[Senate Hearing 111-921]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 111-921
 
     FIELD HEARING ON VETERANS' ACCESS TO BENEFITS AND SERVICES IN 
                               APPALACHIA

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                             APRIL 5, 2010

                               __________

       Printed for the use of the Committee on Veterans' Affairs


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                     COMMITTEE ON VETERANS' AFFAIRS

                   Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West         Richard Burr, North Carolina, 
    Virginia                             Ranking Member
Patty Murray, Washington             Lindsey O. Graham, South Carolina
Bernard Sanders, (I) Vermont         Johnny Isakson, Georgia
Sherrod Brown, Ohio                  Roger F. Wicker, Mississippi
Jim Webb, Virginia                   Mike Johanns, Nebraska
Jon Tester, Montana                  Scott P. Brown, Massachusetts
Mark Begich, Alaska
Roland W. Burris, Illinois
Arlen Specter, Pennsylvania
                    William E. Brew, Staff Director
                 Lupe Wissel, Republican Staff Director


                            C O N T E N T S

                              ----------                              

                             April 5, 2010
                                SENATORS

                                                                   Page
Brown, Hon. Sherrod, U.S. Senator from Ohio......................     1

                               WITNESSES

Greenlee, Rich, MSW, PhD, Dean, Ohio University Eastern Campus...     4
    Prepared statement...........................................     6
Maupin, Lucinda, Veterans Service Officer, Belmont County........    12
    Prepared statement...........................................    14
Neutzling, Andrea Michele, Veteran, Meigs County.................    15
    Prepared statement...........................................    17
Graves, Kim A., Eastern Area Director, Veterans Benefits 
  Administration, U.S. Department of Veterans Affairs; 
  accompanied by Joyce Cange, Director, Cleveland Regional 
  Office; Jack Hetrick, Director, VA Healthcare System of Ohio 
  (VISN 10); Jeffrey Gering, Director, Chillicothe VA Medical 
  Center.........................................................    26
    Prepared statement...........................................    28
Bill Hartnett, Director, Ohio Department of Veterans Services....    31
    Prepared statement...........................................    33


     FIELD HEARING ON VETERANS' ACCESS TO BENEFITS AND SERVICES IN 
                               APPALACHIA

                              ----------                              


                         MONDAY, APRIL 5, 2010

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                     Cambridge, OH.
    The Committee met, pursuant to notice, at 11:18 a.m., at 
the Scottish Rite Auditorium, Hon. Sherrod Brown, Member of the 
Committee, presiding.

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

    Senator Brown. I call the meeting of the Senate Veterans 
Committee to order. Thank you all for joining us. Chairman 
Akaka and Ranking Member Burr, who were very cooperative, sent 
along both Democratic and Republican staff to Cambridge to 
assist us today. Senator Akaka, whose home State is Hawaii, 
likes to begin these hearings with ``Aloha,'' so I guess will 
do the same, but I don't want you to think I'm going up town by 
acting like I speak Hawaiian or something.
    Welcome to all of you here. A special thanks to a whole 
host of people who have been particularly helpful: Tom Fisher, 
Carl Lambert, Troy Simmons, and David Moyer, who are doing the 
lights and sound, and are the facilities manager and the 
director of this beautiful theater. As I was walking in, I 
talked to Tom and Carl about how theaters like this bring back 
memories. If you're my age or older you remember sitting up in 
the balcony and watching movies on a Saturday and putting gum 
underneath your seat and all the things people have done for 50 
years in these theaters. Thank you for that memory, but more 
importantly what we're doing here today.
    I have got a handful of introductions: County Commissioners 
Steve Allen, Tom Loughlin, and Steve Douglas are here; also 
Linda Secrest, who is out of the agency next door, the Linda 
Secrest Drug & Alcohol Abuse Programs, and she obviously has a 
direct impact some of these veterans programs, too. Outside I 
met the head of the Veterans Service Organization in Noble 
County. Is he here still? I appreciate his comments about how 
hard he has worked--he's done this for 21 years, you said?
    Unidentified Speaker. Yes.
    Senator Brown. You have worked hard on making sure that 
every returning vet that comes to Caldwell or is anywhere in 
Noble County, a small, well-populated but rural county where 
people come and go and where you don't necessarily know they're 
in the community--how quickly you have run to The American 
Legion, the VFW, and other veterans organizations to locate 
these returning veterans so they can get screening and 
treatment. There was one vet who was hit by a bomb--we call 
them IEDs--but they're really bombs, in Iraq or was it 
Afghanistan?
    Unidentified Speaker. Iraq.
    Senator Brown. He didn't think he needed treatment. He had 
already had treatment and didn't need really much else, but the 
VSO convinced him to come in. Now they're following his medical 
progress and helping him to make his life better. That's why 
the community services that the VSOs are providing are so very, 
very important.
    I would like also to introduce before the hearing, in 
earnest, Doug Babcock, who is behind me. Doug is from Galion, 
OH, grew up near where I did in Mansfield. Doug is from our 
Washington, DC, office and works tirelessly on behalf of 
veterans. Doug's wife is from Zanesville, so Doug is close to 
home, just one county over.
    Today's field hearing is an official U.S. Senate Committee 
on Veterans' Affairs hearing, or an official Senate hearing. 
Everything that will happen today--the rules, the procedures, 
the testimony--is just like you would see if you attended a 
Senate Veterans' Affairs Committee hearing in Washington, DC.
    Chairman Akaka and the Committee are holding this hearing 
in Appalachian Ohio because it is important to hear directly 
from veterans in their hometowns and in their regions. Senior 
Committee staff members are here. The testimony will be 
recorded and available for every Member of the Committee, the 
Senate, and the public.
    Thank you, first of all, to the witnesses for testifying, 
who I want to introduce in a moment. Thanks for your service to 
our Nation and its veterans. Thanks also everyone here who 
works in their communities, with our State and Federal 
Government, and local governments on behalf of our veterans.
    Veterans in Appalachia face unique challenges, from social 
and economic isolation to distant health care facilities and 
misallocation and lack of resources. It is vital that these 
challenges are understood by the Committee and the Senate, so 
as laws and regulations are written, the concerns of these 
veterans are heard and are addressed.
    It's fitting that this hearing is being held in Cambridge, 
OH. This great city predates the State of Ohio, when pioneer 
Ebenezer Zane named it while cutting roads through the 
Northwest Territory. For more than 200 years Ohioans have been 
calling these rolling hills home, building middle-class 
communities, raising families, and pursuing the American Dream.
    Across the street is the John Herschel Glenn, Jr. Post 
Office, named in honor of the famed astronaut and statesman. 
The former Marine pilot is a typical representative of 
Appalachian Ohio: patriot, hard worker, family man, principled, 
and true to his values. I am honored that we could bring this 
field hearing to his birthplace.
    Veterans in Appalachia don't always go out and orbit the 
earth or serve in the U.S. Senate or become the epicenter of 
our Nation's most historic moments of the 20th Century. Yet, in 
many ways, veterans in Appalachian Ohio constitute the very 
character of our Nation, serving our country in times of war 
and returning home to become teachers and police officers, 
doctors, business and civic leaders, factory workers, and 
craftsmen. But too many Appalachian Ohio veterans continue to 
struggle with the results of their service to our country or 
otherwise face difficulties transitioning from soldier to 
citizen.
    Last week I visited the Chillicothe Veterans Medical 
Center, one of the most important medical centers of the 
country, serving this State, this part of the State, very well.
    In 2007 I held a Senate field hearing in New Philadelphia 
that focused on VA health care in Appalachia. At that hearing, 
Terry Carson, a hospital administrator from Cadiz, not too far 
away, testified about the challenges of providing care for 
rural veterans. He testified about how his hospital was trying 
to do the right thing when treating vets facing medical 
emergencies. But as much care as the hospital could provide, 
the hospital often got stuck with the medical bill because the 
VA, through a series of rules and regulations, prohibited it 
from getting reimbursed.
    After hearing his testimony, and that of Appalachian Ohio 
veterans, I introduced The Veterans Emergency Care Fairness Act 
of 2007 to require the VA to reimburse a private hospital, 
which are more often than not in rural counties, for emergency 
care before a vet is transferred to a VA medical center. 
Congressman Zack Space of Ohio's 18th District, who joined me 
at that hearing, introduced the House version of the bill. That 
bill is now law.
    While we were successful in enacting that law, it's clear 
that challenges or problems facing veterans in Appalachia 
remain. Vets in our part of Ohio struggle with access to 
information about benefits, health care, education, and job 
training. Larger cities have more resources and veterans have 
shorter distances to travel to access them. The economic 
outlook happens to be tougher if you live in Guernsey County 
and any of the surrounding counties. The economic outlook is 
tougher here than it is in Columbus, just over an hour away.
    As citizens face difficult financial realities and barriers 
to economic opportunities, Appalachians struggle to keep up 
with their big city and suburban counterparts. Simply put, 
there are more economic resources available for veterans in the 
larger and more populated areas than there are in more rural 
areas, of course. There are more private resources, more non-
profit resources, more governmental resources, and more people 
available to lend a helping hand.
    Despite these challenges, we recognize that veterans where 
ever they may live are entitled to benefits they have earned 
and deserve, benefits that include higher education, home 
ownership, and job training. Veterans have always been, as we 
know, the key to powering our Nation.
    When Franklin Roosevelt signed into law the original GI 
Bill in 1944, it not only provided servicemembers with an 
education, it strengthened our Nation. Imagine in those years 
after World War II where seven million veterans took advantage 
of the GI Bill. It meant a great opportunity for each one of 
those seven million veterans in getting an education, getting 
work, building a home, and starting a family. It helped quite a 
bit in creating the prosperity that this Nation enjoyed after 
World War II. That is an example of government helping both 
individual people and the larger public.
    The Department of Veterans Affairs Mission Statement reads: 
``To fulfill President Lincoln's promise `To care for him who 
shall have borne the battle, and for his widow, and his orphan' 
by serving and honoring the men and women who are America's 
veterans.''
    Thank you again for attending the hearing. We will now hear 
testimony from two panels of witnesses. Our first panel I'll 
introduce and call for each of them to speak roughly 5 minutes, 
or however long they need, and then we'll have questions.
    Our first panel of witnesses consists of three veterans. 
Two of them will describe their story and experience living in 
Appalachia as a veteran. We will start with Dr. Greenlee from 
St. Clairsville.
    Dr. Greenlee is an expert on Appalachia and will paint a 
picture of Appalachia and what people living here face in their 
daily lives. As a veteran, his perspective is particularly 
useful. Dr. Greenlee is a well known expert throughout eastern 
Ohio and earned his Ph.D. in social work from The Ohio State 
University. He has a Masters of Social Work degree from the 
University of Pittsburgh and a Bachelor of Science degree from 
the University of Maryland and currently serves as Dean of Ohio 
University's Eastern Campus in St. Clairsville.
    We'll then hear from Cindy Maupin, who served 8 years in 
the Army. Not only is she a veteran, but also serves veterans 
and their families every day as Director and County Veterans 
Service Officer in Belmont County. She has been in that 
position for the last 9 years. She graduated in 1980 from 
Bellaire High School. She has worked for the Belmont County 
Veterans Office since June 2001. She's a lifelong resident of 
Belmont County and currently resides in Bellaire with her 
husband Don and son, Woody.
    Our last witness is Andrea Neutzling from Pomeroy in Meigs 
County. She served active duty in the Army for 4 years, then 
5\1/2\ years in the Army Reserve. She was deployed to both 
Korea and Iraq. She was assigned to military intelligence. 
While in Iraq she was wounded in the shoulder, which put an end 
to her aspirations to be a police officer when she returned to 
civilian life. She is currently studying for a degree in 
counter-terrorism at Ohio University. Thank you all for your 
service to our country and thank you all for continuing to 
serve veterans. Dr. Greenlee will start.

