[Senate Hearing 110-167]
[From the U.S. Government Publishing Office]


                                                         S. Hrg.110-167
 
    FIELD HEARING ON ADDRESSING THE NEEDS OF VETERANS IN RURAL AREAS 
=======================================================================




                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                             JULY 21, 2007

                               __________

       Printed for the use of the Committee on Veterans' Affairs


 Available via the World Wide Web: http://www.access.gpo.gov/congress/
                                 senate


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                     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





















                            C O N T E N T S

                              ----------                              

                             July 21, 2007
                                SENATORS

                                                                   Page
Tester, Hon. Jon, U.S. Senator from Montana......................     1
Baucus, Hon. Max, U.S. Senator from Montana......................     2
Salazar, Hon. Ken, U.S. Senator from Colorado....................     4

                               WITNESSES

Chapman, Alvy, Commander, Department of Montana, Disabled 
  American Veterans..............................................     7
    Prepared statement...........................................     9
Parmelee, Ronald, Montana Liaison for the Mountain States 
  Chapter, Paralyzed Veterans of America.........................    10
    Prepared statement...........................................    11
McLean, David, Commander, Montana Department, The American Legion    12
    Prepared statement...........................................    14
Keith, Heavyrunner, Director, Operation Glacier Warrior..........    16
    Prepared statement...........................................    17
Burgess, John, Vietnam Veteran...................................    18
Williams, Travis, Operation Iraqi Freedom Veteran................    19
    Prepared statement...........................................    20
Hartman, Richard, Ph.D., Director for Policy, Analysis and 
  Forecasting, Veterans Health Administration, Department of 
  Veterans Affairs; accompanied by William Feeley, M.S.W., FACHE, 
  Under Secretary for Health for Operations and Management, 
  Department of Veterans Affairs.................................    30
    Prepared statement...........................................    32
Grippen, Glen, M.D., Network Director, VISN 19, Department of 
  Veterans Affairs; accompanied by Joe Underkofler, Director, VA 
  Montana Health Care System, Department of Veterans Affairs.....    33
    Prepared statement...........................................    35
Foster, Joe, Administrator, Montana Veterans Affairs Division....    36
    Prepared statement...........................................    38
Mosley, Randall, Major General, Adjutant General, Montana 
  National Guard.................................................    39
    Prepared statement...........................................    40
      PDHRA Task Force Report....................................    43

                                APPENDIX

Formaz, Pete, NCAC-II, LAC, President, Montana Association of 
  Alcohol and Drug Abuse Counselors, on Behalf of NAADAC, The 
  Association for Addiction Professionals; prepared statement....    81
Velazquez, Tracy, Executive Director, Montana Mental Health 
  Association; letter............................................    82


    FIELD HEARING ON ADDRESSING THE NEEDS OF VETERANS IN RURAL AREAS

                              ----------                              


                        SATURDAY, JULY 21, 2007

                               U.S. Senate,
                    Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice at 12 p.m., at 
Montana State University, Great Falls College of Technology, 
Great Falls, Montana. Hon. Jon Tester, Member of the Senate 
Committee on Veterans' Affairs, presiding.
    Present: Senators Tester, Baucus, and Salazar.

             OPENING STATEMENT OF HON. JON TESTER, 
                   U.S. SENATOR FROM MONTANA

    Senator Tester. It's twelve o'clock noon. Will the hearing 
of the Senate Committee on Veterans' Affairs come to order. I 
want to thank each and every one of you who have come out today 
on such a beautiful day, a little warm, but that's the way it's 
been. I appreciate you taking time out of you folks' schedule 
to come here, and I want to thank everybody that has served in 
the military, I want to thank the spouses and families of those 
who have served in the military, whether you've served 40 years 
or 40 days. All three of us up here really appreciate your 
service to this country.
    Over the last two years, I've been doing a lot of listening 
to Montana veterans. Today's session is going to be a little 
bit different. Max, Ken and myself hope to learn a lot from 
Montana veterans here today about what is going on on the 
ground so that we can take your suggestions and concerns back 
to Washington.
    I might also add that the officials that are here today 
from the Guard, from the veterans' organizations will be also 
learning and listening as we speak. We are joined by several 
officials from the VA, both here and out from DC, and I hope 
that they will learn and listen to your concerns, as well. All 
of our panelists have come a long way to be here. I want to 
thank you for being here.
    It is my pleasure to have some distinguished guests up here 
at the head table with me. Senator Max Baucus, Max really needs 
no introduction. He has been in public service to the State of 
Montana and the U.S. Senate for a good many years, and he is 
the Chairman of the powerful Senate Finance Committee.
    Senator Salazar from Colorado is the lead author of the 
Rural Veterans Health Care Improvement Act, which is aimed at 
improving the lives of rural veterans. It's a piece of 
legislation that Max and I strongly support. Ken, I want to 
thank you very, very much for coming and spending a little time 
in the beautiful State of 
Montana.
    Exactly seven months ago, the President signed into 
legislation a bill creating a new Veterans Affairs Office and 
told the VA that it needed to use this new office to pay 
special attention to the issues that access the health care, 
mental health and long-term health care among rural veterans. 
Seven months later the two top positions to access the health 
care have not yet been filled, and we just don't have any 
indication at this point in time that the VA in Washington is 
going to take this new office seriously. It's an area that 
concerns all of us.
    I hope that the folks at the VA will take note of the 
witnesses' testimony here today and take note of just how many 
folks have come out to this hearing. The number of people in 
this room who have given up their Saturday afternoon should 
send a clear message to the VA that the veterans in Montana 
expect and deserve the same quality and availability of health 
care that the veterans in Los Angeles, Seattle or any major 
metropolitan area are able to get. And so it will take a real 
commitment from the VA and Congress to be sure the VA has the 
resources; to do the right job.
    Before I turn it over to Max and Ken for any opening 
statements that they may have, I just want to explain how this 
will work today.
    After we hear from the witnesses, we have two panels of 
witnesses, we will open the hearing up to comments from the 
audience. We will have a microphone and you'll have to come up 
to the microphone. After the formal part of the hearing ends, 
I'll ask you to come up and get in line and you'll have an 
opportunity to speak.
    I will say that you need to be concise. We're going to give 
you two minutes, and I'll probably be pretty right on that. So 
be concise and get right to the point so that the next person 
can speak and we can get in as many people as possible to 
testify. We do have other obligations today, so the time is 
limited. I don't want to cut any folks off, but I may have to 
do that. You are also encouraged, very, very much encouraged to 
submit written testimony, if you like, because that is also 
very, very helpful, as helpful as the spoken testimony, by the 
way.
    Now, I would like to turn to Senator Baucus for any opening 
statement that he might have.

                 STATEMENT OF HON. MAX BAUCUS, 
                   U.S. SENATOR FROM MONTANA

    Senator Baucus. Thank you, Senator Tester.
    First, I want to tell everybody just how proud I am to have 
Jon Tester serving with me and serving all of you in the U.S. 
Senate. We're very lucky to have Jon, especially on the 
Veterans' Affairs Committee. He has stood up to help veterans 
get all the care they deserve and need. Jon is a stand-up guy. 
He's very direct, makes things happen. And I just want to thank 
you, Jon, for having this hearing here in our state.
    Second of all, I want to introduce Senator Salazar from 
down south, not too far south, in Colorado. When you get to 
know Ken Salazar, you'll know what I'm next going to say is 
true, that Ken is a real person. He is just a solid, solid 
westerner, he listens to people, he's real, he's the real deal. 
And I'm just very, very honored, Ken, that you're here in our 
state. I know you have in Colorado some of the same issues we 
have, but it's an honor for us, especially as a Member of this 
Committee with the insight that you have to help us solve some 
problems. Thank you.
    President George Washington, one of our most distinguished 
veterans quoted this, he said, ``The willingness with which our 
young people are likely to serve in any war, no matter how 
justified, shall be directly proportional as to how they 
perceive the veterans of earlier wars, how they were treated 
and appreciated by their country.''
    I believe Americans will always step up and serve our 
country, but I think President Washington's warning should not 
be ignored, it's really key, basically, to the degree with 
which young men and women do want to serve currently and in the 
future. We're very proud of our country, of our proud tradition 
of service.
    We know our soldiers by far are the best in the world, they 
are the most brave, have the most strength, compassion, and our 
soldiers make just tremendous sacrifices. Our soldiers spend 
six to fifteen months away from their families at the time of 
deployment, they miss birthdays, Little League games, recitals, 
their spouses are forced to pick up the slack.
    Montana currently has 7,000 men and women serving on active 
duty in Guard units. Half of Montana's 3,500 Guard personnel 
have been deployed to either Iraq or Afghanistan, leaving 
behind their jobs, businesses and families. Some of our 
soldiers may come home, some have been sacrificed to our 
country too, 3,900 killed in Iraq and Afghanistan since 2005, 
29,000 injured. Twenty-two of those killed in Iraq and 
Afghanistan come from Montana.
    Also, the nature of the problems we face has changed 
because of body armor and improved medical technology, 
thousands of soldiers are surviving blasts that in previous 
wars would have been deadly. Many of these survivors struggle 
to readjust to life back home. It's because of war that they 
are living with missing arms, legs, without peace of mind, 
their minds constantly return to the battlefield they left 
behind. It happens. Now, Vietnam vets are starting to 
reexperience some of the traumas they had with Iraq tragedies. 
And a few can see or understand these scars.
    We all have met and know a lot of soldiers, men and women 
who return, many lost an arm, a leg. I go to Walter Reed often. 
I remember this one captain, he was from down around Columbus, 
he was going through such pain and struggle with such a 
terrific attitude, a real up-front, solid guy, and he's going 
through all kinds of therapy. He's fly fishing for himself 
personally and to teach other vets about fly fishing, anything 
that works. And I call him up from time to time to see how 
things are going. He's always upbeat, but, you know, there is 
an awful lot going through his head and mind, as well, that we 
still have to work on. It means so much to me.
    The Nation, we're now only coming to terms with physical 
injuries from the war. Traumatic brain injuries, post-traumatic 
stress disorder, depression, injuries that linger on well after 
our soldiers have left the battlefield that require care for 
many years after they return home. The conflicts in Iraq and 
Afghanistan are producing tremendous strain on the services 
offered to the vets returning from combat. Since 2001, the 
system has seen more than 25 percent increase in the number of 
patients it is serving. Personnel in these facilities are often 
dedicated, hardworking people, but the recently reported 
conditions, for example, the outpatient services of Walter 
Reed, project a support system under severe strain, at its very 
best.
    Veterans can face a complicated maze of paperwork, 
appointments to secure basic health care benefits. In fact, in 
May of 2007, a study found that on average it takes the VA 127 
days to process a disability compensation claim; 127 days, on 
average. That's up from an average of only 16 days in 2003. And 
appeals take an average of 657 days. Moreover, the accuracy of 
the VA compensation decisions is only 88 percent, meaning that 
thousands of vets will go without the benefits they deserve.
    These challenges clearly are compounded in rural states 
like ours where vets are often forced to travel long distances 
for care. The vet living in Malta, the closest VA hospital is 
in Helena, a 600-mile round-trip drive, and with the gas prices 
such as they are, the drive can cost hundreds of dollars.
    Today's hearing is focused on the challenges of providing 
veterans care in rural areas. As Senator Tester said, we have 
two excellent panels to help us get to the bottom of this and 
do all we possibly can to make sure our vets have clearly the 
best possible medical care that they deserve.
    I want to especially thank General Mosley for coming today, 
I've read his report, for making improvements to the care 
soldiers are receiving after returning from combat top 
priority. Thank you for your efforts. I thought that was an 
excellent report, by the way. From what I can tell, it hit the 
nail on the head. I also want to really thank Travis Williams, 
sitting here in the front row. Thank you, Travis, for coming. 
We've all read your statement and we're all deeply moved by it. 
Your story is one of inspiration, and we're all very fortunate 
to have the opportunity to hear and learn from you today 
because you can help a lot of us folks by just explaining what 
you went through and helping us at this table to understand 
what we have to do. I can't thank you enough for what 
you're doing.
    We owe a special debt to our vets, clearly, to do all we 
can. And let's make sure this hearing is one we can look back 
upon, and maybe not too many days, weeks, months from now, and 
say, Hey, we got some things done.
    Thank you, again, Jon, for opening this hearing.
    Senator Tester. Senator Salazar.

                STATEMENT OF HON. KEN SALAZAR, 
                   U.S. SENATOR FROM COLORADO

    Senator Salazar. Thank you very much, Senator Tester. And 
let me just start out by, first of all, acknowledging both 
Senator Tester and Senator Baucus and your Senator from the 
south, not too far from here, a lot of times when I've been on 
the senate floor voting, Max and I will decide we're going to 
cast our votes the way the west would want us to cast our 
votes. That is, with a sense of independence and with a sense 
of wanting to transcend partisan politics and to make sure what 
we're doing is doing the best for our country, as well.
    Senator Baucus. Not the south, but the west.
    Senator Salazar. That's right, the west.
    Truly, Senator Baucus is an incredible voice for Montana, 
and his chairmanship of the Finance Committee is something 
we're all very, very proud of. Senator Tester has made his 
presence known immediately in the U.S. Senate and his service 
on the Veterans' Affairs Committee, so we're all very, very 
proud of him.
    Let me say that I want to thank, besides thanking my hosts 
here, who are Max and Jon, I want to say thank you to the 
veterans who are here. You are the ones we traveled here to 
hold this hearing to learn more from you, and we look forward 
to the testimony from the witnesses. And I want to thank the 
veterans service organizations, because I know you have 
provided so many services to the vets here in Montana and all 
around the country. So thank you for also being a part of this.
    When I look at my job as a United States Senator, the 
reality of it is that we have a lot of things we have to work 
on. One of the highest of our priorities is making sure that 
the nearly 25 million veterans that we have in America are in 
fact taken care of. We can, in fact, walk the talk that George 
Washington said that we should walk and that Abraham Lincoln 
reinforced, that we, as a grateful Nation, are really standing 
up and saying that we're not only going to support you in the 
battlefield but we're also going to support you when you come 
back home.
    So part of our mission today is to make sure that we're 
doing everything that we can as the United States of America 
and as the U.S. Senate in providing those services. For the 1.4 
million veterans that served in Operation Iraqi Freedom and 
Operation Enduring Freedom, we also thank them for their 
sacrifice and for the duty that they have carried on on behalf 
of our Nation. It's incumbent upon us, with the new challenges 
that we're facing, to make sure that we're doing everything to 
address some of the challenges that our veterans are facing 
when they come back home.
    The Congressional action that we have taken this year, I 
think, has been a direction, a good direction, a new direction 
and doing some good things for veterans. Let me say that for 
the first time the veterans service organizations here, I 
think, would be proud of the fact that the budget of the U.S. 
Congress, for the first time in its history, actually have 
fully funded the Independent Budget of the veterans service 
organizations. That's a major movement in the right direction.
    And as I've studied that budget and looked at how we will 
move forward, it seems to me that some of our focus is, first 
of all, dealing with some of the mental health issues that 
we're facing when we recognize the fact that 35 percent of all 
of the returning veterans from Iraq and Afghanistan are facing 
some kind of PTSD, we need to make sure that the mental health 
services of our country are being delivered to those veterans 
who have served.
    Second of all, Senator Baucus and Senator Tester and I were 
talking about the number of Iraqi war vets who are coming back 
with some form of TBI, traumatic brain injury. And the 
statistics now is 17, 18 percent of all members who have served 
in Iraq are coming back with TBI. So we need to keep a focus on 
that.
    Third, because of the kinds of injuries that the veterans 
are facing today in Iraq and Afghanistan, we need to make sure 
that the prosthetics programs of the vets are in fact working.
    And, lastly, let me just say, this particular hearing is 
incredibly important to me because it's only when you come from 
a place like Montana or you come from a place like where I grew 
up in Colorado, 300 miles south of Denver, you realize there 
really are two Americas, there is the America of Los Angeles 
and Seattle and New York and New Orleans, and then there is the 
America which is really the rural America which has a whole set 
of challenges that are very different from those major 
communities.
    And so it is with those thoughts in mind that two years ago 
I introduced legislation that created the Office of Rural 
Veterans Affairs. I know you'll hear some testimony about how 
that is going, that it is making significant progress, that 
that delivers on its mission, and the mission was to make sure 
that the disparity that existed between the health care 
delivered to veterans in rural areas and major metropolitan 
areas, that we address that disparity.
    Dr. Jonathan Furlow did a study of some 700,000 vets across 
America several years ago. He found that there was a huge 
disparity. If you were in the metro areas, you got a higher 
quality of service than if you lived in the rural areas. So 
Senator Tester's efforts of trying to put a focus on what the 
challenges are for rural veterans is a very important agenda. 
And he and I and Senator Baucus have addressed some of that 
disparity.
    At the end of the day, the people who we can learn from the 
most are the veterans who are actually in the system out in 
rural communities. And so this hearing today will help us 
figure out how we can move forward with this agenda so that we 
can address the needs of the rural veterans and we can also 
address the disparity that currently exists between the rural 
and metropolitan areas.
    Thank you to all of you who have given up a good part of 
your Saturday to come and tell us what we ought to do. And, 
Travis, especially you, I spoke with you earlier, I read your 
testimony on the plane on the way from Washington. I was very 
moved by it. And I thank you, and I thank all of you who have 
served our country.
    Senator Tester. Thank you, Senator Salazar.
    Before I introduce the witnesses, I want to mention just a 
couple of people who are very, very important to this Committee 
who I failed to mention earlier. The Chairman of the Veterans' 
Affairs Committee is Senator Akaka out of Hawaii, and he has 
sent his deputy staff director, Kim Lipsky. Would you stand up 
so they know who you are. And the reason it's important for you 
to get to know these folks is when this meeting is over with, I 
don't want to assign extra duty, but it's always good to bend 
their ears if you have questions.
    Senator Craig out of Idaho is the Ranking Member, and he 
has been good enough to send a gentleman by the name of Jeff 
Gall to the Committee meeting. There is Jeff back there in the 
back.
    So be sure and visit with these folks. You know what makes 
any government work well is the staff, so we really appreciate 
you folks coming down and your bosses sending you here.
    Now the first panel, we've got a very distinguished first 
panel. I would ask the panelists to come up to the microphone 
when you speak so everybody can hear your testimony. Try to be 
concise. You don't need to read what you have there, try to 
summarize it, take four or five minutes would be great.
    The panel consists of Mr. Alvy Chapman, Commander of the 
Disabled American Veterans of Montana. Alvy served from 1984 to 
1990 in the U.S. Army. He has been involved with the DAV since 
1993, holding both chapter and department level positions 
almost every year since 1993. He was voted Department Commander 
at the DAV's convention in June 2006 and was reelected to a 
second term in that position in June of 2007. Alvy, welcome to 
the 
hearing.
    The second panelist is Mr. Ron Parmelee, Montana Liaison 
for the Paralyzed Veterans of America. Ron served in the U.S. 
Navy from 1961 to 1965, Chief of Prosthetics at Fort Harrison 
VA for nearly 20 years, 1977 to 1995. Montana Liaison to the 
Mountain States PVA since 1995.
    Our third panelist, Dave McLean, Commander of the American 
Legion of Montana from Anaconda. Dave is a Naval Academy 
graduate, the year was 1958. Navy fighter pilot from 1959 to 
1966, Vietnam vet. He's worked for Senator Mansfield in 
Washington, returned to Anaconda, practiced law, was elected 
vice-commander of the Montana Legion in 2006.
    Fourth, we've got Keith Heavyrunner. He is the Director of 
Operation Glacier Warrior, a nonprofit, all-volunteer 
organization, Veterans Helping Veterans, Veterans with 
Disabilities and Gold Star Families. He is a member of the 
Blackfeet Nation. His oldest son is an active-duty soldier at 
Fort Bliss. Welcome, Keith.
    John Burgess. John is a Vietnam vet, who served in the 
Marine Corps from 1966 to 1968. He's a lifelong Montanan and 
currently lives in Belt.
    And the final presenter in this panel will be Lance 
Corporal Travis Williams, retired as a Marine Corps veteran 
from Missoula who served in Operation Iraqi Freedom in 2004 and 
2005. He served four years in all, and Travis has a very 
enlightening story to tell.
    Gentlemen, I want to thank you all for being here and your 
service to this country. And if you would come up to the 
podium, we'll get it underway. After the panelists speak, then 
there will be a short time for questions from Max and Ken and 
myself, and then we'll move to the next panel. So, Alvy, if 
you'll step up to the 
microphone.

