[Senate Hearing 110-278] [From the U.S. Government Publishing Office] S. Hrg. 110-278 HEALTH CARE FOR ALASKA NATIVE VETERANS RETURNING FROM KUWAIT AND IRAQ AND OTHER NATIVE VETERANS LIVING IN ALASKA NATIVE VILLAGES ======================================================================= FIELD HEARING before the COMMITTEE ON INDIAN AFFAIRS UNITED STATES SENATE ONE HUNDRED TENTH CONGRESS FIRST SESSION __________ NOVEMBER 30, 2007 __________ Printed for the use of the Committee on Indian Affairs U.S. GOVERNMENT PRINTING OFFICE 40-268 PDF WASHINGTON DC: 2008 --------------------------------------------------------------------- For sale by the Superintendent of Documents, U.S. Government Printing Office Internet: bookstore.gpo.gov Phone: toll free (866)512-1800 DC area (202)512-1800 Fax: (202) 512-2250 Mail Stop SSOP, Washington, DC 20402-0001 COMMITTEE ON INDIAN AFFAIRS BYRON L. DORGAN, North Dakota, Chairman LISA MURKOWSKI, Alaska, Vice Chairman DANIEL K. INOUYE, Hawaii JOHN McCAIN, Arizona KENT CONRAD, North Dakota TOM COBURN, M.D., Oklahoma DANIEL K. AKAKA, Hawaii JOHN BARRASSO, Wyoming TIM JOHNSON, South Dakota PETE V. DOMENICI, New Mexico MARIA CANTWELL, Washington GORDON H. SMITH, Oregon CLAIRE McCASKILL, Missouri RICHARD BURR, North Carolina JON TESTER, Montana Sara G. Garland, Majority Staff Director David A. Mullon, Jr., Minority Staff Director C O N T E N T S ---------- Page Hearing held on November 30, 2007................................ 1 Statement of Senator Murkowski................................... 1 Witnesses Angapak, Sr., Nelson N., Vice President, Alaska Federation of Natives; accompanied by Reverend William Nicholson, Pastor, Anchorage Moravian Church...................................... 28 Prepared statement with attachments.......................... 30 Davidson, Valerie, Senior Director, Legal and Intergovernmental Affairs, Alaska Native Tribal Health Consortium................ 38 Prepared statement........................................... 44 Katkus, Brigadier General Thomas, Commander, Alaska Army National Guard, accompanied by: Lieutenant Colonel Dave Osborn, Commander, Third Battalion; First Sergeant John Flynn; and Sergeant First Class Jeffery Kowchee, Alaska Army National Guard.......................................................... 5 Prepared statement........................................... 7 Spector, Alexander, Director, Alaska VA Healthcare System and Regional Office................................................ 22 Prepared statement........................................... 24 Appendix Angapak, Sr., Nelson N., Vice President, Alaska Federation of Natives, supplementary information............................. 68 Dorgan, Hon. Byron L., U.S. Senator from North Dakota, prepared statement...................................................... 67 HEALTH CARE FOR ALASKA NATIVE VETERANS RETURNING FROM KUWAIT AND IRAQ AND OTHER NATIVE VETERANS LIVING IN ALASKA NATIVE VILLAGES ---------- FRIDAY, NOVEMBER 30, 2007 U.S. Senate, Committee on Indian Affairs, Anchorage, AK. The Committee met, pursuant to notice, at 9:30 a.m. at the Egan Convention Center in Anchorage, Alaska, Hon. Lisa Murkowski, Vice Chairman of the Committee, presiding. OPENING STATEMENT OF HON. LISA MURKOWSKI, U.S. SENATOR FROM ALASKA Senator Murkowski. Good morning, and as the Vice Chairman of the Senate Committee on Indian Affairs, it is an honor, it is a privilege to be with you this morning and to gavel this field hearing in. I bring you greetings from the Chairman of the Indian Affairs Committee, Senator Byron Dorgan. He is from the State of North Dakota. Senator Dorgan is not able to join us here this morning. He extends his apologies, but he has submitted a statement that will be included into the record. I think it is fair to say that it is a very bipartisan committee. We work in a very cooperative fashion. I have a good partnership with the Chairman of the Committee, Senator Dorgan. I appreciate the effort that his staff has made, as well as my staff to make the hearing this morning possible. This morning, up front, I have with me David Mullon. David serves as the Republican Staff Director for the Senate Committee on Indian Affairs. David comes to us from Oklahoma. He is a member of the Cherokee Nation. I would also like to take the opportunity this morning to introduce a new addition to my staff, I believe a very great addition to my staff of the Indian Affairs Committee, Jerry Moses. He is an Athabascan Indian, grew up in Fairbanks. His family is from Stevens Village. He holds a law degree from the University of Arizona. He has a Master's Degree in Public Health from Harvard University. Jerry has most recently come to us from the IHS, Indian Health Service. We are very pleased to welcome him to the Committee staff. He has a great deal to offer us and I hope you will make that connection and know that on the Committee you have got somebody who is very focused on the healthcare issues of our Alaska Natives. Before I offer my opening statement this morning, I want to just address a few housekeeping details. This field hearing is going to be conducted in the same manner that we conduct our hearings in Washington, D.C. We have invited two panels of witnesses who will speak to the topic of the hearing this morning. We will go down the line. We will hear from each of the individual witnesses. Each one of those witnesses has prepared a statement. I do believe the statements are all out on the front table there. We have asked that the witnesses summarize their prepared statements. When they have finished their statements, I will then have some questions for them and we will then conclude the hearing. It is also the practice of the Senate Indian Affairs Committee to accept written statements, written comments from all who wish to submit them. The statements that we receive will be made part of the Committee record. We will hold the record open until December 14th for anyone who wishes to submit a statement. If at all possible, we ask that the statements and comments be submitted by e-mail. The e-mail address is [email protected]. Again, that address is [email protected]. I will give you this address again at the conclusion of the hearing. If you can't e-mail your comments, you can provide written comments to either Jerry or to David. They will tell you where to mail the testimony. At this time, I would like to take the opportunity to introduce our invited witnesses this morning. The first panel consists of members of our National Guard. We have Brigadier General Tom Katkus. He is the commander of the Alaska Army National Guard. He enlisted in the Alaska National Guard in October of 1977. This was about 30 years ago. He was commissioned as a Second Lieutenant in 1980, rose through the officer ranks to assume command of the Army Guard in April of 2007. In his civilian life, General Katkus was an Anchorage Police Officer for 21 years, retiring from the force in December of 2000. We are very pleased to have you with us this morning, General. We also have Lieutenant Colonel Dave Osborn. He is the commander of the Third Battalion. Dave is joined by two of his NCOs. We have First Sergeant John Flynn from Bethel and Sergeant First Class Jeffery Kowchee, originally from White Mountain, also Bethel and I believe currently residing in Wasilla. Gentleman, we are very pleased to have you with us this morning. I would invite you to be seated. I will introduce the next panel and offer some preliminary comments and then we will get to your statements. The second panel that we have this morning is comprised of Mr. Alex Spector. He is the Director of the Alaska VA Healthcare System and Regional Office. He is responsible for VA healthcare delivery within the state of Alaska and the VA clinic here in Anchorage, also the joint venture hospital on Elmendorf and the outpatient clinics in Fairbanks and Kenai. We welcome you, Mr. Spector. We also have on the second panel, Mr. Nelson Angapak. He is the Vice President of Alaska Federation of Natives. He serves on the VA's National Advisory Committee on Minority Veterans. Nelson served admirably in the U.S. Army from 1969 to 1971. He has advocated for the interest of our Native Veterans for well over three decades now and your service is greatly appreciated. We are pleased to have you with us this morning, Nelson. Nelson is also joined by Reverend William Nicholson who is the pastor of the Anchorage Moravian Church. Reverend Nicholson originally comes to us from Dillingham. He joined the Alaska National Guard as a Chaplain. He is attached to the Second Scout Battalion, the 29th Infantry, but I also understand that you have ministered to the troops from the 1148th Field Artillery of the Idaho National Guard during their service in Iraq in 2005. We appreciate your service and very pleased that you will be able to address us this morning. The final member of the second panel is Valerie Davidson. Valerie is the Senior Director, Legal and Intergovernmental Affairs for the Alaska Native Tribal Health Consortium. ANTHC is celebrating their 10th anniversary this year. Valerie received her law degree from the University of New Mexico Law School, regarded as among the best, certainly among the best and brightest of our Alaska Native community's cadre of emerging leaders. We are very proud of you, Valerie, for all of the work that you do and pleased that you are with us this morning. Before we go to hearing from our panels, I want to offer a few opening comments of my own. Before I do that, I see that we are already maxed out with our chairs. I apologize for that. With the Provider's Conference going on and everything happening, we got the room that we could get. I don't know whether there are additional chairs that we can squeeze in on the back, but I am more than happy to have chairs be put along the side up front so that those folks in the back don't have to stand for the next couple of hours. So please, if you need to rearrange things, you are not disturbing us up here by doing so. We acknowledge that the month of November is designated as the National American Indian Heritage month. Today happens to be the last day of American Indian Heritage month. We also acknowledge November as being the month that we celebrate and recognize Veteran's Day. So it is particularly appropriate that during this month that the Senate Committee on Indian Affairs reflects on the contributions of our Native peoples to the defense of this great nation. It is fitting that we renew our commitment to ensure that the promises that are made to our Veterans, particularly our Native Veterans, are promises that are kept. The Department of Defense has noted that Native Americans have the highest rate of service per capita when compared to other groups of Americans. Now, in many respects, American Indians and Alaska Natives are no different from others who volunteer for military service, but they do, according to the studies that are conducted for the Defense Department, they do have distinct cultural values which drive them to serve their country and these values are summed up in the phrase proud warrior tradition. The phrase proud warrior tradition embodies values such as strength, honor, pride, devotion and wisdom. These are the values that have earned organizations like the Navajo Code Talkers and the Native Scouts of our own Alaska Territorial Guard places of great respect in American history. In his proclamation designating November of 2007 as National American Indian Heritage month, President Bush extended our nation's gratitude to the American Indians and the Alaska Natives who serve in our nation's military and work to extend the blessings of liberty around the world. Like other Americans, our Native people have given the ultimate sacrifice for their service. We find reports that to date, 40 American Indians and Alaska Natives have given their lives in Iraq. At this time, we think about those who have served, who have given that ultimate sacrifice. Robert Blohm of Kenai, he was a descendant of Cook Inlet Region shareholders. He gave his life as a member of the 425 Airborne out of Ft. Rich back in 2006. Also, a young man I had an opportunity to meet at Walter Reed, Latseen Benson, a Tlingit, who lost both of his legs in Iraq while serving in the 101st Airborne. As I mentioned, I met him at Walter Reed. The next time he was back here in the state, it was quite triumphantly when he competed in the 2006 Veteran's National Wheelchair Games. We also have Staff Sergeant William F. Brown, an Inupiat Eskimo from Barrow. He lost his life while serving with the Third Battalion, the 297th Infantry Brigade with the Alaska National Guard. Also Staff Sergeant Brown along with Sergeant First Class George Dauma of Fairbanks, who were both killed in 2006 when their Humvee was struck by a tractor trailer during training maneuvers near Camp Shelby. The focus of the hearing today is on the soldiers of the Third Battalion, the 297th Infantry of our Alaska National Guard who just recently returned from their year's service in Kuwait and Southern Iraq. 580 soldiers of the 3-297th came from all parts of the state. They represented, we understand, 81 communities throughout Alaska. They include substantial numbers of Alaska Natives and other residents of the Bush communities of rural Alaska. Now, we are blessed. We are blessed that the members of the 3-297 did not suffer any casualties during their year of service overseas, but don't believe for a minute that this was a picnic over there. This unit conducted routine security, route security operations in full body armor in 140-degree heat. Lieutenant Colonel Dave Osborn, who commands the 3-297th said that unit had a number of IED incidents in their area of operations. Fortunately, they didn't get hit, but again, it was a difficult situation. I was very privileged to be able to travel to Camp Shelby in Mississippi to see the members of the 3-297th, to see them off in October of 2006. I was equally privileged to be able to welcome them back home this past October. During this preceding year, I have conducted many meetings, many hours of meetings with officials of the VA, the Alaska National Guard, the Alaska Federation of Natives, our Alaska Native Healthcare Delivery System, to ensure that the healthcare needs of our returning guardsmen, who may live in our Native Villages of rural Alaska, may live off the road system, that the system is adequate, that the system meets the healthcare needs not only of those who live in our hub communities, but those who live in other parts of the state as well. The Veterans' Administration and the Alaska Department of Military and Veterans' Affairs have entered into a Memorandum of Understanding on how each will address the needs of our returning Guard members. In that Memorandum of Understanding, in the preamble, it provides that the growing number of Veterans returning to rural Alaska from mobilizations in support of the global war on terror necessitates a comprehensive and a practical approach toward improving access to the full spectrum of Veterans' benefits with an emphasis on healthcare. It is recognized that a combined effort will augment the ongoing comprehensive effort to ensure military service members and their families are honored for their valuable and honorable service to our country. Contained within that Memorandum of Understanding is a provision for a seamless transition. We want to know that there is a transition that does work, that does provide for the needs of those who have so honorably served. Now that the members of the 3-297 are home, it is time to put that plan to care for them as Veterans on the record, to inquire whether those plans are adequate to address the need and to ensure that the plans are going to be faithfully carried out. So that is truly the purpose of this morning's hearings. Again, I thank the witnesses for your attendance and your testimony today and with that, I would like to begin hearing from the witnesses. We do understand that your written testimony has been provided so anything that you can share above and beyond is equally appreciated, and with that, General Katkus, we will begin with you. Thank you and good morning. STATEMENT OF BRIGADIER GENERAL THOMAS KATKUS, COMMANDER, ALASKA ARMY NATIONAL GUARD, ACCOMPANIED BY: LIEUTENANT COLONEL DAVE OSBORN, COMMANDER, THIRD BATTALION; FIRST SERGEANT JOHN FLYNN; AND SERGEANT FIRST CLASS JEFFERY KOWCHEE, ALASKA ARMY NATIONAL GUARD Brigadier General Katkus. Good morning. I am Brigadier General Tom Katkus. I am the Commander of the Alaska Army National Guard speaking to you today on behalf of Adjutant General of Alaska, Major General Craig Campbell. I am grateful for this opportunity to speak with you regarding the access and delivery of benefits and services to members of the Alaska National Guard and their families living in Native Villages throughout rural Alaska. Native members make up 17 percent of the Alaska Army National Guard. In the last 45 days, the Alaska Army National Guard demobilized the largest group of soldiers from active duty since World War II. We are welcoming back hundreds of soldiers and airmen who have faithfully and voluntarily served this country in a time of war. As we send them home to Villages across Alaska, we want to ensure necessary assistance and medical care is both available and accessible for these returning heroes. With so many only recently returned, we have yet to feel the full impact of the demands on this system. We are closely monitoring the support that our soldiers receive. Our soldiers are predominantly stationed in the Kuwait area of operation. This is often confused with being a relatively safe assignment. However, two of these companies work daily in Southern Iraq providing route security, personal security and traffic control. Others were first responders to frequent traffic accidents, both minor and catastrophic, outside of the wire, vehicle-borne IEDs were a daily threat for these soldiers. Approximately 15 percent of the 580 soldiers were from rural Alaska. In anticipation of many of the challenges these soldiers would face upon returning to Alaska, the Alaska Veterans' Affairs Healthcare System and Regional Office, the Anchorage Veterans' Bureau Benefit Administration and the Alaska Department of Military and Veterans' Affairs signed the memorandum that you just noted on September 12, 2007. The MOU does define the mutually agreed upon requirements, expectations and obligations of organizations to meet the needs of our soldiers as they return home. This was an initial step in initiating a comprehensive and practical approach toward improving access to the full spectrum of Veteran benefits while emphasizing healthcare. Some program initiatives also include beyond this, the Home Station Reunion and Reitegration Workshop for returning Veterans. That program dictates that within 90 to 180 days of returning from mobilizations, that the National Guard conduct a workshop and this workshop will coincide with the Post Deployment Health Reassessments where soldiers and individual cases are reviewed and we provide the opportunity to enroll in the VA system. We understand our combat Veterans will need continuing transition assistance beyond this reintegration. We have established a multi-disciplinary team which visits remote Alaska for ensuring continued availability of services and the successful reintegration of Veterans into the communities. This Mobile Outreach Team's goal is to make sure that a visit is conducted within 12 months after the unit's return from the combat zone in the respective battalion areas to include Bethel, Nome and Juneau. The National Guard Bureau has initiated several programs to support soldiers and their families. They have assisted in funding a Transition Assistance Advisor who provides information and advocates Entitlements and Benefits for the soldiers and their families. We also have two Military Family Life Consultants. These professionals are able to travel to all locations for individual and family counseling. This is a free program to all members of the National Guard. Additionally, we are getting two other full-time counselors that will be located in Fairbanks and Anchorage areas. They will be available in the community for easy access. Our Family Programs Unit is a team of over 25 people ready to provide help to families, whether it is direct assistance, counseling or meeting financial needs. There are various services and programs available for all ages under the Family Program's umbrella. Additionally, our chaplains are available for travel throughout the state to provide training and assistance as needed. A Troop Support Team consisting of numerous Veterans Service Organizations have joined together to build a comprehensive plan to support our soldiers and family members. Specifically, their first application was traveling to Camp Shelby and ensuring that our soldiers were briefed on benefits and processes to successfully navigate this very complicated system. According to the members at Camp Shelby, Alaska was the only state to do this. Approximately 54 soldiers remain in the Warrior Transition Unit today. 