STATEMENT OF RICHARD W. GREENLEE, Ph.D., ASSOCIATE PROFESSOR OF 
       SOCIAL WORK, DEAN, OHIO UNIVERSITY EASTERN CAMPUS

    Mr. Greenlee. As a veteran of both the Army and Air Force, 
I'm honored to be able to speak to you today on Appalachian 
culture and veterans.
    Historically, the residents of Appalachia have faced 
chronically high rates of poverty, substandard housing, 
inadequate schools, poor health care for many generations, yet 
when they are called they serve.
    Despite these many challenges, they have survived and in 
some situations flourished. Resiliency is a major component of 
their constitution. The ability to get knocked down on many 
occasions and get back up and take care of their families and 
themselves with limited outside help is commendable. Their 
environment has often required them to learn how to make do, 
make it last, and do without. They don't ask for much from 
others. They rarely ask for help, but when they do ask, they 
ask that they be listened to in a respectful manner so that 
their voices can be heard and they can have some influence over 
their own lives and health care.
    Behringer has identified some important cultural barriers 
that have affected utilization of health care services in this 
region: (1) there is a general sense of mistrust of health care 
professionals and a fear of being taken advantage of by the 
system; (2) Appalachians also fail to assert themselves in 
seeking health care. This also promotes poor patient/provider 
communication and goal setting; (3) the cultural need for 
privacy and pride often leads to low health care utilization 
and poor followup with referrals; (4) there continues to be a 
general sense of fatalism that ``whatever will be will be'' and 
there is not much one can do about it, leading to less 
utilization of services; (5) some health care providers lack 
sensitivity to the cultural needs and concerns of Appalachian 
patients and are therefore incapable of establishing the 
necessary rapport with patients to be helpful.
    The following are recommendations for Effective Practice 
with Appalachian Veterans: (1) health care providers should 
consider doing the following: (a) learn about the local 
culture; (b) make themselves accessible; (c) provide flexible 
services; (d) build a personal relationship with patients 
first; and (e) involve patients in their own treatment plan. 
This will facilitate the development of a positive 
practitioner/patient partnership. (2) comprehensive public 
education programs are needed to help community members, social 
workers and clergy understand the signs and symptoms of 
diseases that veterans may be experiencing so they can conduct 
interventions to promote the utilization of health care 
services by veterans in the community with people they trust; 
(3) veterans and their families need to be apprised of all the 
services that they are entitled to as a veteran of the armed 
services; (4) health education is critical if we are to ensure 
that Appalachian veterans don't base their health care 
decisions on inaccurate information they receive from family 
and friends, or wrongful interpretation of data they read on 
the Internet; (5) Browning and others suggest that 
practitioners: (a) help patients find the words to describe 
their condition; (b) be careful to assess the psychological 
aspects of physical complaints by patients; (c) connect with 
the patients' feelings; (d) learn the local language for 
``nerve'' conditions; and (e) be prepared to spend an adequate 
amount of time with patients to effectively listen, learn, and 
establish rapport with them.
    In conclusion, Appalachians value most their families and 
home place. They respect others and expect to be respected by 
others regardless of their station in life. They value the 
freedom to live their lives with limited outside or government 
interference. They take care of their own with minimal requests 
for outside assistance. However, in dire emergencies, when they 
have ventured out to seek assistance from government agencies, 
they have found these agencies to be disrespectful, overwrought 
with bureaucratic red tape, with stringent eligibility criteria 
that often left them with little or no help. For those who 
received assistance, many feel they have had to pay too high a 
price for it, with their very self-worth and dignity sacrificed 
in the process. They have often encountered health care 
providers that have not treated them as a person, but rather as 
a case number, further alienating them from the health care 
system.
    For these reasons, many Appalachian veterans and their 
families never seek help; they do the best they can through 
self help. This is oftentimes not enough for those encountering 
depression, anxiety or post traumatic stress due to their 
previous combat experience. Thankfully this is not necessary. 
If we are to effectively help the Appalachian veterans and 
their families we will need to educate them and the public 
about the impact of the combat experience on these veterans.
    We will need to implement aggressive outreach programs 
informing veterans about the services that are available to 
them. We will need to treat them with dignity and create 
assistance that acknowledges them as people first, patients 
second. We will have to be vigilant in our advocacy for 
veterans when the system does not own up to its end of the 
bargain that veterans signed on for when they joined the 
military. If we do this Appalachians will do what they have 
always done. Their fighting spirit will rise again and they 
will take on these objectives and with the resilience that they 
are most famous for, they will put their lives back together in 
the place they call home, Appalachia.
    [The prepared statement of Mr. Greenlee follows:]

 Prepared Statement of Richard W. Greenlee, Ph.D., Associate Professor 
          of Social Work, Dean, Ohio University Eastern Campus

                              INTRODUCTION

    As a veteran of the both the U.S. Army and the U.S. Air Force, 
where I served as a social work/psychology specialist in the Army and 
clinical social worker in the Air Force, I am honored to be asked to 
speak to you today about Appalachian culture and veterans. My family 
came to Belmont County, Ohio, in the early 1800's. My roots in 
Appalachian Ohio run deep, and my commitment to the region is strong. 
Having grown up in a coal mining family, I vividly remember the 
challenges I faced in adapting to the military culture when I moved 
from Bethesda, Ohio, to Ft. Knox, Kentucky, to Ft. Sam Houston, Texas, 
to my permanent duty station at Walter Reed Army Medical Center in 
Washington, DC. I learned to co-exist simultaneously within two very 
unique and different worlds. This life experience, along with my 
education and training as a social worker, have shaped my current 
understanding that culture is all encompassing. There can be little 
doubt that my Appalachian cultural experience, has had a significant 
impact on how I perceive and respond to the world around me, as it does 
others who come from the region.

                         DEFINITION OF CULTURE

    Culture as defined by Bates and Plog (1990) ``is a system of shared 
beliefs, values, customs, behaviors, and artifacts that the members of 
a society use to cope with their world and with one another, and are 
transmitted from generation to generation through learning.'' It ``is 
the lens through which all things are viewed and how it is 
interpreted,'' (Briggs, Briggs, & Leary, 2005, p. 95). Subsequently, 
culture impacts all that we see and how we experience events in our 
lives.

                           APPALACHIA DEFINED

    According to the Appalachian Regional Commission (ARC), Appalachia 
is a region defined by Federal legislation that extends from 
Mississippi to New York, through 13 states, 420 counties, 205,000 
square miles with 24.8 million people. West Virginia is the only state 
completely encased in the Appalachian region. Thirty-two counties 
located in the southern and eastern sections of Ohio are considered to 
be part of the Appalachian region. Appalachia is characterized by slow 
population growth and a greater proportion of the population being over 
the age of 65 than the rest of the Nation. According to the 2000 census 
data, Non-Hispanic Whites account for 88 percent of the Appalachian 
population (20.1 million people). Twelve percent of the population are 
minorities with 8 percent being Non-Hispanic Blacks (1.9 million 
people), 2 percent Hispanic (465,000 people) and 2 percent defined as 
Other Races (471,000 people) which may include: American Indians, 
Asians, Pacific Islanders and multiracial persons (Pollard, 2004).

                          APPALACHIANS DEFINED

    The term Appalachian can be ambiguous and difficult to define. As 
noted by Keefe (2005), the term Appalachian is largely one used by 
outsiders and scholars and not commonly adopted by members of the 
Appalachian communities in which they reside. However, Friedl, (1978, 
p.2) provides us with a working definition for our purposes. He states, 
``* * * any person who was born, or one of whose parents was born, in a 
county designated by the Federal Government as falling within the 
Appalachian region'' can be defined as an Appalachian.

                        LACK OF MINORITY STATUS

    In general, the residents of Appalachia are not protected as a 
racial or ethnic minority and as previously noted, most Appalachians do 
not recognize the term Appalachian, nor do they see themselves as part 
of this group. Nevertheless, Appalachians do, in many ways, reflect the 
characteristics of a minority group as defined by De Hoyos, De Hoyos 
and Anderson (1986):

        Any group whose members have limited access to conditionally 
        rewarding roles, and therefore, are typically deprived of such 
        social rewards as money, respect, social status, security, 
        recognition, challenges, new experiences, opportunities to grow 
        and so forth. (p. 64)

    Throughout its history, Appalachia has faced chronically high rates 
of poverty, unemployment, substandard housing, low educational 
attainment and poor health care. These challenges continue to be 
concerns as is evident in the recent findings of an Appalachian 
Regional Commission report (2010) entitled, Socioeconomic Overview of 
Appalachia 2010:

     116 counties with a poverty rate 1.5 times the U.S. 
average
     Lower college completion rate than U.S. at large (17.6% 
Appalachian to 24.4% U.S.)
     Lower per capita market income than U.S. ($24,360 
Appalachian to $32,930 U.S.)
     Two-thirds of Appalachian counties now have higher 
unemployment rates than the United States as a whole (276 of 420 
counties)
     More Appalachians have become discouraged workers and have 
given up searching for jobs
     Between 2000 and 2007 Appalachia lost more than 35,000 
jobs in farming, forestry and natural resources and another 424,000 
jobs in manufacturing (22% loss)

    To make matters worse, the public is still prone to promoting a 
fictitious image of the dumb, ignorant hillbilly who never existed 
(Slone, 1978). Slone (1978) states:

        These lies and half-truths have done our children more damage 
        than anything else. They have taken more from us than that 
        large coal and gas companies did by cheating our forefathers 
        out of their minerals, for that was just money. These writers 
        have taken our pride and dignity and disgraced us in the eyes 
        of the outside world. When our children go into the cities for 
        work or are drafted into the army, they are forced to deny 
        their heritage, change their way of talking, and pretend to be 
        someone else, or be made to feel ashamed, when they really have 
        something to be proud of.'' (pp. xii & xiii)

    Not too long ago, CBS made plans to put on a proposed reality show 
to find the quintessential ``Appalachian'' family based on The Beverly 
Hillbillies and Abercrombie & Fitch sold t-shirts that said, ``West 
Virginia, It's All Relative.'' (Biggers, 2006, p. xiii) These kinds of 
culturally insensitive acts that promote stereotypes need to be 
confronted and instead, educational campaigns that promote the many 
achievements of Appalachian men and women need to be established.