 STATEMENT OF ALVY CHAPMAN, COMMANDER, DEPARTMENT OF MONTANA, 
                   DISABLED AMERICAN VETERANS

    Mr. Chapman. Thank you, Senator Tester, and Max, welcome, 
Senator Salazar. The Department of Montana Disabled American 
Veterans has 5,500 members in the State of Montana. Our goal, 
of course, is to provide the best service that we can to 
Montana veterans and we do have some things that we'd like to 
talk about.
    One is our DAV transportation system here in Montana. Right 
now, we're running 41 vans, we're logging about 760,000 miles a 
year. Right now, we have been as high as one million miles in 
one year. To run this program takes two full-time employees, we 
have one for western Montana and one for eastern Montana, that 
one is located in Billings and one at the VA at Fort Harrison.
    Underneath them, we have 22 local area coordinators. These 
are the people that actually take the call from the veterans 
and set them up with a ride on our van to get to a VA hospital. 
They're probably the most important people in our system, and 
they are all volunteers. Some of these people will do more than 
what we ask of them, they take calls at night and weekends, 
just do anything they can do to provide service to our 
veterans.
    Underneath those 22 voluntary coordinators, locally we have 
about 250 drivers in the State of Montana. I didn't bring my 
hours, but I don't think the hours are even relevant because 
these people put in a lot more hours than is even reported in 
our own system. We have volunteers that drive 60 miles to even 
just get the van and go pick up a veteran and will drive 60 
miles home. So it's quite a program. And it takes a lot of 
people to make it work.
    The way the vans are bought by the DAV is through your DAV 
organization, through the local VFW and American Legion posts 
that help purchase vans, and then our national organization 
pays half of it. And starting last year, our Board of Montana 
Veterans Affairs here in Montana started giving us a grant to 
help purchase vans. And actually, we had quite a purchase last 
year of 12 vans and 5 this year, so we're increasing this 
program every year, and we suspect that we're probably going to 
continue to grow for at least the next three years.
    Of course, the van program wouldn't be as successful as it 
is without the efforts of the VA itself. I know that we had 
some concerns about Walter Reed Medical Center, but it is our 
opinion of the DAV that we have the finest health care that the 
VA has to offer, which is under Joe Underkofler and his staff 
at Fort 
Harrison VA.
    One of the issues that I know that we're watching right now 
is the travel pay issue, bringing the travel pay up to a 
Federal rate, is what we understand. Our concern there is that 
we would like to see it fully funded instead of just throwing 
that on top of what the VA already has to do. Our concern is 
that, especially in a rural state like Montana, it could cost 
Joe Underkofler and his staff far more money than it would cost 
someone back in the east because there are more VA hospitals, 
less distance to travel. So the burden for our rural states 
would be higher than those of on the east coast.
    The other thing on the travel pay is we want to make sure 
that it doesn't do away with our van program. Yes, it is a lot 
of work for us to run that program, but it is very much needed. 
Even if you have travel pay out there, that's not going to 
diminish the need of the veteran that can't drive himself or 
the veteran that has an automobile that cannot travel the 
distance to get to that medical appointment. So there is always 
going to be a need for the van program, as far as we're 
concerned. So we would like that to be taken into 
consideration.
    The amount of money that these volunteers and the DAV and 
the other service organizations save the VA by providing us a 
transportation network is a lot of money, and what we'd like to 
see is maybe some more assistance in trying to keep that 
program together and keep it running for the veterans of 
Montana.
    And with that, I guess I'll let everybody else come up and 
give their remarks.
    [The prepared statement of Mr. Chapman follows:]
    Prepared Statement of Alvy A. Chapman, Commander, Department of 
                  Montana, Disabled American Veterans
    Dear Chairman and Senators:
    The Department of Montana of the Disabled American Veterans (DAV) 
with 5,500 members appreciates your concerns with the services being 
provided to the many men and women that have served this great Nation. 
Made up exclusively of men and women disabled in our Nation's defense, 
the DAV is dedicated to one, single purpose--building better lives for 
America's disabled veterans and their families. It is through this 
promise to our Nation's veterans that the DAV, Department of Montana 
has entered into a project with the Department of Veterans Affairs (DVA 
or VA) known as the Veterans Transportation Network (VTN).
    The transportation network is filling a gap left by the closure of 
the Miles City Hospital in Eastern Montana and the lack of services 
across our great state. Many of our veterans that are depending on VA 
Medical Services are getting older and as you know the cost of fuel is 
rising sharply and leaving many veterans without the means to get to 
medical care. Because of the vast area that Fort Harrison is serving, 
some of our veterans are traveling two days to get to a medical 
appointment and then two days to return home. That is four to five days 
for a medical appointment. That is where the transportation network 
comes in as a much needed program for states such as Montana. Our 
Network consists of two full-time coordinators, 22 volunteer local 
coordinators and approximately 250 volunteer drivers.
    The time and effort that these volunteers provide to the VA and DAV 
is outstanding to say the least. Many volunteers are putting in 12 hour 
days or more and driving as much as 500 miles per day. The burden of 
purchasing the 42 vans currently in service is being met through the 
many DAV, VFW and American Legion posts throughout the state along with 
many caring citizens that just want to help veterans get to their 
medical appointments. The State of Montana Veterans Affairs Board has 
stepped forward starting last year and has been assisting us with a 
grant to purchase more vans to cover more territory in the state. 
Without these resources the program would not be where it is today. The 
other half of van costs is met through the DAV National Office with 
grants through the Colorado Trust.
    The two employees are paid through the Department of Montana DAV. 
We receive some grant dollars again from our National Organization. The 
rest is paid through our membership and fundraising efforts.
    Of course the program was designed to fill a need because of the 
low pay veterans receive to travel to medical care. Raising the travel 
amounts will not diminish the need for the transportation network. Many 
of our passengers are from the greatest generation and are becoming 
unable to drive themselves. Other veterans own automobiles that cannot 
make the long trips to Fort Harrison. Therefore, we see a need for this 
program long into the future. We would like to see some assistance such 
as Federal grants for the specific purpose of running a program such as 
ours. Like I said there are 42 vans with almost 300 people involved in 
making the system work. That qualifies as a large business that runs on 
a shoestring budget. The money that these volunteers save the 
government is astronomical and we would like to see some of those 
savings be used to help support the program.
    We would like to thank you for the opportunity to bring our 
concerns before you. We are always willing to come and talk about the 
transportation network. It is our belief that the network is the next 
best thing to the medical care itself.

    Senator Tester. Thank you, Alvy. I will probably have a few 
questions when we're done, for sure, and I'm sure Senator 
Baucus and Senator Salazar will have some questions.
    Ron Parmelee.

STATEMENT OF RONALD PARMELEE, MONTANA LIAISON FOR THE MOUNTAIN 
         STATES CHAPTER, PARALYZED VETERANS OF AMERICA

    Mr. Parmelee. My name is Ronald Parmelee. I am the 
Paralyzed Veterans of America Liaison in Montana for the 
Mountain States Chapter in Denver, Colorado. I appreciate the 
opportunity to take a few minutes of your time.
    Montana's VA healthcare system is good and helps many 
veterans. The outpatient clinic, along with the DAV 
transportation system helps many Montana veterans in the rural 
area. Like all systems, there are some veterans who get lost. 
This is true in the case of the spinal cord veterans in 
Montana. They have no one place to go in VISN 19. Montana 
spinal cord veterans have connections with the first spinal 
cord units where they received treatment, such as Woods, Palo 
Alto or Seattle. This is where they get their continuing 
treatment.
    With the proposed spinal cord injury unit in the Denver VA 
Hospital at Fitzsimmons, there was to be a 30-bed acute care 
unit. The number jumps between 15, 20 to 30 acute care beds, 
depending on who you talk to. The number of spinal cord injured 
veterans in Wyoming, Colorado, Utah and Montana really need the 
use of a 30-bed acute care unit. We need the Montana 
Congressional delegation to support this program.
    Other veterans in special categories also get lost. For 
instance, the VA doctor orders a heart cath and the VA 
cardiologist, just by looking at the veteran, says ``no.'' The 
veteran is not stable enough to be transferred to another VA, 
but once stable, the transfer will take place. The veteran is 
concerned of the treatment he will receive at the other VA, 
being in a strange city and not knowing if he will be OK. What 
will the Denver doctors think when Fort Harrison says ``no'' ? 
Ten days later he is in fair condition using his own health 
insurance, TRICARE, he has the procedure done at the community 
hospital and is told that he will have to pay what TRICARE does 
not pay. That just doesn't seem fair, especially when the 
community cardiologist finds there is a problem and has to put 
two stents in. The veteran returns to Fort Harrison for 
recovery. At the VA, no one says anything to him about the 
procedure, one way or the other. Thank goodness for the ward 
doctor who insisted that he have this procedure done.
    Another problem is doctors' orders getting lost in the 
system. One example is a special floor-to-wall railing. There 
were specific specifications and these were given to 
Prosthetics by the doctor. The veteran has waited over two 
months. He called the VA and was told they would check into it 
and call him back. That was over a month ago. He still calls 
and no return calls. Answering machines are great.
    Other areas of concerns are when the veteran's primary care 
physician is reassigned and the veteran is left with no one to 
turn to. Seriously ill veterans get to see a physician's 
assistant or a nurse practitioner.
    Appointments that are supposed to be made for two-week 
follow-ups are sometimes taking six to eight weeks. Again, 90 
percent of Montana veterans are taken care of with little or no 
problem. They are good doctors, nurses and staff; some bend 
over backwards to help. I have seen patients waiting to see 
their provider and a staff worker comes by and takes them where 
they need to go ahead of schedule because of their condition.
    Thank you for letting me take a few minutes of your time.
    [The prepared statement of Mr. Parmelee follows:]
    Prepared Statement of Ronald Parmelee, Montana Liaison for the 
         Mountain States Chapter, Paralyzed Veterans of America
    My name is Ronald Parmelee, and I am the Paralyzed Veterans of 
America Liaison in Montana for the Mountain States Chapter in Denver, 
Colorado. I appreciate the opportunity to take a few minutes of your 
time.
    Montana VA Healthcare System is good and helps many veterans. The 
Outpatient Clinic along with the DAV Transportation Network helps 
Montana veterans in rural areas. Like all systems there are some 
veterans who get lost. This is true in the case of spinal cord veterans 
in Montana. They have no one place to go in VISN 19. Montana spinal 
cord veterans have connections with the first spinal cord units where 
they received treatment such as Woods, Palo Alto or Seattle. This is 
where they continue to receive treatment.
    With the purposed spinal cord injury unit in the Denver VA 
Hospital, at Fitzsimmons, there was to be a 30-bed acute care unit. The 
numbers jumped between 15 to 20 to 30 acute care beds, depending on who 
you talk to. The number of spinal cord veterans in Wyoming, Colorado, 
Utah and Montana really need the use of this 30-bed acute care unit. We 
need the Montana Congressional delegates to support this program.
    Other veterans in special categories also get lost. For instance, 
the VA doctor orders a heart cath and the VA cardiologist just by 
looking at the veteran says ``no''. The veteran is not stable enough to 
be transferred to another VA, but when stable the transfer will take 
place. The veteran is concerned of the treatment he will receive at the 
other VA. Being in a strange city and not knowing if he will be OK. 
What will Denver doctors think when Fort Harrison says no? Ten days 
later when he is in fair condition, using his own heath insurance 
(TRICARE) he has the procedure done at the Community Hospital and is 
told he will have to pay what TRICARE doesn't pay, that just does not 
seem fair. Especially when the community cardiologist finds there is a 
problem and has to put 2 stints in. The veteran is returned to Fort 
Harrison for recovery. At the VA no one says anything to him about the 
procedure one way or the other. Thank goodness his ward doctor insisted 
that he have the procedure done. Even when it was noted that this was a 
necessary thing to save this veterans life, the VA refused to pay for 
the procedure even though the veteran is 100 percent service connected. 
Part of this service connection is for his heart condition.
    Another problem is doctor's orders getting lost in the system. One 
example is a special floor to wall railing. There were special 
specifications and this was given to Prosthetics by the doctor. The 
veteran has waited for over two months. He called the VA and was told 
they would check on it and call him back. That was over a month ago. He 
still calls and no return calls; answering machines are great.
    Other areas of concern are when the veteran's primary care 
physician is reassigned and the veteran is left with no one to turn to. 
The seriously ill veterans get to see a Physician Assistant or a Nurse 
Practitioner.
    Appointments that are supposed to be made for two-week follow-up 
visits sometimes take 6-8 weeks.
    A lot of frustration is working with a Nurse Practitioner and 
waiting for who ever is pinch hitting for the transferred physician to 
make a decision and get back with the NP who gets back with the 
veteran.
    When there is a problem the veterans does not know where to go, who 
to talk to. Also when the veterans want to put input in their cases 
they are ignored.
    Again, 90 percent of the Montana veterans are taken care of with 
little problem. There are good doctors, nurses and staff. Some bend 
over backwards to help. I have seen patients waiting to see their 
provider and a staff worker comes and taken them where they need to be 
ahead of schedule because of their condition.
    Thank you for letting me take a few minutes of your time.

    Senator Tester. Thank you very much, Ron. I appreciate your 
testimony.
    And next we have Dave McLean.