37 of those are from specifically the 3rd Battalion. We, in Alaska, have more significant challenges than other states. However, we are working diligently to make sure our program is supplemented through the National Guard Bureau Programs and that no soldier gets left behind. We stand ready to assist our soldiers with access to the benefits they are entitled. I highly encourage the VA and the Native Health System to continue to partner together to provide ready access to those in rural areas. Transportation, travel expenses, access to facilities and the lack of understanding of the various cultural issues are hurdles which must be overcome. We will continue to help our soldiers. However, there is a tremendous shortfall between the benefits earned and current access for our rural soldiers. I would like to thank Senator Murkowski for this opportunity to appear before this Committee. Thank you, ma'am. [The prepared statement of Brigadier General Katkus follows:] Prepared Statement of Brigadier General Thomas Katkus, Commander, Alaska Army National Guard Good afternoon, I am Brigadier General Thomas Katkus, Commander of the Alaska Army National Guard, speaking to you today on behalf of the Adjutant General of Alaska, Major General Craig Campbell. I am grateful for this opportunity to speak with you regarding the access and delivery of benefits and services to members of the Alaska National Guard and their families living in native villages throughout rural Alaska. Native members make up 17 percent of Alaska Army National Guard. In the last 45 days, the Alaska Army National Guard demobilized the largest group of Soldiers from active duty since World War II. We are welcoming back hundreds of Soldiers and Airmen who have faithfully and voluntarily served this country in time of war. As we send them home to villages all across Alaska, we want to ensure necessary assistance and medical care is both available and accessible for these returning Heroes. With so many only recently returned, we have yet to feel the full impact of the demands on the system. We are closely monitoring the support our Soldiers receive. Our Soldiers were predominantly stationed in the Kuwait Area of Operation (AOR). This is often confused with being a relatively safe assignment. However, two of these companies worked daily in Southern Iraq, providing route security, personnel security, and traffic control. Others were first responders to frequent traffic accidents, both minor and catastrophic, outside the wire all the while the stress of vehicle borne IEDs was a daily threat for all the Soldiers. Approximately 15 percent of these 575 Soldiers were from rural Alaska. In anticipation of the many challenges these Soldiers would face upon returning to Alaska, the Alaska Veterans Affairs Healthcare System and Regional Office, the Anchorage Veterans Benefits Administration, and the Alaska Department of Military and Veterans Affairs signed a Memorandum of Understanding on 12 September 2007. The MOU defines the mutually agreed upon requirements, expectations, and obligations of the organizations to meet the needs of our Veteran reservists as they return home. This was an initial step in initiating a comprehensive and practical approach towards improving access to the full spectrum of Veteran benefits while emphasizing healthcare. Some program initiatives include a Home Station Reunion and Reintegration Workshop for returning Veterans. Within 90-180 days of returning from a mobilization, we conduct this workshop for our Veterans. This workshop will coincide with the Post Deployment Health Reassessments where the Soldiers individual case is reviewed and we provide the opportunity to enroll in the VA system. We understand our combat Veterans will need continuing transition assistance beyond the reintegration. We have established a multi- disciplinary team which visits remote Alaska for ensuring continued availability of services and the successful reintegration of Veterans into the communities. A Mobile Outreach Team goal is that a visit will be conducted within 12 months after a unit's return from a combat zone at their respective Battalion Headquarters in Bethel, Nome or Juneau. The National Guard Bureau has initiated several programs to support Soldiers and their families. They have assisted in funding a Transition Assistance Advisor, who provides information and advocates Entitlements and Benefits for the Soldiers and their families. We also have two Military Family Life Consultants. These professionals are able to travel to all locations for individual and family counseling. This is a free program to all members of the National Guard. Additionally we are getting two additional full time counselors that will be located in the Fairbanks and Anchorage areas. They will be available in the community for ease of access. Our Family Programs unit is a team of over of 25 people ready to provide help to the families, whether it is direct assistance, counseling, or meeting financial needs. There are various services and programs available for all ages under the family programs umbrella. Our chaplains are available to travel throughout the state to provide training and assistance as needed. The Troop Support Team consisting of numerous Veterans Service Organizations have teamed together to build a comprehensive plan of support to our Soldiers and family members. Specifically they traveled to Camp Shelby and ensured our Soldiers were briefed on benefits and processes to successfully navigate this complicated system. (According to Camp Shelby personnel, Alaska is the only state to do this.) The Soldiers were provided a health questionnaire which exposed various issues. Approximately 54 Soldiers remain in a Warrior Transition Unit today, 37 from 3rd Battalion. We in Alaska have more significant challenges than other states have, however, we are working diligently to make sure our program is supplemented through the National Guard Bureau Programs and that no Soldier gets left behind. We stand ready to assist our Soldiers with access to the benefits they are entitled. I highly encourage the VA and the Native Health System to continue to partner together to provide ready access to those in rural areas. Transportation, travel expenses, access to facilities, and lack of understanding of cultural issues are hurdles which must be overcome. We will continue to help our Soldiers. However, there is tremendous shortfall between benefits earned and current access for our rural Soldiers. I would like to thank Senator Murkowski for this opportunity to appear before this Committee. Senator Murkowski. Thank you, General. Gentlemen, I don't know whether you would like to add a prepared comment or whether your preference is to take questions from me, but if you have statements that you would like included, this is certainly the time to present them. First Sergeant Flynn. Ma'am, thank you. [Speaking Native language.] Hello, my name is John Flynn. There are seven talking points I would like to bring out. First, history is father--my father, two uncles, three brothers were in the--either the Territorial Guard or part of the National Guard and currently I am the only one in the service right now. Education; this is the most important issue. We, the National Guard needs to educate our soldiers on a VA entitlement. VA must educate the Native health providers. Native health providers must be able to recognize the VA claims. Not all soldiers, especially Natives, understand the benefits that are entitled to them being in the remote areas. It is hard for us to understand what benefits are available to us. Travel; with the travels or the airfares sky rocketing in the rural areas, it--most individuals who do not have jobs need to come up with at least $1,000 to travel into Bethel or into Anchorage for VA. This includes airfare, hotel, meals and transportation. Healthcare or health aid versus doctors' assessments; health aides in the Villages are eyes and ears for the doctors in the hub areas. Health aides assess the individual, then calls the doctor to determine if it is a necessity for an individual to travel to the hub areas. Then the doctor decides if the individual needs more care then sends him into the hub areas for screening or extra care, too soon to tell. The post traumatic health reassessment, right now it is too early to tell--see if the soldiers that were in the theater (ph) have problems. It would take up to four to six months to see if an individual has any problem or any medical issues. Seventy-five percent of the YK Delta that was deployed to the theater are in the average age of 28 or younger. These young soldiers have like--or I'm sorry, these young soldiers will not say that if they have post traumatic in other words, they suck it up. Our culture; Native heritage is like most Natives are willing to bend backwards to help others, but will not stand up for themselves to ask for help and lastly, ma'am, I would like to thank you for giving the opportunity to speak. [Speaking Native language.] Senator Murkowski. First Sergeant Flynn, thank you for your comments. Thank you for your service. First Sergeant Flynn. Thank you. Senator Murkowski. I appreciate it so much. Lieutenant Colonel Osborn. Sergeant First Class Kowchee. Sergeant First Class Kowchee. [Speaking Native language.] My name is Jeff Kowchee. I am originally from White Mountain as you know. Good morning, Vice Chairman. Good morning, honorable members of the U.S. Senate Committee on Indian Affairs. I appreciate this opportunity for me to talk. I am currently on active duty, active Guard Reserve, and I am presently assigned to the Warrior Transition Unit on Fort Richardson or otherwise known as WTU. WTU is a unit in which soldiers are placed to focus on resolving their medical issues. We, the soldiers, comprise of various units and various Villages and towns across Alaska and Alaska military bases. I have returned from my 15-month deployment in support of Operation Iraqi Freedom. I am here to discuss my knowledge and experience with the VA and the VA benefits in the rural areas. Prior to the deployment, I had not heard very much about the VA and the VA benefits. Basically, my experience with the VA is Veterans calling the Bethel National Guard office requesting information for the VA such as phone numbers, addresses, locations and, you know, what benefits do they offer of which I was able to find information and pass it onto them. Pretty much, that is the extent of my experience with the VA. As for information, I have seen a few brief handouts about the VA, but other than that, that is about it. Now that I have had the opportunity to work with a regular Army unit in Ft. Richardson, I have gained a lot of knowledge about the VA and the WTU has mandatory briefings and classes that we are required to attend and the VA briefing was one of them. Within the two-hour briefing that I had over there, it was--I became somewhat aware of the steps to take to enroll into the VA once I decided to get out. It was a very excellent briefing and I was not aware that there were so manyh steps to take to enroll and see about getting the VA benefits. I have not attended or I haven't heard this type of briefing before and I'm not sure and I don't think that there is a briefing like that anywhere beyond Anchorage or Fairbanks, you know, in the rural areas. I know this briefing and information would greatly enhance the knowledge out there for those soldiers, those Veterans over in the rural areas. This briefing that I have experienced has not been the same at all for the briefing here in the Anchorage bowl area that is offered to the soldiers and Veterans and also out there to the soldiers in the Villages and Veterans. Aside from these notes on my way up here, I have--of course there is a conference going on down there, downstairs, I ran into four Veterans. One is retired. Three had been separated, they are no longer members of Alaska National Guard. They were from Teller, Kwinhagak, Tuksuk Bay and Nunapitchuk. These four soldiers or, you know, Veterans, I had asked if, you know, what do they know about the VA? They said not very much. I asked them a second question. Okay, do you know what kinds of benefits would be offered if you were qualified? They said no. So this information about the VA and the briefing that I have seen, it would benefit the rural areas greatly and it would be very helpful to those Veterans, whether it is a Korean Veteran, Vietnam vets, score four (ph) vets, or OIF Veterans. I would encourage that any of the Veterans that may be hearing this testimony now to reach out to the VA to see what they possibly may be allowed as a benefit and I would encourage that the VA, you know, reach or provide the same information that is available here to the rural areas as well. Thank you again for allowing me to take this opportunity to discuss this. Thank you very much. Senator Murkowski. Thank you, Sergeant First Class Kowchee, I appreciate it and I appreciate the suggestions and I will follow-up with a specific question to you on that. Lieutenant Osborn. Lieutenant Colonel Osborn. That is all we have, ma'am. Senator Murkowski. Thank you. Let me ask you then, and I think I will start with you, Sergeant Kowchee, yesterday when I visited the WTU, you had a suggestion that perhaps one way that we can do better in getting the information out to our Veterans about the benefits that are available is to have a level of outreach and the VA does have some outreach, but we know that Alaska is big and our Villages are spread far and wide, but we also appreciate that sometimes the messenger that is best isn't necessarily the individual that works in the Anchorage office who comes into the Village and says I am here for two hours. What questions do you have? Oftentimes the way that we get the message through is through the right messenger. Do you have any suggestions as to how we can do better in networking with those Veterans through using other Alaska Native Veterans in conjunction with the VA? Sergeant First Class Kowchee. Yes, ma'am. As we discussed briefly yesterday, I did make the recommendation that we do allow soldiers such as First Sergeant Flynn and myself and other leaders from certain areas have the same briefing or the same information to them and brought along with them so when they go back to Teller, Nunapitchuk, Brevig or Chefornak, that these leaders or these soldiers, you know, capturing this data, capturing this knowledge, capturing this briefing that I've seen, bring it along with them from here on out there to the soldiers that are currently Alaska National Guard members, having that information available to them so they have this knowledge about what is available to them. This would be probably a quick fix for getting information out, you know, which I would recommend and perhaps the VA office actually going out there and extending, you know, this knowledge, this information to other service members who are Veterans from the Marine Corps or Coast Guard. Senator Murkowski. And of course, the challenge is just as you have described from your encounter down in the main hall here. We have Veterans all over the state that once they have separated, once they have gone home, we lose them and the ability to get the information about the benefits that are available is oftentimes just lost and I know that Mr. Angapak has been working on this for years trying to figure out how we can better facilitate that level of communication and to have an Alaska Native Veteran liaison that really has the ability to get out and get the information into all of our Villages where we have so many Veterans. We have not been successful with that yet. I appreciate your suggestion there. I want to ask further to all of you here; you have mentioned, Sergeant Kowchee, that the information that you have received as part of the WTU has been exceptional in terms of what benefits that are available out there, but it is your impression that this information isn't replicated throughout. So you have gotten a great deal of assistance, but you know that there are others that are not out there. Now, I know that when you all were at Camp Shelby, there were people from the VA there. I met them, who were there to explain the benefits that you would receive. Tell me about the adequacy of what you received while you were there at Shelby. Was it sufficient? Was it helpful for Sergeant Flynn? First Sergeant Flynn. Ma'am, I was in that briefing. It is like--to me, it is in the wrong time of demobilization. It is when we, soldiers, are thinking of going home is not the right time to give that information. Senator Murkowski. So in other words, you are now back on American soil. You are itching to get home and these people want to talk to you about benefits down the road. So it is in one ear, out the other? First Sergeant Flynn. Yes, ma'am. Senator Murkowski. So what would your suggestion be in terms of when would be a good time to give you that information so that it can be assimilated, you can act on it then? First Sergeant Flynn. Ma'am, probably it would be either prior to deployment or in the middle of deployment. I am just talking here. I have not discussed what would be more beneficial as far as getting the information to the soldiers. Senator Murkowski. But not immediately after returning? First Sergeant Flynn. Yes, ma'am. Senator Murkowski. Would you agree with that, Sergeant Kowchee? Sergeant First Class Kowchee. Yes, ma'am, I would agree with that. Senator Murkowski. Lieutenant Colonel Osborn? Lieutenant Colonel Osborn. Good morning, ma'am. The post deployment health assessment that was alluded to in some of the statements, what that is is an Army requirement and so all soldiers have to get on the website and, you know, you have-- everybody has their personal account and it even has a medical, you know, piece to it. So the post deployment health assessment is filled out by every soldier 30 days prior to redeployment and from those statements that you put down as an individual soldier, you sit with a healthcare provider before you leave theater and you discuss whatever those issues may be, whether it is, you know, back pain, stomach problems, problems sleeping, whatever those problems may be. They counsel the individual a little bit and then once you get to the redeployment station, which ours was MOB Station Shelby, you again sit with a healthcare provider and they go over those issues again. In our case at Camp Shelby, we did have the WTU from Ft. Rich present representing both the WTU at Fairbanks as well as Ft. Rich. They, you know, they--based on what the soldier's problem may be, then they accepted them into the WTU and we were lucky enough to bring those soldiers straight back to Alaska. My discussion with the healthcare providers at Shelby was that they normally send them to either Ft. Gordon or whatever, you know, Ft. Benning, wherever there might be a hospital to facilitate those requirements that a soldier might have. I was brutally honest with the Colonel. I told him, I said listen, you either accept them, let us move them back to Alaska or they won't be in the WTU and they will go home with whatever medical issues they have and so they allowed us to bring our soldiers back to Alaska, especially Alaska Guard. I was like wait a minute. You can do whatever you want with Army soldiers, but you know, these are Guardsmen. So they never--some soldiers were sent downtown to see a healthcare provider, but at Camp Shelby, they didn't have an Army hospital to really help people out that might have a medical issue. Along with that, the VA provided a station where you checked in. Now, the active Guard and Reserve soldiers, you know, they still have a career to fulfill and then they will eventually get, you know, enrolled in VA, but all of the part-time soldiers were taken to the station and they should have filled out the enrollment which also identifies all of the issues you had during that 15-month deployment. I think the number was over 250 actually enrolled in VA or registered with VA and may have, you know, written down that they had some medical issues while deployed or dental issues. So between the post deployment health assessment, the registering with the VA, the majority of the soldiers were captured, if they have an issue. Now, the follow-up to that, I'm told, does take awhile to, you know, enter the registration and get these 250 plus soldiers an appointment with the VA. The Alaska Guard stands by, of course, to facilitate, you know, VA support to all of our soldiers throughout Alaska and even if that requires transportation because we, you know, we move our soldiers throughout the state every month, not all of them, of course, but you know, we have training events and we can, you know, we can work through some of those issues. I hope that was a little bit clearer on everything that happened at Shelby. Senator Murkowski. Let me ask though, I have had some interesting conversations this week as I have been discussing Veterans' issues and one of the things that I keep hearing from those that--these who our young vets that I was meeting with, they said you know what, kind of the same comment that you made Sergeant Flynn, when I get out, I am ready to get out and if I check any box that may delay me, you know, I am thinking about home. I am thinking about what I am going to do when I can go on leave here, when I can just make this break, and so I am not suggesting that we are not always honest when we fill out these questionnaires, but at the time, you are feeling pretty fine because you are going home and it is not until you have been back home for awhile and you kind of settle back down. You are no longer running off the adrenalin that kept you moving while you were over in the desert. You are now back and you are dealing with family and jobs and other issues and all of a sudden, you are finding that you have sleep issues, you have anger management issues. There are things that are coming up and now you are looking at it and saying well, I hate to admit it, but maybe I am not as fine as I thought when I first filled out that questionnaire. I think we are recognizing that the timing of when we ask the questions is very important and I appreciate your comments on that, but we need to know that even if you have now gone back to Bethel, if you need that follow-up care, that we are going to be able to provide for you. Now under the service agreement, you are entitled to a minimum of two years of free healthcare from the VA. You are also entitled to the 90 days of free dental treatment from the VA, but we also know that the clinic is here and we have got the outpatient clinics that we have in Fairbanks and on the Kenai, but the question then becomes how do you get back and forth from, is this benefit that you have been promised a good benefit? Comments? We have got a couple from the outlying regions. I know that you are not in White Mountain anymore, but if your family was still in White Mountain, what does this benefit mean to you? Sergeant First Class Kowchee. Well, ma'am, the majority of the witnesses here or, you