committee move expeditiously on that and the Congress move
    expeditiously.
        Once again, we agree with our distinguished colleagues from
    the VFW in the intent of the ``Veterans Timely Access To
    Healthcare,'' ``Richard Helm Access To Healthcare Options And
    Resources Act,'' and the ``Rural Veterans Access To Care Act''
    are well-intentioned. However, we come back to the point that
    if you are not adequately funding the system to serve folks
    within the system, where are you going to get the money in
    order to contract out?
        Mr. Snyder hit it right. At the moment, it is a zero sum
    game. And if you take away from that, then you are going to be
    taking away resources from within the system.
        We are philosophically not opposed to contracting out where
    it is in the best interest of the veteran. However, we need
    adequate funding before you start taking money out of the
    system.
        Because I am out of time, I will stop there. And the rest
    of the statement on the other bills, I think is contained
    therein. I would be happy to answer any questions, Mr.
    Chairman. Thank you.
        [The prepared statement of Mr. Weidman appears on p. 92.]
        Mr. Michaud. Well, once again, I would like to thank all
    the panelists for your testimony. It was very interesting.
    There are a lot of common themes throughout each of your
    statements.
        I just have a few questions for VFW. You mentioned Project
    HERO. This might be a more appropriate question for the VA.
    When is that report due out? Do you have any idea?
        Mr. Cullinan. I talked with our health policy person and
    there seems to be some uncertainty as to when exactly it is
    going to come out. The only thing is it is, from our
    understanding, it is gathering very valuable information with
    respect to these kinds of projects. So it is something worth
    waiting for.
        Mr. Michaud. Okay. Mr. Weidman.
        Mr. Weidman. If I may comment. Originally Project HERO was
    designed because there was a strong interest on the part of the
    Congress to standardize across Veterans Integrated Services
    Networks (VISNs) and between hospitals the cost of various
    goods and services. And this was a laudable goal on the part of
    the Congress, pointing out the fact that it was all over the
    map in terms of what we were paying for the same service or
    same good from hospital to hospital.
        So Project HERO, inappropriately named as VVA would
    maintain, was supposed to standardize that. And, in fact, the
    first draft RFP was a fire sale on clinical care across the
    board to the private sector. We said time out. What do you all
    think you are doing. This is not what the Congress intended.
    They intended you to rationalize that which you were already
    contracting out. And it has scaled back several times.
        But the problem with all of this contracting out right now
    is that you give them an inch, they take a mile. And until we
    can have confidence that the intent of the Congress is not
    going to be distorted by the way in which it is actually
    implemented, VVA has no choice but to oppose it, sir.
        Mr. Michaud. You mentioned support of the legislation
    dealing with the hospital in Texas. As you all know, VA went
    through an extensive process, the CARES process, and hopefully
    we will be able to move forward on that more aggressively than
    we have in the past.
        Do you think the Texas hospital should be put before the
    CARES process or should we follow the CARES process first?
        Mr. Hollingsworth. Mr. Chairman, AMVETS, as I indicated,
    did support the CARES process and there were some decisions. I
    think there was 18 studies. Some of those were going to require
    further analysis. To the best of my knowledge, the VA has not
    responded to some of those.
        In addition, I would like to add that during the 108th
    Congress, there was a separate study that VA, I believe, was
    mandated to do with regards to that specific region and that
    report is still supposed to be forthcoming.
        Mr. Michaud. Okay. Great.
        Mr. Weidman. Unlike our colleagues, Mr. Chairman, VVA does
    not support the CARES process in its current form. We would
    characterize it as an organized way of going wrong with
    confidence. It is based on a civilian medical formula for
    people who can afford HMOs and PPOs. They have adjusted
    somewhat for mental health and somewhat for blind and visual
    and for prosthetics, but they only adjusted a formula that is
    fatally flawed. It does not address veterans' healthcare and as
    a result is always going to underestimate the needs. Let me
    give you one example, if I may.
        That formula is predicated on one to three presentations
    per individual who walks through the door. VA averages at their
    hospitals five to seven presentations per individual who comes
    through the front door. So the burn rate, if you will, of
    clinical resources is much higher among veterans than it is
    among the civilian population who are middle class, well fed
    who that formula is based on.
        As a result of that, it is going to continually
    underestimate not only the amount of care needed but the shape
    of care needed. There is a dramatic difference between civilian
    medicine and veterans' healthcare medicine. And until we start
    to think of veterans' healthcare as a set of occupational
    healthcare entities or occupational health for a set of very
    dangerous occupations, we are going to continue to go wrong.
        So we think that the need for the south Texas facility is
    self-evident and we should move on it immediately, sir.
        Mr. Michaud. Thank you.
        And my last question, and I will preface it with some
    comments, deals with access to healthcare. And I agree with the
    comments that you have all made. We have definitely got to
    adequately fund VA which is extremely important. And I think a
    lot of problems related to the bills that we have heard today
    and ones that we will be hearing hit on that core issue about
    not adequately funding VA.
        However, even if VA was adequately funded, my concern still
    would be the access issue in rural areas. And I know in some of
    the comments, there was talk about it being more expensive and
    less cost-effective. That is probably true, but when you look
    at veterans in rural areas, if they are going to get the
    services that they need, we might have to pay a little bit more
    for those services because I do not think it would be cost-
    effective to have clinics throughout all the rural areas.
        So is that a fair assumption on all the VSOs that even if
    we do adequately fund the VA, which I think we definitely have
    to do, that there still will be a need for fee-for-service
    arrangements for veterans who live in rural areas?
        Mr. Cullinan. Mr. Chairman, speaking on behalf of the VFW,
    we certainly have no philosophical or other kind of objection
    to providing contract-based care. VA has existing authority to
    do that. We would urge that they do it more judiciously,
    perhaps more liberally.
        The only thing we do not want to see is contract care
    suddenly supplanting the VA's own infrastructure. That is our
    concern and, of course the cost of all this.
        Mr. Michaud. I agree with that comment.
        Are any of the VSOs, following up on that same line of
    questioning, aware of any VISNs out there now that are abusing
    the fee-for-service contracting out services?
        Mr. Hollingsworth. Mr. Chairman, AMVETS is not aware of
    that, but some of this delves into a territory I do not think
    we want to go today which has to do with the medical care cost
    collection funds and how we fund things.
        I think overall, you know, AMVETS says, hey, we need to get
    the services that veterans are entitled to receive or that they
    are authorized to receive and we should provide those services.
        I think our overriding concern with some of the legislation
    presented today is the simple fact that the Secretary does have
    this authorization and so there is no need for separate
    legislation to do this. If the needs are not being met, then
    let us get the VA to act within their existing authorizations.
        Mr. Atizado. Mr. Chairman, if I may, with regards to the
    VISNs that make extensive use of contractor fee-basis care, I
    think if you look to the hearing with regards to Project HERO,
    it was mentioned in that hearing that the four VISNs that were
    chosen were chosen specifically for their high utilization rate
    of contracting fee care.
        With regards to rural care, I think once we all agree with
    the fact that to provide this care is going to be higher than
    what we are all used to, then we would have to shift our idea
    of cost-effective care specifically for this population.
        The concerns that all my colleagues have here on this side
    of the table is the idea that has been presented on how to deal
    with this issue. Much of them require VA, takes out
    flexibility, it is a hard trigger legislation, which, if I may
    say, we could probably look more toward a soft trigger,
    something that would allow us to be more aware of the
    situation, be more cognizant, and be more prudent as well as
    take incremental steps to really address this problem.
        This is a very huge problem, particularly for the new
    veterans from OIF/OEF. And we really should take the time to
    take a look at this instead of coming up with this potentially,
    and I say this, potentially dangerous legislation with the way
    it is written.
        Mr. Weidman. VVA is not, as I mentioned before,
    philosophically opposed to contracting out as long as it is
    done judiciously and as long as the system is adequately
    funded.
        I am keenly familiar with what you are talking about, Mr.
    Michaud. A decade following military service in Vietnam, I
    lived in northern New England and was 2\1/2\ hours if the roads
    were dry, which you cannot assume in northern New England, from
    White River Junction. And so I am familiar with the difficulty
    in receiving care from VA when you have those kinds of
    distances.
        But the real issue here is if you have adequate funding for
    the overall system and using, as our good friends from the DAV
    put it, judicious use of the already contract fee provider
    mechanism, then we would have no objection whatsoever.
        Mr. Michaud. Great. Well, once again, I would like to thank
    the panel for your testimony today. I look forward to working
    with you as we continue moving forward in this Congress to deal
    with issues important to veterans. Our door is always open. So,
    once again, thank you for your testimony.
        Sorry for the delay. And I would ask the last panel to
    please come up. On the panel is Dr. Cross, who is the Acting
    Principal Deputy Under Secretary for Health. He is accompanied
    by Walter Hall who is the Assistant General Counsel for the
    Department of Veterans Affairs.
        And, once again, I apologize for the lengthiness of the
    hearing on these pieces of legislation. Unfortunately, votes
    got in the way.
        So without any further ado, Dr. Cross, once again, welcome
    and I look forward to your comments.

      STATEMENT OF GERALD M. CROSS, M.D., FAAFP, ACTING PRINCIPAL
          DEPUTY UNDER SECRETARY FOR HEALTH, VETERANS HEALTH
         ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS;
    ACCOMPANIED BY WALTER A. HALL, ASSISTANT GENERAL COUNSEL, U.S.
                     DEPARTMENT OF VETERANS AFFAIRS

        Dr. Cross. Good afternoon, Mr. Chairman and Members of the
    Subcommittee, and thank you for inviting me here today to
    present the Administration's views on several bills that would
    affect programs administered by the Department of Veterans
    Affairs in the provision of healthcare to veterans.
        With me today is Walter Hall. He is the Assistant General
    Counsel.
        The various bills under consideration address issues that
    include wait times, expanded access to healthcare in rural
    areas, the provision of chiropractic care, and multilingual
    outreach.
        Mr. Chairman, knowing my time is limited, I will address
    these issues collectively by subject. And I would like to
    submit my written testimony which provides additional in-depth
    information for the record.
        Mr. Michaud. Without objection, so ordered.
        Dr. Cross. House Resolution 92 deals with waiting times.
    Specifically House Resolution 92 addresses wait times for
    appointment scheduling as well as the issue of waiting room
    times. Both issues are important to VA and VA has no
    significant objection with respect to the 30-day standard for
    scheduling patients.
        We would, however, ask the Committee to change the bill
    language to clarify that it would apply only to new patients.
    It is these patients who need to be tracked to understand that
    there are difficulties accessing the VA system.
        Turning to waiting room times, we would like to submit to
    the Subcommittee results from our customer satisfaction survey
    which is independently done indicating nearly 80 percent of
    patients waiting for primary care services are seen within 20
    minutes of their appointment time and more than 70 percent of
    veterans are seen within 20 minutes of their specialty care
    appointment time.
        We feel that House Resolution 92 would not remedy the wait
    experience of the patient for a particular visit and further
    that the remedy is based on a flawed assumption that all
    private care in the community meets the proposed standards.
        House Resolution 315 and House Resolution 1527 address
    expanded access to healthcare for veterans in rural and highly
    rural areas. VA is concerned that both of these bills would
    undermine further expansion of our system to facilities in
    rural areas.
        VHA recently established the Office of Rural Health in
    accordance with Congress' mandate in the ``Veterans Benefits
    Healthcare And Information Technology Act of 2006.'' This
    office will determine how we can continue to build on what we
    have already successfully accomplished and to expand on that
    expertise in caring for our rural and highly rural veterans
    who, in fact, rate their satisfaction of care higher than their
    urban veteran counterparts.
        House Resolution 538 defines provisions of care for
    veterans in far south Texas. VA at the request of Senator Kay
    Bailey-Hutchinson has contracted to evaluate and to report on
    current needs in the south Texas region. The results from the
    study are due in July of this year.
        VA respectfully requests that the Subcommittee await the
    results of this ongoing evaluation before considering whether
    to mandate a particular means for addressing the healthcare
    needs of veterans in that area.
        House Resolution 1426 would provide enrolled veterans the
    option of receiving care outside the VA healthcare system. VA
    strongly opposes enactment of this bill. Not only could it lead
    to the undoing of a world-class VA healthcare system, but it
    would also fragment the care our veterans receive because they
    would no longer have a complete set of medical records
    reflecting their comprehensive care.
        House Resolution 463 would terminate the administrative
    freeze on enrollment of veterans in Category 8. VA strongly
    opposes this bill. The bill would render meaningless the
    prioritized enrollment system mandated by Congress in 1996. VA
    would have to add capacity to absorb the increased workload
    this bill would entail. But in the interim, the quality and
    timeliness of VA healthcare would suffer.
        House Resolution 1470 and 1471 deal with chiropractic care
    programs in the VA. VA does not oppose increasing the number of
    VA sites providing chiropractic care. However, at this time, we
    do not believe that chiropractic care at all VA medical centers
    is warranted. To date, 98 percent of our patients can receive
    chiropractic care within 30 days of their desired date.
        And VA also strongly objects to extending the field of
    chiropractic care to the treatment of other medical conditions.
    We believe that it is in our patients' best interest to
    continue having their individual primary care providers remain
    in charge of managing their care, particularly since our aging
    population exhibits complex medical conditions requiring
    intensive and highly integrated clinical management skills that
    are better managed in a primary care setting.
        House Resolution 542 would require VA services in a
    language other than English for veterans with limited English
    proficiency. We believe that we are already meeting the intent
    of this bill.
        On February 12, 2007, VHA issued a new directive updating
    the guidance previously set forth regarding services to
    individuals with limited English proficiency. Similar documents
    have also been issued by the National Cemetery Administration
    (NCA) and by the Veterans Benefits Administration (VBA).
        These action plans ensure that VA facilities and programs
    fully implement all such requirements.
        Sir, this concludes my prepared statement. Mr. Chairman, we
    are still in the process of developing cost estimates for these
    bills and we will supply them for the record when they are
    cleared. And I would be pleased to answer any questions you
    have.
        [The prepared statement of Dr. Cross appears on p. 94.]
        Mr. Michaud. Thank you very much, Dr. Cross.
        When do you think they will be cleared as far as the cost
    estimates?
        Dr. Cross. Well, I do not have a date in mind at this
    point, but this is of great interest and concern. And, sir, we
    will cooperate with you and do it as quickly as possible.
        Mr. Michaud. Okay. Great. In your written testimony, you
    also said you will provide comments on H.R. 1944, the rural
    healthcare bill as well. When do you think you will have those?
        Dr. Cross. H.R. 1944 is a bill that we have just seen. It
    just came over, I believe, and so we looked at it. It concerns
    TBI. Obviously TBI is of intense interest to us and our system
    right now.
        My view of it, and this is not official, is that the intent
    of the bill and many of the things in the bill are consistent
    with the direction that we are pursuing right now.
        Mr. Michaud. But when will you have it? You said you would
    have written testimony on those two specific bills.
        Dr. Cross. Having just gotten it, I am sure that it will
    take a couple of weeks.
        Mr. Michaud. Project HERO, when is that report due or when
    will it be ready?
        Dr. Cross. Actually, HERO is to some degree just being
    kicked off because it was announced in January and I believe
    the first RFPs just went out in, I believe, April. And so it is
    very, very early in the process.
        We are using four sites, four VISNs. The focus is on the
    effectiveness of how we do our current contracting to make it
    more effective. And I will have to get you in writing, sir, the
    answer as to exactly when the date is for that to be turned in.
    It is a 5-year pilot project.
        Mr. Michaud. And you heard from Vietnam Veterans of America
    about the enrollment ban on Priority 8 veterans, that
    originally that was put in place because of lack of funding
    within the VA and it was only supposed to be temporary. But it
    appears that the VA intends to make that permanent; is that
    correct?
        Dr. Cross. It is correct that we do not have any plans to
    change the current regulation at this time. And it is more than
    a funding issue. It is also a capacity issue and it will take
    time and funding substantially to incorporate that large bolus
    of an additional population.
        Mr. Michaud. When you talked about waiting lists I believe
    you said that we ought to look at new patients, not existing
    veterans. Why is that?
        Dr. Cross. I wanted to explain that. I am really pleased
    that you asked because we deal with a chronic disease model of
    care given the nature of the patients that we see.
        A patient who is coming in to us over a period of decades
    for their blood pressure control, for cardiac evaluation, for
    cholesterol, for PTSD, they do not necessarily need to be seen
    every month. And so we want to be careful. If you set a 30-day
    standard, we may be telling them they do not need to come back
    for 2 months or 3 months or 6 months.
        So we use something called the desired date. And I have to
    explain that to you because that is a negotiation between the
    doctor, the scheduler, and the patient as to what is
    appropriate time for them to come in and what is convenient for
    them as well, what fits into their schedule.
        And an arbitrary standard of simply 30 days measure does
    not account for that finesse within our system. The new
    patients, a hard number of 30 days is just fine, I think,
    because that person making that initial request, we want to get
    them in. There is no desired date issue. We assume that they
    want to be seen as soon as possible.
        And so that is why I made that distinction, and we would
    support that.
        Mr. Michaud. You also mentioned the Office of Rural Health.
    Have you already hired the individual?
        Dr. Cross. We have already established the office. We have
    assigned the duties to our Policy and Planning Chief, Pat
    Vandenberg, but our intent is to move forward with further
    development of that office. And I think we were given an end-
    point target date of the end of the summer or the end of the
    fiscal year. And we are working hard to meet that. We will meet
    that.
        Mr. Michaud. And what are you looking for for an individual
    to run the Office of Rural Health?
        Dr. Cross. Well, I am not sure if I have the criteria all
    in mind, sir, but I would be happy to share those with you. We
    want someone who is committed in the same way that you are to
    moving this forward for our rural veterans.
        And may I please say, you know, we had the rural health
    hearing just a short time ago. This is a strategic direction
    for us. We are moving out with more and more Community-Based
    Outpatient Clinics. We are moving out with more telemedicine,
    telemental health. We want to reach out into those communities.
        But there is a new technique that we want to add in, which
    we are already doing to some degree, outreach clinics. We
    always put the CBOCs on the map and that is a big deal. But we
    want to have also clinics that are CBOCs that are part time,
    that do not really count as a full CBOC. We call them outreach
    clinics. We have about a dozen of those so far.
        And those serve that need of that very small population
    going into perhaps leased space in the community part time, 1
    day a week, 2 days a week, half day a week where we can meet
    those veterans' needs so they do not have to leave that
    community, can get their prescription refilled, can get their
    blood test done, and so forth. And that is one of our strategic
    directions.
        Mr. Michaud. You heard the testimony from my colleagues on
    both sides of the aisle this morning and unfortunately a lot of
    it relates to funding issues, and it is not only the
    Administration's lack of looking at what we need for the VA,
    but it is also Congress' lack of taking the initiative to
    provide the appropriate funding.
        I think if we do have appropriate funding, whether it is
    assured or mandatory funding, that a lot of these problems, a
    lot of the legislation we are having today, would not
    necessarily be here. Funding is a big issue, as is funding for
    rural healthcare when you look at the men and women who are
    currently serving in our military today in rural areas.
        My only concern, and hopefully you will keep this in mind,
    is even though rural healthcare might be important for some
    over at VA, I do not think that is necessarily true for all.
    And that is where a lot of us who represent rural regions are
    concerned.
        As for the CARES process, had that process been moving
    along a lot quicker than it has, I think a lot of these
    problems would not be here.
        But, again, it boils down to funding issues. A good
    example, is Maine. During the CARES process, VISN 1 had
    recommendations for a CBOC, and I believe five clinics. Yet,
    when we talked with the region one VISN Director, they never
    even requested a business plan.
        That does not give me a good feeling that the interests,
    particularly as you have heard earlier this morning from other
    Members of Congress, that if you have a VISN Director who sits
    in a metropolitan area, that they really understand what is
    happening out there with our men and women who served this
    country in rural areas. And I think it is very important that
    we do have a focus on taking care of veterans regardless of
    where they live.
        I look forward to working with you, Doctor, as we move
    forward in this Congress on a lot of the issues that we have to
    deal with. And I look forward to working with my colleagues on
    both sides of the aisle because, as I stated over and over
    again, veterans' issues are not Democratic or Republican
    issues. They are American issues.
        The situation at Walter Reed, the situation with Bob
    Woodruff, some of the articles that have come out as far as
    taking care of our men and women who are serving and who have
    served our Nation, have not been good. But the bottom line is
    good, particularly when you look at the budget that was passed
    about a month ago as it relates to VA.
        And we have to make sure that we continue onward in this
    area, and I appreciate all the work that you are doing, Doctor
    and Mr. Hall, within the VA system and I look forward to
    working with both of you as we move forward along with the
    VSOs.
        At this time, I would actually ask, since Mr. Miller was
    unable to make it back, if Counsel on either side might have
    any questions?
        Ms. Dunn. No.
        Mr. Tucker. I do have two quick questions.
        Mr. Michaud. Okay. Yes, Mr. Tucker.
        Mr. Tucker. Thank you.
        Dr. Cross, just two quick questions. One a little more
    philosophical than the other.
        You state that you are looking at outreach clinics as
    providing some of the primary care in rural areas. Is this
    similar to what HHS is doing and is there any overlap between
    what you are doing or trying to do and what HHS is currently
    doing?
        Dr. Cross. I think there is a very important distinction on
    a couple of aspects of that. The outreach clinics that we have,
    like our CBOCs, are tied into our system. For instance, they
    are tied in by our electronic health record system. That
    promotes a level of safety, for instance, in prescribing that,
    you know, I think is different from the civilian community that
    uses paper prescriptions.
        The same screening criteria, and we are very proud of this,
    this is so important as was mentioned by one of the VSOs, that
    this is a unique thing that we must do for our veterans. So we
    screen them for PTSD. We screen them now for TBI, all of the
    OIF and OEF that we see. We screen them for alcoholism and so
    forth.
        We are focused on those issues. And it is hard to explain
    sometimes what that distinction is, but I think that
    distinction is very important.
        Mr. Tucker. And my last one is more philosophical. As we
    are trying to address rural healthcare needs and trying to
    figure out the best mix of VA services and possibly other
    services and how to provide that care, how do you see the VA
    providing healthcare in the next decade or next two decades? Is
    it going to be based on the system that we have today with a VA
    medical center and a hub and spoke system with Community-Based
    Outpatient Clinics? Are we going to be looking at building more
    and more Community-Based Outpatient Clinics in rural areas to
    provide primary care and other services or how is the VA
    approaching what healthcare will be like in the next decade or
    so?
        Dr. Cross. Dr. Kussman just led a summit meeting where we
    looked at the future of VA healthcare as a group with our VISN
    Directors and Program Chiefs. VA healthcare is going to look
    very different in a lot of respects. We are going to become
    less institutionalized.
        The idea that the patient has to leave home to get medical
    care is not necessarily the way that we want to go. We think
    that much more can be done in the community and at home. Let me
    give you a couple of examples.
        Information, we have the My HealtheVet Web site so that
    they can get the information that is wholesome and reliable in
    their own home for those who have a computer and Internet
    access. We let them refill their prescriptions sitting at their
    desk at home and just log in and take care of that.
        We will download their medical records to the individual
    electronically. So if by chance we do send them off somewhere,
    we do fee-basis care in the rural environment and other places,
    they can print off and take the relevant materials with them to
    that institution that does not have electronic records.
        I think that we are going to have less focus on grand,
    large, giant institutions and much more on meeting the needs in
    other ways. We are doing that with nursing homes, moving away
    from the standard model to a less restrictive model. We are
    doing home-based primary care where we send people out to visit
    in the home. We are spending $175 million on 2008 budget for
    home-based permanent care.
        I think that is the direction, and I think it will look
    different. I think it will be innovative and I think it will
    meet the needs of our patients actually better.
        Mr. Michaud. Just one last question. I know money is an
    issue and it will help. I am also concerned that we make sure
    that we provide adequate healthcare but in a manner that is
    cost-effective. And this just is a rough idea I am throwing out
    to get your thoughts.
        When you look at what we have for a system in State
    Veterans Homes, have you looked at trying to partner with the
    State Veterans Homes, for instance, if they have a Veterans
    Home to take care of our veterans long term but also saying,
    well, maybe that might be an area where the Veterans Home might
    be able to build a CBOC or a clinic and have a community,
    veterans' community there by utilizing another entity as far as
    partnerships? Is that something that you are looking at?
        Dr. Cross. I think we are very open to that idea. I think
    that is a good idea. I think we are actually doing that in some
    locations already where we have a little campus, not
    necessarily the traditional VA campus, but elsewhere where we
    put a number of services collocated, regional office, VBA
    services, and State Veterans Homes, those kind of things.
        A number of State Veterans Homes, I believe, and I am not
    sure of the number, are located actually on campuses with the
    VA. So that works in the other direction as well.
        Mr. Michaud. Okay. Great. Once again, I want to thank both
    you, Dr. Cross, and Mr. Hall, for your testimony as well as all
    the other previous panels, and look forward to working with you
    as we move forward in this Congress. Once again, thank you very
    much.
        With no further questions, the hearing is adjourned.
        [Whereupon, at 1:23 p.m., the Subcommittee was adjourned.]

                                A P P E N D I X

                                  ----------

                 Prepared Statement of Hon. Michael H. Michaud
                        Chairman, Subcommittee on Health
        I would like to thank everyone for coming today.
        Today's legislative hearing will be the first of many this
    Subcommittee plans on holding to provide Members of Congress, veterans,
    the VA and other interested parties with the opportunity to discuss
    legislation within the Subcommittee's jurisdiction in a clear and
    orderly process.
        I don't necessarily agree or disagree with the bills before us
    today, but I believe that this is an important process that will
    encourage frank discussions and new ideas.
        We have 11 bills before us and one discussion draft.
        The discussion draft represents some of my ideas to improve the
    quality of care available to our rural veterans and the ability to
    access that care such as:

          Establishing mobile vet centers, improving information
    technology and technology sharing between VA and non-VA providers;
          Establishing a Rural Veterans Advisory Committee;
          Creating Centers of Excellence to encourage research and
    innovative healthcare to address the needs of rural veterans; and
          Encourage more healthcare professionals to work in rural
    areas.

        I look forward to hearing the views of our witnesses on this
    discussion draft and the other bills before us.
        I also look forward to working with everyone here to improve the
    quality of care available to our veterans.

                     Prepared Statement of Hon. Jeff Miller
               Ranking Republican Member, Subcommittee on Health
        Thank you, Mr. Chairman.
        I appreciate your holding this legislative hearing today and
    welcome the opportunity to discuss the 12 different legislative
    proposals before us focusing on providing better healthcare access for
    veterans.
        There has been an unprecedented demand for the Department of
    Veterans Affairs (VA) healthcare. Since 2003, the number of patients VA
    is treating has grown from 4.8 million to an expected 5.8 million in FY
    2008. In 2008, VA anticipates treating 263,000 Operation Iraqi Freedom
    (OIF) and Operation Enduring Freedom (OEF) veterans, 25.8 percent more
    than the 2007 level. This surge in demand for healthcare is expected to
    continue and creates new challenges for VA's capacity to deliver both
    primary and specialty care.
        Two of the bills we will consider today, H.R. 92, the Veterans
    Timely Access to Healthcare Act, and H.R. 339, the Veterans Outpatient
    Care Access Act of 2007, would require VA to contract for care for
    veterans who are unable to be seen in a VA facility in a timely manner.
    Since 2004, VA has reported a substantial improvement in the percent of
    veterans who receive appointments within 30 days of a patient's desired
    date, stating they are meeting their established 30 day goal for 96
    percent of primary care and 94 percent of specialty care patients.
    However, statistics mean nothing to a veteran who is delayed care
    because they are placed on a waiting list. If VA cannot meet its own
    established standard for any veteran, that patient should be given the
    choice to receive care in a non-VA facility.
        Last week, this Subcommittee held a hearing on veterans' access to
    care that highlighted our concern that veterans in rural areas face
    additional challenges to receiving healthcare as these areas are
    traditionally underserved. In the Pensacola area of Florida, in my
    district, the nearest inpatient VA facility is located approximately
    125 miles away in Biloxi, Mississippi.
        Several of the bills we will examine would specifically address the
    needs of veterans living in rural or geographically remote areas. One
    of the bills, H.R. 1527, the Rural Veterans Access to Care Act,
    introduced by our fellow Subcommittee Member, Jerry Moran, would allow
    a highly rural veteran enrolled in VA healthcare to receive services
    through a local provider if that veteran chooses to receive non-
    Department care. It would also allow VA pharmacies to fill
    prescriptions written by non-Department providers for these veterans.
        In March, this Subcommittee held a hearing to assess the
    rehabilitation needs and care of our injured servicemembers with
    Traumatic Brain Injury (TBI). These injured servicemembers and their
    families are relying on VA to provide a full continuum of first class
    care and support for their complete recovery--from inpatient services
    at the Polytrauma Rehabilitation Centers, to outpatient rehabilitation
    to long-term care services in their home communities. At this hearing
    we will consider H.R. 1944, the Veterans Traumatic Brain Injury
    Treatment Act of 2007. This bill would among other requirements,
    establish a comprehensive program of long-term care for post-acute TBI
    in four geographic regions.
        Additionally, we will discuss legislation to improve the provision
    of chiropractic care through VA medical centers. According to a
    November 2006 VA study, musculoskeletal ailments are among the top
    health problems of veterans returning from Iraq and Afghanistan.
        We will also consider H.R. 463, the Honor Our Commitment to
    Veterans Act. This legislation would change the law to require the
    Secretary of Veterans Affairs to administer the VA healthcare
    enrollment system as to enroll any eligible veteran who applies. The
    President's Task Force to Improve Healthcare Delivery For Our Nation's
    Veterans, in their 2003 Final Report, issued a recommendation that
    ``The present uncertain access status and funding of Priority Group 8
    veterans is unacceptable. Individual veterans have not known from year
    to year if they will be granted access to VA care. The President and
    Congress should work together to solve this problem.''
        In closing, I want to thank the Members who have brought these
    bills before us and all of our witnesses appearing here today. I look
    forward to engaging in a productive discussion about legislation that
    will help us provide the best care for our veterans, whether it is
    through contract care, or requiring more VA medical centers to provide
    chiropractic services.
        Thank you, Mr. Chairman, I yield back.