                      APPALACHIAN CULTURAL TRAITS

    In a review of the literature, Susan Keefe identifies a set of core 
Appalachian values that include: ``egalitarianism, independence and 
individualism, personalism, familism, a religious world view, 
neighborliness, love of the land, and the avoidance of conflict'' 
(Keefe, 2005, p. 10).
    Egalitarianism is the ``belief that fundamentally one man or woman 
is as good as another or at least can be if he or she tries'' (Maloney, 
2005, p. 328). Subsequently, Appalachians judge a person by their 
actions and not the degrees or credentials they hold.
    Independence is a shared value among many Appalachians. They 
cherish their freedom. They tend to be antagonistic toward government 
regulation (Greenlee, 1993). In a study of the working poor of 
Appalachian Ohio (Greenlee, 1991), the author of this paper asked the 
following question: ``Who do you trust around here to help you?'' One 
respondent stated:

         * * * family, close friends, but as far as the government I'd 
        rather not deal with them if I don't have to. (p. 70)

    Another said:

        I think the government has been the least helpful. As for the 
        needs and where to go for help, I think it has been 
        individuals. The church has been terrific * * * but the 
        government agencies just don't come knockin' on your door 
        sayin' look this is available to you. (p. 70)

    Fiene (2005) found that women in alcoholic homes ``guard family 
secrets'', are ``reluctant to acknowledge family alcohol problems 
publicly,'' avoid ``reliance on co-workers for help,'' and rely 
``mostly on independent self-help as a means of coping'' (p. 243). I 
would argue that this is a common response for many Appalachians for 
personal and family concerns.
    Individualism is the strong belief in self-reliance and the 
expectation that one will take care of his or her own problems without 
the assistance of others and that dependency on others for any reason 
reflects negatively on a person. Subsequently, individuals tend to deny 
they have health problems until they are so severe they have to seek 
help and by the time they seek help it may be too late to effectively 
treat the disease. In addition, as noted above by Fiene (2005), 
Appalachians will read books, consult with friends, and surf the 
Internet in an attempt to self-diagnose and treat their own problems. 
This can create a whole other set of problems from misdiagnosis, to 
over-analysis of the side effects of medication to rationalize not 
using them, and to the creation of a self-argument to discontinue 
seeing a physician because ``he doesn't know what he is doing.''
    Personalism is based on personal relationships, not titles. Here, 
failure on the part of practitioners to establish a relationship with 
the patient first, by using rote questioning and maintaining rigid 
procedures held in place by bureaucratic red tape, may lead the patient 
to feeling like a number and ultimately to patient alienation. 
Appalachians will tend to reject these providers and their services 
when they perceive that they are not being treated as an individual.
    Familism is a core value in Appalachia. Family is the primary 
source of support in times of difficulty and the reason why many will 
not leave the region in times of high unemployment and limited 
opportunities. They overwhelmingly prefer to stay with family and stick 
it out until times improve.
    In times of difficulty, the most common support for Appalachians is 
their family and friends. The second most highly regarded source of 
support is the church. In a study conducted by the author of this 
paper, ``governmental services were the most talked about, the least 
used, and the most negatively viewed of all three support systems'' 
(Greenlee and Lantz, 1993).
    Many Appalachians have a religious world view. They are distrustful 
of government agencies and services, but they trust in the church-based 
social services. Even when poverty-stricken, the church provides them 
with a sense of identity and self-worth. The church gives them 
opportunities to demonstrate their competence through volunteerism and 
provides them with a source of emotional and financial support. This 
informal network also provides them with a host of support services 
such as food, small loans, transportation and personal assistance in 
emergencies (Greenlee, 1993).
    The concept of neighborliness may be an asset that could be 
utilized by health care practitioners. These practitioners could 
arrange for family, friends or other community members who are driven 
culturally to help their neighbors and who have had positive 
experiences with the health care system, to share their experiences and 
provide emotional support to Appalachian veterans who may be 
considering treatment options.
    Love of land and place are key ingredients in the character of 
Appalachians. It is important for them to own land and to look after 
it. This connection with the land provides them with a sense of 
meaning, safety and security that may go back several generations on 
the old home place. Loss of a home place can be very detrimental to the 
Appalachians sense of self and identity and promote disorientation.
    Appalachians often seek to avoid conflict at all cost. This can 
create problems when health care practitioners try to impose their will 
on clients by strongly encouraging them to adhere to certain aspects of 
a treatment plan without true agreement on the part of clients. 
Appalachian clients will often nod their heads in seeming agreement and 
approval of the suggestions, when they really do not agree and do not 
intend to follow through on the recommended treatment.
    In a qualitative study of a group of women in Appalachia who had 
been diagnosed with depression (Browning, Andrews and Niemczura, 2000), 
the researchers discovered that fatalism and the stigma of a mental 
health diagnosis caused these women to delay seeking treatment for 
their depression. Browning, et al. (2000) found that the women were 
afraid to tell others about their symptoms for fear of being made fun 
of or not being taken seriously. This resulted in an isolation that at 
some point results in a ``paralytic crisis,'' and a critical juncture 
in which they would finally seek professional help for their 
depression. These women reported that their husbands never asked what 
was going on and they never told them. Participants in the study ``felt 
an overwhelming need for health care providers to understand the nature 
of their depression'' (Browning, et al., 2000, p. 30). Many of them 
presented their problems as physical problems that are culturally more 
acceptable or referred to their depression as ``nerves.'' In addition, 
the researchers found that it was vitally important for medical 
practitioners to take time to listen to what the patient was really 
saying so they could accurately diagnose the depression and prescribe 
the appropriate treatment.

               VETERANS ATTITUDES TOWARD SOCIAL SERVICES

    Military veterans have been found to be less likely than the 
general population to seek mental health services due to perceived 
stigma (Hoge, Castro, Messer, McGurk, Cotting, & Koffman, (2004). 
Combine this with the Appalachians resistance to seeking mental health 
treatment or help of any kind (Behringer and Friedell, 2006), and the 
combination of the two cultures, one military, the other regional 
affiliation, and it is highly unlikely that Appalachian veterans will 
voluntarily seek help for depression, anxiety or Post Traumatic Stress 
Disorder that they may be experiencing upon returning home from the 
service. These attitudes will require comprehensive education and 
outreach efforts to help them upon leaving the military.

                   STRENGTHS OF APPALACHIAN VETERANS

    Many of the Appalachian veteran's cultural values can be positive 
attributes and curative factors if an astute health care provider can 
marshal them as resources. If the practitioner treats the individual 
with dignity and respect (egalitarianism) there is hope that a 
therapeutic relationship can be established where mutual respect can 
lead to effective implementation and follow through with a treatment 
regimen.
    If the practitioner can tap into the strength of the individual who 
needs to be treated like a person and not a number and empower them to 
make their own decisions about their diagnosis and treatment decisions, 
then their resistance to becoming dependent on others can be a good 
thing for long term efficacy of interventions.
    If the health care workers utilize the church pastor and friends 
who patients respect in the community, they are more apt to listen to 
their advice and utilize the support services that they provide due to 
the greater degree of trust they have in these organizations and 
people.
    It is important to recognize the safety, security and identity that 
come with Appalachian individuals being able to stay in their own 
homes, on their own land and in their own communities. Whenever 
possible, services need to be provided as close to home as possible to 
increase the likelihood that patients will follow though with these 
support services, not to mention their ability to find transportation 
to make appointments located long distances from their homes.
    Finally, it is important that medical providers listen to clients 
describe in their own words what they believe the problems are and how 
they can best be assisted. They need to listen to concerns about 
``nerves'' and the need for ``nerve pills.'' They need to tune into the 
underlying message that may come with a myriad of physical complaints 
that may actually be psychologically based stress disorders. If they do 
not listen, they will not hear, or they may not even be told, what is 
really going on in that patient's life and subsequently, prescribe the 
wrong treatment for the wrong problem.
    Historically, the residents of Appalachia have faced chronic and 
severe poverty, substandard housing, inadequate schools, and poor 
health care for many generations. Despite these many challenges, they 
have survived and in some situations flourished. Resilience is a major 
component of their constitution. The ability to get knocked down on 
many occasions, get back up, take care of their families and themselves 
with limited outside help is commendable. Their environment has often 
required them to learn how to make do, make it last and do without 
(Greenlee, 1993). They don't ask for much from others. They rarely ask 
for help, but when they do ask, they ask that they be listened to in a 
respectful manner, so that their voices can be heard, and they can have 
some influence over their own lives and health care.

         BARRIERS TO PROVIDING SERVICES TO APPALACHIAN VETERANS

    The following are cultural barriers to effective utilization of 
health care services in the region, even when they are available, as 
identified by Behringer, Friedell, Dorgan, Hutson, Naney, Phillips, 
Krishman and Cantrell, 2007:

     There is a general sense of distrust of health care 
professionals and a ``fear of being taken advantage of by `the system' 
'', (Behringer and Friedell, 2006, p. 3).
     Appalachians often fail to assert themselves in seeking 
health care. This also promotes poor patient/provider communication and 
goal setting.
     The cultural need for privacy and pride often leads to low 
health care utilization and poor follow-up with referrals.
     For many rural Appalachians access to health care is 
limited due to limited income, insurance and access to reliable 
transportation.
     Availability of health care services locally may be 
limited.
     There continues to be a general sense of fatalism that 
``whatever will be will be'' and there is not much one can do about it, 
leading to less utilization of services.
     Some health care providers lack sensitivity to the 
cultural needs and concerns of Appalachian patients and are therefore 
incapable of establishing the necessary rapport with patients to be 
helpful. This is compounded by insider/outsider dynamics (McDonald), 
where providers will always be considered outsiders if they were not 
born and raised in the community, even after many years of residency. 
These outsiders (often health care practitioners) are often seen as 
temporary residents who are not really committed to the community and 
are not to be trusted. However, even though it may be more difficult 
for outsiders, once trust is established over time with members of the 
community, it is long lasting regardless of one's insider/outsider 
status.

    RECOMMENDATIONS FOR EFFECTIVE PRACTICE WITH APPALACHIAN VETERANS

    1. Health care providers should consider doing the following: a) 
learn about the local culture; b) make themselves accessible; c) 
provide flexible services; d) build a personal relationship with 
patients first; and e) involve the patients in their own treatment 
planning. This will facilitate the development of a positive 
practitioner-patient partnership. If health care providers are to be 
effective in working with veterans living in the Appalachian region it 
is critical that they become culturally competent and adept at 
communicating with Appalachian veterans in such a way that they are 
able to establish rapport.
    2. Comprehensive public education programs are needed to help 
community members, social workers and clergy understand the signs and 
symptoms of diseases that veterans may be experiencing, so they can 
conduct interventions to promote the utilization of health care 
services by veterans in the community.
    3. Prevention, education and outreach services by agencies that are 
respected in the community must be employed to increase utilization of 
health care services.
    4. Veterans and their families need to be apprised of all the 
services that they are entitled to as a veteran of the armed services. 
Aggressive outreach campaigns will be necessary and the establishment 
of a rural public transportation system to improve access to services.
    5. Key gatekeepers in the community must be educated about the 
mental health and health care needs of veterans and the services 
available to them. Sponsors, preferably veterans, need to be identified 
who can vouch for the effectiveness of treatment. Receiving help from 
people they know and trust is the most effective way for Appalachian 
veterans to overcome the fatalistic attitude of ``it won't make any 
difference what I do.''
    6. Health education is critical if we are to ensure that 
Appalachian veterans don't base their health care decisions on 
inaccurate information they receive from family and friends, or 
wrongful interpretation of data they read on the Internet.
    7. Browning, Andrews, and Niemczura (2000) suggest that 
practitioners: a) help patients find the words to describe their 
condition; b) be careful to assess the psychological aspects of 
physical complaints by patients; c) connect with the patients' 
feelings; d) learn the local language for ``nerve'' conditions; and e) 
be prepared to spend an adequate amount of time with patients to 
effectively listen, learn and establish rapport with them.