know, the members here in Anchorage and other places may not fully understand the challenges in getting someone from the rural areas on over here to visit the VA Hospital, but they---- Senator Murkowski. Well, can you explain because this is not just to this room, this testimony that we are hearing today is going to be read by my colleagues back in Washington, D.C. that have no concept of what it means to be from White Mountain and getting from White Mountain to Anchorage, Alaska. Can you just speak to that on the record? Sergeant First Class Kowchee. Yes, ma'am. As First Sergeant Flynn was mentioning earlier about the travel in from the rural areas to here, it is a lot different from traveling from Mississippi or Washington, D.C. to here, Anchorage. There are multiple challenges. If you would imagine going from here on out to Bethel, Nome, Kotzebue, Barrow by jet, that is a comfort in itself just getting there. Going out to Nunapitchuk, Teller, Brevig, Nuiqsut or, you know, some place beyond where there is a jet that is available to land, it is a little bit more challenging and much more expensive as well. Senator Murkowski. What is the cost? Sergeant First Class Kowchee. It could cost about $1,000 to get from the Bethel area on over here and going back over and that includes what First Sergeant Flynn was indicating yesterday, you know, the airfare, the plane ticket, the car rental, you know, or the taxi cabs, the restaurants, you know, and hotels, you know, everything else, so it can get pretty expensive for someone to get from the Village to here that depends on a number of issues or a number of things as well, such as weather, such as flight times, such as available planes. It can go within days for someone to get out from the Village maybe even to Bethel or even to get back for that matter. So it is not only transportation and hotel efforts here in Anchorage, but also in Bethel, Nome, Kotzebue and Barrow as well. So it is a one-step process in which a lot of the Lower 48 people may not understand. Senator Murkowski. So if you have these benefits that are promised to you, you know that they are out there, but you have to fund yourself, your travel, your lodging, your transportation, food to come in for the promised benefits, how likely is it that you will use them? Sergeant First Class Kowchee. As in being paid or the cost of it? Senator Murkowski. Well, if you know that you have got to fund your travel to come into town to go to the VA clinic for the care that has been promised to you for your service, you have this two years free healthcare, 90 days free dental, is this a benefit that works if you live in a remote or an outlying Village where the cost to come to town are what we know them to be? I want to know whether or not this is a good benefit or whether we need to enhance it. Sergeant First Class Kowchee. For the VA benefits for a Veteran out there, I think it would offer good services for those Veterans out there in the rural areas, I think it would be excellent for them. Senator Murkowski. General? Brigadier General Katkus. I stated in my last segment, access is very difficult. I've been in the Alaska National Guard for over 30 years and one of our biggest challenges is to move people from point to point. As Sergeant Kowchee just indicated, everything from weather to mechanical issues on aircraft to just other bad luck can change things and one important key that you didn't hit on there is it took several weeks to get this appointment. After the soldier or the Veteran goes through all of the effort to get here, if in fact they got stayed along the way anywhere along there, such as the aircraft went down or weather held them up, now they get here to Anchorage one day late. They might as well go home and reschedule again. So there are no contingency backup dates set within a window. It is a specific time and if they miss that time, they get to reinvest all of that time, effort and money once again. So again, that just adds to the preponderance or the stacked tolerances of why that benefit is really a challenge for anyone living in remote Alaska. Lieutenant Colonel Osborn. I have a comment, ma'am. Senator Murkowski. Lieutenant Colonel. Lieutenant Colonel Osborn. One of the issues that we have worked through for numerous years is we do have Department of Defense health providers in rural Alaska, U.S. Public Health Service. We, you know, to stay current in your status in the Guard and Reserve, you have to have physicals, you have to have dental check-ups, et cetera. We have been lucky enough to be able to work through that within the Guard, but I don't understand why the VA can't use those DOD or, you know, Federal officers who are also doctors, dentists, et cetera in rural Alaska to facilitate a VA benefit and we have discussed that at the State level, of course, several times and everybody just shrugs their shoulders and it is, you know, that whole cooperation, partnership issue needs to be worked through. It really does. First Sergeant Flynn. Ma'am, to answer your question on airfare---- Senator Murkowski. Yes. First Sergeant Flynn.--I am originally from Chefornak, but I work in Bethel. If you compare the Anchorage to Seattle flight, it is like $250 special round trip. It is $300 round trip from Bethel to Chefornak, which is a 45 minute flight. Senator Murkowski. And that just gets you to Bethel? First Sergeant Flynn. Yes, ma'am. Senator Murkowski. The access issue is very, very real and if the funding is not available for the transportation and all of the ancillary costs that are associated with it, it makes me wonder how valuable a benefit is. If you can get into the facility and get that treatment, that is good, that is the preferred, but we recognize that we have different challenges in this state where you have communities that are not part of a road system. We don't have the systems that other states have and it puts us in a very distinct and a very unique category. Now out in, whether it is Chefornak or White Mountain, certainly Bethel, there at YKHC, we have got the community--the health centers, we have got the clinics. Is this where you would go for the care if you are looking at this and saying I simply don't have the money for the plane ticket? Is that a correct statement? Sergeant First Class Kowchee. Yes, ma'am. That is where the majority of the rural areas do get their healthcare, is in the hubs, the major hubs such as Bethel, Nome, Kotzebue. So the majority of the treatment is there in Bethel and if there is anymore severe treatment that is needed for the medical condition, then they would be sent over here to Anchorage. Senator Murkowski. Let me ask a question, and I don't know whether any of you will feel necessarily comfortable in dealing with this in this particular forum, but knowing what you have gone through this past year over in Kuwait, knowing the men that stood by you and the tasks that you dealt with, what kind of post deployment issues, health issues, concerns should we be looking for? Do you have any sense of that at this point in time or is it yet too early? First Sergeant Flynn. I can probably answer that. Senator Murkowski. Sergeant Flynn. First Sergeant Flynn. Ma'am, the rate, like I said earlier, the average age of soldiers in the YK Delta was 28 or under. The health issue that probably will come up later on in their mid-30's to early 40's will be lung--some--they will have lung problems due to high dust or sand inhalants due to some sand storms. Senator Murkowski. Anything else any of you would care to add? [No audible response.] Senator Murkowski. Let me ask then a question about the family support. This is something that I have taken on just with a very personal interest, not only for our Guard, but for our active. It is very important that we recognize that you all can't do the job that we have asked you to do without the support back home, without knowing that your families are being cared for and that basically all is well so that you can focus on your mission. Did your families have the level of support that you had hoped for prior to you going over? Sergeant First Class Kowchee. The---- Senator Murkowski. Sergeant Kowchee. Sergeant First Class Kowchee. Yes, ma'am, the family support group was available, you know, because we did move here to the Anchorage bowl area and it was somewhat sustained and maintained throughout my deployment here, but I feel that maybe a little bit more effort in maybe checking on my wife would have been good for her and my family as well. Senator Murkowski. Any other comments on family support? First Sergeant Flynn. Probably it is--my wife was working for the region in Bethel and it is probably an okay--for the families, but it was--for her, it was hard to reach out to the outlying areas. It is like mainly it was beneficial for the hub, not the outlying areas. Senator Murkowski. General. Brigadier General Katkus. Ma'am, I would like to address family support in some general areas that this is a fairly new challenge for the Alaska National Guard to deploy in the numbers that we have and certainly standing up the family support groups in the manners that best supported the troops, we are still working on because family support is going to continue now, probably more challenging now than ever, and I think our cooperation with the National Guard Bureau and some of the efforts we are taking are very positive and we are going to have continued challenges. So I think the jury is still out on how effective we are going to do there as most of the troops have only recently deployed and I see the lion's share of family support is addressing issues now that they have returned home also. So there is still that part of the equation we will be evaluated on, I'm sure. Senator Murkowski. We are still learning. Lieutenant Colonel Osborn. Lieutenant Colonel Osborn. Ma'am, I want to back up to the post-traumatic stress that you mentioned earlier. I guess I am the one that probably needs to answer that. Some of the missions that soldiers were on, you mentioned response to accidents, but some of those calls, I mean, those were like weekly. Kuwait is one of the most dangerous places in the world to drive. There were accidents in our--where we resided in our bases weekly. Soldiers had to respond to secure the areas because, you know, you never knew if the accident was staged and there would have been, you know, an explosion to perhaps injure first providers. So at some of the camps, they had to respond to these accidents and these accidents were quite catastrophic. A lot of people died in the short time that we were there on the highways. In addition to that, there was the stress--I mean, we didn't really have days off. I mean, you are working seven days a week whether you are shift or however your commander ran your shifts, but you mentioned a little bit, the heat. I went straight from Afghanistan to meet up with the Battalion. It was a lot hotter in that part of the Middle East than it was in Afghanistan and I was in Southern Afghanistan, which is pretty much desert terrain as well, not up in the mountains, but I mean, it is 140 degrees many, many days. You are wearing all of the body armor that is required across the border in Iraq and although the missions many times were not, you know, direct contact type missions, they are very monotonous and, you know, there were--so these guys had missions of reconnaissance of routes, looking for IEDs. So it was very monotonous and with that heat and the pressure put on them and their shifts, and they worked every day, every single day, they were out, you know, working. So that whole post-traumatic stress, I have no idea how to even analyze it. In my, you know, experience in the Army, I have talked to people that were in Desert Storm One, et cetera, and they didn't even know they had PTSD until several months after redeployment and then something triggered whatever it is inside them and they realized they have a problem. So again, what John Flynn said, it is a little early to be analyzing that there is no problem with our soldiers. Senator Murkowski. Well, let me follow-up with that and it maybe requires a response from you, Lieutenant Colonel Osborn or from you, General Katkus. I had received a letter earlier this year from Mr. Spector over at the VA kind of outlining the plan based on the Memorandum of Understanding and in that letter, it states that the current Guard Unit, the 3-297, has been stationed, and this is from the letter, has been stationed behind the lines in Kuwait and therefore, they should have less need for mental health services associated with combat. You have just described the situation over there, Lieutenant Colonel Osborn. We know that you were out looking for the IEDs. Just because they don't blow you up doesn't mean that doesn't cause a great deal of stress and anxiety. In your judgment, is the VA's planning assessment flawed just because you weren't on the front lines, just because you are not out in Baghdad is the situation different? Can you respond to that? Sergeant First Class Kowchee. I will respond first on that. Let me back up to just an experience with the Anchorage Police Department, just because you are assigned in Anchorage or you are assigned in Wasilla, which is much smaller, your risk is always there and that is stressful and you always face that. So if you are in Kuwait or whether you are in downtown Iraq, you are at war and you are going to have the stress and as Lieutenant Colonel Osborn just commented, those soldiers were at war every day and they have to be mentally prepared and they have to be ready to perform their duties. That is stressful. They are exposed to it and it is just by luck or happen chance that they didn't have a direct engagement. So I would say that the stress is there wherever their assignment, whether it was Kuwait or into Iraq itself. Senator Murkowski. Well, then, given that and recognizing, as you have said, you don't come home with a sign all of a sudden on your chest that says, you know, I woke up and now I have got PTSD, it is something that may kind of creep up on you. You may think, again, that you are fine. We are still learning a great deal about the mental damage that is caused by war and what we are seeing in these OIE and OIA (ph). We are learning a lot in a very short time period. Given this scenario, do you feel that we are prepared to handle that aspect of the damage that is a consequence of war, and this is the mental side. Do we have what it takes? Sergeant Kowchee, you are over there at WTU. Lieutenant Colonel Osborn, you have got a great deal of insight on this. Are we ready to do right by our service men and women when it comes to the mental care that will be required? Lieutenant Colonel Osborn. If I could, ma'am, just to set the record straight, the Battalion resided in Kuwait. We worked for area support group Kuwait Commander. We had two separate missions in Southern Iraq. Two companies ran those missions, not simultaneously, you know, one mission moved into another area. Those two companies, you know, you are talking 200 and probably about almost 300 guys operated in Iraq throughout that deployment. So, almost two-thirds of the soldiers operated in Southern Iraq, IEDs, small arms fire, threat of hijacking and the whole, you know, the whole thing. So I don't know where that statement came from. I would like to know. My experience, just to set the record straight as well, I lived in the YK Delta for quite awhile. The transportation issue, I was a Battalion Commander in the YK Delta. The YK Delta alone is like the size of South and North Dakota combined without roads. Many times soldiers are using their personal snow machine or boat just to get to their drill period. If we don't have a helicopter available or a cruise available, and it is really tough to move people around, my full-time job is the Operations Officer for the Brigade and we are moving people around the state continuously and it is really difficult and we have assets at our fingertips, so just a little bit of insight into transportation. Senator Murkowski. Did anyone care to comment on whether or not you think we have got the mental health specialists, the behavioral health specialists to assist? Lieutenant Colonel Osborn. That was my next issue. Being a former YK Delta resident, there--everyone should know that we have a high rate of suicide in Alaska, especially rural Alaska, and I can't say that we have the facilities and care per, you know, needed for people that aren't Veterans. Joe. Senator Murkowski. Anything further? Sergeant First Class Kowchee. Yes, sir, ma'am. The level of healthcare out there, it--I don't think the mental health workers, I'm not sure, you know, this is my opinion, and I'm not sure if they are educated on, you know, PTSD for those soldiers out there that return from supporting the Operation Iraqi Freedom. I don't think they are aware of the signs and the, you know, what to look out for and I am not sure if they are prepared to help them out. Senator Murkowski. General. Brigadier General Katkus. Ma'am, directly to answer your question, it is unfortunate, but I don't think we will see a lot of these cases independent and by themselves. It is going to be combined with some type of alcohol influence and/or domestic violence or some type of a physical demonstration where either the paramedics and/or the local law enforcement are going to show up and they are not going to be properly trained in evaluating that this is PTSD. They are going to see this as an alcohol problem or a family fight and probably take the wrong tactics in applying the--or trying to solve the solution. So we don't know how big the problem is yet because our soldiers are just recently back, but overall, we have got a lot of soldiers coming back to Alaska, not just in our rural area and as first responders, I think that we really do need to make sure everyone is onboard on the training so that they have got a wide-open mind when they go to calls such as this because, again, it is not going to be a sterile environment where we are interviewing a soldier and discover we have PTSD. We are going to have a problem when we see this on the street, in a house, in a local area or in a rural area. Senator Murkowski. And this is where it goes far beyond just the VA kind of help? Brigadier General Katkus. Absolutely. Senator Murkowski. The whole community must be involved in this. We are going to hear from Pastor Nicholson in just a few moments. We are going to need the clergy. We are going to need the community. We are going to need the health aides. We are going to need everybody to be that support and to be aware that there may be issues that come up and to understand kind of what to look for. There is a great deal of education that needs to go on and as all of you have indicated, we are still just learning what we are dealing with. So the action plan can't be fully sketched out until we know better what we are dealing with. General, let me ask you; when I was over at the WTU yesterday at Ft. Rich, during that visit, I learned that if one of our returning Guardsmen is found to have a medical issue after they have been discharged from active, that the Guard then has the option of reactivating the individual so that they can receive care for that particular issue through the WTU, through the War Transition Unit, in the military medical system as active duty. Do you intend to utilize this program to get the Government-funded care and maintenance for those who, for instance, might be out in a Village and that access to care is very, very limited? Do you see this as potentially one of the ways that we can work through this? Brigadier General Katkus. Ma'am, that is a very good option to use. It may be cumbersome and we are not familiar with exactly how it works, but that is a very good option to go through. Another challenge though, is the soldier that has left service, that is not available to them. So those are some of the challenges also. Senator Murkowski. So it really depends on your status as to whether or not this option is available? Brigadier General Katkus. Correct. That is not a cure all. That is an option and each case, we hope to be able to evaluate specifically and individually and if that is the best option to address it for the soldier, that is exactly what we will do, but again, there will be other situations where they are either not in the service or some other challenge prohibits that from happening. Senator Murkowski. Right. Let me ask just a couple of more questions of you, General Katkus. We are going to hear a little bit more about the Memorandum of Understanding that the State and the VA have entered into. When I have discussed this with your boss, General Campbell, we have certainly encouraged the VA to think outside the box when it comes to providing the healthcare in rural Alaska. In terms of the provisions in this MOU, the key components in your opinion, what do you think the VA should do, must do to most effectively serve our returning Guardsmen? Brigadier General Katkus. To get a specific solution, I don't have right now, but it is a communication tool and that is probably the best effort, is education and communication. The lively discussion that I spent with my staff yesterday in preparation for today's testimony gave me a very broad experience or gave the ability to watch my senior leadership not totally know what the VA benefits are that available out there. So if I have got folks that have been in the Guard as long as I have that don't thoroughly understand it, the challenges are going to be there trying to get the soldiers at the lower end of the food chain there, those 28-year and younger soldiers to understand it, are going to be extremely challenging. What that MOU does is really start a dialog and that dialog needs to be continued. If we look at the MOU is this the solution. This is what we are going to implement, I think we are going to fail. That is just breaking the ice to get started and it has got to continue on and take all of the challenges we discussed this morning and figure out with multiple people looking at