     Prepared Statement of Hon. Steve Pearce, a Representative in Congress
                          from the State of New Mexico
        I would like to thank Chairman Filner, Ranking Member Buyer,
    Subcommittee on Health Chairman Michaud and Ranking Member Miller for
    the opportunity to discuss this issue that is critical to the veterans
    of the State of New Mexico. Today I am calling on you and Members of
    the Veterans Affairs Committee to support my legislation, H.R. 315, the
    Help Establish Access to Local Timely Healthcare for Your (HEALTHY)
    Vets Act.
        In New Mexico's rural communities, many of our veterans are
    deprived of accessible medical facilities and face the high cost of
    gasoline to travel and to obtain care. My legislation would require the
    Secretary of Veterans Affairs to contract with local doctors and
    hospitals on a case-by-case basis to provide medical services,
    including primary care, for those veterans who live far away from VA
    medical facilities. This would expand the ability of our local health
    providers in southern New Mexico to provide more convenient, efficient
    medical services for veterans who live in areas that are far away from
    established VA facilities.
        Currently, veterans residing in southeast New Mexico must drive
    between 400 and 500 miles roundtrip to receive care at New Mexico's
    only VA Hospital located in Albuquerque. I consistently hear stories
    from my constituents about the detrimental impact this long-distance
    drive has on their ability to access timely care and overall health.
    One Marine veteran amputee began having uncontrollable drainage from
    his ``good'' foot and was making 2 to 3 trips a week to the Albuquerque
    VA hospital. This equates to 18 hours of drive time a week. After 4
    months, he finally lost his foot. Several local civilian healthcare
    experts feel the unfortunate travel ``marathon'' contributed to the
    failure to save his foot.
        Another 87-year-old Bataan veteran developed a serious bladder
    infection and was directed to make the 6 hour roundtrip drive along
    with his 85-year-old wife. Halfway through his treatments prostate
    cancer was found and additional trips had to be made for chemotherapy.
    After 7 months of trips, he died and his wife's health was seriously
    damaged after the strain of such long-distance care.
        Today, I know you will hear from several National Veterans Service
    Organizations who may not support my bill and others under
    consideration today. That is because many of these groups have
    committed themselves to the goal of ``keeping VA dollars inside the
    VA.'' I understand this concept and believe at first glance it sounds
    like a commonsense approach to VA budgeting. But following this logic,
    the only way to get more localized access to care for veterans in my
    district would be to build new facilities in areas closer to their
    homes.
        I believe there is a need for a full-service Veterans Health Center
    in southern New Mexico and would love to see that come to fruition.
    However, I am a realistic man as are the veterans living in rural New
    Mexico. With the tight budgetary constraints our Nation faces, and the
    smaller population in States like New Mexico, that idea is much easier
    said than done. This is a reality veterans living in rural areas have
    been forced to accept.
        Since that solution is not realistic at this time, we must work to
    find other solutions to this problem that is hurting our veterans with
    every 6-8 hour roundtrip journey to the hospital. Unfortunately, the
    idea of expanded contracting authority raises flags with certain
    Veterans Service Organizations that see it as a step toward
    privatization. They characterize this as the Federal Government
    brushing aside its commitment to care for the men and women who have
    served our Country.
        Well I will tell you that the Federal Government and the VA are not
    adequately living up to their commitment and serving my constituents
    under the current system. John Taylor, a life member of the Military
    Order of the Purple Heart and life member of the Disabled American
    Veterans, lives in Roswell, NM which is approximately 200 miles away
    from Albuquerque. In a letter John wrote to me:

              ``Rural veterans in New Mexico are dying and losing body
            parts because of a 6 hour, roundtrip drive to the nearest VA
            hospital in this State. . . . Our VSO legislative
            representatives from the DAV, etc. have no experience or live
            in contact with this issue, as they are from large urban areas
            with massive facilities and infrastructure for support. The
            classic response to invitations requesting visits to our rural
            areas has historically been, `we'll try, but it takes time to
            get out there, and we have a very busy schedule.' I submit the
            same time that is an inconvenience to executives is the same
            time killing my fellow veterans or at the very least, causing
            serious exacerbation of their medical problems.''

        U.S. Army Retired LTC Charlie Revie, a member of the Uniformed
    Services Disabled Retirees, noted that the drive from Las Cruces to our
    only major VA facility is a 250 mile one way trip--from Hobbs, the
    distance is 320 miles.
        The notion that providing contracted care to veterans through local
    doctors at non-VA facilities is somehow a way to finagle out of caring
    for them is absurd. Under my legislation, the VA will clearly still pay
    for the care veterans obtain at non-VA facilities. Veterans in my
    district and across rural America have been hearing politicians talk
    about increasing access for years. It is simply imperative Congress
    take these issues seriously this year.
        After the reports regarding conditions at Walter Reed Army Medical
    Center, the House passed the Wounded Warrior Assistance Act, which
    takes steps to shed light on the bureaucratic process that plagues the
    VA. It improves communications amongst DoD, VA and Congress and
    strengthens the process for returning soldiers transitioning into the
    VA healthcare system. All these measures are extremely important and I
    hope the Senate works to pass similar legislation. But we must not just
    be a reactionary Congress that only finds time to fix issues in light
    of displeasing media reports. Without any changes to allow veterans
    more localized access to care, many soldiers returning from Iraq and
    Afghanistan who return home to their families in southern New Mexico
    will face the extensive 400+ mile trek to the VA medical center in
    Albuquerque.
        I appreciate the opportunity to present my legislation to the
    Committee and speak on this issue which deserves the attention of
    Congress. Our veterans in rural America deserve no less.

       Prepared Statement of Hon. Ginny Brown-Waite, a Representative in
                       Congress from the State of Florida
        Thank you for allowing me to appear before the Subcommittee today.
        I appreciate the opportunity to testify on my legislation, H.R. 92,
    the Veterans Timely Access to Healthcare Act.
        When I first came to Congress in 2003, I introduced this measure
    after hearing of the long wait times facing some veterans in need of
    healthcare at the VA. Frankly, the stories many of us have heard about
    these delays are unacceptable. These holdups can worsen the veteran's
    health and impose a greater financial hardship on everyone involved. In
    some situations, these wait times can be the difference between life
    and death.
        Events in Iraq and Afghanistan also remind us of the urgent matter
    at hand. With thousands of soldiers returning from the front lines,
    many of whom will require immediate healthcare, VA medical facilities
    face a difficult task. Unless Congress takes action, wait times will
    only continue to grow.
        My legislation would help ensure that our Nation's veterans receive
    timely healthcare. For veterans seeking primary care from the VA, my
    bill would establish a 30-day timeframe as the standard for access to
    medical services. This standard would cover from the time an individual
    schedules a visit until they actually see a medical provider. In the
    event this standard is unachievable, the VA would have authorization to
    contract for care from a private provider. At the same time, my bill
    also grants the VA some flexibility in meeting this standard. For those
    facilities in geographic areas that have a 90 percent or greater rate
    of complying with this requirement, the contracting provisions would
    not be necessary. Finally, this legislation would establish
    comprehensive reporting requirements on wait times for individuals
    seeking care at VA medical facilities.
        As Members of Congress, we have an extraordinary responsibility to
    veterans. These brave men and women answered the call in our time of
    need; it is only fitting that we take care of them in their own. I look
    forward to working with my colleagues on the critical issue of wait
    times. I would be happy to take any questions regarding my legislation.
        Thank you.

    Prepared Statement of Hon. Solomon Ortiz, a Representative in Congress
                            from the State of Texas
        Mr. Chairman, thank you for this opportunity to speak on behalf of
    south Texas veterans and help this Subcommittee understand the urgent
    need for a veterans' hospital for the men and women who fought for us.
        Here with me today are members of the Veterans Alliance of the Rio
    Grande Valley--so you can see the faces of the south Texans affected by
    the lack of a hospital . . . the Rio Grande Valley is the southernmost
    tip of my district.
        Here with me are: Jose Maria Vasquez, Ruben Cordoba, and Max
    Balamaris, Polo Uresti, Frank Albiar, and Mr. Felix Rodriguez.
        My legislation gives the government flexibility in establishing a
    way to deal with hospital services in south Texas . . . but the only
    real solution for the area is a hospital.
        Bottom line: veterans' inpatient healthcare must be available where
    the veterans live, not several hours away.
        These guys have fought, bled and sacrificed for this Nation--they
    need something that belongs to them . . . a hospital that get's them
    the care they need where they live--not 5 hours away.
        We know the VA plays the numbers game--but the numbers do not
    reflect the need . . . particularly in the Rio Grande Valley.
        When the VA commissioned their CARES study they recognized the far
    south Texas area was in need of acute inpatient care.
        They decided to meet this demand through contracting or leasing
    beds in local communities, an approach simply not working.
        Veterans are still traveling in large numbers to Audie Murphy in
    San Antonio for care, and for many who are treated for emergencies at
    area hospitals, the bills go unpaid by VA.
        Many veterans are so disgusted by the level of VA health services,
    they simply do not sign up for VA healthcare.
        You have heard me describe the conditions of south Texas vets;
    today I want to show you experiences of veterans themselves . . .
    veterans who shed blood for our Nation . . . veterans whose healthcare
    is utterly inferior.
        South Texas veterans regularly travel 5 hours there and back to a
    15 minute appointment that took months to get.
        Sometimes they need to stay overnight in San Antonio . . .
    sometimes, veterans find after the strenuous trip, their appointment
    has been canceled.
        We've scrubbed the names to prevent any retaliation for truth
    telling. . . . And my time will run out before I'm done, but I want you
    to hear the stories I hear. . . .
        A 21-year-old Iraq war veteran came home badly wounded in his
    spine.
        He's now at Audie Murphy in San Antonio.
        He was being moved by hospital staff from the bed to a wheelchair--
    but they moved too quickly and damaged his spine even more.
        He has a lifetime of going back and forth to San Antonio for
    treatment . . . and his family has a lifetime of committing to take him
    there regularly.

                                   __________
        One veteran underwent emergency heart surgery; his wife called the
    local clinic and she was directed to call 911; he was admitted for the
    emergency surgery locally.
        His benefits coordinator told him to follow up with a local
    cardiologist to chart his progress since there wasn't a cardiologist at
    the clinic.
        He did, but VA did not pay and on the 3rd visit, the cardiologist's
    office told him to pay upfront for all services.
        The VA clinic then told him he should have gone to a cardiologist
    in San Antonio.
        By now, his sutures were infected and leaking.
        Eventually, he got an appointment to see a VA cardiologist 5 weeks
    later.
        The stress from all this prompted his psychiatrist to increase the
    dosage on his meds.
        When he got to San Antonio, the cardiologist was surprised to learn
    he had surgery.
        He was prescribed more high blood pressure medication.
        That made him faint from low blood pressure, panicking his wife . .
    . she called a home health nurse who suggested stopping all meds and
    going immediately to the hospital.
        He did not want to go to the hospital because they had not been
    paid and he might be refused.
        He was poor--so the nurse recommended that he drink a Coca-Cola
    with crackers, which helped temporarily.
        Due to a faulty medical records system, he was prescribed too much
    medication.
        Since then, he travels to San Antonio to monitor his heart.
        He travels 5 hours, has a 10 minute procedure done, and once was
    told to return in 48 hours.
        He did not qualify for lodging so he returned to the Valley. After
    2 days he returned for a procedure that took under 5 minutes.
        That equals 2 trips to San Antonio in 2 days . . . traveling about
    25 hours . . . to be seen a total of 15 minutes.
                                   __________
        A retired disabled veteran is in the midst of several surgeries to
    correct service injuries, in numerous visits to San Antonio, the
    nearest VA hospital to the Valley.
        When he had shoulder surgery, he spent the night in his car so the
    anesthesia could wear off . . . and he didn't take any pain medication
    so he could make the 4 hour drive back home. . . .
        He had to stop several times along the way to vomit from the pain.
        He also had to sleep once in his car in San Antonio to make an
    early appointment because by the time he arrived in San Antonio all the
    rooms available for veterans had been taken.
                                   __________
        A constituent's brother had a triple bypass done in San Antonio
    Audie Murphy Veterans Hospital in 2005.
        During the course of his recovery at home, he developed
    complications that needed to be monitored closely.
        The VA medical provider told him that he needed to be monitored
    closely; then later that day, he got a call from the VA clinic that he
    needed to go to the nearest hospital taking veterans.
        Once there, he was moved by ambulance to another area hospital,
    where he was admitted after advising the hospital he was a veteran and
    showing his ID card.
        The hospital got the clearance from San Antonio VA and admitted
    him.
        His medical bills there have not been paid because the VA is
    claiming that ``VA facilities were feasibly available to provide the
    care.''
        The VA said his brother could have traveled to San Antonio under
    the dangerous medical problems he was having.
        His brother does not want to ``rock the boat'' because of his heart
    condition and other medical problems.
        In a sense, he is held hostage by our government.

                                   __________
        A family member said this: Congress should also hear about the
    hardship that the vet's family must also endure.
        She has a full-time job but must miss work, taking leave, to take a
    loved one to San Antonio.
        She cannot let him go by himself whenever they do procedures that
    require anesthesia or manipulation of his neck or spine.
        He is usually in so much pain and/or drowsy with medication that he
    cannot drive.
        He has a hard time sitting for long periods, and San Antonio is 5
    hours away.
        They must also make arrangements for the kids if they are not
    getting back before school's out.
        A couple of times he's had to go alone because she couldn't leave
    work or find another driver.
        Then she is so worried about him driving that she cannot function
    at work, going out several times to call to make sure he is OK.
        She also notes the travel pay is woefully insufficient, given gas
    prices.
        They have to fill up twice to get there and back, plus pay for
    meals.
        She notes that hospitalized vets would be better off near friends
    and family to keep them in good spirits.
                                   __________
        A Vietnam vet still being treated for post-traumatic stress
    disorder; has two sons, both active-duty military, who have served
    multiple tours in Iraq.
        After a late-night phone call from a son saying that he'd been hurt
    in an IED explosion, his post-traumatic stress surfaced . . . when he
    called to see the psychiatrist, he was told the soonest appointment was
    in 6 months.

                                   __________
        The district director for the Veterans of Foreign Wars in the
    Valley says VA provides good medical care.
        The doctors and staff do the best they can with what they have.
        The problem is getting into the system to get the care.
        He says, ``We believe we've earned the right to see a doctor where
    we live.''

                                   __________
        Veteran and State Rep. Aaron Pena says what isn't spoken is the
    sense that they are being ignored despite the long history of
    Hispanics' service to the U.S. military.
        We've fought in almost every American war . . . and we're still
    being ignored.

                                   __________
        The disabilities of a Port Isabel veteran who served two tours in
    Vietnam are made worse by a round trip on a crowded van, and an
    overnight stay in a dirty hotel.
        Fourteen months ago he went to a private emergency room, which then
    sent him by ambulance to San Antonio to treat a kidney infection.
        VA still has not paid for the emergency visit--ironically today,
    April 26, is his deadline to pay the local hospital $10,000 since VA
    won't pay.

                                   __________
        An Iraq veteran is haunted by some of the terrible things he saw in
    combat leading to depression and thoughts of suicide.
        His friend got him to go to the VA office . . . where he was
    referred to the VA hospital in Waco for evaluation for post-traumatic
    stress.
        He was told he needed to begin regular sessions, and he'd get an
    appointment in the mail.
        Three weeks later, he got a letter from VA that he could see the
    doctor in 8 months.
                                   __________
        Another veteran notes: ``It's hard to hold a job when you have to
    miss work four or five times a month to travel to San Antonio for
    medical appointments.''

                                   __________
        One veteran has utilized the VA healthcare systems in Reno, Nevada
    and Fargo, North Dakota, and he reports both were very good.
        Conversely, his experience with the clinics in Harlingen and
    McAllen are ``ongoing nightmares.''
        Lately he's been trying to get an appointment with the psychiatrist
    in Harlingen.
        Every time he calls, he's put on hold and eventually hangs up after
    waiting and waiting.
        He was not alone among veterans who suspect some manner of
    ``Federal racism'' when our Nation is only anxious to send border
    patrol agents, but no hospital to treat military veterans who live
    here.

                                   __________
        A daughter who misses her dad says her father served in the U.S.
    Army and came home needing psychological care catered to what a veteran
    experiences--and taking into consideration the stigma a Hispanic man
    feels with depression.
        She lost her father to suicide and wishes that care was available.

                                   __________
        Another veteran learned the VA now accepted that Agent Orange could
    have affected sailors in the Tonkin Gulf.
        The VA did not respond to him since he was not a ``wounded
    veteran.''
        He also has diabetes for which they will not treat him.
        He believes they want to wait until he cannot care for himself at
    all rather than helping him prevent the devastation of diabetes while
    he can.

                                   __________
        A former military wife said her ex-husband and daughter now live in
    San Antonio and her son has plans of retiring there too--merely to be
    closer to military medical facilities.
        Veterans are forced to choose between living near home and family,
    or living near healthcare.
                                   __________
        Another veteran notes many soldiers from the Valley can not afford
    the trip, much less the expense it takes to visit these facilities.
        He notes many veterans have died never getting the medical
    attention they needed.
        He calls the VA health system in south Texas a ``disastrous
    situation.''

                                   __________
        A former sergeant says: The cruel irony of extra stress on various
    disabilities caused by traveling 5 hours to a VA hospital makes
    conditions even worse.
        And like several others I heard from, he issued an invitation for
    any of my colleagues here today to join them on the 5 hour ride to San
    Antonio in the van.

                                   __________
        A retired major notes local access would promote early diagnosis
    and early cure for ailments that would otherwise generate higher
    treatment costs if left untreated.
        He also has the novel suggestion of using hospital ships as a
    veteran's hospital.

                                   __________
        A retired Air Force sergeant--who is covered by TRICARE benefits--
    knows he is lucky to have access to local medical facilities.
        Always a soldier, he volunteered to drive the van to San Antonio.
        He would drive from Raymondville to Brownsville to pick up veterans
    at 6 a.m. then to San Benito then Harlingen and then back to
    Raymondville, where the actual trip to San Antonio commenced.
        He reiterated what many people said: It's not a straight 5\1/2\
    hour trip since they had to stop various times for restroom breaks.
        And he was prohibited from helping the vets in and out of the van
    out of liability concerns.
        Most veterans he drove had to wait hours to be seen for just a 15
    minute visit, then they began the long trek back.

                                   __________
        The widow of a Vietnam-era vet said he died 9 years ago of a heart
    attack and almost certainly from a lung problem associated with his
    exposure to Agent Orange.
        He never pursued a diagnosis because the San Antonio facility was
    too far and he was not able to make the trip.
        The one time he did for hearing loss from a mortar concussion while
    in Vietnam, he found that the number of people they were trying to
    serve was too great for quality care.
        He never went back again.
                                   __________
        A captain with the 1st Cavalry in Iraq was wounded in 2003 by an
    IED that ruptured both ear drums and left his right side littered with
    pieces of shrapnel, many still remain.
        He plans to retire in the next 4 years.
        He said he's gotten good treatment while on active duty, but
    worries about the time when he retires, with no local VA hospital in
    the area.
        He talks regularly with local veterans that can not afford to make
    the drive to San Antonio because they can't afford the gas or can't
    drive or have no one to take them.
                                   __________

        Another veteran echoes many voices in saying south Texas veterans
    should be treated by local medical resources.
        He lives in Corpus Christi, but worries about what the cost of
    transportation does to an aging veteran's population with higher
    poverty rates in the Rio Grande Valley.
        Extended trips place unnecessary physical stress on veterans, it
    places a financial burden on Valley veterans and their families as
    well.
        He sustained a head injury, which resulted in a visible dent in the
    skull.
        After headaches and memory issues, the VA physician sent him to
    Audie Murphy for a CT scan; and he had no option but to drive the 300
    mile round trip to the VA facility.
        That trip not only put him at risk, but the safety of other drivers
    as well.

                                   __________

        Another veteran invites all of us to come experience the long and
    painful ride from south Texas to San Antonio to visit a doctor.

                                   __________

        A south Texan speaks on behalf of friends married to veterans; she
    is incensed that for healthcare they must be inconvenienced financially
    (gas, food, overnight stays for vets and families) and time-wise, which
    interferes with their jobs.

                                   __________

        The brother of a constituent is medically retired from the Air
    Force and must travel to San Antonio every month for his medical
    treatments.
        It takes a day out of his life and requires a long ride back and
    forth.

                                   __________

        Another retired veteran chooses the expense of private care over
    the time it takes waiting at the local clinic or taking the time to
    travel to San Antonio.

                                   __________

        Another veteran also speaks to the trouble and time consuming
    nature of going so far for procedures.
        He knows that by the time you arrive your problems just seem to
    increase.

                                   __________

        A Corpus Christi veteran laid out the context of getting treatment
    in San Antonio: She said it is a 12 hour ordeal to get to San Antonio,
    get tended to at Audie Murphy, and return home.
        It costs two tanks of gas and a whole day of work. The $26.00 for
    travel does not cover nearly the cost.
                                   __________

        Placido Salazar, State Veterans' Affairs Officer of The American GI
    Forum of Texas, tells me that some veterans from the Valley were
    recently in San Antonio for 3 days of appointments; they told him that
    a manager at the associated hotel would not release a room to them
    until 6:00 p.m., (using very abusive language); with one of the
    veterans not getting a meal in more than 24 hours.

    [PETITIONS SUBMITTED BY REPRESENTATIVE ORTIZ ARE BEING RETAINED IN THE
    PERMANENT COMMITTEE HEARING FILES AND ARE NOT BEING PRINTED.]

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                  ----------

              ADDENDA--LETTERS AND STORIES OF SOUTH TEXAS VETERANS
        Last week, some veterans from the Valley that were in San Antonio
    for 3 days of appointments at Audie Murphy called me to inform me that
    one of the managers at the Oak Hill Hotel on Wurzbach Road had given
    them a hard time, in not releasing a room to them until 6:00 p.m.,
    (using very abusive language) with one of the veterans not getting a
    meal in more than 24 hours.
        THAT is totally unacceptable, but I believe we got the situation
    corrected. If anybody else should have trouble at that hotel or any
    other type of problem, I will be glad to try to assist. Just call me,
    any day--any time (210) 658-9756.

                                                        Placido Salazar
    State Veterans' Affairs Officer of The American GI Forum of Texas (2
                                                           10) 658-9756
                                   __________
        My father served in the U.S. Army and came home to marry the girl
    next door, raise a family consisting of four kids, but never truly felt
    at peace because he suffered from what he was exposed to while he was
    in the Army.
        He needed psychological care catered to what a veteran experiences
    taking into consideration the stigma a Hispanic man must deal with for
    feeling depressed.
        He ended up committing suicide years later leaving us all behind to
    miss him dearly. Please build a complete veterans hospital in the
    Valley, our veterans deserve and need it.

                Thank you,
                                                 Army Veterans Daughter
                                   __________
        I am a veteran here in south Texas and would be willing to go to
    Washington next week, in order to prepare the Congressman for his
    testimony.
        I live on a fixed income but will drive if I have to be there.
        I am sure I can get at least two other vets from here to go with
    me. Please call me ASAP to speak of this.

                Thanks,
                                                                  Lydia
                                   __________
    Congressman Ortiz,

        It is with great pleasure and honor that I congratulate you for
    your efforts to bring a veterans hospital to south Texas. While south
    Texas is one of the homes of many heroes who have given their lives in
    foreign wars for the sake of freedom in America, south Texas remains
    one of the poorest areas in the Nation where veterans have difficulties
    finding jobs and medical care. As a Navy veteran of the Vietnam War, I
    served on a destroyer for several months in the Tonkin Gulf and also on
    an expedition to the Sea of Japan during the USS Pueblo incident where
    the North Koreans boarded one of our ships and took our men prisoners.
        At some point in my life I became diabetic while no one in my
    immediate family (father, mother, or grandparents), were diabetic. For
    10 years I have addressed diabetes on my own. One day a Vietnam vet
    friend told me that I could have been affected by Agent Orange even
    though I was aboard a destroyer and that the VA was now accepting that
    Agent Orange could have affected sailors in the Tonkin Gulf. I reported
    to the VA clinic in Corpus Christi and basically they did not respond
    to my request for nothing more than diabetic medication which is
    extremely expensive.
        I am one of those individuals that will address health issues with
    or without VA assistance. However, my DD 214 clearly states that I
    served in the Tonkin Gulf and shows my veterans status, but somehow no
    one seemed to know what I was talking about when I visited the VA
    clinic in Corpus Christi. They told me they needed more documentation
    and that I was not a wounded veteran. Nevertheless, I was not looking
    for any kind of monetary compensation, but rather for help with
    medication for my diabetes only.
        The thought occurred to me that one day I will probably need
    assistance from the VA hospital in San Antonio, but will not get it
    because I am not a wounded veteran, but have been afflicted with
    diabetes that may have occurred in the Tonkin Gulf. The VA made
    available benefits for veterans of the Tonkin Gulf, but no one at the
    VA clinic seems to know that.
        While I have assisted many veterans by taking them for medical
    service at Audie Murphy, many were not wounded veterans. I suppose that
    they want to wait until I am unable to care for myself entirely to
    provide service, if any, instead of helping me now prevent the
    devastation of diabetes while I can. I have seen many veterans struggle
    with transportation to San Antonio for service and as you well know I
    provided services for many senior citizens from Kleberg for many years
    that needed to go to Audie Murphy. Now I am one of them and a veteran
    who volunteered during the Vietnam War.
        I know that many vets struggle getting to San Antonio from the
    coastal bend to receive services. A hospital closer to us would be
    appreciated by all veterans and in fact every region across America
    should have one more so we need to spend money on expanding economic
    efforts rather than basically serving special interests like oil and
    uranium mining. I for one am disappointed with the reception I received
    at the Corpus Christi VA and surely I am not going to beg for their
    attention to my need and get kicked in the face every time I ask.
        Hopefully, you will be successful in your bid for a VA hospital for
    veterans that is long overdue and maybe a revamping of existing VA
    clinics and services so that vets like myself who need assistance are
    not turned down because someone there does not understand what being
    aboard a destroyer in the Tonkin Gulf means.
        I remain your friend and supporter of many years,

                                   Ben Figueroa, BA, MA, LCDC, CPS, CPM

                                   __________
    Dear Congressman Ortiz,

        Thank you so very much in you support of our veterans and their
    welfare. Though I am not a veteran, my daughter, son and ex-husband are
    veterans along with other family members.
        I feel that a veteran's hospital is greatly needed in the Valley.
    My ex-husband along with my daughter are now living in San Antonio and
    my son has plans of retiring there too. Why? You guessed it. . . .
    Military medical facilities.
        My ex-husband was diagnosed with cancer along with other Vietnam
    medical issues and has had to leave his immediate family and move to
    San Antonio in order to be closer to medical assistance.
        Thank you so much, again, for taking on this task. My prayers are
    with you.

                Sincerely,
                                                        Beatrice Weaver
                                   __________
    To whom it may concern:

        My name is Jim Hodges, Jr., a Vietnam veteran from Brownsville,
    Texas. I am the proud Past-Commander of America's Last Patrol Inc.,
    Post 2. I am also the son and nephew of a couple WWII veterans. I am
    also involved in trying to get a veterans hospital in the Rio Grande
    Valley.
        My relatives served in WWII, Korea, Vietnam and every conflict our
    wonderful country has ever been involved in. They have had and have an
    extremely hard time getting the medical attention that they earned.
    Many of my relatives and friends can not go to the VA hospitals in
    Houston, San Antonio and/or Fort Bliss. Most of these soldiers are
    ``POOR'' and can not afford the trip much less the expense it takes to
    visit these facilities.
        Many have past away never getting the medical attention they
    needed. I am blessed that I can go to the VA here in the Houston area
    where I live. BUT, there are many in this area who can not.
        That is why there is a ``shuttle'' to help those veterans who can
    not afford it and/or are not able to drive. How can we expect our
    veterans to make that 300 to 500 mile trip to a veterans hospital?
    Thank you for your help and attention to this ``disastrous situation.''

                In service to our country,
                                                    Mr. Jim Hodges, Jr.
                                                           832-228-2758
                                   __________
    To whom it may concern!

        My problem with VA healthcare is the extra stress on our
    disabilities caused by traveling 5 hours to a VA hospital. That is one
    way only. Also, 24/7 medical care that is needed by service-connected
    veterans. Let the Veterans' Affairs Committee come to the Rio Grande
    Valley and travel to VA on a van?

