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



                                                        S. Hrg. 110-146
 
SENATE-HOUSE JOINT FIELD HEARING ON ISSUES FACING VETERANS IN THE RURAL 
                          AREAS OF APPALACHIA

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


                             JOINT HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                                AND THE

                     COMMITTEE ON VETERANS' AFFAIRS
                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                              MAY 29, 2007

                               __________

       Printed for the use of the Committee on Veterans' Affairs


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                                 senate



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                 SENATE COMMITTEE ON VETERANS' AFFAIRS

                   Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West         Larry E. Craig, Idaho, Ranking 
    Virginia                             Member
Patty Murray, Washington             Arlen Specter, Pennsylvania
Barack Obama, Illinois               Richard M. Burr, North Carolina
Bernard Sanders, (I) Vermont         Johnny Isakson, Georgia
Sherrod Brown, Ohio                  Lindsey O. Graham, South Carolina
Jim Webb, Virginia                   Kay Bailey Hutchison, Texas
Jon Tester, Montana                  John Ensign, Nevada
                    William E. Brew, Staff Director
                 Lupe Wissel, Republican Staff Director

                  HOUSE COMMITTEE ON VETERANS' AFFAIRS

                    Bob Filner, California, Chairman
Corrine Brown, Florida               Steve Buyer, Indiana, Ranking 
Vic Snyder, Arkansas                     Member
Michael Michaud, Maine               Cliff Stearns, Florida
Stephanie Herseth Sandlin, South     Jerry Moran, Kansas
    Dakota                           Richard Baker, Louisiana
Harry E. Mitchell, Arizona           Henry Brown, South 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 Bilbray, California
Ciro 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 Shorter, Staff Director
                Jim Lariviere, Republican Staff Director


                            C O N T E N T S

                              ----------                              

                              May 29, 2007
                                SENATORS

                                                                   Page
Brown, Hon. Sherrod, U.S. Senator from Ohio......................     1
Space, Hon. Zachary, House Representative from Ohio..............     3

                               WITNESSES

Anderson, Frank, Government Relations Director, Buckeye Chapter, 
  Paralyzed Veterans of America..................................     5
    Prepared statement...........................................     8
Moore, Larry D., Legislative Chairman, Department of Ohio, 
  Veterans of Foreign Wars of the United States..................    12
    Prepared statement...........................................    14
Ondick, George, Executive Director, Department of Ohio, AMVETS...    16
    Prepared statement...........................................    18
Bertschy, Robert H., Vice Commander, Department of Ohio, Disabled 
  American Veterans..............................................    22
    Prepared statement...........................................    24
Burke, Thomas R., President, Buckeye State Council, Vietnam 
  Veterans of America............................................    26
    Prepared statement...........................................    28
Lanthorn, Donald R., Service Director, Department of Ohio, The 
  American Legion................................................    30
    Prepared statement...........................................    32
Carson, Terry M., Chief Executive Officer, Harrison Community 
  Hospital.......................................................    39
    Prepared statement...........................................    41
Cross, Gerald M., M.D., FAAFP, Acting Principal Deputy Under 
  Secretary for Health, Department of Veterans Affairs...........    42
    Prepared statement...........................................    44


SENATE-HOUSE JOINT FIELD HEARING ON ISSUES FACING VETERANS IN THE RURAL 
                          AREAS OF APPALACHIA

                              ----------                              


                         TUESDAY, MAY 29, 2007

                             U.S. Congress,
              Joint Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committees met, pursuant to notice, at 10 a.m., in 
Founders Hall Auditorium, Kent State University-Tuscarawas, 330 
University Drive, NE., New Philadelphia, Ohio, Hon. Sherrod 
Brown (Member of the Senate Committee on Veterans' Affairs) and 
Zachary Space (Member of the House Committee on Veterans' 
Affairs) presiding.
    Present: Senator Brown and Representative Space.

           OPENING STATEMENT OF HON. SHERROD BROWN, 
                     U.S. SENATOR FROM OHIO

    Senator Brown. I'm Senator Sherrod Brown, joining with 
Congressman Zach Space, many representatives of the veterans 
community, and others here this morning, and I so appreciate 
your all being here.
    I would begin the day first by asking for a moment of 
silence for the 3,400 Americans who have died in the Iraq-
Afghanistan, and the literally tens of thousands of Americans 
who have been injured, if we can start with a moment of 
silence. Thank you. I especially thank the veterans in the 
audience who are here, the veterans who will testify, the 
veterans' advocates who are with us. Every one of these veteran 
advocates have already--I believe every single one has been to 
see me in Washington. I assume many of them have been to see 
Congressman Space with his position on the Veterans' Committee. 
We know the importance of all of that.
    I thank Gregg Andrews, the Dean of Tuscarawas Branch of 
Kent State University, thank him and his staff for allowing us 
to be here. I want to, again, especially thank those that have 
come from all over the state to testify today.
    It's fitting, of course, that we're holding this hearing 
the day after Memorial Day, a date to honor our Nation's fallen 
men and women in uniform. We're focusing on improving services 
for our Nation's veterans, so we may honor them, as well. We 
have a full slate of issues, and a very ambitious agenda, so 
I'll keep my remarks brief.
    The purpose of the field hearing is to hear from veterans 
in Ohio so that we can make better decisions in Washington that 
affect our Nation's veterans. This is an official hearing. We 
have people from the Veterans' Committee in Washington. This is 
the first of its kind. To our knowledge, it's the first time 
the House and Senate Veterans' Committee have ever done a joint 
hearing outside of Washington, and we chose to do it in the 
heartland of sort of East Central Ohio, so that particularly 
veterans facing the unique problems that veterans do in rural 
Ohio, and rural parts of this country can be heard.
    We know that the Veterans' Administration, a public system, 
not a privatized one. We know that the VA gives the best 
healthcare in the country, and in the world, when it's funded 
properly. We also know the President's budget fell about $4 
billion short in funding what veterans' organizations have 
asked that we fund.
    The good news is that the Congress, now the House and the 
Senate, are working under a recently passed budget that very 
closely mirrors the request of the Independent Budget. The 
Independent Budget was put together by all the veterans service 
organizations consulting with each other, and consulting with 
the VA. And we have very closely followed the requests of that 
budget.
    While not everyone in this auditorium, of course, agrees on 
the Wars in Iraq and Afghanistan, we all agree we need to do 
everything we can to care and provide for our veterans, not 
just this year or next year, but in the decades ahead, because 
we know the immense costs. We're spending some $2.1 billion a 
week on the War in Iraq. Some estimates have shown that 
veterans' healthcare, because of the War in Iraq, will cost us 
upwards of $600 billion in the years ahead. We need to prepare 
for that now. It's not this year, next year. It's not even this 
decade, next decade only. It is costs that we need to be 
responsible for as elected officials, as veterans' advocates, 
as citizens, and as veterans, we need to prepare for, perhaps, 
as long as 50 years.
    Ohio is home, as we know, to more than one million 
veterans. These proud men and women and their families have 
sacrificed, as we know, to serve our Nation. There are Ohioans 
in this room who helped to defeat tyranny in World War II. 
There are veterans in this room who served in the conflicts of 
the cold war, enabling the United States to eventually defeat 
totalitarianism, and we have a new group of veterans, 
obviously, from the post-cold war era, from Bosnia, from 
Afghanistan, and from two conflicts in Iraq and 
Kuwait.
    Some of Ohio's veterans include Presidents Grant and 
Harrison, and Hayes and Garfield, and McKinley. Others, like 
John Glenn and Neil Armstrong, and Clark Gable, and General 
Sherman, and General Sheridan. Ohio is proud of our veterans 
who were our soldiers in combat today, proud of our veterans 
who are still living, proud of our veterans who are no longer 
with us, who served this country. I look forward to hearing the 
testimony today. We have a distinguished panel of witnesses.
    Before we get started, I will run through how this will 
work. First, Congressman Space will deliver his opening 
remarks. Then we'll proceed to hear from each witness. I will 
introduce three of the witnesses, he will introduce three. 
We'll do the introduction, then the witnesses testify. Then 
Congressman Space and I will take about five minutes to ask 
questions, and then we'll proceed to the second panel.
    I want to make a handful quickly of acknowledgments of 
people that have been helpful. I mentioned Dean Andrews, Walter 
Gritzan with Administrative and Business Services with Kent 
State; Carla Barker, who is the Assistant to Dean Andrews; Kim 
Lipsky, with the Senate on Veterans' Affairs, thank you, Kim; 
Bill Cahill, also from Senate Veterans' Affairs Committee who's 
in the back; Chris Austin from House Veterans' Affairs 
Committee; Jean Wilson from my office. From Congressman Space's 
office, Ken Engstrom, Cindy Cunningham, Mike Calevski, Barb 
Lawrence, Shirley Farver; and from Congressman Wilson's office, 
Dan Craig. Also, from my office are Doug Babcock, Beth Thames, 
Nick Watt, Laura Pechaitis, and I believe that takes care of 
everybody.
    So it's my pleasure to, not introduce because he's your 
Congressman, and in his first five months in Washington, he's 
done an outstanding job of convincing us to do this, convincing 
the Veterans' Committee in both Houses to do this first of its 
kind in the country hearing. A lot of the credit for that goes 
to Congressman Space, who has started so well, especially 
advocating for this region. He just took me into Dean Andrews 
office to advocate for something on this campus, so he doesn't 
miss any opportunity to fight for his district.
    Congressman Space.

              STATEMENT OF HON. ZACHARY T. SPACE, 
                 HOUSE REPRESENTATIVE FROM OHIO

    Mr. Space. Thank you, Senator Brown, for the introduction, 
and it is a real pleasure to be here with you today. Thank you 
for your hard work, as well as that of your staff, and the 
staff of the Senate Veterans' Affairs Committee in organizing 
today's events. I would simply state, rather than reiterate, 
just thank those same folks that you singled out, with the 
addition of Jillian Carroll, who's behind me here on my staff 
in Washington, DC.
    This is a truly special occasion, and I think it's the 
first of its kind, to my knowledge, anyway. We've managed to 
bring together the House and the Senate Veterans' Affairs 
Committees outside of Washington, DC, and we've done that here 
in Ohio, and right here in New Philadelphia in the heart of 
Ohio's 18th Congressional District. This is an indication, I 
believe, of the importance of the topics that we're going to be 
discussing today. And I am, indeed, delighted to be back here 
in New Philadelphia, just a few miles from my hometown of 
Dover.
    A special thank you, again, to Kent State University for 
allowing us to use these facilities. We very much appreciate 
their hospitality. Specifically, I'd like to thank Dean Gregg 
Andrews, Walt Gritzan, and Carla Barker, along with the rest of 
the staff, and the Tuscarawas campus community for being so 
accommodating and giving us the run of the place.
    Kent State has a special place in my heart. This, without 
question, serves as one of our most precious assets here in 
Tuscarawas County. It has given many, literally thousands, of 
young, bright, aspiring students the opportunity to further 
their education. Some of those bright, aspiring students are 
family members of mine, and we, in my family, certainly 
appreciate the value that this regional campus brings to our 
community.
    It's also my privilege to be in the company of eight 
distinguished witnesses today. I'm very much looking forward to 
hearing your testimony, gentlemen, and I look forward to 
engaging in a question and answer exchange, as well.
    I'd like to take the opportunity to recognize the members 
of my Veterans Advisory Board, many of whom are here today. I'm 
indebted to these men and women for their commitment in 
assisting me as I advocate for the needs of our Nation's 
veterans, and I cannot think of a better way, to more 
specifically advocate on behalf of Ohio's 18th District's 
veterans than to ask some of Ohio 18 veterans where they stand. 
I will rely upon the Vets Advisory Board that we created in the 
coming weeks, and months, to give their informed opinions, as 
they've already begun to do. I know I will continue to ask for 
their input on other important issues, as well.
    Can I ask those members of the Veterans Advisory Committee 
that we've created to please stand, and be recognized. Thank 
you, ladies and gentlemen. Can we have a round of applause for 
them, please.
    (Applause.)
    Mr. Space. They have traveled here to New Philadelphia from 
all parts of the 18th District, some taking more than 3 hours 
to get here today, so they should be commended, and I'd like to 
thank them for their work on behalf of our District's veterans.
    Finally, I'd like to thank the audience for their 
attendance today. I appreciate your interest in the issues 
facing rural veterans, and I appreciate you taking the time out 
of your day to join us here this morning. I hope we all find 
this event to be a useful exchange of information, as well as a 
productive forum for identifying specific problems that rural 
veterans are facing, as well as crafting solutions. My personal 
goal is to translate the ideas we hear today into legislative 
fixes back in Washington.
    A significant number of my constituents in Ohio's 18th 
District are veterans, which is why I was eager to serve on 
this Committee. A large number of our veterans live in rural 
areas around the country. I repeated hear from these rural 
veterans about the difficulties they have in accessing VA 
services and care. Ohio 18 is lucky enough to have a VA Medical 
Center in Chillicothe; however, that VAMC is about 159 miles 
from where we sit today. The closest VAMC for folks here in New 
Philadelphia is the Cleveland facility, and that's about 72 
miles from where we sit. After that, the next closest facility 
is in Pittsburgh. And we are lucky enough to have a CBOC here 
in New Philadelphia, but, of course, those CBOCs do not have 
the same capabilities as full-fledged hospitals.
    I plan on working with the VA to expand their services here 
in the 18th District. I know that will be a long, and very 
difficult battle, but I think that what we'll hear today will 
convince many that these steps are necessary to better serve 
our rural veterans.
    I'm also concerned that rural veterans are putting off 
their doctors' visits because it is such a hassle to get to 
their doctors. I'm afraid that by skipping check-ups thought to 
be non-essential, veterans are suffering in the long-term by 
not seeking preventative care. Often, it's too late when a 
medical emergency occurs.
    I know Mr. Carson can speak to the problems that non-VA 
hospitals face when they open their doors to veterans, too. In 
emergencies, our veterans need immediate care. They do not have 
the luxury of traveling over an hour to a VA facility. Our 
private hospitals have done their best to care for these 
veterans in their times of need, but they've done so without 
the assurance that they'll be reimbursed by the VA after-the-
fact. I look forward to discussing both this problem, and 
solutions to it.
    And, finally, I'm also concerned that as gas prices 
continue to shoot through the roof, it's become increasingly 
more difficult for rural veterans who, again, drive long 
distances, to afford trips to the VA facilities. The current 
mileage reimbursement rate of 11 cents per mile comes nowhere 
near the $3.30 plus cost of gasoline per gallon. I believe this 
must be addressed, as well.
    Again, I'd like to thank you all for coming today, and I'd 
like to turn it back over to Senator Brown to introduce our 
first witness today on our first panel.
    Senator Brown.
    Senator Brown. Thank you, Congressman Space. Our first 
witness will be Frank Anderson. Frank has been an advocate for 
veterans as long as I can remember, comes to my office at least 
once a year. I see him in Cleveland from time to time. He grew 
up in Cleveland, joined the Armed Forces in 1976, was injured 
in a training exercise, I believe at Fort Jackson, South 
Carolina. He has advocated for paralyzed veterans ever since. 
He and his wife, Joanna, wife of 34 years, have raised five 
children. He's always been there as an advocate, and always 
will be there as an advocate. We appreciate so much what he's 
done for veterans, generally, and specifically for the 
Paralyzed Veterans of America.
    Mr. Anderson.

  STATEMENT OF FRANK ANDERSON, GOVERNMENT RELATIONS DIRECTOR, 
                  BUCKEYE CHAPTER, PARALYZED 
                      VETERANS OF AMERICA