 STATEMENT OF DAVID McLEAN, COMMANDER, MONTANA DEPARTMENT, THE 
                        AMERICAN LEGION

    Mr. McLean. Thank you, Senator Tester. I'm supposed to 
remind you that at the St. Patrick's parade in Anaconda you 
told the veterans you were going to get over and talk to them. 
They know you're busy, but they're looking forward to you 
making it.
    Senator Tester. I guess that's on the record.
    Mr. McLean. Senator Baucus, Ray Cutler sends his best. He 
said, I knew ``Max'' when he was ``Max.''
    Senator Baucus. I hope I still am ``Max.'' But say hello to 
Ray. I have very fond memories of Ray, he's a great guy.
    Mr. McLean. Senator Salazar, we have a mutual friend, Tom 
Bock, from Colorado, who is your National Commander of the 
American Legion, doing a very fine job, as a matter of fact. He 
is convinced the State of Montana, we should pass the 
legislation to have a national commander from Montana. We 
passed that in Kalispell two weeks ago. I'll be carrying that 
to Indianapolis soon to tell Tom. Thank you.
    Ladies and Gentlemen, Veterans, I want to quickly hit on a 
point. If you think we like standing here in these silly hats 
and colored neckties and coats, let me tell you, there are a 
lot of other things I'd rather be doing today. But we have 
learned the lesson of why it is important to belong to 
veterans' organizations, and it's called political clout and 
it's called publicity. If any one of you wants to go to the VA 
or one of the senators' offices and individually try to get 
something done, having served on a Senate staff, I can tell you 
that they will pay attention to you and your request will 
probably lost. But when there are 13,000 members of the 
American Legion or 5,500 members of the DAV or whatever the 
number is, and the VFW speaking in a collective voice on your 
behalf, let me tell you, they listen. That is why it is 
important to belong to a veteran's organization. I realize it's 
an imposition to pay dues, but you have to take a look at what 
those dues do for you and try to understand that it is the many 
voices together. My grandmother said it best: ``When more than 
one person prays together, God hears you better.'' The same 
thing comes with requests for VA funding, VA assistance.
    First of all, I want to thank the VA for being there. We 
greatly appreciate the VA system and all that it has done. It 
is easy to come before committees such as this or go to the VA 
and say, We need this or we need that, but let's thank them for 
being there and doing what they have already done. Let's thank 
them for something else, that they are willing to listen to us. 
They're willing to admit they're not perfect, they're willing 
to say to us, Come and tell us what you need and let's try to 
get it for you.
    This is the type of attitude that we need, this is the type 
of attitude that is going to cause our system to improve. This 
Senate Committee is interested in hearing about rural health 
care issues.
    I remember the last time that the big wigs came to talk to 
us about rural health care issues, what we left with is that in 
Montana you don't even have rural health care, you have 
frontier health care. And that's not a joke, that's serious.
    It's gotten better, but one of the reasons we're here today 
is to try to point out what we think is necessary to continue 
to make it better. Remember, in 1993 the U.S. Congress 
indicated that they wanted the VA system open to all veterans. 
That was a congressional mandate. And to this point in time, 14 
years later, that's unsuccessful. The VA system is not open to 
all veterans. If you think it is, be a Priority 8 veteran and 
try to get benefits. We're working on it.
    Senator Tester came to Kalispell and addressed the 
convention. He's interested in it, they're working on it. We've 
got to continue to work together. We've got to open up the VA 
system to all veterans. There are studies that have been 
conducted by the VA and the DAV that indicate that veterans 
that reside in rural areas such as Montana will receive poorer 
health care than their urban components. Stands to reason.
    What do we have in Montana? One major medical center where 
veterans can get their benefits. As a matter of fact, from Fort 
Harrison, Helena, Montana to Fargo, North Dakota, there are no 
major health care facilities available to veterans.
    Now, I'll talk in a minute about community-based outpatient 
centers, and they're great. We used to have a major VA medical 
hospital in Miles City, Montana. I may be mistaken, and I'll be 
glad to be corrected if I am, but I think that's the only major 
VA hospital that has been closed in the United States of 
America. It's not there anymore. What do we have to fill the 
gap with?
    I just mentioned it, community-based outpatient clinics. 
There are over 700 of these in the country. This is an attempt 
by the VA to bring health care closer to the veterans. We have 
nine, I think Theresa told me, in Montana, two new ones going 
to come, one to Cut Bank and one to Lewistown. That's great. 
But they're not major health centers. As a matter of fact, most 
of them are not staffed by physicians, they're staffed, the one 
in Anaconda is staffed by a nurse practitioner, and she's 
great. None of them, none of them, none of them take care of 
mental health issues. This is really important. I believe 
personally that every CBOC should have a physician on staff and 
at least every other one around the state should have mental 
health care available.
    Everyone's acquainted with the care access program. The 
care access program wants to have more CBOCs, and that's fine. 
But, remember this, if we're talking about quality health care, 
you've also got to fund it. If you've got nine community health 
centers in the pot dividing up the health care, you get a 
certain level of health care. If you've got dividing up the 
same amount of money, you're getting less health care. So 
that's what we have to convince the VA and the Congress about, 
is help us fund these things.
    Funding is extremely important. That's why I personally 
believe, and it is the position of the American Legion, we 
cannot continue to tolerate discretionary funding for the 
Veterans' Administration. We need to get to a system of 
mandatory funding. The problem in my mind with discretionary 
funding is that you get a bunch at the beginning of the year. 
Now, quite honestly, somewhere along the line, down the way, 
you're going to get emergency appropriations, as has happened 
for the last couple of years. A few months later, you may get a 
second or third one, but how does the VA plan for its staffing 
at the beginning of the year? They don't have enough money, 
they lay them off, so when the second set of funding comes in, 
where is the staff? Mandatory funding is something we all have 
to work for and think about. This is extremely important.
    We must also remember that the CBOCs are not the only 
avenue that is available for health care. We can enhance 
existing partnerships within the communities with other Federal 
agencies to provide health care. I'll give you an example, the 
Indian Health Service is an example. What are we going to hear? 
We're going to start talking about how the Federal Government 
cannot give you, one example, to use your Medicare because one 
Federal agency can't bill another one. They do it in the Indian 
Health Service. The Veterans' Administration is losing money on 
me now because I'm now on Medicare, but I can't use my Medicare 
to get my health care. What they'll lose, in addition to my 
Medicare payments, they're losing my supplement money. These 
are issues that we have to address. We've got to help the 
Congress understand how we can help finance the care that we 
feel that we need.
    There was a Presidential Task Force formed to improve 
health care delivery to our Nation's veterans, and they made 
several recommendations to the DOD and the VA, and one of them 
said this: The VA and the DOD should declare that joint 
ventures are integral to the standard operations of both 
departments. This was recommendation No. 4.8 of the final 
report issued in May of 2003. And to this date, not a single 
one has materialized.
    Yet, for example, there are military bases in many 
communities where veterans can get health care. Let's talk 
about a point that Senator Baucus brought up, and it's really 
important.
    Senator Tester. I have to ask you to wrap it up.
    Mr. McLean. Let's talk quickly about traumatic brain 
injury. OIF, Operation Iraqi Freedom, and OEF, Operation 
Enduring Freedom, veterans are returning home now, many have 
traumatic brain injuries, but there is no available care for 
them. We have to get something done for people coming back with 
these terrible 
problems.
    During your questioning, please be sure and ask about what 
is going to be done with health care. Be sure and ask about 
what we can do to get doctors in every outpatient clinic. And 
be sure and ask about what we can do, as has been ably pointed 
out, to get an increase for mileage for veterans. We could 
probably go on and talk for hours today, but you all have 
things to say, too, so I will thank you for your time.
    Thank you.
    [The prepared statement of Mr. McLean follows:]
            Prepared Statement of David McLean, Commander, 
                Montana Department, The American Legion
    Thank you for this opportunity to present The American Legion's 
views on access to quality health care for veterans in general and 
veterans in rural communities in particular. Research conducted by the 
Department of Veterans Affairs (VA) indicated that veterans residing in 
rural areas are in poorer health than their urban counterparts. It was 
further reported that nationwide, one in five veterans who enrolled to 
receive VA health care lives in rural areas. Providing quality health 
care in a rural setting has proven to be very challenging, given 
factors such as limited availability of skilled care providers and 
inadequate access to care. Even more challenging will be VA's ability 
to provide treatment and rehabilitation to rural veterans who suffer 
from the signature ailments of the ongoing Global War on Terror--
traumatic blast injuries and combat-related mental health conditions. 
VA's efforts need to be especially focused on these issues.
               community based outpatient clinics (cboc)
    A vital element of VA's transformation in the 1990s, was the 
creation of CBOCs to move access closer to the veterans' community. A 
recent VA study noted that access to care might be a key factor in why 
rural veterans appear to be in poorer health. CBOCs were designed to 
bring health care closer to where veterans reside. Over the last 
several years, VA has opened up hundreds of CBOCs throughout the system 
and today there are over 700 that provide health care to the Nation's 
veterans. By and large, CBOCs have been pretty successful; however, of 
concern to The American Legion is that many of the CBOCs are at or near 
capacity and many still do not provide adequate mental health services 
to veterans in need.
    One of the recommendations of the Capital Assets Realignment for 
Enhanced Services (CARES) recommendations was for more, not less, CBOCs 
across the Nation. The American Legion strongly supports this 
recommendation, especially those identified for rural areas; however, 
limited VA discretionary funding has limited the number of new CBOCs 
each fiscal year.
    There is great difficulty serving veterans in rural areas. Veterans 
in states such as Nebraska, Iowa, North Dakota, South Dakota, Wyoming, 
and Montana face extremely long drives, a shortage of health care 
providers and bad weather. The Veterans Integrated Services Networks 
(VISNs) rely heavily upon CBOCs to close the gap.
    The provision of mental health services in CBOCs is even more 
critical today with the ongoing wars in Iraq and Afghanistan. It has 
been estimated that nearly 30 percent of the veterans who are returning 
from combat suffer from some type of mental stress. Further, statistics 
show that mental health is one of the top three reasons a returning 
veteran seeks VA health care. The American Legion believes that VA 
needs to continue to emphasize to the facilities the importance of 
mental health services in CBOCs and we urge VA to ensure the adequate 
staffing of mental health providers in the CBOC setting.
    CBOCs are not the only avenue with which VA can provide access to 
quality health care to rural veterans. Enhancing existing partnerships 
with communities and other Federal agencies, such as the Indian Health 
Service, will help to alleviate some of the barriers that exist such as 
the high cost of contracting for care in the rural setting. 
Coordinating services with Medicare or with other healthcare systems 
that are based in rural areas is another way to help provide quality 
care.
    The Presidential Task Force to Improve Health Care Delivery for Our 
Nation's Veterans made several recommendations for DOD and VA, one of 
which: VA and DOD should declare that joint ventures are integral to 
the standard operations of both Departments. (Recommendation 4.8) Since 
this Task Force's final report in May 2003, none have materialized--yet 
there are military bases in many rural communities.
                    traumatic brain injury patients
    In a July 2006 report entitled Health Status of and Services for 
Operation Enduring Freedom and Operation Iraqi Freedom Veterans after 
Traumatic Brain Injury Rehabilitation, the Department of Veterans 
Affairs' Office of Inspector General examined the Veterans Health 
Administration's ability to meet the needs of OIF/OEF veterans who 
suffered from traumatic brain injury (TBI). Fifty-two patients from 
around the country--including Montana, Colorado, North Dakota, and 
Washington state--were interviewed at least 1 year after completing 
inpatient rehabilitation from a Lead Center (Minneapolis, MN; Palo 
Alto, CA; Richmond, VA; and Tampa, FL) included those who lived in 
states with rural veteran populations.
    Many of the obstacles for the TBI veterans and their family members 
were similar. Forty-eight percent of the patients indicated that there 
were few resources in the community for brain injury-related problems. 
Thirty-eight percent indicated that transportation was a major 
obstacle. Seventeen percent indicated that they did not have money to 
pay for medical, rehabilitation, and injury-related services.
    Some of the challenges noted by family members who care for these 
veterans in rural settings include: the necessity for complicated 
special arrangements and the absence of VA rehabilitative care in their 
communities.
    Case managers working at Lead Centers and several secondary centers 
noted limited ability to follow patients after discharge to rural areas 
and lack of adequate transportation.
    These limitations place undue hardship on the veterans' families as 
well. Those contributing to the report, as well as veterans who have 
contacted The America Legion, have shared many examples of the manner 
in which families have been devastated by caring for TBI injured 
veterans. They have sacrificed financially, have lost jobs that 
provided the sole income for the family, and have endured extended 
separations from children. It is The American Legion's belief that VA 
needs to continue to improve access to quality primary and specialty 
heath care services for veterans residing in rural and highly rural 
areas.
                              vet centers
    Vet Centers are another important resource, especially for combat 
veterans experiencing readjustment issues who do not live in close 
proximity to a VA medical facility. Because Vet Centers are community 
based and veterans are assessed the day they seek services, they 
receive timely care and are not subjected to wait lists. Some of the 
services provided include: individual and group counseling; family and 
marital counseling; military sexual trauma counseling; and, 
bereavement.
    The American Legion believes veterans should not be penalized or 
forced to travel long distances to access quality health care because 
of where they choose to live. We urge VA to improve access to quality 
primary and specialty health care services, using all available means 
at their disposal, for veterans living in rural and highly rural areas.
    Again, thank you Mr. Chairman for giving The American Legion this 
opportunity to present its views on such important issues. We look 
forward to working with the Committee to bring an end to the 
disparities that exist in access to quality health care in rural areas.

    Senator Tester. Next up is Keith Heavyrunner.

  STATEMENT OF KEITH HEAVYRUNNER, DIRECTOR, OPERATION GLACIER 
                            WARRIOR

    Mr. Heavyrunner. Good afternoon, Senators, it's nice to 
meet you. The Blackfeet Tribe Old Person sends his regards and 
best wishes to you guys.
    My name is Keith Heavyrunner. I am an enrolled member of 
the Blackfeet Nation, Browning, Montana. I have a son stationed 
at Fort Bliss, Texas, three-and-a-half years serving in the 
military. My youngest brother is currently serving in the 
military.
    I grew up on the Blackfeet Tribal Reservation. I'm a member 
of the Montana Veterans Affairs Division, National American 
Indian Veterans, Inc., Operation Glacier Warrior and the 
National Native American Veterans' Memorial. I'm here to speak 
about Operation Glacier Warrior.
    Operation Glacier Warrior is an annual three days of 
outdoor activities on the Blackfeet Reservation and in Glacier 
National Park. Operation Glacier Warrior is honoring all 
Montana families who are serving or have served in all branches 
of the service. Operation Glacier Warrior, most importantly, 
provides opportunity for veterans to speak with fellow veterans 
and families who have dealt with similar difficulties in their 
lives. Operation Glacier Warrior is also lifting the spirit of 
Gold Star Families who have lost a son, daughter, mother or 
father. We support our soldiers, marines, sailors and airmen 
returning home from the war by helping them in traditional ways 
in the transition from the military into civilian life. 
Resources range from counseling from accredited counselors to 
traditional healers. The volunteers consist of members of the 
Blackfeet Tribe, members of the Montana National Guard and 
members of the Northwest Montana Veterans Stand Down out of 
Kalispell.
    As of June 30, 2007, from the State of Montana, there have 
been 201 wounded veterans from Iraq and 19 have been killed in 
action. It's unknown how many have been wounded in Afghanistan, 
two killed in Afghanistan.
    Also, I brought the statistics from Colorado since we have 
a Senator from Colorado. As of June 30th of 2007, for the State 
of Colorado, 440 wounded and 49 killed in Afghanistan. As of 
July 19th, 2007, 3,628 have been killed in Iraq. I don't know 
the statistics on how many have been killed in Afghanistan.
    The Native American Indians who served in World War I, 
which at that time we weren't even recognized as citizens of 
the United States, approximately 6,000 Native American Indians 
served in World War I, and the original code talkers were the 
Choctaw Indians of Oklahoma during World War II. Minnie 
Spotted-Wolf is the first Native American Indian woman to serve 
in the Marine Corps. She is from Heart Butte, Montana. During 
World War II, 44,000 Native American Indians served their 
country.
    The tradition has continued on with the Korean War, 
Vietnam, Desert Storm and Iraqi Operation Freedom. Many Native 
Americans have joined the military right after 9/11. The 
Vietnam veterans need to continue to be thanked for their 
service in the military. Like the Vietnam veterans, we do not 
want the new returning veterans to wait 30 years to file their 
claim for their VA benefits.
    It's unknown how many Montana homeless veterans are out 
there, but I have heard there are now Iraq veterans that are 
homeless. Northwest Montana Veterans Stand Down in Kalispell, 
Montana provides help to about 40 families a month. On July 9, 
2007, there were 12 families, and 7 of them were homeless. 
During the summer, there are more homeless veterans than in the 
winter. Mr. Allen Erickson has been working with the homeless 
veterans since 2000, providing assistance such as food and 
clothing. In addition, he is in need of more help and 
assistance with the utilities and trying to find jobs for them.
    Thank you, Senators.
    [The prepared statement of Mr. Heavyrunner follows:]
          Prepared Statement of Keith Heavyrunner, Director, 
                       Operation Glacier Warrior
    Greetings, Senator Jon Tester, Senator Max Baucus and Senator Ken 
Salazar;
     My name is Keith Heavyrunner I am an enrolled member of the 
Blackfeet Nation, Browning, Montana I am currently married to Bessie 
Heavyrunner, I have six children. My oldest son is station at Fort 
Bliss, Texas as United States Army, Signal Support Specialist.
    I come from a family of 5 brothers and 3 sisters. My youngest 
brother is currently in the Montana National Guard as a Staff 
Sergeants. I have a nephew with the Marines station in Iraq and another 
nephew station in the army at Fort Leonard Wood Missouri I also have 
another nephew leaving in August for the Army.
    I grew up on the Blackfeet reservation and attend the Browning 
public schools.
    I listed into the United States Army in 1979 to 1983. After 
returning back home to Browning I did work such as carpenter work, 
farming, ranching, United States Postal Service as a contractor and in 
2001 I was hired as the Veteran Tribal Representing for the Blackfeet 
Tribe.
    My duties as Tribal Veterans Director is completing claims for 
veterans, transporting veterans to appointments through out Montana, 
working with the men and women currently in the military, hold special 
ceremonial for the men and women returning home from the military.
    I serve on several boards; I am with the Montana Veterans Affairs 
Division, Native American Indian Veterans, Inc., Operation Glacier 
Warriors and the National Native American Indian Veterans Memorial.
    Operation Glacier Warrior is an annual 3 days of outdoor activities 
on the Blackfeet Reservation and in Glacier National Park, Montana. 
Operation Glacier Warrior is honoring All Montana Families who are 
serving or have served in all branches of the military. Operation 
Glacier Warrior most importantly provides the opportunity for veterans 
to speak with fellow veterans and families who have dealt with similar 
difficulties in their lives. Operation Glacier warrior is also lifting 
the spirit of Gold Star families who have lost a son, daughter, mother 
or father. Additionally we support our soldiers, Marines, Sailors and 
Airmen returning home from the war by helping them in the transition 
from the military into civilian life. Resources range from counseling 
from accredited counselors to traditional healers. The volunteers 
consist of member of the Blackfeet tribe, members of the Montana 
National Guard and members of the Northwest Montana Veterans Stand Down 
out of Kalispell, Mt As of June 30, 2007 for the state of Montana 201 
wounded and 19 Killed in Action. Unknown how many wounded in 
Afghanistan, 2 killed in action in Afghanistan.
    As of June 30, 2007 for the state of Colorado 440 wounded and 49 
killed in action and as of July 19, 2007 3628 killed in Iraq.
    Native American Indians who served in World War 1, which at that 
time Native Americans Indians were not recognized as US citizens. 
Approximately 6 thousand Native American Indians served in World War I 
and the original code talkers were the Choctaw Indians of Oklahoma, 
During World War II Minnie Spotted Wolf is the first native American 
Indian woman to serve in the marine's corp. she is from Heart Butte, 
Montana. During world war II 44, 000 native American Indians served.
    The tradition has continue on with the Korean War, Vietnam, Desert 
Storm, and Iraqi Operation Freedom. This will continue on as future 
generations come of age. Native American Indians are one of the largest 
ethnic groups to volunteer for the military. The reason for 
volunteering is a family warrior traditions, poverty and the reason for 
native American Indian serving during world war II per the veterans did 
not want to see another invasion from other countries, like the one 
that now is here today.
    Many Native American Indians has join the military after 9/11 to 
stop terrorism.
    Vietnam veterans, needs to continue thanking them for their service 
in the military. Like the Vietnam veterans we do not want the new 
returning veterans to wait 30 years to file their claim for there VA 
benefits.
    Unknown how many Montana homeless veterans there are but I have 
heard there are now Iraqi veteran that are homeless. Northwest Montana 
Veteran's Stand Down in Kalispell Montana provides help to about 40 
families a month. July 9, 2007 there were 12 families and out of 7 of 
them were homeless. During the summer there are more homeless veterans 
then in the winter. Mr. Allen Erickson has been working with the 
homeless veterans since 2000 providing assistance such as food and 
clothing. In addition he is in need of more help and assistance such as 
food and providing assistance with the utilities as it is become a 
growing problem.

    Senator Tester. Thank you very much.
    Appreciate it, Keith. John Burgess will be next.

           STATEMENT OF JOHN BURGESS, VIETNAM VETERAN

    Mr. Burgess. Thank you, Senators, for having me here. We 
were discussing the situation on the mileage reimbursement, and 
I kind of figured it out, it's about 230 miles for me to drive 
to Helena from Belt, Montana, and that figures out to be 11 
cents a mile, which comes to $25.30. And then, for some reason, 
the VA takes $6 off of that, so that comes up to $19.30.
    When I go to gas up, my truck gets 17 miles per gallon of 
gas. For 230 miles divided by 17, it takes 13.5 gallons, and I 
figure that at $3 a gallon, at the time it was $3.30, and that 
comes up $41.50. So I'm kind of getting reimbursed about half 
of what it costs me, for the gas. And if they're going to raise 
it up, I'm wondering if they're going to raise up the price 
that they deduct off from it, too. Inflation.
    These are supposed to be good guys. Well, anyway, I was 
diagnosed with lichen planus from Agent Orange. This happened 
about 41 years ago. They sent me to a couple of dermatologists 
and they checked it out and they gave me some salve, the first 
one didn't work, gave me some more, the second one didn't work. 
Now, I'm on the third and it's still not working. When I go to 
the clinic, they ask me on a scale of one to ten how bad my 
pain is. Well, I usually tell them it's about four because, 
really, you don't have a lot of pain with it. But if you asked 
me what the itching was like, I'd tell you about a ten.
    Now, that's about all I have. Thank you very much.
    Senator Tester. Thank you, John.
    Next is Travis Williams.