                                                     Sgt. James Krummel
                                   __________
                                                         April 21, 2007

    Congressman Solomon Ortiz
    3649 Leopard Street
    Corpus Christi, Texas 7841

    Subject: VA Hospital in South Texas

    Dear Congressman Ortiz:

        It is most encouraging to hear of your fight to provide the
    veterans of south Texas with a VA hospital. Please allow me to offer
    some suggestions that may help. Among the most salient reasons for
    locating such a facility in this area are the following points:

        1.  Local access would enhance participation by some veterans who
    are discouraged by the travel distance to out-of-town VA facilities.
    This in turn would promote early diagnosis and early cure for ailments
    that would otherwise generate higher treatment costs if left untreated.
    Equally, it would also benefit those who are too seriously ill to
    tolerate the commuting stress. All of this would lead to more efficient
    expenditure of VA healthcare dollars.
        2.  With the Port of Corpus Christi's expanded terminal now able to
    handle large volume military hardware shipping, it lends itself to
    accept hospital ships that have become a major factor in saving
    military lives. At a time when America's freedoms are challenged in all
    parts of the globe, the ability to have a hospital facility that could
    accept large numbers of military patients from a waterborne hospital
    vehicle, would be strategically and economically prudent. It makes
    little sense to dock such a vehicle in outer ports and then air-
    transport the patients to inland hospitals. Corpus Christi could
    service all of that need in one location, and could easily provide
    contingency plans for expansion in national emergencies. Also, the
    government could save by incorporating the ancillary services such as
    lab, X-ray, and pharmacy, in a location that could handle both active
    and retired military personnel. This would provide economy of scale in
    areas of high cost medical technology, which is a primary reason for
    escalating health costs.
        3.  A large VA hospital facility would help mend the region's
    physician shortage. Logically, some VA physicians serving the region
    would elect to remain here in private practice. This would provide
    relief in Medicare services, such as rheumatology (among other
    specialties), that are heavily skewed to a narrow panel of physicians
    who accept and treat Medicare patients in this region. Again, this
    would deliver Medicare budget economies by early diagnosis and
    treatment.

        The above three points are only a sample of the issues that stress
    a need for a VA hospital in this region. I truly hope you are
    successful in your effort. If I can be of further assistance, please do
    not hesitate to call upon me. I can be reached at 361-993-6905.

                With best personal regards,
                                                         John D. Falcon
                                                      Major, USA (Ret.)
                                   __________
    Dear Congressman Ortiz,

        I myself a veteran retired of 20 years serving in the U.S. Air
    Force do not need to travel the long distance being I have TRICARE
    benefits to visit local medical facilities. I was a volunteer driver
    for 8 months and at one time I drove twice a week for 2 months being
    there wasn't other drivers. The trip was to leave on Sunday and return
    on Monday. The other to leave on Wednesday and return on Thursday.
        I would drive from Raymondville to Brownsville, Texas to pick up
    veterans early in the morning, 6 a.m., to return to San Benito then
    Harlingen and then back to Raymondville. After picking up the remaining
    vets at Raymondville we started the longer trip to the VA hospital in
    San Antonio, TX.
        The trip was not a straight 5\1/2\ hours, we had to stop various
    times due to some of the vets needing to use the restrooms due to
    medical problems such as prostate illnesses and others needing to
    stretch out, as you know or can visualize a WWII veteran sitting on
    such a long trip and of course also climbing on and off a 15 passenger
    van. We as driver were not, repeat not, able to help him on or off the
    van due to liability. The veterans had to be ambulatory.
        Upon arrival, the veterans would be dropped off at the entrance and
    from then on they were on their own, able to walk on their own or not
    he or she needed to walk to report to their appointment for the same
    day or the next. Most of the veterans had to wait hours to be seen for
    just a 15 minute visit and be released for the rest of the day and wait
    to return on the 5\1/2\ hour trip.
        Before departing back to the Valley, Raymondville, Harlingen, San
    Benito and Brownsville, the veterans needed to be located from wherever
    their appointment was at, which wasn't very simple due to the other
    ``many'' veterans who had similar appointments.

                Yours truly,
                                            Tsgt. Rafel M. Cisneros III
                                                U.S. Air Force, Retired
                                   __________
        My name is CPT Martin Albert Longoria and I am currently serving
    with the 1st Cavalry Division which is in Iraq.
        I was wounded in November 2003 by an IED that ruptured both of my
    ear drums and left the right side of my body littered with pieces of
    shrapnel that are affecting me today. I have pieces that are in my
    hands which I am having trouble with as we speak to include my calf and
    thigh.
        The pieces that were left in me for the last 3 years are working
    their way out and some have already been removed. In the next 4 years I
    plan on retiring, but I will still have pieces of shrapnel that will
    eventually work their way out too. While being on active duty I have
    received good treatment. When a piece of shrapnel needs to be removed
    it is.
        However, the day will come when I retire and having a local VA
    hospital in the area would make a difference to those that are not as
    financially stable as others. I have talked with local veterans that
    can not afford to make the drive to San Antonio because they can't
    afford the gas and can't drive for some health reason or have no one to
    take them.
        We as local veterans have served our country when called upon to
    PROTECT IT and DEFEND IT no matter what and some have died doing it. I
    have served with many local soldiers from the south Texas area in war
    and peace, but who is going to take care of this generation of
    veterans. We as a country seem to make the same mistakes from past
    conflicts in not providing adequate healthcare for our past veterans.
        When its budget time you will not hesitate to give yourself a
    raise, but when it comes to us the veteran it seems we are put on the
    back burner for political jargon. I hope what I have expressed helps
    with this cause that is taking place and I hope it helps the veterans
    that have served as proudly as I have. Please remember this when you
    are sitting at home or in your office. We have served being away from
    loved ones and doing what is asked of us.

                                   __________
        Thank you for the opportunity to provide comments on the
    availability of veterans' healthcare in south Texas. It is common
    knowledge to everyone in the region that south Texas veterans' are
    underserved as far as veterans' healthcare is concerned.
        The problem didn't occur overnight and has been a gradual process.
    No blame is being assessed. The time has come, however, to rectify the
    problem for both current and future veterans.
        The south Texas veteran population is spread over a large area with
    many veterans living in rural environments. Many south Texas counties
    have no significant metro type area and consequently are limited in any
    medical resources, much less those for the veteran populations.
        This particular concern could be addressed in Congressman Ortiz's
    bill which in part provides south Texas veterans be treated by local
    medical resources. That would insure that every veteran would have
    access to appropriate medical care in a timely manner. Often, it can
    take months for a veteran to get scheduled for what would otherwise be
    a routine medical visit. That needs to be changed.
        The Veterans' Health Administration (VHA) is well known for its
    quality care especially preventive medicine. In some cases veterans
    have to go to extraordinary lengths to receive the preventative care.
    First hand experience may illustrate some of these inequities.
        This veteran suffers from Chronic Obstructive Pulmonary Disease
    (COPD). It's a progressive lung disease with no known cure. Competent
    medical practices contend a COPD patient take a pulmonary function test
    (PFT) twice a year or at a minimum of once a year. A complete PFT takes
    around 45 minutes.
        COPD is typically diagnosed in patients at around middle age
    thereby suggesting that the COPD population is older than the rest of
    the veteran population. The pulmonary function lab at Audie L. Murphy
    Memorial Veterans Hospital in San Antonio, Texas is the only PFT
    resource available to south Texas veterans enrolled in the VHA system.
    There are, however, facilities in Corpus Christi as well as in the Rio
    Grande Valley where the test can be taken.
        The round trip for this writer is about 300 miles or maybe a bit
    more than 5 hours driving time. Therefore, it takes nearly 6 hours to
    get the test. Of those 6 hours, more than 5 are driving time. For older
    patients that becomes a real issue.
        For veterans in the Rio Grande Valley, the distance and drive time
    is slightly more than doubled. That would mean a veteran and probably a
    veteran getting up in years would be required to drive 10 or 11 hours
    for a 45-minute test. That is problematic and raises a legitimate issue
    about the burden and travel stresses on an older veteran with a
    disease, which will probably end his or her life.
        Another issue is the cost of transportation be it by private
    accommodation or some commercial means. The Valley has an aging
    veterans population according to the last census data. It also has
    higher poverty rates. In addition to an extended trip placing
    unnecessary physical stresses on veterans, it places a financial burden
    on Valley veterans and their families as well. That needs to be
    remedied.
        There are other routine procedures, which necessitate a trip to
    Audie Murphy. This veteran had sustained a head injury, which resulted
    in a visible dent in the skull. After discussing ongoing headaches and
    memory issues, the VA physician said a skull series or CT scan was
    necessary.
        That routine procedure necessitated a trip to Audie Murphy. The
    veteran had no option but to drive the 300 mile round trip to the VA
    facility. The safety of that endeavor is questionable at best. Not only
    was the veteran put at risk, but the safety of other drivers as well.
        There was about a 10-minute wait for the X-ray procedure and the
    scan itself took 6 or 7 minutes. A cup of coffee left in the car was
    still hot for the return drive home. Out of 5 hours and 15 minutes for
    the CT scan, 5 hours was driving. The same imaging could have been done
    locally or in the Valley.
        It was later learned that the injury triggered two strokes as well
    as a bifrontal hygroma. The hygroma is dead brain tissue that has
    filled with fluid. The wisdom of having a patient make that kind of
    drive is indeed questionable. Consider the patient, made maybe more
    frail making that trip from Brownsville, Texas. An argument could be
    made that such a trip would simply be reckless.
        One other trip to Audie Murphy is especially haunting. This veteran
    needed to go to the cardiac lab in San Antonio for a thallium stress
    test. That's a routine procedure for evaluation of the heart. The
    procedure was scheduled for morning.
        In order to make the appointment, it was necessary to leave Corpus
    Christi before daylight. It was soon learned that the veteran's night
    vision had deteriorated to the point of making the trip dangerous. That
    is now a new concern for Valley veterans. The thallium stress test is
    available nearly everywhere and in most communities with a hospital.
        The test itself is a simple procedure with an 8-minute protocol on
    a treadmill. At the end of the treadmill a nuclear dye is injected.
    Next, the patient waits for a period of time measured in hours for the
    dye to circulate. Then multiple images of the heart are taken.
        While waiting for the imaging in the lobby of Audie Murphy, an
    elderly man was encountered. We visited for a while. He said that he
    caught a ride in a VA van in Cameron County, Texas. He continued that
    he got on the van way before daybreak for the ride to San Antonio.
        Although the purpose of his visit is not recalled, he said only 15
    to 20 minutes of his time was needed at the hospital. Then he had to
    wait hours until 3:00 p.m. to catch the van back to Cameron County. He
    said it would probably be dark when he got back.
        He was clearly tired. He had family in Corpus Christi. We talked
    about his staying with them and then going back to Cameron County the
    day after. We called his family who thought that it was a great idea.
    He rode to Corpus Christi with this veteran.
        Ever since, there has been a concern about other Valley residents
    who have had to endure the same travel stresses. That man should have
    never been put into that position. Whatever services he needed should
    have been obtainable in or near Cameron County.
        While having to make a trip to Audie L. Murphy may be an
    inconvenience to this veteran, to Valley veterans it is a more serious
    matter. First the trip is onerous, especially on the older or frailer
    veterans. Secondly, the cost of the trip in some cases could
    conceivably cause veterans to avoid necessary medical care, simply
    because they couldn't afford the transportation.
        The current delivery of veterans' health is inadequate and in many
    cases not being made reasonably available. A case for making what would
    be customarily considered outpatient services available through
    existing private sector resources should be relatively easy to see and
    make. A veteran should be able to get procedures as those discussed
    above near his or her home town.
        A matter not clear in the bill is that of emergency room care. An
    uninsured visit to an emergency room can be financially catastrophic.
    Today, if a veteran calls facilities as the Corpus Christi Outpatient
    Clinic or even Audie L. Murphy Memorial Veterans' Hospital, the caller
    will hear a recording to the effect that if the call is an emergency,
    call 911.
        Any such medical care is at the veteran's expense. On the other
    hand, should there be a VHA hospital nearby or an ER that contracts
    with the VHA, the veteran is covered. Acute medical care should be
    available to any veteran wherever they are situated.
        Within the last several years, a sibling sustained a head injury in
    a fall. Although the sibling died after a few days, the emergency room
    and intensive care bill was around $70,000. Such could be devastating
    to a veteran's survivors.
        With or without a new hospital many of the routine medical services
    such as stress tests, pulmonary function tests and numerous
    radiological procedures can be done competently, cost effectively, and
    with fewer burdens on the veteran.
        As far as inpatient care is concerned, this veteran would prefer to
    get to a real veterans' hospital if able. It would make no difference
    if the facility were located in either the Valley or San Antonio. If it
    were an acute matter, the preference would be the first facility
    contracted with VHA if a VHA facility were not nearby.
        The ability to provide routine medical procedures as well as acute
    or emergency room care should be available in nearly every community in
    south Texas. That would necessarily contemplate the public-private
    component of the bill or some combination of the other provisions.
        Your consideration of these remarks is appreciated.

                                                      Claude V. D'Unger
                                   __________
    To whom it may concern:

        I'm a decorated veteran who served two tours in Vietnam, 1967
    through 1969. I'm a 100% permanent disabled veteran. The 5-hour trips I
    have to make to San Antonio for any special needs the clinics can't
    perform is making my disabilities worse. The round trip is made on a
    crowded van, and the overnight stay in a dirty hotel is a hardship. I'm
    too sick to drive myself. If you are in a wheelchair you can't ride the
    vans. I'm saddened to see the old WWII veteran of 90 years old suffer
    this way as well. I went to an emergency room at a private hospital 14
    months ago and then was sent up by ambulance to the Audie Murphy
    veterans hospital in San Antonio Texas for a kidney infection. To this
    day I'm still waiting for so-called due process. I've talked to three
    different people in fee-basis with the most recent being the
    supervisor. They all told me it would be 45 days with the last contact
    on April 3rd. Well guess what, nothing yet. I'm currently being
    threatened and I have until April 26, 2007 before bill collectors are
    given the job to collect $10,000 from me, for what I shouldn't have to
    be concerned about. My credit is at risk because fee-basis is
    backlogged, so they keep saying. This is a big mess with a lot of
    stress. I truly have lost faith in this VA nightmare. Give the veterans
    what they deserve or tear down this VA system and close the doors and
    let us use our cards like (Medicare) and pick and choose our own
    doctors and hospitals. I'm not too proud being a veteran because
    there's too much disgrace and shortcomings from a broken-down system.
    Another disgruntled veteran? Maybe so but it shouldn't be this way.
    This substandard treatment for veterans in the Rio Grande Valley is
    unacceptable as it is anywhere in the U.S.A. Please let our voice be
    heard, we the people. Veterans don't want our new veterans to endure
    these shortcomings. Do what's right--PROVIDE FOR ALL WHO DESERVE.

                                                            Dan Kerkow,
                                                      Port Isabel Texas
                                   __________
    Honorable Sir:

        I do not know if you have heard from any of the family members of
    the disabled veterans from the Rio Grande Valley that require travel to
    San Antonio for appointments, but I believe that Congress should also
    hear about the hardship that the vet's family must also endure. I have
    a full-time job at one of the area hospitals. When my fiancee needs to
    go to San Antonio for certain procedures, I have to take time off from
    work to accompany him. It causes me to lose work time, and the only way
    I can make up that money is to use my vacation days. I cannot let him
    go by himself whenever they do procedures that require anesthesia or
    manipulation of his neck or spine. He is usually in so much pain and/or
    drowsy with medication that he cannot drive. He has a hard time sitting
    for long periods, and San Antonio is 4 hours away, and sometimes longer
    when we have to stop so that he can stretch to relieve the pain. A
    couple of times he has had to go on his own because I cannot take off
    from work and we cannot find anyone else to go with him. He has had to
    lie to the staff that he has a driver. Then I am so worried about him
    driving that I cannot even function at work, and am having to go out
    several times to call him to make sure he is OK. We also have to make
    arrangements for our kids if we are not getting back before they get
    home from school. We have had to go to San Antonio just to get a result
    of an X-ray or CT scan. This requires at least 8 hours of driving for
    an appointment that lasts 10 minutes. Where is the justice in that?
        I know several veterans that have to go to San Antonio for
    treatments or procedures; some do not have family members that can
    drive them to San Antonio or reliable vehicles or they are taking care
    of small children at home. What are they supposed to do? The van that
    is supposed to be available to these vets is not really available; it
    only runs on certain days and with limited space and with no handicap
    accommodations. Sometimes some procedures have to be scheduled for the
    weekend; like my fiancee's MRI that's scheduled for a Sunday; he also
    has another appointment scheduled for Monday for a spinal procedure. I
    cannot even make that appointment with him because I cannot take the
    time off. This means we have to call around and see who can go with
    him. What happens to those vets that have no one to take them and no
    bus available? Rescheduling appointments can take up to 6 months or
    more.
        I have heard several horror stories from these vets and I think it
    is a shame that our vets are having to sleep in their cars overnight
    because there is no room available at the designated hotel and they
    have to be there for an early morning appointment. And travel pay?? You
    have got to be kidding; with gas prices the way they are, we barely get
    enough for one tank full of gas. We have to fill up twice to get there
    and back, plus pay for meals. How about when these vets are
    hospitalized up there? Isn't it better for them to be near friends and
    family that can visit and keep him/her in good spirits? Isn't this
    supposed to be better for them, rather than being all alone away from
    everyone?
        The Valley has several thousand vets already and will have more
    when these young men and women return home from our current conflicts.
    Are they going to have to suffer the same hardships?
        Congress needs to stop turning a deaf ear and a blind eye to our
    situation in the Rio Grande Valley. Our veterans have willingly given
    their service to the United States. It is time to return that service.
    How can Congress appropriate money for every other cause except this
    one, when it means taking care of our own? These men and women deserve
    better; we all owe it to them.

                Sincerely,
                                                         Anabeth Molina
                                   __________
        I am a strong supporter of establishing a veterans hospital in
    south Texas as soon as possible. Veterans who have to visit a hospital
    have to travel all the way to San Antonio, TX to take care of their
    medical needs. I venture to say that the majority of the personnel
    voting against this issue have never been in the military. I will ask
    these opponents of the medical facility in south Texas to please take a
    trip all the way from south Texas to San Antonio to visit a doctor.
        But take this trip when he/she/they are in pain or sit in a
    wheelchair for the trip and see how they like it. I dare any one of
    those opponents to try taking this trip! If he/she/they decide to do so
    please let me know so I can get the news media to cover this trip. You
    may quote me on any or all of the above statements.
                                                          Lino Trevino,
                                                       305 Beverly Dr.,
                                                      Schertz, TX 78154
                                   __________
        I HAVE SEVERAL CLOSE FRIENDS WHO'S HUSBANDS ARE VETERANS AND THEY
    TELL ME, AND I CAN ALSO SEE, WHAT THEY HAVE TO GO THROUGH EVERY TIME
    THEY HAVE TO LEAVE FOR SAN ANTONIO. IT IS SUCH AN INCONVENIENCE FOR
    THEM AND THEIR FAMILY, PLUS THE COST FOR THEM AS WELL, SINCE THE COST
    OF GAS HAS GONE UP AND THEN THE COST OF A HOTEL IF THEY HAVE TO STAY
    PLUS FOOD ETC. . . .
        COULD WE NOT USE THE HOSPITAL AT THE CORPUS CHRISTI ARMY DEPOT ON
    BASE, BUILD IT UP AND MAKE IT BIGGER, HIRE THE DOCTORS AND NURSES
    NEEDED TO MAKE LIFE A LITTLE EASIER FOR ALL OUR DESERVING VETERANS.
        I AM DEFINITELY FOR A VETERAN'S HOSPITAL IN THE SOUTH TEXAS AREA.
                YOURS TRULY,
                                                         OLGA RODRIGUEZ

        Olga V. Rodriguez, CCISD Office of Food Services, 4922 Westway,
    Corpus Christi, TX 78408, (361) 844-0222, Fax: (361) 844-0226.

                                   __________
    The Honorable Congressman Ortiz,

        My husband is a Vietnam War veteran and my father is a World War II
    veteran. Both had injuries due to the war and both have to make trips
    to San Antonio at the Audie Murphy Hospital. My father is in his mid
    80's and it is getting harder and harder for him to make trips to San
    Antonio. My husband also has had problems getting to San Antonio. . . .
    I feel they both served their country and gave their all while doing so
    and they need to have you be their voice to tell Congress that there is
    a great need here in south Texas to have a veteran's hospital. Thank
    you for what you are trying to do for our loved ones that have served
    their country because they believe in our traditions and also served
    with honor.
        Many blessings to you.

                Sincerely,
                                                       Elizabeth Jasso,
                                              Food Service Coordinator,
                                                     Corpus Christi ISD
                                   __________
    Dear Congressman Solomon P. Ortiz:
        I have a brother who is medically retired from the U.S. Air Force.
    He must travel to San Antonio every month for his medical treatments.
    It takes a day out of his life and requires a long ride back and forth.
    I am also a retired veteran but choose to see my own doctors rather
    than spend a long time waiting at the local clinic or taking the time
    to travel to San Antonio. It would be a blessing to many of us veterans
    if we had a hospital here in Corpus Christi or nearby.
        I would like for you to know that I am a registered Republican but
    I started voting for you when you ran and was elected sheriff of Nueces
    County. You may remember I was an active member of Associated Clubs of
    Texas (ACT). I have voted for you each time you ran for Congress. I am
    confident that you can get the veterans hospital for us.

                Respectfully,
                                                      Richard D. Hanson
                                   __________
    Dear Sir:

        I appreciate this opportunity to give my opinion on veteran's care
    in south Texas. I have been a part of the VA healthcare systems in
    Reno, Nevada and Fargo, North Dakota. Both Reno and Fargo were very
    good. These were medical hospitals, not clinics. My experience with the
    clinics in both Harlingen and McAllen are ongoing nightmares. Lately I
    have been trying to simply get an appointment with my psychiatrist in
    Harlingen. Every time I call I get put on hold and eventually I hang up
    after waiting and waiting. I finally gave up but I will try again soon.
    This is just one example. I dread trying to do anything with the
    veterans care facilities here. I have tried to figure out why it is
    that an area that seems to have more veterans per capita than any other
    area of the Nation has the poorest healthcare for them. I suspect a
    type of Federal racism. I can't understand what else it might be. The
    employees in both clinics are overworked way beyond the point of
    laughability. The thought that maybe we don't need a VA hospital in
    this area is so ridiculous I feel embarrassed for whoever might be
    thinking this. Many veterans won't use the facilities here. They self-
    diagnose and then pick up meds in Mexico.
        I am Douglas R. Brown. My phone is 956-579-4441. I will reveal any
    other personal information about myself if you need it. I am available
    to talk to anyone.

                                   __________
    Congressman Ortiz:

        We need a Veterans Administration hospital in the Rio Grande Valley
    so that we do not have to travel to San Antonio for acute care. I have
    had a couple of near-death experiences dealing with the bureaucracy of
    the Veterans Administration as it provides healthcare to us veterans.
        I underwent bypass heart surgery under an emergency basis as a
    result of a heart attack. My wife called our local clinic and she was
    directed to call 911 and that if I was service-connected the VA would
    cover. I in fact did have the surgery. I had no problem being admitted,
    but after my release from the hospital everything changed. Upon release
    we provided the VA clinic with the hospital doctors' recommended post
    surgery instructions. I was placed under new medication.
        Unfortunately, the nurse which received those medical instructions
    did not input them into my computer medical records. I was at home
    without medication and had to turn to a private pharmacist to obtain
    them. No one at the VA had requested the new medication. I went to the
    benefits coordinator and told him that I needed to follow up with a
    cardiologist to chart my progress. He told me since there wasn't a
    cardiologist at the clinic that he saw no problem if I followed up with
    the local cardiologist. I did and VA did not pay. I was taking Coumadin
    and had to be monitored weekly.
        After three visits, the cardiologist's office advised me of the
    problem with the VA and requested that I pay up front for all services.
    I called the clinic and was told that the VA says that I should have
    gone to a cardiologist in San Antonio. By this time, my sutures had
    become infected and I was leaking fluids. I went to the clinic and was
    told that they would assign a home health nurse to monitor the sutures.
    She was given very specific instructions and was limited on what she
    could do.
        I then attempted to get an appointment to see a VA cardiologist
    which had been seeing me, but was told at the local VA that they did
    not do that and I should call San Antonio directly. I did and was able
    to get an appointment 5 weeks after my release. By this time I was all
    stressed out and had to see my psychiatrist. He doubled my dosage on my
    medication in order to help me. When I arrived in San Antonio, the
    cardiologist did not know that I had had surgery.
        She was surprised because she thought that I was coming up to San
    Antonio for a heart catheterization. She thought that I had a valve
    problem and was surprised that they had found two arteries that were
    clogged. She was irritated because she did not have my up to date
    medical records. I showed her my sutures and she was visibly irritated
    because they were infected.
        She tried calling the local VA clinic but could not get the line.
    She immediately called the surgeon's office and made arrangements that
    I be seen immediately. She reviewed all my medications and made
    changes. The surgeon cleansed my sutures and told me to return to the
    surgeon that had done my surgery so that he could follow up locally. I
    returned home and continued with problems with my sutures.
        I was also prescribed more high blood pressure medication. I was
    taking so much medication that my blood pressure fell down almost to
    the point that I was fainting. There was no way to reach the VA because
    it happened on a weekend, not even the toll-free nurses number. My wife
    panicked and called the home health nurse which suggested that I quit
    taking the medications and go immediately to the hospital. I did not
    want to go because the hospital had not been paid and I might be
    refused.
        The nurse recommended that I drink a Coca-Cola with crackers, which
    I did. Thank God that the home remedy that the nurse recommended
    worked. On Monday I called San Antonio and told them what had happened
    and they took me off some medication and I was told that I was taking
    too much medication. (The reason for this is the faulty medical records
    system.) I returned to the surgeon that performed the surgery and I
    told him that the VA had sent me back to him.
        His office called the VA and I assumed it had been approved. He saw
    my sutures and was very concerned and wondered what the VA was doing.
    He immediately ordered wound therapy and I was given a 3 times a week
    regimen for about 2 months. Since then, I have had to travel to San
    Antonio to have a halter placed to monitor my heart. I traveled 5
    hours. When I arrived I had the procedure done, which took about two
    (2) minutes. I was told to return in 48 hours. I did not qualify for
    lodging so I returned to the Valley. After 2 days I returned to have it
    removed. Again I traveled 5 hours to get there. The procedure to remove
    it took 45 seconds to a minute. I had to make two (2) trips to San
    Antonio to be seen a total of 2\1/2\ to 3 minutes. Why? Because this
    procedure could not be done at the local clinic?
        On my last visit to my medical provider at the clinic I was
    assigned a new doctor. When I was being triaged, the nurse asked me if
    I had any past surgeries. I told her, hell yes, I just had a bypass,
    isn't it in the records. I told her that I even had to go to San
    Antonio to have a halter to monitor my heart. She wondered out loud as
    to why they had sent me to San Antonio for a procedure that could have
    been done locally. The doctor and I reviewed my medical and I was
    surprised that some of the medication that I had been ordered to stop
    was still on the active list. I told him that I had not refilled those
    prescriptions. He deleted them from my record. I had to update him on
    what had happened since my surgery.
        The hospital and the doctors that did the surgery have not been
    paid and I am getting medical billings from them. The fee service
    people at the VA told me that I could have gone to San Antonio for the
    medical services. They did not have any records in their files
    indicating that a VA doctor had approved the medical. I told him that
    the hospital had called and that they were given the okay or they would
    not have allowed the services. I told him that I had no choice but to
    go to a local hospital because it was an ``emergency.'' And since the
    clinic had not provided post surgery care, I had had to follow up with
    the doctors.
        I am doing fine now. I am gradually recovering from the surgery.
    But while I was suffering with the infection to my surgery and the
    delicacy of the operation I had to make two (2) trips to San Antonio, a
    total of almost 20 hours in a car. The pain and discomfort that I
    suffered made me think, why in the hell did I choose the VA for my
    medical.
        I have gone to San Antonio on previous occasions to see the
    cardiologists only to find out that the echograms and ekg's done at a
    local hospital were not available. They were not sent up there because
    the VA had not paid. The cardiologist was visibly disturbed by this and
    she ordered new ones done since I was in San Antonio already. She
    showed concern that I had traveled all the way from the Valley and that
    I would not be seen due to the lack of the medical being sent to her.
        I have had to go to San Antonio for other minor exams that took 15
    to 20 minutes. The stress test could have been done locally, the
    allergy tests could have been done locally, the breathing test could
    have been done locally, and my skin rash exams could easily have been
    done locally. But I had to travel to San Antonio for them because the
    Rio Grande Valley does not have acute care to provide healthcare for
    us.

                Sincerely,
                                                     Arturo Treto Garza
                                   __________
    Honorable Solomon Ortiz,

        Thank you for getting our needs in the Rio Grande Valley heard.
    Yes, we do need a hospital for us. Having to travel to San Antonio is
    just so much trouble and time consuming. Sometimes it just does not
    help, by the time you arrive your problems just seem to increase. We
    need all the help we can muster.