    Mr. Anderson. Thank you, Mr. Chairman. Mr. Chairman, 
Members of the Committee, on behalf of the Buckeye Chapter of 
Paralyzed Veterans of America, I'd like to thank you for the 
opportunity to testify before you today on issues facing 
veterans who live here in Ohio, and surrounding states. The 
challenges facing veterans here, particularly with regards to 
healthcare, are not uniquely different to many of the other 
areas of the country. However, if the VA can figure out the 
best ways to address them here, they can certainly apply those 
actions across the board.
    Due to the broad areas of possibilities, I will limit my 
comments to a few key areas that we believe require the 
greatest focus, and that are of the utmost importance. My 
comments will focus on the broader healthcare concern, 
specifically for rural veterans. I will also address our 
concerns about VA long-term care services, specifically for 
Operation Enduring Freedom, and Operation Iraqi Freedom 
veterans, as well as for veterans with spinal cord injuries or 
dysfunction. Finally, I will comment on veterans' benefits 
issues, particularly for members of the National Guard and 
Reserves.
    Given the attention that these Committees are faced on the 
issues of access to healthcare for rural veterans, it is only 
appropriate that this joint hearing be held in the state with 
many veterans who live in rural areas. PVA recognizes that 
there is no easy solution to meeting the needs of these 
veterans who live in rural areas. These veterans were not 
originally the target of 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 systems from veterans outside of typical urban or 
suburban settings.
    However, PVA remains concerned that in addressing the 
problems 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 the VA 
healthcare facilities, recognizing the fact that they do not 
always live close to the facilities. The services provided by 
the VA, particularly specialized services like spinal cord 
injury care, are unmatched in the private sector. If a larger 
pool of veterans was sent into the private sector for 
healthcare, the diversity of services and expertise in 
different fields is placed in jeopardy.
    Ultimately, PVA has a serious concern about any attempts to 
give the VA additional leverage to broaden the contracting out 
of healthcare services to veterans in geographically remote or 
rural areas. If you review the early stages of PVA's Project 
HERO, it is apparent that is a direction that some VA senior 
leadership would like to go. PVA adamantly opposes any effort 
to privatize the VA healthcare system, turning it into an 
insurer of care, and not a provider of care. Privatization is 
ultimately a means for the Federal Government to shift its 
responsibility of caring for the men and women who serve.
    PVA believes that any broader contracting out of healthcare 
service would almost certainly lead to a diminution of 
established quality, safety, and continuity of VA care. It is 
important to know 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 to the private sector. The VA's 
medical and prosthetic research program, designed to study and, 
hopefully, overcome the ills of disease and injury consequent 
to military service, would lose focus and purpose. 
Additionally, Title 38, U.S. 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.
    Furthermore, veterans who are sent out to a private sector 
for care would lose 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.
    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.
    We also believe that the VA could address the needs of 
rural veteran through broad applications of the ``hub-and-
spoke'' principle. A veteran can get his or her basic care at a 
community-based outpatient clinic (CBOC). However, if the 
veteran requires more intensive care, or a special procedure, 
he or she can be referred to a larger VA medical center. This 
would ensure the veteran continues to get the best quality care 
provided by the VA, thereby maintaining the viability of the 
system.
    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. Attempts to define ``geographically inaccessible'' 
have proven to be a very subjective effort. Access to VA 
healthcare is subject not only to population density or 
distance, but time, as well.
    PVA believes that one possible way to address the concerns 
of rural veterans is to correct the mileage reimbursement 
inequity that currently exists. It is wholly unacceptable that 
veterans have to live with the 11 cents per mile reimbursement 
rate that the VA currently provides, when all federal employees 
receive 48 cents per mile. In fact, PVA believes that some of 
the difficulty in providing care to veterans in limited access 
areas, particularly rural areas, might be eliminated with a 
sensible reimbursement rate.
    We believe that veterans will be less likely to complain 
about access issues as a result of their geographic location if 
they know that they would not have to put the majority of the 
travel expense out of their own pocket. This is a change that 
has been long overdue, and we urge the Committee and all of 
Congress to take immediate action to correct this inequity.
    In the end, we believe that in order for the VA to best 
meet this need, 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.
    In long-term care, one of the primary concerns for PVA and 
its membership is access to long-term care services in the VA. 
We have particular concerns about long-term care options for 
veterans of the newest conflicts in Iraq and Afghanistan. PVA 
believes that the age-appropriate VA non-institutional and 
institutional long-term care programming for young OEF and OIF 
veterans must be a priority for veterans and their committees. 
New VA non-
institutional and institutional long-term care programs must 
come on line, and existing programs must be re-engineered to 
meet the various needs of a younger veterans population.
    VA non-institutional long-term care program must be 
required to assist the younger injured veterans with 
catastrophic disabilities who need a wide range of support 
services, such as personal attendant services, programs to 
train attendants, peer support programs, assistive technology, 
hospital-based home care teams that are trained to treat and 
monitor specific disabilities, and transportation services. 
These younger veterans need expedited access to VA benefits, 
such as VA's Home Improvement/Structural Alteration Grant, and 
VA's adaptive housing, and auto programs.
    Senator Brown. Mr. Anderson, could you try to summarize 
your testimony? You've gone beyond the time, but if you can 
sort of summarize the end.
    Mr. Anderson. Yes, sir.
    Senator Brown. Thank you.
    Mr. Anderson. We see that our veterans in rural areas do 
need access to the system and long-term care, and operation of 
VA so that they can address these needs, and our older 
veterans. And we look forward to working with the VA and its 
staff to make sure that our veterans are receiving timely and 
quality care.
    [The prepared statement of Mr. Anderson follows:]
 Prepared Statement of Frank Anderson, Government Relations Director, 
             Buckeye Chapter, Paralyzed Veterans of America
    Mr. Chairman and Members of the Committees, on behalf of the 
Buckeye Chapter of Paralyzed Veterans of America (PVA) I would like to 
thank you for the opportunity to testify before you today on the issues 
facing veterans who live here in Ohio and surrounding states. The 
challenges facing veterans here, particularly with regards to health 
care, are not uniquely different to many other areas of the country. 
However, if the VA can figure out the best way to address them here, 
they can certainly apply those actions across the board.
    Due to the broad array of possibilities, I will limit my comments 
to a few key areas that we believe require the greatest focus and that 
are of the utmost importance. My comments will focus on broader health 
care concerns, specifically for rural veterans. I will also address our 
concerns about VA long-term care services, specifically for Operation 
Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans as 
well as for veterans with spinal cord injury or dysfunction. Finally, I 
will comment on veterans' benefits issues, particularly for members of 
the National Guard and Reserves.
                           rural health care
    Given the attention that these Committees have placed on the issue 
of access to health care for rural veterans, it is only appropriate 
that this joint hearing be held in a state with many veterans who live 
in rural areas. 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.
    However, PVA remains concerned that in addressing the problem of 
access for these veterans, the long-term viability of the VA health 
care system may be threatened. PVA members rely on the direct services 
provided by VA health care 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 health care, the diversity of services and 
expertise in different fields is placed in jeopardy.
    Ultimately, PVA has serious concerns about any attempt to give the 
VA additional leverage to broaden contracting out of health care 
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. PVA 
adamantly opposes any effort to privatize the VA health care system, 
turning it into an insurer of care and not a provider of care. 
Privatization is ultimately a means for the Federal Government to shift 
its responsibility of caring for the men and women who served.
    PVA believes that any broader contracting out of health care 
services would almost certainly lead to a diminution of established 
quality, safety and continuity of VA care. It is important to note that 
VA's specialized health care 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 to the private sector. The VA's medical and prosthetic 
research program, designed to study and hopefully overcome the ills of 
disease and injury consequent to military service, would lose focus and 
purpose. 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.
    Furthermore, veterans who are sent out to the private sector for 
care 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.
    Current law limits VA in contracting for private health care 
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.
    We also believe that the VA could address the needs of rural 
veterans through broad application of the ``hub-and-spoke'' principle. 
A veteran can get his or her basic care at a community-based outpatient 
clinic (CBOC). However, if the veteran requires more intensive care or 
a special procedure, he or she can then be referred to a larger VA 
medical center. 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.
    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. Attempts to define ``geographically inaccessible'' have proven 
to be a very subjective effort. Access to VA health care is subject not 
only to population density or distance, but time as well.
    PVA believes that one possible way to address the concerns of rural 
veterans is to correct the mileage reimbursement inequity that 
currently exists. It is wholly unacceptable that veterans have to live 
with the 11 cents per mile reimbursement rate that the VA currently 
provides when all Federal employees receive 48 cents per mile. In fact, 
PVA believes that some of the difficulty in providing care to veterans 
in limited access areas, particularly rural areas, might be eliminated 
with a sensible reimbursement rate. We believe that veterans would be 
less likely to complain about access issues as a result of their 
geographic location if they know that they will not have to foot the 
majority of the travel expense out of their own pocket. This is a 
change that has been long overdue, and we urge the Committees and all 
of Congress to take immediate action to correct this inequity.
    In the end, we believe that in order for the VA to best meet this 
demand, adequate funding needs to be provided for VA health care 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.
                             long term care
    One of the primary concerns for PVA and its membership is access to 
long-term care services in the VA. We have particular concerns about 
the long-term care options for veterans of the newest conflicts in Iraq 
and Afghanistan. PVA believes that age-appropriate VA non-institutional 
and institutional long-term care programming for young OEF/OIF veterans 
must be a priority for VA and these Committees. New VA non-
institutional and institutional long-term care programs must come on 
line and existing programs must be re-engineered to meet the various 
needs of a younger veteran population.
    VA's non-institutional long-term care programs will be required to 
assist younger injured veterans with catastrophic disabilities who need 
a wide range of support services such as: personal attendant services, 
programs to train attendants, peer support programs, assistive 
technology, hospital-based home care teams that are trained to treat 
and monitor specific disabilities, and transportation services. These 
younger veterans need expedited access to VA benefits such as VA's Home 
Improvement/Structural Alteration (HISA) grant, and VA's adaptive 
housing and auto programs so they can leave institutional settings and 
go home as soon as possible. PVA also believes that VA's long-term care 
programs must be linked to VA's new polytrauma centers so that younger 
veterans can receive injury specific annual medical evaluations and 
continued access to specialized rehabilitation, if required, following 
initial discharge.
    VA's institutional nursing home care programs must change direction 
as well. Nursing home services created to meet the needs of aging 
veterans will not serve young veterans well. As pointed out in The 
Independent Budget for FY 2008, VA's Geriatric and Extended Care staff 
must make every effort to create an environment for young veterans that 
recognizes they have different needs. Younger catastrophically injured 
veterans must be surrounded by forward-thinking administrators and 
staff that can adapt to youthful needs and interests. The entire 
nursing home culture must be changed for these individuals, not just 
modified. For example, therapy programs, living units, meals, 
recreation programs, and policy must be changed to accommodate young 
veterans entering the VA long-term care system.
    PVA is also concerned that many veterans with spinal cord injury 
and disease are not receiving the specialized long-term care they 
require. VA has reported that over 900 veterans with SCI/D are 
receiving long-term care outside of VA's four SCI/D designated long-
term care facilities. However, VA cannot report where these veterans 
are located or if their need for specialized medical care is being 
coordinated with area VA SCI/D centers.
    Today's VA SCI/D long-term care capacity cannot meet current or 
future demand for these specialized services. Waiting lists exist at 
the four designated SCI/D facilities.
    Currently, VA only operates 125 staffed long-term care (nursing 
home) beds for veterans with SCI/D. These facilities are located at: 
Brockton, Massachusetts (30 beds); Castle Point, New York (15 beds); 
Hampton, Virginia (50 beds); and 30 beds at the Hines Residential Care 
Facility in Chicago, Illinois. Geographic accessibility is a major 
problem because none of these facilities are located west of the 
Mississippi River. New designated VA SCI/D long-term care facilities 
must be strategically located to achieve a national geographic balance 
to long-term care to meet the needs of veterans with SCI/D that do not 
live on the East coast of the United States.
    VA's own Capital Asset Realignment for Enhanced Services (CARES) 
data for SCI/D long-term care reveals a looming gap in long-term care 
beds to meet future demand. VA data projects an SCI/D long-term care 
bed gap of 705 beds in 2012 and a larger bed gap of 1,358 for the year 
2022. VA's proposed CARES SCI/D long-term care projects would add 
needed capacity (100 beds) but are very slow to come on line. CARES 
proposes adding 30 SCI/D LTC beds at Tampa, Florida; 20 beds at 
Cleveland, Ohio; 20 beds at Memphis, Tennessee; and 30 beds at Long 
Beach, California. The CARES Tampa project is currently under 
construction but is not scheduled to open for another 2 years and the 
Cleveland project is currently in the design phase but remains years 
from completion. The Buckeye Chapter is particularly pleased that the 
Cleveland/Brecksville project is moving forward. This will prove to be 
a critical facility for meeting the long-term, specialized care needs 
of PVA members. Finally, the Memphis and Long Beach projects have not 
even entered the planning stage at this time.
    Methods for closing the VA SCI/D long-term care bed gap and 
resolving the geographic access service issue are part of the same 
problem for PVA. VA's Construction Budget for 2008 includes plans for 
new 120 bed VA nursing homes to be located in Las Vegas, Nevada and at 
the new medical center campus in Denver, Colorado. Also, VA has 
announced construction planning of a new 140 bed nursing home care unit 
in Des Moines, Iowa.
    Mr. Chairman, PVA needs your support to ensure VA construction 
planning dedicates a percentage of beds at each new VA nursing home 
facility for veterans with SCI/D. PVA requests that Congress mandate 
that VA provide for a 15 percent bed set-aside in each new VA nursing 
home construction project to serve veterans with SCI/D and other 
catastrophic disabilities. These facilities will require some special 
architectural design improvements and trained staff to meet veteran 
need. However, much of the design work has already been accomplished by 
PVA and VA's Facility Management team. This Congressional action will 
help reduce the SCI/D bed-gap and help meet the current and future 
demand for long-term care. While a 15 percent bed allocation in new VA 
nursing home construction plus the proposed CARES LTC projects do not 
solve the looming bed gap problem in the short run it is a good first 
step and these additions will improve VA's SCI/D long-term care 
capacity in the western portion of the country.
    Public Law 109-461 required VA to develop and publish a strategic 
plan for long-term care. PVA congratulates Congress on understanding 
the importance of this issue to ensure that America's catastrophically 
disabled and aging veteran population is well cared for. During the 
organization of VA's strategic long-term care plan PVA calls on VA and 
Congress to pay careful attention to the institutional and non-
institutional long-term care needs of veterans with SCI/D and other 
catastrophic disabilities. We request that PVA and other veterans 
service organizations have an opportunity to provide input and assist 
VA as it moves forward in the development of this important document.
    In the past, and even today, many veterans with spinal cord injury 
or disease and other catastrophic disabilities were shunned from 
admittance to both VA and community nursing homes because of their high 
acuity needs. PVA believes that catastrophic disability must never be 
grounds to refuse admittance to VA or contract VA long-term care 
services. PL 109-461 requires VA to include data on, ``the provision of 
care for catastrophically disabled veterans; and the geographic 
distribution of catastrophically disabled veterans.'' This information 
is critical if VA's strategic plan is to adequately address the needs 
of this population.
                           veterans benefits
    PVA realizes that there is a desire to fix the problems with the 
claims backlog in the Veterans Benefits Administration (VBA) 
immediately. However, we must emphasize that there is no quick fix that 
can be implemented to fix these problems. The backlog has become too 
extensive to simply place some arbitrary requirement on VBA that will 
not address the long-term situation.
    We believe that the VA cannot continue to make changes in VBA, and 
specifically the claims process, sporadically. We believe that the only 
way the VA will ever get a handle on the claims process, the backlog, 
and associated problems is to pick a specific date to make major 
changes. It cannot implement change piecemeal.
    We realize that fixing the discharge and subsequent claims process 
is no easy task. However, we should not be shooting at individual 
targets to attempt to fix the overall problem. It will take innovative 
approaches focused on the broader system.
    In the end, we believe that many of the problems in the Veterans 
Benefits Administration are centered on proper training and 
accountability. Without uniform training across all of VBA on the 
standards established in regulations, problems will continue to arise 
and the claims backlog will continue to grow. Furthermore, it is 
absolutely essential that VBA personnel at all levels be held 
accountable for their own actions and the actions of their 
subordinates. Although we continue to advocate for adequate resources 
and additional staff, these steps will not go far enough if training 
and accountability are not a major component. Similarly, we recognize 
that veterans service organizations have a commensurate obligation to 
properly train and supervise their personnel.
    Finally, despite efforts by VA to address all of the needs and 
concerns of OEF/OIF veterans, another population of these men and women 
still continue to receive lesser service than their active duty 
counterparts--National Guard and Reserves. We have testified many times 
in the past as to the importance of effective outreach, particularly 
for the National Guard and Reserves. It is only appropriate that 
National Guard and Reserve servicemembers be handled in the same way as 
active duty servicemembers. The level of service being required of 
these men and women in current operations more than justifies the need 
to inform them of all of the health care and benefits services 
available.
    Mr. Chairman and Members of the Committees, the Buckeye Chapter 
stands ready to assist you in any way to address the needs of veterans 
here in Ohio and across America. It is vitally important that we work 
together to ensure that the best improvements are made to benefit 
veterans and their families.
    Thank you again for the opportunity to testify. I would be happy to 
answer any questions that you might have.

    Senator Brown. Thank you. And understand, everyone's 
written statement will be in the record in its entirety. These 
statements will be used as we use Committee hearings in 
Washington to move forward, as Congressman Space said, on 
legislative efforts. One of the efforts you mentioned, Mr. 
Anderson, on the mileage reimbursement should have been fixed a 
long time ago. I am convinced it will be fixed in this 
Congress. Senator Tester, and I, and others from Montana have 
worked on legislation, and we will move forward on that, so 
thank you for that.
    Mr. Larry Moore is our next witness. Mr. Moore was in 
active duty as a U.S. Navy CB in Vietnam from 1968 to 1970, 
State Legislative Impact Chairman of the Veterans of Foreign 
Wars, Department of Ohio. He's Director of the Richland County 
Veterans Service Commission, and he spoke a couple of days ago 
with my mother in Mansfield.
    So, Mr. Moore, nice to have you with us. Thank you.

          STATEMENT OF LARRY MOORE, STATE LEGISLATIVE 
 DIRECTOR, DEPARTMENT OF OHIO, VETERANS OF FOREIGN WARS OF THE 
                         UNITED STATES

    Mr. Moore. Well, thank you. Thank you, ladies and 
gentlemen. Senator Brown, Representative Space, I am pleased to 
be here before you today representing the 139,000 men and women 
of the Veterans of Foreign Wars Department of Ohio, and our 
Ladies 
Auxiliary.
    The first issue to be addressed today is access to the VA 
healthcare system by veterans living in rural areas. Continuing 
to expand VA community-based outreach clinics by either leasing 
existing space, or new construction, should be one of the 
priorities of the VA and Congress. The goal of these clinics is 
to bring healthcare to a local level for our veterans, and 
expanding these types of facilities in rural areas only makes 
good sense.
    The community-based outpatient clinics provide basic 
healthcare needs, with an emphasis on preventative measures to 
screen and test for such things as diabetes, heart conditions, 
prostate cancer, and mental health conditions. The clinics 
staff, registered nurses, and licensed social case workers, who 
provide medical and mental healthcare covering an average of 
six counties both in the clinic office, and at the veteran's 
personal home.
    Studies have shown that the VA healthcare is less costly 
than that in the private sector. Expansion of these clinics 
would potentially save the taxpayers millions of dollars, and 
continue to bring medical treatments on a local level, rather 
than the past practice of a regional VA medical center. If a 
primary doctor feels a veteran needs to see a specialist, then 
he will make an appointment at one of the VA medical centers; 
however, this causes a problem for veterans living in rural 
areas, because these centers can be hundreds of miles from his 
home, with no public transportation available. This forces him 
to either provide his own transportation, rely on a family 
member or friend to transport him for his appointment.
    The VA does provide gas mileage reimbursement to VA medical 
facilities for appointments, but not at the present IRS rate of 
48.5 cents per mile currently allowed to any businessman, 
county, state, or federal employee. The VA allows only 11 cents 
per mile. Most veterans I work with find this to be a complete 
joke, and will not even bother filling out the paperwork for 
the reimbursement. Not only do I agree this is a complete joke, 
but I also feel it is a total insult to those who honorably 
served this country.
    I would ask Congress to investigate and find a solution 
that allows that reflects today's high gasoline cost, not that 
of 1960. The majority of the veterans must make multiple trips 
to these regional VA medical centers. For example, on average, 
it takes three trips for hearing aids, dental crowns, and 
eyeglasses, and cancer treatments of radiation and chemotherapy 
can take ten trips. To someone living in an already 
economically depressed region, can you imagine the difficulty 
and personal expense to the veteran and his family? Is this 
what Congress meant in 1996 when legislation was passed, 
stating that all honorably discharged veterans would be 
eligible for VA healthcare as long as you can get there.
    The VA Health Administration has developed a program to 
provide more home care for patients. The program, which would 
allow practitioners to manage more patients, is called Care 
Coordination. This program would eliminate the need for 
frequent visits by patients to VA medical facilities. Through 
the Internet, telephone lines, and telemedicine units, such as 
the glucometer devices, VHA medical professionals will remotely 
observe patients with multiple chronic conditions, such as 
mental health, diabetes, congestive heart failure, and spinal 
cord injury.
    One such device, called a Telebuddy, attaches to a 
patient's phone jack. The patient responds to questions about 
how he is feeling, and whether he took his medication. If there 
is no problem, the device flashes green. If the patient does 
not answer, the patient's case manager is notified. This is an 
extremely useful tool to those VA staffers who make these house 
calls, especially on the mental health side. These units are 
programmed to ask targeted questions that could provide early 
warning that the veteran's possible depression or PTSD 
condition may be at a level dangerous to himself, or his 
family.
    Construction of new CBOCs, community-based outreach 
clinics, cannot happen over night. And in the meantime, short-
term solutions need to be addressed. Some of those short-term 
solutions presently being considered by Congress are the 
following. House Resolution 92, the Veterans Timely Access to 
Health Care Act.