problems, identifying those solutions. So it is a communication tool, ma'am. Senator Murkowski. Well, it is and the one thing that I really like about this MOU, it has got four goals and the fourth goal is commit to meet regularly to address and work on the issues. To me, this is something that is very fluid, but you have got to have that ongoing discussion. To just say that, well, we have signed an MOU and now our Guardsmen are being addressed and taken care of, it is just words on paper. So, I am with you on that. Brigadier General Katkus. That is exactly right. Senator Murkowski. You know, when I was out there at Shelby when you all were taking off, we all remember how hot it was that day. It was October. Who would have thought it would be 100 degrees and 110 percent humidity and I was dying in the heat. You all were standing out there in full uniform, standing as you listened to, you know, your high mucky mucks speak to you and I was quite concerned. I am looking out at this group of Alaskans from Chefornak to White Mountain to Bethel to Angoon and I am thinking I don't know how they are going to do it over there, and I have to tell you that the men that came back were men who had accomplished a mission with a level of pride and satisfaction in work very well done, truly came back as a very proud and unified unit of soldiers and you made us all proud. As Alaskans, you made us exceptionally proud. As Americans, you made us proud, but I want to ask you, General, because I want you to have the microphone in front of you to tell Alaskans how this unit performed over there in conditions that those of us at this table, I don't know could have handled. So, if you can just brag on the men and their mission for a few minutes, I would be honored to listen to you? Brigadier General Katkus. Ma'am, the members of the Alaska Army National Guard performed magnificently. That is the bottom line. I have to be careful not to brag too much on just the Third Battalion because our aviators are out there in harm's way and they had risky missions, as is our security force currently deployed out there, but every deployment we have had so far, our soldiers have stood the test. They've answered the call. It is a volunteer organization, yet they are out there doing the missions required of them and they are doing them exceptionally well. They have not missed a requirement. They have not seceded in any of the missions that were asked of them. They performed and they performed absolutely remarkably. Senator Murkowski. Well, we are exceptionally proud of all of you and for what you have done and for your continued service. I think we recognize, particularly out in some of our smaller communities, the role model that you serve to the young people out there, to the elders who served with pride and distinction in the Territorial Guard. You truly are examples of proud warriors and we honor and we respect you. What we are trying to do today in putting some of your words on the record is to make sure that when we say we support our troops, we are doing more than just giving a bumper sticker slogan, that we are carrying through with that show of support by giving you the services that you have earned and showing you the respect that you have earned as you have served us. So let's make sure that we continue this dialog. It doesn't necessarily have to be over a witness table, but we need to make sure that we are doing right by you and your service and in order to do so, we need to know what is happening across the state as you are dealing with those who have served us. So I would encourage you to keep up the communication with us. Our door is open always, but again, thank you for all that you have done, your continued service, and thank you for your testimony this morning. It is greatly appreciated. With that, we will turn to our second panel. So, at this time, I would like to have join us at the table, Mr. Alex Spector, the Director of the Alaska VA Healthcare System and Regional Office here in Anchorage, Mr. Nelson Angapak, the Vice President of Alaska Federation of Natives, also accompanied by Reverend William Nicholson, who is the Pastor of the Anchorage Moravian Church, and Ms. Valerie Davidson, the Senior Director of Legal and Intergovernmental Affairs at the Alaska Native Tribal Health Consortium based here in Anchorage. We will also have General Katkus at the end of the table in case we have further questions, keep him on the hot seat for a little while longer. We appreciate that, General. Let's make sure everyone has got water and what we will do, since we have already heard from General Katkus, we will go from you, Mr. Spector, on down in delivering your testimony. We do have your written testimony, which will be included as a full part of the record, so any summary or add-ons that you would like to make at this time are welcome and appropriate. We are pleased to have you as part of the hearing this morning and appreciate what you do in your service at the Veterans' Administration. Thank you, Mr. Spector. You may proceed. STATEMENT OF ALEXANDER SPECTOR, DIRECTOR, ALASKA VA HEALTHCARE SYSTEM AND REGIONAL OFFICE Mr. Spector. Thank you, and good morning, Madam Vice Chairman and members of the Committee. I am Alex Spector, Director of the Alaska VA Healthcare System, and I thank you for this opportunity to provide information regarding the Alaska VA Healthcare Systems' delivery of healthcare services to Alaska Veterans and our ongoing efforts to prepare for the return of servicemen and women who have served in Iraq and Afghanistan. It is my honor to be here today. The Alaska VA Healthcare System and Regional Office delivers care to eligible Veterans through clinical care sites, also sharing joint venture sites with our DOD facilities, referral to the closest VA facility and purchase of care. That Alaska VA provides medical care to Alaska Veterans through a series of VA clinics located in Anchorage, Fairbanks and Kenai. In addition, we are pending approval for a clinic in the Mat-Su Valley. The Alaska VA also participates in one of nine nationally recognized VA/DOD joint venture relationships with the Third Medical Group, Elmendorf Air Force Base and an Inter Service Sharing Agreement with Bassett Army Community Hospital at Fort Wainwright. If care is not available at an Alaska VA clinic or through one of the VA/DOD facilities, care is referred to the nearest VA facility, the VA Puget Sound Healthcare System in Seattle. If these facilities are not able to meet the medical urgency required for consultation or treatment, Federal statute allows VA to purchase care from non-VA facilities. This same statute indicates such fee for service, fee care, will be consistent with what is provided in the contiguous United States. As for preparations and outreach for Operation Enduring Freedom/Operation Iraqi Freedom, OEF/OIF actions, these actions have included hiring of dedicated staff for outreach to soldiers and families. We have an OEF/OIF Program Manager, Transition Patient Advocate and a Social Work Case Manager for these returning soldiers. We have hired additional mental health staff. We have provided education to Alaska Native Regional Hospital staff and to Village clinic staff and we have developed, as mentioned previously, a Memorandum of Understanding with the State of Alaska National Guard to provide mutual support to our returning National Guard soldiers. As a result of established partnerships, the Alaska VA has through the Alaska Federal Healthcare Partnership, Alaska VA staff were invited to present at six Alaska Native Regional Health Corporations on VA eligibility benefits and healthcare, post-traumatic stress disorder and reintegration issues. In addition to the educational aspect of these sessions, VA staff and the Alaska Native Tribal Health staff focused on providing a pathway of care for each system to work together in order to assure that soldiers returning to their respective areas and other Veterans living in these rural areas could seamlessly use their Alaska Native health benefits as well as use their benefits through the VA Healthcare System. Each person participating in these sessions was given a packet of information with names and phone numbers to be able to contact individuals at the VA to bust through bureaucracy to make that seamless transition, if necessary. Added mental health staffing has placed the Alaska VA in good position to begin tele-mental health, which has been initiated in our VA community-based outpatient clinic in Kenai. This will prepare us for our next trial of tele-mental health, which we hope to do with the Yukon Kuskokwim Health Corporation in Western Alaska. We met with YKHC staff in September to begin these discussions on how this process could work between the VA and YKHC. The Alaska VA has been able to establish relationships with the Alaska National Guard and the Department of Defense. VA staff regularly participate in active duty and National Guard pre and post deployments in addition to ongoing contact with the Warrior in Transition units located in Ft. Richardson and Ft. Wainwright. In summary, the Alaska VA has spent this last year preparing for our returning servicemen and women by adding staff and working closely with our Federal and State partners in assuring a seamless transition from DOD and Tribal Health System care to the VA care. Madam Chairman, Vice Chairman, thank you again for this opportunity to speak about VA care in the state of Alaska and I will be happy to answer any of your questions. [The prepared statement of Mr. Spector follows:] Prepared Statement of Alexander Spector, Director, Alaska VA Healthcare System and Regional Office Good morning Mr. Chairman and Members of the Committee. I am Alexander Spector, Director of the Alaska VA Healthcare System. Thank you for this opportunity to provide information regarding the Alaska VA Healthcare System's current partnerships with Indian Health Services (IHS) and our on-going efforts to prepare for the return of service men and women who have served in Iraq and Afghanistan. It is my honor to be here today. Current VA/IHS Partnerships: The Alaska Federal Health Care Partnership (AFHCP) provides a strong mechanism through which VA takes care of Alaska Native veterans by active cooperation with Federal and tribal entities which provide direct health care services in the State of Alaska. The Alaska VA Healthcare System is a very active participant in the AFHCP--a formal, voluntary organization which works to leverage resources, optimize capabilities, and promote innovation. The Alaska VA Director serves as the Chair of this group. Members include VA, Alaska Native Tribal Health Consortium, Alaska Native Medical Center, Indian Health Service, U.S. Army, U.S. Air Force, and U.S. Coast Guard. The following are a few examples of the many accomplishments of the AFHCP and programs underway that increase access to high quality, cost- effective care for over 280,000 tribal/Federal beneficiaries, many of whom are veterans. The AFHCP programs are vital in VA's ongoing work to provide Alaska Native veterans a pathway to care. The Alaska Federal Health Care Access Network is one of the largest medical facility and forward telemedicine systems in the world. The system is heavily utilized in the rural areas of the state, providing a tool for Alaskan Native Clinic Health Aides (CHAs), who are the sole primary care providers in many of the villages. The AFHCAN system allows a Health Aide to build a case on the telemedicine cart and forward to a licensed provider for further care, and to provide oversight of the Health Aide's work. This system has expanded access to Alaska Native veterans and improved oversight, and thereby the quality of the care provided by the CHAs. The AFHCP Federal Education Sharing Group conducts joint education and training sessions for AFHCP members. VA has taken the lead in applying for an education grant to conduct a two-day education summit on Traumatic Brain Injury for Federal and community providers in FY08. The Alaska Federal Health Care Partnership Teleradiology Project has brought enhanced x-ray capabilities and digital capability to over 50 communities in the state, most of them rural native communities without roads. This technology allows a trained health aide, in a rural frontier area, to take x-ray studies and forward them electronically to a radiologist in a metropolitan area for interpretation, cutting this processing time from days to minutes. In addition, this program eliminated the environmental health hazards in the Alaska Native communities posed by the chemicals used in wet x-ray processing. The Alaska Home Telehealth Monitoring Initiative, modeled from VA's Care Coordination/Home Telehealth (CCHT) program, is now providing services to participating organizations in rural Alaska. Currently, four regional health corporations are placing home monitoring devices in the homes of Alaskan Native patients, many of whom are veterans, to provide regular monitoring of chronic conditions. This allows timely intervention when a condition begins to deteriorate, rather than waiting for the patient's unmonitored condition to worsen to the point at which they must be seen in the Emergency Room or require admission. The U.S. Army Medical Department Activity-Alaska is also participating in this initiative. The program is monitoring patients in both urban (Anchorage, Fairbanks) and rural areas (Delta Junction, St. George, Kotzebue, Dillingham, Togiak, False Pass, Whittier) both with and without a road system. This is yet another example of VA providing our Alaska Native veterans a pathway to receive high quality health care. Additionally, the Alaska Federal Health Care Partnership has more projects in the planning stage that will bring expanded access to our veterans living in rural Alaska such as: AFHCP Tele-Behavioral Health Agreement--This agreement reflects the cooperation between DoD, VA, and the Alaska Native Health Corporations in providing mental health care to DoD beneficiaries and veterans. The Alaska Federal Partnership's new program will assure a telemedicine connection for veterans returning to rural Alaska with the VA, as well as active duty DoD and DoD family members. Through the use of live clinical videoconferencing, the patients will be seen at the location where they generally receive care, and will have access to a psychologist or psychiatrist located at the Anchorage VA Clinic, DOD site or community Tricare provider, as appropriate. This will greatly expand mental health services to Alaska Native veterans located in rural Alaska. We believe these cooperative efforts with Federal partners enhance both access and quality of the health care to our veterans in the state, particularly those who are seen primarily in the Alaska Tribal Health System. Access to Alaska VA Health Care: Ensuring access to high quality health care and veteran's benefits to Alaska's veterans is challenged dramatically by the geography and population demographics in Alaska. In order to provide these services, the Alaska VA Healthcare System and Regional Office (AVAHSRO) draw upon an array of traditional and non- traditional VA resources. The AVAHSRO provides medical care to Alaska veterans through a series of clinics located in Anchorage, Fairbanks, and Kenai. The Alaska VA also participates in one of nine nationally recognized VA/DoD Joint Venture relationships with the 3rd Medical Group (MDG), Elmendorf Air Force Base, and an Inter Service Sharing Agreement with Bassett Army Community Hospital at Fort Wainwright. If care is not available at an Alaska VA Clinic or through one of the VA/ DoD facilities, care is referred to the nearest VA facility, the VA Puget Sound Healthcare System (VAPSHCS) in Seattle, WA. If these facilities are not able to meet the medical urgency required for consultation or treatment, Federal statute allows VA to contract with non-VA facilities for care. This same statute indicates such fee-for- service (fee) care will be consistent with that provided in the contiguous States. In FY07, the Alaska VA purchased $39,150,000 in health care for veterans within Alaska. Our Anchorage VA facility became operational on May 5, 1992. At the time of the opening, VA was providing care and services for approximately 4,000 veterans through contract community providers. This represented 90 percent of the Alaska VA operating budget. Opening the Anchorage facility permitted expansion of the number of veterans served by VA medical staff. The new site also expanded the types of services directly available to Alaska's veterans. Improvements to the delivery of services have enhanced quality, access, productivity, operational efficiency and patient satisfaction. The Fairbanks VA Community Based Outpatient Clinic (CBOC) was activated in 1997 and is located within Bassett Army Community Hospital (BACH) on Ft. Wainwright as part of a VA/DoD interagency sharing agreement. The Kenai VA CBOC was activated in November 2001. The numbers of veterans served by the Alaska VA has steadily increased. In FY07, the AVAHSRO provided a total of 167,237 outpatient visits (112,273 VA clinic visits plus 54,964 visits purchased from community providers) for 14,383 unique veterans. There are 27,335 Alaska veterans enrolled in VA Healthcare System. In addition to AVAHSRO direct sites of care, a VA contact representative is located in the Juneau Federal Building to provide general information on VA health care and provide veteran benefits information and services for the Regional Office.
According to VA's strategic planning methodology, 74 percent of Alaska veterans live within 60 minutes driving time to VA primary care (see table below for distribution of Alaska veteran population). The other 26 perecent of veterans outside the road system may be eligible for reimbursement of travel expenses to VA sites of care provided they meet VA's statutory criteria for beneficiary travel benefits. The beneficiary travel budget for FY07 was $2,467,502 compared to $1,878,056 in FY06. Distribution of Alaska Veteran Population ------------------------------------------------------------------------ Vet Pop Percentage ------------------------------------------------------------------------ Anchorage/MatSu/Kenai 41,722 63 Fairbanks Area 10,908 17 Southeast Alaska 6,859 10 West/SW Alaska 2,188 3 Northern Alaska 2,209 3 Kodiak 1,221 2 Valdez/Cordova 1,141 2 ------------------------------------------------------------------------ (As of 9-30-2006 VA Website) Consistent with the Secretary's CARES Decision of May 2004, the AVAHSRO is following through on plans to construct a new replacement outpatient clinic to support health care operations in the Anchorage Bowl. Construction of the replacement clinic will be on 10 acres of Air Force land adjacent to the Joint Venture Medical Facility, Air Force 3rd Medical Group Hospital. The construction contract was awarded in June 2007, and site work started in July. The target completion date is January 2010. The new clinic will provide space to meet projected demand for primary care, specialty care, and outpatient mental health services through 2022. Development of a CBOC in the Mat-Su Valley is in the 2008 VISN 20 Strategic Plan. A business plan has been developed and submitted. It will assist the AVAHSRO by mitigating, to the extent possible, the need for a primary care waiting list for appointments in Anchorage, as well as provide medical care closer to home for patients currently enrolled at the Anchorage VA Clinic. The AVAHSRO has been greatly challenged by a lack of available clinic space at the Anchorage facility; due to increased missions, increased demand by new patients, and new employees (e.g. OEF/OIF and mental health initiatives). Providing local access to this target population would relieve the access and physical space issues. Outreach for Operation Enduring Freedom/Operation Iraqi Freedom (OEF/ OIF) Veterans Preparation has included: Hiring of dedicated staff for outreach to soldiers and families. Additional mental health staffing. Providing education to Alaska Native regional hospital staff and to village clinic staff. Development of a Memorandum of Understanding with the State of Alaska National Guard to provide mutual support to our returning National Guard soldiers. In our ongoing efforts to ensure a seamless transition from DoD care to VA healthcare, the Alaska VA has continued to enhance staffing and designated positions for Operation Enduring Freedom/Operations Iraqi Freedom (OEF/OIF) outreach. We have a designated OEF/OIF Program Manager, Transition Patient Advocate, and a Case Manager to work with OEF/OIF veterans. There is special emphasis placed on care to those who are injured and severely wounded OEF/OIF veterans. For those OEF/OIF on Active Duty status, DoD maintains responsibility for healthcare services. Our dedicated team has worked closely with the Warrior Transition Units (WTU) located on Ft. Richardson and Ft. Wainwright, to ensure a smooth ``hand off'' of soldiers to the VA system. They visit the WTUs on a monthly basis during the WTU town hall meetings and more frequently as needed. During FY07, VA OEF/OIF staff provided 20 VA briefings to Active Duty, Guard, and Reserve members. Currently the Alaska VA is seeing Active Duty members of the 4-25th Battalion as they return to Ft. Richardson. VA staff have been present during the demobilizations at the invitation of the Army. As of November 21, 2007, they had briefed over 1,368 soldiers about VA benefits. Alaska VA will continue to staff a VA information table until the entire battalion has returned. Alaska VA Healthcare has increased staffing in our Mental Health Service. We currently have three psychiatrists and two psychiatric nurse practitioners. Since returning soldiers present as a high risk for suicide, a full-time suicide prevention coordinator reported for duty August 20, 2007. A Recovery Coordinator has been hired to work with community resources for chronically mentally ill patients. We are also working with the VA Puget Sound Health Care System and Alaska Brain Network in support of veterans with Traumatic Brain Injury. Two Peer Support Technicians have been hired in our Homeless Veterans Service--one to work with our outreach social worker in the community and one to work with veterans in the Domiciliary Residential Rehabilitation Treatment Program and VA Supported Housing Program. The VA Community Based Outpatient Clinics (CBOC) located in Fairbanks and Kenai now have social workers hired and in place at both locations. Telepsychiatry has been initiated with the VA CBOC in Kenai. This will prepare us for the next trial of Tele-Psychiatry which we hope to do with the Yukon-Kuskokwim Health Corporation (YKHC) in western Alaska. We met with YKHC staff in September to begin discussions on how this process could work between the VA and YKHC. In preparation for the returning Alaska National Guard 3rd Battalion 297 Infantry, a VA outreach team, consisting of staff from VA Healthcare, Veterans Benefits Regional Office, and the Vet Center, partnered with the Alaska Native Tribal Health Consortium to provide proactive education on VA eligibility for benefits and healthcare, Post Traumatic Stress Disorder, and Reintegration Issues to several Alaska Native Health Care organizations from September 11-28, 2007. The following organizations responded to VA's offer to provide this education: South East Alaska Regional Health Consortium (SEARHC) in Juneau and Sitka, Arctic Slope Native Association in Barrow, Norton Sound Health Corporation in Nome, Yukon-Kuskokwim Health Corporation in Bethel, and Bristol Bay Health Corporation in Dillingham. Over 150 village health aides, behavioral health specialists, mental health staff, primary care providers, nurses, and administrative staff participated. Some of those participating did so through video teleconferencing. The team will travel to Maniilaq Health Corporation in Kotzebue on December 10. In addition to the educational aspect of these sessions, VA staff and Alaska Native Tribal Health staff focused on providing a pathway of care for each system to work together in order to ensure the soldiers returning to their respective areas (and other veterans living in these rural areas) could seamlessly use their Alaska Native health benefits as well as use their benefits through the VA healthcare system. Each person participating in the sessions was given a packet of information with names and phone numbers to be able to contact individuals at VA. Regular follow-up with organization points of contact will occur by our VA OEF/OIF Manager to ensure that non-active duty Alaska Native veterans have access to the VA healthcare system. On September 11, 2007, the Alaska VA Healthcare System, Anchorage Regional Office Veterans Benefits Administration, and the Alaska Department of Military and Veterans Affairs signed a Memorandum of Understanding (MOU). The specific goals of the MOU are written as follows: 1. Ensure Seamless Delivery of Health Care Services to Rural Veterans. 