                Respectfully,
                                                        Jose Benavides,
                                                    334 McDavitt Blvd.,
                                               Brownsville, Texas 78521
                                   __________
    Dear Congressman Ortiz:

        My brother had a triple bypass done in San Antonio Audie Murphy
    Veterans Hospital in 2005. He returned after a 2 week stay at Audie
    Murphy and continued with his post-surgery care. During the course of
    his recovery, he developed complications with a blood thinning
    medication called Coumadin. That medication had to be monitored
    closely. On one occasion he went to the Harlingen Outpatient Clinic
    with problems.
        His VA medical provider told him that he needed to be monitored
    closely for his PT INR and that he needed to take vitamin K. He sent
    him home while he ordered his new dosage of medication.
        He told my brother that maybe the pharmacy in McAllen might deliver
    the medication later that day. As soon as my brother arrived at his
    home, he received a call from the VA clinic that he needed to go to the
    nearest hospital immediately and was told that Dolly Vinsant Memorial
    Hospital in San Benito was taking veterans.
        My sister-in-law drove him right away to DVMH. At DVMH he was told
    that he was very sick and he was immediately transferred to Valley
    Baptist Medical Center in Harlingen, TX by ambulance. He was admitted
    because he advised the hospital that he was a veteran and showed his ID
    card. The hospital got the clearance from San Antonio VA and admitted
    him. He was given two pints of blood and was required to stay for 4
    days to recover.
        His medical billings have not been paid because the VA is claiming
    that ``VA facilities were feasibly available to provide the care.'' In
    other words, the VA felt that my brother could have traveled to San
    Antonio under the dangerous medical problems he was having.
        He barely made it to the local hospital let alone to San Antonio
    which is 4 to 5 hours away by car. The VA clinic did not tell him that
    they would provide an ambulance for him to take him to San Antonio,
    they know better. There is no such thing. What his VA medical provider
    did do and under an abundance of caution was referred him to the
    nearest local hospital.
        If the VA feels that our veterans can immediately fly or magically
    transfer themselves to San Antonio for medical care under emergency
    conditions, then I wish they would let us in on the secret.
        Once again the VA is using the excuse that medical VA facilities
    were feasibly available. The local VA clinic does not even have a
    cardiologist. VA facilities are not ``feasibly available'' for veterans
    with emergencies and or acute care problems.
        This is another reason why we need a VA hospital for the Rio Grande
    Valley. My brother does not want to rock the boat because of his heart
    condition and other medical problems which have developed. He does not
    want to jeopardize the healthcare that he does receive from the VA. In
    other words, he is in a sense held hostage by our government.

                Sincerely,
                                                           Arturo Garza
                                   __________
    Dear Congressman Ortiz,

        My husband, Alfonso X. Soto, an army veteran of the Vietnam War
    died 9 years ago. I believe that at the time of his heart attack he was
    also suffering from a problem with his lungs possibly due to his
    exposure to Agent Orange while in Vietnam. He never persued a diagnosis
    mainly because the San Antonio facility was too far and he was not able
    to make the trip. The one time he did go due to hearing loss from a
    mortar concussion also while in Vietnam, he found that the number of
    people they were trying to serve was too great for quality care. He
    never went back again.
        My husband is gone, but for the sake of other veterans who deserve
    our support and in light of the number of young men and women from our
    area serving in Iraq, who will need physical and psychological support
    when they return, I ask that you actively pursue a facility in the
    south Texas area. Each time I drive by the old Valley Regional facility
    just sitting there with no purpose, I wonder at the possibility of a
    veteran's hospital in Brownsville, Texas. Congressman, I know you are a
    man of vision. Please do what you can.

                Sincerely,
                                                        Neida Ruth Soto
                                   __________
    Mr. Ortiz:

        I am a 54-year-old black female veteran and I retired and live in
    Corpus Christi, Texas. I have 60% service-connected disability and find
    it ridiculous and cumbersome to have to travel to San Antonio for
    visits to Audie Murphy. I have to take off from work for a day as
    opposed to 1 to 2 hours to have a mammogram, an X-ray, consults which
    take all day waiting, and 10 minutes to get done.
        I usually have appointments at 12 p.m. which means I must go to bed
    early enough, to get up around 6 a.m. leave Corpus no later than 7:30
    to make sure I get to Audie 30 minutes prior to my appointment. Once I
    am checked in; and I will take my last appointments for instance, I
    wait for 1 hour to be called, and another 2 hours before I am seen.
    They reimburse me $26.00 for the appointment and we know that does not
    even fill a tank.
        I must miss a day of work of course because it is a full day
    evolution to get this completed. I work on the military base located at
    NASCC. It has a large hospital that is being used as a clinic. I do not
    know why the government is underutilizing the facility and requiring
    veterans from our surrounding cities as well as those here in Corpus to
    travel miles for services that can be provided right here. This will
    show the appreciation for the veterans, employ qualified physicians,
    get adequate services and probably allow the people that have fought
    for our country the availability to convenience in knowing what some of
    our brothers and sisters died for was not in vain.
        The last visit to San Antonio I was in a room with several other
    veterans. We all realized through conversation that we were all from
    either Corpus, Robstown, Brownsville, and other surrounding areas of
    Corpus. This was ridiculous because some had been there since 8 a.m.
    and it was already 11 a.m. and they had not been serviced. My
    appointment was 11 a.m. and I was seen at 1 p.m. and left at 4 p.m.
    This was a full day of work and not counting me driving up there and
    returning home, which by the way I arrived at 7 p.m.
        So basically from beginning to end it took me 12 hours to get to
    San Antonio, get serviced at Audie Murphy, caused me to fill my tank
    twice, going and coming, I took off a whole day of work and got 26
    dollars for my troubles and all of this could have cost nothing but
    probably 4 hours of time if I could have used the hospital already in
    Corpus or some facility that is comparable.
        I sincerely appreciate you fighting this battle for us because it
    is becoming increasing difficult to travel those miles for treatment
    that can be completed in Corpus Christi. I cannot say enough that
    finally someone is noticing that we veterans do not ask for much but
    when we do it is because we feel we need it, deserve it and it is a
    doable request.
        Thanks for the time and energy put forth for this cause.

                                             Billie P. Harvey, USN-Ret.
                                   __________

        I favorably support the proposal(s) concerning the establishment of
    a VA hospital in the Rio Grande Valley, not just ``south Texas.''
        Even though I am a retired and VA-disabled U.S. Army Vietnam War
    veteran, I have not used VA facilities, other than the Disabled Veteran
    license plate benefit. Perhaps I will need their services in the
    future.
        I do, however, recognize and support the efforts of you, and our
    VA-eligible brothers and sisters, to gain relatively local access to VA
    care, other than crowded, overloaded VA clinics.
        This effort needs to be sustained to fruition even though this may
    not be the year for success.
        Carry on, sir.

                Most respectfully yours,
                                                      John M. Lawrence,
                                                 1SG, U.S. Army (Ret.),
                                                   26 Winterhaven Lane,
                                                  Brownsville, TX 78526
                                   __________

        We need all the support from you to make this recommendation become
    a reality. For several years I have seen and helped other veterans
    travel to San Antonio for their medical problems.
        It is time to open their eyes, that we do need a hospital here in
    the Valley. The Harlingen area will be getting a new outpatient clinic
    within the next few months but this will not help because we still need
    to travel to San Antonio.
        It's great but we need a hospital here. There's too many of us
    veterans who need a hospital. It's very difficulty for us to travel
    because of our illnesses and no support for our families when we are
    there. I have advised those veterans that they need to speak out so
    that our congressmen hear us.
        Our vote means a lot and if we get together we can have a great
    impact in our coming elections. Once again, thank you for your support
    and I hope that you can convince the VA Committee.

                                                          Miguel Rangel
                                   __________

        My opinion on this matter is that in the Rio Grande Valley, there
    is a serious need of a VA hospital.
        There are many vets that because of the drive to San Antonio most
    of them would rather just not worry about being seen at the VA. For
    those who make that 4-hour drive it is not as easy at it seems.
        It is very tiring and the fuel cost, lodging, and food is very
    costly for those that depend on a family member to take them to their
    appointments. The travel pay assistance that one receives is not enough
    to cover these expenses.
        Having a hospital in the Valley would benefit the vets that have
    supported this Nation and now it is time for the Nation to step up to
    the plate and assist our south Texas veterans. I am a Navy vet and
    hearing their stories of war and their sacrifice that they face each
    and every day is something I do not wish on anyone.
        Mr. Ortiz, we in south Texas are behind you 100% and do appreciate
    everything you have done for us. We stand next to you in this battle
    and I pray that those who make this decision will hear our cries for
    help.

                God Bless,
                                                        Joseph D. Ramos
                                   __________
    Dear Rep. Ortiz:

        I'm a Vietnam veteran with several service-related health problems.
    I've made about 8 trips to Audie Murphy in San Antonio this past year
    and am scheduled to make several more in the next month or so. My
    health is still well enough where I can make the trips OK. As my
    conditions worsen I know it will get harder and harder to make the 5-
    hour trip each way.
        I see a lot of veterans from the Valley every time I go there.
    There are a lot of veterans who cannot make the trip on their own. They
    make the trip by bus or take relatives who I'm sure have to make
    sacrifices missing work, caring for children and other parents to make
    the trip. It is a real hardship for most veterans and their families to
    have to go all the way to San Antonio for medical care.
        Americans from the Rio Grande Valley have always responded with
    great patriotism when our country had called. PLEASE HELP THE MANY,
    MANY VETERANS FROM THE VALLEY GET A VA HOSPITAL IN THE VALLEY.

                                                       Filiberto Conde,
                                                    Rancho Viejo, Texas
                                   __________
                                                         April 24, 2007

    Dear Congressman Ortiz:

        I'm a disabled vet from WWII who used to drive 357 miles to San
    Antonio for treatment but I can't do that anymore. I now visit the
    Harlingen outpatient clinic and the McAllen outpatient clinic for
    podiatry. They do the best they can with limited space and equipment
    and time.
        This Valley is in dire need of a hospital or more inpatient clinics
    to deal with the thousands of vets from the previous war era and now
    the Iraq War.
        Congressman Ortiz, I know you will do your best to remedy this
    situation, anything you do will be appreciated.

                Sincerely,
                                                          Bernard Reyes
                                                         Staff Sergeant
                                                 99th Infantry Division
                                                       1st and 3rd Army
                                                           World War II
                                   __________
    Mr. Ortiz:

        First of all I'm not a veteran but I do work with them. I was a
    scout leader and I teach all my kids the importance of honoring a vet
    (a warrior). Here in the Valley our warriors have given up 3% of all
    deaths compared to 1% in any community in all the Nation in all wars
    and are the most highly decorated in the Nation. Just on that alone our
    Valley warriors deserve more than what they are getting.

                                                    Epifanio Valdez III
                                   __________
    Respectable Congressman Ortiz:

        You have our support and encouragement. Do us well. And, thank you
    in advance. Tomorrow, my husband and I will get up at 4:30 a.m. to get
    ready and be on our way to San Antonio by 6:00 a.m. My husband has an
    appointment with the cardiologist. He has a heart condition and we have
    to make that trip periodically. Our trip is not any longer than the
    veterans that come from Brownsville, McAllen and all those other small
    towns. Many of our veterans can not afford private supplemental
    insurance. If we have a medical emergency after the hours of operation
    of our local VA clinic or during the weekend that requires
    hospitalization we are encouraged to go to our local emergency room,
    but that leaves us with the total expenses. The other alternative is to
    drive to the VA hospital in San Antonio at whatever time and with a
    near-death condition. The services and attention in Audie Murphy are
    excellent, but Audie Murphy is overextended. It is a problem to find a
    parking space due to the number of patients they see daily. Every time
    we go we see the increase in patients and it will only get worse
    especially with soldiers coming from the war. Also, because south Texas
    is the temporary home for many veterans that come for the winter. Yes,
    we need a veterans' hospital in south Texas.

                Sincerely,
                                                          Miltan Martiz

                                                   Rudolph Salinas, Sr.
                                                     Korean War Veteran
                                   __________
    Vets fight for hospital in Valley
    They endure long trips, long waits, lots of red tape to get healthcare
    12:37 AM CDT on Sunday, April 22, 2007

    By DAVID McLEMORE / The Dallas Morning News
    Brad Doherty/Special Contributor
       Veteran Steve Dunn of Harlingen must travel hundreds of miles to
              receive treatment at the VA hospital in San Antonio

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    WESLACO--Every Sunday and Wednesday morning, small groups of military
    veterans, some in their faded camouflage shirts, stand patiently at
    designated locations in the Rio Grande Valley, waiting for the ``vet
    van.''
        Veteran Steve Dunn of Harlingen must travel hundreds of miles to
    receive treatment at the VA hospital in San Antonio. Eventually, two
    government-leased, 15-passenger vans will weave their way to the stops
    between McAllen and Brownsville, picking up the passengers for the 240-
    mile drive to the Audie Murphy Veterans Memorial Hospital in San
    Antonio.
        They'll travel 5 hours to an appointment that took months to get.
    Sometimes, it's for a specialized X-ray that takes 15 minutes.
    Sometimes it's for a procedure that requires an overnight stay in San
    Antonio. And sometimes, veterans find, their appointment has been
    canceled.
        On most days, the vans leave behind people who reserved a place
    weeks in advance or waited in line in the hope that someone would miss
    the van, veterans say.
        ``It's a long trip. But it's the only way to get to the hospital,''
    said Ruben Cordova, a Navy veteran with Persian Gulf service. ``The
    buses aren't handicapped accessible and you have to tell the driver if
    you need to go to the bathroom. People bring their breakfast tacos and
    pain meds and hope for the best.''
        For years, veterans in the VA system in south Texas--which at last
    count numbered more than 107,000 for the 60-county service area--have
    been asking for their own VA hospital. They're tired of traveling
    hundreds of miles, enduring long waits for care and putting up with
    bureaucratic snarls.
        And with their numbers on the rise, they want the hospital now. The
    patient load at the south Texas VA facilities has grown 31 percent
    since 2001.
        ``We've never said VA doesn't provide good medical care,'' said
    Felix Rodriguez, district director for the Veterans of Foreign Wars in
    the Valley. ``The doctors and staff do the best they can with what they
    have. The problem is getting into the system to get the care. There are
    too many barriers to eligibility.''
        There is also a sense of promises not kept, Mr. Rodriguez added.
        Their complaints come at a time when VA facilities are coming under
    attack following reports of inadequate care at Walter Reed Army Medical
    Center in Washington, D.C.
        ``We did what we were asked by this country and we don't believe
    there is any excuse, any reason for VA to refuse to build a veterans
    hospital here,'' he said. ``We believe we've earned the right to see a
    doctor where we live.''
        The Department of Veterans Affairs operates two routine healthcare
    clinics in the Valley--one in McAllen, the other in Harlingen. The
    clinics are part of the south Texas Veterans Healthcare System, which
    also includes the Audie Murphy hospital in San Antonio, a smaller
    facility at Kerrville, and outpatient clinics in Corpus Christi, San
    Antonio and the Valley.
        For the more complicated procedures, veterans have no choice but to
    drive to San Antonio.
        The VA takes the veterans' concerns seriously, said Amjed Baghdadi,
    spokesman for the San Antonio-based south Texas health system.
        It's launched a feasibility study for either a hospital or expanded
    outpatient services in the Valley. And in 2003, the VA received
    approval for an outpatient clinic at Harlingen as a temporary measure
    pending construction of a primary care clinic scheduled for completion
    later this year, Mr. Baghdadi said.
        The new clinic will provide expanded audiology, dental and pharmacy
    services, as well as physical therapy, mental health and social work
    services not now available.
        Veterans groups are glad for the new clinic. But they believe a
    fully staffed hospital would better fit their needs.
    Unprecedented growth
        Nationally, VA's medical system has experienced unprecedented
    growth, ballooning 22 percent since 2001 when it had 4.1 million
    veterans registered. It now has 5.3 million, including 1.7 million in
    Texas. And while the largest single group is Vietnam-era vets, the
    number of Iraq and Afghanistan vets is growing.
        The Texas Veterans Commission reports it has received about 2,000
    discharge documents a month since 2001.
        ``Iraq and Afghanistan veterans are a rapidly growing component of
    VA care,'' said Terry Jemison, VA spokesman. ``Just a year ago, they
    made up 2 percent of our
    caseload. With the war continuing, we anticipate their numbers will cont
    inue to rise.''
        In south Texas, about 3 percent of the patient load is veterans of
    Iraq and Afghanistan.
        Yet VA projections about 3 years ago showed veterans requiring VA
    services diminishing. A report by a special commission appointed to
    study Valley veteran health needs, said only 10 beds were needed for
    both the Lower Rio Grande Valley and the Coastal Bend area near Corpus
    Christi.
        Homer Gallegos, a Vietnam vet and a member of VFW Post 8788 in
    McAllen, fears returning modern vets will soon face the same inadequate
    reception at VA that veterans of his war did.
        ``When I returned home after Vietnam, there were few resources here
    for veterans and VA wasn't equipped to handle the number of veterans
    coming back,'' he said. ``Now, we're seeing some of the same things
    with the Iraqi vets. I'm really afraid these guys are going to fall
    through the cracks.''
        Young vets are dealing with a host of different problems, Mr.
    Gallegos said, from an increasing number of head and brain injuries and
    amputations to emotional problems resulting from the combat they saw
    and the strain of multiple deployments to the war zones.
        ``Right now, the younger guys don't feel comfortable with the VA
    system and they don't relate much to the concerns of the older vets,''
    Mr. Gallegos said.
        The younger vets are more worried about ``getting jobs, getting
    married and aren't too concerned with long-term health issues,'' he
    said. ``I just don't want them to get lost.''
    More sad than angry
        State Rep. Aaron Pena, D-Edinburg, who represents part of Hidalgo
    County and is also a military veteran, has joined the call for
    construction of a VA hospital in the Valley.
        ``What the veterans in my district tell me is that health services
    to vets is lacking, distant and bureaucratic,'' he said. ``There is
    more sadness than anger when they talk about this. They want to believe
    the system will respond to their needs. They gave so much and they feel
    forgotten.
        ``But what isn't spoken is the sense that they are being ignored
    despite the long history of Hispanics' service to the U.S. military,''
    he said. ``We've fought in almost every American war and we feel we've
    suffered disproportionately in the current war. And we're still being
    ignored.''
        Approximately 10 percent of the 320 Texans killed in Iraq and
    Afghanistan are from south Texas. According to Defense Department data,
    100,000 Hispanics currently on active duty make up about 9 percent of
    the military.
        Mike Escobedo, 38, returned home to the Valley in 1982 after a 4-
    year hitch in the Marines. But it wasn't until 17 years later that he
    learned he could get his hearing loss--a result of working around
    aircraft--treated at a VA clinic.
        To go to the audiologist, he must still periodically travel to San
    Antonio.
        ``It's not so bad for me, but we have a lot of older vets and
    people without arms or legs who need more care,'' he said. ``They
    shouldn't have to spend 5 hours in a van to see the doctor.''
    Seeking help
        Jesus Bocanegra, 25, a veteran of Iraq, came home to Progresso
    nearly 3 years ago. After he was discharged, memories of some of the
    terrible things he saw in combat led to severe depression and thoughts
    of suicide.
        A friend talked him into going to the VA office in McAllen. He was
    subsequently referred to the VA hospital in Waco for evaluation for
    post-traumatic stress disorder and intensive treatment.
        Caseworkers there told him he needed to begin regular sessions with
    a therapist once he returned to the Valley.
        ``They told me I'd get an appointment in the mail,'' Mr. Bocanegra
    said. ``Three weeks later, I got a letter from VA that I could see the
    doctor in 8 months. I had heard about red tape, but I didn't realize
    how bad it was.''
        Currently, there are five full-time VA psychological counselors and
    two part-timers for the entire Valley, a VA spokesman said.
        Mr. Bocanegra said only three are available at any given time. The
    veteran clinics in Harlingen and McAllen are closed on the weekends.
    The PTSD hotline is available from 8 a.m. to 5 p.m., he said.
        ``There's a lot of people not getting the help they need and
    they're falling off a cliff and there's no net,'' Mr. Bocanegra said.
    ``The Viet vets have been dealing with this kind of stuff for 30 years.
    But there's a lot of Iraq vets coming back, and we're not going to wait
    that long to get someone's attention.''
        In late 2005, Mr. Bocanegra and two dozen other veterans
    participated in a 5-day march from the Valley to San Antonio to promote
    the need for a VA hospital. Shortly thereafter, the VA commissioned the
    study to determine whether a VA-staffed hospital in south Texas is
    warranted.
        ``Let's face it. This is a largely Hispanic area that the feds
    routinely ignore unless they want to send more Border Patrol agents,''
    he said. ``But Hispanics have a lot of pride and they're proud to serve
    our country. In return, we get a lot of promises, but no one does
    anything about it.''
        VA officials said the study, later expanded to include evaluation
    for specialty outpatient care, should be completed this summer.
        In the meantime, the outpatient clinic expansion in Harlingen will
    result in increased mental health services, as well as improved access
    to some of the services now available only in San Antonio, Mr. Baghdadi
    said. ``The south Texas Veterans Healthcare System is actively working
    to increase access to services throughout the system,'' he said.
        U.S. Sen. Kay Bailey-Hutchison, a Ranking Member of the Veterans
    Affairs Appropriations Subcommittee, recently pushed VA Secretary Jim
    Nicholson on the delay of the report.
        ``Secretary Nicholson assured me that the study I requested in
    February 2006 to determine the need to establish a veterans hospital in
    the Valley will be completed by July,'' Ms. Hutchison said. ``This
    study has taken an awfully long time and I am anxious to learn the
    results. Our veterans in the Valley deserve accessible, quality care.''
    Twenty-five year effort
        U.S. Rep. Solomon Ortiz, whose district covers much of the Valley,
    said he's tried for 25 years to get a VA hospital in south Texas. Time
    and again, VA officials said there weren't enough veterans or enough in
    the budget.
        ``Congressman Ortiz has been at this so long, it's gotten to the
    point he's boiled the argument down to its essence out of
    frustration,'' said Cathy Travis, the congressman's spokeswoman. ``We
    want south Texas veterans to get the healthcare they need where they
    live. However it gets done, let's do it.''
        Veterans in the Valley have no shortage of stories about treatment
    delayed, appointments scheduled months in advance, long waits, and
    piles and piles of paperwork to receive medical treatment.
        Mr. Cordova received a referral for an MRI for persistent shoulder
    pain. It took the VA 3 weeks to notify him that he would have an
    appointment in San Antonio 4 months later. After a 5-hour drive, the
    procedure took 15 minutes.
        ``You can't afford not to make an appointment,'' he said. ``If you
    miss an appointment or have to reschedule, everything starts back at
    ground zero and it's many more months before you see a doctor.''
        Mr. Cordova is 90 percent disabled. Like many Valley veterans, he
    finds that the difficulties in getting appointments and traveling to
    meet them make it hard to maintain a sense of normalcy.
        ``It's hard to hold a job when you have to miss work four or five
    times a month to travel to San Antonio for medical appointments.''
        Apolonio Uresti is a Vietnam veteran still being treated for post-
    traumatic stress disorder. His father is a World War II veteran. His
    two sons, both active-duty military, have served multiple tours in
    Iraq.
        Recently, a late-night phone call from one of his sons saying that
    he'd been hurt in an IED explosion dredged up memories of Mr. Uresti's
    own war experiences.
        He called the clinic in Harlingen about seeing the psychiatrist. He
    was told the soonest appointment was in 6 months.
        ``You get tired of waiting,'' he said. ``When my sons leave active
    duty, I'll have to tell them that they will have to fight to make the
    government keep its end of the bargain. I've seen it in my Dad's life
    and in mine.''

                                   __________
    Ortiz wants to hear from south Texas veterans ahead of key hearing
    20 April 2007
    Steve Taylor, Rio Grande Guardian

    WASHINGTON--U.S. Rep. Solomon Ortiz wants to hear from south Texas
    veterans about the healthcare they are receiving and the efforts they
    have to make to get it. And he wants it in a hurry.

        Ortiz, D-Corpus Christi, is set to testify at a hearing of the
    House Veterans' Affairs Subcommittee on Health regarding his
    legislation to establish a veterans hospital in south Texas next
    Thursday.
        Ortiz said he wants south Texas veterans to send him messages,
    stories, petitions--anything that will help the Veterans' Affairs
    Subcommittee on Health understand the context of the difficulties south
    Texas veterans face.
        ``I know the time is short, but our veterans need to `surge' now to
    help me characterize for Congress the everyday difficulties they
    encounter in terms of healthcare,'' said Ortiz, a veteran himself. ``I
    want to tell these guys the personal stories of south Texas veterans.''
        In January, Ortiz introduced the South Texas Veterans Access to
    Care Act, which requires the VA to advise Congress in 180 days how they
    will tend to the acute healthcare needs for south Texans.
        Ortiz introduced the same bill last year in an attempt to get the
    Administration to deal realistically with the massive number of wounded
    veterans in south Texas.
        Ortiz has asked in for the construction of a veterans' hospital for
    south Texas in each Congress that he has served. ``Each year, the bill
    is rebuffed, mostly for financial reasons,'' he said. ``Testifying
    before the Health Subcommittee next week will be a step forward for
    this legislation.''
        Perhaps one of the Rio Grande Valley veterans the House Veterans'
    Affairs Subcommittee on Health would like to hear from is Ruben
    Cordova, a USN retired disabled veteran.
        Cordova is waiting to have several surgeries to correct injuries he
    had sustained while in the service. That means numerous visits to the
    Audie Murphy hospital in San Antonio, the nearest VA hospital to the
    Valley.
        ``The worst case was when I had shoulder surgery and I spent the
    night in my car so that the anesthesia would wear off. I didn't take
    any pain medication so that I could make the 4-hour drive back home,''
    Cordova said.
        ``The pain was unbearable and I had to make several stops along the
    way to vomit from the pain. But that was what I had to do because it is
    the only place for veterans to have surgery.''
        Cordova said he had also slept in his car in San Antonio to make an
    early appointment.
        ``By the time I arrived in San Antonio all the rooms available for
    veterans had been issued out,'' he said.
        Cordova said he knew of many veterans that cannot sit for very long
    periods and have to lay down while in transit to San Antonio. ``Their
    family has to make arrangements to transport their loved ones in these
    conditions to make their appointments,'' he said. ``If a veteran
    doesn't make their appointment they sometimes have to wait until there
    is an available appointment--usually another 6 months.''
        Cordova said people who don't have to live these ordeals don't know
    what veterans and their families have to endure.
        ``I wish you would live through a trip with a veteran and see what
    it takes to have medical attention,'' Cordova told the Guardian.
        ``Veterans don't want a handout they want what is rightfully
    theirs. We want service from our government without questions just like
    we served without questioning what was asked of us. We were ready to do
    or die for our country. Now it's time to receive.''
        Ortiz said his legislation gives the government three different
    options in establishing a method to better provide acute healthcare
    services for veterans in south Texas.
        ``They can either establish a public-private venture to provide
    inpatient services; or they can build a hospital there; or they can
    utilize an existing military treatment facility with a sharing
    agreement,'' Ortiz said. ``The end result is that veterans' inpatient
    healthcare are attended to, near where the veterans live, not several
    hours away.''
        Ortiz said veterans should email their stories to:
    ortizvets@mail.house.gov or hand-deliver them to his Brownsville office
    by noon Wednesday, April 25.

     Copyright of Rio Grande Guardian, www.riograndeguardian.com; 2007.