              HOUSE RESOLUTION 315, THE HEALTHY VETS ACT; 
                          HOUSE RESOLUTION 339

    The VFW strongly supports the intent of these types of 
legislation. We do have some concerns, however, with the 
potential for overuse of contracting care, but there are 
certainly areas where its use is proper. Fee-basis care is more 
expensive than that of the 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.

                         HOUSE RESOLUTION 1426

    The VFW strongly opposes this legislation, which would 
allow any veteran to elect to receive contracted care whenever 
they choose. 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 in the future. That is 
unacceptable.

             DRAFT BILL, THE RURAL VETERANS HEALTH CARE ACT

    The VFW supports this bill, which would make changes and 
improvements to the availability of healthcare for rural area 
veterans. With over 44 percent of the returning servicemembers 
living in rural areas, the access problem they, and all 
veterans, face are of increasing importance. This legislation 
acknowledges that, and we are happy to support it.
    Lastly, I would ask Congress to bear in mind the long-term 
cost of care for those wounded servicemembers returning from 
the War in Iraq. Head and limb injuries are signature wounds of 
this war, because Iraqi insurgents have made the IED their 
weapon of choice. Modern armor and rapid care mean that most of 
the injured survive, but many live with traumatic brain 
injuries and 
amputations.
    I would point out the hidden danger with respect to head 
injuries. Between January 2003 and April of 2006, of the 692 
traumatic brain injuries treated at Walter Reed Army Hospital, 
nearly 90 percent had non-penetrating head injuries from the 
sheer concussion of the blast from an IED. Returning combat 
veterans may not know they suffer such a wound, and since this 
type of injury isn't immediately apparent or visible to the 
naked eye, medical personnel may miss the diagnosis if the 
proper screening methods are not used.
    Coupled with TBI-type injuries, there's Post Traumatic 
Stress Disorder, better known as PTSD. Many servicemembers have 
had multiple deployments to combat zones, and studies show 
there is a 50 percent greater chance these combat veterans may 
develop issues involving PTSD; and in most cases, these are 
young men and women with serious service-connected disabilities 
who will need expensive care for many years.
    My hope is more emphasis will be put on screening for TBI, 
depression, and PTSD. I do not wish to have another sobbing 
mother in my office personally blaming herself for her 20-year-
old Marine reservist son's suicide, who just returned from a 
tour in Iraq.
    The VA system may not be perfect, but when adequately 
funded in a timely manner by Congress, the ability to deliver 
quality healthcare and reduce lengthy claims waiting periods 
for service-connected disabilities could be achieved.
    Senator Brown, Representative Space, this concludes the 
VFW's testimony, and I would be happy to answer any questions 
you may have. Thank you.
    [The prepared statement of Mr. Moore follows:]
Prepared Statement of Larry D. Moore, Legislative Chairman, Department 
         of Ohio, Veterans of Foreign Wars of the United States
    Senator Brown and Representative Space:
    I am pleased to be here before you today representing the one 
hundred and thirty-nine thousand men and women of the Veterans of 
Foreign Wars Department of Ohio and our Ladies Auxiliary.
    The first issue to be addressed today is access to the VA 
healthcare system by veterans living in rural areas. Continuing to 
expand VA community based outreach clinics by either leasing existing 
space or new construction should be one of the priorities of the VA and 
Congress. The goal of these clinics is to bring health care to a local 
level for our veterans, and expanding these types of facilities into 
rural areas only makes good sense. The Community Based Outpatient 
Clinics provide basic healthcare needs, with an emphasis on preventive 
measures to screen and test for such things as diabetes, heart 
conditions, prostate cancer, and mental health conditions. The clinics 
staff registered nurses and licensed social case workers, who provide 
medical and mental healthcare covering an average of six counties both 
in the clinic office and at the veterans personal home. Studies have 
shown that VA healthcare is less costly than in the private sector. 
Expansion of these clinics would potentially save the taxpayers 
millions of dollars, and continue to bring medical treatments on a 
local level rather than the past practice of a regional VA medical 
center. If the primary doctor feels the veteran needs to see a 
specialist, then he will make an appointment at one of the VA medical 
centers; however, this causes a problem for veterans living in rural 
areas, because these centers can be hundreds of miles from his home 
with no public transportation available. This forces him to either 
provide his own transportation or rely on a family member or a friend 
to transport him for his appointment.
    The VA does provide gas mileage reimbursement to VA medical 
facilities for appointments, but not at the present IRS rate of 48 
cents per mile currently allowed to any businessman or county, state or 
Federal employee--the VA allows veterans only 11 cents per mile. Most 
veterans I work with find this to be a complete joke, and will not even 
bother filling out the paperwork for the reimbursement. Not only do I 
agree that this is a complete joke, but also I feel this is a total 
insult to those who honorably served this country. I would ask Congress 
to investigate, and find a solution to allow a gas reimbursement that 
reflects today's high gasoline cost, not that of 1960. The majority of 
veterans must make multiple trips to these regional VA medical 
centers--for example on average it takes three trips for hearing aids, 
dental crowns, and eyeglasses, and cancer treatments of radiation and 
chemotherapy can take ten trips. To someone living in an already 
economically depressed region, can you imagine the difficulty and 
personal expense to the veteran and his family?! Is this what Congress 
meant in 1996 when legislation was passed, stating that all honorably 
discharged veterans were eligible for VA health care as long you can 
get there?!
    The VA Health Administration has developed a program to provide 
more home care to patients. The program, which would allow 
practitioners to manage more patients, is called care coordination. 
This program would help eliminate the need for frequent visits by 
patients to VA medical facilities. Through the Internet, telephone 
lines and telemedicine units such as glucometer devices, VHA medical 
professionals will remotely observe patients with multiple chronic 
conditions such as mental illness, diabetes, congestive heart failure, 
and spinal cord injury. One such device, called a Telebuddy, attaches 
to a patient's phone jack. The patient responds to questions about how 
he is feeling and whether he took his medication. If there is no 
problem, the device flashes green. If the patient does not answer, the 
patient's case manager is notified. This is an extremely useful tool to 
those VA staffers who make these house calls, especially on the mental 
health side, these units are programmed to ask targeted questions that 
could provide early warning that the veterans possible depression or 
PTSD condition maybe at a level dangerous to himself or his family.
    Construction of new CBOCs cannot happen over night, and in the 
meantime, short term solutions need to be addressed. Some of those 
short-term solutions presently being considered by Congress are the 
following:
        h.r. 92, the veterans timely access to health care act; 
                h.r. 315, the healthy vets act; h.r. 339
    The VFW strongly supports the intent of these types of legislation. 
We do have concerns, however, with the potential for overuse of 
contracting care but there are certainly areas where its use is proper. 
Fee-basis care is more expensive than that of the VA, and we believe 
that it would do great harm to those veterans who elect to stay in the 
high-quality VA health care system by taking away funding for the 
system as a whole.
                               h.r. 1426
    The VFW strongly opposes this legislation, which would allow any 
veteran to elect to receive contracted care whenever they choose. 
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.
             draft bill, the rural veterans health care act
    The VFW supports this bill, which would make changes and 
improvements to the availability of health care for rural veterans. 
With over 44 percent of returning servicemembers living in rural areas, 
the access problems they and all veterans face are of increasing 
importance. This legislation acknowledges that, and we are happy to 
support it.
    Lastly, I would ask Congress to bear in mind the long-term cost of 
care for those wounded servicemembers returning from the War on Terror. 
Head and limb injuries are signature wounds of this war, because Iraqi 
insurgents have made the IED their weapon of choice. Modern armor and 
rapid care mean that most of the injured survive, but many live with 
traumatic brain injuries and amputations. I would point out the hidden 
danger with respect to head injuries--between January 2003 and April 
2006, of the 692 traumatic brain injuries treated at Walter Reed Army 
Hospital, nearly 90 percent had non-penetrating head injuries from the 
sheer concussion of the blast from IEDs. Returning combat veterans may 
not know they have suffered such a wound, and since this type of injury 
isn't immediately apparent or visible to the naked eye, medical 
personnel may miss the diagnosis if the proper screening methods are 
not used. Coupled with TBI type injuries is Post Traumatic Stress 
Disorder (PTSD). Many servicemembers have had multiple deployments to 
combat zones, and studies now show there is a 50 percent greater chance 
these combat veterans may develop issues involving PTSD; and in most 
cases these are young men and women with serious service-connected 
disabilities, who will need expensive care for many years. My hope is 
more emphasis will be put on screening for TBI, depression, and PTSD. I 
do not wish to have another sobbing mother sit in my office personally 
blaming herself for her twenty-year old marine reservist son's suicide, 
who just returned from a tour in Iraq.
    The VA System may not be perfect, but when adequately funded in a 
timely manner by Congress, the ability to deliver quality healthcare 
and reduce lengthy claims waiting periods for service-connected 
disabilities could be achieved.
    Senator Brown and Representative Space, this concludes the VFW's 
testimony, I would be happy to answer any questions you may have.
    Thank you.

    Senator Brown. Thank you very much, Mr. Moore.
    George Ondick, his wife, Monica, graduated from Avon High 
School, a community in Lorain County where I live. He is 
Executive Director of AMVETS Ohio, currently the Vice President 
of the Ohio Veterans' Hall of Fame Foundation. He graduated 
from high school and entered the United States Marine Corps, 
was discharged in 1971.
    Mr. Ondick, glad to have you. Thank you.

 STATEMENT OF GEORGE ONDICK, EXECUTIVE DIRECTOR, DEPARTMENT OF 
                          OHIO, AMVETS

    Mr. Ondick. Thank you, Senator.
    Mr. Chairman, Members of the Committee, I'm pleased to 
appear today to offer testimony on behalf of the Ohio AMVETS 
related to Department of Veterans' Affairs remote and rural 
veterans' issues.
    In a 2004 study of more than 767,000 veterans by Veterans' 
Affairs researchers shows those in rural areas are in poorer 
health than their urban counterparts. The findings reported in 
the October American Journal of Public Health, validate the 
recent and ongoing VA efforts to expand healthcare for rural 
patients.
    ``We need to think about veterans who live in rural 
settings as a special population, and we need to carefully 
consider their needs when designing healthcare delivery 
systems,'' said study leader William B. Weeks, a physician and 
researcher with White River Junction VA Medical Center and 
Dartmouth Medical School. Senior author on the study was 
Jonathan B. Perlin, VA Acting under-
secretary for health.
    The study included 767,109 veterans who had used VA 
healthcare between 1996 and 1999. VA had then just begun 
setting up community-based outpatient clinics (CBOCs) to 
provide primary care closer to home for rural veterans. Today, 
there are nearly 700 CBOCs in the VA's nationwide system, and 
recent recommendations from the VA's Capital Asset Realignment 
for Enhanced Services initiatives call for the establishment of 
more than 150 additional CBOCs.
    Many veterans living in remote areas have found several 
problems on reaching the VA Medical Centers and VA Clinics; 
some due to their inability to obtain transportation, and 
others due to inability to pay for their transportation. In 
Ohio, most county Veterans Service Commissions will provide 
transportation for ``qualified'' veterans. However, a disabled 
veteran going for VA healthcare, may receive from the VA a 
mileage allotment of 11 cents per mile, with a $3 deductible 
each way. Compare that 11 cents to a VA employee receiving 48.5 
cents, which is considerably more for the same trip, and no 
deductible. Why is there a difference? The veteran has to pay 
the same $3.50 for fuel, as does the VA employee.
    Veterans' Affairs community-based outpatient clinics were 
established to change from the centralized idea of admitting 
many veterans to a hospital for treatment, to smaller, more 
localized service on an outpatient basis. This, seemingly, is 
much better for the patient, the family, and the VA budget. It 
has worked quite well until the veterans' healthcare outreach 
was stopped due to budget 
restrictions.
    The VA Health Administration had an outreach program that 
worked quite well. The VAMCs would send a team, a doctor, 
nurse, technician, and an administrative clerk, to various 
remote areas to do routine healthcare. In southern Ohio, there 
were many examples; a team went to Pomeroy, 88 miles away from 
the Chillicothe VAMC, and Jackson, 45 miles away from the 
Chillicothe VAMC, as well as several other locations. In 
Jackson, they set up shop in a veterans service organization 
post. In Pomeroy, they used part of the Holzer Clinic. There 
were may outreach clinics in operations, until the budget 
problems in January 2003 caused their closing.
    The VA policy on establishing VA CBOCs was established so a 
veteran would not have to travel over 35 miles to obtain 
healthcare. It was changed to 40 miles. Now the strange thing 
is, in northern Ohio, there are VA clinics fairly well covering 
all geographic areas, and only one facility is scheduled to 
close, and it is within the 40 mile limit.
    Now, I was just reviewing the map with Mr. Montague, and 
the CBOCs are in a 30-mile radius; however, the drive time and 
distance is greater. The infrastructure in rural areas is not 
the same as in urban areas.
    Mr. Ondick. I'd like to correct that, and move on.
    Those veterans who depended on outreach visits must now 
travel 80 miles or more to visit a doctor to get their 
treatments, and then drive back 80 miles or so. For those 
needing radiation, they are further transferred to Cincinnati 
in a van. In Cincinnati, they are given their radiation 
treatment, which causes great nausea, then delivered back to 
their vehicle for the 80 miles or more drive home. What a way 
to say thank you for your service.
    The understandable rationale is that the VA facilities are 
set up in areas that will service the largest number of 
veterans, and thus, being cost-effective. This put us in our 
present conundrum of providing for veterans's in remote and 
rural areas. These veterans served and sacrificed just as much 
as their counterparts in large populated areas. It is AMVETS' 
position that we need the VA medical outreach re-established 
for those in remote and rural areas of Ohio, and the Nation. We 
owe our rural veterans this service, and more.
    The AMVETS is currently providing outreach to veterans in 
southern Ohio, filing claims on their behalf. With each claim 
we file, we create another access dilemma for the veterans we 
serve. Again, it is the AMVETS' position that we need the VA 
medical outreached re-established for those veterans in remote 
and rural areas of Ohio and this Nation. I also believe the VA 
created an Office of Rural Health Care, it should be funded and 
supported.
    I would also like to take this time to reiterate the AMVETS 
legislative priorities for 2007, and they are as follows. I'm 
not going to go into great detail on this. I will headline 
those, because they've been brought to the Committee's 
attention in the past, and you have the testimony.
    The President's Budget Request for VA in Fiscal Year 2008 
seeks approximately $86.7 billion for veterans' benefits and 
services. This amounts to $39.4 billion in discretionary 
funding, and $44.9 billion in mandatory appropriations. In 
Fiscal Year 2008, AMVETS requests roughly $43.6 billion in 
discretionary funding.
    We seek mandatory funding for VA healthcare, extended 
enrollment for OEF and OIF veterans, seamless transition, Post 
Traumatic Stress Disorder, and Traumatic Brain Injury care for 
our veterans, VA burial allowance, and taking care of the VA 
claims 
backlog.
    I'd like to thank you for this opportunity to testify, and 
if you have any questions regarding these priorities, or you 
need additional information, you can reach me at my office. I'd 
like to thank you for holding this hearing, and providing us 
the opportunity to present testimony.
    [The prepared statement of Mr. Ondick follows:]
       Prepared Statement of George Ondick, Executive Director, 
                       Department of Ohio, AMVETS
    Mr. Chairman and Members of the Subcommittee:
    I am pleased to appear today to offer testimony on behalf of Ohio 
AMVETS related to Department of Veterans Affairs (VA) remote and rural 
veterans' issues.
    In a 2004 study of more than 767,000 veterans by Veterans Affairs 
researchers shows those in rural areas are in poorer health than their 
urban counterparts. The findings, reported in the October American 
Journal of Public Health, validate recent and ongoing VA efforts to 
expand health care for rural patients.
    ``We need to think about veterans who live in rural settings as a 
special population, and we need to carefully consider their needs when 
designing healthcare delivery systems,'' said study leader William B. 
Weeks, M.D., MBA, a physician and researcher with the White River 
Junction VA Medical Center and Dartmouth Medical School. Senior author 
on the study was Jonathan B. Perlin, M.D., Ph.D., VA's acting Under 
Secretary for Health.
    The study included 767,109 veterans who had used VA healthcare 
between 1996 and 1999. VA had then just begun setting up Community 
Based Outpatient Clinics (CBOCs) to provide primary care closer to home 
for rural veterans. Today there are nearly 700 CBOCs in VA's nationwide 
system, and recent recommendations from VA's Capital Asset Realignment 
for Enhanced Services (CARES) initiative call for the establishment of 
more than 150 additional CBOCs.
    Many veterans living in remote areas have found several problems on 
reaching the VA Medical Centers and VA Clinics; some, due to their 
inability to obtain transportation, and others due to inability to pay 
for their transportation. In Ohio, most County Veterans Service 
Commissions will provide transportation for ``qualified'' veterans. 
However, a disabled veteran going for VA Healthcare, may receive from 
the VA mileage of 11 cents per mile with a $3 deductible each way. 
Compare that 11 cents to a VA employee receiving 48.5 cents which is 
considerably more for the same trip and no deductible. Why is there a 
difference? The veteran has to pay the same $3.50 for fuel as does the 
VA employee.
    Veterans Affairs Community Based Outpatient Clinics (VA CBOCs or 
CBOC) were established to change from the centralized idea of admitting 
many veterans to a hospital for treatment, to smaller, more localized 
service on a outpatient basis. This seemingly is much better for the 
patient, the family and the VA budget. It had worked quite well until 
the veterans' healthcare outreach was stopped due to budget 
restrictions.
    The VA Health Administration had an outreach program that worked 
quite well. The VAMCs would send a team (a doctor, nurse, technician 
and admin clerk) to various remote areas to do the routine healthcare. 
In southern Ohio, there were many examples: a team went to Pomeroy, 88 
miles away from the Chillicothe VAMC, and Jackson, 45 miles away from 
the Chillicothe VAMC, as well as several other locations. In Jackson, 
they set up shop in a VSO post. In Pomeroy, they used part of the 
Holzer Clinic. There were many ``outreach clinics'' in operation, until 
the budget problems in January 2003 caused their closing.
    The VA policy on establishing VA CBOCs was established so a veteran 
would not have to travel over 35 miles to obtain healthcare. It was 
changed to 40 miles. Now the strange thing is in northern Ohio, there 
are VA Clinics fairly well covering all geographic areas and only one 
facility is scheduled to close and it is within 40 miles of VA clinics 
on each side (see attached map showing VISN 10 only so the NW corner of 
Ohio appears uncovered). This gives us an idea of the problem. In the 
western portion, the Cincinnati area, there are plenty of VA 
facilities, many within 30 miles of one another. In remote/rural 
southeast Ohio, it is a different story. The CBOC program has been 
curtailed. There are VA CBOCs in Athens, Portsmouth and Marietta, which 
cover as much area as 20 facilities in other areas of Ohio. Those 
veterans who depended on outreach visits must now travel 80 or more 
miles to visit a doctor to get their treatments and then drive back 80 
or so miles. For those needing radiation, they are further transferred 
to Cincinnati in a van. In Cincinnati, they are given their radiation 
treatment, which causes great nausea, then delivered back to their 
vehicle for the 80 miles or more drive home. What a way to say thank 
you for your service to our great Nation!!!
[GRAPHIC] [TIFF OMITTED] 37533.001

    [Note: Since the map is not printed in color, the following 
describes the legend.]