 STATEMENT OF TRAVIS WILLIAMS, OPERATION IRAQI FREEDOM VETERAN

    Mr. Williams. Thank you, everyone, for coming today. My 
name is Travis Williams. I served in the Marine Corps from 
August 2002 to August 2006. And in 2005, I was deployed to Iraq 
with a unit out of Ohio, an infantry unit, Lima Company, 3rd 
Battalion 25th, to serve in the Al Anbar province. When we got 
there, it had been about a little over a year before any U.S. 
presence was known in that province, and they coined it the 
``Wild West of Iraq.''
    While we were there, we're more or less unprepared for what 
initially hit us, but we learned quick. For seven months, we 
cleared cities, villages and farmlands and we were engaged, not 
on a daily basis, but at least two or three times a week. 
Anyway, the main part of my story is, August 3, 2005, we were 
sent into the city of Barwanna, because six of our snipers had 
been killed, and one body was missing. The weapons were all 
captured by the enemy, so we were sent to find them. While 
making assault and entry into the city, one of our vehicles was 
blown up. In the vehicle were my whole squad and three other 
marines and an interpreter.
    I guess that story sort of made me famous, I guess, or 
known, and for that I received fairly good care from the VA, 
and I appreciate everything they do for me. But I can only hope 
that someone doesn't have to go through something like that in 
order to get that quality of care, because I have numerous 
friends who were with me over there, but they just happened to 
be in a different squad in our platoon and lost the same 
friends, and haven't gone to seek help or haven't received the 
help they need yet.
    I don't know too much about all the bills or any of 
legislation going on with VA funding or anything like that. The 
care I've received has been excellent. I do have my quips about 
having to set up appointments months out for the clinics, but 
my gratitude far outweighs those, so I just want to get the 
point across that it doesn't take some horrific incident to 
cause PTSD. It manifests in everyone differently. And I do 
agree with some of the points made that there needs to be more 
staff for mental health because the signs of battle not only 
show on the outside but on the inside, and I think that a lot 
of times they're only taken seriously when they show on the 
outside, and there is a lot more going on inside.
    That's all I have. Thank you.
    [The prepared statement of Mr. Williams follows:]
 Prepared Statement of Travis Williams, Operation Iraqi Freedom Veteran
    My name is Travis Williams and this is my story . . .
    I have lived in Montana since I was 6 years old. I graduated high 
school from Helena Capital in 2002 and shortly thereafter joined the 
Marine Corps. I guess I was attracted to the challenge, so I decided to 
test myself against their standards. I found I was able to adapt to the 
rigors of the Marine lifestyle quite readily. This was strange due to 
the fact that in high school I was completely opposite of every ideal 
they could throw my way. I found a sense of direction in the Marine 
Corps.
    When I returned to Montana, I checked into my Reserve unit in 
Billings. In August of 2003 I enrolled at the University of Montana and 
attended classes between my monthly drills. In December of 2004, 9 
Marines including myself received orders to activate with Lima Co. 3rd 
Battalion 25th Marines out of Columbus, Ohio.
    We met up with our new unit in 29 Palms, California on January 5th 
2005. We spent 2 months getting acquainted and training with Lima Co. 
before we left for Iraq. By the time we stepped on the plane, we were 
analogous to a family. We said our goodbyes and headed into the 
unknown.
    Upon arrival in Kuwait we were informed that we were going to 
Iraq's now infamous Al Anbar province. Our home base was Haditha Dam 
which was guarded by the Azerbaijanis. They ran the security so that we 
would be able to conduct mobile operations throughout Iraq's largest 
province.
    Our battle rhythm was demanding to say the least. We were 180 
strong patrolling and clearing an area half the size of the country. My 
first major firefight was a two-hour siege of the town of New Ubaydi, 
Iraq. This town lies near the Syrian border where we were always sure 
to find resistance. During two hours of door to door fighting we had 
moved two blocks into the city. My platoon already had 5 casualties and 
the platoon adjacent had lost 8. This was my first taste of what war 
really was. It was most definitely unlike anything I had ever 
experienced, but it still felt exhilarating, never have I felt so alive 
and scared at the same time.
    After experiencing the sights, smells, and sounds of battle and its 
aftermath, my emotions seemed to dull or shutdown. I later learned that 
this was a defense mechanism that allowed me to continue to operate in 
a combat zone. To the best of my knowledge, every marine seemed to 
experience this in one form or another.
    By our two-month mark, we had all been engaged and fancied 
ourselves combat veterans. Everyone had either lost a friend or seen 
one carried away in a Medevac. We faced IEDs, mortar rounds, rockets, 
and small arms fire on a repetitive daily basis. Soon it was becoming 
hard to distinguish the real enemy, those we fought or those who made 
us fight. This double fronted battle only strengthened our small unit 
fraternity. Eventually, we recognized that someone on our side was 
continually putting us in harms way. We came to trust only each other 
and the outside world became irrelevant. We fought for each other not 
national policy or the ideals of democracy. Little did we know that 
this was only the beginning.
    In August 2005, our Battalion lost 24 marines in about 10 days. 
Thirteen of them were from our company. On August 1st a team of our 
snipers were compromised and all 6 of them killed. On August 3rd we 
headed into the city of Barwanna, which was about 8 miles from our dam 
to recover the weapons of our fallen comrades. While entering the city, 
one of our troop transport vehicles or ``tracks'' as we call them was 
hit by a massive improvised explosive device (IED). To date it was the 
largest I had seen, I knew whoever was in that vehicle was probably 
dead. As I ran closer I realized that it was my squad that was in the 
track. In that moment, I truly understood the meaning of loneliness. In 
one fell swoop, the only family I had known for 6 months was taken from 
me. The bonds tempered by the fire of battle exceed those of any other. 
I felt alone and beached in a world I no longer wanted to be a part of.
    After a couple hours we were ordered to continue with the mission 
as though nothing had happened. By noon you could already see the 
videos of the explosion on Al Jazeera. We stayed out for another week 
before they let us go back to the dam. I lost my appetite, and I most 
certainly did not sleep. It only got worse from there.
    We still had another month of operations ahead of us. I had become 
very indifferent as to whether I lived or not. The battalion flew in a 
team of psychologists for us to speak with. During the middle of the 
first meeting, one doctor had fallen asleep. This only reiterated the 
belief that all we had was each other. That incident left me absolutely 
bitter to anyone that was not part of our unit.
    When we arrived home it seemed surreal. I felt more out of place 
here than I did in Iraq. I isolated myself from friends and family and 
dwelled in my emptiness. In November of 2005 I went to Ohio to meet the 
families of those I called my brothers. The experience was second only 
in terms of difficulty to accepting the loss of my best friends. I was 
drunk and angry and the only person I could blame was myself. I was 
certainly on the beaten path of destruction.
    Upon my return to Missoula I received a phone call from Deb McBee, 
a veteran's service officer from the Military Order of the Purple 
Heart. She had read an article about what had happened to my squad and 
recommended I see someone at the VA clinic. I took her advice and 
enrolled for medical services. My VA physician referred me to David 
Anderson, the veteran's liaison for Western Montana Mental Health 
Clinic.
    Dave made an immediate impression on me as someone who had 
experienced the atrocities of war firsthand. He served with 1st 
Battalion 9th Marines, the most engaged unit in the history of the 
Marine Corps. If I had a glimmer of hope it definitely came from this 
man. He only works with true combat vets so I was honored when he 
offered to help me out.
    About 8 months later I received a disability rating of 50 percent 
for Post Traumatic Stress Disorder from the VA. Shortly thereafter I 
was discharged from the Marine Corps. With a rating of that size I was 
eligible for the VOC rehab program so I decided to pursue it. With 
Dave's help I changed my major to PRE MED and I am currently pursuing 
that field. I still see Dave on a weekly basis, and his wisdom has been 
paramount in terms of my recovery.

    Senator Tester. Thank you very much, Travis. Appreciate 
your service, and all of you folks' service to veterans and in 
the field. I'm just going to ask with a few questions real 
quick. Ron, I'll start with you. I can ask this question to 
some of the folks in the next panel, too, if you don't know.
    But I was curious, you said that the spinal cord injury 
folks had no availability for health care in this region and 
that they were going to propose a 20- to 30-bed unit in Denver, 
Colorado. That's correct, right?
    Mr. Parmelee. That's correct. The thing is, spinal cord 
injury patients have to be handled differently than the normal 
patient. They have to be turned, they have to be taught how to 
do stuff. A lot of times the nurses can do more harm than what 
the patient came in with.
    Senator Tester. Where do these folks have to go now?
    Mr. Parmelee. They go to Seattle, they go to Woods, they go 
to Palo Alto, some go to New Mexico.
    Senator Tester. How long is this proposal--you said it's 
still a proposal, it's not a reality yet. Right?
    Mr. Parmelee. They're still working on some funding, is the 
last I heard.
    Senator Tester. How long has that been on the docket, how 
long have you been trying to get this done in Denver?
    Mr. Parmelee. We were trying to get a spinal cord unit 
there before they were going to move, and that's been a good 20 
years. The ones who are in Denver were the majority of the 
spinal cord ones. They had to go to New Mexico. It's 
ridiculous.
    Senator Tester. Yes, it is ridiculous.
    Mr. Parmelee. Especially if you have an open decubiti and 
are trying to travel to go there.
    Senator Tester. Thank you very much.
    Alvy, I wanted to ask you a couple of real quick questions. 
You said you had 41 vans in total, 760,000 miles this year. How 
many drivers do you have?
    Mr. Chapman. We have 250 drivers.
    Senator Tester. Is there a problem with being able to keep 
those folks? I mean, do you always have a driver, since it's a 
voluntary thing?
    Mr. Chapman. Not always. The local coordinators get their 
drivers, and it fluctuates from time to time.
    Senator Tester. So what happens if you can't get a driver? 
They just don't get to use the van, is that how that works?
    Mr. Chapman. Yes. The driver has to be qualified through 
the VA to drive a van; we just can't put anybody in that van. 
So there are cases where sometimes we don't have a volunteer to 
drive that van so it can't go.
    Senator Tester. Got you. OK. The Veterans Affairs' 
Committee recently approved a bill that would allow the VA to 
make transportation grants up to $50,000. It's not a huge 
amount of money but it could make a difference. If you were in 
a position that you could check off on a few things, what would 
you prioritize to make travel easier for vets, particularly in 
the rural frontier areas of the state? What would you do? Would 
it be--let me give you some examples that flip through my mind. 
With your program with the vans, should we look at ways to pay 
drivers or could you not pay them enough to do it, or should we 
be looking at more vans in the field, should we be looking at 
more regular runs to Fort Harrison or the clinics? Where would 
you put the priorities?
    Mr. Chapman. We're looking at this right now, and I think 
our priorities with our program right now is going to be to get 
more vans out there. Obviously, with as big a state as we have, 
41 vans is not covering it. We have the entire area around 
Glasgow not being served at all, so we're going for Glasgow 
next and then Glendive.
    What I think would help tremendously is we put all of our 
dollars into these two HSCs, the two employees that we have, 
but they're based in Billings and Helena. What I'd like to see 
is us having the ability, like the commander of the DAV or even 
a rapid-response team, to be able to go out to Glendive and 
actually set that up. But, see, there is travel cost and stuff 
associated with that, and right now we're so strapped on the 
dollars that we can't get out there.
    Senator Tester. Got you. Thank you very much.
    Dave, and Max may, in fact, know this question, but I'm 
going to ask you. Why did they close the hospital in Miles 
City, since it's the only one closed in the U.S.? Why?
    Mr. McLean. I believe the answer that they gave is it 
wasn't being used regularly year-around.
    Ruddy Riley is our department service officer, and he's an 
institution in veterans affairs from the veterans 
organizations.
    Senator Tester. Ruddy, why did they close the VA hospital?
    Mr. Riley. They closed it because there are seven patients 
a day, the average patients are seven patients a day. They 
couldn't justify a full hospital for that.
    Senator Tester. What do they need to justify a full 
hospital?
    Mr. Riley. I never did hear a figure.
    Senator Tester. I may ask somebody on the next panel in 
case they know. Thank you very much.
    Dave, real quick, you said that most of the clinics are 
staffed by PAs, not physicians. Is that true across--is that 
all of them? Is that a Montana-specific thing or is that the 
way it is across the country?
    Mr. McLean. I'm afraid I can't answer that question. I 
think the VA can answer it. I do know--and they're working on 
it all the time. I think up in Kalispell, for example, there 
are three physicians available as compared to other areas like 
Anaconda where there are none. But the important thing, to me, 
is there are no health care practitioners, mental health care 
practitioners, and that is where we're seeing most of the 
veterans coming home really being let down right now.
    Senator Tester. Mr. Heavyrunner, real quick, the VA signed 
an agreement in 2003 with Indian Health Service to work on some 
pretty broad areas, five of them particularly on reservations, 
reservation specific. Those areas included communication 
access, target benefits awareness program, partnerships with 
native organizations and health promotion. Do you see the VA in 
Indian country working in any of those areas aggressively or 
even working in any of those areas?
    Mr. Heavyrunner. Not really right now, I've not seen it. I 
could be more informed about it when they come up and visit 
about it, but I know we're waiting for a TLC line, something 
like that, to come into IHS. We do have a lot of veterans on 
the reservations. From any other ethnic group, we are the 
highest enlisted in the military, the lowest to receive 
benefits or help from the VA. We have been working on that in 
the last couple of years with Buck Richardson who has been 
working with a TVR program, Travel Veterans Representative 
program. James Floyd out of the Salt Lake City area has been 
working very hard to get more people on the reservations to 
help the Native American veterans out there.
    Senator Tester. Good. John, real quick. You talked about 
the travel reimbursement, you talked about it being woefully 
inadequate, which it is, and we're working on getting that 
bumped up. But the question is, for me, you can't talk for 
anybody else, but when you're losing, when it's just for 
gasoline, by the way, not insurance, not tires, not anything 
else, wear and tear on the car, it's costing you money out of 
your pocket to get the health care, does that have an impact on 
your ability to--do you have to let some things go because of 
that, because you simply didn't have the money to get there on 
a personal basis?
    Mr. Burgess. Yes, I have.
    Senator Tester. So I would think if that's true with you, 
it's probably true with other veterans that live in places a 
long ways away from Fort Harrison?
    Mr. Burgess. I'm sure it's even worse.
    Senator Tester. Lastly, Travis, as was said earlier, I 
appreciate your service. In your written testimony, you didn't 
talk about it in the verbal, which was fine, but you talked 
about, in your written testimony, having a psychologist or a 
psychiatrist, I can't remember which, come in and do an 
assessment. I think you said the guy fell asleep and so it 
didn't do a lot of good. In fact, it made you a bit suspicious, 
which I think it would do to anybody.
    I guess the question is, as you've transitioned out of 
active military into becoming a civilian veteran, was there any 
point in time in there where folks talked to you about your 
combat duty and what happened to you in the field to try to get 
to know exactly what you had been through? Because it sounds 
like your engagements were more often than not.
    Mr. Williams. Yes. Just for the record, the psychologist 
that fell asleep was not a VA doctor.
    Senator Tester. He was active military?
    Mr. Williams. That's correct. When I got home, I didn't 
talk to anybody and I didn't seek any help. Actually----
    Senator Tester. Did anybody reach out to you?
    Mr. Williams. Yes. Deb McBee from the Military Order of the 
Purple Heart, she read my article and gave me a call. And after 
I spoke with other people that I knew from Helena that worked 
in the VA and kind of, I guess I was more suspicious of her 
intentions, but they assured me that----
    Senator Tester. How about before that time, when you were 
still active military, was there any kind of debriefing as to 
what you went through?
    Mr. Williams. The debriefing was where one of the doctors 
fell asleep. And then after that, we were offered--you know, 
they offer it to you if anybody needs to talk to somebody, you 
can go to a chaplain or the military doctors, but it's kind of 
a different--you know, it's kind of letting your guard down, I 
guess, to go speak with somebody then. And the way I felt, I 
guess, at the time, I felt the best way to handle it was just 
to bottle it up and wait until I got home.
    Senator Tester. Got you. I appreciate it. I have to point 
out that, before I turn it over to Senator Baucus, one of the 
big concerns we have had on the Veterans' Affairs Committee is 
the transition between active military to civilian life and 
making sure that those medical records make the transfer, 
making sure that you're debriefed appropriately and completely 
when you're still in the active military so that the VA can 
take those records and move forward in a way that makes sense 
to the individual.
    With that said, Senator Baucus?
    Senator Baucus. I'd like to follow up a little bit with 
what Senator Tester was asking you, Travis. Again, reading your 
statement, I picked this up from other veterans, there is a 
certain sense that your real support group are your buddies, 
the people that you trained with, that you fought with. And 
also reading your statement, you get the sense that, 
particularly on Iraq, you're leaving active duty, this guy kind 
of fell asleep, and you're kind of looking for a support 
system, the only support system you really have are your 
buddies. So when you come home, it's a real problem because you 
lose that support system because when you come back home, it's 
kind of alien to you. I know you said in your statement, ``I 
almost felt more comfortable in Iraq'' than you did when you 
came home.
    Mr. Williams. The main reason for that was the unit we were 
with was from Ohio, right, two weeks before leaving the country 
we got separated from that unit, all the reservists that were 
from the RD Battalion got separated from the infantry units and 
we got thrown in the mix with people we didn't know for our 
decompression time. And then when we got sent home--so, you 
know, all my friends got sent home with the Ohio unit and I 
came out here. They had their support unit and they had doctors 
on hand. They had everything ready when they got home. When we 
got home, it was almost like they almost forgot we were coming 
home that day.
    Senator Baucus. Right. And I guess some units get broken up 
like that, too, that's not uncommon to experience?
    Mr. Williams. No.
    Senator Baucus. So one potential solution is to try to 
address the breaking up of units, it seems to me. Would that 
help or not?
    Mr. Williams. In theory, it's a good idea, but it can't 
happen that way all the time.
    Senator Baucus. I have no idea if this works at all, but 
what suggestions do you have for training? I can see that 
you've had training on how to deal with potential PTSD and so 
forth. I mean, when you went through training, was there any 
part of the training program that would help you and others to 
deal with that potential problem after you come back home?
    Mr. Williams. We had, you know, hip-pocket classes on PTSD 
and symptoms, battle stress, things like that, but I don't 
think it's a problem in the training. I think it's more a fact 
of life that when you're at war with a bunch of guys, you know, 
who is going to be the first one to admit they're having 
problems dealing with seeing things. It comes with the job.
    Senator Baucus. Right. When you're over there, that's true. 
But before going over there, is there a role or a place for 
people like you who have gone through this experience to help 
those now in basic training, a role that would help not only 
you but help them?
    Mr. Williams. I definitely think so. I believe I tried to 
get toward that with my comments about my psychologist in that 
when we come home it's hard to trust somebody who has little 
knowledge about the realities of war. And I think that prior 
veterans, prior combat veterans are a huge asset in helping us 
get back. I mean, myself, when I came home, I didn't trust 
anybody, I was drinking.
    Senator Baucus. But you found a fellow you trusted in, 
David somebody.
    Mr. Williams. Yes, David Anderson.
    Senator Baucus. He's a marine, he's seen wars and battle, 
therefore, there is a guy you kind of relate to?
    Mr. Williams. Yes, sir.
    Senator Baucus. Is that sort of common, do you think, is 
your experience pretty common? I know you were split up from 
your Ohio group.
    Mr. Williams. I don't know if it's that common. I wish it 
was, I mean, I've tried to tell all my friends, and Dave's 
opened himself up to talk to me, I mean he's given his number 
out to plenty of my friends in Ohio, if they need to talk to 
him, ever. But I think that also it's not just a matter of 
having those people on hand, it's a matter of the veteran 
himself actually going to get the help, if he can. I guess you 
can't really expect to be spoon-fed everything.
    Senator Baucus. Clearly. But still it's important to 
anticipate potential problems, do the best you can to get 
prepared, as with training. I guess what I'm trying to figure 
out here is how we, in rural areas, get not just proportionate 
care but almost more than proportionate care. I mean, what 
bothers me, and Miles City is the example, I remember that we 
tried everything under the sun to keep that hospital open. I 
brought, just for the sake of my colleagues here and some of 
you here, Majority Leader George Mitchell to Montana to 
highlight to keeping that Miles City Hospital open. We got in 
an airplane, I think it was in Lewistown and flew, going over 
to Miles City. He turned and said, Max, haven't we crossed 
Montana already.
    So, no, we have a ways to go. We've got the folks from 
Miles City, and then we've got the folks from Billings, we put 
him in a van and we turned off the air conditioning so he 
realized how far it is. We did all we could, but we just 
couldn't prevail, frankly, to keep the hospital open. Basically 
the argument is what you just heard, well, there are only seven 
beds there. And I say, so what, there are seven bodies, those 
are seven Montanans and those are seven vets. You know, you're 
a vet in a bigger city, you have facilities there, it's there.
    But in our state, there isn't very much in this state. We 
need some kind of mandate that gives proportionate dollars for 
rural communities because of the cost of travel that we just 
talked about, because of the cost of no support system, because 
you don't have many buddies when you get to a small town. You 
get to a big town, there are a lot of buddies and people who 
have seen combat, a support system. There is where we get 
caught because it's a tyranny of the averages, it doesn't pay 
for itself, therefore, you have to cut it. It's the wrong 
question to ask, does it pay for itself. The question is, 
should the care be given, I think it should. There has to be 
some way to bump it up, not just an average. Dave touched on 
that a little bit about mandates. It's not quite the same 
point, but something along the lines. Maybe Dave can expand a 
little bit on the idea or your thoughts about some kind of 
mandate dollars.
    Mr. McLean. Let me read you a letter:

        Dear Sir,
          I'm a World War II veteran, two years in the 
        Southwest Pacific. I came home without a scratch 
        mentally or physically and, believe me, my true 
        feelings are that my Uncle Sam owes me nothing for 
        doing what we had to do.
          Here is where the Legion can help. Several months 
        ago, I received a letter from the VA that it was time 
        for my annual physical exam, I should call the Bozeman, 
        Montana office, which is a CBOC, to set up an 
        appointment. Sounds great. I called at 8 a.m. Monday 
        morning, the line was busy. OK. I waited 15 minutes and 
        called again. The phone rang but no answer. I called 
        three more times that Monday, the phone would ring but 
        no answer.
          I went through the same procedure for the next 14 
        working days, 8 a.m. in the morning, the line was busy, 
        and from there on the phone would ring and no one would 
        answer. Finally, I got to make my appointment. When I 
        met with the doctor, I asked her about the difficulty I 
        had getting an appointment. She told me they were so 
        busy and so shorthanded, they couldn't answer the phone 
        most of the time.
          I cannot say enough good things about the doctor and 
        her staff. They are great. But they are really 
        overworked. I have my own doctor in Livingston and I go 
        to the VA once a year to keep my record clean. My heart 
        breaks when I see veterans that really need medical 
        help and need to wait just to get a phone call through 
        to get an appointment. Our government treats them like 
        heroes overseas and then treats them like second-class 
        citizens when they get home. Please don't throw this in 
        the garbage. Raise hell in the proper places. By the 
        way, I've been in the Legion for 41 years.
            Thank you.
                                                  Walter W. O'Hara.