       Prepared Statement of Hon. Steven R. Rothman, a Representative in
                     Congress from the State of New Jersey
        Let me begin by thanking the Committee on Veterans' Affairs for
    allowing me to testify. I want to especially recognize the leadership
    of Chairman Bob Filner and Ranking Member Steve Buyer. Under your
    stewardship, this Committee is continuing its important work in looking
    after our veterans.
        Mr. Chairman and Members of the Committee, I am here today to
    testify about the moral responsibility and practical obligation of the
    Federal Government to honor its commitment to all of our veterans--
    namely, the commitment to provide them with quality, affordable
    healthcare.
        It is a moral responsibility because the American Government makes
    a promise to every veteran. We say that because you have volunteered to
    put your lives on the line for freedom--because you are willing to
    sacrifice yourself for the good of all Americans--because of this
    courage, we will take care of you when you leave the service.
        We don't make that promise with our fingers crossed. We don't tack
    on fine print or attach a bunch of strings to the promise. We make that
    promise freely because our veterans gave freely of themselves in the
    service.
        It is a practical obligation because how on Earth can a young
    soldier fight with all of his willpower on behalf of a government if he
    meets a 60-year-old veteran who is battling cancer without any
    healthcare because he has been banned by his own President from
    enrolling in the healthcare service for veterans?
        It's outrageous. Yet, as the representative for more than 156,000
    veterans, I have heard story after story from veterans in Bergen,
    Hudson, and Passaic Counties who tell me that their government has
    broken its promise to them.
        That's because in January 2003, the Bush Administration decided to
    cut costs by telling veterans designated as ``Priority 8'' that they
    are banned from enrolling in the VA health system and will no longer
    have access to VA hospitals, clinics and medications.
        The Administration defended its decision by saying that Priority 8
    veterans make too much money to be worth the added expense. I say
    that's hogwash.
        Hogwash because a veteran is a veteran is a veteran. Hogwash
    because we made a promise to those men and women to take care of them
    and there is absolutely no justification whatsoever for breaking that
    word. And hogwash because those veterans often live in areas where the
    cost of living eats up all of the income that the Bush Administration
    seems to think they have.
        In fact, the national income threshold for Priority 8 veterans is
    $26,902. I don't know of any town in America where that qualifies as
    Bill Gates-style wealth. And in towns where the amount is slightly
    higher, it is still much too low to account for the high cost of
    living. Bergen County--which I represent--has the second largest
    concentration of veterans in the State of New Jersey and the largest
    number of Priority 8 veterans. All in all, it is estimated that nearly
    5,000 veterans in New Jersey alone have been turned away from the VA
    healthcare system. Nationwide, the number of veterans turned away is
    over 273,000.
        Turned away--listen to those words. I don't have to tell the good
    Members of this Committee how terrible a message we send to young
    soldiers when we ``turn away'' 273,000 veterans from the VA healthcare
    system.
        We ``turned away'' hundreds of thousands of brave servicemembers
    who said they were willing to die for the freedom of all Americans when
    they are at their most vulnerable.
        The fact is that ``turned away'' is another way of saying we broke
    our promise. We broke our promise to 273,000 veterans. We broke our
    promise to people who said they were willing to die for the freedom of
    all Americans and we broke our promise when they were at their most
    vulnerable.
        Imagine: You have a loved one who is 60 years old. He served
    bravely for 10 years as a young man and afterward worked hard as a
    civilian for decades, raised a family. But suddenly, he is diagnosed
    with cancer. He doesn't have health insurance. He can't afford private
    health insurance. So he turns to the Veterans Administration to save
    his life. But our VA says to him: `Sorry, Charlie. You should've come
    to us before January 2003. We can't care for you. You're out of luck.'
        Can you imagine? Can you imagine what that does to the faith of all
    our veterans in their government? Can you imagine what that does to the
    morale and trust of our current soldiers serving in Iraq and
    Afghanistan?
        It's not right and I believe this Committee must ensure that we
    stop breaking our promise.
        That's why I have introduced the Honor Our Commitment to Veterans
    Act, which tells the Bush Administration that it can't just promise to
    care for our veterans, but has to actually care for them. I strongly
    urge the good Members of this Committee to consider and move on this
    legislation.
        Republicans and Democrats will never agree on everything, but we
    should all agree on the importance of keeping our promises to veterans.
        As I said earlier, those promises weren't made with our fingers
    crossed behind our backs. They were promises made in earnest and they
    are promises that we must keep--for the good of our veterans and of our
    country. I will submit my full remarks for the record.
        Once again, I thank the Committee, Chairman Filner, and Ranking
    Member Buyer for your time and consideration of the Honor Our
    Commitment to Veterans Act and the very important issue of providing
    healthcare to all of our veterans.

      Prepared Statement of Hon. Tom Latham, a Representative in Congress
                             from the State of Iowa
        Mr. Chairman and Members of the Subcommittee, I am honored to have
    the opportunity to testify before you today regarding H.R. 1426, the
    Veterans' Access to Local Healthcare Options and Resources Act, known
    as the VALOR Act.
        I introduced this legislation in response to growing concern
    expressed by veterans in my district regarding access to VA healthcare.
    Veterans who live in rural parts of my district must travel long
    distances to VA medical facilities to receive the healthcare promised
    to them. Oftentimes they have to wait months for an appointment. They
    are frequently forced to give up a full day, sometimes in fragile
    condition, to travel for care. Despite the remarkable improvement in
    the quality of VA healthcare during the past decade, the fact remains
    that not all America's veterans have equal access to these services.
        One example of this inequity is the story of a Vietnam Army veteran
    from Fort Dodge, Iowa. This recipient of the Bronze Star is service-
    disabled, and he estimates that he has made the 4-hour round trip from
    Fort Dodge to the VA medical center in Des Moines more than 100 times
    over the last 3 years. Because he cannot drive, he relies, like many
    veterans, on a shuttle graciously provided by one of the Veterans'
    Service Organizations, which takes up to 10 or more veterans to Des
    Moines at a time. Since they have to wait until the last appointment to
    return, the trip takes an entire day, starting at 5:00 a.m. and
    returning late in the evening.
        Countless similar cases have been reported to me by veterans in my
    district. This situation leads me to ask the question, ``Can we really
    say that we are providing `top quality' care for our veterans when so
    many have limited access to it?'' Out of nearly 8 million veterans
    enrolled in the VA healthcare system last year only 5 million veterans
    actually used VA healthcare. Recent reports show that the VA healthcare
    system continues to match or outrank private-sector healthcare in
    overall quality and consumer satisfaction. Out-of-pocket costs are
    extremely low, particularly for service-connected veterans. So why are
    less than two-thirds of the veterans enrolled in the system actually
    using it? I believe that access problems account for a great deal of
    this disparity. For millions of veterans, VA healthcare is simply not
    readily accessible, especially in rural areas.
        VA-funded research conducted by Dr. William Weeks and his
    colleagues from the VA Outcomes Group highlights the urgent need for
    action to increase healthcare access for our rural veterans. This
    research supports the conclusion that, compared with their urban
    counterparts, rural veterans have a higher prevalence of mental and
    physical health problems, but the least access to VA healthcare.
        I am concerned that this disparity will continue to grow over time
    unless we do something to stop it. First, rural residents are
    overrepresented among veterans. The VA Outcomes Group found that 22% of
    veterans are rural, compared with 14% among the general population.
    Furthermore, rural veterans are overrepresented among those serving in
    Iraq and Afghanistan, due to increased use of the National Guard and
    Reserve units. These units are often dispersed in rural areas, far from
    large urban centers or concentrations of veterans where VA facilities
    tend to be located. As I previously mentioned, rural veterans are
    already more likely to experience health problems. With large numbers
    of these veterans returning from combat, the need for VA healthcare in
    rural areas will increase dramatically in coming years.
        The VALOR Act aims at meeting this need by providing veterans with
    an option to receive care they would otherwise be eligible to receive
    in a VA facility, at a local hospital or physician's office. To provide
    this option the legislation builds on the existing VA system for
    contracting with non-VA providers known as fee-basis care. The VA
    already has specific statutory authority to contract with non-VA
    facilities for medical care, but it is subject to a number of
    restrictions that limit its use.
        The VALOR Act would require an expansion of fee-basis care to allow
    greater access to VA-funded healthcare in local communities. Under the
    bill, covered services include hospital care, medical services,
    rehabilitative services and preventative health services that a veteran
    would be eligible to receive at a VA facility. It also clarifies that
    VA drugs can be obtained with prescriptions written by contracted
    providers.
        In region 23, which includes Iowa, the VA already spends roughly 10
    percent of its regional healthcare budget on fee-basis care. The fee-
    basis system is already in place, and I believe expanding this system
    would be a very practical way to address the rural access problem. I
    understand that some are concerned about ensuring quality of care for
    veterans in expanding fee-basis. I would answer that access to care is
    a key component of quality, which is currently lacking for many rural
    veterans.
        I also understand there are concerns about the integrity of VA
    medical records for veterans moving between VA and non-VA providers.
    This is one of the issues being addressed in the VA's Project HERO
    demonstration programs. It is not an insurmountable problem, and I
    applaud the Chairman for including in his draft rural health bill a
    provision specifically establishing a health information technology
    pilot program to examine ways to improve quality of care for veterans
    who use fee-basis care.
        I know that many of my colleagues representing rural districts
    share my concerns about access to care for veterans. I applaud Jerry
    Moran and Steven Pearce for also bringing legislation forward that
    would allow veterans to get care closer to home. I ask Members of the
    Subcommittee to carefully consider H.R. 1426 and I look forward to
    working with you to improve access to healthcare for our rural
    veterans.

    Prepared Statement of Hon. Jason Altmire, a Representative in Congress
                         from the State of Pennsylvania
        I would like to thank Chairman Michaud, Ranking Member Miller and
    Members of the Committee for the opportunity to testify today about
    H.R. 1944, the Veterans Traumatic Brain Injury Act of 2007, bipartisan
    legislation that I introduced to increase the screening and treatment
    of traumatic brain injuries (TBI) for our Nation's veterans.
        Mr. Chairman, we are facing an impending crisis in this country.
    Our brave men and women are returning from Iraq and Afghanistan with
    TBI at an alarming rate. Of those treated at Walter Reed Army Medical
    Center, 65 percent have been diagnosed with TBI as a primary or co-
    morbid diagnosis. Many now consider TBI to be the signature injury of
    the wars in Iraq and Afghanistan.
        I am concerned that the Veterans Affairs Administration may not be
    properly identifying and treating TBI among the Nation's veterans. It
    is estimated that more than half of all combat casualties have
    associated brain injuries. Most of them include mild TBI, which is
    often missed in initial exams as physicians attend to other more
    apparent injuries.
        The Veterans Traumatic Brain Injury Act improves the coordination
    of TBI care for our Nation's veterans by requiring the Veterans Affairs
    Administration to screen veterans for symptoms, develop and operate a
    comprehensive program of long-term care for post-acute TBI
    rehabilitation, establish TBI transition offices at all polytrauma
    network sites, and create and maintain a TBI veteran health registry.
        In our first 4 months, the 110th Congress has taken enormous
    strides in meeting its commitment to veterans. We have provided more
    than $11 billion in increased funding for veterans' healthcare and
    passed the Wounded Warrior Assistance Act to improve the management of
    their medical care.
        I believe that we owe no greater debt than to our veterans and,
    while we have made some progress, we can do more to improve their
    healthcare. To this end, the bipartisan Veterans Traumatic Brain Injury
    Act will allow us to properly screen America's returning heroes for TBI
    and improve their treatment.
        Thank you for the opportunity to speak today. I would be pleased to
    answer any questions that you may have.

                     Prepared Statement of Hon. Bob Filner
                    Chairman, Committee on Veterans' Affairs
        I appreciate the opportunity to speak on two bills of importance to
    veterans, especially to the veterans returning from the wars in Iraq
    and Afghanistan.
        Right now, a special opportunity presents itself!! Forty-two
    percent of the medical problems in the returning servicemembers from
    Iraq and Afghanistan are musculoskeletal, and many can undoubtedly
    benefit from chiropractic care. I am one American who has benefited
    from chiropractic care, so I can promote it in absolute good faith.
        H.R. 1470, which former Congressman Jeb Bradley introduced last
    session, is the Chiropractic Care Available to All Veterans Act. It
    requires that chiropractors are phased into the VA, with not fewer than
    75 medical centers by the end of December 2009 and all by the end of
    2011.
        H.R. 1471, re-introduced from my bill (H.R. 917) in the last
    session, is the BACK Our Veterans Health Act (The Better Access to
    Chiropractors to Keep Our Veterans Healthy Act.) It requires that
    veterans have direct access to chiropractic care at VA hospitals and
    clinics, so that veterans do not have to go through a general
    practitioner, or ``gatekeeper'' as this doctor is sometimes called.
        We must remember that since the creation of the VA healthcare
    system, the Nation's doctors of chiropractic have been kept outside and
    all but prevented from providing proven, cost-effective, and much-
    needed care to veterans. So we are grateful that access is becoming
    greater.
        The support for VA chiropractic care is bipartisan in nature. You
    may recall that former Secretary Anthony Principi released a policy
    directive before his departure regarding the true and full integration
    of chiropractic care in the VA.
        Now, Secretary Nicholson and I have developed a truly working
    relationship, so chiropractic is an area that I will be working on with
    him. Both Republican and Democratic VA Committee Members have supported
    the inclusion of chiropractic care in the VA.
        I have worked closely with chiropractic patients, particularly our
    veterans, on these two bills, as well as with the American Chiropractic
    Association. Hopefully, the two bills I have introduced might not even
    be necessary, because the VA will continue on its own to do what is
    right.
        But as insurance, it is important to pass H.R. 1470 and H.R. 1471.

      Prepared Statement of Shannon Middleton, Deputy Director for Health
        Veterans Affairs and Rehabilitation Commission, American Legion
        Mr. Chairman and Members of the Subcommittee:
        Thank you for this opportunity to present The American Legion's
    view on the several pieces of legislation being considered by the
    Subcommittee today. In recent years, The American Legion conducted a
    program, ``I Am Not a Number,'' that identified many of the access
    problems identified in these bills. In addition, The American Legion's
    series, A System Worth Saving, has also validated many of the issues
    addressed. Research conducted by the Department of Veterans Affairs
    (VA) indicated that veterans residing in rural areas are in poorer
    health than their urban counterparts. Providing quality healthcare in a
    rural setting has proven to be very challenging, given factors such as
    limited availability of skilled care providers and inadequate access to
    care. The American Legion commends the Subcommittee for holding a
    hearing to discuss these very important and timely issues.
    Improving Timeliness of Healthcare
        H.R. 92, Veterans Timely Access to Healthcare Act, seeks to
    establish standards of access to healthcare provided by the Department
    of Veteran Affairs (VA). Although timeliness of care is not a challenge
    unique to rural areas, veterans who reside in rural areas face an
    additional challenge to accessing care. Setting standards for
    timeliness in the delivery of healthcare and requiring VA to report on
    how these standards were executed will provide a realistic illustration
    of the ongoing challenges of rural veterans in gaining timely access to
    care. It will allow VA and lawmakers to determine the best ways to
    improve timely access for rural veterans. The American Legion supports
    this endeavor.
        H.R. 315, Help Establish Access to Local Timely Healthcare for Your
    Vets (HEALTHY Vets), would require the VA to contract with community
    healthcare providers to improve access to healthcare for veterans in
    highly rural areas. The American Legion believes that, where there is
    very limited access to VA healthcare, it is in the best interest of
    veterans residing in highly rural areas that local care be made
    available to them. Some of these veterans have physical limitations or
    suffer from conditions that make extensive travel dangerous. Many
    veterans have expressed concerns to The American Legion about their
    limited financial resources prohibiting travel, citing the rising cost
    of gas, the limitations of the mileage reimbursement rate, and the need
    to pay for overnight accommodations, as huge obstacles. Providing
    contracted care in highly rural communities--when VA healthcare
    services are not possible--would alleviate the unwarranted hardships
    these veterans encounter when seeking access to VA healthcare.
        H.R. 339, Veterans Outpatient Care Access Act of 2007, would
    improve access at outpatient clinics with exceptionally long waiting
    periods by allowing veterans to utilize non-VA providers. The American
    Legion has no official position on this issue, but believes that more
    focus should be placed on remedying the causes of the long wait periods
    to ensure timeliness of care. Doing otherwise would perpetuate the
    problem.
    Improving Eligibility for Healthcare
        H.R. 463, Honor Our Commitment to Veterans Act, discusses lifting
    the healthcare enrollment restriction on Priority Group 8 veterans. A
    total of 378,495 Priority Group 8 veterans have been denied enrollment
    from the time the restriction was instituted in January 2003. The
    American Legion believes that a more effective method of ensuring that
    VA can continue to provide quality care to veterans would be to ensure
    that VA is sufficiently funded to care for their needs, not limiting
    access for those who have incomes that fall above means tests
    thresholds. These veterans are required to make copayments, in addition
    to identifying their third-party health insurance that will reimburse
    VA for reasonable charges. Many of these Priority Group 8 veterans may
    very well be VA employees, Medicare beneficiaries, TRICARE or TRICARE
    for Life beneficiaries, or enrolled in the Federal Employees Health
    Benefits Program. The American Legion supports the lifting of the
    current prohibition on healthcare enrollment restriction for Priority
    Group 8 and exploring effective means to improve third-party
    reimbursement collections.
    Improving Access to Healthcare
        H.R. 538, South Texas Veterans Access to Care Act of 2007,
    addresses the healthcare needs of those who reside in south Texas.
    Although The American Legion has no official position on this proposal,
    we believe that VA should do everything in its power to improve access
    to its healthcare system for those residing in rural areas.
        H.R. 542, bill to Require the Department of Veterans Affairs to
    Provide Mental Health Services in Languages other than English, seeks
    to make mental health services available in languages other than
    English for those who have limited English proficiency. The American
    Legion strongly supports English as the official language of the United
    States. However, The American Legion believes that VA needs to remove
    any hindrance that prevents veterans from obtaining the care they have
    earned through their military service. This is an extremely important
    issue for family members who may be required, by law, to make medical
    procedure decisions on behalf of a veteran.
        H.R. 1426, the Richard Helm Veterans' Access to Local Healthcare
    Options Resources Act, would provide veterans enrolled in the VA
    healthcare system the option of receiving covered health services
    through non-VA facilities. It also would allow VA to fill prescriptions
    obtained from non-VA doctors. The American Legion believes that VA is a
    Federal healthcare provider not a Federal health insurer like the
    Department of Health and Human Services (Centers for Medicare and
    Medicare Services). Clearly, there will be unique situations in which
    VA should and must reimburse other healthcare providers, but this
    should be the exception to the rule, not a standard practice. Veterans
    should not have to travel hundreds of miles for healthcare or
    rehabilitation.
        The American Legion believes veterans should not be penalized or
    forced to travel long distances to access quality healthcare because of
    where they choose to live. It is more important that VA is adequately
    funded at a level that would allow it to service the needs of veterans
    and to improve access to quality primary and specialty healthcare
    services, using all available means at their disposal, for veterans
    living in rural and highly rural areas.
        The American Legion also supports VA pharmacy benefits for enrolled
    veterans when prescribed by an authorized VA physician or provider in
    the course of providing medical care.
    Improving Healthcare and Treatment
        H.R. 1470, the Chiropractic Care Available to All Veterans Act,
    seeks to make chiropractic care available at all VA medical centers.
    The American Legion has no official position on this issue.
        H.R. 1471, Better Access to Chiropractors to Keep Our Veterans
    Healthy Act (BACK Our Veterans Health Act), would allow eligible
    veterans direct access to chiropractic care. The American Legion has no
    official position on this issue.
        H.R. 1527, the Rural Veterans Access to Care Act, would allow
    highly rural veterans who are enrolled in the VA healthcare system to
    receive covered healthcare services through non-VA providers. It would
    also allow VA to fill non-VA prescriptions for highly rural veterans.
    As stated previously, The American Legion believes that, when there is
    no other acceptable VA healthcare option, veterans residing in highly
    rural and rural areas should be able to receive healthcare services
    through non-VA providers.
        The American Legion supports VA pharmacy benefits for enrolled
    veterans when prescribed by an authorized VA physician or provider in
    the course of providing medical care.
        Draft Discussion, Rural Veterans Healthcare Act of 2007, discusses
    a pilot program utilizing mobile vet centers in rural areas for a
    period of 5 years. The provisions in this bill are essential in
    addressing the challenges to providing quality care for rural veterans:
        Section 2 establishes mobile vet centers. The mobile vet centers
    would provide a glimpse of health issues affecting rural veterans,
    while providing care to mitigate the problem of inaccessibility.
        Section 3 establishes a health information technology program. The
    health information technology program would ensure that rural veterans
    receive continuum of care.
        Section 4 describes the establishment and duties of an Advisory
    Committee. The Advisory Committee on Rural Veterans would regularly
    assess the needs of rural veterans and identify gaps in policy and
    care.
        Section 5 addresses research and training. Rural health research,
    education and clinical care centers would afford VA the opportunity to
    build strategies to improve its system of care for rural veterans, as
    well as educate and train healthcare professionals on health issues
    prevalent in specific rural veteran populations. It also mandates the
    designation of centers for rural health research, education and
    clinical activities.
        Section 6 addresses homelessness. It identifies that homeless
    veterans in rural areas have more challenges in obtaining local
    resources.
        Section 7 discusses rotations and medical residents in rural areas,
    establishing programs to enhance education/training/recruitment and
    retention of nurses and allied health professionals in rural areas.
    Since VA has had challenges with finding providers who can furnish the
    types of services needed by veterans in rural areas, this section
    offers a remedy that would result in the ability of VA to provide
    quality care to rural veterans in their communities.
        H.R. 1944, Veterans Traumatic Brain Injury Treatment Act of 2007,
    seeks to have certain veterans screened for symptoms of traumatic brain
    injury. It also discusses the creation of a comprehensive program for
    long-term care and rehabilitation that includes residential, community
    and home-based components. The American Legion believes that the
    provisions in this bill are both necessary and timely. Symptoms of
    traumatic brain injury may not be obvious and may be dismissed or may
    occur over time. Screening those who were known to have been subjected
    to blast trauma in theater--even if they have no visible physical
    wounds--would aid in diagnosing injuries more quickly. Early diagnosis
    would also help to mitigate the effects of the trauma and improve the
    chances of a successful rehabilitation.
        Mr. Chairman, a critical element in screening veterans from
    traumatic brain injury will begin with the quality of the military
    health records. The Department of Defense (DoD) and VA must work in
    close harmony on this newest identified medical condition. DoD
    healthcare providers must work to identify and document ``blast
    injuries,'' especially non-penetrating traumatic brain injury. DoD and
    VA established the Defense and Veterans Brain Injury Center. However,
    there remains little expertise to formulate an effective definition,
    clinical guidelines, and treatment for returning Operation Enduring
    Freedom and Operation Iraqi Freedom veterans.
        In most cases, not only is the diagnoses of the less visible
    injuries of war difficult, physical wounds may ``mask'' the accurate
    diagnosis and treatment of traumatic brain injury. Blast impacts may
    not be properly documented and consequently the patient may have
    potential brain injuries that may very well go undetected until much
    later after behavioral changes become more evident.
        Currently, DoD does not measure individual cognitive ability upon
    enlistment or pre-deployment; therefore, it is much more difficult to
    measure any decrease in cognitive ability after deployment that is due
    to military service. This clearly complicates diagnosis, treatment, and
    service-connection determinations.
        Again, thank you, Mr. Chairman, for giving The American Legion this
    opportunity to present its views on such an important issue. The
    hearing is very timely and we look forward to working with the
    Subcommittee to bring an end to the disparities that exist in access to
    quality healthcare in rural areas.

                  Prepared Statement of Kimo S. Hollingsworth
           National Legislative Director, American Veterans (AMVETS)
        Mr. Chairman and Members of the Subcommittee:
        I am pleased to appear today to offer testimony on behalf of
    American Veterans (AMVETS) related to pending Department of Veterans
    Affairs (VA) healthcare bills before this Subcommittee.
        The VA healthcare system has evolved into one of the best
    healthcare systems in the Nation. The Veterans Health Administration
    (VHA) is uniquely qualified to care for veterans' needs because of its
    highly specialized experience in treating service-connected injuries.
    The VHA provides a wide array of specialized services to veterans and
    this type of care is extremely expensive. It is absolutely critical
    that the VA healthcare system be fully funded.
        The central problem for veterans with regards to the VA healthcare
    system is how to access the system in a timely fashion. Over the years
    VA has become increasingly efficient in providing timely care, though
    problems still remain.
        As this Committee is aware, AMVETS hosted the ``National Symposium
    for the Needs of Young Veterans'' in Chicago, Illinois last year. More
    than 500 veterans, active duty and National Guard and Reserve
    personnel, family members, and others who care for veterans examined
    the growing needs of our returning veterans. Some of the issues
    relevant to today's hearing identified at the Symposium include timely
    access to VA healthcare and funding for the Department. AMVETS believes
    these issues are inextricably linked.
        Regarding the 12 bills that this hearing is supposed to cover,
    AMVETS will discuss the nature of the overriding issue(s) of these
    proposals and some of our recommended solutions. Overall, AMVETS is
    concerned about the ``wave'' of legislative proposals to mandate the
    Secretary of the VA to contract out medical and other services. AMVETS
    recognizes that many of these bills are well intentioned and our
    organization supports veterans being able to access the benefits and
    healthcare they are legally authorized to receive.
        Mr. Chairman, veterans enrolled in the VA are already allowed to
    elect coverage in a non-VA facility. Veterans are free to choose when
    and where they receive medical care. One of the common themes for all
    of these proposals is allowing veterans to receive care at non-VA
    facilities and providers and having the Secretary of Veterans Affairs
    be responsible for the cost of coverage.
        AMVETS reaffirms its commitment that service-disabled veterans
    should have the highest priority access to VA healthcare services and
    these services should be of the highest quality. AMVETS believes that
    service-connected veterans currently have that level of access and
    quality in VA today. VA's current policy statement on this issue
    clearly affirms this priority, as follows:

              ``VA is committed to providing priority care for non-emergent
            outpatient medical services and inpatient hospital care for any
            veteran seeking treatment of his or her service-connected
            disability. It is VA's policy to provide priority access to
            outpatient medical care and elective inpatient hospital care
            for any veteran who requires non-emergent care for a service-
            connected disability. . . . For veterans who are 50 percent
            service-connected or higher, VA's policy is to provide priority
            access to medical services and inpatient care, regardless if
            treatment is needed for their service-connected disability.''

        Many of today's proposals risk some potential unintended
    consequences to include quality control and safety, and potential
    adverse impact on the statutory requirement by VA to maintain the
    capacity of specialized medical programs in Public Law 104-262.
    Overall, these proposals would seem to move VA toward higher costs. The
    escalating costs of healthcare in the private sector are well
    documented and VA has done an excellent job of holding down costs
    compared to the private healthcare industry.
        AMVETS believes the central question to all of these ``contract''
    proposals is whether or not Members of Congress believe the VA
    healthcare system is a national asset worth preserving or a system that
    should be abandoned. AMVETS believes the problem with VA continues to
    be access to the system. This in turn is reliant on appropriate levels
    of funding to hire staff, operate facilities and clinics and provide
    unique and specialized services. Appropriate levels of funding would
    also allow VA to open outpatient clinics and provide other contractual
    arrangements to provide VA sanctioned healthcare.
        As we are all well aware, the Secretary of VA already has the
    authority to enter into contracts for medical services. Many of these
    proposals have some ``triggering'' mechanism that would mandate the
    Secretary to contract care. These ``triggering'' mechanisms appear to
    be a ``one-time'' event that authorizes veterans to ``opt out of the
    system'' and have VA pick up the costs. For lack of a better word,
    these bills appear to authorize a ``vouchering system.''
        Sections 212 and 213 of Public Law 109-461 are specifically
    targeted at advancing the healthcare needs of veterans living in rural
    areas. VA is mandated to establish an Office of Rural Health within the
    Veterans Health Administration (VHA). The office is charged with
    improving VA healthcare for veterans living in rural and remote areas.
    Among other provisions, the law requires an extensive assessment of the
    existing VA fee-basis system of private healthcare, and eventual
    development of a VA plan to improve access and quality of care for
    enrolled veterans who live in rural areas. AMVETS would encourage
    Congress to fully fund the Office of Rural Health and allow VA to
    conduct the mandated assessment.
        Regarding the overall issue of VA providing timely access to care,
    the Government Performance and Results Act, Public Law 103-62, requires
    that agencies develop measurable performance goals and report results
    against these goals. In the President's Fiscal Year 2008 budget
    request, VA focuses on the Secretary of Veterans Affairs priority of
    providing timely and accessible healthcare that sets a national
    standard of excellence for the healthcare industry. VA generally tracks
    the timeliness of care in two broad areas--primary and specialty clinic
    appointments. Over the next year, the percent of appointments scheduled
    within 30 days of the desired date is expected to reach 96 percent for
    primary care appointments and 95 percent for specialty care
    appointments.
        In July 2005, the VA Office of Inspector General reported that
    VHA's scheduling procedures needed to be improved and issued eight
    recommendations. As of September 2006, five of the eight
    recommendations for improvement remained open and AMVETS would
    encourage the Department to implement the remaining recommendations.
        The issue of nonservice-connected veterans accessing VA healthcare
    is not new. Since colonial times, this country has pledged its
    continued support for medical care and other benefits for those who
    served in the military. During the 1920s, three Federal agencies--the
    Veterans Bureau, the Bureau of Pensions in the Interior Department, and
    the National Home for Disabled Volunteer Soldiers--administered various
    benefits for the Nation's veterans. The Congress, in 1924, gave wartime
    veterans with nonservice-connected conditions access to Veterans'
    Bureau hospitals. With the establishment of the Veterans Administration
    (VA) in 1930, previously fragmented care for veterans was consolidated
    under one agency. Over the years, Congress expanded eligibility for
    hospital care and it was gradually extended to wartime veterans with
    low incomes; then, in 1973, to peacetime veterans with low incomes; and
    finally, in 1986, to higher-income veterans.
        In 1996, Congress passed and the President signed H.R. 3118, the
    Veterans' Healthcare Eligibility Reform Act. This veterans' healthcare
    bill updated and simplified many of the outdated and existing
    eligibility rules in effect at that time. Most importantly, the bill
    established a ``medical need'' as the sole test for veterans who enroll
    for care with VA. In short, veterans have generally always had access
    to the VA healthcare system and they should not now be denied access
    because of a lack of funding; especially if they are willing to pay for
    these healthcare services.
        The Capital Asset Realignment for Enhanced Services (CARES) was
    supposed to be a systemwide process to prepare the VA for meeting the
    current and future healthcare needs of veterans. CARES addressed the
    appropriate clinical role of small facilities, vacant space, the
    potential for enhanced use leases and the consolidation of services and
    campuses. To date, it is the most comprehensive analysis of VA's
    healthcare infrastructure conducted.
        In May 2004, the VA issued a Decision Document that was supposed to
    serve as VA's guide for capital planning decisions. Annual updates with
    new forecasts of future demand were supposed to be incorporated in VA's
    strategic planning process. The May 2004 Decision Document identified
    18 sites for additional analysis and studies. Overall AMVETS supported
    the CARES Commission process.
        As a veteran and patriotic organization, AMVETS also associates
    itself for the purpose ``to help unify divergent groups in the overall
    interest of American democracy.'' Veterans earn benefits and services,
    and are granted access to the system by virtue of their qualifying
    military service. This should continue to be the overriding principle
    when discussing veterans' issues. Mandating the Secretary to provide
    services in other than the English language only serves to create
    division and separation among veterans that took an oath to uphold and
    defend the Constitution of the United States in English.
        Mr. Chairman, Public Law 107-135 mandated the VA to require
    implementation of a nationwide chiropractic care program. VA was less
    than enthusiastic about this endeavor and it took the Department until
    June 2004 to actually make these services available. Overall,
    chiropractic care is a complementary and alternative healthcare
    profession with the purpose of diagnosing and treating mechanical
    disorders of the spine and musculoskeletal system with the intention of
    affecting the nervous system and improving health. A similar program
    was mandated on the Department of Defense (DoD) around the same
    timeframe and DOD. It is AMVETS understanding that the DoD program has
    been highly successful and we would like to see similar results at the
    VA.
        VA's approach to Post-Traumatic Stress Disorder (PTSD) is to
    promote early recognition of this condition for those who meet formal
    criteria for diagnosis and those with partial symptoms. The goal is to
    make evidence-based treatments available early to prevent chronicity
    and lasting impairment. The same must be done for Traumatic Brain
    Injury (TBI). However, there is no medical diagnostic code specific to
    TBI--a patient may carry more than one diagnostic code (fracture of
    facial bones, concussions, and/or brain injury of an unspecified
    nature, etc.). AMVETS is asking Congress to increase funding for PTSD
    and TBI, with an emphasis on developing improved screening techniques
    and assigning a new medical code specifically for TBI.
        Mr. Chairman, this concludes my testimony.