                               CONCLUSION

    Appalachians value most their families and home place. They respect 
others and expect to be respected by others regardless of their station 
in life. They value the freedom to live their lives with limited 
outside or government interference. They take care of their own with 
minimal requests for outside assistance. However, in dire emergencies, 
when they have ventured out to seek assistance from government 
agencies, they have found these agencies to be disrespectful, over 
wrought with bureaucratic red tape, with stringent eligibility criteria 
that often left them with little or no help. For those who received 
assistance, many feel they have had to pay too high a price for it, 
with their very self-worth and dignity sacrificed in the process. They 
have often encountered health care providers that have not treated them 
as a person, but rather as a case number, further alienating them from 
the health care system. For these reasons, many Appalachian veterans 
and their families never seek help, and do the best they can through 
self-help. This is often times not enough for the veteran who is 
encountering depression, anxiety or post-traumatic stress due to their 
previous combat experience.
    Thankfully, this is not necessary. If we are to effectively help 
the Appalachian veterans and their families, we will need to educate 
them and the public about the impact of the combat experience on these 
veterans. We will need to implement aggressive outreach programs 
informing veterans about the services that are available to them. We 
will need to treat them with dignity and create a system that 
acknowledges them as people first, and patients second. And we will 
have to be vigilant in our advocacy for veterans, when the system does 
not own up to its end of the bargain, that veterans signed on for when 
they joined the military.
    If we do this, Appalachians will do as they have always done. Their 
fighting spirit will rise again, and they will take on these 
challenges, and with the resilience that they are most famous for, they 
will put their lives back together, in the place they call home . . . 
Appalachia.
                                 ______
                                 
References
Appalachian Regional Commission (2010). Socioeconomic Overview of 
            Appalachia 2010. Washington, DC: Appalachian Regional 
            Commission.
Bates, D.G. & Plog, F. (1990). Cultural anthropology. New York, NY: 
            McGraw-Hill.
Bauer, W.M. & Growick, B. (July/August/September 2003). Rehabilitation 
            counseling in Appalachian America. Journal of 
            Rehabilitation, 69, 18-24.
Behringer, B. and Friedell, G. (October 2006). Appalachia: Where place 
            matters in health. Preventing Chronic Disease: Public 
            Health Research, Practice, and Policy, 3, 1-4.
Behringer, B., Friedell, G., Dorgan, K., Hutson, S., Naney, C., 
            Phillips, A., Krishnan, K., and Cantrell, E. (2007). 
            Understanding the challenges of reducing cancer in 
            Appalachia: Addressing a place-based health disparity 
            population. Californian Journal of Health Promotion, 5, 40-
            49.
Biggers, J. (2006). The United States of Appalachia. Emeryville, CA: 
            Shoemaker & Hoard.
Briggs, H.E., Briggs, A.D., & Leary, J.D. (2005). Promoting culturally 
            competent systems of care through statewide family advocacy 
            networks. Best Practices in Mental Health, 1, 77-99.
Browning, D., Andrews, C. and Niemczura, C. (May 2000). Cultural 
            influences on careseeking by depressed women in rural 
            Appalachia. The American Journal for Nurse Practitioners, 
            22-32.
De Hoyos, G., De Hoyos, A., & Anderson, C. (January-February 1986). 
            Sociocultural dislocation: Beyond The Dual Perspective. 
            Social Work, 61-67.
Friedl, J. (1978). Health care services and the Appalachian migrant. 
            Columbus, OH: Ohio State University.
Greenlee, R.W. (1993). Religion, faith, and the poor Appalachian 
            family: An eco-existential perspective. Social Work and 
            Christianity: An International Journal, 20, 8-25.
Greenlee, R.W. & Lantz, J.E. (April 1993). Family coping strategies and 
            the rural Appalachian Poor, Contemporary Family Therapy, 
            15, 121-137.
Greenlee, R.W. (1991). And yet they are poor: A naturalistic study of 
            rural poverty and the working poor people of Appalachian 
            Ohio. The Ohio State University, Columbus, OH.
Hoge, C.W., Castro, C.A., Messer, S.C., McGurk, D., Cotting, D.I., and 
            Koffman, R.L. (September 1, 2004). New England Journal of 
            Medicine, 351, 13-22.
Howell, B.J. & Fiene, J.I. (2005). Designing employee assistance 
            programs for Appalachian working-class women: The alcohol 
            and stress research project. In S. Keefe (Ed.), Appalachian 
            cultural competency (pp. 247-264). Knoxville: The 
            University of Tennessee.
Keefe, S. (2005). Appalachian cultural competency: A guide for medical, 
            mental health, and social service professionals. Knoxville, 
            TN: The University of Tennessee Press.
Maloney, M. E. (2005). Evaluating a rite of passage program for 
            adolescent Appalachian males. In S. Keefe (Ed.), 
            Appalachian cultural competency (pp. 315-334). Knoxville: 
            The University of Tennessee.
McDonald, F. (Summer 1990). A case study of insider-outsider dynamics 
            in rural community development. Human Services in the Rural 
            Environment, 14, 15-20.
Pollard, K. M. (September 2004). A ``New Diversity'': Race and 
            Ethnicity in the Appalachian Region. Washington, DC: 
            Population Reference Bureau.
Slone, V.M. (1979). What my heart wants to tell. Lexington, KY: The 
            University of Kentucky Press.

    Senator Brown. Thank you, Dr. Greenlee. Ms. Maupin.

  STATEMENT OF LUCINDA J. MAUPIN, EXECUTIVE DIRECTOR, BELMONT 
                     COUNTY VETERANS OFFICE

    Ms. Maupin. In the almost 9 years of working with the 
veterans in this area I have found that one of the biggest 
complaints from our veterans is access to health care. Our 
veterans are part of VISN 4 and use the VAMC in Pittsburgh, PA, 
which is 60 miles away and approximately 100 miles, in some 
cases more, for veterans living at the opposite end of the 
county.
    Our office provides transportation for veterans using the 
DAV transportation program. We have two vans that go up daily. 
We go Monday through Friday and we pay two full-time drivers 
from our county funds. When a veteran is scheduled for a 
compensation or pension exam they may have to go to Columbus or 
Mount Vernon, OH, which, there again, is about 120 miles from 
Belmont County. We provide transportation for those trips using 
our office van. Each trip means paying a part-time backup 
driver to drive the van. Even with the three vans that we have 
available, it does not seem to be enough. Our vans are full 
almost every day and there are times when we do not have the 
county van available to take a veteran to his or her 
compensation and pension exam.
    For an example, this Wednesday we had to deny 
transportation to a veteran to Mount Vernon. Our county van 
will not be available. I had a call from the St. Clairsville 
outpatient clinic on April 1 asking if we could provide a 
veteran who did not have transportation to the VA Primary Care 
Clinic or to the pickup point to go to Pittsburgh. 
Unfortunately we cannot do that due to the cost of another 
driver. The veteran who the clinic was calling about was 
tracked down by the clinic after calling the VA's suicide 
hotline. This veteran could have died because the care he 
needed was not available.
    Veterans in our area do not have access to emergency care. 
If a veteran visits a local emergency room he or she is charged 
for the visit unless the VA decided the visit was life 
threatening. When transportation is not available, a veteran 
may have no other option but to go to a local emergency room. 
Our county vans transport Monday through Friday. The first van 
leaves at 6 a.m. to Pittsburgh and comes back at noon. We have 
a van that leaves Belmont County at 10 a.m. to Pittsburgh and 
leaves Pittsburgh when the last veteran is finished. We do not 
cover the weekends or holidays or any nighttime transportation. 
With additional funds for drivers, we have the vans available, 
we could make a difference.
    Another problem we have in our area is that a lot of 
veterans and family members do not know we are here for them. 
We have put advertisements in the local papers and set up 
tables at the county fair and other events held throughout the 
county but we still do not reach everybody. Outreach can make a 
big difference to a veteran or his or her widow. I had a 
veteran from Powhatan Point, which is around 30 miles from our 
office, tell me I actually saved his life. He had lost his 
family in the floods in Shadyside on June 14 of '92. Shortly 
afterwards lost his job and eventually he was planning on 
taking his own life. Someone had told him that our office would 
pay utility bills for him and he wanted to put his affairs in 
order before he killed himself. So he came to the Powhatan City 
Building where I have a satellite office open each week and I 
told him about VA Pension. He decided to apply and within 3 
weeks he had his claim approved, and he credits our office for 
saving him. I feel that if we had additional funds to advertise 
or to set up more satellite offices we could reach more 
veterans and possibly change more lives.
    Widows or widowers are a forgotten group who are, in some 
cases, worse off than the veteran when it comes to knowing who 
to look for when they need help. A veteran can usually find 
information from other veterans or service organizations. A 
widow or widower may not have anyone they can turn to to get 
information on benefits. I have recommended to some of the 
service organizations to advise their members to pre-plan for 
their death so that their spouses know exactly what paperwork 
is needed and what he or she will be entitled to upon his or 
her death. We need to seek out our elderly widows and widowers 
and our veterans who can no longer make it to our office to 
make sure they get the benefits they are entitled to. In order 
to do this we need additional funds. We would need funding to 
provide a service officer for additional satellite offices and 
transportation.
    Another problem facing Appalachia is the number of lost 
jobs in our area. So many of our veterans have been laid off 
from the steel mills and coal mines and other companies that 
have been affected by our economy. They do not have the 
education needed to find other gainful employment to compete 
with younger people who have an advantage over someone who may 
not have the training in computers or modern technology. Our 
older veterans who have lost their jobs have let their GI Bill 
or VEAP benefits expire. If they wanted to go to college they 
would be faced with having to take out student loans and after 
graduation they would have to start over with a large debt to 
repay. A veteran would be more likely to return to school if 
funds were available to help pay for his or her education.
    I feel that the county veterans offices are the link 
between the VA and the veteran. We need additional funding to 
develop and make our programs a success. Our office not only 
works with the veterans of Belmont County, we also help the 
veterans who come to us from West Virginia. We see the need for 
more transportation, easier access to health care, more service 
officers, and better education benefits every day. Rather than 
be bound to a county or State border, it would be great to be 
able to assist all veterans of our region. Thank you.
    [The prepared statement of Ms. Maupin follows:]

     Prepared Statement of Lucinda J. Maupin, Executive Director, 
                     Belmont County Veterans Office