2. Enhance Home Station Reunion and Reintegration Workshop for Returning GWOT Veterans to Include Post Deployment Health Reassessments. 3. Create Multidisciplinary Mobile Outreach Teams. 4. Commit to Meet Regularly to Address Work Issues. The National Guard has included designated VA staff in all Post Deployment Health Risk Assessment (PDHRA) sessions for returning soldiers to answer questions and enroll new veterans into the VA healthcare system. In FY07, the Alaska VA OEF/OIF staff participated in the National Guard's four PDHRAs involving 154 returning service members. In October, the Alaska VA sent OEF/OIF staff to meet the Alaska National Guard 3rd Battalion 297 Infantry at Camp Shelby, Mississippi. Each returning service member was given a VA information packet about enrollment as well as phone numbers for designated OEF/OIF points of contact and sites of Alaska VA healthcare, benefits and Vet Centers. VA staff were able to assist 352 returning service members in completing VA health care applications on site. Of the 600 National Guard members who were deployed, approximately 49 percent live in the South Central Alaska, 25 percent in Western Alaska, 11 percent in Southeast Alaska, 8 percent in Fairbanks, 6 percent in Nome/Barrow, and the remaining 1 percent in Kodiak. The National Guard has also invited VA OEF/OIF staff to travel with them as they go to the rural armories to conduct Re-Integration activities on drill weekends. Mr. Chairman, thank you again for this opportunity to speak about VA health care in the state of Alaska. At this time, I am happy to answer any questions. Senator Murkowski. Thank you, Mr. Spector. I appreciate your testimony and we will next go to Mr. Nelson Agapak. STATEMENT OF NELSON N. ANGAPAK, SR., VICE PRESIDENT, ALASKA FEDERATION OF NATIVES; ACCOMPANIED BY REVEREND WILLIAM NICHOLSON, PASTOR, ANCHORAGE MORAVIAN CHURCH Mr. Angapak. Good morning. Senator Murkowski. Good morning. Mr. Angapak. Welcome to Alaska. This gentleman from Fairbanks was telling me earlier today that he has never heard of the Village of Nunakauyak. Senator Murkowski. Well, we will have to get him out there. Mr. Angapak. And I accused him of having limited his access to Fairbanks area and he ought to travel throughout. Senator Murkowski. It is a challenge to. Mr. Angapak. Madam Chair, on behalf of the Alaska Native community, we congratulate you for the support, but in particular, the confidence of the other U.S. Senators for appointing you Vice Chairman of this Committee. I think it will go a long ways toward dealing with issues that impact the Veterans in the State of Alaska. For the record, my name is Nelson Angapak, Vice President of Alaska Federation of Natives. Dealing with Veterans' issues have become a passion for some of us. If the lessons we learned from Vietnam, conflicts are to apply, Madam Chair, those must be applied. Some of our returning troops from Vietnam survived the bullets of the other side only to be killed by the bullets of the red tape from the Veterans' Administration. The VA has absolutely no presence in rural Alaska, absolutely none at this point. Last Friday, I met with Gene Peltola, President and CEO of Yukon Health Corporation, and he advises the following; VA had not visited Bethel until such time that you had called them. He tells me there have been two visits by VA, but he says there are no tangible results on the ground, where rubber meets the ground. I applaud the efforts of the VA, but I think efforts of the VA must go beyond words. There must be delivery of what was promised us. I am a Veteran. I served from 1969 to 1971. At the time of my separation, Madam Chair, I wanted to get out of service so quickly. I wanted to separate myself from service so quickly that when I was asked these questions dealing with my health issues, I told the people there I am all fine. I am just fine. I think the same thing has happened with our troops from out there. They want to get out of separation so quickly that they are telling them I am fine. Pastor Nicholson is free to hit me when I tell you this; among one of the conversations that we had together at the time of his separation, he told me without being very specific that he did the same thing. I think, Madam Chair, VA must truly go beyond words in dealing with the issues that impact our Veterans in rural Alaska. Let me quote you something that is part of my statement. Veterans in rural Alaska and America; the challenge of providing services to rural and isolated Veteran population extends beyond the boundaries of Native Americans and Alaska Natives. It affects all Veterans living in rural and isolated areas of the continental United States and its territories. We recognize and we compliment the United States Department of Veterans' Affairs for its strides in identifying and implementing systems and programs for rural and isolated areas. Yet, challenges continue to affect the minority Veteran population, and in particular, the Alaska Natives living in rural Alaska. I believe that this affects the returning members of the 3rd Battalion. I've walked through VA. I have met with Mr. Spector a number of times, but I think VA can do a lot more. VA must promote culturally and geographically relevant outreach programs and efforts throughout the state of Alaska. If it is necessary, Madam Chair, I hope you will push for additional funds to do that. VA must improve diversity at all levels of VA Alaska with Veterans of various military backgrounds and rand reflective of both officer and enlisted members to ensure equitable representation of Veterans and their experiences. You know, I don't think I need to elaborate that, but for example, in the Yupik society, one of the most important factors in our society is our family unit, our parents, our grandparents. That is the kind of culturally relevant outreach VA should consider. Reaching out not only to the Veterans, but to the family members who are in the position to assist those Veterans in dealing with the ghosts of their deployment overseas. I think, Senator Murkowski, if necessary, the United States Congress should consider legislation that would mandate the United States Department of Veterans' Affairs to address the medical needs of Veterans living in rural America and in particular, Alaska Native Villages, including the mental health needs of the relevant--I'm sorry, returning members Third Battalion, 297 Infantry. If there are no meaningful strikes in this area, perhaps it is time that the United States Congress considers asking General Accounting Office, GAO, to do an independent evaluation of the services that VA provides to our Veterans in rural Alaska. I think if such an independent study is done, that might be beneficial, not only for VA, but for our returning troops in rural Alaska, and finally, if this does not get the job done, maybe there should be an IG inspection as to why the delivery of healthcare to our Veterans in rural Alaska are not included, really. Finally, I would like to request that my letter of June, I believe, July 5, to Secretary James Nicholson addressing the alternative needs of delivery and benefits to the Veterans living in rural Alaska be included. I also would like to request that my letter to you of July 14, asking you to assist us in this area, be incorporated into the record of this hearing, and finally, this morning I got a letter from the Department of Veterans' Affairs under Secretary for Health dealing with the returning members of OIF and OEF issues. It talks about--it is a form letter. Dear Veteran, but I won't read the whole thing, but there are the following issues of additional warnings that may include PTSD; hopelessness, rage, anger, seeking revenge, acting reckless, that type of thing. I would like to request that this letter also be incorporated into the record of this hearing so that you will see firsthand how the VA may try to improve the delivery of healthcare of our Veterans. Thank you. Senator Murkowski. All of those mentioned will be included as part of the record from this field hearing, and thank you for your testimony and for your service. Mr. Angapak. Thank you. [The prepared statement of Mr. Angapak follows:] Prepared Statement of Nelson N. Angapak, Sr. Vice President, Alaska Federation of Natives Introduction Good morning Madam Vice Chairperson Lisa Murkowski: Honorable members of the U. S. Senate Committee on Indian Affairs and gentlemen: On behalf of the Alaska Natives and the American Indians, congratulations for being appointed to this position recently. This promotion demonstrates the confidence and the trust of the other U.S. Senators of your talents and capacities that you have as a member of the U.S. Senate. For the record, my name is Nelson N. Angapak, Sr., Vice President, Alaska Federation of Natives (AFN). For your information, AFN is a statewide Native organization formed in 1966 to represent Alaska's 100,000+ Eskimos, Indians and Aleuts on concerns and issues affecting their rights and property interests. I am a veteran and I served in active duty in the U.S. Army from 1969 to 1971; I was honorably discharged. On behalf of AFN, its Board of Directors and membership, thank you very much for inviting me to submit this statement to the U.S. Senate Committee on Indian Affairs on the access to and delivery of healthcare services to the returning members of the 3rd Battalion, 297th Infantry Brigade, Alaska National Guard who have recently returned from their deployment in Kuwait and Iraq and other Alaska Native veterans residing in Native villages of rural Alaska. I want to take this opportunity to thank you and the U.S. Senate for having worked with AFN and the Alaska Native Community during the past millennium on issues of concern to AFN and the Alaska Native Community. During the last millennium, U.S. Congress passed a series of historic legislation that benefited the Alaska Native Community. Some examples of such legislation include, but are not limited to: P.L. 92- 203, the Alaska Native Claims Settlement Act; Indian Child Welfare Act, the Indian Self-Determination Act, Title VIII of the Alaska National Interest Lands Conservation Act; just to name a few. I would like to bring the following points to your attention up front: 1. As the 20th century closes, there are nearly 190,000 Native American military veterans. It is well recognized that, historically, Native Americans (including Alaska Natives), have the highest record of service per capita when compared to other ethnic groups. The reasons behind this disproportionate contribution are complex and deeply rooted in traditional American Indian culture. In many respects, Native Americans are no different from others who volunteer for military service. They do, however, have distinctive cultural values which drive them to serve their country. One such value is their proud warrior tradition. \1\ --------------------------------------------------------------------------- \1\ http://www.history.navy.mil/faqs/faq61-1.htm. 2. The Native American's strong sense of patriotism and courage emerged once again during the Vietnam era. More than 42,000 Native Americans, more than 90 percent of them volunteers, fought in Vietnam. Native American contributions in United States military combat continued in the 1980s and 1990s as they served in Grenada, Panama, Somalia, and the Persian Gulf. \2\ I would venture to say that 100% of the members of the 3rd Battalion, 297th Infantry Brigade volunteered to serve this nation in its Armed Forces. --------------------------------------------------------------------------- \2\ Ibid. 3. The outbreak of World War II brought Native American warriors back to the battlefield in defense of their homeland. Although now eligible for the draft by virtue of the Snyder Act, which gave citizenship to American Indians in 1924, conscription alone does not account for the disproportionate number of Native Americans who joined the armed services. More than 44,000 Native Americans, out of a total Native American population of less than 350,000, served with distinction between 1941 and 1945 in both the European and Pacific theaters of war. Native American men and women on the home front also showed an intense desire to serve their country, and were an integral part of the war effort. More than 40,000 Indian people left their reservations to work in ordnance depots, factories, and other war industries. Native Americans also invested more than $50 million in war bonds, and contributed generously to the Red Cross and the Army and Navy Relief societies. \3\ --------------------------------------------------------------------------- \3\ Ibid. Please note that these three points were excerpted from a website of the Department of the Navy--Naval Historical Center; 805 Kidder Breese SE--Washington Navy Yard; Washington DC 20374-5060. This is public information that is readily available for the people of the --------------------------------------------------------------------------- United Stated of America. The Need for this Hearing on the Delivery of Healthcare and Other Benefits to our Troops in Alaska Native Villages in Rural Alaska Thank you for demonstrating your concern for the well-being of all of our veterans; and in particular, the Alaska Native veterans living in remote rural Alaska villages. You've demonstrated your concern for the well being of our veterans in multitude ways; arranging this meeting of individuals and organizations concerned with the healthcare and other issues impacting our veterans, this public hearing, etc. I for one appreciate the commitment that you've demonstrated by your actions on veterans' issues. Please allow me to quote the comments you made on November 10, 2006--Veterans' Day: Thousands of Alaskans are serving in Iraq and Afghanistan today. We have extensive deployments from our military bases in Fairbanks and Anchorage. Additionally, over 600 members of the Alaska National Guard's 3rd Battalion who hail from nearly every community in Alaska--Southeast to Barrow. They've survived the summer heat at Camp Shelby in Mississippi. They will perform with valor in the Middle East. But they will have quite an adjustment ahead when they return home--many to remote places where veterans' services are hard to come by. They will be seeking the sympathetic ears of soldiers, sailors, airmen and marines who have been there and done that. I know Alaskans will provide that support and more. \4\ --------------------------------------------------------------------------- \4\ Quote from Press Release of November 10, 2006. I know deep in my heart, that you have a genuine interests for the well being of the Alaska Native and other veterans in Alaska, and in particular, those living in rural Alaska. Your intentions and concerns for the well-being of our veterans is genuine and you have demonstrated that time and time again by your actions and those actions speak louder than your words. Thank you very much for this. I know many of the returning members of the 3rd Battalion, 297th Infantry Brigade National Guard, many of them on a first name basis; from the Yukon Kuskokwim area. I've seen the National Guard members themselves when they are on R&R from their deployments and you know, some of them are different, their spouses and other family members also have told me that the guard member from their families are different; they appear the same physically but are different in other ways. I think the other ways they are referring to may be the manner in which the guard members are dealing with their deployment in Kuwait and the incursions many of them took into Southern Iraq. I think we can say we understand what these guys are experiencing but until we've been in their shoes, I don't think we can understand what they are going through. Many of the family members have told me these things because of the trust they have on their clergy. I serve as an acolyte in the Anchorage Moravia Church; and it has been in this capacity that people from the Yukon/Kuskokwim have told me these things. The best way of describing an acolyte in the Moravian Church is that we are commissioned by our church to carry out the duties of a pastor in absence of one--baptizing, officiating the Holy Communion, officiating marriages just to name a few. The biggest concern I've expressed time and again is the delivery of benefits our troops earned during their deployments overseas. Present paradigm: a veteran has to travel to Anchorage or other urban settings for their initial evaluation--they may not have the financial resources to accomplish this; and if they, when push comes to shove, the returning member will likely chose to help their family members rather than themselves if they find having to help their families or take care of their personal ghosts. Alternative means of delivering healthcare and other benefits to our veterans living in rural Alaska villages exist and may include, but are not limited to: 1. Utilization of telemedicine where available assuming VA's system is compatible to what is exists out there; (If VA's software is not compatible to the software utilized by the providers of telemedicine in rural Alaska, it seems such software can be developed for this purpose.) This capability exists and it has a great potential of being an innovative means of delivering healthcare and other benefits to the returning members of the 3rd Battalion, 297th Infantry Brigade, Alaska National Guard who have recently returned from their deployment in Kuwait and Iraq and other Alaska Native veterans residing in Native villages of rural Alaska. On Saturday, October 27, 2007, the delegates to the 2007 AFN Convention passed the attached resolutions: Welcoming home the 1st, 2nd, and 3rd Battalion 297th Army National Guard: This resolution welcoming the returning troops was passed unanimously by the delegates to the 2007 SFN Convention in Fairbanks, Alaska. 