                    Prepared Statement of Adrian M. Atizado
      Assistant National Legislative Director, Disabled American Veterans
        Mr. Chairman and Members of the Committee:
        On behalf of the more than 1.3 million members of the Disabled
    American Veterans (DAV) and its auxiliary, I wish to express my
    appreciation for this opportunity to present the views of our
    organization on healthcare legislation before the Subcommittee.
        The DAV is an organization devoted to advancing the interests of
    service-connected disabled veterans, their dependents and survivors.
    For the past 8 decades, the DAV has been devoted to one single purpose:
    building better lives for our Nation's disabled veterans and their
    families.
        The measures before the Subcommittee today cover a range of issues
    important to DAV, to veterans and their families. My testimony includes
    a synopsis of each of the bills you are considering, along with DAV's
    position or other commentary. We ordered our testimony numerically by
    bill in the same way you listed the bills in your letter inviting our
    testimony.
        We have previously testified that through their extraordinary
    sacrifices and contributions in military service, veterans have earned
    the right to the Department of Veterans Affairs (VA) healthcare as a
    continuing cost of national defense. Moreover, we adamantly believe
    America's free citizens, as beneficiaries of veterans' service and
    sacrifices throughout our history, desire that the government fully
    honor its moral obligation to provide quality and timely healthcare
    services to wartime service-connected disabled veterans.
        This Subcommittee is aware the DAV is opposed to any initiative
    that would turn VA into a primary insurer rather than a provider of
    healthcare to veterans. We believe VA must use its resources to
    maintain the base of its healthcare services, which is provided through
    and by VA healthcare facilities and healthcare providers. This current
    form of VA healthcare has served well to the benefit of all veterans,
    offers an uninterrupted flow of services to veterans in need, and
    ensures the quality of those services. VA is well recognized as
    America's best healthcare value, with the lowest error rates, highest
    satisfaction rate and lowest cost. Why would Congress want to contract
    out some of those services, at higher error rates, lower satisfaction,
    and higher cost?
        Notably, VA currently spends $2 billion or more each year on
    contract healthcare services, from all sources. Unfortunately, as VA's
    contract workloads have grown significantly, it has not been able to
    monitor this care, consider its relative costs, analyze patient care
    outcomes, or even establish patient satisfaction measures for most
    contract providers. VA has no systematic process for contracted care
    services to ensure that:

          care is safely delivered by certified, licensed,
    credentialed providers;
          continuity of care is sufficiently monitored, and that
    patients are properly directed back to the VA healthcare system
    following private care;
          veterans' medical records accurately reflect the care
    provided and the associated pharmaceutical, laboratory, radiology and
    other key information relevant to the episode(s) of care; and
          the care received is consistent with a continuum of VA
    care.

        The DAV is deeply concerned that any bill seeking to contract for
    care outside VA without addressing these concerns would essentially
    shift medical resources and veterans from VA to the private sector to
    the detriment of the VA healthcare system and eventually sick and
    disabled veterans themselves. Any proposal to contract for care with
    non-Department facilities and providers would encourage VA to refer
    patients, and thereby spend dollars for their care outside a system
    that is specifically created for veterans. Such a proposal sets a
    dangerous precedent that, if allowed to expand, could endanger VA
    facilities' ability to maintain a full range of specialized inpatient
    and outpatient services for all enrolled veterans. It would erode
    Veterans Health Administration's (VHA) patient resource base, undermine
    VHA's ability to maintain its specialized service programs, and
    endanger the well-being of veteran patients under care within the
    system.
        This Subcommittee is well aware of the funding crisis VA healthcare
    is experiencing and its impact on sick and disabled veterans who depend
    on VA's specialized programs. In the years since open enrollment was
    terminated, VA has been forced to do more with less. Even though over
    the past two budget cycles, Congress has provided increased
    discretionary appropriations for veterans' healthcare, the funding
    levels have not kept pace with VA's current services costs and the
    steady and significant increases in demand for services from enrolled
    veterans. If given sufficient funding on time to meet the growing need
    of all enrolled veterans' healthcare, including rural veterans, VA
    should be held accountable for meeting demand in a timely manner. Only
    as a last resort would we want care to be contracted out. Moreover, if
    VA timely receives adequate appropriations, it should be expected to
    plan for the appropriate number of staff, infrastructure, and other
    resources necessary to provide veterans medical care in a cost-
    effective manner.
                                    H.R. 92
        The stated goal of this bill is to provide timely access to VA
    healthcare. To accomplish this, a 30-day standard would be established
    as the maximum length of time that a veteran would have to wait to
    receive an appointment for primary care in a VA facility. It would also
    direct VA to establish a standard for the maximum length of time that a
    veteran would have to wait to actually see a provider on the day of a
    scheduled appointment. Under the bill, if the Secretary found that any
    particular VA geographic service area failed to substantially comply
    with the time standards, facilities in that area would be required to
    contract for the care of a veteran in each instance in which facilities
    would be unable to meet those standards. The contracting requirement
    would be mandatory for veterans who are classified within enrollment
    Priority Groups 1 through 7, and discretionary for those within
    Priority Group 8.
        The bill would require the Secretary to carry out a one-time
    examination of waiting time data for the entire system, stratified by
    geographic service area. The Secretary would be required to issue a
    determination regarding compliance with the standard in each geographic
    service area. If the compliance rate for any area were below 90
    percent, then facilities located in that area would be subject to the
    requirement that they contract for care whenever they are unable to
    meet those standards. The bill would also require that the Department
    of Veterans Affairs (VA) submit a variety of reports to the Committees
    on Veterans' Affairs concerning the purposes of the bill.
        In addition, the bill's language pertaining to the payment
    mechanism VA would use for outpatient services provided under the terms
    of the bill is unclear. Specifically, if VA's reimbursement rate were
    linked to current policy under Part B of the Medicare Program, VA would
    be required to pay private providers 80 percent of the scheduler fee
    amount for which Medicare is ordinarily responsible. Under Medicare,
    beneficiaries must meet an annual Part B deductible for all outpatient
    services. Participating physicians under the Part B program can only
    receive equitable reimbursement for services rendered by invoicing
    Medicare beneficiaries the remaining 20 percent of the scheduler
    amount, and collect deductibles for given services or procedures.
        DAV has a longstanding legislative resolution stating our firm
    opposition to copayments in VA healthcare. Under this measure, if a
    non-Department facility or provider were to receive the standard 80
    percent of the fee schedule amount for which Medicare pays for a
    particular service, and they are forbidden to bill the veteran for any
    difference between the billed charges and the amount paid by VA, then,
    we believe this may act as a strong disincentive for private healthcare
    providers to accept and treat veterans under this authority,
    frustrating the very purposes of the bill.
        Mr. Chairman, this Subcommittee held a thoroughgoing legislative
    hearing on September 30, 2003 (Serial No. 108-24) to consider an
    earlier version of this same bill. Among the statements made at that
    hearing was the following, by the then-Under Secretary for Health, Dr.
    Robert Roswell:

              ``My concern is that in the long run, I believe veterans are
            better served if we build a system of care that will address
            their needs, not leave it up to geographic location or a
            particular clinic that they might choose to use to determine
            what their healthcare benefit is on any particular day or any
            particular month. Ultimately, I think we have to build the
            system that addresses those needs. And purchasing care, because
            we are frustrated with waiting times, may not be the best way
            to do it. It might be, I don't know. I think we have to explore
            that in greater detail. I do believe there are a number of
            things that this Committee could do to enhance veterans' access
            to care. And I appreciate the leadership of the Committee in
            seeking those issues.''

        The Subcommittee apparently agreed with Under Secretary Roswell.
    After considering all the views of witnesses and Members, and reviewing
    a series of policy issues raised by that bill, the Subcommittee took no
    further action on that bill for the duration of that Congress. We do
    not believe circumstances have changed since that time that would
    warrant this Subcommittee to take any action on the bill now. While we
    appreciate that on its surface this bill would seem helpful in the
    short run to some veterans, its probable but unintended destructive
    consequences demand that we oppose it.
                                    H.R. 315
        This bill would expand VA's existing authority to contract for
    private healthcare by redefining ``geographic inaccessibility'' through
    the use of population density markers and highway mileage distance from
    VA facilities. Under the bill, if a veteran's home of residence met a
    given inaccessibility standard, the Secretary would be required to
    permit that veteran to receive private healthcare for primary care,
    acute or chronic symptom management and for ``nontherapeutic medical
    services.'' Most likely the Congressional Budget Office would conclude
    this bill constitutes mandatory spending under the PAYGO policy of the
    House.
        As indicated in many other forums including this one, DAV supports
    passage of mandatory, guaranteed or assured VA funding to ensure sick
    and disabled veterans receive adequate VA healthcare, but we do not
    support mandatory funding for private providers to care for veterans
    via a VA insurance function. Thus, similar to H.R. 92, we do not
    support this bill.
                                    H.R. 339
        This bill would require the Secretary, in the case of a VA facility
    with a waiting list of 6 months or greater, to provide for any veteran
    so informed of that waiting period, contract services by private
    providers under the same terms and conditions as those services would
    be provided in a VA facility.
        DAV opposes this bill for the same reasons we are concerned about
    the two earlier bills dealing with access. Insufficient resources is a
    primary cause of delayed access to care. This can be surmounted with
    new resources. This measure, like the others similarly aimed, would
    exacerbate VA's problems by stripping it of what limited resources it
    possesses to care for the patients now in the VA system, making its
    rationing and waiting lists even worse.
                                    H.R. 463
        This bill would legislatively moot Title 38, section 1705, thereby
    rescinding the Secretary's authority to establish and operate a system
    of annual enrollments for VA healthcare, and it would make every
    American veteran entitled to enrollment for VA healthcare on request.
    Over 1,000,000 veterans have unsuccessfully attempted to enroll in VA
    healthcare since the cut-off of enrollments for Priority 8 veterans
    occurred in 2003. While we certainly support the proponent's premise
    that every veteran who wants it should be able to enroll in VA
    healthcare, without a major infusion of new funding, enactment of this
    bill would worsen VA's financial situation, not improve it, and would
    not serve veterans well. We recommend the Subcommittee defer action on
    this bill until after Congress enacts mandatory, guaranteed or assured
    funding for VA healthcare.
                                    H.R. 538
        This bill would establish a requirement for a special study of the
    needs of veterans in 24 counties of ``far south Texas,'' with the goal
    of establishing either a public-private venture, a full service VA
    facility, or a shared VA-military facility to meet their healthcare
    needs.
        In accordance with our Constitution and Bylaws, the DAV's
    legislative agenda is determined by mandates formed by resolutions
    adopted by our membership. We have no resolution specific to the
    provisions of this measure. While we have some concerns about whether
    this bill would contravene the results of the recent Capital Assets
    Realignment for Enhanced Services (CARES) process in one particular
    geographic area, to the exception of all others, we take no official
    position on its passage.
                                    H.R. 542
        This bill would require VA mental health counseling to be provided
    in languages other than English when veterans are not English-
    proficient. The bill would also require the VA Secretary to ensure the
    purposes of Executive Order 13166, dealing with English as a second
    language among Federal beneficiaries, are carried out.
        Again, we have no resolution relevant to the provisions of this
    measure; however, its purposes appear beneficial and therefore DAV
    would not oppose passage of this measure.
                                   H.R. 1426
        This bill would empower an enrolled veteran to elect to receive VA
    healthcare from private sources. Under its terms, the Secretary would
    have no discretion to deny such an election once it was made. The bill
    would also provide a medication benefit to all enrolled veterans for
    the dispensing of VA pharmaceuticals based on prescriptions written by
    private physicians. For similar reasons supporting our opposition to
    H.R. 92, H.R. 315 and H.R. 339, we oppose this bill.
                            H.R. 1470 and H.R. 1471
        H.R. 1470 would expand VA chiropractic care by requiring such
    services to be available in at least 75 VA medical centers before the
    end of 2009 and available at all medical centers by the end of 2011. VA
    was authorized to offer chiropractic care and services under the
    provisions of section 204 of Public Law 107-135, the Department of
    Veterans Affairs Healthcare Programs Enhancement Act of 2001. We
    believe chiropractic care offers a valuable healthcare service to
    veterans and DAV members support the systemwide availability of
    chiropractic services within the VA healthcare system.
        While we support broader availability of chiropractic in VA
    facilities that would be brought about by enactment of H.R. 1470, the
    purpose of H.R. 1471 raises concerns. This bill would establish
    chiropractic service practitioners on the same level as VA medical
    doctors in the direct provision of primary care services. Each veteran
    receiving care in VA is assigned a single primary care provider, a
    medical doctor. A VA primary care provider is part of a primary care
    team charged with the responsibility for addressing the healthcare
    needs of the veterans assigned to that team. Accordingly, we believe in
    the VA healthcare system, access to chiropractic services should be
    provided in consultation with VA primary care providers responsible
    for maintaining the overall health of patients assigned to them. Thus,
    we oppose
    H.R. 1471.
                                   H.R. 1527
        Similar to H.R. 315, reviewed above in this testimony, this bill
    would grant election to veterans living at considerable distances from
    VA facilities to choose private care instead of care in VA facilities.
    The Secretary would not be able to deny this election, and VA would be
    required to pay associated costs. Furthermore, this measure would
    provide a pharmaceutical service similar to that of H.R. 1426. DAV
    opposes this bill for the same reasons as we oppose the earlier
    measures.
    Draft Bill--Veterans' Rural Healthcare
        The bill would require the Secretary to establish a mobile ``vet
    center'' pilot program in rural areas, and a pilot program for health
    information exchange with rural clinics, critical access hospitals and
    community health centers in rural areas. It would create an Advisory
    Committee on Rural Veterans and specify its membership and mission. The
    bill would establish at least four VA rural health research, education
    and clinical activities centers in VA medical centers in rural areas.
    It would amend section 2061 of Chapter 20, Title 38, United States
    Code, by adding the term ``rural'' as one of several groups defined
    with special needs to be addressed through VA's homeless assistance
    programs. The bill would expand VA's graduate medical educational
    mission into rural areas and enhance the education, training,
    recruitment and retention of nurses in rural areas. Finally, the bill
    would require a series of reports from the VA Secretary dealing with
    several of the matters contained in the bill.
        As this Committee is aware, the cost of providing care in rural and
    remote areas is higher than in urban settings. In much of our
    deliberation on this issue, we struggle to find a way to fill the
    indeterminate gap between limited resources and the demand for rural
    healthcare. We are hopeful the creation of an Advisory Committee on
    Rural Veterans and the Rural Health Research, Education and Clinical
    Care Centers will strive to strike the balance we seek when providing
    better outreach and high quality VA medical care to veterans residing
    in rural and remote areas. Moreover, when striving for good stewardship
    of taxpayer dollars we ask due consideration be given to the cost
    effectiveness of the mobile vet center program, which is a concern for
    such a program serving rural areas. Much of the content of this bill is
    consistent with recommendations of the Independent Budget. Further, we
    believe this measure is a good first step in addressing the healthcare
    needs of rural veterans, thus; DAV fully supports its purposes.
                                   H.R. 1944
        The Veterans Traumatic Brain Injury Act of 2007 would require the
    VA to establish a screening program for all veterans of Operations
    Iraqi and Enduring Freedom, of the Persian Gulf War and earlier
    conflicts dating from 1998. The bill would require the Secretary to
    report the results of such screening to Congress on an annual basis.
    The bill would require the Secretary to establish comprehensive
    traumatic brain injury (TBI) rehabilitation programs in four
    geographically dispersed polytrauma network sites (presently centered
    in Richmond, Minneapolis, Tampa and Palo Alto VA medical centers), and
    to report that establishment within 1 year of enactment, with
    additional information about the veterans so served. The bill would
    establish a TBI transition office within each polytrauma network to
    coordinate healthcare delivery and other services. The bill would
    require VA to establish cooperative agreements with other entities
    capable of providing appropriate services to veterans with TBI.
    Finally, the bill would establish a TBI registry to identify, track and
    communicate with, veterans suffering from TBI.
        Mr. Chairman, much of the content of this bill is consistent with
    our review of TBI and our recommendations in the Independent Budget for
    fiscal year 2008. Clearly, TBI is going to remain a major focus of VA
    healthcare for the next several decades. Press reports indicate that
    over 12,000 improvised explosive devices (IEDs) have been detonated in
    the current OIF/OEF campaigns. This means the average soldier or marine
    has been exposed to concussion, possibly multiple times. VA needs to
    prepare for this coming healthcare challenge, particularly for those
    veterans whose exposure may be classified as ``mild,'' or ``moderate''
    in nature and when no head wound resulted from that exposure. We
    believe this is going to be one of VA's greatest healthcare challenges
    in the near term. This bill will aid VA in making those preparations;
    thus, we fully support its enactment.
        In previous testimony, the DAV has raised concerns regarding the
    lack of effective screening and clinical assessment tools for mild to
    moderate TBI. While we applaud the Committee for considering this bill,
    and we support it, we note that VA issued a directive in the past 2
    weeks (VHA Directive 2007-013), implementing a TBI initiative that
    features a screening ``pop up'' within the VistA clinical software
    system. The directive also makes reference to a screening protocol and
    the mandatory continuing education requirement for specialized training
    in TBI. The directive makes no mention of the clinical assessment tool,
    which was the subject of a vigorous discussion at the Committee's
    hearing on September 28, 2006. We understand that earlier this year, VA
    established a clinical task group to develop that clinical assessment
    tool, and we urge the Subcommittee to closely monitor this development
    to ensure that tool is put into the hands of VA practitioners at the
    earliest possible time.
        Furthermore, we recommend greater flexibility be afforded to the
    Secretary regarding the number of locations for which the comprehensive
    program for long-term traumatic brain injury rehabilitation shall be
    carried out, such that if the need arises to expand the program, the
    current language limits VA's ability to meet that need. Also, the
    legislative language for eligibility of a veteran to receive care under
    this program may preclude veterans suffering from service-connected
    TBI. Finally, a provision of this measure encourages the Secretary to
    provide the comprehensive program for long-term traumatic brain injury
    rehabilitation through cooperative agreements with appropriate public
    or private entities. We are cognizant of the opportunities a
    cooperative agreement may offer but left undefined as currently
    written, we are concerned that this provision may overtime erode VA's
    special emphasis program of TBI care.
        Mr. Chairman, this concludes my testimony. I and other members of
    the DAV Legislative Staff will be pleased to make ourselves available
    to you and your staffs for further discussion of our positions on any
    of these issues, in hopes of working toward compromise on measures that
    we can eventually support. Thank you for asking DAV to testify today. I
    will be pleased to respond to any of your or other Committee Members'
    questions.

                        Prepared Statement of Carl Blake
          National Legislative Director, Paralyzed Veterans of America
        Mr. Chairman and Members of the Subcommittee, on behalf of
    Paralyzed Veterans of America (PVA), I would like to thank you for the
    opportunity to testify today regarding the proposed legislation. We
    recognize that the Department of Veterans Affairs (VA) faces serious
    challenges as it continues to face rapidly growing demand on its
    healthcare system. It seems ironic that in the face of some criticism
    about the care being provided in VA facilities that the demand on the
    system has never been higher.
           H.R. 92, THE ``VETERANS TIMELY ACCESS TO HEALTHCARE ACT''
        H.R. 92, the ``Veterans Timely Access to Healthcare Act,'' would
    establish standards of access to care within the VA healthcare system.
    Under the provisions of this legislation, the VA will be required to
    provide a primary care appointment to veterans seeking healthcare
    within 30 days of a request for an appointment. If a VA facility is
    unable to meet the 30-day standard for a veteran, then the VA must make
    an appointment for that veteran with a non-VA provider, thereby
    contracting out the healthcare service. The legislation also requires
    the Secretary of the VA to report to Congress each quarter of a fiscal
    year on the efforts of the VA healthcare system to meet this 30-day
    access standard.
        Access is indeed a critical concern of PVA. The number of veterans
    enrolled in the VA is approaching 8 million and the number of unique
    users is nearly 6 million. Despite the ongoing policy to deny
    enrollment to Category 8 veterans, the numbers of enrolled veterans
    will continue to increase, particularly as more and more veterans of
    the Global War on Terror take advantage of the services in VA.
        Unfortunately, funding for VA healthcare has not kept pace with the
    growing demand. Furthermore, Congress has failed to live up to its
    responsibility to provide adequate funding in a timely manner. Despite
    a positive funding outlook for this year, we remain skeptical. As long
    as VA continues to receive funding months into its fiscal year, it will
    never be able to properly plan to meet demand. To that end, access
    standards without sufficient funding provided by the start of the
    fiscal year are standards in name only.
        PVA is concerned that contracting healthcare services to private
    facilities when access standards are not met is not an appropriate
    enforcement mechanism for ensuring access to care. In fact, it may
    actually serve as a disincentive to achieve timely access for veterans
    seeking care. Contracting out to private providers will leave the VA
    with the difficult task of ensuring that veterans seeking treatment at
    non-VA facilities are receiving quality healthcare. We do think that
    access standards are important, but we believe that the answer to
    providing timely care is in providing sufficient funding in the first
    place in order to negate the impetus driving healthcare rationing. For
    these reasons, PVA cannot support H.R. 92.
      H.R. 315, THE ``HELP ESTABLISH ACCESS TO TIMELY HEALTHCARE FOR YOUR
                           VETS (HEALTHY VETS) ACT''
              H.R. 1527, THE ``RURAL VETERANS ACCESS TO CARE ACT''
        Because these two bills principally address the same issue, I will
    outline our concerns with the proposed bills in one statement. PVA is
    fully aware of the challenges the VA faces every day to provide timely
    access to quality healthcare for veterans who live in rural areas of
    the country. However, we are concerned that in addressing the problem
    of access for these veterans, the long-term viability of the VA
    healthcare system may be threatened. PVA members rely on the direct
    services provided by VA healthcare facilities recognizing the fact that
    they do not always live close to the facility. The services provided by
    VA, particularly specialized services like spinal cord injury care, are
    unmatched in the private sector. If a larger pool of veterans is sent
    into the private sector for healthcare, the diversity of services and
    expertise in different fields is placed in jeopardy.
        Ultimately, PVA has serious concerns about the provisions of this
    legislation that would give VA additional leverage to broaden
    contracting out of healthcare services to veterans in geographically
    remote or rural areas. If you review the early stages of VA's Project
    HERO, it is apparent that this is a direction that some VA senior
    leadership would like to go. We believe that this pilot program would
    set a dangerous precedent, encouraging those who would like to see the
    VA privatized. Privatization is ultimately a means for the Federal
    Government to shift its responsibility of caring for the men and women
    who served.
        Current law limits VA in contracting for private healthcare
    services to instances in which VA facilities are incapable of providing
    necessary care to a veteran; when VA facilities are geographically
    inaccessible to a veteran for necessary care; when medical emergency
    prevents a veteran from receiving care in a VA facility; to complete an
    episode of VA care; and, for certain specialty examinations to assist
    VA in adjudicating disability claims. The VA could better meet the
    demands of rural veterans through more judicious application of its
    fee-for-service program.
        In the end, we believe that in order for the VA to best meet this
    demand, adequate funding needs to be provided for VA healthcare in a
    timely manner. As we previously stated, placing the VA in the position
    it has dealt with for many years because Congress continues to wrangle
    over Federal budgets, does not prepare the VA to properly meet demand,
    including demand in rural areas.
        Finally, we realize that it is an extremely difficult task to
    establish a standard for when a veteran's home is considered to be
    rural. This legislation attempts to do so by stating defining
    ``geographically inaccessible'' in terms of a population density as it
    relates to a distance from a VA facility. However, this is very much a
    subjective idea. Access to VA healthcare is subject not only to
    population density or distance, but time as well. The difficulty in
    addressing this subject is apparent just by comparing the methods that
    the proposed bills take to define rural accessibility. However, due to
    the concerns that we have outlined, PVA cannot support H.R. 315 or H.R.
    1527.
             H.R. 339, THE ``VETERANS OUTPATIENT CARE ACCESS ACT''
        PVA opposes H.R. 339, the ``Veterans Outpatient Care Access Act.''
    As with the previous bills discussed, this bill would simply encourage
    broader contracting out of healthcare services without attempting to
    fix the problems that exist as a result of insufficient funding. With
    adequate resources and staffing, the challenges faced by outpatient
    clinics could be minimized. However, with the passage of this
    legislation, the VA would be discouraged from doing the right thing.
    For example, if a local clinic loses a particular specialty doctor,
    that clinic would likely turn to a contract provider without trying to
    refill that position.
        Legislation such as this, once again, allows the Federal Government
    to absolve itself from the responsibility to care for the men and women
    who have served and sacrificed for this country. It is time for
    Congress to stop trying to pass the buck and provide the resources it
    will take the VA to provide this critical care. It makes no sense to
    continue to consider legislation that would lead veterans away from the
    best healthcare system in America.
             H.R. 463, THE ``HONOR OUR COMMITMENT TO VETERANS ACT''
        PVA fully supports H.R. 463, the ``Honor Our Commitment to Veterans
    Act.'' The provisions of this legislation are in accordance with the
    recommendations of The Independent Budget. We have continued to
    advocate for this policy to be overturned since it was put into place.
    It is unacceptable that these veterans are being denied access to
    healthcare simply because the Administration and Congress have been
    unwilling to provide the necessary funding to reopen the VA healthcare
    system to them. We believe this policy should be overturned and that
    adequate resources should be provided to overturn this policy decision.
        VA estimates that more than 1.5 million Category 8 veterans will
    have been denied enrollment in the VA healthcare system by FY 2008.
    Assuming a utilization rate of 20 percent, in order to reopen the
    system to these deserving veterans, The Independent Budget estimates
    that VA will require approximately $366 million in discretionary
    dollars.
           H.R. 538, THE ``SOUTH TEXAS VETERANS ACCESS TO CARE ACT''
        PVA has no official position on this legislation. We believe that
    this is a local access issue. If a demonstrated need is there, then the
    VA must develop a solution to meet the needs of the men and women in
    this region.
                                    H.R. 542
        PVA has no opposition to the provisions of H.R. 542. Overall, we
    are pleased with the direction that VA has taken and the progress it
    has made with respect to its mental health programs. A great deal of
    time and resources have been invested in the VA's mental health
    programs in recent years to meet the growing demand of new veterans
    from Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF).
    The War Supplemental currently being debated even includes significant
    additional resources to meet the mental health needs of OEF/OIF
    veterans. Many of the servicemembers who have served in OEF/OIF have
    experienced mild to severe mental health problems. Our only concern is
    that the VA does not invest considerable resources into the
    requirements of this legislation if the demand for such services is not
    really there. However, given that we do not have specifics about this
    type of demand, we would simply urge the VA to proceed with caution.
      H.R. 1426, THE ``RICHARD HELM VETERANS' ACCESS TO LOCAL HEALTHCARE
                          OPTIONS AND RESOURCES ACT''
        PVA finds it difficult to comprehend the rationale for establishing
    a precedent for veterans in the VA healthcare system to leave that
    system and seek services elsewhere, as this proposed legislation would
    do. Over the past year we have read, as I am sure every Member of
    Congress has, all of the accolades given to VA healthcare by
    independent observers, newsweeklies and other publications. While we
    believe VA represents the best available care, oversight is needed to
    provide an additional guarantee that VA-provided services are of the
    highest quality for all veterans who use VA, especially for those with
    service-connected disabilities.
        While this legislation may be well intentioned, the potential
    unintended consequences far outweigh any benefit that this bill might
    provide. There would almost certainly be a diminution of established
    quality, safety and continuity of VA care if veterans were to leave the
    system. It is important to note that VA's specialized healthcare
    programs, authorized by Congress and designed expressly to meet the
    needs of combat-wounded and ill veterans, such as the blind
    rehabilitation centers, prosthetic and sensory aid programs,
    readjustment counseling, polytrauma and spinal cord injury centers, the
    centers for war-related illnesses, and the national center for post-
    traumatic stress disorder, as well as several others, would be
    irreparably affected by the loss of service-connected veterans from
    those programs. The VA's medical and prosthetic research program,
    designed to study and hopefully cure the ills of disease and injury
    consequent to military service, would lose focus and purpose were
    service-connected veterans no longer present in VA healthcare.
    Additionally, Title 38, United States Code, section 1706(b)1 requires
    VA to maintain the capacity of these specialized medical programs, and
    not let their capacity fall below that which existed at the time when
    Public Law 104-262 was enacted.
        While as a consequence of enactment of this bill some service-
    connected veterans might seek care in the private sector as a matter of
    personal convenience, they would lose the many safeguards built into
    the VA system through its patient safety program, evidence-based
    medicine, electronic medical records and medication verification
    program. These unique VA features culminate in the highest quality care
    available, public or private. Loss of these safeguards, that are
    generally not available in private sector systems, would equate to
    diminished oversight and coordination of care, and ultimately may
    result in lower quality of care for those who deserve it most.
        With regards to the prescription drug provisions included in the
    legislation, P.L. 108-199, the ``Consolidated Appropriations Act of
    2004'' provided the Secretary of VA the authority to dispense
    prescription drugs from Veterans Health Administration (VHA) facilities
    to enrolled veterans with prescriptions written by private physicians.
    Included in the public law, and further explained in the Conference
    Report H. Rpt. 108-401, was the requirement that the VA would incur no
    additional cost in providing such a benefit.
        VA physicians, by being the sole source of care, have been fully
    able to monitor patients for potentially contra-indicative
    prescriptions. PVA is concerned that if VA is to accept non-VA
    physician written prescriptions, veteran patients may be put at risk
    with this loss of monitoring should the patient seek treatment both
    inside and outside the VA healthcare system.
       H.R. 1470, THE ``CHIROPRACTIC CARE AVAILABLE TO ALL VETERANS ACT''
        PVA has no opposition to H.R. 1470, the ``Chiropractic Care
    Available to All Veterans Act.'' Chiropractic care is another medical
    service that could benefit many veterans and disabled veterans who face
    spinal and musculoskeletal difficulties. Currently, the VA provides
    chiropractic care in selected sites in accordance with P.L. 107-135,
    the ``Department of Veterans Affairs Healthcare Programs Enhancement
    Act of 2001.'' We see no problem with expanding this specialty care to
    the broader VA healthcare system; however, we must emphasize that
    adequate resources must be appropriated to allow VA to provide this
    care.
     H.R. 1471, THE ``BETTER ACCESS TO CHIROPRACTORS TO KEEP OUR VETERANS
                                 HEALTHY ACT''
        As we previously stated, PVA has no objection to the provision of
    chiropractic care within the VA healthcare system. However, we do not
    support section 3 of this legislation which would elevate chiropractors
    to the status of a primary care physician in the VA. The primary care
    provider is responsible for assessment of illness and injury and triage
    to the appropriate specialty care. The primary care provider also
    provides basic care far beyond the scope of musculoskeletal conditions
    and the interaction with the nervous system--the principal focus of
    chiropractors. We believe that chiropractic care should be provided in
    consultation with the primary care provider responsible for the total
    healthcare needs of the veteran.
        H.R. 1944, THE ``VETERANS TRAUMATIC BRAIN INJURY TREATMENT ACT''
        PVA supports H.R. 1944, the ``Veterans Traumatic Brain Injury
    Treatment Act.'' It is fair to say that traumatic brain injury (TBI) is
    considered the signature health crisis for Operation Enduring Freedom
    (OEF) and Operation Iraqi Freedom (OIF) veterans. We believe that the
    provisions of this legislation will enhance the ability of the VA to
    provide comprehensive care for veterans with TBI; however, we also have
    a couple of concerns with the legislation.
        Proper screening for this newest generation of veterans is critical
    to their immediate and long-term care. Unofficial statistics suggest
    that many OEF/OIF veterans have suffered mild brain injuries that have
    gone undiagnosed. In many cases, symptoms have manifested themselves
    after the veterans have returned home. The Department of Defense (DoD)
    admits that it lacks a systemwide approach for proper identification,
    management, and surveillance for individuals who sustain mild to
    moderate TBI. It is only appropriate that the VA be able to fill the
    gap left by DoD.
        Furthermore, it will allow the VA to identify veterans who have
    experienced a TBI but whose symptoms have been masked by other
    conditions. We have heard anecdotally that this is a particular problem
    for veterans who have incurred a spinal cord injury in the upper
    cervical spine. Veterans who have incurred this level of injury as a
    result of a blast incident often have experienced a traumatic brain
    injury as well. However, their symptoms may be diagnosed as the result
    of their significant impairment at the cervical spinal level.
        PVA certainly supports the need for a comprehensive long-term care
    program for veterans who have experienced TBI. The VA is the only real
    healthcare system in America capable of providing complex sustaining
    care over the life of the seriously disabled veteran. Private treatment
    options often give no consideration whatsoever to the long-term care
    needs of the veteran. Meanwhile, the VA has developed its long-term
    care program across the broad spectrum of services for many years.
        However, we have some concern about the provision of this
    legislation that defines an eligible veteran as one who has served on
    active duty in a combat theater of operations. Recognizing that the
    vast majority of newly injured TBI veterans have experienced their
    injury as a result of combat service, this should not preclude the VA
    from providing long-term care services to any TBI veteran whose
    condition is service-connected.
        PVA also is concerned about the provision within the section
    establishing TBI transition offices that further encourages cooperation
    with public and private entities. We understand that outside facilities
    and programs can bring some level of expertise to this population of
    veterans. However, we would hope that the VA would see fit to invest
    the majority of its resources in improving its own TBI programs, even
    as it taps into outside expertise. We urge the Congress, and VA, to
    proceed with caution as it looks to services provided outside of the VA
    healthcare system.
                     THE ``VETERANS RURAL HEALTHCARE ACT''
        PVA recognizes that there is no easy solution to meeting the needs
    of veterans who live in rural areas. These veterans were not originally
    the target population of men and women that the VA expected to treat.
    However, the VA decision to expand to an outpatient network through the
    Community-Based Outpatient Clinics reflected the growing demand on the
    VA system from veterans outside of typical urban or suburban settings.
        PVA has no objection to the proposal to create two mobile vet
    centers. However, the one caution we would offer is that services
    provided in this manner tend to be more expensive and less cost-
    effective. I would suggest that mobile services tend to be much more
    cost-effective in areas where a large segment of the target population
    can be served because it drives down the overall cost-per-patient. This
    implies that mobile centers would be best served in urban areas.
    However, we are willing to allow this pilot program to test the waters.
    We would suggest that the length of the program be shortened to 3 years
    or less so as to allow a sooner cost-benefit analysis of that program.
        We fully support the creation of an Advisory Committee on Rural
    Veterans. We are particularly pleased that the legislation includes a
    provision for Veterans Service Organization representation; however, we
    believe that more than one voice should be included. While the proposal
    includes the Secretary of Health and Human Services and the Director of
    the Indian Health Service as ex officio Members of the Committee, we
    believe that the Department of Defense Under Secretary for Personnel
    and Readiness or the Assistant Secretary of Defense for Health Affairs
    should also be included. This committee could provide well-researched
    and reasonably considered alternatives for rural healthcare.
        We also support the creation of rural health research, education,
    and clinical care centers. These centers would essentially serve as
    centers-of-excellence for rural healthcare. This could allow the VA to
    address the needs of rural veterans through broad application of the
    ``hub-and-spoke'' principle. This is the same structure utilized in the
    spinal cord injury service. A veteran can get his or her basic care at
    a Community-Based Outpatient Clinic (spoke). However, if the veteran
    requires more intensive care or a special procedure, he or she can then
    be referred to the larger rural research, education, and clinical care
    center (hub). This would ensure that the veteran continues to get the
    best quality care provided directly by the VA, thereby maintaining the
    viability of the system. It will also allow the VA to develop
    excellence within the actual VA healthcare system, instead of farming
    out these services to the private sector.
        Mr. Chairman and Members of the Subcommittee, we recognize that the
    challenges the VA faces in the healthcare arena are difficult. However,
    we must reiterate that the VA will struggle to meet the ever-growing
    demand of veterans, particularly rural veterans, as long as it does not
    receive adequate resources in a timely manner. It is unreasonable, and
    frankly unacceptable, to place expectations on VA to meet certain types
    of demand, if it is not given the resources and tools necessary.
    Furthermore, allowing the VA to send veterans out into the private
    sector for care will absolutely not be the most cost-effective
    approach, nor will it allow veterans to get the best quality of care.
        We look forward to working with the Subcommittee to develop
    workable solutions that will allow veterans to get the best quality
    care available. I would like to thank you again for allowing us to
    testify on these important measures. I would be happy to answer any
    questions that you might have.

