[Senate Hearing 110-278]
[From the U.S. Government Publishing Office]

                                                        S. Hrg. 110-278


                             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

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                      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
                Sara G. Garland, Majority Staff Director
             David A. Mullon, Jr., Minority Staff Director

                            C O N T E N T S

Hearing held on November 30, 2007................................     1
Statement of Senator Murkowski...................................     1


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


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 


                       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.

                    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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.


    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 
    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 
    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 
    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 

   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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    Senator Murkowski. Anything else any of you would care to 
    [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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 


    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 
    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 
Outreach for Operation Enduring Freedom/Operation Iraqi Freedom (OEF/
        OIF) Veterans
    Preparation has included:

   Hiring of dedicated staff for outreach to soldiers and 

   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 
    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 
    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 
    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 

        1. Ensure Seamless Delivery of Health Care Services to Rural 

        2. Enhance Home Station Reunion and Reintegration Workshop for 
        Returning GWOT Veterans to Include Post Deployment Health 

        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.

                        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 
    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 
    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 
    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 
    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 
    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, 
    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 
    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
    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 
    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 

        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 
    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\ 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 

        -- George W. Bush, Executive Memorandum (September 2004), 
        ``Government-to-Government Relationship with Tribal 

   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 
    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.


    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 
    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 
    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.


    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 
    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 
    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 
    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 
    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


    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 
    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 
    Senator Murkowski. If they meet a certain income 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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