    My name is Lucinda J. Maupin, I have been a lifelong resident of 
Belmont County, Ohio and I am a veteran of the United States Army 
serving on active duty from November 1981 to June 1989. In July 2001 I 
was hired as an administrative assistant to the Belmont County Veterans 
Service Officer. In January 2003 I became the Executive Director of the 
Belmont County Veterans Office. I am also a life member of the Veterans 
of Foreign Wars, a member of the American Legion, AMVETS, and an 
accredited County Veterans Service Officer with the Ohio State 
Association of County Veterans Service Officers and the National 
Association of County Veterans Service Officers.
    In the almost nine years of working with the veterans in this area 
I have found that one of the biggest complaints from our veterans is 
access to health care. Our veterans are part of VISN 4 and use the VAMC 
in Pittsburgh, Pennsylvania which is sixty miles away from our office 
and up to approximately one hundred miles for veterans living at the 
opposite end of the county. Our office provides transportation for 
veteran using the DAV transportation program. We have two vans that 
provide transportation to Pittsburgh Monday through Friday and we pay 
two full time drivers from our county funds. When a veteran is 
scheduled for a compensation or pension (C&P) examination they might 
have to go to Columbus or Mount Vernon, Ohio and we provide 
transportation for those trips using our office van. Each trip means 
paying a part time back up driver to drive the van. Even with the three 
vans that we have available it does not seem to be enough. Our vans are 
full almost every day and there are times when we do not have the 
county van available to take a veteran to his/her C&P exam. This 
Wednesday, April 7, 2010, I had to deny a veteran transportation to 
Mount Vernon, Knox Community Hospital because our county van will not 
be available. I had a call from the St. Clairsville outpatient clinic 
on April 1, 2010, asking if we could provide veterans who did not have 
transportation to the VA Primary Care Clinic or to the pickup points 
for the vans to Pittsburgh and unfortunately we cannot do that due to 
the cost of another driver. The veteran who the clinic was calling 
about was tracked down by the clinic after calling the VA's suicide 
hotline. This veteran could have died because the care he needed was 
not available.
    Veterans in our area do not have access to emergency care. If a 
veteran visits a local emergency room he/she is charged for the visit 
unless the VA decides the visit was life threatening, when 
transportation is not available a veteran may have no other option but 
to go to a local emergency room. Our county vans transport Monday 
through Friday the first van leaves at 6:00 a.m. to Pittsburgh and 
leaves to come back to Belmont County at 12:00 p.m. We have a van that 
leaves Belmont County at 10:00 a.m. to Pittsburgh and leaves Pittsburgh 
when the last veteran is finished. We do not cover the weekends or 
holidays or any night time transportation. With additional funds for 
drivers (we have the vans) we could make a big difference.
    Another problem we have in our area is that a lot of veterans and 
family members do not know we are here for them. We have put 
advertisements in the local papers and set up tables at the county fair 
and other events held throughout the county but we still do not reach 
everybody. Outreach can make a big difference to a veteran or his/her 
widow. I had a veteran from Powhatan Point tell me that I saved his 
life. He had lost his family in the floods in Shadyside, Ohio on 
June 14, 1992, shortly afterwards he lost his job and eventually he was 
planning on taking his own life. Someone had told him that our office 
would pay utility bills for him and he wanted to put his affairs in 
order before he killed himself so he came to the Powhatan City Building 
where I have a satellite office open each week and I told him about VA 
Pension. He decided to apply and within three weeks (that was the only 
time I have ever had a claim approved in three weeks) he was approved 
and he credits our office for saving him. I feel that if we had 
additional funds to advertise or to set up more satellite offices we 
could reach more veterans and possibly change more lives.
    Widows or widowers are a forgotten group who are, in some cases, 
worse off than the veteran when it comes to knowing who to look for 
when they need help. A veteran can usually find information from other 
veterans or service organizations. A widow or widower may not have 
anyone they can turn to, to get information on benefits. I have 
recommended to some of the service organizations to advise their 
members to pre plan for their death benefits so their spouses know 
exactly what paperwork is needed and what he/she will be entitled to 
upon his/her death. We need to seek out our elderly widows/widowers and 
our veterans who can no longer make it to our office and make sure they 
get the benefits they are entitled to and in order to do this we need 
additional funds. We would need funding to provide a service officer 
for additional satellite offices and transportation.
    Another problem facing Appalachia is the number of lost jobs in our 
area. So many of our veterans have been laid off from the steel mills 
and coal mines and other companies that have been affected by our 
economy and they do not have the education needed to find other gainful 
employment and compete with younger people who have an advantage over 
someone who may not have the training in computers or modern 
technology. Our older veterans who have lost their jobs have let their 
GI Bill or VEAP benefits expire and if they wanted to go to college 
they would be faced with having to take out student loans and after 
graduating they would have to start over with a large debt to repay. A 
veteran would be more likely to return to school if funds were 
available to help pay for his/her education.
    I feel the county veterans offices are the link between the VA and 
the veteran. We need additional funding to develop and make our 
programs a success. Our office not only works with the veterans of 
Belmont County but we also help the veterans who come to us from West 
Virginia and we see the need for more transportation, easier access to 
health care, more service officers, and better education benefits every 
day, and rather than be bound to a county or state border it would be 
great to be able to assist all veterans of our region.

    Thank you.

    Senator Brown. Thank you, Ms. Maupin.
    Ms. Neutzling.

   STATEMENT OF ANDREA MICHELE NEUTZLING, VETERAN, U.S. ARMY 
           SPECIALIST, MILITARY INTELLIGENCE ANALYST

    Ms. Neutzling. I live with my father so I have someone to 
help care for my daughter while I'm in school. In December 2007 
my father applied for the HEAP program to help with our heating 
costs for the wintertime. He was denied benefits for the HEAP 
program because of the fact where I was living with him and I 
had made too much the previous year. When they had called to 
inform us that we were denied, I was the one who answered the 
phone, and I asked them why. They said because I had made too 
much. I asked them--I explained to them--I go, ``Well, I was in 
Iraq. I was in the war zone the entire year.'' And she goes, 
``Well, I'm sorry, ma'am, but you just made too much.'' So, OK, 
in other words, you're punishing us because I was in the war. 
I'm a veteran, so you're punishing us, ``You made too much.''
    From January 2008 to March 2009 I was attending Ohio 
University. I took a break from school and started back up at 
Rio Grande, the University of Rio Grande, this past January. 
Before I started my classes I spoke with my VA Education Rep 
and he informed me that I should put in for the Post-9/11 GI 
Bill since I would be granted 100 percent benefits. I applied 
was accepted for the Post-9/11 program. Then, when I started 
receiving my monthly benefits I found out I was actually 
getting less from the Post-9/11 than I was getting from the 
Montgomery GI Bill.
    In order for me to go back to the original GI Bill I would 
have to file an appeal with the VA and then they can decide 
whether or not to let me go back to the Montgomery GI Bill. I 
feel that there should have been some way for me to find out 
which I would have gotten more benefits from before I formally 
switched from one program to the other.
    A lot of my issues lay within the VA itself. In order for 
me to receive my care, I have to travel to the Chillicothe VA 
medical center, which is 2 hours away from me. Yes, there is an 
outpatient clinic in Athens, which is a 30-minute drive, but 
most of my issues cannot be handled at the outpatient clinic, 
along with some of the veterans from my county cannot who 
afford to the make drive to Chillicothe. We can go to the VSO 
and get a drive to the clinic as long as we notify them a week 
in advance. I am forgetful for medical reasons and so I do not 
usually remember about my appointment until the day before when 
the VA calls me to remind me of my appointment the next day. If 
there would be some way to get more VA outpatient clinics and 
have the VA send us to a local doctor or hospital it would be a 
lot easier for veterans in my area to get their health care 
taken care of.
    My shoulder injury has never fully recovered. I've had one 
surgery on it while I was in New Jersey on medical hold orders. 
I get prescribed Flexeril from the VA as a muscle relaxer, but 
it does not do me any good for I have developed a high 
tolerance to it while I was in Iraq. Most other muscle relaxers 
can make a person's blood pressure drop. I already suffer from 
low blood pressure. It's even documented in my medical records. 
The VA will not cover Metaflaxin, which is the only muscle 
relaxer that I've found that does not affect my blood pressure. 
Because it is not formulary, they will not cover it. The VA 
rated me zero percent for my shoulder saying I had no loss of 
range of motion, which I have. I'm currently seeing a civilian 
orthopedic doctor so I can submit paperwork for a reevaluation 
for my shoulder injury.
    I couldn't be rated for PTSD because the VA couldn't gather 
sufficient support. When I went to file for it, they wanted me 
to recount everything. At that time I wasn't ready to discuss, 
let alone write down all my accounts of being raped, having a 
British soldier die in my arms, and seeing what happened after 
detainees would beat the life out of each other. The few times 
I went to Mental Health. I had one doctor ask me, since I had 
all these problems with the military, why I wanted to stay in. 
I told him it wasn't the military I had problems with, it was 
some of the people in the military.
    The VA will not determine if I even had a mild TBI. When I 
injured my shoulder I blacked out, I'm not sure for how long, I 
just know that ever since then my moods change drastically. If 
it's not military related I tend to forget things I just 
learned earlier in the week. This makes it even harder for me 
at school.
    Before I was sent to Iraq I was attending Hocking College 
in Nelsonville, OH, taking police science classes. I was 
working on becoming a police officer. But when I injured my 
shoulder, I could no longer do sit-ups and push-ups. Those two 
things are mandatory for becoming an officer in the State of 
Ohio. I was using my GI Bill for this. I lost $5,000 of my GI 
Bill because I couldn't continue.
    I tried to get into the VEAP program. I had to go to 
Columbus and take numerous skills tests, and then they said I 
would have to talk to people in my potential job field and ask 
them questions about things like what the benefits are, the pay 
and duties. I plan on going into a government job once I get my 
Bachelors degree. I know I can't just go up to one of those 
types of agencies asking questions, so I was denied that 
benefit. I'll run out of my GI Bill benefits before I get my 
degree. But many younger veterans will probably be facing that 
problem also because the GI Bill was designed when school cost 
roughly $50,000 for 4 years of education.
    The VA in Chillicothe has designated a specific team for 
some vets, but unlike Columbus VA there are men in the area. 
Chillicothe doesn't have a permanent mental health doctor that 
is a woman. This makes it harder for any female vet with a 
military sexual trauma to go in and talk to them.
    Ever since I was in Iraq I've had problems with my lungs. I 
worked downwind from the burn pits on my camp, but the VA is 
mostly concentrating on the Balad burn pits. Camp Bucca's burn 
pit is directly upwind from the internment facility, for the 
first 9 months I was over there. I had even contracted 
pneumonia within those first 9 months. Now anytime I develop an 
upper respiratory infection I have to go and get a shot of 
antibiotics and oral antibiotics to take to prevent it from 
developing into pneumonia. But since I cannot prove I was 
downwind from the pit, I can't claim it with the VA.
    I am the granddaughter of a Korean War veteran. My 
grandfather was very disillusioned by the VA. I do not want to 
be disillusioned by the VA. The VA has been specifically 
related to the old-fashioned combat where there is a line in 
combat, there's lines drawn. This is where the VA is. They have 
not advanced their properties and their thinking into the type 
of combat situations veterans are facing in this day and age.
    [The prepared statement of Ms. Neutzling follows:]

  Prepared Statement of Andrea Michele Neutzling, Veteran, U.S. Army 
               Specialist, Military Intelligence Analyst