    Senator Baucus. That says it all. I gave the statistics, 
I'm told there is about 25 percent additional sort of pressure 
on the system now because of vets coming home from Iraq and 
Afghanistan, so forth, which puts more strain on the system. 
Any of you who might want to address that, do you experience 
that at home, kind of the point made by that letter that Dave 
read, give us your feelings. Everybody's trying to do a good 
job, the VA wants to do a good job with you. If there are a lot 
more vets coming home, it's kind of tough. But you can shed a 
light on what you've experienced with some of that.
    When we first got involved in the invasion of Iraq, the 
second time the American Legion went before the Veterans' 
Affairs Committee, we did everything we could to try and get 
the VA to gear up for these people who are coming back. 
Unfortunately, it fell on deaf ears at that time. Now, we are 
into the problem and it's just an overwhelming problem, so 
we're trying to close the barn door afterwards.
    We're going to ask that question to the second panel so 
that the second panel can hear what you and others are saying.
    One quick additional point, we, in the Congress, are in the 
process of expending an extra $3 billion more for vets, and 
Senator Salazar mentioned this point, that it seems like that 
is going to make a big difference. It's not just for next year, 
Fiscal Year 2008, it's because it's our hope, frankly, that 
will deal with a lot of additional pressures that are being put 
on the system.
    One final point, Dave, it's my understanding, it's a good 
one, jurisdictional Medicare. You were saying that maybe we 
ought to get some benefit out of the Medicare dollars that are 
spent. I didn't quite understand your point.
    Mr. McLean. There are many in the room that can answer this 
better than I can. My understanding, when you're on Medicare, 
the VA says they can't bill Medicare for help because one 
government agency cannot bill another government agency. 
They're losing billions of dollars. Behind every Medicare 
recipient is the secondary policy. If the VA provides the care 
to somebody and can bill Medicare, the supplemental policy, 
that's part of the bill they don't have to foot.
    Senator Baucus. That's a good point. As you all know, the 
slight problem is the Medicare system is about to go belly up 
in about 6, 8, 10 years from now.
    Mr. McLean. It better last longer than that. I have a life 
expectancy of 20 years.
    Senator Baucus. Thank you very much.
    Senator Tester. Senator Salazar.
    Senator Salazar. Thanks, Senator Tester.
    Let me ask you a couple of questions, first, to you, 
Travis. You tell a story which is an incredible story and a 
true story, and I would encourage, not only you, but others to 
make sure that your story is told so that the people who are 
making policy know what that story is.
    Senator Baucus. If I might add on that, I suggest that 
statement get published widely. It will make a big difference.
    Senator Salazar. It seems to me you went to Iraq. You came 
back and you went through this period of being very, very lost, 
very, very lost. Describe for us, short, in a couple of 
paragraphs, what kind of transition occurred from the time you 
came back from Iraq, you were debriefed. I'm sure you probably 
got some health care and then you were let go and you were lost 
for a very long time. What did the DOD do and where did the VA 
pick up? Did they do anything to help you?
    Mr. Williams. The transition coming back, basically what 
happened was we flew out of Kuwait after we had been split up 
during our decompression time, which is the last two weeks in 
Iraq, is where you go back to a major, bigger base where you're 
less likely to be engaged, and it's more or less exactly what 
it says, decompression time. You get split up according to the 
states that you're going to fly back into the country to, and 
that's pretty much the two weeks. That's your next group that 
you're stuck with.
    So you go through, you have these classes about when you're 
coming home, signs of PTSD and battle stress, stuff like that, 
just to kind of make you aware.
    And then they bring you through, quickly, kind of a 
shakedown class of the benefits offered by the VA. And from 
what I know now as compared to what I knew then, they far 
exceed what they told us when we were coming back.
    And so I was released from my unit that night that I got 
home, told to come back in in about a week. Went and checked 
back in, turned in my gear, and they just kind of cut you 
loose. I mean, you talk with the medical staff on hand, which 
was a Navy Corpsman, Seaman Chief, and then you just kind of 
get cutoff and let go. And you have pay, you get paid vacation 
when you get off, so you've got 2 months of getting paid to 
where you don't have to do anything, you don't have to work and 
you're getting paid. So usually, I mean, not to speak for 
everyone, in my case, it ended up being 4 weeks of just going 
and getting drunk and thinking about everything that happened, 
and doing all this stuff in my own head with alcohol was not a 
good mixture.
    And to top that off, when we got back, we had a month 
before the Marine Corps Ball, the Birthday Ball, and I was 
planning on going to Ohio to meet the families of my friends. 
And so when I got there, I stayed there for a week visiting the 
grave sites and family members and trying to answer as many 
questions as I could for them. And it was nice to get it over 
with, but it was also one of the hardest things I've had to 
deal with. It was pretty terrible. I can't describe it any 
other way.
    After that, I came home and then that's when I received a 
call from the Military Order of the Purple Heart, and my whole 
problem is, without that call, I probably wouldn't have gone to 
seek help or known about any of the benefits that the VA has to 
offer. And I know that's the case with a lot of my friends 
because----
    Senator Salazar. In those two or three months, did the VA 
contact you?
    Mr. Williams. No. I contacted the VA.
    Senator Salazar. You contacted the VA after the Military 
Order of the Purple Heart contacted you?
    Mr. Williams. Yes.
    Senator Salazar. Although you were here and this whole 
issue of the transition from DOD over to the VA is a keystone 
issue focused on by Jon Tester, by Senator Baucus and caring 
about veterans' problems, there is a lot of attention being 
placed on what is happening with the returning veterans from 
Iraq and from Afghanistan, so obviously we would welcome your 
comments on that.
    Very quickly, Jon, you talked to John Burgess, you talked 
about the reimbursement, half the gas is basically what you 
get? Senator Tester has legislation that Senator Baucus and I 
are supporting, we're going to get it done to increase some 
mileage reimbursement, 28 cents per mile is what the 
legislation proposes. Would that help?
    Mr. Burgess. Yes, it sure would. Twenty-two cents would 
help at least break even.
    Senator Salazar. Eleven cents just doesn't do it?
    Mr. Burgess. That's right. Just tell them, don't mess with 
that $6.
    Senator Salazar. If I can, Mr. Heavyrunner, in terms of the 
Native American issues and services, is there a difference in 
terms of how the VA--let me ask this question. We're here 
dealing with the disparity that we frankly know from a 
scientific point of view exists between what happens in urban 
communities and what happens in rural communities. Is there 
that same kind of disparity with respect to Native Americans 
who have served and their treatment from the VA and the general 
population?
    Mr. Heavyrunner. I think so. It's pretty much the same.
    Senator Salazar. Would you say it would be important for us 
in the U.S. Senate to at least put some attention with respect 
to Native Americans and VA services to Native Americans?
    Mr. Heavyrunner. Yes, sir. I know that right now we're 
dealing with a lot of PTSD with Native Americans returning from 
Iraq, and we're also using a lot of our traditional healing to 
help these young men when they come back from Iraq, but the 
more combat veterans we put in Operation Glacier Warrior, the 
more help they'll get. What I'm saying is, there is a need. The 
more we can help these young men and women as older veterans, 
the better off we are.
    Senator Salazar. Thank you.
    Mr. Chapman, to you, the legislation, again, that all of us 
are supporting would create a program and make available like 
$50,000. Would that help with some of the transportation 
challenges here in Montana if your organization were to get a 
$50,000 grant a year?
    Mr. Chapman. It would help quite a bit. We buy our vans 
through donations and whatnot. We don't have the ability to get 
up to this area and work with people, so we could get a van in 
that area and then provide service to them.
    Senator Salazar. Speaking of the Native Americans?
    Mr. Chapman. That's where the grant monies help out 
tremendously. It would then give us more opportunity to help us 
work with the hardest-to-serve regions.
    Senator Salazar. If I could ask you, Dave, in terms of the 
Independent Budget, you obviously are very familiar with 
veterans' issues, the funding by the Congress, that we can get 
this done. We have a lot of struggle ahead of us before we get 
there, if we do fund the Independent Budget, and the VSO comes 
up with it, is that a step in the right direction?
    Mr. McLean. It's definitely a step in the right direction, 
yes.
    Senator Salazar. We need your help. You know, we're out of 
time, but we've learned a lot from all of you.
    Senator Tester. Thank you, panelists, and Senator Baucus 
and Senator Salazar. It's not easy, but I appreciate your input 
and very, very much respect your point of view and it's very, 
very 
helpful.
    Our second panel consists of some, once again, some very, 
very fine individuals from the VA in Washington, Dr. Richard 
Hartman, joined by the Undersecretary for Health for Operations 
and Management, Mr. Feeley, is the chief operations officer 
responsible for the Veterans Integrated Service Network. We're 
also pleased to have, and I had the opportunity to meet for the 
first time the head of the VISN here for Montana and Colorado, 
Dr. Glen Grippen. Dr. Grippen is joined by the head of the VA 
Hospital in Helena, Dr. Joe Underkofler. Joe Foster is here 
representing the State of Montana Veterans Affairs Division. 
I've had an opportunity to work with Joe on several occasions, 
he's a good man. General Randy Mosley, who also is a fine man 
in his own right.
    Thank you very much for your service to the State. We're 
going to start out with Dr. Hartman. I'm going to ask you folks 
to be very brief. We've got very limited time, and I know there 
are a lot of questions to be asked of you fellows, so rock and 
fire.

   STATEMENT OF RICHARD HARTMAN, Ph.D., DIRECTOR FOR POLICY, 
  ANALYSIS, AND FORECASTING, VETERANS HEALTH ADMINISTRATION, 
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY WILLIAM FEELEY, 
 M.S.W., FACHE, UNDER SECRETARY FOR HEALTH FOR OPERATIONS AND 
           MANAGEMENT, DEPARTMENT OF VETERANS AFFAIRS

    Dr. Hartman. Good afternoon, Mr. Chairman, Members of the 
Committee and people of Montana and panelists. Thank you for 
the opportunity to discuss the VA's ongoing efforts to provide 
safe, effective, efficient and compassionate health care to 
veterans residing in rural areas. I'm accompanied by Mr. 
William Feeley, the VA's Deputy Undersecretary for Health 
Operations and Management.
    My remarks will briefly review the national challenge 
presented by rural health care and the VA's strategic direction 
and initiatives that are underway. While I'm here to present 
the VA's national overview and direction for addressing the 
needs of our rural veterans, Mr. Grippen, Mr. Floyd and Mr. 
Underkofler are here to give you the firsthand account of their 
implementation and experience as it is happening here in 
Montana and in Network 19 with our veteran population.
    Among the entire enrolled VA population, 39 percent were 
classified as rural veterans at the end of Fiscal Year 2006. 
And among the entire enrolled VA population, 2 percent were 
classified as ``highly rural.'' Highly rural refers to counties 
with less than seven citizens per square mile.
    Researchers have studied the rural health care experience, 
including a number of articles that looked at VA health care. 
Three studies have found that veterans living in rural areas 
tend to be slightly older and have slightly more physical 
health problems but fewer mental health conditions, as compared 
to suburban and urban veterans.
    VA's strategic direction is to enhance non-institutional 
care with less dependence on large institutions. We provide 
home-based 
primary care as well as home-based programs. We're using tele-
medicine and tele-mental health to reach into the veterans' 
homes and into community clinics, including tribal clinics. 
This allows us to evaluate and follow patients without them 
having to travel to large medical centers. We're 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 further increase access to care, the VA has over 880 
outpatient clinics, of which over 700 are Community-Based 
Outpatient Clinics, or CBOCs, located around the country. 
Forty-five percent of our CBOCs are located in rural or highly 
rural areas. In addition, we are expanding these efforts with 
the establishment of outreach clinics, such as the one 
announced by the Secretary that will be opening in Craig, 
Colorado. There are currently 12 open outreach clinics.
    VA is focusing additional attention on the special needs of 
veterans who reside in rural areas. In accordance with Section 
212 of the Public Law 109-146, VA has established an Office of 
Rural Health. The mission of the Office is to develop policies 
and identify and disseminate best practices and innovations to 
improve services to veterans who reside in rural areas. The 
office is accomplishing this by coordinating delivery of 
current services to ensure the needs of rural veterans are 
being considered. VHA is working to incorporate the unique 
needs of rural veterans as new programs are 
implemented.
    In addition to our internal efforts, VA continues to look 
for ways to collaborate with complementary Federal efforts to 
address the needs of health care for rural veterans. We have 
partnerships with Health and Human Services, including the 
Indian Health Service, IHS, and HHS's Office of Rural Health 
Policy, collaborating in the delivery of health care in rural 
communities.
    Thank you for your continuing support of our veterans. The 
VA recognizes the importance and the challenge of service in 
rural areas, and we believe our current and planned efforts are 
addressing these concerns for your current and emerging 
veterans. I'll be happy to answer any questions you may have.
    [The prepared statement of Dr. Hartman follows:]
  Prepared Statement of Richard Hartman, Ph.D., Director for Policy, 
Analysis and Forecasting, Veterans Health Administration, Department of 
                            Veterans Affairs
    Good afternoon, Mr. Chairman, Members of the Committee and visiting 
members. Thank you for the opportunity to discuss VA's ongoing efforts 
to provide safe, effective, efficient and compassionate health care to 
veterans residing in rural areas. I am accompanied today by Mr. William 
Feeley, VA's Deputy Under Secretary for Health for Operations and 
Management.
    My remarks will briefly review the national challenge presented by 
rural health care and VA's strategic direction and initiatives that are 
underway. While I am here to present VA's national overview and 
direction for addressing the needs of our rural veterans, Mr. Grippen, 
Mr. Floyd and Mr. Underkofler are here to give you the firsthand 
account of their implementation and experience as it is happening here 
in Montana and Network 19 with our veteran population.
    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 seven 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 have slightly more physical health problems but 
fewer mental health conditions--as compared to suburban and urban 
veterans.
    VA's strategic direction is to enhance non-institutional care with 
less dependence on large institutions. We provide home based primary 
care as well as other home based programs. We are using tele-medicine 
and tele-mental health to reach into the veterans' homes and into 
community clinics, including tribal clinics. This allows us to evaluate 
and follow patients without them having to travel to large medical 
centers. 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 further increase access to care, VA has over 880 outpatient 
clinics, of which, over 700 are Community Based Outpatient Clinics (or 
CBOCs) located around the country. Forty-five percent of our CBOCs are 
located in rural or highly rural areas. In addition, we are expanding 
these efforts with the establishment of outreach clinics, such as the 
one announced by the Secretary that will be opening in Craig, Colorado. 
There are currently twelve open outreach clinics.
    VA is focusing additional attention on the special needs of 
veterans who reside in rural areas. In accordance with Section 212 of 
the Public Law 109-461, VA has established an Office of Rural Health. 
The mission of the Office is to develop policies and identify and 
disseminate best practices and innovations to improve services to 
veterans who reside in rural areas. The office is accomplishing this by 
coordinating delivery of current services to ensure the needs of rural 
veterans are being considered. VHA is working to incorporate the unique 
needs of rural veterans as new programs are implemented.
    In addition to our internal efforts, VA continues to look for ways 
to collaborate with complementary federal efforts to address the needs 
of health care for rural veterans. We have partnerships with Health and 
Human Services (HHS), including the Indian Health Service (IHS) and 
HHS's Office of Rural Health Policy, collaborating in the delivery of 
health care in rural communities.
    Thank you for your continuing support of our veterans. VA 
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. I will be happy to 
answer any questions you may have.

    Senator Tester. Thank you very much, Dr. Hartman. Do you 
have a flight to catch, Dr. Grippen?
    Dr.  Grippen. All three of us do.
    Senator Tester. Dr. Grippen, you're up to bat next.

      STATEMENT OF GLEN GRIPPEN, M.D., NETWORK DIRECTOR, 
VISN 19, DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY JOE M. 
     UNDERKOFLER, DIRECTOR, VA MONTANA HEALTH CARE SYSTEM, 
                    DEPARTMENT OF VETERANS 
                            AFFAIRS