    Chillicothe VAMC = Blue
      Cambridge CBOC, Lancaster, Marietta, Athens, Portsmouth.

    Cincinnati VAMC = Yellow
      Hamilton CBOC, Clermont County CBOC, Bellevue CBOC, Florence, KY
        Ft. Thomas, IN campus.

    Louis Stokes Cleveland VAMC = Green
      Lorain CBOC, Painesville, Sandusky, McCafferty, Ravenna, Akron, 
Mansfield,
        Warren, Youngstown, Canton, East Liverpool, New Philadelphia.

    Chalmers P. Wylie Outpatient Clinic = Red
      Marion CBOC, Grove City CBOC, Newark, Zanesville.

    Dayton VAMC = Magenta
      Lima CBOC, Richmond IN CBOC, Sprinfield, Middletown.

    The understandable rationale is that VA facilities are set up in 
areas that will service the largest number of veterans and thus being 
cost effective. This put us in our present conundrum of providing for 
veterans in remote/rural areas. Those veterans served and sacrificed 
just as much as their counterparts in large populated areas. It is 
AMVETS' position that we need the VA medical outreach reestablished for 
those in remote/rural areas of Ohio and the Nation. We owe our rural 
area veterans this service and more.
    The AMVETS is currently providing outreach to veterans in southern 
Ohio, filing claims on their behalf. With each claim we file, we create 
another access dilemma for the veterans we serve. Again, it is AMVETS' 
position that we need the VA medical outreach reestablished for those 
in remote/rural areas of Ohio and the Nation. I also believe the VA 
created an Office of Rural Health Care it should be funded, and 
supported.
    I would also like to take the time to reiterate the AMVETS 
legislative priorities for 2007, they are as follows:
      the department veterans affairs (va) fiscal year 2008 budget
    The President's budget request for VA in Fiscal Year (FY) 2008 
seeks approximately $86.7 billion for veterans' benefits and services. 
This amounts to $39.4 billion in discretionary funding and $44.9 
billion in mandatory appropriations. In FY 2008, AMVETS requests 
roughly $43.6 billion in discretionary funding.
                  mandatory funding for va health care
    In May 2001, President George W. Bush signed Executive Order 13214 
creating the President's Task Force to Improve Health Care Delivery for 
Our Nation's Veterans (PTF). In May 2003, the PTF issued its final 
report and recommended that ``the Federal Government should provide 
full funding . . . and that full funding should occur through 
modifications to the current budget and appropriations process, by 
using a mandatory funding mechanism.'' Recent history demonstrates why 
Congress should pass legislation to make VA health care funding 
mandatory spending. In FY 2005, VA faced a $1.3 billion shortfall in 
spending and Congress had to include additional funding in emergency 
appropriations. For FY 2007, Congress failed to pass the annual VA 
spending bill and the department is operating under a Continuing 
Resolution well below FY 2007 requested levels.
                 extend enrollment for oef/oif veterans
    H.R. 612 and S. 383 introduced in the House of Representative and 
the Senate, respectively, would extend from 2 years to 5 years, 
following discharge or release from active duty, the eligibility period 
for veterans who served in combat during or after the Persian Gulf War. 
Continued eligibility would allow veterans to receive hospital care, 
medical services, or nursing home care provided by the Secretary of 
Veterans Affairs, notwithstanding a lack of evidence to conclude that 
their condition is attributable to such service. AMVETS fully supports 
the passage of legislation to extend the 2-year priority enrollment for 
OEF/OIF veterans.
                          seamless transition
    In March 2007, GAO testified that the Department of Defense (DOD) 
and VA were still having problems sharing the necessary medical records 
the VA needed to determine whether servicemembers' medical conditions 
allowed participation in VA's rehabilitation activities. Congress 
should require the two agencies to develop electronic medical records 
that are interoperable, bidirectional, and standards-based. Congress 
should also require DOD to conduct mandatory separation physicals for 
all separating service personnel and also utilize the Benefits Delivery 
at Discharge (BDD) joint separation exam that was developed and agreed 
to by both agencies.
                 post traumatic stress disorder (ptsd) 
                    and traumatic brain injury (tbi)
    VA operates a network of more than 190 specialized Post Traumatic 
Stress Disorder (PTSD) outpatient treatment programs throughout the 
country. Vet Centers are seeing a rapid increase in their enrollment. 
Equally important, AMVETS is concerned about the lack of awareness and 
screening among health care professionals for Traumatic Brain Injury 
(TBI). PTSD and TBI clinically present the same symptoms and the 
problem for medical personnel is trying to differentiate between PTSD 
and TBI. VA's approach to PTSD is to promote early recognition of this 
condition and the same must be done for TBI. In addition, there is no 
medical diagnostic code specific to TBI. 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.
                          va burial allowance
    VA reimbursement benefits were first instituted in 1973 and 
provided $150 in reimbursements for deaths that were not service-
related. In 2001 the plot allowance was increased for the first time in 
more than 28 years, to $300. The non-service-connected burial allowance 
was last adjusted in 1978 and now also provides $300. AMVETS supports 
increasing the non-service-connected burial benefit from $300 to $1,270 
and increasing the plot allowance from $300 to $745, an amount 
proportionally equal to the original benefit. In 2001, Congress 
increased the burial allowance for service-related deaths from $500 to 
$2,000. Prior to this adjustment, the allowance had been untouched 
since 1988. AMVETS recommends increasing the service-related burial 
benefit from $2,000 to $4,100, restoring the value of burial costs to 
its original proportionate level.
                           va claims backlog
    The VA Claims Backlog is now over 600,000 outstanding claims and it 
continues to grow at a rapid rate. VA's estimates that over 263,000 
OEF/OIF veterans will seek VA services and most will want to file a 
claim. At the end of FY 2006, rating-related compensation claims were 
pending an average of 127 days, which is 16 days more than at the end 
of FY 2003. During the same period, the inventory of rating-related 
claims grew by almost half, in part because of increased filing of 
claims, including those filed by veterans of the Iraq and Afghanistan 
conflicts. Meanwhile, appeals resolution remains a lengthy process, 
taking an average of 657 days in FY 2006. Overall, a lack of quality 
control is central to this issue and VA must establish a long-term 
strategy focused on attaining quality and not merely achieving quotas 
in claims processing. AMVETS supports increased funding for VA to hire 
more Full Time Equivalents (FTEs) in order to address the backlog. 
AMVETS also supports the practice putting adjudication officers in VA 
offices aboard active duty military bases.
    If you have questions regarding these priorities, or you need 
additional information, I can be reached at (614) 431-6990 Again, thank 
you for holding this hearing and providing AMVETS the opportunity to 
present its views.

    Senator Brown. Mr. Ondick, thank you. And if you would like 
to correct the CBOCs part of your testimony and resubmit, that 
would be fine, if you would like to make those written changes. 
And I'd like to introduce Mr. Montague. Thank you for joining 
us from Stokes. He is the CEO of Stokes Medical Center which 
coordinates most of veterans' care in the state. Thank you for 
joining us, Mr. Montague.
    Congressman Space.
    Mr. Space. Thanks, Senator Brown. I'd like to thank you, 
the first three witnesses. Before I introduce the remaining 
witnesses on this panel, I would ask or remind you to speak as 
closely to the mic as you can to eliminate feedback. And if you 
hear that sound, that means that you've surpassed the 7-minute 
limit, and we'd ask that you begin to wrap-up your testimony.
    I'd like to now present Mr. Robert Bertschy, who is a World 
War II and Korean era Navy veteran, and is also serving as 
Senior Vice Commander of the Disabled American Veterans for the 
Department of Ohio.
    Mr. Bertschy.

STATEMENT OF ROBERT BERTSCHY, SENIOR VICE COMMANDER, DEPARTMENT 
              OF OHIO, DISABLED AMERICAN VETERANS

    Mr. Bertschy. Thank you, sir. On behalf of more than 41,000 
members of the Disabled American Veterans and its Auxiliary in 
Ohio, I am honored to appear before you this morning to discuss 
the agenda and major concerns of our Nation's wartime disabled 
veterans and their families. Herman Morton, DAV Department of 
Ohio Commander, sends his regrets that he could not attend this 
hearing due to another commitment.
    Senator Sherrod Brown and Representative Space, I want to 
personally congratulate you for hosting this hearing, and 
wanting to learn more about our veteran issues here in Ohio. 
The Disabled American Veterans mission is service to veterans.
    I am proud to report that our Ohio DAV Transportation 
Network has 43 DAV vans, with 130 volunteer drivers, 
transporting thousands of veterans to and from the VA Medical 
Centers and community-based outpatient clinics. There are five 
VA Medical Centers, 29 CBOCs in Ohio, VA VISN 10. Louis Stokes 
Cleveland VA has two VA Medical Centers, and 12 CBOCs serving 
veterans.
    Louis Stokes Cleveland has 18 vans, and 40 drivers; 
Chillicothe has 15 vans and 40 drivers; Dayton has 3 vans with 
10 drivers; Columbus has 4 vans with 11 drivers, and Cincinnati 
has 2 vans with 10 drivers.
    DAV volunteer drivers are saving the VA thousands of 
dollars. Ohio Veterans Service Commission County Offices has 
paid drivers that also transport veterans to and from the VA 
Medical Centers.
    Although there have been cases where veterans living in 
rural areas encounter difficulty in obtaining transportation on 
a timely basis, this has been more of problem for such veterans 
getting to Cincinnati VA Medical Center than others. It is not 
felt that the lack of transportation is a real problem.
    We have a lot of veterans coming home from Iraq and 
Afghanistan. Are we prepared to help them? What good are all 
these medical centers and clinics, volunteer drivers and vans, 
if we aren't getting the VA appropriations from Congress on a 
timely manner? Additional funds for hiring more doctors and 
nurses at the VA medical centers are needed to improve the 
delays in providing timely clinic appointments for our 
veterans. Many veterans will have serious injuries requiring 
long-term care. Amputations, traumatic brain injuries, vision 
loss, and mental health issues are only a few healthcare issues 
facing our veterans, as well as the VA in providing services. 
Our veterans must not be forgotten for their sacrifices made in 
time of war. Their sacrifices and service to our great Nation 
shall not be in vain. We need your commitment that Washington 
will not forget our veterans. Please make this commitment a top 
priority for their service.
    At the veterans' joint meeting in Washington, DC, in 
February, we asked the new senators and representatives to 
support VA mandatory funding. The 2008 Fiscal Year Budget comes 
close to providing adequate funding. It does not guarantee that 
VA funds will be available, when needed, since even though it 
is in the budget, the majority of VA funds are subject to the 
legislative process throughout the fiscal year, and is subject 
to the ravages of other funding constraints. Mandatory funding 
will not cost more tax dollars, and would prompt timely, and 
proper management of the VA budget, and, thus, provide better, 
more timely care for our sick, wounded and disabled veterans. 
At the beginning of each fiscal year, mandatory funding will 
not force the VA to go into a shut-down fiscal mode until 
Congress figures it out.
    Also, we ask you to repeal the attorney fee provisions, 
Public Law 109-461.
    Ranking Member of the U.S. Senate Committee on Veterans' 
Affairs, Senator Larry Craig, inserted provision in this bill 
to remove the bar against attorneys charging veterans a fee for 
filing a claim. Our DAV Service Officers are very well trained 
to assist veterans and their families in filing VA claims for 
benefits they have earned, and we do it for free. It has been 
this way since the Civil War. As the saying goes, why fix it if 
isn't broke?
    The Disabled American Veterans is a non-partisan veterans 
service organization, but I personally feel that Senate 
Majority Leader Harry Reid should stop his negative attitude, 
and accusations of defeat in Iraq.
    At a press conference on Capitol Hill, he claimed that 
``this war is lost and the surge is not accomplishing 
anything.'' He claims that the Iraqi War was a ``failure''. 
What kind of message does this send to our soldiers, Marine and 
Sailors overseas? This is having a negative impact on our 
troops that are in harm's way.
    In effect, statements of this type by our elected leaders 
gives aid and comfort to our enemies, serving to prolong the 
conflict, and cause hardship and loss of lives of our brave 
soldiers.
    If you look at all of the cars with signs, ``Support Our 
Troops'', on them, and then have our politicians say we are 
losing the war is shameful. He would have us quit on our 
troops, even though they haven't quit on us, or their mission 
in Iraq.
    Be assured, DAV will continue supporting our veterans, 
their families, and VA hospital programs. Again, DAV National 
Service Officers, professional staff are the very best trained 
who are representing thousands of veteran filing VA claims for 
earned benefits, and we do not charge for our services.
    The VA must hire more adjudicators to process veterans' 
claims for benefits they have earned and are not receiving them 
in a reasonable time, especially for our World War II veterans.
    I want to thank you for all that your Veterans' Committees 
in Washington, DC, have done for our disabled veterans, and for 
all you will do in the future. Thank you for allowing me to 
appear before you on behalf of the Disabled American Veterans, 
Department of Ohio. God Bless all of you, God Bless our 
American troops in harm's way, and God Bless the USA.
    [The prepared statement of Mr. Bertschy follows:]
       Prepared Statement of Robert H. Bertschy, Vice Commander, 
             Department of Ohio, Disabled American Veterans
    On behalf of more than 41,000 members of the Disabled American 
Veterans (DAV) and its Auxiliary in Ohio, I am honored to appear before 
you this morning to discuss the agenda and major concerns of our 
Nation's wartime disabled veterans and their families. Herman Morton, 
DAV Department of Ohio Commander, sends his regrets that he could not 
attend this hearing due to another commitment.
    Senator Sherrod Brown and Representative Zach Space, I want to 
personally congratulate you for hosting this hearing and wanting to 
learn more about our veterans issues here in Ohio.
    The Disabled American Veterans mission is service to veterans.
    I am proud to report that our Ohio DAV Transportation Network has 
43 DAV vans with 130 volunteer drivers transporting thousands of 
veterans to and from the VA Medical Centers (VAMCs) and Community Based 
Outpatient Clinics (CBOCs). There are 5 VAMCs, 29 CBOCs in Ohio VA VISN 
10. Louis Stokes Cleveland VA has 2 VAMCs, and 12 CBOCs serving 
veterans.

 
------------------------------------------------------------------------
                                                   Volunteer
                      VAMC                          drivers      Vans
------------------------------------------------------------------------
Louis Stokes Cleveland..........................         40          18
Chillicothe.....................................         40          15
Dayton..........................................         10           3
Columbus........................................         11           4
Cincinnati......................................         10           2
------------------------------------------------------------------------


    DAV volunteer drivers are all volunteers saving the VA thousands of 
dollars. Ohio Veterans Service Commission County Offices has paid 
drivers that also transport veterans to and from the VAMCs.
    Although, there have been cases where veterans living in rural 
areas encounter difficulty in obtaining transportation on a timely 
basis. This has been more of a problem for such veterans getting to 
Cincinnati VAMC than others. It is not felt that lack of transportation 
is the REAL problem!!
    We have a lot of veterans coming home from Iraq and Afghanistan. 
Are we prepared to help them? What good are all of these medical 
centers and clinics, volunteer drivers and vans if we aren't getting 
the VA appropriations from Congress on a timely manner? Additional 
funds for hiring more doctors and nurses at the VA medical facilities 
are needed to improve the delays in providing timely clinic 
appointments for our veterans. Many veterans will have serious injuries 
requiring long-term care. Amputations, traumatic brain injuries, vision 
loss and mental health issues are only a few healthcare issues facing 
our veterans as well as the VA in providing services. Our veterans must 
not be forgotten for the sacrifices made in time of war. Their 
sacrifices and service to our great Nation shall not be in vain. We 
need your commitment that Washington will not forget our veterans. 
Please make this commitment, a top priority, for their service.
    At the Veterans' joint meeting in Washington, DC, in February, we 
asked the new senators and representatives to support ``VA mandatory 
funding''. The 2008 Fiscal Year Budget comes close to providing 
adequate funding. It does not guarantee that VA funds will be available 
when needed since, even though it is in the budget, the majority of VA 
funds are subject to the legislative process throughout the fiscal year 
and is subject to the ravages of other funding constraints. ``Mandatory 
Funding'' will not cost more tax dollars and would prompt, timely and 
proper management of the VA budget and thus provide better, more timely 
care for our sick, wounded and disabled veterans. At the beginning of 
each fiscal year Mandatory funding will not force the VA to go into a 
shut-down fiscal mode until Congress figures it out.
    Also, we ask you to repeal the attorney fee provisions, Public Law 
109-461. Ranking member of the U.S. Senate Committee on Veteran' 
Affairs, Senator Larry Craig, inserted provisions in this bill to 
remove the bar against attorneys charging veterans a fee for filing a 
claim. Our DAV Service Officers are very well trained to assist 
veterans and their families in filing VA claims for benefits they have 
earned and we do it for free. It has been this way since the Civil War. 
Why fix it if it isn't broke?
    The Disabled American Veterans is a nonpartisan veterans service 
organization, but I personally feel that Senate Majority Leader Harry 
Reid should stop his negative attitude and accusations of defeat in 
Iraq. At a press conference on Capitol Hill, he claimed that ``this war 
is lost and the surge is not accomplishing anything.'' He claims that 
the Iraqi War was a ``failure.'' What kind of message does this send to 
our soldiers, marines and sailors overseas? This is having a negative 
impact on our troops that are in harm's way. In effect, statements of 
this type by our elected leaders gives ``aid and comfort'' to our 
enemies, serving to prolong the conflict and cause hardship and loss of 
lives of our brave soldiers.
    If you look at all of the cars with signs, ``Support Our Troops,'' 
on them and then have our politicians say we are losing the war is 
shameful. He would have us quit on our troops, even though they haven't 
quit on us or their mission in Iraq.
    Be assured, DAV will continue supporting our veterans, their 
families and VA hospital programs. Again, DAV National Service Officers 
professional staff are the very best trained who are representing 
thousands of veterans filing VA claims for earned benefits and we do 
not charge for our services.
    The VA must hire more adjudicators to process veterans' claims for 
benefits they have earned and are not receiving them in a reasonable 
time. Especially for our WW II veterans.
    Thank you for all that your veterans' committees in Washington, DC, 
have done for our disabled veterans and for all you will do in the 
future. Thank you for allowing me to appear before you on behalf of the 
Disabled American Veterans, Department of Ohio. God Bless all of you, 
God Bless our American troops in harm's way and God Bless the USA.