    In December 2007, my father applied for HEAP, I live with him so I 
have someone to take care of my daughter while I am in school, and he 
was denied HEAP benefits because I made too much the year before. From 
June 2005 to August 2005 I was in New Jersey preparing to deploy. 
August 2005 until August 2006 I was stationed at Camp Bucca, Iraq. Upon 
returning I was kept at Fort Dix, New Jersey, to get my shoulder injury 
taken care of. I was released from active duty June 2007. The
    HEAP office called and spoke directly to me to inform us that we 
would not be receiving HEAP benefits. When I was told why, I got upset 
and even asked why it seemed that we were being punished pretty much 
because I served in a war. They said that wasn't the reason at all, it 
was because I made too much the year before, I replied with I was in 
Iraq and then being treated for an injury that year. All she could say 
was I'm sorry you feel that way ma'am.
    From January 2008 into March 2009 I was attending Ohio University 
on the MGIB. I took a break from school from April 2009 until just this 
past January; I attend the University of Rio Grande. Before I began 
classes this year I talked to the VA Education rep at my school, was 
informed that I would probably get more money from the Post-9/11 GI 
Bill than I got from the MGIB. I did the paper work to switch over. 
When I began school and started getting my monthly payment I found I 
went to getting less a month under the new GI Bill. There should have 
been a way to find out how much under both I would have gotten before I 
switched, so I could go with the better one.
    My county's Veterans Service Officer has told me about numerous 
programs available to me as a veteran; including the Military Injury 
Relief Fund. I haven't tried for anything other than the HEAP, Medical 
Card, and Food Assistance.
    Most of my issues lay within the VA itself. In order for me to 
receive my care, I have to travel to Chillicothe VA, which is a 2 hour 
drive for me; yes there is an outpatient clinic in Athens, a 30 minute 
drive away. Some of the Veterans in my county can't afford to make the 
drive to Chillicothe. Yes we can get a ride to there through the county 
VSO, but we have to give them at least a week notice. I'm bit forgetful 
so I don't remember about my appointment until the day before when the 
VA would call me. If we could get some more VA outpatient clinics, or 
even have the VA send us to a local doctor instead. Even for things 
like orthopedics and certain surgeries we have to travel to places like 
Columbus or Huntington, when there are places like Holzer and Pleasant 
Valley Hospitals closer for us.
    My shoulder injury has never fully recovered; I've had one surgery 
on it while I was in New Jersey on Medical Hold orders. I get 
prescribed Flexeril as a muscle relaxer, but it doesn't do any good for 
me. I developed very high tolerance to it while I was in Iraq. Most 
other muscle relaxers can make a person's blood pressure drop. I 
already suffer from Low Blood Pressure, it's even documented into my 
medical records, and the only other muscle relaxer I've found to work 
for me and not mess up my BP is Metaflaxin a.k.a. Skelaxin. But I can't 
get it from VA because it's not Formulary. It doesn't help that the VA 
rated me 0% for my shoulder, saying I had no loss of my range of 
motion, which I have. I'm currently seeing a civilian orthopedic 
doctor, so I can submit paperwork for a reevaluation.
    I couldn't be rated for PTSD because the VA couldn't gather 
sufficient support. When I went to file for it, they wanted me to 
recount everything. At that time I wasn't ready to discuss, let alone 
write down my accounts of being raped, having a British soldier die in 
my arms, and seeing what happened after detainees would beat the life 
out of each other. The few times I went to Mental Health, I had one 
doctor ask me if I had all these problems with the military why I 
wanted to stay in. I told him, it wasn't the military I had problems 
with; it was some of the people.
    The VA won't determine if I even have a Mild TBI. When I injured my 
shoulder I blacked out; I'm not sure for how long unfortunately. I just 
know that ever since then my moods change drastically, and if it's not 
military related I tend to forget things I just learned earlier in the 
week. This makes it even harder for me at school.
    Before I was sent to Iraq I was attending Hocking College in 
Nelsonville Ohio, taking police science classes. I was working on 
becoming a police officer. But when I injured my shoulder, I could no 
longer do sit-ups and then my push-ups became a problem also. Those two 
things are mandatory for becoming an officer in the state of Ohio. I 
was using my GI Bill for this. I lost $5000 of my GI Bill, because I 
couldn't continue. I tried to get into the VEAP program. I had to go to 
Columbus and take numerous skills test, and then they said I would have 
to talk to people in my potential job field and ask them questions 
about things like what the benefits are, the pay, and duties. I plan on 
going into a government job once I get my Bachelors degree; I know I 
can't just go up to one of those types of agency asking questions. So I 
was denied that benefit. I'll run out of my GI Bill benefits before I 
get my degree. But many younger veterans will be facing that problem 
anyway, because the GI Bill was designed when school cost $50,000 for 4 
years of an education.
    The VA in Chillicothe has designated a specific team for women 
vets, but unlike Columbus VA there are men in the area. Chillicothe 
doesn't have a permanent Mental Health doctor that is a woman. This 
makes it harder for any female vet with a Military Sexual Trauma (MST) 
to go in and talk to them.
    Ever since I was in Iraq I've had problems with my lungs. I worked 
downwind from the burn pits on my camp. But the VA is mostly 
concentrating on the Balad burn pits. Camp Bucca had a burn pit 
directly upwind from the Internment facility, for the first 9 months I 
was over there. I had even contracted pneumonia within those first 9 
months. Now anytime I develop an upper respiratory infection, I have to 
go and get a shot of antibiotics and oral antibiotics to take, to 
prevent it from developing into pneumonia. But since I can't prove I 
was downwind from the bit I can't claim it to the VA.
    I grew up looking forward to serve my country from the time I was 
about 8 years old. I'm the Granddaughter of a Korean War vet, and I 
don't want to be disillusioned by the VA like my grandfather is. I 
expect the US Government to take care of all veterans no matter what 
generation they are in. My daughter, who is almost seven, plans on 
going into the military, either Air Force or Army; she hasn't decided. 
I hope that the VA will be more adequately prepared for that time than 
they are now. The VA seems to be stuck in thinking about how we fought 
wars in WWII, instead of advancing in preparing for the way the world 
changes and how wars are fought change with the times also.