2. Utilization of existing health care facilities that exist in rural Alaska with VA reimbursing them for treating veterans in these facilities. This may require legislation to treat non- Alaska Native veterans if the health care facilities in rural Alaska are for Alaska Natives. I think this has the greatest potential of being an alternative method of delivering healthcare and other benefits to the returning members of the 3rd Battalion, 297th Infantry Brigade, Alaska National Guard who have recently returned from their deployment in Kuwait and Iraq and other Alaska Native veterans residing in Native villages of rural Alaska. Healthcare facilities in rural Alaska and VA care for veterans living in rural Alaska: This resolution was passed unanimously by the delegates to the 2007 SFN Convention in Fairbanks, Alaska urging VA to utilize healthcare facilities as a means of addressing the healthcare needs of our veterans living in rural Alaska. I've raised these points over and over in the past with the VA personnel and to date; I have not seen any earth shaking and convincing evidence and documents whereby VA promises that they have found different means of dealing with the delivery of these benefits our veterans have so rightly earned. As a matter of fact, I met with Mr. Peltola, President and CEO of the Yukon Kuskokwim Health Corporation on Friday, November 23, 2007 and we discussed this hearing and the fact that I was invited to testify in front of this committee on Friday, November 30, 2007. Mr. Peltola advised me that he met with you, Senator Murkowski, in August of this year (2007) in which he advised you that he has not met with anybody from the Alaska office of the U.S. Department of Veterans Affairs. He then advised that shortly after he had informed you of this fact, someone from Alaska VA offices have flown to Bethel to meet with him and his staff twice on the issues impacting the returning members of the 3rd Battalion, 297th Infantry Brigade. To date, he has not seen anything developing from these meetings; his conclusion was--this was all talk as he has not seen any developments on the delivery of healthcare and other benefits promised our troops from the time they were in active duty in the U.S. Armed Forces. Senator Murkowski, I've been involved in a number of meetings where VA personnel were present a number of times and to date, I've heard discussions of some plans or things VA is doing or plans to do in Alaska on the delivery of healthcare and other benefits to our veterans in rural Alaska; but to date, I have not seen any tangible things that Alaska VA is doing on finding ways and means of improving the delivery of the benefits promised our veterans in living in rural Alaska and in particular, the Alaska Native villages. Mr. Peltola and I have one common major concern: our returning troops, just like the other members of the OEF/OIF veterans across this nation will be experiencing mental health issues and we are not certain that VA in Alaska is ready to address this issue head on. VA in Alaska has no presence in rural Alaska any place. They live in accordance to their present paradigm of operation--veterans living in rural Alaska must pay their own way to the urban settings in Anchorage to be even considered for their initial evaluations; I do not see this paradigm changing anytime soon; not for the veterans of World War II, not for the veterans of `Nam Conflict, not for the veterans of the Kosovo Conflict, nor do I see VA changing its paradigm even for our troops from rural Alaska who deployed pursuant to OEF/OIF. Veterans in Rural Alaska and America The challenge of providing services to a rural and isolated veteran population extends beyond the boundaries of Native Americans and Alaska Natives; it affects all veterans living in rural and isolated areas of the Continental United States, and its territories. We recognize and we compliment the U.S. Department of Veterans Affairs for its strides in identifying and implementing systems and programs for rural and isolated areas; yet, challenges continue to affect that minority veteran population; and in particular, the Alaska Native veterans living in rural Alaska. This affects the returning members of the 3rd Battalion, 297th Infantry Brigade. There are some things that VA in Alaska must consider and some of those include, but are not limited to the following: Promote culturally and geographically relevant outreach programs and efforts throughout the VA, by Increasing and funding more fulltime positions for the training and hiring of Minority veterans, including Alaska Natives in Alaska in areas, where there is a large minority veteran population. At the present time, I do not think that there is a single Alaska Native on the staff of Alaska VA in any policy making position. We recommend that VA Alaska considers hiring Alaska Natives in policy making positions who understand the needs of the veterans living in rural Alaska, and in particular, the Alaska Natives. Increasing outreach, responsiveness, and formal consultation with tribal governments and tribal leaders, particularly out in the field. This issue has been the subject of several presidential addresses: -- Richard M. Nixon, ``1970 Special Message to the Congress on Indian Affairs;'' -- Ronald Regan, ``1983 Statement on Indian Policy;'' -- George H.W. Bush, ``1991 Statement Reaffirming the Government-to-Government Relationship Between the Federal Government and Indian Tribal Governments;'' -- William J. Clinton, Executive Memorandum (April 1994), ``Government to Government Relations with Native American Tribal Governments'', and Executive Order 13175 (November 2000), ``Consultation & Coordination with Indian Tribal Government;'' -- George W. Bush, Executive Memorandum (September 2004), ``Government-to-Government Relationship with Tribal Governments.'' Improving transition processing for Reserve and National Guard personnel returning from deployments. Improve diversity at all staff levels of the VA Alaska with veterans of various military background and rank reflective of both officer and enlisted members to ensure equitable representation of veterans and their experiences. There is no need to elaborate on this matter; but the following should be included, at the very least: VA must establish and monitor intensive training program for Senior VA leaders, managers, and their staff, on cultural diversities and language competencies within the veteran population being served. VA must employ or train personnel to be conversant in the predominant language or dialect within its sphere of influence and/or operation in order to assure the highest level of customer service. As an example, I think the Yupik language is the easiest language one can learn; many from my generation did not have to go to school to learn to speak Yupik; that is how easy this language is. The United States Congress, if necessary, should consider legislation that would mandate U.S. Department of Veterans Affairs to address the medical needs of veterans living in rural America and in particular, Alaska Native villages, including the mental health needs of the returning members of the 3rd Battalion, 297th Infantry Brigade. Finally, if VA Alaska does not demonstrate any visible means of addressing the needs of our veterans living in rural Alaska, maybe it is time for U.S. Congress to consider asking the United States Government Accountability Office (GAO), ``the investigative arm of Congress'' and ``the congressional watchdog'' to investigate what VA Alaska is doing on the delivery of healthcare to the veterans of OEF/ OIF in rural America and in particular, in rural Alaska villages and report its findings to Congress. I think such an investigation would be impartial and have credence since that is the job of GAO. GAO supports Congress in meeting its constitutional responsibilities and helps improve the performance and ensure the accountability of the federal government for the benefit of the American people, in this instance, veterans in America. GAO's work includes oversight of federal programs; insight into ways to make government more efficient, effective, ethical and equitable; and foresight of long-term trends and challenges. GAO's reports, testimonies, legal decisions and opinions make a difference for Congress and the Nation. \5\ --------------------------------------------------------------------------- \5\ http://www.gao.gov/. --------------------------------------------------------------------------- This final recommendation is a result of having thought of this over and over but in the end; it may be something that Congress might consider on the national insofar as the delivery of healthcare and other benefits to our veterans living in rural America and Alaska, especially in the Alaska Native villages. I incorporated the two resolutions that were passed by the delegates of the 2007 AFN Convention in Fairbanks, Alaska as part of my statement. I thank you for allowing me to submit this statement; I ask that my oral and written comments be incorporated into this hearing record. If you have any questions concerning my statement, please feel free to ask them. Attachments [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] Senator Murkowski. Reverend Nicholson, welcome. Reverend Nicholson. Yes. I would like to thank Mr. Nelson Angapak for inviting me to appear before you, Senator Murkowski, and mainly to share from the standpoint of a pastor and chaplain. I would like to share that recently I met with the Bishop Nikolai, the top religious official in the state of Alaska, and he assured me, and I know there are many other clergymen throughout the state of Alaska that are praying for our men and women in uniform who are in harm's way, and certainly we pray for our leaders from President Bush on down to the congressional people and so forth and our prayers go out for you. I would like to thank you, Senator Murkowski, for allowing me to share a few brief words. My name for the record is William Nicholson. I have served in the U.S. Army during OIF III. I am an Alaska Native from the Bristol Bay region and now live in Eagle River. I've served as a pastor for a long time, but recently in the Anchorage Moravian church for just about seven years. Soon I will finish 11 years in the Alaska Army National Guard as a chaplain. Let me share this; I don't think that we should minimize the problems that our vets and our families are suffering. As a civilian clergyman and chaplain of the 207th Brigade, Alaska Army National Guard, in the last month and a half, I have dealt with families that are disintegrating, that are suffering because of deployment to Iraq. Two families that had soldiers in Kuwait and another one that served in the striker brigade, who is now in the Alaska Army National Guard. I believe from my experience that post-traumatic stress disorder is a real concern. Also, the long deployment away from the family is weakening what really should have been good relationships and certainly there are many other--this is the tip of the iceberg. There are many other families and soldiers that need help out there. As one caregiver, I had done my part to do, my job and I would like to commend all of the other caregivers, whether it is family support or the mental health officials, whoever is involved with these families and vets are to be commended for their part. I know one of the very proactive, very positive activities that I looked at and participated in were the predeployment briefs that occurred down in the YK area before the soldiers left for Kuwait and I was happy as one clergyman to be invited and I know there were several other clergy from other denominations that were invited to listen in on the predeployment briefs and out of that came an interest on the part of several clergy. I was one of them. I, in turn, went back to our conference, the 23 churches, the Synod of the Alaskan Moravian Raven Church and also briefed them that we had soldiers going overseas and family members left behind that need to have support and I think that was a very good gesture. I personally gave a presentation to our Synod and prepared the clergy to be sensitive of the needs of the families and soldiers needing help. Now that our soldiers are back, it is a wonderful time, but it is also a painful time. One proactive idea that I would like to throw out here as far as follow-up which I plan on executing myself is to provide training for our clergy. We have our Synod every January, but I really feel that the clergy in our own denomination as well as the clergy within the state of Alaska who live and work in the rural areas should understand very clearly what post-traumatic stress disorder is, what the symptoms are, and how to refer our soldiers who are really experiencing difficulty. Thank you, Senator Murkowski. I will be free to remain and answer questions. Thank you so much. Senator Murkowski. I appreciate the testimony and your service. Ms. Davidson, welcome. STATEMENT OF VALERIE DAVIDSON, SENIOR DIRECTOR, LEGAL AND INTERGOVERNMENTAL AFFAIRS, ALASKA NATIVE TRIBAL HEALTH CONSORTIUM Ms. Davidson. Good morning, Madam Vice Chair and for the record, members of the Committee. [Speaking Native language.] Good morning, my name is Valerie Davidson. I am from Bethel and my mother's family is Yup'ik from Kwigillingok originally. We want to thank you for the opportunity to testify today about this very important issue. One of the things that we all know is that every Veteran regardless of geography, where they live or regardless of race, who need medical care, whether that is primary healthcare or behavioral healthcare, should have meaningful access to care. In Alaska, we always say, and I know you are great at reminding your colleagues in the Senate that Alaska is different, and for people who live in rural Alaska, rural Alaska is really different. There are a number of barriers, including the lack of VA infrastructure in rural Alaska, the lack of funding and authority to support the already existing rural health system and also the lack of systems that provide meaningful medical information throughout various different health systems. The most effective and efficient way to be able to extend the VA's capacity to be able to provide healthcare to Alaska's rural Veterans is by enhancing the Tribal health system's capacity to be able to provide healthcare and I want to emphasize that I want you to know that for the record, I didn't specifically limit that comment to Alaska Native Veterans. In many of the rural communities, in fact almost all of them, the rural healthcare system, the Tribal healthcare system, is the only healthcare system that is available to provide healthcare to anyone regardless of whether they are Alaska Native or not. Specifically, we recommend two things. One is the creation of a VA clinical encounter rate that is flexible enough to include both behavioral health as well as telemedicine to reimuburse IHS, and in Alaska, those are Tribally operated facilities that provide care to Veterans and their families. That precedent already exists for contracted community- based care in the Lower 48 states and surely if they can do it in the Lower 48 states, they should be able to extend that authority here in Alaska where our challenges to care are even more acute. The other challenge that we run into is both the IHS and the VA are both considered payers of last resort and any time you are dealing with two combating payers of last resort, which one really is the payer of last resort. In our opinion, the payer of last resort truly should be the Tribal Health System which is funded at a much less rate than the VA currently is. In addition, we also think that care should be extended to family where it is appropriate in order to be able to provide the best and most culturally appropriate care to allow Veterans to be able to reintegrate back into the community. NTHC, as you know, has been a really proud partner in the Alaska/Federal Healthcare Partnership and those comments and the extent of our involvement have been already outlined by Mr. Spector in both his written and oral testimony. In the interest of time, I am not going to delve into those, but I use that as an example to show that when we do pool our resources together and when we do work together, it is amazing what we can accomplish together, but I think regardless of that, I think we all agree, and what we have heard today from the previous panel is that despite our best efforts, we can work really hard. We can try really hard. We are missing the mark. There is more work that needs to be done to ensure that Veterans who live in rural communities have the same access to care that Veterans who live in Anchorage or in the Mat-Su Valley do. Extending the healthcare, the VA's ability to provide healthcare through the Tribal Health System and through our 216 health facilities in rural Alaska and throughout Alaska really is the obvious answer. The Tribal Health System just for the record and for those who don't know it as well as you do, is a voluntary affiliation of over 30 Alaska Tribes and Tribal Health Organizations that provide care throughout Alaska, throughout rural Alaska and we serve approximately 130,000 Alaska Natives, the majority of whom live in rural Alaska and interestingly enough, the majority of the patients that we serve live in communities of the average size of 350 people. The level of care in each community really depends on the location and the size. Typically, half of our patients receive their healthcare in 180 small Village clinics through 550 community health aides or practitioners statewide, 125 behavioral health aides who have training in both mental health and substance abuse and alcohol training, 12 dental health aides therapists, about 20 dental health aides, which is a lower level of dental health aide therapists, and 100 personal care or home care attendants, and again, half of our patient encounters in the Tribal Health System occur at those small Village clinics in Villages of approximately 350 people. Additional services are provided through referrals through the subregional clinic, through the regional hospitals. There are six regional hospitals and, again, those are the only hospitals that are available in that entire region. As an example, the Yukon Kuskokwim Health Corporation's hospital in Bethel is the only hospital that is available in the region about the size of the state of Oregon or 75,000 square miles and there are no roads connecting any of those communities. Of course, for tertiary care, our patients come in here to Anchorage. In addition to that care that already exists, we also can extend the care and extend that through our capabilities with telemedicine where local providers in our community can access care through the telemedicine system to providers outside of our health system and outside of our communities. One of the things that we know is our Veterans--we hear repeatedly that the current picture of healthcare for Veterans who live in rural Alaska is really complicated and almost inaccessible. Transportation is extremely expensive. You are lucky if you live in a community where you can get a $400 roundtrip plane ticket to come to the nearest clinic. Some communities, just to get from that community to Anchorage is a $1,000 roundtrip airfare and that is airfare alone. The other challenge is that if the Veteran doesn't fall within the correct priority level or percentage of disability or income requirements, the VA can't pay for travel and so that is an additional complicating factor. One of the other tenets of our ability to provide care to people who live in rural Alaska, and specifically right now I am going to speak to Alaska Natives, is our ability to be able to provide culturally appropriate care, not only to the Veteran, but also to the entire family. We know from our own experience that culturally-based care combined with family involvement is often the most effective way and the only effective way to treat our patients. At its absolute basic, Alaska Natives are more likely to seek healthcare in a system in which they feel comfortable. People who look like them, people who speak the same language, being able to go talk to a health aide, being able to speak to that health aide in Yup'ik, somebody who knows who they are, who knows what their experience has been and who also knows what their family experienced while they were gone. The other thing that is really critical, sometimes I think we miss in terms of access to primary care is the role that access to primary care plays in relationship to behavioral health. There is a critical link in terms of behavioral healthcare access since a majority of behavioral health issues are actually diagnosed in primary care visits and not by a referral to a behavioral health specialist. There are recent studies that have done--that indicate we can absolutely expect behavioral health issues to arise and we are not going to see them through a mental health professional. We are going to see them at our primary care visits. For example, a recent study looked at 100,000 Veterans who separated from active duty between 2001 and 2005, who sought care from a VA medical facility, and they looked at combination diagnoses, medical diagnoses of any kind and more than gunshot, more than anything else, the most common dual diagnosis was for post-traumatic stress disorder and depression, and in addition to that--and that is more than any other physical ailment. In addition to that, young soldiers were more than three times more likely than Veterans over 40 years old to be diagnosed with post-traumatic stress disorder and other mental health disorders and I am recalling the comment that was made earlier that the average age of the Veteran in the YK region is 28. The other issue is--so we know that those folks are going to--we can expect that. We just know that from the research and this is among regular Veterans. It is among Veterans who are also experiencing the huge cultural differences of moving from a community in which everyone speaks Yup'ik to a completely different foreign country where you speak to your Commander in English and then you are in another community that speaks another language entirely and I can't even begin to comprehend the strain of marching around in heavy armor at 140 degrees when our bodies are made for 20, 30 below, is just perfectly comfortable with us. So that is pretty close to a 200-degree comfort zone temperature difference. The other is outside of the military realm, there was a recent multinational study that was done unfortunately of people who had successfully committed suicide and what they found is that only one-third of those individuals, who unfortunately had taken their lives by suicide, had seen a mental healthcare specialist of any kind in the year before they took their lives. In contrast, 77 percent of those people who had ultimately taken their lives by suicide had seen a primary care provider. Seventy-seven percent had been to see a primary care provider and what is most startling is that during their primary care visit, they identified vague, nonspecific conditions like I'm having trouble sleeping, I'm having trouble eating. I'm experiencing a variety of physical manifestations that really indicate an underlying behavioral health issue and that we know that with a proper nine-question screening test, behavioral health screening test that takes two or three minutes at their primary