    Dr.  Grippen. Good afternoon, Mr. Chairman. Thank you for 
the opportunity to discuss VISN 19 and the health care services 
we offer to the veterans it's our privilege to serve. My 
remarks will primarily talk about the current programs and 
collaborative efforts in Network 19.
    The VA Rocky Mountain Network 19 covers a geographic area 
of 470,000 square miles across nine states and principally 
serves the states of Colorado, Montana, Utah, and Wyoming. Our 
service area also extends into portions of Idaho, Kansas, 
Nebraska, Nevada and North Dakota. We are the second largest VA 
Network in terms of geographic area and deliver health care 
services to urban, rural and frontier locales. Distances 
between our medical centers, severe weather, secondary roads, 
and high mountain passes are significant factors to veterans' 
access to care.
    Network 19 is constantly focused on providing care closer 
to veterans, both in their homes and in their communities. We 
have established Community Based Outpatient Clinics or Outreach 
Clinics as sites of the care to provide high quality primary 
care and mental health care to veterans. Network 19 currently 
has 32 CBOCs and one Outreach Clinic. Ten CBOCs are located in 
Colorado, five in Wyoming, nine in Montana, five in Utah, two 
in Nevada, one of which is an Outreach Clinic, one in Idaho, 
and one in Nebraska.
    Most of these CBOCs are located in rural areas. Network 19 
will open six additional sites of care in 2007 and 2008. These 
new sites are planned for the West Valley of Salt Lake City; 
Lewistown, Montana; Cut Bank, Montana; Craig, Colorado; 
Burlington, Colorado; and Elko, Nevada.
    Network 19 is a national leader in Care Coordination and 
Telehealth. We serve more than 1,000 veterans in Care 
Coordination Home Telehealth programs. Fourteen care 
coordinators use disease management protocols and home 
telehealth technologies such as the Health Buddy. The Health 
Buddy is an in-home messaging device that serves as a 
connection between patients at home and care providers.
    We have 26 other telehealth programs across the Network, 
including primary care, home care, cardiology, dermatology, 
retinal screening, radiology, rehab and polytrauma. We are 
using 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 long distances.
    Network 19 serves a large Native American population and 
through our Tribal Veterans Representative program, we have 
been successful in our outreach to the sovereign nations of 
Nevada, Idaho, Colorado, Wyoming and Montana. Agreements with 
the Indian Health Service have allowed us to expand our tele-
mental health to the nations of the Crow, and Northern Cheyenne 
of Montana and the Eastern Shoshone and Northern Arapaho of 
Wyoming. We plan to expand tele-mental services to three 
reservations in Montana, Rocky Boy, Fort Belknap and Fort Peck 
in the next six months. These agreements also open the door to 
establish referral patterns from IHS clinics to VA medical 
centers.
    Access to mental health resources is one of the concerns 
facing veterans in rural areas. Therefore, comprehensive mental 
health care is one of the top priorities of VISN 19. We have 
added 140 mental health positions over the last 4 years. Some 
of these positions have been placed in CBOCs to add resources 
and greater mental health expertise in primary care sites. Each 
medical center has a designated Suicide Prevention Coordinator. 
These activities include identification of veterans at high 
risk for suicide and education of providers, veterans and 
families and members of the community. The Network has added 
staff to improve the coordination and delivery of care to the 
following programs: Post-Traumatic Stress Disorder, Substance 
Abuse, Mental Health/Primary Care Integration, Homeless 
programs, and for the re-entry of incarcerated veterans.
    Network 19 is being called upon to deliver 21st century 
health care to 21st century combat veterans. They are young. 
Many have young families. Some have suffered traumatic injury 
on the battlefield. Our mission is to ensure continuity and 
improved coordination of health care for seriously injured 
veterans.
    We have been aggressive with our outreach efforts to these 
soldiers by participating in the out-briefings for returning 
soldiers, and we make individual contact with soldiers 
identified by DOD as being injured. Our medical centers 
actively collaborate with state National Guard and Reserve 
components to ensure that no returning soldier slips through 
the cracks.
    Network 19 has enhanced their Operation Enduring Freedom/
Operation Iraqi Freedom program staff to provide intensive case 
management in every state for seriously injured soldiers. 
Transition Patient Advocates serve as personal advocates for 
seriously injured returning veterans by traveling to Walter 
Reed, meeting with the families, and helping the veteran 
navigate the VA system.
    We have established a Polytrauma System of Care for 
veterans across the country. This system of care consists of 
teams of doctors, therapists, nurses, case workers and other 
health care experts who work closely with our patients and 
their families to provide top-quality individualized care. Our 
goal is to help veterans and service members achieve their 
highest potential level of recovery and 
functioning.
    The Denver VA Medical Center has been designated as the 
VISN 19 Polytrauma Site, which works directly with the Palo 
Alto VAMC as our Polytrauma Rehabilitation Center. The Grand 
Junction VAMC and the Salt Lake City Medical Center have 
Polytrauma Support Clinics, and the Sheridan, Cheyenne and 
Montana VA Medical Centers have designated polytrauma points of 
contact. The goal of this system of care is to ensure that 
important specialty care can still be provided to veterans as 
close as possible to their homes.
    Senator Tester. Could I just get the rest of your testimony 
just to put in the record, and then we'll have some time for 
questions. Appreciate your participation very much. Thank you.
    Dr.  Grippen. Senators, thank you.
    [The prepared statement of Dr. Grippen follows:]
    Prepared Statement of Glen Grippen, Network Director, VISN 19, 
                     Department of Veterans Affairs
    Good afternoon, Mr. Chairman and Members of the Senate Committee on 
Veterans' Affairs. Thank you for the opportunity to discuss the VA 
Rocky Mountain Network 19 and the health care services we offer to the 
veterans it is our privilege to serve. My remarks will briefly review 
current programs and collaborative efforts in Network 19 and our plans 
to increase services and access to care.
    The VA Rocky Mountain Network 19 covers a geographic area of 
470,000 square miles across nine states and principally serves the 
states of Colorado, Montana, Utah, and Wyoming. Our service area also 
extends into portions of Idaho, Kansas, Nebraska, Nevada, and North 
Dakota. We are the second largest VA Network in terms of geographic 
area and deliver health care services to urban, rural and frontier 
locales. Distances between our medical centers, severe weather, 
secondary roads, and high mountain passes are significant factors to 
veterans' access to care.
    Network 19 has consequently focused on providing care closer to 
veterans both in their homes and in their communities. We have 
established Community Based Outpatient Clinics (CBOCs) or Outreach 
Clinics as sites of care to provide high quality primary care and 
mental health care to veterans. Network 19 currently has 32 CBOCs and 
one Outreach Clinic: ten CBOCs are located in Colorado, five in 
Wyoming, nine in Montana, five in Utah, two in Nevada--one of which is 
an outreach clinic--one in Idaho, and one in Nebraska. Most of these 
CBOCs are located in rural areas. Network 19 will open six additional 
sites of care in FY 2007 and FY 2008. These new sites are planned for 
the West Valley of Salt Lake City; Lewistown, Montana; Cut Bank, 
Montana; Craig, Colorado; Burlington, Colorado; and Elko, Nevada.
    Network 19 is a national leader in Care Coordination and 
Telehealth. We serve more than 1,000 veterans in Care Coordination Home 
Telehealth programs. Fourteen care coordinators use disease management 
protocols and home telehealth technologies such as the Health Buddy. 
The Health Buddy is an in home messaging device that serves as a 
connection between patients at home and care providers, facilitating 
patient education and monitoring of chronic diseases. We have 26 other 
telehealth programs across the Network including primary care, home 
care, cardiology, dermatology, retinal screening, radiology, 
rehabilitation and polytrauma. We are also using 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 long 
distances.
    Network 19 serves a large Native American population and through 
our Tribal Veterans Representative program, we have been successful in 
our outreach to the sovereign nations of Nevada, Idaho, Colorado, 
Wyoming, and Montana. Agreements with the Indian Health Service (IHS) 
have allowed us to expand our tele-mental health program to the nations 
of the Crow, and Northern Cheyenne of Montana, and the Eastern Shoshone 
and Northern Arapahoe of Wyoming. We plan to bring tele-mental services 
to three reservations in Montana (Rocky Boy, Fort Belknap and Fort 
Peck) in the next 6 months. These agreements also open the door to 
establish referral patterns from IHS clinics to VA medical centers, and 
improve sharing of medical information.
    Access to mental health resources is one of the concerns facing 
veterans in rural areas. Therefore, comprehensive mental health care is 
one of the top priorities for Network 19. We have added 140 mental 
health positions. Some of these positions have been placed in CBOCs to 
add resources and greater mental health expertise in primary care 
clinics. Each medical center has a designated Suicide Prevention 
Coordinator. Their activities include identification of veterans at 
high risk for suicide and education of providers, veterans and families 
and members of the community. The Network has added staff to improve 
the coordination and delivery of care to the following programs: Post 
Traumatic Stress Disorder; Substance Abuse; Mental Health/Primary Care 
Integration; Homeless programs; and for the re-entry of incarcerated 
veterans.
    Network 19 is being called upon to deliver 21st century health care 
to 21st century combat veterans. They are young. Many have young 
families. Some have suffered traumatic injury on the battlefield. Our 
mission is to ensure continuity and improved coordination of healthcare 
for seriously injured or ill servicemembers returning from theaters of 
combat as they transition from DOD to VA.
    We have been aggressive with our outreach efforts to these soldiers 
by participating in out-briefings for returning soldiers and we make 
individual contact with soldiers identified by DOD as having an injury. 
Our medical centers actively collaborate with state national Guard and 
Reserve components to ensure that no returning soldier slips through 
the cracks.
    Network 19 has enhanced their Operation Enduring Freedom/Operation 
Iraqi Freedom program staff to provide intensive case management in 
every state for seriously injured soldiers. Transition Patient 
Advocates serve as personal advocates for seriously injured returning 
veterans by traveling to Walter Reed, meeting with the families, and 
helping the veteran navigate the VA system.
    We have established a Polytrauma System of Care for veterans and 
active duty personnel with lasting disabilities due to Polytrauma and 
Traumatic Brain Injury. This system of care consists of teams of 
doctors, therapists, nurses, case workers and other health care experts 
who work closely with our patients and their families to provide top-
quality individualized care. Our goal is to help veterans and 
servicemembers achieve their highest possible level of recovery and 
functioning. The Denver VA Medical Center has been designated as the 
VISN 19 Polytrauma Site working directly with the Palo Alto VAMC as our 
Polytrauma Rehabilitation Center. The Grand Junction VAMC and the Salt 
Lake City Medical Center have Polytrauma Support Clinics and the 
Sheridan, Cheyenne and Montana VA Medical Centers have designated 
Polytrauma points of contact. The goal of this system of care is to 
ensure that important specialty care can still be provided to veterans 
as close to home as possible.
    Also, the Vet Center program provides quality readjustment 
counseling and community outreach to combat veterans and their 
families. There are several Vet Center sites throughout VISN 19's 
geographical area.
    The demand for Long Term Care has greatly increased due to the 
aging veteran population. Network 19 has developed an array of home and 
community based care services. We have five Home Based Primary Care 
Programs in our VISN. In addition, VISN 19 has a unique program for 
non-VA, or fee basis care which includes a nurse-managed system of care 
authorization and review. Through this system we have supported home 
based care and community based outpatient care--devoting more than 
$28.5 million to this program in FY 2007 to date, and almost $61 
million to care in the community.
    Contracts with community care providers also serve to improve 
access. As an example, in Montana, where advanced practice mental 
health providers have traditionally been scarce, we contract with three 
community mental health systems across the state to augment VA staff 
and provide treatment of severe mental illness, medication management, 
psychotherapy, and case management for veterans in their local 
communities.
    Transportation in the Rocky Mountain States is an unremitting 
challenge. Assistance from the Disabled American Veterans 
Transportation Network makes the journey to secondary care much easier 
for our patients. DAV has established a responsive, professional 
network and we cannot thank them enough. In the last 6 months in 
Montana alone, DAV has operated 46 vans, utilizing 246 volunteer 
drivers who have driven almost 400,000 miles and transported almost 
9,000 veterans for VA care.
    Network 19 is committed to providing quality health care to 
veterans, regardless of where they live. New technologies allow us to 
provide that quality care in any location. We remain keenly aware of 
the importance and challenges of service in rural areas, and 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 you may have.

    Senator Tester. Joe Foster is next.

            STATEMENT OF JOE FOSTER, ADMINISTRATOR, 
               MONTANA VETERANS AFFAIRS DIVISION

    Mr. Foster. Thank you for taking your time to be with us 
here today.
    The Montana Veterans Affairs Division does not provide 
health services to veterans. However, we are instrumental in 
the process by which all our veterans, particularly those in 
Montana's rural areas, attain Federal VA health services and 
benefits. We currently operate 10 veterans service offices 
located throughout the state; and it is through these offices 
that the great majority of Montana's veterans attain Federal VA 
disability compensation, pension and burial benefits, and have 
the opportunity to enroll into the VA Montana Healthcare 
System, either by completing the VA Form 10-10 EZ or through 
the process of being rated with some level of service-connected 
disability.
    Outside of a community-based veterans service office in 
Hamilton, my agency's service offices are the only ones located 
outside of the Fort Harrison VA Center near Helena, and it is 
through these State of Montana offices that the great majority 
of our veterans attain the benefits to which they are entitled. 
In fact, within two months, we will be establishing our 11th 
veterans service office, which will be located in Wolf Point, 
and its outreach area will include the northeastern corner of 
the state.
    According to the 2000 census, Montana has the third lowest 
population density in the Nation, with 46 percent living in 
what is officially termed ``Rural Areas.'' As it happens, 
Montana has the Nation's second-highest veteran per capita 
population. So, obviously, we have veterans outreach service 
challenges in regards to the provision of veteran health and 
benefits access and services.
    Before I make my lone recommendation which would assist the 
Montana Veterans Affairs Division in providing greater services 
to its rural veterans, I will share three statistics with you 
that reflect how good a job the VA-Montana Healthcare System, 
the VA Montana's Veterans' Benefits Regional Office, the 
state's veterans service organizations, and the Montana 
Veterans Affairs Division does in the outreach of its services 
to your veterans, both rural and non-rural.
    These statistics are part of an analysis I conducted in 
2005 and presented to the Montana Legislature's State 
Administration and Veterans Affairs Interim Committee, and each 
directly reflects how well VA health and benefit services are 
provided in our extremely rural state compared to nationally 
and to our western region.
    First, in 2004, almost 25 percent of Montana's vets were 
enrolled in the VA Healthcare System. This percentage was the 
9th highest nationally and 2nd highest in the 11 Western States 
I compared--Arizona, California, Colorado, Idaho, Montana, 
Nevada, New Mexico, Oregon, Utah, Washington and Wyoming.
    Second, in 2004, 12.1 percent of Montana's veterans were 
receiving Federal VA disability compensation. This percentage 
was 15th highest nationally and 4th highest in the 11 western 
states.
    And, last, Power of Attorney representation. This is a 
document a veteran signs which authorizes my Division or one of 
the national veterans service organizations to represent him or 
her in developing a disability compensation claim and serving 
as that veteran's advocate throughout the claims development, 
rating and, as necessary, appeals process. Essentially,a it is 
the authorizing document whereby a veteran attains professional 
veterans benefits services. In 2004, 76.3 percent of Montana's 
veterans had power of attorney representation. This percentage 
was second highest nationally and number one of the 11 Western 
States.
    To summarize, despite the challenges inherent in such a 
large and rural state, Montana has a veterans services program 
that works very well and continues to improve and, in fact, is 
a national leader and model to be emulated. With continued 
support from Congress and from Montana's Governor and 
legislature, we will continue to improve, which takes me to my 
lone recommendation.
    Various bills have been introduced in Congress intended to 
provide Federal grants to the states for rural veterans service 
outreach programs. This kind of financial support is needed and 
would be appreciated. I believe that the grants should be made 
available strictly at the state organizational level and at the 
Tribal Nation level, and the grant's usage should be left 
entirely up to the state of the Tribal Nation, no strings 
attached, just performance measures.
    [The prepared statement of Mr. Foster follows:]
           Prepared Statement of Joe Foster, Administrator, 
                   Montana Veterans Affairs Division
    Senator Tester, Senator Baucus and Senator Salazar, thank you for 
investing your valuable time to being with us in Montana, and asking me 
to participate in this hearing, which is to focus on veteran health 
care and services in rural areas.
    While the Montana Veterans Affairs Division does not provide health 
services to veterans, we are instrumental in the process by which all 
our veterans--particularly those in Montana's rural areas--attain 
Federal VA health services and benefits. We currently operate 10 
veterans service offices located throughout the state; and it is 
through these offices that the great majority of Montana's veterans 
attain Federal VA disability compensation, pension and burial benefits; 
and have the opportunity to enroll into the VA-Montana Healthcare 
System--either by completing the VA Form 10-10 EZ or through the 
process of being rated with some level of service-connected disability.
    Outside of a community-based veterans service office in Hamilton, 
my agency's service offices are the only ones located outside of the 
Fort Harrison VA Center near Helena--and it is through these State of 
Montana offices that the great majority of our veterans attain the 
benefits to which they are entitled. In fact, within two months we will 
be establishing our 11th veterans service office--which will be located 
in Wolf Point, and its outreach area will include the northeastern 
corner of the state.
    According to the 2000 census, Montana has the third lowest 
population density in the Nation--with 46 percent living in what is 
officially termed ``Rural Area.'' As it happens, Montana also has the 
Nation's second-highest veteran per capita population. So, obviously, 
we have veterans outreach service challenges in regards to the 
provision of veteran health and benefits access and services. But 
before I make my lone recommendation which would assist the Montana 
Veterans Affairs Division provide greater services to its rural 
veterans, I will share three statistics with you that reflect how good 
a job the VA-Montana Healthcare System, the VA-Montana's veterans 
benefits Regional Office, the state's veterans service organizations, 
and the Montana Veterans Affairs Division does in the outreach of its 
services to our veterans--both rural and non-rural. These statistics 
are part of an analysis I conducted in 2005 and presented to the 
Montana Legislature's State Administration and Veterans Affairs Interim 
Committee, and each directly reflects how well VA health and benefit 
services are provided in our extremely rural state.

     In 2004, almost 25 percent of Montana's veterans were 
enrolled in the VA Health Care System. This percentage was the 9th 
highest nationally, and 2nd highest in the 11 Western states I 
compared--Arizona, California, Colorado, Idaho, Montana, Nevada, New 
Mexico, Oregon, Utah, Washington and Wyoming.
     In 2004, 12.1 percent of Montana's veterans were receiving 
Federal VA disability compensation. This percentage was 15th highest 
nationally, and 4th highest in the 11 Western states.
     Power of Attorney representation--This is a document a 
veteran signs which authorizes my division or one of the national 
veterans service organizations to represent him or her in developing a 
disability compensation claim and serving as that veteran's advocate 
throughout the claims development, rating and--as necessary--appeals 
process. Essentially it is the authorizing document whereby a veteran 
attains professional veterans benefits services. In 2004, 76.3 percent 
of Montana's veterans had power of attorney representation. This 
percentage was 2nd highest nationally, and #1 of the 11 Western states.

    To summarize, despite the challenges inherent in such a large and 
rural state, Montana has a veterans services program that works very 
well and continues to improve, and--in fact--is a national leader and 
model to be emulated. With continued support from Congress, and from 
Montana's Governor and legislature, we will continue to improve--which 
takes me to my lone recommendation:
    Various bills have been introduced in Congress intended to provide 
Federal grants to the states for rural veterans service outreach 
programs. This kind of financial support is needed and would be 
appreciated. I believe that the grants should be made available 
strictly at the state organizational level and at the Tribal Nation 
level, and the grant's usage should be left entirely up to the state or 
Tribal Nation; no strings attached--just performance measures.
    Thank you for this opportunity to speak, and thank you, Sen. 
Tester, for bringing this hearing to Montana.

    Senator Tester. Thank you very much. Appreciate it.
    General Mosley, unfortunately, we're about out of time, so 
you have to make it brief.