    Senator Brown. Thank you, Ms. Neutzling. Thank you all. I 
would ask that the second panel address the concerns of Ms. 
Neutzling and Ms. Maupin, specifically. I also would appreciate 
Dr. Greenlee addressing these issues raised. Some are about 
funding and some are more fundamental, so give us your thoughts 
about some of these issues. I'll start with Ms. Neutzling. Does 
the Montgomery GI Bill provide more benefits to you than the 
new GI Bill?
    Ms. Neutzling. Yes.
    Senator Brown. Do you know why, or did VA explain to you 
why, because that was not the intent? I know the new GI Bill is 
more updated and has other kinds of benefits. Can you tell me 
what you know about that?
    Ms. Neutzling. When I asked them about this, they say, 
``Well, your tuition is paid directly from us.'' I was like, 
``Yes, but I was getting roughly, with the Montgomery GI Bill, 
I was getting just over $2,000 a month.'' I was like, ``I can 
pay that, pay my tuition with that monthly payment right there. 
But with the Post-9/11 I get my tuition paid to the school, but 
then I get housing which is only $941.''
    Senator Brown. OK. I would like to hear from the VA about 
the math because that was never the intent of that bill, but if 
the situation is right with Ms. Neutzling that benefit would be 
less. So I really want to understand that better. You live in 
Pomeroy?
    Ms. Neutzling. Yes.
    Senator Brown. It's a half hour to Athens, so it's two plus 
hours to Chillicothe or Columbus?
    Ms. Neutzling. Yes.
    Senator Brown. Athens--you made reference to it simply not 
having the medical expertise for your shoulder, or is it the 
lung issue or all of them?
    Ms. Neutzling. Pretty much all of them. I find it's easier 
if they just send me straight to Chillicothe; so it's just 
easier to go to Chillicothe.
    Senator Brown. Do you ever use Athens for basic care or for 
pharmaceuticals?
    Ms. Neutzling. I just go the Athens clinic for mental 
health care because they have an intern there that's female to 
help with the PTSD and MST. So I was attending--I was going to 
Athens for that. That was the only reason I was going to 
Athens.
    Senator Brown. In the issue of the bus and the van from 
Pomeroy to Chillicothe, they work with the VA on that and there 
ought to be a way they can get you that line so you can get a 
seat on the bus.
    Ms. Neutzling. If my appointment is made in enough time and 
maybe mail it out, mail a little letter, to remind me about 2 
weeks before. Then I will usually put it somewhere to find it 
to remind myself to go and set it up, but then I completely 
forget where I placed it.
    Senator Brown. Well, if you can't remember you might have 
the Veterans Service Organization Officer in Meigs County help. 
There ought to be a way that they can sit down and work this 
through with you so that you can have some help. Make a copy of 
it so they can make the reservation on the bus or whatever.
    I don't understand, Ms. Neutzling, how when you're going to 
Chillicothe for your shoulder, why VA would continue to say 
you're zero percent disabled on your shoulder. Have you taken 
that up with anybody at the Chillicothe Hospital in terms of 
getting reclassified?
    Ms. Neutzling. I have discussed it with my county VSO and 
he told me that I just need to get some new paperwork to have 
it reevaluated, then I should have my rating changed.
    Senator Brown. And the paperwork come from Chillicothe.
    Ms. Neutzling. They rated me zero percent, so I have 
refused to go to the VA, because of that; so I have been going 
to a civilian doctor for my shoulder.
    Senator Brown. I would hope the VA can address that--Kim, 
if you would. I would hope that we can help you with that. The 
VA is an amazing institution that gives and makes fewer medical 
errors than any other facility and any other medical group in 
the country. But they're also huge and still make some 
mistakes, you know.
    Ms. Neutzling. Even if I had to have surgery on my shoulder 
again a second time they would usually send me out to 
Huntington or Columbus.
    Senator Brown. To the VA?
    Ms. Neutzling. To the VA, yeah; because the Chillicothe 
facility at the time didn't have those services.
    Senator Brown. I understand that. Chillicothe does some 
things better and that it has a terrific program. You have a 
building for homeless veterans, and you've got some other 
programs, as we pointed out. Each one has different 
specialties. Thank you very much.
    When you're in school you have classmates who are veterans?
    Ms. Neutzling. A few classmates who are veterans.
    Senator Brown. All right. One of the discussions similar to 
this--I was at Cleveland State with some veterans, a group of 
about eight or 10 veterans, and we walked around. Cleveland 
State and Youngstown State both have specific programs for 
integrating veterans into the university setting, understanding 
that a 22-year-old veteran who has come back from Iraq has a 
pretty different view of looking at the world than a 19-year-
old straight out of high school going to Cleveland State, a 
more sophisticated view of the world, as you do, from your 
experiences. You saw things that many of us in this room have 
never seen and experienced things that many of us never will 
have to experience. So we're trying to figure out ways of 
helping veterans integrate into a university setting.
    Do you feel that you and your veteran friends at OU are 
getting the right kind of experiences--or a better question: is 
there anything we can do better?
    Well, think about it. You don't have to answer right now, 
but we would love to hear if you've got thoughts on that.
    Ms. Neutzling. Honestly about the only way is because when 
I was going to OU and I sit there with my classmates, and, I 
mean, at the time I'm 28 and all of my classmates were mostly 
all 17, 18-year-olds fresh out of high school as you say, and 
they would ask me--they would just be like, ``Did you kill 
anybody?'' They would ask, you know, the typical questions 
after they find out that you've been over there. It does get a 
little annoying and sometimes you don't want people to know 
you're a veteran.
    Senator Brown. That's something we need to address. Thank 
you for that.
    Ms. Maupin, thank you again for your service as a veteran 
and for the service you still bring to veterans. You are 
actually based out of Bellaire?
    Ms. Maupin. St. Clairsville.
    Senator Brown. St. Clairsville. Is there one in 
Steubenville? I should know that.
    Ms. Maupin. No.
    Senator Brown. So you have people from Jefferson County, 
Harrison County, Monroe County, and a few from across the 
river?
    Ms. Maupin. A lot of our veterans come from West Virginia 
and Belmont County; and then I think Ed Massey over in 
Jefferson County, I don't know, do your veterans use St. 
Clairsville?
    Mr. Massey. Yes.
    Senator Brown. The CBOC--your understand that the CBOCs 
can't do everything for Ms. Neutzling that a big hospital can 
do of course? You understand that? They never will. But are we 
providing the quality of service and the breadth of service 
that we should be?
    Ms. Maupin. You'll hear it both ways, and unfortunately I 
can't use the VA health care system because I make too much 
money, but that's another issue. Anybody who has to see a 
specialist has to go to Pittsburgh. So, you know, the clinics 
are good if you've got a cold or if you're going in for a 
checkup; the clinic provides excellent care, but the sicker 
veterans are the ones that have to travel the farthest. To me, 
that's not acceptable. I mean, we have veterans who can't--we 
don't allow veterans on our vans who can't get on and off by 
themselves. So you'll have somebody come in who has to try to 
get to the hospital in Pittsburgh who is very sick. We do 
provide a special van. If we have somebody who can't ride in 
our van we will take them in our county van. But, there again, 
our county van is spread so thin and it might be in Mount 
Vernon or Columbus. You know, we're going in all different 
directions here. It just seems so bad to me that the sicker 
veterans have to go the farthest for treatment.
    Senator Brown. So what is the solution to that? I mean, we 
can't build Chillicothe-sized hospitals in 30 places obviously. 
So what----
    Ms. Maupin. In our case it would be additional drivers. I 
mean, it would be additional money for additional drivers and 
additional vans. I know that right now that's a county issue, 
you know, that our payroll comes from the county. But there has 
to be a better way for the veteran to get their treatment. 
There's no reason in the world why she should have to, or any 
veteran, to have mental issues and have to worry about where or 
how they're going to get treatment.
    Senator Brown. One of the problems, whether it's in 
Jefferson County or Noble County or Richland County, where I 
grew up, is to get benefits to veterans. I think Appalachia 
seems to have a little more difficulty because of people's 
natural self reliance, which Americans have generally and 
Appalachians seem to have even more. There are all kinds of 
benefits out there for veterans, things like HEAP that Ms. 
Neutzling talked about, the energy assistance program, things 
like the earned income tax credit, you know. She and a lot of 
families are eligible for that.
    How do we get veterans to apply? What do you do as Veteran 
Service Officers in St. Clairsville or Flushing or Bellaire or, 
you know, anywhere else in Belmont County? What do you do to 
let veterans know they may be eligible for those programs? All 
Americans, not just veterans, but all Americans are eligible 
for something. Say they're making $30,000 a year with a couple 
of kids, a single parent trying to make it, how can that 
individual get a significant tax break, get a thousand or 
$2,000 back, as a reward for working hard and playing by the 
rules?
    What are you doing about that?
    Ms. Maupin. What we count on, we count on the Service 
Organization to do a lot of spreading the word about what we 
offer. Now, we're lucky, not all counties get the money to 
provide assistance. We have--our office is able to help 
somebody with a utility bill throughout the winter. We go from 
November to March just like HEAP does. If they're eligible for 
HEAP they're eligible to come in and get heating assistance 
from us, too. But a lot of people say they don't know about it. 
The additional funds for outreach, you can't reach everybody by 
setting up a table at the county fair or putting an article in 
the newspaper.
    Advertising, I was actually--no thanks to the county 
commissioners--I was criticized for getting into a parade, 
spending county money so we could hand out fliers for heating 
assistance. They didn't want us to take our county funds and 
use it for that type of outreach. So everything we've tried to 
do, short of putting an ad over on TV, and I haven't checked 
into the cost of that, but if they're going to criticize us for 
getting into a local parade they're going to criticize us for 
spending more money on ads.
    Senator Brown. The Veteran Service Organization, the 
officers around the State talk to one another. Has there ever 
been a discussion on sort of the best way to let veterans know 
these kind of things? Is there any way of getting that word out 
to veterans about all this?
    Ms. Maupin. The Ohio Department of Veterans Affairs has 
come up with a poster that actually offers the 1-800 number; 
but then you have the veterans that have spent 3 years in the 
service who don't think they're entitled to benefits. They 
don't know that they're even considered a veteran. I think 
that's where we lose a lot of people. I didn't know until I 
started working for the veterans office that I would have been 
eligible for health care.
    Senator Brown. I would hope Mr. Hartnett when he comes and 
testifies would talk about some of that. That's not even 
counting--those are the posters you put in the Legion and the 
VFW. That's not counting veterans that come home and don't know 
what they're entitled to.
    Ms. Maupin. Our local service organization, the average age 
of their members are probably 50 and over. The younger people 
aren't going into the service organizations. I don't know if 
that's in every area or in our area, but they're not joining.
    Senator Brown. They go home to Brilliant or wherever and 
never connect with you?
    Ms. Maupin. Right.
    Senator Brown. Last question: what is your average day? How 
often do veterans walk in and say, ``I'm home, is there 
anything you can do to help?''
    Ms. Maupin. We've recently relocated. We were in a building 
in St. Clairsville that wasn't handicap accessible, it didn't 
have any parking and nobody really knew we were there. There 
was nothing on the outside of the building. So just recently we 
moved to Bellaire. Our office is on the main street, it's got a 
ramp into the building, it's big, we have coffee and we 
advertise that a veteran can come in and sit and watch TV. We 
were donated a TV.
    Senator Brown. Where are you located?
    Ms. Maupin. Belmont Street.
    Senator Brown. You have offices in Powhatan, too?
    Ms. Maupin. We have a satellite office in Powhatan. I go 
down there once a week and I spend a couple hours down there. 
We have a satellite office in Barnesville, which is also quite 
a distance. We have a satellite office in Flushing. So when we 
moved, we readjusted our satellite offices to make sure that we 
tried to get the veterans in to see us. We work with the public 
libraries, and the libraries have let us set up there.
    Senator Brown. The places in Barnesville and Powhatan----
    Ms. Maupin. Are the libraries.
    Senator Brown [continuing]. Are the libraries? You said 
Flushing is in a library?
    Ms. Maupin. In Flushing, yes.
    Senator Brown. OK. You have posters up in all kinds of 
public places saying to call this 1-800 number or whatever?
    Ms. Maupin. Yes.
    Senator Brown. OK, good. Thank you.
    Dr. Greenlee, how do you overcome the sort of American feel 
of self-reliance and the Appalachian view even more so that 
people want to be by themselves more and they have a wonderful 
system of community here? How do you overcome that, to let 
people know that we're not giving you these things, you've 
earned this as a veteran; you've earned this education benefit, 
you've earned this health care benefit, you've earned these 
other benefits for community assistance and that sort of thing? 
How do you do that?
    Dr. Greenlee. Well, it's not an easy thing to do. But I 
think first off, I think you've got to get people they trust 
out in the community who are actually making a connection with 
them. But first they have to be educated about all of these 
issues that they face and their families need to be educated 
about this because they're going to be the people who are most 
likely influencing them to go for help, even though they may 
not want to go for help.
    Social services are very complex about who is eligible for 
what. I think it's hard for a flier to explain. I think most of 
us probably wouldn't know what we are eligible for and in what 
context for almost anything. Because of that, people have to be 
very finely educated about that. We need to use clergy from the 
churches, we need to use people from the schools, people from 
even their grade schools and their junior highs and their 
service organizations. I'm a member of the American Legion and 
I'm one of the younger people sitting in there on occasion. So 
it's a much older group of people involved.
    I think that we need to engage every one of those areas in 
going out and reaching out to people and knocking on doors and 
talking to them about these services, then making sure they do 
understand this isn't charity. The last thing anybody wants to 
do is take something for nothing. I think sometimes there's 
ways you can acknowledge that for them so that they can feel 
more comfortable in accepting that. Then once you do get them 
the treatment, and it's going a long ways away, if you ask 
anybody in our county, if you ask people--I'm on a fair board 
committee helping them, and no one from one side of the county 
will come to the other side of the county because they consider 
that to be so far away, that it's unreachable.
    Then to ask people to go to a city, which they feel 
uncomfortable anyhow, to go to the veterans hospital, and when 
you walk in there, as soon as somebody is treated, and I 
understand the pressures of trying to accomplish a lot quickly, 
but as soon as you act like you're in a hurry and ``I want you 
to fill this out,'' ``Go down here,'' ``Get here,'' they've 
already shown you that they don't care about you, you're only a 
number, and you don't ever want to come back.
    Many of them are going to fire the agency, not tell them 
they're fired, but never come back again. They would rather 
suffer through their pain than try to figure out looking on the 
Internet, talking to family and friends how the best way to 
handle it because they are, in many times, they feel they've 
been humiliated and they've been made to feel like this is 
charity rather than something they've earned by their service.
    I think what happens is you have a veteran who oftentimes 
is taught to be tough and then you look at the Appalachian 
culture that says the same thing, you've got a double whammy. 
It's going to take personal face-to-face relationships to turn 
that around. It's going to take at least some money because 
people can't get out. They can't even get out of the home 
they're in because they don't have a car that runs anymore. 
They don't even have telephones that people are talking about. 
I can't tell you how many people I know who do not have phones.
    If I could share one thing. This is a little short thing 
written by--it's a poem that was written by a woman named Diane 
Gilliam Fisher. It kind of gives us an education on how fast 
you can alienate somebody. She is originally from West 
Virginia. She calls this thing Sheepskin.