    Mr. Space. Thank you, Mr. Bertschy. I'd like to now 
introduce Mr. Tom Burke, President of the Vietnam Veterans of 
America, Buckeye State Council. I'm privileged to introduce Mr. 
Burke. Not only are you a panelist today, but you are also a 
constituent. I understand that you live just a few blocks from 
here, where we sit this morning.
    Good morning, and thank you for your anticipated testimony.

   STATEMENT OF TOM BURKE, PRESIDENT, BUCKEYE STATE COUNCIL, 
                  VIETNAM VETERANS OF AMERICA

    Mr. Burke. Thank you. On behalf of the members and families 
of the Vietnam Veterans of America, Buckeye State Council, we 
bid you welcome. To Congressman Space we say, ``Welcome Home.'' 
We'd like to thank you all for what it is that you do for us. 
We wish to express our deep appreciation to you all for taking 
time out of your schedules to come to New Philadelphia for the 
purpose of hearing veterans concerns firsthand.
    It is my great privilege to speak to you today to present 
the thoughts and comments gathered from Vietnam Veterans of 
Ohio on issues that impact members of small town America. 
Funding you approve in the interest of Veterans Across America, 
certainly make us better than we were many years. The recent 
funding increase of $3.6 billion for the veterans Healthcare is 
certainly important and necessary. It goes without saying that 
sufficient funding for veterans must be met, or nothing 
happens.
    In preparing for today's hearing, I have spoken to many 
veterans. Not surprisingly, the number one issue that comes up 
across the board is their concern for healthcare. More than 
half of the veterans who avail themselves of VA facilities here 
in Ohio are without medical insurance of any kind. VA hospital 
facilities located in the Cleveland, Cincinnati, Chillicothe, 
and Dayton, access to VA facilities in urban areas is 
practically unlimited because veterans can go to VA emergency 
wards for treatment of ailments. However, this is not the case 
for rural veterans.
    We have the VA clinics in smaller cities on this side of 
the state. The clinic here in New Philadelphia is said to be 
the fastest growing clinic in the state. This is due to the 
ever-increasing medical needs by not only older veterans, but 
by the new crop of veterans currently returning from the war 
zone. It is not secret that the media sources report that the 
VA is at the breaking point.
    These reports concern many veterans because they fear the 
VA will attempt to scale back their care because of limited 
funding, or because of the influx of current Iraq and 
Afghanistan veterans returning from the combat zone. VA clinic 
facilities are situated in Canton, Youngstown, Akron, each 
providing different specialties for the veterans. The medical 
help that these facilities provide through dedicated doctors, 
nurses, and staff is absolutely critical to the healthcare of 
veterans in non-urban areas.
    An issue that many veterans grimace at in Oho is this; 
veterans whose incomes are at the poverty level have little 
choice concerning healthcare. However, they are fortunate that 
the system does provide care for them. veterans turn to the VA 
for medical assistance for a variety of reasons. Reasons cited 
by veterans include those whose income or lack of service-
related disability forces them into Category 7 and 8, but a 
majority of these veterans have no medical insurance. Others 
have no employer sponsored medical insurance, and still others 
are deemed uninsurable by the private sector. Most of these 
veterans can ill afford private insurance under any 
circumstances. Many veterans in Ohio and elsewhere are denied 
care by the current Administration as a matter of policy. 
Fortunately, some got in during the open enrollment period 
before the Administration closed the door. Estimates of these 
veterans now sitting out there are roughly 500,000 since 2003. 
Gentlemen, this closed door policy must be rescinded. It is 
time to reopen the VA health care system to Priority 8 
veterans, who were restricted from enrolling since January of 
2003.
    The closest VA hospital for us here in this area is 
Cleveland. To get to the Cleveland Wade Park VA hospital is 
approximately 200 miles round trip, or more, at best, depending 
on the veteran's location of residence. The VA current mileage 
scale allows veterans going to any facility 11 cents per mile. 
Gasoline currently is better than $3 a gallon. First of all, 
this computation does not compute. A majority of Priority 6, 7, 
and none of the Priority 8 veterans who are currently in the 
system get any mileage at all. The VA simply says ``you make 
too much money''. Yet, others of higher priority, regardless of 
their income, still receive mileage. This does not make sense 
to most veterans, nor do they believe it is fair.
    I have a check here from one veteran that lives in Carolton 
that was going to the VA facility at Canton. They held back $18 
as a hold-back, and he went to the--if you don't go to the 
facility more than three times a month, you don't get the full 
pay. Well, the government issued him a check for mileage for 16 
cents. It seems a little incredible that a veteran going to a 
VA facility gets a mileage check for 16 cents. The paper and 
the administration fees would cost more than that to put it 
out. It doesn't make any sense to us.
    I've been in many conversations concerning veterans not 
only here in Ohio, but about everywhere I go concerning the 
backlog of VA claim adjudication. No one seems to know what the 
actual number is, four, five, six hundred thousand, but one 
thing is sure, it's a big number, and must be dealt with as 
quickly as possible. Many veterans are concerned about the time 
that it takes to get a rating at all after there claims have 
been submitted. I am advised by our VSO people that waits of 
one to two years are not out of the question for initial 
claims. If one appeals a decision, add another two to five 
years. Gentlemen, this is simply not acceptable. With the new 
crop of veterans returning from our current war zone, there is 
a high concern among older veterans that their claims are 
getting lost in the bureaucratic log jam. We understand that 
new adjudicators are coming, but we need to be assured that the 
new kids on the block are properly trained, and held 
accountable for their work.
    Gentlemen, the balance of my comments are submitted for the 
record. That concludes my comments. Thank you.
    [The prepared statement of Mr. Burke follows:]
    Prepared Statement of Thomas R. Burke, President, Buckeye State 
                  Council, Vietnam Veterans of America
    To the distinguished Members of the House/Senate Veterans Affairs 
Committee who have come to the fair City of New Philadelphia, Ohio this 
morning. On behalf of the members and families of Vietnam Veterans of 
America, Buckeye State Council we bid you welcome. To Congressman Space 
we say ``Welcome Home.'' To all we thank you for what it is that you do 
for us. We wish to express our deep appreciation to you all for taking 
the time out of your schedules to come to New Philadelphia for the 
purpose of hearing veterans concerns firsthand.
    It is my great privilege to speak to you today to present the 
thoughts and comments gathered from Vietnam Veterans of Ohio on issues 
that impact our members of small town America. Rather than providing 
you with a laundry list, I will attempt this morning is to bring to you 
only those issues that arose in conversation time and again. We are 
aware that difficult decisions must be made by this Committee for the 
benefit of all veterans. Funding you approve in the interest of 
veterans across America, certainly make us better today than we were 
many years ago. The recent funding increase of $3.6 billion for 
veterans health care is truly important and necessary. It goes without 
saying that sufficient funding for veterans must be met or nothing 
happens. We also know that many issues remain.
              funding veterans health care and rural care
    In preparing for today's hearing, I have spoken to many veterans. 
Not surprisingly the number one issue that comes up across the board is 
their concern for health care. Ohio currently has one million plus 
veterans. Nearly 8,000 of those veterans call Tuscarawas county their 
home. Funding for veteran issues concerning research, toxic exposure, 
the effects of Traumatic Brain Injury, Post traumatic stress disorder, 
prosthetic limbs, homeless veterans, our POW/MIA's issues, improvement 
of facilities that treat all our veterans and combat wounded. All these 
and more must be funded by money distributed from Congress from non-
discretionary funding sources. This is the only way that veterans can 
be assured that their issues will not be lost.
    More than half of the veterans who avail themselves of VA 
facilities here in Ohio are without medical insurance of any kind. VA 
hospital facilities are located in Cleveland, Cincinnati, Chillicothe, 
and Dayton. Access to VA hospital facilities in urban areas is almost 
unlimited because veterans can go to the VA emergency wards for 
treatment of ailments. However, that is not the case for rural 
veterans. We have VA Clinics in smaller cities on this side of the 
state. The clinic here in New Philadelphia is said to be the fastest 
growing clinic in the state. This is due to the ever increasing medical 
needs by not only older veterans, but by the new crop of veterans 
currently returning from the war zone. It is no secret that media 
sources report that the VA is at the breaking point.
    These reports concern many veterans because they fear VA will 
attempt to scale back their care because of limited funding or the 
influx of current Iraq and Afghanistan veterans returning from the 
combat zone. Additional VA clinic facilities are situated in Canton, 
Youngstown and Akron each providing different specialties for veterans. 
The medical help that these facilities provide through dedicated 
doctors, nurses and staff is absolutely critical to the health care of 
veterans in non-urban areas.
    For the most part veterans rate services provided by clinics and 
hospitals as good to excellent. However, we find that medical clinic 
access seems to vary from clinic to clinic. A veteran will usually get 
in to see a doctor at a clinic about once very 6 months as part of a 
routine wellness physical if he or she is in the system. Should you be 
a new patient seeking treatment you may wait a longer period of time. 
Many of the veterans stated that if they become ill between their 
normal visits to the clinic, that they are unable to see a VA doctor if 
they request appointments. All believe that this is a result of VA 
limiting staffing policies. At a time when VA should be gearing up 
personnel, i.e., current veterans returning, putting more pressure on 
the system to perform, they seem to be going the other way. Veterans 
who seek help at the VA facilities that are rated 100 percent are 
admitted within a couple of days. Others who are less than a 100 
percent may not get in at all if they are sick. The same also holds 
true for dental care as well. Some veterans have come to believe their 
access to VA facilities may be based on their Priority status or lack 
thereof. Perhaps a facility that has a larger staff may afford that 
clinic to accommodate the veteran needs. Veterans note that there does 
not seem to be any uniformity between facilities.
    An issue that many veterans grimace at in Ohio is this. Veterans 
whose incomes are at the poverty level have little choices, concerning 
health care; however, they are fortunate that the system does provide 
care for them. Veterans turn to the VA for medical assistance for a 
variety of reasons. Reasons cited by veterans include those whose 
income or lack of service related disability, forces them into Priority 
7 and 8, but a majority of these veterans have no medical insurance. 
Others have no employer sponsored medical insurance and still others 
are deemed uninsurable by the private sector. Most of these veterans 
can ill afford private insurance under any circumstances. Many veterans 
in Ohio and elsewhere are denied health care by the current 
Administration as a matter of policy. Fortunately some got in during 
the open enrollment period before the Administration closed the door. 
Estimates of these veterans now sitting out there are roughly 500,000 
since 2003. Gentlemen, this closed door policy must be rescinded. It is 
time to reopen the VA health care system for Priority 8 veterans, who 
were restricted from enrolling in January 2003.
    Additionally, insufficient funding by Congress to take care of all 
who were promised health care as a condition of their service, still 
others who are forced to private health care and cannot afford 
prescription medications they need. We add a big thank you for VA 
prescription drug service, in some cases a life saving service. 
Ironically, Congress always seems to be able to find funds to wage war, 
which is necessary to support current combat troops. We certainly need 
to support our troops. However, once home, the Congress must find the 
necessary funds to treat and care for our veterans.
                               revamping
    A revamping of the funding for veterans health care is an 
overwhelming issue that must be dealt with. H.R. 1382 is a start, 
Mandatory Funding for Veterans Health Care 2008. Gentlemen the current 
discretionary funding method for VA medical care simply does not work. 
VVA has long maintained that accountability must be built into any 
system of funding for the VA. Simply throwing cash at a problem will 
probably not work either. We must find long term solutions. Veterans in 
Ohio are certainly willing if not eager to work with whoever it takes, 
to find a way to ensure the VA has the funding to meet its mandate to 
``care for them who have borne the battle.'' If we cannot find a way to 
maintain and improve care as time proceeds, we may find all veterans 
without benefits. This is a fate that we cannot let happen. Perhaps a 
bipartisan group should be formed whether in our state or on a national 
level to study the issues, options and hopefully solutions.
                             mileage issue
    The closest VA hospital for us is Cleveland. To get to Cleveland 
Wade Park VA hospital is a 200-mile roundtrip or more at best depending 
on the veterans' location of residence. The VA current mileage scale 
allows veterans going to any facility eleven (11) cents per mile. 
Gasoline currently is better than three dollars a gallon. First of all 
this computation does not compute. A majority of Priority six (6) seven 
(7) and none of the Priority eight (8) veterans who are currently in 
the system get any mileage at all. The VA says ``you make too much 
money''. Say what? Yet others of higher priority regardless of their 
income still receive mileage. This does not make sense to most 
veterans, nor do they believe it is fair.
                                outreach
    In the State of Ohio, we have found that many veterans who have 
served honorably simply are unaware of benefits and or services that 
they are entitled too. Many were not told of available benefits or 
services when they left their branch of service and never thought 
another thing about it. Outreach should be an ongoing effort to all 
veterans but especially in country veterans so they become aware that 
their likelihood of contracting a dreadful disease is much higher than 
the general public.
                     adjudication of claim backlog
    I have been involved in many conversations concerning veterans not 
only here in Ohio but about everywhere I go concerning the current 
backlog of VA claim adjudication. No one seems to know what the actual 
number is, four, five, six, and hundred thousand. But one thing is for 
sure. It's a big number and must be dealt with as quickly as possible. 
Many veterans are concerned about the length of time that is takes to 
get a rating at all after claims have been submitted. I am advised by 
our VSO people that waits of 1 to 2 years are not out of the question 
for an initial claim. If one appeals a decision add another 2 to 5 
years. This is simply not acceptable. With the new crop of veterans 
returning from our current war zone, there is high concern among older 
veterans that their claims are getting lost in the bureaucratic log 
jam. We understand that new adjudicators are coming, but we need to be 
assured that the new kids on the block are properly trained and held 
accountable for their work.
                          employment, training
    It seems that the so called ``veterans preference'' which we all 
know is on the books nationally certainly does not appear close to 
being enforced. Veterans both National Guard and Reservists returning 
to Ohio have faced no job or a job that has been reengineered, in 
effect again losing their career position. To veterans who return with 
less of a body than they started with they certainly deserve to be 
given chance to maintain employment if they are physically able to do 
so for their own well being. To assist veterans who are unemployed or 
underemployed with new or additional training seems vital to us. 
Veterans who lose their jobs should have the opportunity to get a re-
education and work skill upgrades. S. 22, S. 644, and H.R. 1102 would 
establish educational assistance for various veterans and Reserve 
elements. Ohio Vietnam Veterans feel these initiatives should be 
supported. With respect to our older veteran population national 
standards now cite retirement age increasing to a minimum age of 66. 
Federal, state, and private employers need to start rethinking their 
priorities toward older veterans and workers in general when it comes 
to keeping them in the workforce. With the increased standards, 
veterans reaching fifty years old or older are being shelved for 
younger less experienced people because their income combined with 
group benefits provided has reached a level that employers increasingly 
are not willing to pay. Federal agencies that provide job services to 
veterans should note this reality shift and make priority changes so 
veterans cannot only maintain their jobs, but find new ones if 
necessary.
                                pow/mia
    The Vietnam Veterans of Ohio, along with The POW/MIA Families, on 
this issue have the strongest possible feelings. Prisoners of War and 
those missing in action must be accounted for and not left behind. We 
urge the Congress pass a resolution. Such resolution should be 
presented to the government of Vietnam to give up relevant wartime 
documents, so the remains of war dead may be brought home and those 
listed as MIA should be accounted for.
    I speak from personal experience when I tell you that having a 
brother KIA in Korea was bad enough for my family. I cannot imagine 
what it would have been like especially for my parents if they had not 
known the fate of their fallen son.
    Distinguished Members of the House and Senate Veterans' Affairs 
Committee that concludes my testimony on behalf of the Vietnam Veterans 
of America, Buckeye State Council.

    Mr. Space. Thank you, Mr. Burke.
    And I'd like to introduce our last witness on the first 
panel, Mr. Donald Lanthorn, a Vietnam veteran, and the 
Department Service Director from The American Legion, 
Department of Ohio.
    Thank you, Mr. Lanthorn, for being here today, and 
presenting your testimony.