 STATEMENT OF MAJOR GENERAL RANDALL MOSLEY, ADJUTANT GENERAL, 
                     MONTANA NATIONAL GUARD

    General Mosley. Mr. Chairman and Members of the Committee, 
you have a report I have given you. I thank you for the 
opportunity to partner with you. Senator Baucus, you made the 
comment that you wanted to be able to look back after this 
hearing and say that we were able to get things done. The last 
time I had an opportunity to partner with Montana's delegation 
was during BRAC. And during BRAC, under the leadership of the 
Montana senators, we were able to convince the Air Force that 
they were wrong. And with the help of Montana State Government, 
the citizens and the people of the community, we changed the 
outcome of BRAC. I think the opportunity is today just like as 
it was then, we have the opportunity in this particular issue 
to partner together to change how we are going to treat Montana 
veterans.
    As I say, in my packet, you have the information, I'll 
point out a couple things that are there besides the report. 
The first is a map of Montana overlaid on the Eastern seaboard. 
One end of Montana is at Washington, DC, and the other is at 
Bangor, Maine. You would not convince anyone living in 
Washington, DC, that they would have to drive to Bangor, Maine 
to get any type of health care. This is not like anywhere else.
    My second point in there, again, is a map of Montana, the 
counties where all the Montana Guardsmen reside and where the 
VA health care centers are located. My testimony was to be 
pretty much in support of the report that was put together to 
assess the Montana National Guard, the Reserve components, 
post-deployment health reassessment program. It was brought to 
the forefront when one of our own members, almost 18 months 
after returning, tragically committed suicide. This sad fact is 
occurring across the Nation. This is an examination of our 
program as well as the partnership between DOD and the Federal 
VA, and there are areas where all of us need to change our 
practices and improve. I think that with your help and 
assistance, that we can do that.
    That's pretty much, in the time allowed, what I would make 
the statement on. Please take time to go through the report, 
and I'll be glad to work with your staff. My staff is analyzing 
every recommendation made, and we will be working with your 
staffs on that. There are three authors of this report, State 
Representative Julie French, Mr. Joe Foster, and Mr. Joe 
Underkofler, who are here today.
    I think State Representative, Julie French, would say the 
issue was really brought up because it was families that 
contacted her. Our soldiers don't necessarily contact the chain 
of command and tell them anything. It's the family members who 
contact our family readiness programs and others, say, Hey, 
I've got a problem with my spouse and you need to help me with 
it. It's a partnership all the way through that we've got to 
strengthen.
    Thank you.
    [The prepared statement of General Mosley follows:]
        Prepared Statement of Major General Randall D. Mosley, 
                Adjutant General, Montana National Guard
    Dear Comittee Members:
    Thank you for the opportunity to present testimony to the field 
hearing of the U.S. Senate Committee on Veterans' Affairs in Great 
Falls, Montana concerning the Needs of Veterans in Rural Areas. I am 
the Commanding General of the Montana National Guard, the Director of 
the Montana Department of Military Affairs, and a member of the 
Governor's cabinet. As the Commanding General, I am responsible for the 
medical readiness of the state's National Guard. As Director of the 
Montana Department of Military Affairs, I am a member of the Montana 
Board of Veterans Affairs which is responsible for statewide service to 
veterans.
    The Montana National Guard consists of over 3,700 members who live 
in virtually every corner of the state. Since 2001, over 80 percent 
have been mobilized for Federal active duty; and since release from 
this duty are now eligible for enrollment in the VA health care system.
    The medical readiness and health care of our post-deployment 
Guardsmen are of extreme importance to both the Governor and me. 
Recently, the Montana National Guard's Post-Deployment Health 
Reassessment (PDHRA) program's scope, execution and adequacy were 
brought to the forefront when Montana Army National Guard member, 
Specialist Christopher Dana, tragically committed suicide on March 4, 
2007. Specialist Dana was federally activated as part of the Montana-
based 1-163rd Infantry Battalion, and deployed to Iraq where he served 
honorably in an intense combat environment.
    When the battalion's tour of duty ended in late 2005--after 18 
months away from home--Specialist Dana was rapidly processed through 
Department of Defense demobilization facilities to expedite both his 
return home and reintegration into the civilian environment. This 
expedited approach is standard operational procedure for Reserve 
Component (National Guard and Reserve) units whose tour of duty 
supporting Operation Iraqi Freedom or Operation Enduring Freedom has 
ended.
    However, Chris Dana's suicide--as well as the many others that have 
occurred nationwide in the aftermath of National Guard and Reserve 
combat veterans' return to mainstream civilian life--has prompted 
Montana's critical assessment of the PDHRA program's effectiveness in 
reintegrating combat veterans into civilian society. Active component 
military members that return to a base or fort can readily access the 
installation's mental and physical health services infrastructure. On 
the other hand, Reserve component combat veterans are transitioned very 
rapidly into the civilian environment--an environment that does not 
necessarily understand what the veteran has been through, and does not 
necessarily have readily identifiable or available mental health 
services.
    A task force of mental health professionals, state and Federal 
healthcare personnel, state legislators, and veterans service 
organizations representatives were assembled to review the PDHRA 
process (as mandated by the Department of Defense) and provide 
recommendations to use in improving the overall reintegration and 
reconstitution process of the state's Reserve component military 
members. Their findings and recommendations, contained within the 
attached report, envision a statewide network of education, support 
services, and resources that will meaningfully assist Montana's 
veterans cope with the emotional and mental health issues resulting 
from serving in combat; and who--once home--are expected to smoothly 
reintegrate into a civilian lifestyle.
    The Task Force report validated that the Montana National Guard is 
following the established Department of Defense (DOD) guidance and 
standards for Post Deployment Health Reassessment. However, the report 
points out that the DOD guidance is inadequate to sufficiently support 
Soldiers and Airmen returning from theater operations. Specifically, 
the report lists 10 findings with 16 recommendations suggesting 
corrective action. Listed below are some of the findings and 
recommendations from the report which the Task Force determined impact 
the National Guard, as well as Reserve and Active Component combat 
veterans, in their successful reintegration into the mainstream, 
civilian environment. I have borrowed liberally the verbiage contained 
in the report, especially as it pertains to veteran healthcare.
    A Significant finding found the Post-Deployment Process for 
returning veterans to be failing in many areas, noting that it has not 
been suitably effective nor conducted in an environment that 
facilitates attaining needed information from veterans who may have or 
are developing Post-Traumatic Stress Disorder (PTSD) or Traumatic Brain 
Injury (TBI) conditions. The Task Force noted a number of deficiencies. 
Demobilization station and home station processing is ineffective in 
identifying mental health issues, except for those who self-report, or 
have already been identified during military service. Identification of 
a veteran's need for mental health services is ultimately based upon 
self-reporting. Query and counseling processes supporting self-
reporting are not mandatory, and existing query and health assessment 
processes are not effective in proactively identifying veterans who may 
need assistance. The query and health assessment events are conducted 
only for a finite time frame. When conducted, they are not done in an 
environment that provides sufficient confidentiality--while mitigating 
any stigmatizing impact. Further, the personnel conducting the query or 
health assessment do not necessarily have the type of professional or 
technical training, education or experience needed to adequately 
recognize a Guardsman's emotional or mental health status. Also at 
issue is the effectiveness and suitability of the query or health 
assessment instruments used.
    The onset of emotional or mental health disability symptoms is 
variable and unpredictable. Symptoms may manifest immediately or take 
years, which is problematic for Guardsmen (and other combat veterans) 
who have been discharged and are no longer a member of a military 
organization. Veteran enrollment into the Federal VA healthcare system 
is not automatic, with insufficient command emphasis to ensure this 
action takes place.
    Another finding addresses the fact that veterans are reluctant to 
disclose mental health issues. Several factors lead to this finding; to 
include concern about negative impacts on their employment and career 
(both in the military and civilian sectors), a perceived social stigma 
attached to emotional or mental health conditions or disorders, and a 
lack of knowledge about or sufficient confidence in available mental 
health services. A veteran's reluctance to disclose mental health 
issues is further impacted by a lack of awareness by the general 
public, employers, and veterans' family members regarding the nature of 
mental health conditions; as well as access to and treatment of these 
types of conditions.
    The report also noted a lack of statewide availability of 
counseling resources, particularly in rural areas. Montana is the 
fourth largest state but with fewer than 1 million residents. Many 
parts of the state are without a robust size community capable of 
sustaining medical or mental health professions. The availability of 
these services may not be timely enough or available in needed 
frequency or proximity. Additionally, a specific centralized 
coordination and referral capability does not exist. Counseling 
services that are or may be available do not necessarily know about 
each other. These services include health services offered by the 
Federal VA, Montana Department of Public Health and Human Services, and 
the communities.
    The Task Force also found that National Guard commanders lack 
education on mental health issues, and the organization lacks an 
effective and well-publicized operational standard and policy that 
would support and maximally retain in military service a Guardsman who 
has a diagnosed emotional or mental health condition. In addition, 
veterans service organizations (e.g., American Legion, Disabled 
American Veterans, Veterans of Foreign Wars, Vietnam Veterans of 
America) have posts/chapters located throughout the state and are not 
consistently utilized as a resource to assist in the post-deployment 
needs. The number of Federal VA Vet Centers is limited and needs to be 
expanded to cover rural areas of Montana.
    The Task Force developed sixteen recommendations that would 
markedly improve the post-deployment health of our returning veterans. 
Expanding and enhancing the PDHRA process was viewed as a critical 
component; leading off with completion of an initial PDHRA for 
Guardsmen within 90 days after discharge from active-duty status or 
during the first scheduled National Guard drill period--whichever is 
earlier. Subsequent PDHRAs need to be scheduled and conducted every 6 
months after the initial query or assessment until a two-year time span 
has elapsed. After the 2-year period, the PDHRA process will accompany 
the required Periodic Health Assessment action. This process needs to 
be accomplished for as long as the Soldier or Airman is in the 
military. Expanding the PDHRA process is currently outside the scope 
and provided resources of the DOD program. Providing additional 
resources to the existing program would ensure program enhancements 
such as the use of more comprehensive and effective mental health 
assessment instruments in the PDHRA process, e.g., VA screening 
templates, or other survey instruments such as the Mississippi Scale or 
the Beck Inventory. Two additional enhancements needed are the 
inclusion of a ``face to face'' educational component in the PDHRA 
process during which issues related to mental illness stigma and self-
reporting of mental health symptoms are discussed and a referral of 
Guardsmen who are identified as having mental health issues to 
appropriate mental health professionals.
    Other recommendations included: Mandate and monitor Guardsmen 
enrollment in the VA healthcare system through completion and 
submission of the VA Form 10-10EZ immediately after redeployment. 
Develop and implement a comprehensive training program for command 
leadership and unit personnel that provides information on mental 
health issues such as combat stress, anxiety, depression and traumatic 
brain injury; leadership also needs to be educated on treatment methods 
for these conditions and educated as to available resources. Develop, 
publish and distribute to all National Guard units and individual 
Guardsmen an information guide that contains--at a minimum--civilian 
and Federal VA resources for medical and mental health services and 
care. Provide information to the National Guard chain-of-command and 
all members regarding programs, resources and contact information to be 
used when a unit member self-reports or is identified as needing 
assistance for emotional or mental health conditions; which would also 
be posted in the Montana National Guard's web site. Actively 
participate in the newly authorized Suicide Prevention Program to be 
administered by the Montana Department of Public Health and Human 
Services. Facilitate the development and implementation of increased 
``informal'' support systems such as the ``Vet to Vet'' peer support 
program; and encourage--at both state and unit command levels--a more 
active and mutually supportive relationship with the state's veterans 
service organizations.
    I have tasked my staff to immediately review the Task Force Report 
and develop a strategy which addresses the above outlined findings. 
Some of the corrective actions necessary to better support our veterans 
and to satisfy the Task Force recommendations can be accomplished 
within my authority as Adjutant General. However, some of the 
corrective measures need assistance from your level. I have directed my 
staff to contact and work closely with Montana's Congressional 
Delegation to begin collaborating on effective solutions to better 
serve our Montana Soldiers and Airmen.
    Your continued support of the Nation's veterans is truly 
appreciated.

    [The PDHRA Task Force Report follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    

    Senator Tester. With that suggestion, I'd like to put the 
entire packet in the record of General Mosley.
    Real quickly, and I don't know who can best answer this, so 
I'm just going to let whoever answers, answer it. Dave McLean 
talked about the fact that there were no mental health services 
provided in any of the clinics. Can you tell me why and can you 
tell me when that may change?
    Dr. Hartman. What we have provided in Montana is we use 
contracts through Southeastern Mental Health, what was called 
Golden Triangle and Southwestern Mental Health to provide 
primary mental health care throughout the state of Montana, 
realizing we could never provide providers all over. Their 
notes are entered into our system so that we can monitor the 
progress of those vets being seen from our mental health 
section in Fort Harrison and, if need be, to bring those people 
in for more intensive care.
    We also use tele-medicine in two forms.
    One, we use it for mental health into all of our CBOCs with 
our providers in Helena. Second, there is a program operated 
out of Denver, Colorado, University of Colorado that's 
currently operating in the Lame Deer and Crow reservations, 
soon to operate in Fort Peck, Fort Benton and Rocky Boy, which 
provides tele-mental health counseling.
    Senator Tester. So what you're saying is there is mental 
health services offered at these clinics?
    Dr. Hartman. It's offered through tele-mental health, yes. 
And then also the local health is done with the contract 
providers.
    Senator Tester. OK. Tele-mental health means you're talking 
to somebody over the TV screen; right?
    Dr. Hartman. That's correct.
    Senator Tester. I appreciate that; I don't want to minimize 
that. But when you're talking about somebody who is, as Senator 
Salazar talked about, 17 to 18 percent are coming back with 
TBI, you have 35 percent coming back with PTSD from these 
current conflicts that we're in, we have a situation that 
Travis delineated somewhat that he went through when he came 
back because of the engagements he was in.
    I honestly, my perspective, I'm not an M.D., like I told 
you before, I'm a farmer, so I don't know this stuff. The fact 
is, though, I think you need somebody you can look in the eye 
and develop that personal relationship. And when might that 
happen, what needs to happen to make that happen? And I don't 
mean to minimize the work you're doing. You're doing great 
work.
    Dr. Hartman. I understand that. Let me try to answer that. 
First off is, before anybody is put out on a contract, they are 
evaluated through our mental health program to evaluate to see 
just where they are, because we don't just put anybody into the 
contract program. And so, therefore, that is the first phase. 
Second is that contract program does provide that face-to-face 
relationship with these providers, in addition to, if they need 
tele-mental health. That is in addition to the direct----
    Senator Tester. How does that get initiated?
    Dr. Hartman. That gets initiated by the identification of 
that person needing that care at Fort Harrison, and then they 
are put into the contract program, and they're identified with 
the provider. We, in turn, get the progress notes from that 
provider and we review those on a regular basis to make sure 
there is progress being made.
    Senator Tester. I don't want to work this over too much, I 
just want to tell you that one of the big concerns that I think 
is out there in Congress, as well as with the veterans 
organizations, and I don't want to speak for the VSOs at all, 
but I will just tell you, it's the concern of folks coming 
back, and the transition between active military and the 
civilian isn't being made properly, and we end up with some 
people that need help, either we don't know they need help or, 
you know, they can't get help.
    Dr. Hartman. I agree. And I also would mention that each 
person returning that's identified that comes to us is put 
through a mental health screening when they come back, so we 
try to do that identification.
    Senator Tester. Thank you very much. I will just tell you 
just one thing, and then I'll turn it over, because we do have 
a lack of time here, and I do want to turn it over to Senator 
Baucus. We're going to see if we can get the six bucks written 
off so that doesn't happen.
    Senator Baucus. That six bucks stuck in my mind, too.
    What is the difference between--you mentioned rural and 
highly rural. Is that correct?
    Dr. Hartman. Yes.
    Senator Baucus. What is the effect of that designation, 
what about those counties, what happens to those counties that 
are rural?
    Dr. Hartman. What we try to do----
    Senator Baucus. Very briefly.
    Dr. Hartman. What we try to do for those areas where we 
have the highly rural is we try to utilize all the services 
within the VA's capacity, that is mental tele-health----
    Senator Baucus. Next question, what more is done in highly 
rural counties compared with rural counties?
    Dr. Hartman. It would be the same. The health care that's 
provided is the same, it doesn't matter if you're highly rural 
or rural.
    Senator Baucus. Do you know our entire state is highly 
rural? We have six people per square mile in Montana, our whole 
state is highly rural, and I just urge you to think of Montana 
as being highly rural. And so what is the relevance of being 
defined as highly rural from the VA perspective? So what?
    Dr. Hartman. From the VA perspective, it goes into the fact 
of capacity and what kinds of services we can buy. I think when 
we talk about the issue of rural health, it's not just a VA 
issue, it's a national issue. When we look at trying to provide 
services to veterans----
    Senator Baucus. I'm trying to understand what is the effect 
of being designated highly rural, if any?
    Dr. Hartman. The effect of the designation of highly rural 
goes by distance----
    Senator Baucus. I'm talking about the VISN services that VA 
provides because a county is rural.
    Dr. Hartman. It doesn't change----
    Senator Baucus. So it's irrelevant. I don't think it should 
be irrelevant. I think it should be very relevant, and I think 
it needs to be figured out how to provide the extra services 
highly rural areas like Montana need.
    Dr. Hartman. We'll definitely take that into consideration.
    Senator Baucus. No. Not take into consideration. Do 
something about it. That's a bureaucratic phrase, ``take into 
consideration.'' We want results. Senator Tester and I wrote 
the VA a letter two months ago and got no response, I have it 
in front of me, basically asking about the consequences of 
closing down the Sidney operations and moving to Glendive. And 
I have the letter right here, dated May 15. No response. I just 
frankly find that not good practice when two senators write the 
VA a letter and there is still no response 2 months later.
    Mr. Hartman, I expect a response next week.
    Dr. Hartman. We'll respond next week.
    Senator Baucus. Thank you very much. I
    appreciate that.
    I want to thank General Mosley for all you're doing. I read 
your report, and I think it's really on target. I'm glad you 
explained to us about the BRAC collaboration. There was such 
teamwork in our BRAC presentation, we got it down to the exact 
number of minutes that I had and General Mosley had, and we 
really practiced it, and it made a big, big difference.
    Thank you, General, thank you for being here.
    I know you in the VA are trying. I don't want to be self-
righteous about this. But the point is you, Mr. Hartman, and 
myself, all of us, we're the hired hands, we're the employees, 
we're working, they're our employers, the veterans are. It's up 
to us to go the extra mile to do everything we possibly can do 
to get the job done. I know you agree with that and believe in 
doing that. I'm asking you to, and me, to remind ourselves 
that's why we're here.
    Senator Salazar. I'm just going to make a brief comment, in 
the interest of time, you move forward with VISN 19 and your 
responsibilities there, I just want to remind you that the 
rural issues that we are talking about here have been central 
to us. We worked with your predecessor, Larry Burrough, to try 
to put a focus on the rural issues. And these three senators 
sitting up here are not going to forget at all the importance 
of rural communities. We have three people that have known the 
reality of farming and ranching in rural America. You'll have 
three senators here that are going to be on you all the way to 
make sure we're taking care of the needs of rural vets.
    Dr. Hartman, I enjoyed our conversation on the plane and I 
enjoyed and look forward to working with you. But what I would 
like to do is ask you, I would ask you to provide us an update 
on the implementation efforts with respect to the Office of 
Rural Veterans Affairs. I was talking to Senator Tester this 
morning, and one of the concerns he raised was the fact that 
the office was created by us, signed into law by the President 
some eight months ago, and we haven't yet made the hiring 
decision with respect to who is going to run the office and 
what exactly it is going to do. I know you've talked about it. 
I want you to go deeper, and as you go deeper, I want you to, 
this is a directive, as well, I want you to address the central 
questions that we're talking about here, how is it that we can 
make sure that these vets that are in the highly rural areas 
are in fact receiving the health care that they ought to be 
receiving, including mental health care.
    In response to Senator Baucus's questions, it seemed that 
the distinction between rural and highly rural essentially are 
irrelevant from the perspective that you have. That's our 
point. We can imagine in some of our very rural communities 
where somebody is trying to access mental health, that that 
mental health may not be there. What I want you to do, you're 
relatively new on the job, I want the VA to give us responses 
with respect to how we make this office get up and functioning 
and what it is that we can try to do to improve services.
    Mr. Feeley. I'd like to comment, if I could, for a minute. 
I'd like to see if we could clear up the demographic issue. 
Forty-five percent of the CBOCs are in a defined rural 
community. I think your point is related to the 2 percent or 6 
citizens per square mile, is the frontier component that we 
heard mentioned earlier. I think that's going to be used as a 
criteria to elevate the importance of rural health care, 
because the travel time for six citizens per square mile is 
going to mean they've got a tougher job of getting health care. 
I think we're going to commit to that.
    I want to let you know that the position has been posted 
for rural health care leader. And that, of, course is going to 
shed light--it was posted yesterday. I'm not defending the fact 
that it took 8 months for it to get posted, but it is posted. I 
can say, when that position is hired, it's going to shed light 
on this issue in a very bright way, drive the attention 
forward.
    I think many of the things going on in Network 19 are a 
role model for many areas of the country, and we're going to 
accelerate that effort.
    I also want to raise the question that Senator Tester asked 
about, that I do understand the hands-on element related to 
mental health, but the future of providing a similar standard 
of care for everyone is going to be this technology revolution 
where we'll be sitting at our television set interfacing with 
our physician 300 hundred miles away, talking to the doctor, 
the nurse and the specialist with us all on the same screen.
    And that may sound very ``Star Wars'ish,'' but it's 
actually going on in some places now. And I believe James Floyd 
and I discussed that last night, that there is a laboratory at 
Salt Lake where they're doing these types of things. This is 
the way we're going to manage chronic illness, in particular.
    Senator Salazar. I would ask, we're going to have a new 
Secretary on aboard, but all these issues that we're talking 
about in rural America, the reason this panel is meeting here, 
the reason I'm here this Saturday in Montana as opposed to 
being some 800 miles to the south, is because I care about 
these issues.
    The reason that Senator Baucus and Senator Tester flew 
essentially through all night to be here is because we care 
about these rural issues. So the message we want to give the VA 
is that, for us, these issues are going to be issues that we're 
going to continue to work on, and we want the best results, we 
want results for the rural areas.
    The mental issues, picking up on Senator Tester's point of 
view, Senator Baucus is one of the people in the forefront in 
terms of health care reform for our country. Mental health, I 
think, is harder. Jon Tester is right, you have to be able to 
look people in the eye. I think Travis will tell you that in 
terms of the people he's dealt with.
    Mr. Feeley. I would like to mention there are 4,000 mental 
health recruitments in the VA in the past 15 months because we, 
too, are committed to the same thing you are, which is making 
sure that these veterans returning are getting good care. It's 
an important assignment.
    Senator Baucus. Briefly, too, you know, this term ``rural'' 
is bandied a lot in the Congress and so forth, but I know you 
understand, I want to reinforce the point that there is rural 
and there is rural. I remember a doctor who came before us, he 
said, ``I'm a rural doc.'' He's from Indiana. I did a 
calculation, Indiana is 22 times more dense than Montana, but 
he thought he was a rural doctor. He was not a rural doctor. 
Indiana is very populated.
    We've got special problems here, and I want to drill that 
into you and ask that you address them.
    Thank you.
    Senator Tester. Real quick, and then we'll take a few 
comments. I think tele-medicine has its potential, but I think 
if you throw out tele-medicine and say, we have that area taken 
care of because we have tele-medicine, that's not the way to do 
business.
    We sent people to war, we have to take care of them when 
they get back. I'm not saying you are not taking care of them, 
but I think it has to be a priority; I don't think it's a 
priority now.
    We can now take comments from the audience. It has to be 
quick and concise. I've been to a lot of veterans hearings, I 
know there are stories that can take days. Very well, quickly 
go ahead.
    Mr. Formaz. There is no inpatient mental health as far as 
drug and alcohol treatment in the state of Montana. There are 
107,000 veterans here and no drug or alcohol treatment. You can 
wait 6 months to go out of state. That just is substandard.
    Ms. French. I am Julie French. I am from a county that has 
1.5 persons per square mile. It is our county and my house 
district that you are not being able to serve by van service. 
Hopefully, Glasgow will be considered for a service center. We 
are very, very concerned about the lack of mental health and 
care for our vets. I will say, I believe there is not even a 
psychologist or psychiatrist east of Billings for eastern 
Montana. When you talk about mental health services, we do not 
have a community center, as they talked about, anywhere near 
us, so it is a huge issue. Our vets will not travel 120 to 200 
miles simply to get care. I remind you, it's almost a thousand 
miles from Scobey, Montana roundtrip to Helena, Montana and 
back. It's almost closer to go to Fargo, North Dakota for 
treatment.
    Mr. Brewer. David Brewer. I'm retired military, and the 
comments that I want to throw out at you, the big thing that I 
saw, like Mr. Williams, when I got off active duty, I had in my 
retirement as well as my separation, it was like they were just 
checking me off the books, it wasn't that in-depth. I was told, 
because my last physical was within 5 years of my separation 
and my retirement, I didn't need anything more, so I wasn't 
asked questions either, just like this gentleman over here.
    The other thing I'd like to point out, my medical records 
were sent, I understood, to St. Louis to be transcribed or 
photocopied or whatever. I don't know what happened to the 
original copy, but I kept copies of mine, and when I made my 
attempt to get something processed through the VA, they 
basically told me, send us a copy of your records. And then 
when I did, they lost them, and it took them 6 months or 9 
months, whatever it was, to try and find those records to 
decide whether or not they were going to do anything. Anyway, 
they sent me a comments form within the first 4 months of when 
I first applied. I should have not filled that out because I 
told them how great it was, and I never heard from them again.
    But I guess that would be my comment, that I think the vets 
should be getting the original copy of their VA medical files 
back after they're photocopied. Why throw them away? Mail them 
to the veterans.
    Another thing I want to throw out, there is, use Amtrak.
    Audience Member. I would like to introduce you to Mr. Tome, 
83 years old yesterday. He has a star, he was on Normandy 
Beach. He has post-traumatic stress disorder. I'm his neighbor. 
I've helped these elderly neighbors, friends of mine, try to 
get the medicines that they need. It's ridiculous. He has 
suffered and I've seen his wife suffer, neither one of them can 
drive to Fort Harrison. They're told that it's in the mail. He 
was told a week ago. His wife can explain all this, that his 
medicine would have been there if it was sent Monday. Today is 
Saturday, it's still not there. He needs this daily several 
times a day. This has gone on now since I've known them, 10 
years. This has to be fixed. I'd like you to just speak to his 
wife one second. She can explain a little bit about how she's 
doing. It needs to be addressed.
    Senator Tester. We've got it. We'll deal with it. You've 
got decisionmakers here that are going to deal with it. And the 
bottom line is if we can get them the medicine, the problem is 
solved, at least this problem.
    Audience Member. Travis here has gone through a lot. Rick, 
my brother, passed away from Vietnam post-traumatic stress. 
Families are suffering, too.
    Audience Member. The only thing I have to say, I've been a 
disabled vet for 10 years, I will say that the VA is great but 
they're understaffed, no doctors, lack of doctors. In Great 
Falls, the doctor sees 1,800 patients.
    Audience Member. I'd like to address the mental health 
issue. The VA has had a new program, they're training peer 
counselors. It's a program called Vet-to-Vet, and they're at 
work on it right now. It's not perfect but, like Travis says, 
it's vets talking to other combat vets, talking about things in 
a language that you understand, and it does provide help.
    Senator Tester. Thank you. Right there.
    Audience Member. The transit providers in this state have a 
deep desire and the expertise and the capital resources to help 
and assist our veterans with vehicles, lift vehicles. The only 
thing we are lacking is the collaborative working relationships 
with local VSOs. I would hope that you would help us foster 
those 
relationships.
    Senator Tester. Have you made the offer to the VSOs to see 
if they would be willing to work with you?
    Audience Member. We have been trying and have met basically 
with a stone wall.
    Senator Tester. Go ahead.
    Mr. Harrison. Gabriel Harrison from Montana, and I have two 
issues. They give us a phone number to call them, and I'm from 
the northern part of Montana, I called and they said, this 
phone number is not a working number. The second one, I have 
physical health care provided by local hospitals. I am in what 
they call debt collection right now since it's been 2 years 
since they billed me.
    Audience Member. I want to say something about the mental 
health. One, I have been going to the mental health clinic 
since 1992, I have been sober 24 years and I have not had 
suicidal thoughts for 4\1/2\ years now. The mental health care 
that I have been getting from the VA is excellent, I cannot say 
anything more. But I do agree that we are understaffed, the 
doctors that I get usually have me put on back order, waiting 
for a doctor, because the doctor I had is no longer there.
    Audience Member. I've got nothing but good to say about the 
health care system that we're having here in Montana, but as a 
Native American from Browning, I've been turned down for 
services up there, and I don't think that's right. I know there 
are more Native Americans here that do get turned down.
    Senator Tester. Were you turned down because you're a 
Priority 8; is that why you were turned down?
    Audience Member. They said I had a residence down here and 
up there and I could probably afford it myself, and they were 
trying to send me to the VA system.
    Senator Tester. Back here in the corner.
    Audience Member. Thank you for the opportunity to address 
you today. I hail from Alaska, and I'm here to ask you for your 
help. In Alaska they don't use comprehensive planning or 
assessment in looking at how they even get to a regional 
center, and these regional centers are being addressed 
administratively. I also want to say that sociologically a lot 
of factors have changed, a lot of the role of the spouse in 
helping the vet has changed through divorce laws and whatnot, 
and so I am asking you to make a finding today of whether this 
is a national issue of national security or if this is just 
assisting the districts, because I feel that Congress should 
address the states and tell the states that this is not a state 
issue, this is a Federal issue.
    Senator Tester. Thank you.
    Mr. Kuntz. My name is Matt Kuntz. I'm an Army veteran who 
is also the stepbrother of the soldier who killed himself due 
to PTSD in our treatment of him a couple months ago. And I have 
two points. One is we need to provide PTSD and traumatic brain 
injury care, regardless of whether or not these guys have 
service-connected status. If you're asking for PTSD care or 
traumatic brain injury care, you're injured. And I'm a service-
connected vet myself, and I know firsthand that it's horrible 
going through that process, and I can't imagine doing it for 
PTSD. It's painful, like it was my ankle that was torn away in 
ranger school, it was a rough, bad process. And trying to deal 
with PTSD, we can't have these guys wait for care.
    My other point is I understand the contract counselors, I 
have a lot of vets call me and ask for help, for whatever 
reason, and we need to train these counselors better, 
legitimately train these people because right now we've got 
them, just like was mentioned, that fall asleep, we've also got 
counselors, these guys tell them what happened to them, and the 
things that they did, and the revulsion shows on their face and 
the guys don't go back to counseling after the counselor looks 
at them in that manner. And I wouldn't go back either. So 
you've finally got them in the door to a counselor, so we need 
to make sure these counselors are trained.
    Mr. Covent. I'm Gerry Covent, and I'm a retired military 
member. I want to hit briefly on the closer-to-home clinic 
care. In Great Falls, when they opened up, it was fabulous. I 
didn't have to travel to Helena for health care. When I'd go to 
an appointment, the doctor wanted to see me in 2 months, I'd 
have that appointment. Nowadays, when I go there to get an 
appointment, they send me a letter to tell me when my 
appointment is going to be. If I have 2 months' worth of 
medicine, just like last week, I'm out of medication and still 
haven't received my letter for an appointment.
    I know here in Great Falls they've lost three providers in 
the past year. Now, you have three people instead of five 
giving care. When I go in to see them, I want to mention that, 
but they're really overworked and understaffed.
    Mr. Riccio. My name is Ray Riccio from Molese, Montana. I'd 
like to make a comment about TBI or traumatic brain injury. In 
1990, I received the first state license to operate an adult 
day care center in Missoula. All of my clients were Medicaid 
clients. I was licensed for eight; my full case load was nearly 
a couple dozen people. Ninety percent of my clients were young 
adults with traumatic brain injury. Traumatic brain injury is 
incredible, what I see happening in a country with all of these 
survivors of conflict coming back with PTSD and traumatic brain 
injury, having cared for most of these people for a number of 
years, I was a member of the Montana Brain Injury Association 
and also the National Traumatic Brain Injury Association, there 
is an overwhelming tidal wave that is going to hit us in this 
country, and I really fear for these survivors that are 
returning.
    Senator Tester. Thank you. This will be the last one.
    Mr. Fletcher. I'm Joe Fletcher, and I have the greatest job 
in the world. I am able to work with vets every day of the 
year. One of the greatest problems that we have sometimes is 
working with vets, especially those who have the mental health 
problems.
    Travis, you're a young Iraq veteran, and I'm beginning to 
see them all the time coming back. But one of the biggest 
problems is around 4 o'clock, no phone rings in the Great Falls 
clinic. The only avenue for that vet that is in a crisis 
situation is the local emergency room. Folks, that needs to be 
fixed.
    Senator Tester. Just real quick, I want to thank everybody 
on the panel, I want to thank everyone who came today. Those of 
you folks who did not have an opportunity to speak, write down 
the problem on a piece of paper and fax it to one of my staff 
members.
    Senator Baucus. I want to thank the panelists for being 
here, thank the people from the agencies for being here. There 
is only one way we solve the problem, and that's if we work 
together. Thank you very much.
    (Whereupon, at 2:30 p.m., the Committee was adjourned.)
                            A P P E N D I X