care visit, that they would have resulted in a behavioral health referral. We also know, as was noted earlier by the previous panel, that Alaska Natives suffer rates of suicide at much higher rates than the other average American population or any other population and we are just very concerned that with the additional strain that our soldiers and their families are experiencing, that we need to be able to do those screenings at every single visit, whether it is a primary care visit, whether they are going to see the dentist or their health aide or whatever that may be. The other is that the issues that were identified earlier like post-traumatic stress disorder that may take awhile to be able to surface, but they are also very common for Veterans who are returning from recent military service, we know that those issues have a much better chance of being caught by people who, not only know the Veteran, who know their families, but can also provide access to immediate culturally appropriate care and within the context of their own homes, their families and within their communities. We also know that these same kinds of issues that are behavioral health issues also apply to people who are needing services after they have been treated for--who are experiencing traumatic brain injuries as well. There are some regions like the YK region who is providing behavioral health screening at their primary care visits and I think that is something we need to do more as a system. One of the things that we should be very mindful of is the significant impact of communities and our healthcare system is the impact that families are undergoing. The transition between departure, the absence and the return of the soldier extends way beyond the soldier, but extends to the family and also to the community and when we have Veterans who are Alaska Native who come from very traditional communities, those cultural differences really exacerbate those challenges and they complicate the transitions. Quite frankly, those challenges are really difficult for people outside of the Tribal Health System to comprehend, to appreciate and to incorporate into culturally appropriate treatment, and as First Sergeant Flynn indicated before, you know, we just--Alaska Native people, especially traditional Alaska Native people, we are taught don't complain, just take it, don't complain and we generally don't ask for help, and a part of that is--and that is especially true when you complicate that with your first medical encounter being with somebody who doesn't speak your language and somebody who is asking you in English how are you doing? Even if you encounter somebody on the street and you ask how are you doing, what is almost 99.9 percent of everybody's response? I'm fine, even if you are not. Unfortunately, we know that the VA doesn't typically extend care to the family and we know that families are going to be tremendously impacted. We expect the Tribal Health System to be seeing a huge increase in services that are going to be necessary for the families of Veterans and we also know that since the VA doesn't typically provide that service to families, that we are going to see the impact. You know, we want to be clear that the Tribal Health System really stands ready and we are proud to be able to serve our returning Veterans. We have done so since the beginning of time. We take care of our own and we are proud to do it. That said, the Tribal Health System is only funded in Alaska at about 50 percent of the level of need and we simply cannot continue to absorb the additional costs of subsidizing care for our returning Veterans. This isn't something that is necessarily commonly talked about, but there are at least three Tribal Health Organizations in our state who are currently experiencing rifts, who are cutting services and cutting programs because of the lack of basic funding to be able to provide our healthcare and this is coming at a time in which we are expecting our services to increase, not to decrease. So additional appropriations along with the payment authority for the VA to pay us for services that we provide just makes the best financial sense. Just in terms--from the testimony that was provided by the VA, it appears that in 2007, and I am not an expert in VA, so I am going--please pardon my creative math here, but from what I could tell, it appeared that in 2007, Veterans had approximately 6.12 outpatient visits per Veteran and that is some Veterans didn't get outpatient care, some did of those who were enrolled in VA. If we estimate that there are approximately 6,000 Alaska Native Veterans plus the Veterans who are receiving care who are not Native, but who are getting care in rural communities because we are the only place to go and you multiply that, those 6,000 times 6.12 times, the IHS encounter rate of $405, that is about 15 million dollars just in terms of providing primary care and we are not getting reimbursed for the services that we provide and it is something that--we should do something about it. We can't continue to be able to subsidize that kind of care. I guess one of the things that we need to remember is that at the end of the day as various healthcare systems, whether it is VA, whether it is the Tribal Healthcare System, whatever it is, we have to ask ourselves if we are providing the very best care to our Veterans and these are people that we are obligated to be able to provide care for and the Alaska Tribal Health System and the VA has mutual beneficiaries. We have separate appropriations. We have distinctly different budgets, but we have very similar missions. We know that we are underfunded and although the VA budget has increased by 40 percent, I think from 1999 to 2005, we know that their resources are not unlimited as well. We think that because the VA has increasing enrollment for eligible Veterans and limited capacities in the facilities in rural Alaska--well, they have no facilities in rural Alaska, that a marriage between access and services between the VA and the existing Tribal Health System on behalf of Veterans is the most effective and most efficient and the most appropriate way to be able to provide that care. By continuing to increase the VA's appropriations and creating a clinical encounter rate, Alaskan Veterans can be assured of meaningful cultural appropriate access to care in the communities in which they live and together we can accomplish this shared mission and our mutual beneficiaries, those Veterans who live in our communities will be better for it. As General Osborn indicated, we are really proud of the fact that our National Guardsmen performed with excellence and he said they did us proud and they hit the mark every single time and for those Veterans who did that for us, isn't it time that we perform with excellence for them, that we hit the mark in providing access, meaningful, local, culturally appropriate access to them? Wouldn't it be great if we were held to the same standard that they were and the service that they provided to our country. And in closing, and I think we can. We just have to eliminate those barriers. We have to make it possible and we have to do them proud just as they did us proud. I think I have probably talked long enough and in closing, we want to thank you again for your leadership and Committee for addressing this very critical issue on behalf of our families. [Speaking Native language.] [The prepared statement of Ms. Davidson follows:] Prepared Statement of Valerie Davidson, Senior Director, Legal and Intergovernmental Affairs, Alaska Native Tribal Health Consortium [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] Senator Murkowski. Thank you, Ms. Davidson. I appreciate your testimony and the level of detail and really, I believe a very positive solution. We have got issues of access that we need to address as our men and women are coming home. We don't need to reinvent the wheel. We have systems in place. They have proven to be effective systems even given the very challenging nature of where they are. We have figured out a way, you know, we don't have a doctor in every Village, we don't have a PA in every Village, but we have figured out a system out in our Villages in rural Alaska where we are able to provide for a level of healthcare that is able to meet that immediate need and to do the follow-up afterwards. I appreciate a great deal your recognition in your oral, as well as your written testimony, that what we are likely going to see happen here as the preferred alternative to provide the services to our Veterans is that they will go to the existing facilities within the Indian Health Service. That is where they are located. You avoid the cost of travel and the transportation expenses, and nobody wants to leave their family when you need help. We need to have that support locally, but when you recognize that you are putting one Federal entity, the IHS, in a situation where they are providing for that level of services that ordinarily would be required or provided through another Federal entity, that of the VA and you don't have a reimbursement going back and forth, that to use your words, you are effectively subsidizing the VA for their obligation. Now, what we have heard from Alaska Natives who have said I've got to get my healthcare somewhere and I will go to the clinic or I will go into Bethel, but as a Veteran, am I not entitled, have I not earned the right to have that Veteran healthcare? So we have got issues of access that we recognize. The challenge for us is how we truly meet that need, how we truly deliver on that promise. Mr. Spector, I want to go to you for just a moment. You have had an opportunity to hear from several, not only on this panel, but in the previous panel, the concern about just the logistics in coming to the VA and coming to the clinic here in Anchorage or even to the outpatient facilities there in Kenai and in Fairbanks. With the, I guess the benefit that is guaranteed to our returning Guardsmen, right now there is a two-year benefit that is provided in terms of the healthcare that is available as well as an additional or 90 days of dental care. You have got a two-year period where the Guardsman is able to take advantage of this. What happens after that two years? Mr. Spector. Well, my understanding on the two-year benefit is that that is given in order for the soldier to have time to apply through our Benefits' Administration for his benefits and establish service--connected service. That is the purpose of why it was set at two years, is my understanding. Senator Murkowski. So it gives them that window then. Give me a clear understanding, because we heard a little bit from Ms. Davidson that there is certain criteria that if you do meet it, transportation is provided, if you don't meet it, transportation is not provided. Can you clarify for us here today what the VA is authorized to provide in terms of air transportation, meal allowance, lodging for those that are off the road system who would come to town for care? What are ground rules? Mr. Spector. Travel eligible Veterans are those that are Veterans that are rated 30 percent or more service connected for travel relating to any condition, Veterans rated less than 30 percent for travel relating to their service connected conditions, and Veterans receiving VA pension benefits, Veterans with an annual income below the maximum applicable annual rate of pension for all conditions and Veterans traveling in relation to a compensation and pension exam. Those Veterans that meet that criteria are also eligible for some lodging eligibility and for Veterans that are on flight schedules where they miss their return home after traveling in, we give them lodging and things like this. Senator Murkowski. Is there a cap on either the travel allowance or the housing allowance, do you know? Mr. Spector. No, there is no cap. There is income criteria, annual income criteria for one group of eligible Veterans. Our lodging is--we have contracts with several hotels in Anchorage that we provide that lodging for. We pay them directly. Senator Murkowski. So if you haven't established your eligibility criteria yet, would VA be able to pick up the cost of transportation and lodging if that has not yet been established? How do you handle that? Mr. Spector. That would be considered a non-service connected Veteran and they would fall under a category of Veterans with an annual income below the maximum acceptable annual rate of pension. They would be eligible for cost of travel. Senator Murkowski. If they meet a certain income requirement? Mr. Spector. Correct. Senator Murkowski. And do you know what the income level requirement is? Mr. Spector. If I can ask my experts here? Senator Murkowski. Yes. Mr. Spector. Approximately $12,000 a year. Senator Murkowski. So if you earn less than 12,000, we will fly you in? Mr. Spector. Correct. Senator Murkowski. That is pretty low, incredibly low. What about Veterans from prior conflicts? We have got a Vietnam vet out in Chefornak, are they being provided any level of transportation or lodging accommodations to come to town for their service issues? Mr. Spector. That same eligibility that I stated is for all Veterans. Senator Murkowski. Okay, so it would depend if they had a 30 percent disability or greater, then they would be eligible for the compensation? Mr. Spector. They are eligible for travel, yes, and if they have 30 percent or less, they are eligible for travel if they are being treated for that condition. So if they have 20 percent for a back injury and they are coming in for treatment for a back injury, they would be eligible for travel because of the 20 percent for back. Senator Murkowski. Then I just want to make sure that I understand what happens in this two-year period. The gentlemen that were in front of us in the first panel here, they've just come home. You have got a minimum of two years free healthcare, 90 days dental. They have not yet gotten their disability compensation. They haven't done any of that. Are they eligible to come to town? Mr. Spector. Under the criteria I just stated, yes. Senator Murkowski. Under the income criteria? Mr. Spector. If they are not in service connected. But I would say in addition, this gets back to our Memorandum of Understanding with the National Guard, we are going to work together and look at situations as they occur and figure out how to get people in if they really need care and we have agreed to look at individual cases and try to figure out how we can move people. In addition, we do have social workers that work with Veterans that are not eligible for travel to find other resources possible that they could possibly use to get their travel taken care of. Senator Murkowski. What if I am a Veteran, I have gone back to Chefornak; I believe I need to come back into town for this treatment. Let's just say it is an ear issue. I talked to somebody yesterday, hearing loss. If it hasn't been determined that this hearing loss is a service connected disability, do I take a gamble in hoping that you are going to pay for my transportation and lodging in? What if I get here and you determine that, sorry, you have been out, you know, you go out hunting and you don't use protective covering over your ears and it is hunting related as opposed to--is that a risk that the individual runs? Mr. Spector. When Veterans enroll for healthcare in the healthcare system that we have, we do obtain information from our benefit side as to their percentage of service connection that is in their record, their healthcare record. So we would know prior to someone seeking an appointment whether they are eligible for travel or not and would inform them. Senator Murkowski. I am just trying to understand whether what we are offering these Guardsmen that we just saw here, whether we are offering them a viable benefit if you happen to live in a remote and an isolated area where transportation costs are as high as they are. If I understand what you are saying, if you make below $12,000 a year, you are going to be taken care of in terms of transportation. Well, if you get a Permanent Fund and if you get a dividend from a Native Corporation, you are probably over that $12,000 there, but you know, looking at what people are paying for fuel costs anymore out in our rural communities, that 12 grand can disappear in an instant. So I am just trying to understand whether we need to be doing something different because of the issues that we face here in Alaska with our isolation and our just very expensive cost of living? Mr. Spector. I would say that based on the travel eligibility, the benefit package for travel eligibility, it still leaves many challenges for Veterans in rural areas for their transportation to VA care in Fairbanks, Anchorage and Kenai. There are many Veterans who struggle with this issue. So this is not an extensive benefit that supports all of our Veterans in rural areas. Senator Murkowski. Have you raised through your chain of command the question of whether or not the VA should establish a policy of paying the transportation and lodging for these vets from these roadless areas across the board so that they can meaningfully receive these benefits? Has that been an issue that has been presented? Mr. Spector. Well, I would say that one of my roles as a Director of VA Healthcare in Alaska is to advocate for Alaska and make our Washington and my regional directors aware of the unique situations in Alaska and I think over the years, we have increased their awareness as to some of these unique challenges and have presented to them information that has enlightened them and educated them as to the situation in Alaska. So I would say yes, I have advocated and have stated and have tried to get, just as you and Senator Stevens tried to get, as many visitors up here to see. You have to see it to believe it. I have brought VA officials up here and I have taken them out to the Villages so they can get the picture that our situation is different, so yes. Senator Murkowski. We need them to get the picture so that we can get the funding because if we can't get the funding, you have got a great benefit on paper, but it doesn't materialize if that individual simply cannot provide for that trip into town for the care. Given that situation then, and this goes back to the comments raised by Ms. Davidson, it certainly seems very prudent for the VA to enter into partnerships with the Alaska Native Healthcare Delivery System to provide for a level of care through the regional hubs. Does the VA have the authority to purchase the care for eligible vets through the Native Healthcare Delivery System? Mr. Spector. There are certain Veterans that are eligible for purchased care based on their service connection and other categories of care. There are certain requirements that care be preauthorized, that a treatment plan be done and that payment can occur when VA services are not available. We do work with the ANTHC system to partner with them as far as a handoff of patients, but the direct payment to the Tribal System for care that they provide is not something that the VA does. Senator Murkowski. And that is something that I have raised with Secretary Principi and Secretary Nicholson and now the new nominee to be Secretary of Veterans' Affairs, General Peak. It just seems to me that this is where we have got to do it. If we don't have the authority to do it, if we need the legislation to make that happen, you have got a system in place that we can utilize. Let's figure out--you have got one Federal agency over here and one Federal agency over here. Let's not be so stovepiped in how this funding works. In looking at the Memorandum of Understanding between the VA and the Department of Military and Veterans' Affairs, I note that in the Goal One, seamless delivery of healthcare services to rural Veterans, the last bullet is an acknowledgment that due to lack of access to a VA facility for healthcare, rural Alaska Native Veterans will probably utilize the Alaska Tribal Health System. So there is an acknowledgment that it is happening, but it seems to me that part of the plan then is to allow for the Indian Healthcare System to provide for the care for our Veterans and they will pay for it and we have got to get to the point where you are taxing an agency that is already underfunded and VA is essentially getting the coverage that they need for our Veterans provided through another Federal agency and I know that this isn't--you and I have talked about this. We are on the same page, I think, but we have got to get to a point where we can get beyond the stovepiped systems because the care has got to be provided and we have got to figure out a way that we provide for the transfer of funding from the VA to reimburse IHS if they are going to be the ones that will provide this service. They have been providing the service and we have got to figure how we make that actually happen, otherwise you are going to further max out a system that is facing some financial strain. One of the things that I find interesting with the Memorandum of Understanding and I am very pleased as I said, that one of the goals is this ongoing dialog and discussion. Let's keep working this through so that we really are moving ourselves to that point where you have got a seamless transition. And I have to tell you with all respect to those that entered into the MOU, when I use the term seamless transition at the--whether it was at the WTU or when I met with the vets at the Vet Center up in Wasilla, they all laughed. They do not believe that we have a seamless transition at this point. So we recognize that we have got a fair amount to do there, but the Memorandum of Understanding is between the VA and the State of Alaska recognizing the need to work with the Native Healthcare System, but yet, we don't have the Alaska Native Healthcare System as party to the Memorandum of Understanding. So is there an understanding or are you working to provide for that further cooperative effort between the Alaska Native Healthcare System and the VA? Mr. Spector. I think I agree with General