                    Prepared Statement of Dennis M. Cullinan
                     Director, National Legislative Service
                 Veterans of Foreign Wars of the United States
        MR. CHAIRMAN AND MEMBERS OF THIS COMMITTEE:
        On behalf of the 2.4 million members of the Veterans of Foreign
    Wars of the U.S. (VFW) and our auxiliaries, I would like to thank you
    for your invitation to testify at today's important hearing on
    healthcare legislation.
        The bills under consideration today mostly revolve around what has
    been the most critical issue confronting the Department of Veterans
    Affairs (VA) healthcare system: access. We have long argued that the
    primary reason for most of the access problems veterans have is because
    of the lack of adequate and timely funding given to VA. We appreciate
    the increases of the last few years, and this year's historic budget
    resolution, but we need to ensure that VA receives the money on time,
    and that subsequent increases in future years keep pace with the needs
    of the veterans' population.
    H.R. 92, the Veterans Timely Access to Healthcare Act
        This legislation would establish access standards within VA for
    veterans seeking care. For primary healthcare appointments, it would
    require veterans to be seen within 30 days. In certain circumstances,
    it would require VA to contract for care when VA is unable to live up
    to that access standard.
        The VFW strongly supports the intent of this legislation, but we do
    have some concerns about the contracting aspect. There is no doubt that
    veterans should not have to wait to access healthcare, especially for
    primary appointments. A few years ago, there were over 300,000 veterans
    throughout the country who were waiting 6 months or more for primary
    healthcare appointments, but VA has made great strides to reduce this
    and most initial appointments are being made within that 30-day
    standard. We do understand that there are certain geographical areas
    where this is not the case, however.
        We are concerned about the cost of contract care, especially when
    VA is acknowledged to provide healthcare at a lower cost than other
    providers. While it would greatly benefit veterans in areas with long
    waiting times, we must be mindful of it not eating into the healthcare
    budget for other locations. If other areas have fewer funds to work
    with they, too, will ration healthcare, increasing waiting times
    systemwide. We must be mindful of these unintended effects, and ensure
    that the entire healthcare system has the funding and resources it
    needs to adequately care for all veterans.
    H.R. 315, the HEALTHY Vets Act
        This legislation aims to improve healthcare access for rural
    veterans by increasing contracting opportunities for veterans in
    geographically remote areas. This issue is of particular concern to our
    members, as a great number of them live far from VA medical centers,
    and often have difficulty accessing their earned healthcare.
        We strongly support the intent of this legislation, which creates a
    sliding scale for contracting eligibility depending on distance and
    county density to determine whether a veteran lives in a rural area.
        We do have concerns, however, with the potential for overuse of
    contracting care, as we did with H.R. 92, but there are certainly areas
    where its use is proper. We must be mindful of a demonstration project
    VA is currently undergoing, Project HERO. We have been supportive of
    Project HERO's aims, and think it might be wise to see how effective
    the demonstration project is, and what lessons can be learned from it
    before making a sweeping legislative change.
        Despite this, there are areas, particularly with respect to the
    challenges faced by today's returning servicemembers suffering from
    traumatic brain injuries and other blast injuries that could be
    supplemented with fee-basis care, but this is an area that is going to
    require strong Congressional oversight to ensure that these wounded
    warriors are receiving optimal care.
    H.R. 33
        The VFW supports the intent of this legislation, which is similar
    to H.R. 92, in that it establishes standards of care for veterans
    waiting to receive care from VA. In the case of H.R. 339, it
    establishes a 6-month access standard for any care a veteran is to
    receive, and if that standard is not met, VA must provide fee-basis
    care.
        In the wide majority of cases, this standard would not come into
    play for primary care, but there are a great many places, especially in
    more rural areas, where specialty care presents unique access problems.
    In these areas, VA might not have the full number of specialists it
    needs, or they have overwhelming patient loads. Regardless, a 6-month
    wait is inexcusably long, and we cannot expect our sick and disabled
    veterans to wait that long, especially when none of us in the room
    today would wait that long for our care.
    H.R. 463
        The VFW strongly supports the goal of this legislation, which would
    end the 4-year freeze on the enrollment of new Category 8 veterans.
    Category 8 veterans are those mostly nonservice-connected veterans
    making above a geographically adjusted amount, and it includes veterans
    making as little as $26,902. These veterans, since January 2003, are no
    longer allowed to enroll in the healthcare system, and are turned away
    from their earned healthcare. VA estimates that 1.5 million veterans
    will have been denied enrollment by the end of fiscal year 2008.
        If this legislation is enacted, Congress must also ensure a
    corresponding funding increase to pay for the care of these veterans.
    It is not enough to have VA make do; that will just result in the
    return of healthcare rationing and growing lines for care. Further,
    this cannot be a 1-year fix. Congress must continuously and fully fund
    VA healthcare in a timely manner in future years.
        The VFW believes that all veterans have earned access to high-
    quality healthcare in a timely manner through their service to this
    Nation. When the freeze was put into place, it was a time of severe
    budget shortages and extreme waiting times. We believe that the policy
    was a short-term fix to allow VA to manage the crisis and feel that it
    is time to end this unfair policy.
    H.R. 542
        The VFW supports this bill, which would make mental health services
    available for veterans with limited English proficiency.
        An increasing number of service men and women are coming from
    foreign countries. There are approximately 30,000 non-citizens serving
    in the military today, coming from around the globe. The vast majority
    of these heroes plan to use their military service as a springboard for
    citizenship, and their dedication to this country's ideals and their
    patriotic spirit, as manifested through their willingness to serve,
    cannot be questioned. These men and women put their lives on the line
    the same way any American-born servicemember does as they fight side-
    by-side. And they often suffer the same disabilities and illnesses.
        Although we understand the difficulty some would have with
    providing options for treatment in other than English, we must be
    mindful that this legislation only covers mental health services, where
    clear and direct communication is integral to treatment and recovery.
    It is often difficult enough for English-speaking natives to
    communicate the emotions and problems they are facing; we cannot throw
    another barrier up for the treatment of those who have given much for
    this country. Their service is just as valuable as that of an English
    speaker, and the care and treatment--to make them whole--is just as
    essential.
    H.R. 1426
        The VFW strongly opposes this legislation, which would allow any
    veteran to elect to receive contracted care whenever they choose. As we
    have acknowledged in our comments to previous legislation, there are
    certainly cases where contract care is appropriate. A blanket and
    widespread use of it to anyone and everyone, however, is shortsighted
    and misguided.
        First, we reiterate our concerns with the costs of such care. Fee-
    basis care is more expensive than that of VA, and we believe that it
    would do great harm to those veterans who elect to stay in the high-
    quality VA healthcare system by taking away funding for the system as a
    whole.
        Second, we have strong concerns about the viability of the
    healthcare system should this bill be enacted. VA has four essential
    missions, all of which depend on one another, and which greatly improve
    the quality of care for all Americans, not just our veterans. (1) It
    serves as the healthcare system for this Nation's sick and disabled
    veterans; (2) It acts as the primary education and training grounds for
    America's healthcare professionals (48,000 medical residents and
    students receive training at VA each year); (3) It provides world-class
    research opportunities and the development of new medical technologies;
    and (4) It is the backup to the Department of Defense healthcare system
    in national emergencies.
        We cannot lessen one of these missions without sacrificing the
    others. Reducing the number of veterans seeking care from VA would do
    irreparable damage to the others, affecting all Americans.
        Further, contract care would present problems, especially with the
    continuum of care and VA's ability to monitor and track the healthcare
    needs of veterans over their entire lives. It would also potentially
    erode the quality of care VA provides, especially with respect to the
    illnesses and disabilities veterans suffer from, such as gunshot wounds
    or prosthetics, and for which VA is uniquely qualified to treat.
        Although this legislation aims to expand the coverage available to
    veterans, it would only dilute the quality and quantity of the services
    provided to new and existing veterans today and into the future. That
    is unacceptable.
    H.R. 1470, the Chiropractic Care Available to All Veterans Act
        The VFW supports this legislation which would require VA medical
    centers to begin hiring chiropractors at each facility. Currently, VA
    averages around one chiropractor per VISN.
        A great number of veterans suffer from musculoskeletal injuries,
    and although chiropractors are not for every veteran, they should be
    available as an option. As part of a team that includes pain management
    and orthopedic specialists as well as physical therapists, a great
    number of injuries can be managed and symptoms improved.
    H.R. 1471
        The VFW opposes this legislation, which would allow veterans to
    receive direct access to chiropractic services. Although we support
    these services, we believe that they should be part of the specialty
    care process, requiring a referral from a primary care physician. This
    is important for case management and to ensure that a veteran's primary
    physician is fully aware of the treatments a veteran is undergoing,
    especially if that chiropractor service is a part of the team-based
    approach we discussed in our comments on H.R. 1470.
        Further, it is important to remember that no other VA healthcare
    specialty allows for direct access by patients.
    H.R. 1527
        We also support the intent of this legislation that would, like
    H.R. 315 discussed above, allow for the contracting of care for certain
    veterans in rural areas.
        Despite our support, our concerns about this legislation are
    similar to those of that bill as well.
        Namely, we are concerned with the continuity of care, as records
    would need to be transferred back and forth, which could create
    difficulties with VA's state-of-the-art electronic medical records
    system. We are also concerned with the costs that such a program could
    incur as fee-basis care is more expensive than that provided by VA.
        We would urge the Committee to consider the results of Project HERO
    before passage of this bill, though. The lessons we can learn from
    this--which would answer some of these questions we have laid out--
    would be beneficial to the entire system, and determine whether a
    large-scale proposal such as this is truly feasible.
    H.R. 1944
        The VFW offers our strong support for this legislation which would
    require VA to implement a screening program for traumatic brain
    injuries (TBI).
        TBI is the signature wound of this war, as thousands of our men and
    women in uniform are being exposed to blasts and other traumas which
    are doing great damage to their brains. This is an area where this
    Nation clearly must do more to care for our sick and disabled, the
    wounded warriors of this war.
        TBI manifests itself in a number of ways. While some are able to
    live with its effects, it makes life extremely difficult for others. We
    know much about its causes and immediate symptoms, but we must know
    more about it. We have repeatedly called for more studies to fully
    understand the injuries, their causes, their effects, and especially
    their long-term impacts.
        This legislation considers the long-term impact, and for those who
    need it, it would establish programs to provide long-term care and
    rehabilitation. This is sorely needed.
        Further, it fosters the development of partnerships with other
    healthcare institutions through the creation of a TBI transition
    office, which is charged with coordinating services that are not
    readily available through VA. Given the difficulties we have sadly seen
    with some of these wounded warriors receiving the care they need,
    especially for those who live far from the polytrauma centers, this is
    an excellent step. Many of these clinics and specialty care facilities
    have great experience with brain injuries and can provide these
    patients the care they desperately need, and VA with the expertise and
    training it needs to fulfill its most sacred of missions.
    Draft Bill, the Rural Veterans Healthcare Act
        The VFW supports this bill which would make changes and
    improvements to the availability of healthcare for rural veterans.
        This legislation includes important provisions that would expand
    vet centers, and create an Advisory Committee on rural veterans. In
    concert with last year's passage of a law that creates an Office of
    Rural Health within VA, there is much potential to reach those veterans
    who have difficulty accessing their earned VA healthcare.
        It also would create four VA healthcare centers on rural health
    research, education and clinical care. These centers would allow for
    research into the delivery of healthcare to rural veterans, education
    and training for healthcare professionals, and for the innovation of
    clinical activities to benefit rural veterans.
        With over 44% of returning servicemembers living in rural areas,
    the access problems they and all veterans face is of increasing
    importance. This legislation acknowledges that, and we are happy to
    support it.
        Mr. Chairman, I thank you for the opportunity to present the VFW's
    views on these important bills today, and I look forward to any
    questions that you or the Members of this Subcommittee may have.

                    Prepared Statement of Richard F. Weidman
              Executive Director for Policy and Government Affairs
                          Vietnam Veterans of America
        Chairman Michaud, Ranking Member Miller, and Members of the
    Subcommittee on Health, Vietnam Veterans of America (VVA) thanks you
    for the opportunity to testify here today. And on behalf of our
    officers, our Board of Directors, our members and their families, we
    thank you, too, for the important work you are doing, and the
    initiatives you are taking, on behalf of our Nation's veterans.
        We would like to focus our comments this morning on three of the
    bills up for your consideration. They are H.R. 463, H.R. 1944, and the
    discussion draft of the ``Rural Veterans Healthcare Act of 2007.''
        Priority 8 Veterans/H.R. 463, the ``Honor Our Commitment to
    Veterans Act,'' would re-open the VA healthcare system to Priority 8
    veterans. These are veterans with an income of less than $28,000 a year
    who are not afflicted with a service-connected disability and who agree
    to make a co-payment for their healthcare and prescription drugs.
        Back in 1996, when Congress passed the Veterans Healthcare
    Eligibility Reform Act, the VA was able to implement major cornerstones
    of its plan to reform how it provided healthcare. The rationale behind
    this initiative was to ensure a patient base that would support the
    infrastructure needed to develop a modern, integrated healthcare
    system. This the VA has done, and in the process it has transformed a
    mediocre, inefficient system into a national model.
        However, the law--that's Public Law 104-262--gave the Secretary of
    Veterans Affairs the authority and responsibility to determine
    eligibility for enrollment based on available resources in any given
    fiscal year. Although the law did not mandate a level of funding or a
    standard of care, it did establish an annual enrollment process and
    categorized veterans into ``priority groups'' to manage enrollment.
        On January 17, 2003, the Secretary made the decision to
    ``temporarily'' suspend Priority 8 veterans from enrolling. While this
    decision may be reconsidered on an annual basis, every budget proposal
    from the Administration since has omitted funding for unenrolled
    Priority 8 veterans and attempts to discourage use and enrollment of
    those ``higher income'' veterans.
        Priority 8 veterans are, for the most part, working- and middle-
    class Americans without compensable disabilities incurred during their
    military service. In its budget proposal for fiscal year 2007, the VA
    estimated that some 1.1 million of these ``higher income'' veterans
    would be discouraged from using their healthcare system because of a
    $250 enrollment fee and increased co-pays for prescription drugs.
    Thankfully, you in Congress have not let this scheme get much beyond
    the proposal phase.
        H.R. 463 would amend Section 1705 of Title 38, United States Code,
    by adding this new subsection: The Secretary shall administer the
    healthcare enrollment system under this section so as to enroll any
    veteran who is eligible under this section for such enrollment and who
    applies for such enrollment.
        Enacting this bill into the law of the land would keep the promise,
    keep the covenant with those veterans who, for whatever reasons, would
    choose to use the VA for their healthcare needs. We believe that their
    addition to the rolls would ease some of the fiscal pressures
    experienced by the VA insofar as it is Priority 7 and 8 veterans whose
    private health insurance accounts for some 40 percent of the VA's
    third-party collections.
        Of course, the bottom line is funding--the funding Congress
    provides--to enable the VA to accommodate those Priority 8 veterans who
    want to avail themselves of the VA's medical services. VVA will be
    releasing shortly a White Paper on veterans' healthcare funding, which
    will place this issue in context.
        TBI/Traumatic brain injury suffered by our troops in Afghanistan
    and Iraq has become so relatively common that it is referred to by its
    acronym, TBI. This affliction is not new; it has only been so codified
    because of the carnage caused by IEDs, improvised explosive devices,
    another acronym that has been incorporated into the dialect of war.
        We understand that the Administration is going to order the
    military to screen all returning troops for mild to moderate cases of
    TBI; those whose brain injuries are more serious are quite obvious to
    clinicians. H.R. 1944, the ``Veterans Traumatic Brain Injury Treatment
    Act of 2007,'' would go a long way toward assuring troops afflicted
    with this debilitating condition that help will be there for them.
    Focusing TBI care at four VA polytrauma centers, establishing and
    maintaining a registry of veterans diagnosed with TBI, and developing
    and inaugurating a comprehensive program for long-term TBI
    rehabilitation will go a long way toward healing the wounded from these
    latest military ventures.
        Rural Veterans Access to Care/How to provide more convenient access
    to quality healthcare for veterans residing in rural areas has been the
    subject of more than a few hearings over the past two sessions of
    Congress. The language in this proposed bill is as sensible as it is
    needed. It would establish pilot projects to see what is most effective
    in providing care. One of these pilots would expand access to vet
    centers via mobile centers in rural areas. Another would establish a
    health information technology program.
        Perhaps more importantly, this legislation would direct the
    Secretary of Veterans Affairs to establish an Advisory Committee on
    Rural Veterans, which would identify specific problems and areas of
    concern and suggest cost-effective solutions. It would require the
    Under Secretary for Health to designate a minimum of four VA healthcare
    facilities as the locations for centers of rural health research,
    education, and clinical activities. And it would establish programs to
    enhance the education, training, recruitment, and retention of nurses
    and other health professionals in rural areas.
        In seeking ways to better serve our rural veterans, this bill would
    not impose bureaucratic ``solutions'' that could and, we believe, would
    only serve to undermine the VA healthcare system. H.R. 92, the
    ``Veterans Timely Access to Healthcare Act,'' would give the VA a scant
    30 days to set up an appointment with a primary-care provider; if a VA
    medical center is unable to meet this standard for access to care, the
    option would be to send a veteran to a non-VA facility. H.R. 1426, the
    ``Richard Helm Veterans' Access to Local Healthcare Options and
    Resources Act,'' would offer an eligible veteran the option of
    obtaining healthcare from a non-VA facility or provider. H.R. 1527, the
    ``Rural Veterans Access to Care Act,'' would expand the use of fee-
    basis care through which private hospitals, healthcare facilities, and
    other third-party healthcare providers are reimbursed. It would impose
    a series of conditions, or distances, to help define ``rural.'' Like
    H.R. 1527, H.R. 315, the inelegantly named ``Help Establish Access to
    Local Timely Healthcare for Your Vets (HEALTHY Vets) Act of 2007''
    would add bureaucratic clutter to those whose responsibility it is to
    provide healthcare for veterans in ``geographically inaccessible''
    areas.
        Rather than improve healthcare for veterans, this quartet of bills,
    along with H.R. 339, the ``Veterans Outpatient Care Access Act of
    2007,'' would, if enacted, usurp the VA healthcare system. Today, one
    out of every ten VA healthcare dollars goes to clinicians and
    facilities outside the VA system. Through a scheme called Project
    HERO--the acronym for Healthcare Effectiveness through Resource
    Optimization--the VA is attempting to get a better handle on the
    dollars spent by VA medical centers on care provided outside of the
    system. We believe that HERO--and this quartet of bills--would only
    serve to hurt what has developed into one of the best-managed care
    systems in the Nation. HERO is a pilot in four VISNs, one that we
    believe will eventuate in half care for twice the cost.
        One bill we do applaud is H.R. 538, the ``South Texas Veterans
    Access to Care Act of 2007.'' ``They've been looking at this for a long
    time,'' one VVA leader in Texas told us. ``We did get an outpatient
    clinic in Conroe, in east Texas, but there are a lot of veterans in
    south Texas who are poorly served.'' If one in five of the 114,000
    veterans there uses the VA as their healthcare provider, that's 11,400
    who have to trek up to San Antonio for any real care.
        H.R. 538 basically says, let's find out the facts, whether the
    needs of veterans in far south Texas for acute inpatient care would
    best be met through a project for a public-private venture to provide
    inpatient services and long-term care in an ex-
    isting facility, through construction of a new full-service, 50-bed
    hospital with a
    125-bed nursing home, or through a sharing agreement with a military
    treatment facility.
        This is a very worthy bill, one that deserves serious consideration
    by this Subcommittee and by the HVAC at large.
        VVA also endorses H.R. 542, which would require the VA to provide
    mental health services in languages other than English, as needed, for
    veterans with limited English proficiency. While it can be argued that,
    to make it in today's military a troop needs proficiency in English, it
    is quite possible that (s)he is more conversant, and more comfortable,
    speaking in his/her native language. And many families of our diverse
    population of servicemembers are hardly fluent in English. When troops
    return from places like Iraq, which have seared their soul and messed
    up their mind, and need counseling, it is highly beneficial to have a
    trained and competent counselor or therapist who can ``relate'' better
    because (s)he speaks Spanish, or French, or Vietnamese.
        Finally, two bills that would effectively expand chiropractic care
    in VA medical centers, H.R. 1470 and H.R. 1471, are also worthy of
    passage--if proper standards of care are spelled out and enforced. We
    also would encourage, as part of these bills, a mandate for the VA to
    examine other ``alternative'' forms of medicine, so long as they
    conform to VA's evidence-based medical study. To this end, VVA suggests
    that part of this legislation should direct the Secretary of Veterans
    Affairs to appoint a committee to look at the efficacy of these
    alternative medical techniques with an eye toward integrating the most
    worthy of them into the VA healthcare system.
        This concludes our testimony. Again, VVA is appreciative of having
    been afforded the opportunity to testify on the merits of these bills.
    We would be pleased to respond to any of your questions.