                              ----------                              

  Prepared Statement of Pete Formaz, NCAC-II, LAC, President, Montana 
Association of Alcohol and Drug Abuse Counselors, on Behalf of NAADAC, 
              The Association for Addiction Professionals
    Senator Baucus and Senator Tester, thank you for accepting my 
testimony on this critical challenge facing our Nation. Access to 
addiction treatment for returning veterans is not merely of political 
or professional interest to me; it is deeply personal as well. After 
serving from 1966-1968 for the U.S. Marine Corps in Vietnam, I returned 
home with post-traumatic stress disorder (PTSD) and alcohol and other 
drug addiction. When I asked for help in 1979 at the Veterans 
Administration (VA) hospital in Long Beach, California, I was told my 
addictions were self-inflicted injuries, and I could deal with them on 
my own. PTSD was unknown/unacknowledged by the VA at that time. I 
continued struggling with my addictions, eventually resulting in my 
homelessness. I achieved sobriety, without help from the VA, in 1981 
and so remain today.
    For the last eight years I have been a certified addiction 
counselor, helping treat those with addictions. In 2006, I became 
president of the Montana affiliate of NAADAC, The Association for 
Addiction Professionals, and I currently chair the recently formed 
NAADAC Task Force on Veterans Policy, which will track issues related 
to veterans' access to addiction treatment and make policy 
recommendations. I am submitting this testimony on behalf of NAADAC.
    Both war and the transition home can be traumatic experiences for 
soldiers and veterans. Trauma has been demonstrated to be a significant 
risk factor in substance use. Although anyone can be at risk of 
addiction, veterans with post-traumatic stress disorders are at special 
risk of substance use disorders as many try to ``self-medicate'' with 
alcohol and other drugs. About 75 percent of Vietnam-era veterans with 
PTSD also had diagnosable substance use disorders. Estimates among 
today's veterans are even higher.
    It is important to note that neither PTSD, PTSD-caused substance 
use nor treatment for those recovering from trauma is limited to 
veterans. In New York City after 9/11, civilians and emergency workers 
diagnosed with PTSD were five times more likely to increase their use 
of cigarettes or marijuana compared to those without the diagnosis. In 
Oklahoma City after the 1995 bombing, over 60 percent of people with 
PTSD reported consuming alcohol to help cope. New research continues to 
help us better understand the physiological effects of trauma on the 
brain as it relates to addiction and PTSD.
    Certified addiction services professionals throughout the United 
States are the frontline health care workers who address these trauma-
related substance use disorders. When there is a sudden, increased need 
for counseling, the addiction services workforce rises to the 
challenge. For example, after Hurricanes Katrina and Rita, there were 
increases in substance use. Working with the Substance Abuse and Mental 
Health Services Administration (SAMHSA), NAADAC recruited certified 
addiction professionals to deploy to the Gulf Coast to help compensate 
for the reduced health care infrastructure and increased demand for 
treatment. Over 200 addiction professionals served in the Gulf Coast 
region in the 6 months following the hurricanes. All were certified in 
the latest evidence-based treatment practices, post-traumatic 
counseling and family systems. Some of those counselors are still in 
New Orleans today.
    Today, the population of high-need veterans is not geographically 
concentrated like the displaced citizens of New Orleans. Our Nation 
must reach out to veterans wherever they are. Many areas--including 
rural Montana--do not have anywhere near the VA treatment facilities 
required to meet the need.
    Fortunately, there are already civilian systems in place to provide 
high-quality, evidence-based treatment. There is a national system of 
treatment providers, qualified by state agencies. Veterans and their 
families who are not able to access the VA system for whatever reason 
should be allowed and encouraged to access treatment from civilian 
treatment providers. Our veterans do not have time to wait for a 
parallel VA system to be built up, and there is no reason to expend the 
overhead and startup costs to replicate a system already in place. The 
VA should collaborate with these existing treatment centers and 
professionals whenever possible to fill unmet needs now. The VA should 
eliminate barriers to this common-sense cooperation whenever possible.
    Increased collaboration with existing treatment providers would 
drastically expand veterans' access to treatment. The U.S. military, 
the VA and Congress should consider expanding access to and quality of 
care in other ways as well:

     When screening for PTSD and substance use disorders, the 
military should wait 45-60 days after the servicemen and women have 
returned home. When screenings occur in the field, there is the 
motivation for servicemen and women to minimize their symptoms for fear 
that a finding of PTSD or substance use disorder would require 
treatment in-theater and delay their return home. Whenever possible (by 
cooperating with existing treatment providers), veterans should be able 
to receive treatment in their own communities.
     Everyone providing addiction treatment services should be 
certified in the latest evidence-based practices to ensure the best 
outcomes for clients.
     The psychological effects of rapid troop re-deployment 
should be investigated.
     Health care available to returning National Guardsmen and 
women must be of the same high quality available to other combat 
forces.
     Female soldiers are also on the frontlines more than in 
previous wars, and health care providers must be sensitive to gender-
dependent warning signs and treatment strategies.

    In closing, I want to remind everyone that creating a more 
efficient and effective system of addiction treatment for veterans not 
only affects (or saves) the lives of veterans themselves, but its 
effect ripples out to their spouses, children, employers and 
communities. This should be a national priority.
    This testimony is submitted on behalf of NAADAC, The Association 
for Addiction Professionals. NAADAC is the largest membership 
association serving treatment and prevention counselors, educators and 
other health care professionals specializing in addiction. NAADAC was 
founded in 1972 as the National Association for Alcohol and Drug Abuse 
Counselors and today has 46 state affiliates and 11,000 members around 
the world.
                                 ______
                                 
                         Montana Mental Health Association,
                                                     July 19, 2007.
Hon. Jon Tester
204 Russell Senate Office Building,
Washington, DC.
    Dear Senator Tester: Thank you for calling Saturday's field hearing 
in Montana on veterans' health. This is a vitally important issue, and 
the Montana Mental Health Association applauds your desire to learn 
more about the healthcare needs of veterans--particularly in the area 
of mental health.
    You will hear firsthand from a number of veterans and their 
families on Saturday who will share with you their struggles to access 
care for themselves and their loved ones. My office has been involved 
with some of these cases, since we have a toll-free resource and 
referral number. It is a challenge for our office to help Montanans--
veterans or not--get the mental health care they need. Fifty out of 
Montana's fifty-six counties are federally designated mental health 
professional shortage areas. A scarcity of providers and the high cost 
of medication and services limit access for all Montanans. For veterans 
and guardsmen, it can be even tougher, due to requirements to use in-
network providers. Montana has the second highest rate of suicide in 
the country, and as National Guardsman Chris Dana's death this spring 
demonstrated, combat-related mental health problems, the difficulty 
that many still have in talking about mental health problems (their own 
or those of their loved ones) and the challenges of negotiating the 
system are contributing to this grim statistic.
    As a former state senator, you would have been proud of the efforts 
made by the Montana legislature to increase funding for mental health 
care for low income Montanans and suicide prevention. The legislature 
also increased funding for mental health services for those returning 
to the community from Montana's prisons. It is time for the Federal 
Government to step up to the plate by improving mental health services 
for those returning to their communities after serving our country in 
wartime, and their families.
    There are a number of ways the Federal Government can do this. Here 
are a few:

     Increase the number of providers who can care for our vets 
and the guardsmen who served in Iraq and Afghanistan. In a frontier 
state like Montana, this is especially important since providers can be 
few and far between.
     Increase funding for both crisis and ongoing mental health 
services so that vets don't face waiting lists or have their numbers of 
visits limited.
     Admit that the experience of going to war can and often 
does result in serious emotional and mental health problems, and help 
make the general public aware of this, too, so that we all can better 
help these returning heroes. Misunderstandings about the biological 
nature of mental health problems and that people can and do recover 
from them; the mistaken belief that depression and other mental 
illnesses mean you have ``weak character'' and the misconception that 
you can just ``tough it out'' or ``act happy to be happy,'' are 
barriers to people getting the services they need. The Montana Mental 
Health Association ran over $20,000 worth of radio ads in the past year 
aimed at military families and returning veterans, and we plan to 
continue our outreach efforts. But a broader effort, supported by the 
Federal Government and the military itself, is also needed.
     Increase funding for research on post traumatic stress 
disorder and other mental health issues. There's a lot we still don't 
know about why some individuals are more prone to develop PTSD, 
depression or substance abuse disorders. Without this knowledge our 
ability to develop medications and other treatment therapies, or to 
effectively reduce the numbers who become affected, is limited. 
Increase in funding to national research institutes is critical to our 
successfully treating and preventing mental health and substance abuse 
problems.
     Recognize and support the role of military families. 
Spouses, parents and children left behind when soldiers are deployed 
often experience high levels of stress, which can result in depression, 
anxiety, and substance abuse. When a deployed soldier returns, his or 
her family may find the readjustment equally or even more stressful, 
particularly if the veteran has developed health problems that might 
include PTSD, a traumatic brain injury, or disabling injury. If these 
families are to survive to help support our vets, they must be provided 
more services as well.

    Once again, thank you, Senator Tester, for shining a light on this 
very important issue. And thanks also to Senators Baucus and Salazar 
for attending the hearing and lending their support for improved health 
services for our veterans. The Montana Mental Health Association stands 
ready to partner with you and others to improve the mental health of 
our veterans and their families. Please contact me at 406-587-7774 or 
[email protected] if you would like further information on 
mental health, our activities in Montana, and how we might assist in 
this critically important effort.
            All best wishes,
                                           Tracy Velazquez,
                                                Executive Director.

  

                                  
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