Katkus. This is the beginning. This was a statement between the National Guard and the VA to work together and it was a message to the rest of Alaska and our community services and others, come on and join us and help us in this area and we have had discussions with Mr. Paul Sherry through the CEO of Alaska Native Tribal Health Consortium and a member of our Alaska Federal Healthcare Partnership of bringing, not only ANTHC, but DOD, active duty Army and Air Force on similar agreements. They have been at the table with us from the beginning. We are having ongoing monthly meetings, not only with them, but also other community social agencies joining this discussion. So this MOU was a good catalyst to begin a discussion and keep it going for the future. So it is just a beginning. Senator Murkowski. Has there been any discussion between the VA and the Alaska Primary Care Association about perhaps utilizing the community health centers to deliver care as yet another option or another vehicle? This is something that I know has been utilized in at least one other state down in the Lower 48. Is this something else that we could look at? Mr. Spector. I think we should look at that, yes. We have not had extensive discussions about the community health clinics and also the legal instrument to share with them. These are things that we are exploring and I am familiar that there is one state in the Lower 48 and I am very interested to see how they are doing this so we can learn. Yes, I will explore that. Senator Murkowski. Well, we are looking into that as well. I think what I am taking away from this particular hearing as well as the series of meetings that I have had over the past couple of days is we have got to use all of the tools in the toolbox and to just say that you are a Veteran, so we just go to--if we build a Veteran's hospital here in Anchorage, we have solved that problem. That does not solve the access issue to our Veterans in this state and we are going to have to utilize, whether it is the Alaska Healthcare Systems through ANTHC, whether it is our community health centers, we have got to be utilizing all of it and I think we have got to get beyond the traditional model that the Lower 48 can use because they are all connected down there. I think we have got to stop looking at them as the way that we operate and we agree that we have to be innovative and if we are not innovative, we are letting down those who have served us. So this is an opportunity for us all to kind of get out of that box and really work on it. So the MOU is a start, but we need to view that as a very, very preliminary start. One more question to you, Mr. Spector, and then I will move onto the rest of the panel here. Mr. Angapak very eloquently kind of outlined the situation that many of our Veterans experience, that there just isn't a VA presence out in rural Alaska that is a meaningful presence. How can we do a better job of that VA outreach? Do you get any kind of funding to conduct this outreach? What do we need to be doing better because it is clearly not satisfactory? Mr. Spector. Well, we have made several initiatives in outreach to rural areas. Mr. Angapak mentioned the Bethel area and YKHC. We have been out there more frequently than he expressed and most recently, we took a team of eligibility healthcare experts and mental health experts to all of the regional or to most of the regional hospitals that accepted our offer. We presented information to the healthcare systems and the regional hospitals regarding Veterans' eligibility, Veterans' benefits and we presented information on post-traumatic stress syndrome disorder from our psychiatric staff, presented in- service education to the primary care physicians and mental health physicians and behavioral health aides. We were connected on the video conferencing to the small Villages in each of those areas and talked about signs and symptoms and warnings for this problem. We provided information with our OEF/OIF manager and our transition patient advocate of how to get people into our system. If you have people that enter the--Veterans who enter the Native Healthcare System that would like to come into the VA system or have a medical or mental health problem that the regional hospitals need assistance on, here is who you get a hold of, here is how you get them into the system to bust that red tape that you hear about and offer these services. It is still early, as the General mentioned, in the return of our soldiers to see the effectiveness of our outreach. We are also working closely with the National Guard again to return to the National Guard sites and armories throughout Western Alaska on return visits, 180 days out, one year out with our mental health staff, with our OEF/OIF manager and address individual problems if they occur later. So we continue to have outreach efforts. Our service organizations in Alaska, also the American Legion, VFW and DAV visit on frequent basis to these sites also. One other effort that we are trying to get started, and Nelson has helped us on this, is what we call our Tribal Veteran Representative Program, and last year, we offered some training to Tribal Veteran representative, people from the various Villages that are trusted Veterans, trusted members of their Tribe that could present benefit information and healthcare information, how to access healthcare. We started out small. We only had two requests, but we are going to do our training again in February or March. We have made some other contacts, especially in the Nome area that we think we are going to increase our representation. I heard from the earlier panel a good idea of recruiting some of our returning soldiers perhaps. So we want to explore that further to provide more information. I agree with the panel members that I think the number one complaint I hear from Veterans is we don't know what our benefits are. We don't know how to access the care and we continue to try to improve that and work on it and brand that in areas, but we still have a long ways to go. Senator Murkowski. Well, I think it is going to be very important that the VA be viewed as a favorable partner and not this stranger that you occasionally see somebody from town come out to the Village. So to have the Tribal representatives, to have the local contact within the community is going to be key, but again, who is going to provide for the funding for this Tribal representative to get around from community to community? You can't expect them to pull 400 bucks out of their pocket to travel from Chefornak to Bethel or wherever. You can't really ask the IHS to, again, pick up that. You can't shift those costs. We have got to say well, if we are going to really provide for meaningful benefits and make sure the people understand them, we are going to have to figure out how we get out there again. So, it is not just allowing for a training and designating somebody, you then have to give them the ability to get out and communicate that message. So we have got to be working with you on that. I look at the makeup of this table and whether you are active, you are Guard, the folks within the Healthcare System, the clergy, the Native leadership, the VA, the Federal agencies, everybody has got to be sitting down and talking about what is really happening. I love goals, they are wonderful, but if you hear that your goal is not being implemented by General Katkus' guys that are out there and Valerie says well, you know, this is what we are getting coming into the clinic here, we have got to have a level of a clear understanding as to what is really going on. We have got to figure out how we can make what is available through the VA and the benefits that have been earned, understandable so that they are usable, otherwise, they are nothing more than kind words on paper. And you mentioned, Mr. Spector, that we are still kind of figuring this out. I think the frustration that I hear in Nelson's voice is hey, us guys from Vietnam, we came back 30 years ago plus and we still haven't received the outreach that we earned and we deserve. We are still waiting for somebody to come and visit us and explain to us our benefits. So we need to recognize that this is an ongoing education. It is not just with OIE/OIA. This obligation is for as long as we are going to be around. Valerie, you wanted to jump in there? Ms. Davidson. I appreciate your question and your comments and I think there is another model where that kind of outreach and education can occur. We have the same challenge in getting people enrolled in Medicaid, Medicare and SCHIP, and I was noticing that Commissioner Karlene Jackson is in the audience today and the State Department of Health and Social Services really has done an excellent job of providing resources to Tribal Health Organizations to be able to do outreach and enrollment efforts for Medicaid, Medicare and SCHIP, which are also very complicated programs, very challenging for folks to apply, et cetera, and that is a model that we can look to, to provide those resources in the local community to be able to get that message out there, to educate people that there is a benefit, to clarify and help people fill out the enrollment forms, and there is one thing that is a little bit interesting here that we should take advantage of our captive and helpful audiences where we can. For example, these folks who are returning are typically men. If they are married, they have wives. If they are not, the probably have girlfriends and these ladies are typically the ones who seek out the benefit and typically the ones who seek out and encourage them to get healthcare and these are also the ladies who these returning soldiers are highly motivated to please after being gone and absent for extended periods of time and I would venture that if we did outreach efforts to the ladies in their lives, whether those are their mothers, their wives, their girlfriends if they are not married or to their grown daughters, that we are going to have one heck of a network out there and I, of course, don't have to explain the power of a lady to you, but it is amazing how much influence a good woman has in the life of a good man. So I think that is something we should look at. Senator Murkowski. It is an excellent idea. You know, when you think about how, and you all have been there, how your benefits package is presented to you, and we heard this from First Sergeant Flynn, who said you know, I get a big packet of stuff and I am thinking about other things. Who knows where that packet of stuff went, but when he got home, his wife probably unpacked things and went through that, but we need--if we can, again, to kind of think outside the box here. Maybe we are not using the right messenger to deliver the important message about the benefits that are available. I think we can be a little bit more creative. I appreciate that and I think Reverend Nicholson, you know, from your perspective as a member of the clergy, the outreach, again, that can go on from within those circles. You are not the VA Benefits' rep, but you are in a position to know and help share information that can be helpful to, not only the 28-year-old vet, but to some of the more senior vets as well. Mr. Spector. Ma'am, if I could address some of that? We had that very discussion this week about the clergy in Alaska and reaching out to them and having some sort of educational session for them. I now have a source, it looks like, to go at least for the Moravian conference in January perhaps that we can present some information because many of the clergy will see problems and people will seek advice from them and, again, the more information they can have. If I could address the packets of information in Camp Shelby? We gave out 300 packets of information to soldiers recognizing that they probably would not read them there, but take them home. Since the return, we have over 200 applications for healthcare through our system. We have almost processed all of those. Most of the soldiers are not asking for an appointment at this time. Most of the Veterans are not asking. They want to be enrolled in case they need that in the future. So we have made some progress with the returning soldiers even already. Senator Murkowski. Let me ask a question to you, Mr. Angapak, and possibly to Reverend Nicholson as well. Earlier this week, I was out in the Valley, went out to the Vet Center there, and I am told that one of the parts of the VA that seems to be working well is the Vet Center. They go, they can get some counseling, they get some help, just kind of understanding the whole process of the benefits and how it all works, kind of how you work with the system, but of course, as you know, we don't have any Vet Centers in rural Alaska. Should we be asking for the bricks and mortar out there in rural Alaska, some other way that we can get out to more Veterans? We recognize that is limiting because then again, that is in just one regional hub, say Bethel or Nome. You talk about the outreach that we would like to have, whether we need to have greater coordination with Native Veteran outreach and advocacy. What can we be doing better to address the outreach issue that you have very clearly raised, Nelson, and you have certainly suggested, Reverend? Mr. Angapak. Thank you very much, Senator Murkowski. Let me respond to that question in the following fashion. I am hopeful that this public hearing is opening the door of us getting out of the paradigm, thinking outside of the box. Now, I think as part of that thinking outside of the box, in the immediate term, I think Vet Centers in rural Alaska is probably not the best idea in the world. I would venture to say that VA should consider utilizing the existing healthcare systems that are already in place. The infrastructure is there, but I think in order to utilize the existing healthcare facilities out there, VA should consider, and including the Indian Health Service, should consider training our physicians in rural Alaska to deal with issues that are faced by our Veterans. I say this because while a psychologist who deals-- psychiatrist and psychologist that deal with general issues of the public, I think those psychologists and psychiatrists have to be trained to recognize issues that are faced by our Veterans, mental health issues like PTSD, that type of thing. So I think in the immediate term, it seems that the right thing to do would be to utilize the existing systems. However, there must be some method whereby the existing healthcare facilities in rural Alaska are reimbursed for the services that they provide to our troops out there. Senator Murkowski. I appreciate it. Reverend Nicholson. Reverend Nicholson. Yes, let me share just some very brief comments here. I certainly appreciate in the interest in allowing the clergy to be involved. I am just one, but I know that there are a good number of clergy, some top religious officials that are interested in the welfare of our Veterans and I can speak from experience during my recent ADSW (ph) for the Alaska Army National Guard (temorary duty), I spent about a week visiting to the top bishops and archbishops of the big- named denominations within this state and I shared with them the need for Army chaplains in the military, but on the side, I had an opportunity to find out what their thoughts were in regards to the welfare of soldiers and their families and I think there is a lot of information that can be shared and I do know that, as I alluded to, Bishop Nikolai of the Russian Orthodox Church, he says Chaplain, come on down. I need you to speak to all of the clergy in this state during their conference and address ministry to troops. We know there are needs there and we are praying daily as clergy, and I suspect that there are many other mainline denominations that would like to be involved, but need the information to respond. I appreciate the fact that spiritual caregiving is treated as important along with the healthcare delivery. The clergy within rural Alaska are seen as leaders within their communities and if there are any problems, usually the clergy are some of the first responders and that has been my concern. I know in Panel A, General Katkus shared that United States Army chaplains within the Alaska Army National Guard context are available to travel and I have done some of that during this deployment to meet in the Villages and I have lived in rural Alaska. Now I live in Eagle River and getting out there with the weather and so forth is very, very difficult. We will set the mission in place. We are going to visit X-number of Villages, but then we find that only just a small proportion of those Villages are actually visited. I think lastly, let me share this, that again, it is a reiteration that we need to train our clergy since they are first responders in many cases to recognize PTSD and how to refer and some of the information that needs to be disseminated is where to refer them. So that is a key too. Senator Murkowski. Absolutely. Reverend Nicholson. Thank you. Senator Murkowski. General Katkus, I am going to give you the last word as the leader of these proud warriors. You have had, anything final that you might like to add at this point in time, we would certainly welcome that. Brigadier General Katkus. Senator, thank you for the opportunity to sit through this panel also and to be here today. It is very important for me to be aware of what is going on all across the board. To tell you that I have been busy the past nine months I have been in this position would be an understatement. The opportunities to always hear a good idea are always present and today was a great opportunity to hear one of the best ideas was the target audience for some of the benefits being the family members. Having been down in Shelby and both, two points of friction were created as a result of the soldiers initially identified to WTU staying locally, that caused a lot of friction to get that turned around where they could come here and our numbers went from near to 0 to 37 just in that small thing alone. To say any friction, that was an understatement also. The other one was slowing down the train on getting them back to Alaska. The soldiers are so anxious to get back here. That is absolutely the wrong time to try to get anything to them. Obviously, when I turned off some jets back there, they got pretty excited about that, but it was a necessity that had to be done because those soldiers weren't doing anything except focus on coming home. So like I said, I live with the friction I create, but for the best reasons and I think I will get a lot more bang for the buck by talking to family members. So thank you for the opportunity of really driving that home today. Thank you, ma'am. Senator Murkowski. I thank you. I thank all of you for giving us your insight, your testimony today. I think it was very valuable. I do hope that we take from this, that this is truly a collaborative effort. When we say there needs to be a comprehensive plan for our Alaska Native Veterans, for all of our Veterans, quite honestly, that means that we all need to be engaged. I think we have had some good suggestions here today. There is a lot that we can follow-up on. We will certainly do that on our end and I would urge you within your respective capacities to do that as well. We have got a great deal to offer. We have great successes in this state despite our challenges and we need to remember that instead of getting overwhelmed by some of the obstacles that we face. Once again, I will remind those that the record on the hearing will remain open until Friday, December 14th, so if you want to supplement any statements or anybody else who would like to provide to that testimony, you can submit it by e-mail to indian.senate.gov. You can mail it or fax to the Committee as well. We do appreciate all of those who have joined us to listen and, again, I would urge you to in your respective capacities do what you can to help our Veterans as they come home and start by first thanking them and then ask what you can do to help them get a job. With that, we will conclude the hearing and, again, thank you very much. [Whereupon, at 12:19 p.m., the Committee was adjourned.] A P P E N D I X Prepared Statement of Hon. Byron L. Dorgan, U.S. Senator from North Dakota I regret that I cannot join my colleague, Senator Murkowski, at today's hearing in Anchorage. I am pleased, however, that Senator Murkowski is chairing today's hearing to receive testimony on the access to and delivery of health care services to members of the 3rd Battalion, 297th Infantry Brigade, Alaska National Guard. I understand these soldiers, many of whom are Alaska Natives, have recently returned from deployment in Kuwait and Iraq. Today's hearing is one more example of Senator Murkowski's commitment to improving health care for Native Americans and Alaska Natives. I am aware that a higher percentage of Native Americans have served in the armed forces, and continue to serve today, compared to the U.S. general population--24 percent versus 19 percent, respectively. I am also mindful that Alaska Natives play a significant role in the Alaska National Guard. I share the Vice Chairman's concern that Native Americans--in Alaska and in the ``lower 48'' states--who serve in the Middle East and in Iraq, in particular, face challenges in having access to health care upon their return from deployment. I look forward to reading the testimony from today's hearing and learning the recommendations of today's witnesses regarding how the Department of Veterans Affairs, the Indian Health Service and the Alaska Native health care delivery system can improve on providing for the needs of returning veterans. I thank Vice Chairman Murkowski for her initiative in seeking answers about the health care services to Alaska Native veterans. I also appreciate that the witnesses have made time in their schedules to present testimony at today's field hearing. ______ Supplementary Information of Nelson N. Angapak, Sr., Vice President, Alaska Federation of Natives [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]