               Prepared Statement of Gerald M. Cross, M.D., FAAFP
               Acting Principal Deputy Under Secretary for Health
      Veterans Health Administration, U.S. Department of Veterans Affairs
        Good morning, Mr. Chairman and Members of the Subcommittee:
        Thank you for inviting me here today to present the
    Administration's views on several bills that would affect Department of
    Veterans Affairs (VA) programs that provide veteran healthcare benefits
    and services. With me today is Walter Hall, Assistant General Counsel.
    We are able to present views for most of the bills on the
    Subcommittee's agenda. However, because of the limited time we have had
    to evaluate these bills, we stand ready to work with you to provide
    further information, including costs, at a later time for those pieces
    of legislation we are not able to fully address today.
    H.R. 92--Standards of Access to Care
        Mr. Chairman, I will begin by addressing H.R. 92. This bill would
    establish 30 days as the standard within which VA must provide a
    veteran with primary care (measured from the day the veteran contacts
    VA seeking primary care to the day on which the primary-care visit is
    completed). The bill would also require VA to establish a standard for
    how promptly patients must be seen in relation to their scheduled
    appointments in VA facilities (measured from the time of day of the
    veteran's scheduled appointment to the time of day the veteran actually
    sees the provider). There would be consequences for those facilities
    that do not meet these standards 90 percent of the time. In such
    facilities, if VA is unable to meet either of these standards with
    respect to a veteran, VA would be required to contract for that
    veteran's care in non-VA facilities if the veteran is enrolled in
    Priority Groups 1-7. VA would be authorized (but not required) to
    contract for such care if the veteran is enrolled in Priority Group 8.
        The bill provides that payments under these contracts could not
    exceed the reimbursement rate under Medicare, and the non-VA facility
    or provider would be prohibited from billing the veteran for the
    difference between the billed amount and the amount of VA's payment.
        We have no significant objection to H.R. 92 with respect to the 30-
    day standard for the scheduling of patients but ask the Committee to
    change the bill language to clarify that it would in fact apply only to
    new patients. It is these patients who need to be tracked to understand
    if there are difficulties accessing the VA system of care. In most
    areas, VA already complies with and exceeds these standards. Almost all
    VA facilities currently comply with the 30-day standard 90 percent or
    more of the time. We note, however, that in those situations where this
    bill would require VA to contract for care, restricting VA to paying
    the Medicare rate could make it difficult for VA to obtain the care in
    the private sector. There is no requirement in the bill that
    contractors, even if they are Medicare providers, agree to accept the
    Medicare rate from VA. This would limit the services that the VA could
    provide to veterans if the services cannot be purchased in the
    community at that rate.
        VA already has in place a standard requiring that a patient see his
    or her provider within 20 minutes of the scheduled appointment. We
    monitor facilities' compliance with this standard periodically through
    the use of quarterly patient satisfaction surveys. These surveys are
    based on a sampling of patients who report retrospectively on their
    perception of their last outpatient VA experience. I'll emphasize here
    that these ``waiting room times'' are important to VA as a matter of
    customer service. Results from the Fiscal Year 06 Customer Satisfaction
    Survey indicate that 77.8% of our patients waiting for primary care
    services are seen within 20 minutes of their appointment, and 70.5% of
    veterans obtaining specialty care services are seen within 20 minutes
    of their appointments. We are unaware of any other metric that could be
    used to implement the bill's requirements.
        We also believe the bill's approach is overly prescriptive and, as
    a result, would not provide latitude that is in the patient's best
    interest. Quality of care would be interrupted and fragmented with an
    increased requirement to send veterans outside the system. Moreover,
    the requirement that VA contract for care for patients waiting more
    than 20 minutes would not remedy the wait-experience of the patient for
    that visit. The bill is also flawed in that it assumes that all private
    care in the community meets the proposed standards. There are no
    measures available to support this assumption.
        Please be assured that VA, from top to bottom, considers within-
    room-time an important aspect of customer service.
        We are still in the process of developing costs for H.R. 92 and
    will provide them for the record.
    H.R. 463--Termination of the Administrative Freeze on Enrollment of
            Veterans in Category 8
        Mr. Chairman, as you and the Subcommittee are well aware, VA
    suspended the enrollment of new veterans in the lowest statutory
    enrollment category (Priority Category 8--veterans with higher incomes
    and no compensable service-connected disabilities) in January of 2003.
    This action was taken to protect the quality and improve the timeliness
    of care provided to veterans in higher enrollment-priority categories.
    H.R. 463 would require VA to enroll all eligible veterans. VA strongly
    opposes enactment of H.R. 463.
        In 1996, Congress passed an Eligibility Reform law that allowed VA
    to treat veterans in the most appropriate treatment setting.
    Additionally, in order to protect the traditional mission of VA (to
    cover the healthcare needs of service-disabled and lower-income
    veterans), that law originally defined seven priority levels (PL) of
    veterans--PL 7 veterans (higher-income and not service-disabled) were
    the lowest priority. The law mandated that beginning in FY 1999, VA use
    its enrollment decision to ensure that care to higher-priority veterans
    was not jeopardized by the infusion of lower-priority veterans into the
    system for the first time. In FYs 1999 through 2002, the VA Secretary
    determined in each year that all veterans were able to enroll. Prior to
    1999, PL 7 veterans' care was not funded in budgets, but they could use
    the system on a space available basis. Consequently, they were only
    about 2% of the annual users. In FY 2001, 25% of enrollees and 21% of
    users were PL 7 veterans (using 9% of the resources). In 2001 PL 7
    veterans were split into two parts--those making above the geographic-
    specific HUD threshold for means tested benefits were moved to a new PL
    8 category. More than half of the 830,000 new enrollees in FY 2002 were
    in Priority Group 8 and VA was not able to provide service-connected
    and lower-income enrolled veterans with timely access to healthcare
    services because of the unprecedented growth in the numbers of the
    newly eligible category of users. When the appropriation was finally
    enacted for FY 2003, VA's Secretary made the decision that the
    Department would not enroll any new PL 8 veterans--but those currently
    in the system would retain their right to care. Every appropriation
    since 2003 has supported this enrollment decision.
        H.R. 463 would essentially render meaningless the prioritized
    enrollment system, leaving VA unable to manage enrollment in a manner
    that ensures quality and access to veterans in higher priorities. VA
    would have to add capacity and funding to absorb the additional
    workload that this bill would entail, and so the quality and timeliness
    of VA healthcare to all veterans, including service-disabled and lower-
    income veterans, would unavoidably suffer until this capacity is added.
        We note VA has authority to enroll combat-theater veterans
    returning from Operation Enduring Freedom and Operation Iraqi Freedom
    in VA's healthcare system and so they are eligible to receive any
    needed medical care or services.
    H.R. 1426--Option for Enrolled Veterans to Receive Covered Health
            Services through Non-VA Facilities
        Mr. Chairman, H.R. 1426 would permit enrolled veterans to elect to
    receive any and all hospital and outpatient care in non-VA facilities.
    Veterans would make their election by simply submitting an application
    to VA. VA would be required to authorize payment for such care pursuant
    to a contract entered into with the facility. In addition, the bill
    would require VA to fill veterans' prescriptions written by non-VA
    physicians.
        VA strongly opposes enactment of H.R. 1426. We fully concur in the
    views of several of the major Veterans Service Organizations, who
    recently wrote to the Chairman of the Senate Committee on Veterans'
    Affairs in opposition to a more modest proposal, S. 815, which would
    permit veterans with service-connected disabilities to obtain their
    healthcare at any private medical facility. (We will provide this
    letter to the Committee for the record.) Legislation to similarly cover
    all enrolled veterans, as proposed by H.R. 1426, would be all the more
    problematic. At bottom, H.R. 1426 could lead to the undoing of the VA
    healthcare system--a world-class healthcare system--as we know it
    today. For this fundamental reason, we must oppose H.R. 1426.
        We also have other concerns. The proposal would fragment the care
    of our veterans. VA would no longer have a complete record of all the
    care a veteran has received. This could lead to VA duplicating care
    already provided in the private sector or providing care that conflicts
    with what the veteran is receiving in the private sector. As you are
    aware, some in the private sector rely on paper records while the VA
    uses a comprehensive electronic health record. Electronic records
    promote patient safety. We are concerned that the bill, if enacted,
    could jeopardize continuity of care for our patients.
        These patient safety concerns also extend to the requirement that
    VA fill veterans' prescriptions written by non-VA physicians. We are a
    provider of care, including pharmacological services. VA should not
    serve as a mere pharmacy; rather VA facilities should continue to be a
    point of care where a veteran can receive all needed care in a safe,
    coordinated, and fully integrated fashion. We provide comprehensive
    care and continuity of care.
        We also point out that VA has neither the capacity to meet this
    demand nor the resources to carry out H.R. 1426. In fact, VA's mail
    order pharmacy service is already at full capacity. Increasing this
    workload would require adding additional capacity, in addition to the
    cost of the additional drugs.
        Although we have not completed our cost projections for this bill,
    we underscore that the bill could have significant cost implications.
    As soon as the cost estimates become available, we will supply them for
    the record.
        Mr. Chairman, I now turn to the two bills currently under
    consideration by the Subcommittee that would address access to
    healthcare for rural veterans.
    H.R. 315--Fee Basis Authority for Veterans for Whom VA Facilities are
            Geographically Inaccessible
    H.R. 1527--Rural Veterans Access to Care Act
        H.R. 315 would require the Secretary to contract with non-VA
    facilities to furnish primary care services, acute or chronic symptom
    management, non-therapeutic medical services, and other medical
    services as deemed appropriate to veterans for whom VA facilities are
    geographically inaccessible. Veterans covered by this bill would
    include those who live in a county with a population density of less
    than 7 people per square mile and who live more than 75 miles away from
    the nearest VA healthcare facility; those who live in a county with a
    population density of more than 7 and less than 8 people per square
    mile and who live more than 100 miles from the nearest VA healthcare
    facility; and those who live in a county with a population density of
    more than 8 and less than 9 people per square mile and who live more
    than 125 miles from the nearest VA medical facility. This bill would
    take effect at the end of a 120-day period beginning on date of the
    enactment.
        H.R.1527 also relates to healthcare for enrolled veterans who
    reside in highly rural areas.
        Section 2 of H.R. 1527 would permit an enrolled eligible veteran to
    elect to receive healthcare through a non-VA healthcare provider.
    Veterans covered by this bill would include: veterans seeking primary
    care services who reside more than 60 miles driving distance from the
    nearest VA facility that provides primary care services; veterans
    seeking acute hospital care who reside more than 120 miles driving
    distance from the nearest VA hospital providing acute care; and,
    veterans seeking tertiary care who reside more than 240 miles driving
    distance from the nearest VA facility providing tertiary care.
        Also covered by section 2 of H.R. 1527 would be veterans whose
    distance from the nearest appropriate VA healthcare facility does not
    exceed the above-stated parameters but who experience hardship or other
    difficulties in traveling to a VA facility such that the Secretary
    deems travel to a VA facility not to be in the veteran's best interest,
    as determined under VA regulations.
        In carrying out section 2, the Secretary would be required to
    consult with the Secretary of Health and Human Services to establish a
    partnership to coordinate care for rural veterans at critical access
    hospitals, community health centers, and rural health clinics.
        Section 3 of H.R. 1527 would require the Secretary to furnish
    covered veterans with prescription drugs that are ordered by licensed,
    non-VA physicians. Under this section, VA would be required to furnish
    these medications in the same manner, and subject to the same
    conditions, as apply to medications that are prescribed by VA
    physicians.
        Both bills would give rise to obstacles to successful
    implementation and further expansion of our strategic plans, which
    focus on delivering healthcare services through sources that are
    nearest to a rural veteran's home. Both bills would create
    administrative issues, and implementation may simply be unworkable. We
    are also concerned that the requirements of section 3 of H.R. 1527
    would result in fragmentation of a veteran's medical care and the
    undermining of the VA formulary process, both of which put the patient
    at increased risk.
        Mr. Chairman, while we share the Subcommittee's concern for
    ensuring that rural veterans have adequate access to needed healthcare
    and services, we ask that the Subcommittee forbear in its consideration
    of either H.R. 315 or H.R. 1527. In accordance with Congress' mandate
    in the ``Veterans Benefits, Healthcare, and Information Technology Act
    of 2006,'' VA just recently established the Office of Rural Health
    (ORH) within the Veterans Health Administration. Part of that office's
    charge is to see how we can continue to expand access to care for rural
    veterans. We therefore recommend that no legislative action be taken in
    this area until VA has had sufficient time to complete and review the
    internal assessments currently underway by ORH and other Department
    components. We will of course share those findings with the
    Subcommittee along with our recommendations.
        VA has already done much to remove barriers to access to care for
    enrolled veterans residing in rural areas. Currently, over 92 percent
    of enrolled veterans reside within 1 hour of a VA facility, and 98.5
    percent of all enrollees are within 90 minutes. Still, we continue our
    efforts to try to ensure that all enrolled veterans living in rural
    areas have adequate and timely access to VA care. We expect the data
    for this year to be even better.
        Community-Based Outpatient Clinics (CBOCs) have been the anchor for
    VA's efforts to expand access to veterans in rural areas. CBOCs are
    complemented by contracts in the community for physician specialty
    services or referrals to local VA medical centers, depending on the
    location of the CBOC and the availability of specialists in the area.
    In addition, there are a number of rural outreach clinics that are
    operated by a parent CBOC to meet the needs of rural veterans, and
    several additional outpatient clinics are positioned to provide care
    for veterans in surrounding rural communities. VA's authority to
    contract for care under 38 U.S.C. 1703 provides a local VA medical
    center director with another avenue through which to meet the needs of
    many rural veterans.
        These efforts have borne fruit. Rural veterans tell us that they
    are satisfied with the services and high-quality care we are providing
    to them. This is substantiated by their reporting higher satisfaction
    with VA services in comparison to their urban counterparts. Moreover,
    performance measure data indicate that as a result of our intensive
    efforts to expand services for rural veterans, veterans have access to
    services much nearer to home. In 1996, VA users of mental health
    services lived an average of 24 miles from the nearest VA clinic; as of
    2006, they now live only 13.8 miles away. Quality of care in the rural
    environment matches that of urban care on 40 standard measures.
        Finally, we note that among the services that VA would be required
    to provide under H.R. 315 are ``non-therapeutic medical services.'' The
    meaning of this term is unclear. If the Subcommittee is to act on H.R.
    315, we ask it specify what services this provision is intended to
    cover.
        We are still in the process of developing cost estimates for both
    H.R. 315 and H.R. 1527. We will supply them for the record as soon as
    they become available.
    H.R. 1470--Enhancement of Chiropractic Care Program
        Mr. Chairman, H.R. 1470 is one of two bills relating to the
    provision of chiropractic care. It would require VA to increase to not
    fewer than 75 the number of VA facilities directly providing
    chiropractic care through VA medical centers and clinics. H.R. 1470
    would require this to be implemented by not later than Decem-
    ber 31, 2009. In addition, H.R. 1470 would require that chiropractic
    care be pro-
    vided at all VA medical centers by no later than December 31, 2011.
        VA does not support H.R. 1470. VA does not oppose eventually
    increasing the number of VA sites providing chiropractic care.
    Currently, there is a facility with an in-house chiropractic care
    program in each of our geographic service areas. However, we do not
    believe, based on current usage rates, that sufficient demand for
    chiropractic care will exist to justify the mandate to provide
    chiropractic care at all VA medical centers by the end of 2011.
    Currently, 98% of VA patients are able to get chiropractic care within
    30 days of their desired date.
        Mr. Chairman, costs for H.R. 1470 are not yet available. We will
    supply them for the record.
    H.R. 1471--Chiropractic Care Practice Expansion
        The second bill on chiropractic care is H.R. 1471. This bill would
    appear to permit eligible veterans to elect to receive needed medical
    services, rehabilitative services, and preventive health services from
    a licensed chiropractor on a direct access basis, as long as the
    chiropractor acts within the scope of practice authorized under his or
    her State license.
        VA uses chiropractic care to address certain muscular-skeletal
    conditions. However, we strongly object to extending, through
    legislation, the field of chiropractic care to the treatment of other
    medical conditions. In our view, because VA's healthcare system is
    national in scope, it should limit the scope of practice of the
    chiropractors to those procedures that are generally recognized to be
    within the scope of their practice, notwithstanding that some States
    may authorize them to provide other procedures.
        We have built our success on the primary care model using
    physicians who are trained and educated in primary care medicine.
    Primary care providers not only coordinate the delivery of healthcare
    services but also make referrals for specialty care, as needed and
    appropriate. We believe it is in our patients' best interest to
    continue having their individual primary care providers remain in
    charge of managing their care.
        H.R. 1471 could also place our patients at serious risk. Our aging
    patient population is characterized by a high degree of co-morbidities
    and complex medical conditions that require intensive and highly
    integrated clinical management skills. Their care should remain under
    the care of individual primary care providers and/or teams.
        Finally, this bill would prohibit the Secretary from discriminating
    among licensed healthcare providers in the determination of needed
    services. However, the meaning and intent of this provision is not
    clear to us.
    H.R. 339--Provision of Care from Non-VA Sources When There is an
            Extended Waiting Period for VA Care
        Mr. Chairman, H.R. 339 would require VA to furnish needed medical
    services from sources outside the Department to veterans who seek
    medical services at a VA outpatient clinic but are informed by the
    clinic that the waiting period for treatment of patients is 6 months or
    longer. This bill would also require such services to be provided under
    the same terms and conditions with respect to eligibility and
    copayments as would apply if such services were provided directly by
    the VA clinic. H.R. 339 would require the Secretary to issue
    regulations to implement this provision, which would take effect 90
    days after enactment of the Act.
        Mr. Chairman, we have not had sufficient time to evaluate H.R. 339
    and its costs. We will provide written comments on this bill for the
    record.
    H.R. 538--Access to Care for Veterans Residing in Far South Texas
        H.R. 538 sets out a series of findings regarding the healthcare
    needs of veterans residing in far south Texas, a geographical area
    defined in the bill. Within 180 days following enactment, the Secretary
    would be required to determine whether the needs of veterans in far
    south Texas would best be met--(1) through a public-private venture to
    provide inpatient services and long-term care to veterans in an
    existing facility in far south Texas; (2) through a project for
    construction of a new full-service, 50-bed hospital with a 125-bed
    nursing home in far south Texas; or (3) through a sharing agreement
    with a military treatment facility in far south Texas. H.R. 538 would
    require the Secretary to notify Congress as to the Secretary's findings
    and to submit a report to Congress identifying which of these options
    has been selected, along with a prospectus that includes projected
    timelines and additional specified data.
        We do not support H.R. 538. At the request of Senator Kay Bailey-
    Hutchison, VA has contracted with Booz Allen Hamilton to evaluate and
    report on current needs in this region of the country. This report is
    due to be delivered to VA in July 2007. VA recommends that Congress
    await the results of this ongoing evaluation before it considers
    whether to mandate a particular means for addressing the healthcare
    needs of these veterans.
    H.R. 542--Provision of VA Services in Languages Other Than English for
            Veterans With Limited English Proficiency
        Mr. Chairman, section 1 of H.R. 542 would require the Secretary to
    ensure that counseling and other authorized mental health services are
    available in both English and a language other than English, if
    requested by a veteran who has limited proficiency in the English
    language. H.R. 542 would further mandate that the Secretary develop
    procedures to identify veterans with limited English proficiency and
    inform them of this provision.
        Section 2 of H.R. 542 would require the Secretary to implement a
    system by which persons with limited English proficiency can
    meaningfully access VA services consistent with, and without unduly
    burdening, the fundamental mission of the Department. This section
    would require the Secretary to work to ensure that recipients of
    financial assistance under VA programs, in turn, provide meaningful
    access to applicants and beneficiaries with limited English
    proficiency.
        Under section 2, the Secretary would also be required to implement
    a plan to improve access to VA programs and activities by eligible
    persons with limited English proficiency, and to ensure that the plan
    is consistent with a guidance document issued by the Attorney General
    in conjunction with Executive Order 13166. The plan would have to
    include specific steps that the Secretary would take to ensure that
    these persons can meaningfully access VA programs and activities.
        Section 3 of H.R. 542 would require the Secretary to carry out a
    number of specified tasks, in developing and implementing the plan
    required by section 2. These tasks would include: (1) conducting a
    thorough assessment of the language needs of the population served by
    VA and identifying the non-English languages that are likely to be
    encountered; (2) developing a comprehensive language assistance program
    to include hiring bilingual staff and interpreters for patient and
    client con-
    tact positions; (3) translating written materials into languages other
    than English; (4) training staff on this VA access policy and its
    implementation; (5) establishing vigilant monitoring and oversight to
    ensure that persons with limited English proficiency have meaningful
    access to healthcare and services; (6) establishing a task force to
    evaluate the implementation and prioritize needed actions to implement
    the access plan; (7) developing a specific plan to ensure seamless
    transition of veterans and their families from Department of Defense
    services and benefits to VA services and benefits, including bilingual
    readjustment and bereavement counseling; (8) establishing a process to
    translate vital documents and other materials, including materials
    available on the World Wide Web, outreach brochures provided to
    servicemembers transitioning into civilian life, and the post-
    deployment health reassessment program; and (9) conducting outreach to
    veterans and their families in communities which may have higher
    proportions of populations with limited English proficiency.
        Finally, section 4 of H.R. 542 would require the Secretary to
    report to Congress on VA's implementation of VHA Directive 2002-006
    (prohibiting discrimination on the basis of national origin for persons
    with limited English proficiency in federally-conducted programs and
    activities and in Federal financial assisted programs). This report
    would also have to include an analysis of VA's capacity to provide
    services to members of the Armed Forces with limited English
    proficiency.
        Because we received a copy of H.R. 542 only very recently, we are
    still in the process of developing views and cost estimates for this
    bill. Once completed, we will provide them for the record. But we would
    like the Subcommittee to know that VA has taken significant steps to
    ensure that Executive Order 13166 is fully implemented throughout the
    Department. On February 12, 2007, VHA issued Directive 2007-009,
    Limited English Proficiency (LEP) Title VI Prohibition Against National
    Origin Discrimination in Federally-Conducted and Federally-Assisted
    Programs and Activities. This new policy updates the guidance
    previously set forth in VHA Directive 2002-006 and sets forth VHA's
    guidance on services to individuals with LEP. Similar guidance
    documents have also been issued by the National Cemetery System and the
    Veterans Benefits Administration. These LEP actions plans ensure that
    VA facilities and programs fully implement all LEP requirements.
        Mr. Chairman, in anticipation of this hearing, we also received a
    draft bill entitled the ``Rural Veterans Healthcare Act of 2007'' and a
    copy of H.R. 1944, the ``Veterans Traumatic Brain Injury Treatment Act
    of 2007.'' Because we received these two bills only very recently, we
    do not have cleared positions or costs to provide on the measures. We
    will provide written comments on the draft bill and H.R. 1944 for the
    record.
        This concludes my prepared statement. I would be pleased to answer
    any questions you or any of the Members of the Subcommittee may have.

                 Statement of the American Academy of Neurology
        The American Academy of Neurology (AAN), representing over 20,000
    neurologists and neuroscience professionals, believes that our veterans
    deserve the best possible care and treatment for neurological injuries
    sustained in their service to our country. The conflicts in Iraq and
    Afghanistan have created an emerging epidemic of traumatic brain injury
    (TBI) among combat veterans. TBI is associated with cognitive
    dysfunction, post-traumatic epilepsy, headaches and other motor and
    sensory neurological complications.
        It is essential that the Federal Government allocate the resources
    to ensure all veterans have access to the necessary neurological
    interventions and long-term treatments that their injuries require. The
    AAN believes that Congress should fund and the Department of Defense
    (DoD) should fully implement pre- and post-deployment cognitive and
    memory screening of all active duty and reserve personnel. Recognizing
    that this is not yet a reality, the AAN supports the goal of H.R. 1944
    to establish a program within the Department of Veterans Affairs (VA)
    to screen veterans who are eligible for hospital care, medical
    services, and nursing home care.
        The AAN also supports the effort to create a comprehensive program
    for long-term traumatic brain injury rehabilitation, but would
    recommend the inclusion of a specific program to address the impacts of
    TBI including seizure disorder. TBI is a major cause of epilepsy. We
    estimate that up to 40 percent of returning service personnel who
    experience TBI will develop epilepsy making this a significant service-
    connected disorder for many veterans.
        Given the likely high rate of service-connected post-traumatic
    epilepsy that veterans with TBI will experience, Congress should
    authorize and the VA should fully implement a national epilepsy
    program. This program should include a statutory mandate and the
    necessary appropriations for Epilepsy Centers of Excellence (CoEs),
    available to all veterans with epilepsy and related seizure disorders.
    Congress should authorize no less than six Epilepsy CoEs to ensure
    adequate geographic distribution and access by veterans to these
    centers. The VA should also implement epilepsy referral clinics in all
    Veterans Integrated Service Networks (VISNs).
        Congress should also appropriate adequate funds to improve the
    integration and coordination of neurology, mental health and
    rehabilitative services in the VA's polytrauma program. Every TBI
    veteran should have a neurologist as part of the rehabilitation team.
    The Neurology and Mental Health Services should become equal partners
    with the Rehabilitation Services with respect to TBI in the polytrauma
    centers and subsequent initiatives involving TBI.
        We support the Committee's efforts to improve VA's delivery of care
    to rural veterans. We recommend that the draft Rural Veterans
    Healthcare Act of 2007 include a provision to improve care to those in
    rural areas with an expansion in telehealth and telemental health
    services offered by the VA to improve the surveillance and treatment of
    veterans with TBI and related seizure disorders. Specifically, VA needs
    to develop its telemedicine capacity to transmit and review
    Electroencephalograms (EEGs), a diagnostic test which measures and
    records brain electrical activity, to VA specialists in epilepsy for
    interpretation as needed. The recommended Epilepsy Centers of
    Excellence would play a vital role in expanding VA's capacity to
    provide rural veterans with state-of-the-art diagnosis and clinical
    care through improvements in telemedicine.
        The American Academy of Neurology appreciates the opportunity to
    comment on H.R. 1944 and the draft Rural Veterans Healthcare Act of
    2007. We stand ready to assist the Health Subcommittee and the full
    Committee in any efforts to help veterans who experience TBI.

    Statement of Hon. Corrine Brown, a Representative in Congress from the
                                State of Florida
        Thank you, Mr. Chairman.
        I appreciate your calling this hearing today to listen to the many
    important bills introduced this Congress relating to veterans.
        As I have known since I was first sworn into Congress in 1993, when
    I first began my service on this Committee, veterans are very important
    to the security and defense of this country.
        Under the leadership of you, Chairman Michaud, and Chairman Filner,
    we are taking back the leadership of veterans issues to this Committee.
    It is important for the Veterans Committee to be the conduit for the
    veterans of this country to the Department of Veterans Affairs.
        Thank you again for holding this hearing and I look forward to
    hearing the testimony of the witnesses.

    Statement of Hon. Ruben Hinojosa, a Representative in Congress from the
                                 State of Texas
        I want to thank Chairman Michaud and Ranking Member Miller for
    holding this important hearing today on legislation that will help
    improve the quality of healthcare for our veterans. I am here to
    express my strong support for H.R. 538, offered by my colleague from
    south Texas, Congressman Solomon Ortiz, of which I am a cosponsor.
        South Texas has a proud history of patriotism and thousands of
    south Texans have fought in all of this country's major wars. They have
    returned to south Texas with a variety of injuries and illnesses as a
    result of their military service. Unfortunately, the closest veterans'
    hospital is more than 300 miles away in San Antonio. Many south Texas
    veterans do not have the financial means to travel to San Antonio and
    stay overnight in hotels waiting for appointments and procedures. The
    VA provides some transportation in cramped vans, but the journey is
    long and many veterans are unable to make the trip.
        In addition to the veterans who make their permanent residence in
    south Texas, my region also sees hundreds of so-called ``Winter
    Texans'' who travel to south Texas to avoid the cold winters. These
    veterans use the limited clinic services currently available and in the
    past the local Veterans Service Region has not even been reimbursed for
    their care. Although the VA has worked to resolve this problem, it
    still has not resolved the problem of how to provide adequate health
    services to this additional population.
        Since coming to Congress, I have been working to get a full-service
    veterans hospital in south Texas. I have brought several Secretaries of
    Veterans' Affairs to the
    region and they all agree that the service is inadequate. Still, nothing
     has been done.
        The veterans in my community are tired of waiting and have taken
    action. Last year, they organized a march to San Antonio to show their
    commitment to getting their own hospital. Hundreds of veterans made the
    300 mile trek to San Antonio in the heat to show the Veterans
    Administration that they were serious.
        I hope the Committee will approve a new veterans' hospital in south
    Texas so that these veterans will finally receive the healthcare they
    deserve.
        Attached to my testimony is a petition signed by over 10,000
    veterans in south Texas in support of a veterans hospital. I ask that
    it be made a part of the hearing record.
        Thank you for your consideration and for holding this important
    hearing.

    [THE PETITION IS BEING RETAINED IN THE PERMANENT COMMITTEE HEARING
    FILES AND IS NOT BEING PRINTED.]