 STATEMENT OF DONALD LANTHORN, SERVICE DIRECTOR, DEPARTMENT OF 
                   OHIO, THE AMERICAN LEGION

    Mr. Lanthorn. Senator Brown, Representative Space, it's my 
pleasure to be here today. Thank you for this opportunity to 
provide our organization's views on VA healthcare, its 
accessibility, and needs to be considered by Congress from the 
point of view of Ohio veterans and members of our organization.
    My first experience with VA healthcare was 30 years ago. At 
that time, VA Medical Centers had long lines, inadequate 
waiting areas, and few facilities. I was appalled by patients 
having to sit in hallways, on the floor, waiting for their 
opportunity to see a doctor, after having traveled perhaps 100 
miles within Ohio to be seen.
    However, even in those trying times, medical care was 
comparable to the private sector, but few with the alternatives 
available through health care insurance would select VA as the 
health care provider of choice. Even veterans with service-
connected 
conditions would often opt for private sector treatment for the 
convenience.
    The 1980s saw some improvement in access, as VA Medical 
Centers in Ohio expanded the ambulatory care clinics, opened a 
few outpatient clinics, and moved toward outpatient, rather 
than inpatient care, as the preferred method of treatment.
    Beginning in 1994, Dr. Kenneth Kizer, VA Undersecretary for 
Health, began revamping the system to his vision of 
accessibility, quality, and safety. He is arguably credited 
with setting in motion the plan that closed under-used 
facilities, established hundreds of new access points with 
clinics, and created a business model of efficiency utilizing 
available technology to digitize records, to common sense in 
informing patients about their medications.
    As word spread of the quality of VA healthcare, veterans 
left their private plans and sought VA healthcare in droves. 
Without funding to handle the patient influx, VA was forced in 
2003 to again restrict access, as waiting lists grew, so now 
only service-
connected and low income veterans were eligible to enroll, 
slamming the door to hundreds of thousands of veterans planning 
on using VA healthcare in retirement, or sooner.
    A vital part of the VA transformation was the accessibility 
created for veterans by establishing community-based outpatient 
Clinics. They brought healthcare closer to where veterans live, 
and provide mental health services, often otherwise not 
available in rural communities.
    Ohio has CBOCs in Athens, Cambridge, Lancaster, Marietta, 
and Portsmouth affiliated with Chillicothe VA Medical Center, 
and Clermont County near Cincinnati VA Medical Center. Dayton 
VAMC has CBOCs in Lima, Middletown, and Springfield. Columbus 
VA Outpatient Clinic serves Grove City, Marion, Newark, and 
Zanesville with CBOCs. Cleveland VAMC, the most aggressive of 
all Ohio Medical Centers in establishing VA points of access, 
has CBOCs in Akron, Canton, East Liverpool, Lorain, Mansfield, 
McCafferty in downtown, New Philadelphia, Painesville, Ravenna, 
Sandusky, Warren, and Youngstown.
    Additionally, Ohio medical facilities have established 
CBOCs in Indiana and Kentucky, which serve Ohio veterans, as 
does the Toledo Clinic, a satellite of Ann Arbor VAMC, and 
other Ohio CBOCs in Ashtabula and St. Clairsville, established 
by VA facilities in bordering states.
    The Ohio American Legion strongly supports the 
recommendation of the Capital Asset Realignment for Enhanced 
Services (CARES), recommendations for more CBOCs, and expanded 
services in those now operating, especially those in rural 
areas. However, limited VA discretionary funding has slowed the 
number of clinics authorized each year. Field stations 
partially meet access needs, but are not sufficient in 
availability or services.
    The current war and its estimated toll on veterans' mental 
health make these services vital in CBOCs for our returning 
troops ease of access. We urge sufficient VA funding to ensure 
adequate staffing.
    Traumatic Brain Injury veterans similarly find few 
community resources in rural areas for TBI-related problems, 
and many cite transportation as a major obstacle. We have 
addressed the transportation issue in Ohio with state 
legislation requiring County Veterans Service Commissions to 
provide it. Now VA must provide the services with the patient 
at the doorstep.
    Vet Centers are another resources VA provides, which is not 
readily available in rural communities. Veterans should not be 
penalized or denied quality healthcare because of where they 
choose to live. We urge Congress and VA to improve access to 
quality primary care, specialty healthcare, and mental health 
services in rural areas.
    As important as access as may be, just as critical is 
timeliness of services. VA has established its own standards 
for access to primary care of 30 days. That is unacceptable to 
most Americans, and especially does not meet the obligations of 
VA to our veterans.
    The Ohio American Legion does not point fingers at problems 
without offering a means of resolution. We disagree with the VA 
decision to deny access to any eligible veteran. Many of these 
veterans have third-party insurance that could reimburse VA, or 
are Medicare-eligible, yet little has been done to improve 
third-party reimbursements for private insurers, and nothing to 
allow VA to receive reimbursement from the Nation's largest 
healthcare insurer, the Centers for Medicare and Medicaid 
Services, as both the Indian Health Services and Department of 
Defense are authorized to bill, collect, and receive.
    Full funding for VA healthcare, full eligibility for all 
veterans, and Medicare reimbursement to VA is the first step 
needed to assure quality healthcare to rural Ohio veterans.
    Thank you, Mr. Chairman, for providing the Ohio American 
Legion this opportunity to address the issues of VA healthcare 
in Ohio, and the disparities that exist in access to quality 
healthcare in rural areas.
    [The prepared statement of Mr. Lanthorn follows:]
      Prepared Statement of Donald R. Lanthorn, Service Director, 
                Department of Ohio, The American Legion
    Mr. Chairman, Members of the Committee. My name is Donald R. 
Lanthorn. I am the Service Director and Legislative Agent for The Ohio 
American Legion.
    It is my pleasure to be here today. Thank you for this opportunity 
to provide our organization's views on VA health care, its 
accessibility and needs to be considered by Congress from the point of 
view of Ohio veterans and members of our organization.
    My first experience with VA health care was thirty years ago. At 
that time VA Medical Centers had long lines, inadequate waiting areas 
and few facilities. I was appalled by patients having to sit in 
hallways, on the floor, waiting for their opportunity to see a doctor, 
after having traveled perhaps one hundred miles within Ohio to be seen.
    However, even in those trying times, medical care was comparable to 
the private sector, but few with the alternatives available through 
health care insurance would select VA as the health care provider of 
choice. Even veterans with service-connected conditions would often opt 
for private sector treatment for the convenience.
    The 1980s saw some improvement in access, as VA Medical Centers in 
Ohio expanded the ambulatory care clinics, opened a few Outpatient 
Clinics and moved toward outpatient, rather than inpatient care, as the 
preferred method of treatment.
    Beginning in 1994 Dr. Kenneth Kizer, VA Undersecretary for Health, 
began revamping the system to his vision of accessibility, quality, and 
safety. He is arguably credited with setting in motion the plan that 
closed underused facilities, established hundreds of new access points 
with clinics, and created a business model of efficiency utilizing 
available technology to digitize records, to common sense in informing 
patients about their medications.
    As word spread of the quality of VA health care, veterans left 
their private plans and sought VA health care in droves. Without 
funding to handle the patient influx, VA was forced in 2003 to again 
restrict access, as waiting lists grew, so now only service connected 
and low income veterans were eligible to enroll, slamming the door to 
hundreds of thousands of veterans planning on using VA health care in 
retirement or sooner.
    A vital part of the VA transformation was the accessibility created 
for veterans by establishing Community Based Outpatient Clinics 
(CBOCs). They brought health care closer to where veterans live and 
provide mental health services often otherwise not available in rural 
communities.
    Ohio has CBOCs in Athens, Cambridge, Lancaster, Marietta and 
Portsmouth affiliated with Chillicothe VAMC, and Clermont County near 
Cincinnati VAMC. Dayton VAMC has CBOCs in Lima, Middletown, and 
Springfield. Columbus VA Outpatient Clinic serves Grove City, Marion, 
Newark, and Zanesville with CBOCs. Cleveland VAMC, the most aggressive 
of all Ohio Medical Centers in establishing VA points of access, has 
CBOCs in Akron, Canton, East Liverpool, Lorain, Mansfield, McCafferty 
in downtown, New Philadelphia, Painesville, Ravenna, Sandusky, Warren 
and Youngstown.
    Additionally, Ohio medical facilities have established CBOCs in 
Indiana and Kentucky, which serve Ohio veterans, as does the Toledo 
Clinic, a satellite of Ann Arbor VAMC, and other Ohio CBOCs in 
Ashtabula and St. Clairsville, established by VA facilities in 
bordering states.
    The Ohio American Legion strongly supports the recommendation of 
the Capital Asset Realignment for Enhanced Services (CARES) 
recommendations for more CBOCs, and expanded services in those now 
operating, especially those in rural areas. However, limited VA 
discretionary funding has slowed the number of clinics authorized each 
year. Field Stations partially meet access needs, but are not 
sufficient in availability or services.
    The current war and its estimated toll on veterans' mental health 
make these services vital in CBOCs for our returning troops ease of 
access. We urge sufficient VA funding to ensure adequate staffing.
    Traumatic Brain Injury (TBI) veterans similarly find few community 
resources in rural areas for TBI related problems, and many cite 
transportation as a major obstacle. We have addressed the 
transportation issue in Ohio with state legislation requiring County 
Veterans Service Commissions to provide it. Now VA must provide the 
services with the patient at the doorstep.
    Vet Centers are another resource VA provides, which is not readily 
available in rural communities. Veterans should not be penalized or 
denied quality health care because of where they choose to live. We 
urge Congress and VA to improve access to quality primary care, 
specialty health care and mental health services in rural areas.
    As important as ``access'' may be, just as critical is 
``timeliness'' of services. VA has established its own standards for 
access to primary care of 30 days. That is unacceptable to most 
Americans, and especially does not meet the obligation of VA to our 
veterans.
    The Ohio American Legion does not point fingers at problems without 
offering a means of resolution. We disagree with the VA decision to 
deny access to any eligible veteran. Many of these veterans have third-
party insurance that could reimburse VA, or are Medicare eligible, yet 
little has been done to improve third-party reimbursements from private 
insurers and nothing to allow VA to receive reimbursement from the 
nation's largest health care insurer, the Centers for Medicare and 
Medicaid Services (CMS), as both the Indian Health Services (IHS) and 
Department of Defense (DoD) are authorized to bill, collect, and 
receive.
    Full funding for VA health care, full eligibility for all veterans, 
and Medicare reimbursement to VA is the first step needed to assure 
quality health care to rural Ohio veterans.
    Thank you, Mr. Chairman, for providing The Ohio American Legion 
this opportunity to address the issues of VA health care in Ohio and 
the disparities that exist in access to quality health care in rural 
areas.

    Senator Brown. Thank you, Mr. Lanthorn.
    I will begin the questioning, and feel free, any of you, to 
jump in if the question is directed at one of you. Feel free to 
also add your thoughts to the answers.
    Mr. Anderson, Mr. Moore talked about contracting out. I'd 
like to pursue that a bit. Mr. Moore, you said that contracted 
care takes money out of the system, and potentially dilutes 
quality of care. Mr. Anderson, you said that you fear that the 
VA will become the insurer of care, not the provider of care. 
That results in a diminution of the quality of care. Would each 
of you expand on that a bit? Mr. Moore first, then Mr. 
Anderson.
    Mr. Moore. Well, again, we're very concerned with that 
aspect. When we're looking for our dollars, and we're fighting 
for our dollars continually, that if you--in the past what I 
saw is simply that when we've contracted in the past to private 
entities, the veteran always end up, seems to me, to suffer. 
The billing system gets messed up. He doesn't get his care on 
time, or it doesn't get paid on time. He gets threatening 
letters continually that that private sector hospital is going 
to turn it over to a collection agency because it hasn't been 
paid by the VA; and, therefore, he's responsible for it. That's 
one of the issues I see that bothers me with contracting care 
out. I've seen that happen several times in the Columbus area 
when they contracted out for some of the--University Hospital, 
a veteran came in with all kinds of problems, threats if the 
bills weren't paid, and everybody is arguing back and forth 
between them and fee-basis, who's responsible for that. Well, 
they are, they aren't. In the end, the poor veteran is sitting 
there suffering, and he's being threatened by ruining his 
credit and everything else. That's one fear I have about 
contracting out. Unless, again, Congress and the VA itself, and 
any of these contracted out medicals really need to look at it 
and keep auditing that system, keep a very strong hand on it, 
making sure that it's done properly.
    Senator Brown. Have you seen an increase in the number of 
veterans who serve with those problems, with the problems of 
the mix of privatized or contracted out care?
    Mr. Moore. Fortunately, most of them in Ohio, we have a 
very strong VA healthcare system in there, thanks to Director 
Montague and others that pushed that. When you look at Ohio 
compared to its sister states that in that Appalachia area that 
we're talking about, West Virginia and Kentucky, you're looking 
at roughly 20 probably rural CBOCs and whatnot within Ohio, but 
in West Virginia you're looking at six or seven CBOCs, in 
Kentucy about the same. And it's very difficult for those 
individuals to get in and get timely healthcare appointments. 
I'm worried that, I think CBOCs and those people who reach out 
to the veterans who make those house calls on those that are 
house-bound, and/or have mental health conditions that make it 
difficult for them to come in, we are very short on those types 
of people. We need more of them. They do an excellent job. 
They're very committed, but I think we're at the point where 
we're starting to overwork them. Mental health individuals have 
to make assessments of some cases in the field, supposed to be 
about an hour or less than that to try to make some kind of 
assessment. I would like to see more of that expansion of 
technology out in the field for those rural people, such as not 
only the Telebuddy, but they have tele-video where the mental 
health individual actually sees that individual on a screen and 
can make assessments, and they can have somewhat of a 
consultation right there at their home.
    Senator Brown. Thank you. Mr. Anderson, about the 
diminution of quality of care. Pull the microphone a little 
closer.
    Mr. Anderson. When you asked me that question, Mr. 
Chairman, I looked at myself, and I think I've received some of 
the best care in the world from the VA. I am a product of that 
service. I'm specialized service intern of spinal cord injury. 
I've been receiving service 27 years, and I've gotten some of 
the best spinal cord injury service around. I've received three 
surgeries there at the VA Medical Center, and I'm going in for 
a third one in another month for Harrington rods, I've been 
experiencing some Harrington rod problems, and the service I 
received from the VA has been excellent. And as specialized 
service, only through the VA have I been able to get that 
quality care of services. And the veterans that I've worked 
with and serve with, only through the VA have we been able to 
get that kind of service. So we have received topnotch service, 
and nowhere have we received such quality care.
    Senator Brown. Mr. Ondick and Mr. Lanthorn, you both talked 
about 700 CBOCs around the country, 150 cares recommended. Do 
you specifically recommend expansion? We just announced this 
week--well, I talked to the Secretary of the VA this week about 
the Hamilton and Parma new expanded CBOCs. Do you specifically 
recommend more in Ohio? And if so, does that potentially take 
money away from other things that the VA is doing? What is your 
thought about additional CBOCs in Ohio, and even specifically 
where, if you are recommending that? Your view, and I'd like to 
ask both of you, but either/or.
    Mr. Ondick.
    Mr. Ondick. I have covered in my testimony the list of the 
facilities that there are in Ohio. There is a significant need 
for a couple of CBOCs in northwestern Ohio, which is not in 
VISN 10, but it is in VISN 11 out of Michigan, and Indiana fall 
into that VISN. Most significantly, that's where our needs need 
to be addressed. However, we could use a couple of CBOCs in----
    Senator Brown. There is one in Lima now. Correct?
    Mr. Ondick. Yes. Yes, there is.
    Senator Brown. Nowhere between Lima and Toledo?
    Mr. Ondick. Actually, Finley and Defiance would probably be 
two good locations, or Finley and Bryan, not knowing where 
there might be one in Michigan.
    Senator Brown. But now there's--outside of Toledo, there's 
Lima, there's Lorain, east of Toledo, nothing in Bowling Green, 
nothing in anywhere else other than Lima at this point?
    Mr. Ondick. And Toledo, yes.
    Senator Brown. And Toledo, yes.
    Mr. Lanthorn. If Mr. Montague would just hold up the map of 
Ohio right here, you can see the locations of all the CBOCs, 
and where the need is.
    Senator Brown. That would be out of the Michigan Center, 
though, correct?
    Mr. Ondick. Marion. In southeastern Ohio, we are dependent 
upon CBOCs in Huntington.
    Senator Brown. They're in East Liverpool, they're here, 
they're Athens, Chillicothe.
    Mr. Ondick. But we are dependent upon CBOCs that are 
located in St. Clairsville, and then, of course, the VA Center 
in Huntington to service Ohio veterans, as well.
    Senator Brown. So there's one in Marion. Correct?
    Mr. Ondick. Yes.
    Senator Brown. So Marion and Lima, and Mansfield.
    Mr. Lanthorn. You could see the areas that need coverage, 
that northwest corner. The areas down in Cincinnati, Dayton are 
covered quite well. There are a few small pockets, and, again 
from my conversation with Mr. Montague earlier, some of the 
small pockets along the river, and up along the eastern part of 
the state are covered by--correct me if I'm wrong, Mr. 
Montague, but they're covered by CBOCs in other states?
    Mr. Space. Mr. Lanthorn, while we're on the subject of 
CBOCs, my understanding is there are five of them in Ohio's 
18th Congressional District. That would include one here in New 
Philadelphia, which I have been told is one of the fastest 
growing CBOCs in the state, community-based outpatient clinics. 
In addition, we've got one in St. Clairsville, Cambridge, 
Zanesville, and Newark. Is that correct?
    Mr. Lanthorn. Yes, sir.
    Mr. Space. Those are the five serving----
    Mr. Ondick. The one in St. Clairsville is not part of VISN 
10. That's one we're depending on another VISN.
    Mr. Space. Right. Those are the five. And the principle 
behind the CBOC concept is, it's kind of--I've heard the 
analogy ``hub and spoke,'' with the hubs being the medical 
centers, like the one we have in Chillicothe, or the one we 
have in Cleveland; with the spokes being the various CBOCs 
situated strategically around the state, try to serve those 
veterans who are not within a short drive to those medical 
centers. I mean, the concept is a good one, and certainly, we 
are encouraged by the recent announcement that there are going 
to be more CBOCs constructed, but the fact of the matter is 
that some of the CBOCs, all of them, actually, have some 
serious limitations when dealing with special needs. And I 
think it was Mr. Ondick that used the example of someone who 
has to travel 80 miles for radiation therapy, and then travel 
80 miles back home. Forget about the fact that the insult of 11 
cents per mile, the mere travel and distance, and inconvenience 
occasioned by that travel is, in and of itself, a significant 
problem that affects almost exclusively rural veterans.
    Aside from making that statement, I wanted to ask you 
whether--and this applies to anyone on the panel--if you've got 
some ideas, some creative thoughts on how we can expand access 
to specialized care in rural America, rural Ohio, in 
particular, over and above what's presently being offered by 
the CBOC hub and spoke system.
    Mr. Ondick. Mr. Chairman, it would certainly behoove the VA 
to, as they provide services in the CBOCs, to provide some 
specialty services at certain CBOCs so that like Women's 
healthcare services be available, if not within the 30-mile 
radius at every CBOC, perhaps overlay those maps with 50 or 60-
mile circles that would assure that those specialty services 
would be available within a certain time and transportation 
frame for all veterans in the state. This is something that 
could be done, I'm sure.
    Mr. Space. Anyone else on the panel have suggestions on how 
we could enhance specialized care for rural veterans?
    Mr. Burke. Congressman, I know that some of my guys that 
have commented about the clinic here in New Philadelphia, it is 
said to be one of the fastest growing in the state. That is 
because there have been a lot of participation by the veterans 
in this area. I'm told that the clinic here will soon have eye 
care, and foot care, podiatry, and the veterans that I've 
talked to have commented that this is really going to be of a 
help to them. The more expanded care that can be provided in 
the small town clinics is certainly going to diminish the time 
that the veteran has to travel to the major hospital for 
whatever purpose he has to go there for. So I suggest that the 
expansion of services at the local clinics would certainly do 
much to help the veterans in the area.
    Senator Brown. Perhaps Mr. Ondick could answer this. Are 
there five VA medical centers in the State of Ohio? How many 
are there in the State of Ohio?
    Mr. Ondick. We have Chillicothe, Cincinnati, Dayton, 
Cleveland.
    Senator Brown. It seems to me that every region of Ohio is 
served by a medical center, with the exception of the 
southeastern area of Ohio.
    Mr. Bertschy. You've got the--one of the problems is 
Harrison County. I think it's Harrison County, and one other 
county, I think it's Jefferson County, that have to go to 
Pittsburgh, and there is no CBOC. Steubenville has a CBOC, or 
close-by, but if you look at the ones close to the Ohio River, 
talking about Morton's Ferry and them areas in there, they have 
to go to Pittsburgh. That's the only place they can go. There 
is no CBOC within a 30-mile radius for them. I think if they 
could expand the old type, what we had, the fee-basis or the 
fee-basis where they could go to their local hospitals to get 
this care would help an awful lot.
    Senator Brown. Excuse me. There's a CBOC in East Liverpool, 
and St. Clairsville. Right?
    Mr. Bertschy. Right. There is----
    Senator Brown. Where?
    Mr. Ondick. St. Clairsville, is it open yet?
    Mr. Bertschy. St. Clairsville is open.
    Mr. Ondick. I was thinking it wasn't open.
    Senator Brown. So where are they not getting service? 
Steubenville doesn't have one, but it's served by----
    Mr. Bertschy. Steubenville has to go to East Liverpool.
    Senator Brown. East Liverpool, or south of there, Mango 
Junction maybe goes to St. Clairsville. I don't know, but where 
do they have to go, to Pittsburgh?
    Mr. Bertschy. Most of them are going--anyone I talked to, I 
don't know in Jefferson County, in Steubenville, that most of 
them will go to Pittsburgh.
    Senator Brown. Rather than St. Clairsville, or East 
Liverpool.
    Mr. Bertschy. Yes.
    Senator Brown. Let me pursue, and Mr. Burke, maybe this is 
for you. You all talked about the 11 cents a mile, and we all--
that's just an embarrassment to all of us. But my understanding 
is there are some cases where people in the community, 
particularly someone is driving, they simply can't drive 
because of their disability, because of their illness, because 
of whatever reason, they don't have car, and I know that 
community organizations that support veterans' groups, 
sometimes, obviously, veterans service organizations and others 
will provide transportation. My understanding is, sometimes 
they are not eligible for reimbursement at all? Someone that's 
helping. Mr. Burke, if you have to go and you can't drive 
yourself, and you get some help from somebody in the community, 
they don't get reimbursed at all. Is there a loophole in the 
law that disqualifies or some prohibition for reimbursement?
    Mr. Bertschy. Well, if you're not service-connected, and if 
you're a Category 7 or 8, if your income is above certain 
levels, the VA simply says you're not eligible for any 
reimbursement as far as mileage goes.
    Senator Brown. So if it's Category 7 or 8.
    Mr. Bertschy. Category 7 or 8, and----
    Senator Brown. Or if you're above a certain income level.
    Mr. Bertschy. And if you're above a certain income level, 
and if you're a veteran, but you have no service-connected 
disability, that is another obstacle to receive----
    Senator Brown. You're eligible to go to the CBOC in East 
Liverpool, but you can't get mileage.
    Mr. Bertschy. Correct.
    Senator Brown. Mr. Moore.
    Mr. Moore. You can't get enrolled if you're a Category 7 or 
8.
    Senator Brown. You can't get enrolled.
    Mr. Bertschy. Right now, that's correct. I'm sorry. That's 
right. Right now, if you're a Priority 8, you can't even get 
enrolled because they've been locked out.
    Mr. Moore. If I could, Senator Brown. Rural areas are 
basically, they use HUD for figuring those financial incomes 
for families, probably for a married couple you're looking at 
rural areas of about $32,280 for a married veteran, and about 
$25,000-$26,000 for a single veteran. If he is that income or 
over that, then he's Category 7 non-service connected, and he's 
not available, or he's not eligible for healthcare.
    If I could, one more. You had asked earlier in regards to 
outsourcing, why it's another reason why we wouldn't want the 
VA to do that; because the VA has a unique ability to treat 
some of these specialized injuries in mental illness that 
nobody has. Nobody else there in the private sector sees the 
amputees, and the burn victims, and the PTSD. They've dealt 
with that for years, and they are the ones with the expertise 
to really handle and give the best healthcare to those injured 
individuals.
    Senator Brown. Thank you all very much for being with us 
and sharing your thoughts, and your experience, and your 
wisdom. Stay in touch with both of us, personally, stay in 
touch with the Veterans' Committee in both houses. I will see 
you all regularly, I'm sure, in the years ahead. And thank you 
for coming to New Philadelphia, and joining us today. Thanks 
very, very much.
    Mr. Space. If I could, before you exit the stage, I just 
had a couple of things I wanted to bring up. First of all, Mr. 
Bertschy, I wanted to commend you for what appears to be having 
logged 85,000 volunteer miles in helping to transport veterans. 
I got that from your resume, and I wanted to commend you for 
that.
    And if I could just, before we leave this subject, because 
of the peculiar concerns of rural Ohio when it comes to 
healthcare; and, Mr. Moore, I want to address this to you, 
again, any others feel free to jump in, but I understand your 
concerns about privatization and pulling funds away from 
speciality treatment that the Veterans' Administration is able 
to administer better than anyone else. I think Mr. Bertschy may 
have mentioned a reference to the prospect of providing local 
community care for some veterans who don't have immediate 
access to veterans' care. And, Mr. Moore, are there situations 
where contracting for healthcare outside of the Veterans' 
Administration, would be appropriate, and would enhance 
veterans' care?
    Mr. Moore. Yes. Like I said, with proper use, there are 
areas I think in need, in rural areas. Obviously, as we talked 
about, chemotherapy treatment and radiation, even when we have 
transportation, even in some of our counties to the medical 
centers at Stokes, when you started getting into that eighth 
and tenth treatment, you get so ill that just getting on the 
public transportation, or having to wait for the other guys to 
come back in a van is just tough on them. Something like that, 
if we could have it specialized where that and a fee-basis 
could be outsourced, they get their--obviously, most areas 
there's somebody, or a medical facility close by that does have 
chemotherapy and radiation treatment.
    Mr. Space. So it might be something worth studying, 
particularly with respect to rural----
    Mr. Moore. Yes, the Veterans of Foreign Wars are not 
totally against that. We think in certain particulars, it could 
be of use. But it has to be, obviously, audited and looked over 
very strongly when you're doing that.
    Mr. Space. All right. Well, thank you, Mr. Moore. Thank you 
all of our panelists. I wish we had more time, but we're on a 
rather tight schedule. When we're through here, I'd ask that 
you exit the stage, and we have seats arranged for you in the 
first row. And our second panel will approach the stage. We're 
going to take about a 5-minute break, and we'll launch into our 
second panel. Thank you.
    [Recess.]
    Mr. Space. We've got the panelists. I ask that all audience 
members take their seats. We'd like to move forward with our 
second panel. Our second panel this morning is Terry Carson, 
Chief Executive Officer of the Harrison Community Hospital in 
Cadiz, Ohio, which is in Harrison County.
    Mr. Carson, I'm privileged to introduce you this morning 
both as a panelist and, again, as a constituent. We look 
forward to hearing your remarks.

      STATEMENT OF TERRY CARSON, CHIEF EXECUTIVE OFFICER, 
                  HARRISON COMMUNITY HOSPITAL

    Mr. Carson. Senator Brown and Congressman Space, we thank 
you very much for taking the time this morning. Frankly, you're 
the only two offices that responded to our letters of issues, 
so we appreciate you taking the personal time, and also the 
time out here in the field.
    I've been for 15 years attempting to meet the challenges of 
providing healthcare to rural communities. My background is 
primarily a big city, Cleveland boy, so when you come out to 
the rural, there are special challenges that you try to meet 
because you take for granted that they're out there, and 
sometimes, it's a very rude awakening when they're not.
    I was drafted in 1965, and I spent my next two years at 
Walter Reed in Washington, DC. And, of course, I was sort of 
dismayed when I heard the reports in the papers not too many 
weeks ago about some of the conditions that have been 
developing. We know that as a first-class military institution. 
I don't think that's a veterans' facility. But when I was 
there, I was a kid coming out of Cleveland, Ohio, never had a 
stitch, never broke anything, and we were treating and serving 
the kids that came right in from Vietnam, and many times they 
had their field bandages on them. So I think it's a system we 
can be awfully proud of, and I think our entire VA system is 
one that we can be proud of. But I think the conditions that 
took place there are probably a good example of you just can't 
pour money down a rat hole and think it's going to develop into 
something. Someone has to watch it, and monitor it, and has to 
make sure that it's working.
    And that's really our message in my brief statement that I 
presented to you folks, is that there has to be a better way to 
tend to those patients who have critical issues out in the 
rural communities, without having them go hundreds of miles to 
a center, because their name happens to be registered there for 
their treatment.
    Sometimes you need to think out of the box, and instead of 
pouring money into a system that perhaps isn't meeting 
everyone's needs, how do you come up with ways to make it work? 
And I was listening to some of the panelists here, and it's 
very humbling to have gone through my military time without 
having an injury, and seeing people that have had some pretty 
devastating things taking place in their lives. But if we can, 
perhaps, take a little chance to improve the system in the 
offering that we're giving, maybe it's time well spent.
    But it may well be something that you could have a panel of 
hospitals, and a panel of physicians who are willing to sign 
onto the VA program, much like we do with the Medicare program 
in offering these services in various communities. If you want 
to put your outpatient clinics adjacent to, or in closer 
proximity to rural facilities, rather than duplicate all the 
programs. You can just pay for--I know darned well it cost a 
whole lot less to provide services in Cadiz, Ohio, than it does 
in downtown Pittsburgh in the VA Hospital. I know because I 
can't hire the nurses, I can't hire the doctors. We can't 
afford to hire them away. And perhaps a decentralization 
approach to this whole thing is one that will make it work a 
little bit better.
    The samples I gave you were those types of patients who 
come to the hospital with an emergency or an urgent situation 
in their personal life, and they can't get treatment at our 
facility because they're on the VA system. We have had problems 
logistically getting them to the facility because either a bed 
wasn't available, or the surgeons weren't available to do the 
work. When we finally did get approval, it is not uncommon for 
that to be taken and withdrawn, so that patients have to go 
back to the hospital and spend two or three days at the 
hospital before they're able to go back up.
    I think there's a level of inconsistency with regard to the 
kind of information that's provided to providers. One might 
tell you to go ahead and do the service because we'll pay for 
it over the long haul, and I heard that issue this morning 
about then the hospital starts dunning the patients because 
they haven't paid the bill. You could have an arrangement much 
like the Medicare program where you know what you're going to 
pay for procedures, and people sign up to do it. That would be 
an acceptable payment situation.
    The other thing is actually getting patients to the 
facilities. Very often, if a community doesn't have a van 
service, it is really the responsibility of a family member, or 
a very good friend. That's not always the best time in their 
lives, anyway, so friendships could strain pretty thin, when 
you start going up to these long facilities, and getting 
someone to take you up and bring you back. So our approach, and 
our discussion really this morning is the logistics of how to 
get patients in the system, how to treat them. And when they 
present themselves as an emergency, it truly is an emergency. 
It's one that would be an emergency for you, or anyone else who 
presented themselves with a crisis.
    I gave you a specific example of someone who broke their 
hip, I think three days later before we could ship them up to 
get the hip taken care of. So our concern is getting those 
patient's services. We want to do it in a very positive, open 
way. We think there are opportunities to work together, and I'm 
really here on behalf of our fellow constituents that we both 
serve. And we think we do a nice job serving your constituency. 
We just want to be able to make it easier for their access to 
it.
    [The prepared statement of Mr. Carson follows:]
    Prepared Statement of Terry M. Carson, Chief Executive Officer, 
                      Harrison Community Hospital
    The Harrison Community Hospital is a Critical Access Hospital 
serving a population of approximately 15,000 citizens in Southeast 
Ohio. Included in our service are our veterans that require various 
levels of care.
    The problem that we experience has to do with treating initial 
emergency/urgent situations and having little success in being able to 
transfer veterans to the appropriate Veterans' Hospital Center.
    Often, we wait days to receive transfer approval, and it is not 
uncommon for those approvals to be withdrawn during the actual 
transfer, and change of direction mid-stream.
    These delays do not serve patients well, and often puts the 
hospital in the position of proceeding with treatment because the care 
needs to be provided. We even have to find alternative facilities to 
accept the patients, knowing that they too will have difficulty 
receiving reimbursement for the care.
    The simple solution would be for facilities such as ours to be 
given approval to treat patients in our community and have the local 
doctors render the necessary care. To be mandated to send patients 65 
to 100 miles away during their crisis really doesn't make that patient 
a priority, just a convenience for the VA Center.
    To offer a coordinated system seems to require better access, local 
treatment or a combination of both.
    Thank you for your interest and the opportunity to discuss this 
important gap in the system.
                               attachment
    Patient, 85, was brought to the ER on 02/23/07. Patient had fallen 
at home and was brought in by ambulance. X-ray showed a fracture of the 
femoral neck left leg. He had only VA insurance. The VA Hospital in 
Pittsburgh was called and we were told it was full. Cleveland VA 
Hospital was also contacted regarding bed availability. They referred 
him to Pittsburgh since he is a patient of this area. We also called 
the VA office in St. Clairsville, Ohio, and they stated that he was a 
patient of theirs and Pittsburgh. Dr. Sandhu, our ER Physician, spoke 
with an ER physician, Dr. Ruhl, at the Pittsburgh VA, who advised him 
to send the patient to that hospital's ER and he would see him. While 
transporting the patient, we received a call from Pittsburgh VA 
refusing to accept him, so we had to turn the squad around and bring 
him back. Dr. Modi accepted the patient and he was admitted here. We 
were told to call in the morning to see if there was a bed available. 
The VA hospital was called each day regarding bed availability. On 02/
25/07, a comment was made to Pat Worrell (Nurse Manager) by Mr. 
Anderson, AOD, Admission's Director, that ``possible transfer on 
Monday, transfer may cause further damage to fracture''. He also said 
that ``they are using too much of the OR time on bones, this is a 
regional center for kidney and liver and they are getting bones from 
everywhere in the region''. Dr. Modi attempted to get another 
orthopedic physician to accept the patient. He finally got in touch 
with one at UPMC who agreed to accept the patient, but the hospital 
wanted the patient to be counseled and sign a form, witnessed, stating 
that he may be responsible for the bill before accepting the patient. 
After speaking with Administration at the VA Hospital and again to the 
St. Clairsville VA Clinic, we were notified that the Pittsburgh VA 
Hospital had a bed and the patient was transferred on 02/26/07.
    Patient, 75, came to the ER on 02/28/07. Found unresponsive at home 
with a blood sugar of 22 and respiratory problems. He was diagnosed 
with sepsis, hypotension, dehydration, hypoglycemic reaction and acute 
pyelonephritis. He required large amounts of IV fluids to maintain BP. 
Attempted to transfer the patient to the two VA hospitals but both did 
not have any beds. Also attempted to transfer the patient to several 
local hospitals with East Ohio Regional Medical Center agreeing to take 
the patient.
    Patient, 35, came to the ER with suicide ideation. He did not have 
any insurance and his mother stated that he had been at the VA Hospital 
in Pittsburgh before. We called that hospital and they put his name on 
the list, they did not have a bed and we were to call every day to see 
if a bed was available. Pam Parrish (Social Services) contacted Chuck 
at the Cadiz VA Office requesting assistance to find a bed. He called 
the VA Hospital, and also was told the same thing, no bed available, 
his name was on the list, and they would try to get him in as soon as 
possible. We also tried the Cleveland VA hospital and left a voice 
mail, but no one called back. The patient was eventually transferred to 
Belmont Community Hospital's Mental Health Unit.

    Senator Brown. Thank you, Mr. Carson.
    Dr. Gerald Cross, who's been with the VA for many years, is 
now the Acting Principal Deputy Under Secretary for Health.
    We appreciate your coming to New Philadelphia, and speaking 
with us today, Dr. Cross.

  STATEMENT OF GERALD M. CROSS, M.D., ACTING PRINCIPAL DEPUTY 
   UNDER SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS

    Dr. Cross. Senator Brown, thank you very much for having me 
here, and I want to say I'm a family physician. I grew up on a 
farm in a rural environment in Virginia. I was a member of the 
4-H Club, and I guess those are my best credentials. I'm here 
with Jack Herrick, Director. Jack, can you stand up so people 
can see you. And we've already had a chance to talk with Mr. 
Carson this morning, so this meeting has already served a 
purpose in that we started the channels of communication to 
work out some of the issues that he's talking about. And, by 
the way, we'll continue that.
    I've ditched my speech, and I've just written down a few 
notes I want to comment on, based on what I heard this morning. 
Rural healthcare is, in fact, very important to us. It's about 
39 percent of our enrolled population for healthcare. And, 
indeed, we have established and are developing an Office of 
Rural Health at the Central Office in Washington. But much more 
than just creating a new office in Washington, I want to tell 
you what we're really doing that's making a difference.
    Strategically, we are doing geographic dispersion. We were 
very much a tertiary big medical center-based organization a 
decade or two ago, and we're changing dramatically, much more 
to continuity, comprehensive care, outpatient care, primary 
care. And we followed through on that. We now have 717 
community-based outpatient clinics. We're planning 20 or more 
of them for 2007, and more for 2008; 207 Vet Centers, and more 
planned in the coming years. These wonderful organizations that 
are so accessible in terms of lack of bureaucracy, just walk in 
and say hello, and somebody there will say hey, welcome. Sit 
down, have a cup of coffee, let's talk.
    Telemedicine and mental health, to make sure that we can do 
specialty consultation, diagnosis, follow-up even at our small 
community-based outpatient clinics of some our specialists, 
like dermatologists, or mental health, especially mental 
health.
    And we don't expect our patients who get medicine every 
month for blood pressure, cholesterol, or whatever to have to 
come to the pharmacy of the big medical center, or even at the 
CBOC. We mail it to them. We deliver the medicine to the home 
wherever that home may be, month after month, year after year.
    And we're moving into a new direction, home-based primary 
care, where we actually send providers out to the home to take 
care of people who are restricted to the home and unable to get 
up and about; $175 million in our 2008 budget just for that one 
program, and many millions of more for other similar, related 
programs.
    So here are the results at the moment. Within 60 minutes of 
care nationwide, 92.5 percent of our enrolled population for 
healthcare. Within 90 minutes nationwide, it's 98.5 percent. 
Mental healthcare is especially interesting. In 1996, the 
average distance traveled for mental healthcare was 26 miles by 
a veteran going to a VA facility. It's now 13 miles, 
approximately.
    Satisfaction among our patients in the rural environment 
exceeds that of those in our urban environment. Quality of care 
is measured by standard indicators, of which we have many. 
Almost exactly matches, on average, that's received in urban 
care.
    Now, sir, I'd like to say just a word about OIF and OEF. 
The secretary some years back opened two years of eligibility 
for anyone returning from the combat theater, that includes OIF 
and OEF. The two years of eligibility that the secretary opened 
sometime back for OIF and OEF still makes it possible for an 
individual coming back from the combat theater to get the care 
they need, and gives them time, if they're going to go through 
a disability process, to get that disability claim done. I 
should say that in the Senate right now, there is a bill to 
extend that two years to five years. And I testified, I think 
about two weeks ago, that we were in support 
of that.
    We're adding staff, doctors, nurses, psychologists, 
especially mental health staff. We're screening everyone coming 
back from the combat theater OIF and OEF for TBI, Traumatic 
Brain Injury. This is something the VA does better than anyone 
else, because of our comprehensive electronic health record. 
And we're doing the same thing for PTSD. We're doing the same 
thing for substance abuse, and we're doing the same thing for 
depression.
    We're the only organization, I believe, that can make those 
statements. And then we're going to follow-through on them. 
We're doing research to find out more about these conditions, 
as we've done a tremendous amount of research, for instance, on 
PTSD. But I want to tell you about two new things, just very 
briefly, and that will be my conclusion.
    Transition Assistance Advisors are in place in every state 
working through the National Guard in the Office of the 
Adjutant General, right in the Governor's office. The states 
can provide services that on a federal level, we don't really 
do, such as providing employment, providing link-ups to the 
local community to find employers ready to hire these returning 
veterans. And these individuals in the Governor's office also 
help to make sure that individual is aware of all the state 
services, and all of the federal services.
    And something very new, and I want you to know about this. 
Transition Patient Advisors, a hundred of them being GS-11s, 
don't have to be medical care workers. We're putting them in 
Ohio, and every other state. And when a new veteran seriously 
injured shows up at Walter Reed or Bethesda, they fly there to 
meet with them, to meet with the family, to follow them a 
couple of times a week, and to make sure that there's no 
falling through the gaps. That concludes my statement, sir.
    [The prepared statement of Dr. Cross follows:]
 Prepared Statement of Gerald M. Cross, M.D., Acting Principal Deputy 
       Under Secretary for Health, Department of Veterans Affairs
    Good Morning, Members of Congress. Thank you for the opportunity to 
discuss VHA's ongoing efforts to provide safe, effective, efficient and 
compassionate health care to veterans residing in rural areas.
    My remarks will briefly review the national challenge presented by 
rural health care, VHA's strategic direction and initiatives underway.
    Among the entire enrolled VA population, 39 percent were classified 
as rural at the end of FY 2006. And among the entire enrolled VA 
population, 2 percent were classified as ``highly rural.'' Highly rural 
refers to counties with less than 7 citizens per square mile.
    Researchers have studied the rural health care experience, 
including a number of articles that looked at VA rural healthcare. 
Three studies have found that veterans living in rural areas tend to be 
slightly older, and more likely to qualify in Priority group 5--that 
is, non-service-connected, zero percent service connected, and low 
income. These same veterans were also less likely to be employed. The 
studies agree that rural veterans had slightly more physical health 
problems but fewer mental health conditions--as compared to suburban 
and urban veterans.
    VHA's strategic direction is to enhance non-institutional care with 
less dependence on large institutions. Instead, we are providing more 
care at home and in the community.
    VHA now has 717 Community Based Outpatient Clinics or CBOCs. Of 
this total, 320 or 45 percent of these are located in rural or highly 
rural areas. We've created Consolidated Mail-Out-Patient Pharmacies or 
CMOPs so that medications are delivered to the patient's home--instead 
of having the patient travel to the hospital. We provide home based 
primary care--devoting more than $175 million to this program in FY 
2008, and more than 95 million dollars for other home based programs. 
We are using tele-medicine and tele-mental health to reach into the 
veterans' homes and into community clinics. This allows us to evaluate 
and follow patients without them having to travel to large medical 
centers. We are far along with our mental health enhancement initiative 
that will add resources and greater mental health expertise in primary 
care clinics. We are also using a special Internet site, providing 
information to veterans in their own home, including up-to-date 
research information, access to portions of their medical records, and 
the ability to refill medications online.
    To accomplish this, VHA is emphasizing primary care and spreading 
out geographically. At the end of FY 2006, 92.5 percent of our 5.4 
million patients were located within 60 minutes of a VA healthcare 
facility. And 98.5 percent were within 90 minutes. Among those who live 
outside the 60-minute range, some are those veterans in highly rural 
areas and some are veterans living in Tribal areas.
    In 2006 evaluations of veteran patient satisfaction, comparing 
rural versus urban veterans, we found that rural patients were more 
satisfied with their health clinics than their urban counterparts.
    We also looked at the quality of care, comparing rural versus urban 
clinics. Looking at 40 standard measures, quality was virtually 
identical overall between rural and urban clinics.
    To continue this strategic support for access and rural health care 
we have over 20 CBOCs for 2007. Forty three percent of these CBOCs are 
in rural or highly rural areas. In addition to these clinics, VA is 
currently working on telecommunications strategies to provide Care 
Coordination/Home Telehealth services in rural areas. Since January 
2004, VHA has trained over 3,500 staff nationally to provide care via 
CCHT.
    In Ohio, there are 5 VA Medical Centers and 32 Community Based 
Outpatient Clinics (CBOCs). In close proximity to Appalachia, (the 
region in the United States that includes the southern Appalachian 
Mountains, extending roughly from southwestern Pennsylvania through 
West Virginia and parts of Kentucky and Tennessee to northwestern 
Georgia) we have 9 CBOCs in Southeastern Ohio and 2 in Kentucky. 
Specifically, East Liverpool (Columbiana County), New Philadelphia 
(Tuscarawas County), Athens (Athens County), Lancaster (Fairfield 
County), Cambridge (Guernsey County), Marietta (Washington County), 
Portsmouth (Scioto County), Batavia (Clermont County), and Zanesville 
(Muskingum County). The 2 (two) Kentucky CBOCs are in Bellevue 
(Covingnton, KY) and in Florence, KY. These CBOCs are located in rural 
areas of Ohio bordering southern Pennsylvania, West Virginia, and parts 
of Kentucky.
    In addition, the Vet Center program provides quality readjustment 
counseling and removes unnecessary barriers to care for veterans and 
family members. Vet Centers engage in extensive community outreach 
activities to directly contact and inform area veterans and to maintain 
active community partnerships with local leaders and service providers 
to facilitate referrals for veterans in need.
    Some Vet Centers are maintained in rural areas to ensure that rural 
veterans and families have access to readjustment counseling services. 
Additionally, we have established Vet Center outstations in rural 
areas. Outstations are administratively connected to a full sized Vet 
Center, use permanently leased space and are usually staffed by one or 
two counselors who provide full time services to area veterans on a 
weekly basis. The Vet Centers also maintain nontraditional hours to 
accommodate veterans traveling in from greater distances.
    Vet Centers in Wheeling, Parkersburg and Huntington, West Virginia 
all located on the Ohio River provide outreach and readjustment 
counseling to veterans in rural Ohio.
    In addition to our internal efforts outlined earlier, VA continues 
to look for ways to collaborate with complementary Federal efforts to 
address the needs of health care for rural veterans. We also have 
partnerships with HHS, including the Indian Health Service and Office 
of Rural Health providing health care in rural communities. We are also 
working to establish relationships with other entities, such as with 
the National Rural Health Association.
    VHA recognizes the importance and the challenge of service in rural 
areas, and we believe our current and planned efforts are addressing 
these concerns for our current and emerging veterans.
    This concludes my statement. At this time I would be pleased to 
answer any questions that you may have.

    Mr. Space. Thank you, Dr. Cross, and I apologize for having 
to cut you off. We are running short on time.
    Incidentally, I think the Patient Advocate Program you just 
referred to is still in its early stages, but I think it's a 
very valuable addition to the Administration.
    I want to talk a little bit about the CBOCs, again. And you 
had mentioned that there are plans to build more than 20 right 
now. Do you have any indication, if the 18th Congressional 
District for the State of Ohio will receive any additional 
CBOCs?
    Dr. Cross. For Ohio, I think there were two, and, Jack, you 
can help me with this. I think one is in Hamilton, and the 
other is----
    Mr. Herrick. Hamilton and Parma were announced this week.
    Mr. Space. Oh, Parma and Hamilton. So that will not 
facilitate or enhance the care of veterans in southeastern 
Ohio. And, second----
    Dr. Cross. We do have other options besides CBOCs.
    Mr. Space. Right.
    Dr. Cross. Outreach Clinics that work for a CBOC, that can 
go into communities. Often they lease space, and we have a 
number of these now. And they're not listed as CBOCs, but they 
can be open for a day a week, or a couple of days a month, and 
provide services for those very small groups of veterans in 
these more remote communities. And we're doing that more and 
more.
    Mr. Space. Right. Now I understand last week we passed 
legislation that will allow for mobile units to enhance TBI 
treatment and care in rural areas, which is also an encouraging 
sign. But the fact remains that many veterans in rural Ohio are 
having to do things like travel 80 miles for radiation 
treatment, and then 80 miles back home again. And as 
Representative of this area, I'm trying to ascertain means by 
which to help solve those problems associated with veterans 
care. And I can't help but get around what may be, to me, an 
apparent need, seemingly a need for the construction of 
additional medical centers, those primary care facilities that 
render services of a broad range to veterans. I understand you 
can't build one in every county.
    We've got 16 counties in my District, we've got five CBOCs 
servicing those counties, and many residents in my District, 
who require specialized care, of course, drive 70, 80, 90, even 
more miles to receive care. Do you see a perceived need for the 
construction of a medical center in southeastern Ohio?
    Dr. Cross. To tell you the truth, sir, I don't know, 
because the CARES process that we've gone through, I want to 
refer to that and see what the findings were from that. That's 
a piece of information I can certainly get for you.
    Mr. Space. You would agree with me that veterans in rural 
areas of America, and specifically in Ohio, do suffer from a 
lower standard of care than those veterans in urban areas, 
simply because of their proximity, or lack thereof, to those 
medical centers.
    Dr. Cross. I don't agree with that for the VA. We've done 
the statistics on the performance measures related to the 
quality of care.
    Mr. Space. I'm not talking about the quality of care.
    Dr. Cross. Absolutely. I understand what you mean. I 
certainly do share that, the access issue by itself. I do need 
to put out one cautionary comment, talking about radiation 
therapy. Radiation oncologists and the equipment that goes with 
radiation therapy is something that wouldn't be found, 
necessarily, in the rural environment anywhere. And so that's a 
real challenge for us, and for everyone else in the civilian 
community, in Medicare, and so forth, to deal with those 
special circumstances. And I think the VA is, in fact, flexible 
about this. And on a case-by-case basis, can make arrangements 
to do what's best for the veteran.
    Mr. Space. And just as a brief follow-up, I mean, it is a 
fact, is it not, that rural Americans have shouldered more than 
their fair share of not just this war, but wars past, as well. 
Correct?
    Dr. Cross. Sir, I expect that that is true.
    Senator Brown. Thank you both, again. Monday, in 
celebrating Memorial Day, there were a couple of numbers I 
wanted to bounce off you, Dr. Cross, and ask for your thoughts 
on. Something along the lines of the Harper's Index, that they 
use that as sort of the box, 27 percent of veterans of the War 
in Iraq and Afghanistan have filed for disability with 
Veterans' Administration, and these are the two upcoming 
numbers that I think are the most significant. Ten percent of 
soldiers given medical discharge in 2001 were given permanent 
disability benefits, but only 3 percent of soldiers given 
medical discharges in 2005, who got permanent disability 
benefits. Why would that be, that 10 percent of those not in 
wartime who left the military were getting permanent disability 
benefits, but only 3 percent of those discharged in 2005? Do 
you have any thoughts about that?.
    Dr. Cross. I think my response would be it's early, and 
over time, we'll get a better picture of what their real 
pattern is going to be. I think it may be a bit premature to 
say what their long-term disability outcome is going to be, at 
this point.
    Senator Brown. Sir, maybe that's right, but I'd be more 
likely to accept that if the military were not doing a bit of a 
better job, certainly a better job than contrast to Vietnam, 
when several people from the last panel came home from Vietnam, 
they, one, weren't welcomed home in too many cases. But, 
second, certainly didn't have the kind of interaction with the 
VA, to talk to them about any kind of physical or mental injury 
they might have had. Today, we're not doing a splendid job, but 
we're doing better, as you suggest with some of your outreach. 
So shouldn't those numbers be higher as a result of that?
    Dr. Cross. Again, I think individuals don't apply for 
disability necessarily right away. There's no limit, there's no 
time limit on when a veteran can apply for disability. We've 
seen veterans applying for disability now for Vietnam.
    Senator Brown. And we're seeing people now from Vietnam, 
because of the attention paid to Iraq, I know. And I know those 
numbers are again going----
    Mr. Cross. So I think----
    Senator Brown. I would like to explore this more. Let me 
shift to continue questioning, for you, Dr. Cross, but 
particularly about Mr. Carson's issue. We've heard from him 
that community hospitals and patients are faced with 
unreimbursed care when after stabilizing emergency patient, 
they can't transfer them to a VA facility because there are no 
beds available in a county as rural as Cadiz and Harrison 
County. We're looking at legislation to ensure that this 
doesn't continue, but two questions. Why is this happening, in 
the first place? And, does the VA actually have the discretion 
to pay these claims? I guess a third question then, if the 
answer is no, is legislation necessary?
    Dr. Cross. There is legislation that relates to the Mill 
Bill. I forget what year that was, I think it was about 2000, 
which sets up emergency care funding for situations where an 
enrolled veteran who has been seen within the previous 24 
months, if I recall correctly, is eligible so that they can go 
to the nearest emergency room and get care. We didn't want a 
situation to occur where a person is having a heart attack and 
drives past the community emergency room to get to a VA 
facility which is some further distance away, which would not 
be to their advantage in that situation. So the Mill Bill 
created, as I understand it, a possibility to get that care 
delivered and covered for a period of about three days, the 
intent then being to transfer them back to a VA Medical Center.
    What I'm hearing this morning, though, I think, and that's 
the value of this hearing, especially to make these kinds of 
link-ups, is that we have some communication issues with Mr. 
Carson's hospital. And I've got my VISN Director here, and 
other staff to make sure that we work some of those out to deal 
with those issues that he's pointed out, and very appropriately 
pointed out.
    Mr. Space. Given the late hour, I just simply don't have 
much more time for questions. Your testimony will be entered 
into the record.
    Dr. Cross, I'm going to revisit, as my last question; and 
that is, given, once again, that we've got a very large area in 
southeastern Ohio served by, what I understand to be about 
65,000 veterans who are living here right now. We've got five 
CBOCs in 16 counties, and admittedly, those rural veterans are 
suffering from a lower standard of care, simply because of the 
drive time to and from medical centers. My request of you is 
that you take measures to inquire with your superiors, and 
conduct a research study whether or not this area of Ohio would 
be a suitable and appropriate location for the construction of 
a VA medical center.
    Dr. Cross. Yes, sir, we'll do that. And I would like to 
also say that we will be delighted to meet with your staff, and 
sit down and discuss any issue that you'd like directly.
    Mr. Space. Thank you, Dr. Cross. Mr. Carson, briefly.
    Mr. Carson. Congressman Space, just one comment on that, 
for what it's worth. I mean, you can look at a map and say 
well, it's just 20 miles, but for those of you who drive the 
District, and the limit is 55, I challenge you to get up to 55 
miles an hour on some of these roads, so that really----
    Mr. Space. Point well taken, Mr. Carson. I'd like to thank 
you both, again, for your testimony.
    Senator Brown. One question, before you close off, if I 
could. And thank you, Congressman Space, I've thought for some 
time that the VA is, in fact, I think probably so the best 
healthcare, when we fund it, the best healthcare in the country 
in terms of medical, lowest numbers of medical errors, 
outcomes, the specialty and the general care that the VA gives. 
I've also seen a commitment, and with some results so far of a 
much better coordination. A commitment from the Secretary with 
a much better coordination from DOD and to veterans' 
healthcare, because it's been uneven, at best, over the last 
years, and I give the VA credit for that.
    But then I see the message that it sends to our troops, to 
our men and women in uniform, when the President and Secretary 
Nicholson ask for a budget billions of dollars less than the 
Independent Budget that the veterans service organizations ask 
for, and they brag to our Committees in both houses that we're 
spending, I think the number they say is 77 percent more than 
2001. Well, yes, but there's been not, certainly new Vietnam 
Vets coming on line, coming to the VA, that weren't coming 
before, and certainly from this war. So I just would ask you, 
Dr. Cross and Mr. Montague, to take back to the VA the message 
that sends to our men and women in uniform, when we're willing 
to spend $2.1 billion a week on a war, and we're not willing to 
fund to the level with the Independent Budget in mandatory 
funding of the VA. And I know you, as a physician, probably 
agree with much of this, but take that message back, how 
important that is.
    So I thank you both for being here, thank you to our 
panelists. And thank you all who have joined us. Why don't you 
close it off, Congressman Space.
    Mr. Space. Thank you, again, Senator Brown. Thank you to 
the panelists, both in the first and second panel. And thank 
you to everyone who came out today in the interest of the 
State's rural veterans.
    Again, I'd like to send a special thanks to Dean Andrews 
and his team here at Kent State for hosting us. Thank you to my 
veterans' Advisory Board for their continued direction and 
knowledge. And thank you to our witnesses, once again, who have 
traveled to get here and present their views, so that we can 
all recognize the serious issues that stand in the way of rural 
veterans obtaining comprehensive care, and access to VA 
services.
    Where a veteran chooses to live should not affect his or 
her access to care. Our country is committed to provide 
healthcare, educational, vocational, and other services to our 
Nation's veterans, and we must follow-through on that promise. 
Telling a veteran that his home, or her home, falls into a 
geographical region that is not cost-effective to serve is not 
in line with keeping the promises previously made to our 
country's heroes. A veteran from rural Ohio gave just as much 
in service to our Nation, and sacrificed just as much, as a 
veteran from New York City, Los Angeles, or Cleveland, Ohio.
    This hearing has given us valuable knowledge about how 
Congress can move forward on important issues facing rural 
veterans. This hearing has brought together many of those who 
are directly involved in caring for these rural veterans, who 
make up approximately 40 percent of our Nation's veterans 
population. I'm extremely optimistic that given the ideas that 
we've heard today, Senator Brown and I will be able to move 
forward with innovative solutions, including legislation. I 
plan on working with Members of the House Veterans' Affairs 
Committee, as well as my colleagues on both sides of the aisle, 
to advance the agenda of rural veterans.
    Today, the day after Memorial Day, we've met to discuss how 
to move forward in better caring for those who have served our 
Nation. Let us also remember to look back on where we've come 
from. Let us remember those brave servicemembers who have given 
their lives in defense of our Nation; 16 from this District in 
this most recent war.
    I wish, also, to thank the veterans in our audience, the 
men and women currently serving, and their families who support 
them, for their past and continued service and sacrifice. It's 
an important honor to work on your behalf, and please know that 
I will continue to do so for as long as I serve in Congress. 
Again, thank you all for being here. Thank you, Senator Brown.
    [Applause.]
    [Whereupon, at 12:02 p.m., the joint hearing adjourned.]



  

                                  
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