        She said, ``I told that doctor flat out what it was. He 
        looks me right in my face, says, `Mrs. Chapman, you can 
        worry a man sick, now, and John has got to work. You 
        let me do the doctoring here unless you got a sheepskin 
        somewhere I don't know about.' All I could think was 
        that old story about a wolf in sheep's clothing. I said 
        `Sheepskin?' He points to a picture frame propped on 
        his desk, diploma wrote in Latin from some college in 
        Virginia. I said, `No, doctor, I got nothing like 
        that.' I did not hold John's hands, speckled with coal 
        tattoos, out to the doctor, did not say, `Read this 
        here, doctor, how easy the dust works in under his 
        skin.' I did not say, `You come home up with us. Read 
        his handkerchiefs, read my pillowslips, grayed with 
        dust, sprayed with coal-black flecks of coughed-up 
        muck.' I did not tell him my learning come nights, from 
        the ragged, rocky-chested racket of my daddy's cough 
        and the only Latin we got to show for it is on his 
        stone. `No. What I know is not wrote on sheepskin, 
        doctor,' I told him. I said, `What I know was wrote on 
        the wall.' ''

    To me that's how easily one statement like that can make a 
person feel like I'm this little. My father had an eighth grade 
education, was a coal miner. They don't appreciate somebody 
like me with an education coming out and telling them what they 
don't know when they know what they see in those rooms. They 
know what they see with that veteran. They know what they're 
experiencing, but don't necessarily know how to tell you about 
it or feel comfortable telling you.
    So it is a long uphill battle and it's going to take person 
to person. It's going to take people who have had experience 
coming out who live there, who are from their community, who 
are veterans that say, ``All right. We've had some troubles, 
we've made some adjustments, people are growing. I want to take 
you and put you in a car and carry you there and I will sit 
there with you.'' I see it all the time.
    When I was at Ohio University down in Athens, before I came 
to the Eastern campus, we brought in a young man that lived out 
in a house with no running water in the house. His mother said, 
``I will find some way to get there.'' I told her, ``I will 
come get you.'' It was out in the middle of Morgan County. She 
said, ``I can't get there.'' I said, ``I will come get you.'' 
Then she said, ``No, I'll get somebody to get me there.'' She 
was proud. She wanted to do it. Now, when I got there I took 
them hand by hand, I carried them to every place. I spent 3 
hours with them walking through every place on that campus, 
getting them financial aid, getting him registered. At the very 
end I had to go to a meeting, so after 3 hours I said, ``I got 
to go, but I'll be right back.'' She said, ``You're not going 
to leave us, are you?'' After all that, she was afraid I was 
going to leave them. That's what you got to do.
    Senator Brown. Thank you all. Thank you for joining us. 
Thanks for your candor, your outspokenness, and your courage. 
Thank you especially for your service to our country. We'll 
call the second panel forward. While we do I want to introduce 
Regina Bryant, who is sitting behind me and Doug. She is from 
Coshocton and is recording, making sure to prepare us the 
official recording for this hearing.
    Would the second panel please come forward as I introduce 
them. I would like to thank our second panel of witnesses for 
testifying. Kim Graves is Director of the Veterans Benefits 
Administration's Eastern Area located in Ann Arbor. Despite 
your affiliation with Ann Arbor, thank you for your service to 
all the Buckeye veterans you serve. She's accompanied by Joyce 
Cange, the Director of the Cleveland Regional Office; Jack 
Hetrick, the Director of the VA Health Care System of Ohio; and 
Jeffrey Gering, the Director of the Chillicothe VA medical 
center. The three of them--Ms. Cange, Mr. Hetrick and Mr. 
Gering--will ask questions, not actually testify. I appreciate 
their being here.
    Ms. Graves is a U.S. Army veteran and has served her 
country in the military and with the VA for more than 25 years. 
She is a graduate of the University of Nebraska, where she 
earned a Bachelor of Arts in Psychology and Sociology with the 
assistance of the VA's Vocational Rehabilitation and Employment 
Program. She also holds a Masters Degree in Public 
Administration.
    Bill Hartnett will conclude today's testimony. Bill is from 
Mansfield, a town I know well and hold close to my heart. He is 
the Director of the Ohio Department of Veterans Services and is 
a U.S. Navy veteran of the Korean War era. He earned a 
Bachelors Degree in education from Kent State, his Masters in 
Education Administration from West Virginia University--I was 
rooting for them by the way, just so you know--and he has a 
Specialist in Education and Theory Degree from Kent State 
University. Bill served in the Ohio House of Representatives 
from 1998 to 2006. His first elected job was the same job and 
place, Richland County, as my first elected job.
    Ms. Graves, your testimony, please.

  STATEMENT OF KIM A. GRAVES, DIRECTOR, EASTERN AREA VETERANS 
 BENEFITS ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
   ACCOMPANIED BY JOYCE CANGE, DIRECTOR, CLEVELAND REGIONAL 
 OFFICE; JACK HETRICK, DIRECTOR, VA HEALTHCARE SYSTEM OF OHIO 
  (VISN 10); JEFFREY GERING, DIRECTOR, CHILLICOTHE VA MEDICAL 
                             CENTER

    Ms. Graves. Thank you, sir. Senator Brown and distinguished 
Members, it is my pleasure to be here today to discuss our 
efforts in meeting the needs of veterans residing in Ohio. As 
you know, joining me today I have very distinguished 
colleagues, and hopefully we will be able to answer any 
questions that you may have at the conclusion of today's 
testimony. I also wanted to extend my thanks to the prior 
panelists and all of those who have joined us here today for 
their service to this Nation.
    In response to Secretary Shinseki's mandate to transform 
the Department, our efforts in Ohio are focused on ensuring the 
delivery of benefits and health care services on a veteran-
centric basis. Veterans' needs are the principal drive of our 
efforts, and we are aware that reaching all of our veterans 
requires sustained emphasis. We are also aware that our 
programs have an economic impact, particularly in areas such as 
Appalachia, and we will continue to focus on the timely and 
effective delivery of benefits and services.
    The Cleveland Regional office provides services and 
outreach to servicemembers and veterans throughout Ohio 
including Wright-Patterson Air Force Base in Dayton. The 
Regional Office administers a full range of benefits including 
disability compensation for veterans and their dependents; 
vocational rehabilitation and employment assistance; home loan 
guaranty and specially adapted housing grants for veterans in 
the six-state jurisdiction of Ohio, Indiana, Michigan, 
Pennsylvania, New Jersey, and Delaware; and we provide outreach 
for all veteran and survivor benefits.
    The Cleveland Regional Office also oversees one of the 
Veterans Benefits Administration's eight National Call Centers, 
staffing a toll-free benefits information line. In addition, 
the Cleveland RO houses VBA's Tiger Team, which is a special 
claims processing team which supports the entire nation in 
reducing the number of claims pending for veterans over the ago 
of 70 and/or claims pending over 1 year.
    The Cleveland RO is responsible for delivering non-medical 
VA benefits and services to Ohio's 913,000 veterans and their 
families. Approximately 108,000 Ohio veterans receive 
disability compensation and pension benefits. VA benefits paid 
in compensation and pension to Ohio veterans totaled nearly 
$1.1 billion in 2009.
    In fiscal year 2009 the Cleveland RO completed nearly 
25,400 decisions on veterans' disability claims, and the Tiger 
Team completed nearly 20,000 additional decisions for veterans 
from across the Nation. In addition, the call center employees 
answered approximately 44,700 calls per month. In fiscal year 
2009 the Cleveland Regional Loan Center guaranteed over 8,200 
loans in Ohio worth over $1.3 billion making home ownership in 
difficult economic times a reality for Ohio veterans and their 
families.
    Currently the Cleveland Regional Office has 573 employees. 
During fiscal 2009 the Regional Office was able to hire 60 
additional employees, including 38 veterans, as a result of the 
American Recovery and Reinvestment Act or ARRA. The Cleveland 
Regional Office is continuously seeking ways to improve its 
delivery of benefits and services to Ohio veterans.
    During fiscal year 2009 the Cleveland Regional Office 
improved in most major benefits--excuse me, in most major 
performance indicators while the incoming claims volume have 
increased to nearly 6.8 percent over the comparable period in 
fiscal year 2009.
    Like you, sir, I have been concerned about the well-
publicized fact that veterans in Ohio historically receive 
lower disability compensation payments than veterans residing 
in other States. I assure you that we take this issue seriously 
and understand the impact of accurate rating decisions on 
Ohio's veterans. Under the Veterans' Benefits Improvement Act 
of 2008 the VA was required to provide a description of any 
discrepancies or differences regarding ratings for service-
connected disabilities among various populations of veterans. 
The VA contracted with the Institute for Defense Analyses, or 
IDA, to perform this study. As in a prior study, IDA concluded 
that there are many demographic and claim reasons for variances 
among States. Reports identifying Ohio as one of the 
historically lowest States in compensation payments are based 
on the totality of benefit awards to all veterans currently 
receiving compensation which represents over 50 years of rating 
decisions. It is noted that in IDA's most recent study it 
showed that for initial claims decided in fiscal years 2006 
through 2008 Ohio's average compensation ranks 30th of all 
States.
    To help ensure we reach as many veterans as possible, 
especially in the heart of Ohio's Appalachian Country, the 
Cleveland Regional Office began providing benefits counseling 
services at the Chillicothe VA Medical Center in January 2010. 
By partnering with the medical center, the regional office now 
staffs a benefits office 2 days per week to assist veterans and 
their families.
    The Cleveland Regional Office also actively works with the 
Ohio Department of Veterans Services to identify and solicit 
claims from Ohio veterans from all areas of the State, 
including Appalachia. We look forward to further development of 
our working relationship with Director Bill Hartnett and the 
Ohio Department of Veterans Services as we work together to 
meet the needs of our veterans.
    The VA has made significant improvements in delivery of 
benefits to Ohio veterans, but we can always do more. Such 
improvements have helped prepare the RO for processing 
approximately 5,000 claims we anticipate receiving as a result 
of the recently announced new Agent Orange presumptive 
conditions. The VA is committed to ensuring the best possible 
services available to Ohio veterans and their families.
    Senator, this concludes my oral testimony for today. Again, 
I greatly appreciate being here today and my colleagues and I 
look forward to answering any questions you may have.
    [The prepared statement of Ms. Graves follows:]

 Prepared Statement of Kim A. Graves, Director, Eastern Area, Veterans 
      Benefits Administration, U.S. Department of Veterans Affairs

    Senator Brown and Members of the Committee, it is my pleasure to be 
here today to discuss our efforts in meeting the needs of Veterans 
residing in Ohio. Joining me today are Joyce Cange, Director of the 
Cleveland regional office (RO), Jack Hetrick, Director of the 
Department of Veterans Affairs (VA) Healthcare System of Ohio (VISN 
10), and Jeffrey Gering, Director of the Chillicothe VA Medical Center 
(VAMC). Today I will discuss important benefits and services provided 
to the Veterans of this state, including those Veterans living in 
Appalachia. I will also update you on improvements the Cleveland RO 
recently made in its service to Ohio Veterans, as well as the VA 
provision of health care services to Veterans in Ohio.
    In response to Secretary Shinseki's mandate to transform the 
Department, our efforts in Ohio are focused on ensuring the delivery of 
benefits and health care services on a Veteran-centric basis. Veterans' 
needs are the principal driver of our efforts, and we are aware that 
reaching all of our Veterans requires sustained emphasis. We are also 
aware that our programs have an economic impact, particularly in areas 
such as Appalachia, and we will continue to focus on the timely and 
effective delivery of benefits and services.

                 BENEFITS PROVIDED BY THE CLEVELAND RO

    The Cleveland RO provides services and outreach to Servicemembers 
and Veterans throughout Ohio including Wright-Patterson Air Force Base 
(AFB) in Dayton. The RO administers the following benefits and 
services:

     Disability compensation for Veterans and their dependents;
     Vocational rehabilitation and employment assistance;
     Home loan guaranty and specially adapted housing grants 
for Veterans in the six-state jurisdiction of Ohio, Indiana, Michigan, 
Pennsylvania, New Jersey, and Delaware; and
     Outreach for all Veteran and survivor benefits.

    The Cleveland RO also oversees one of the Veterans Benefits 
Administration's (VBA) eight National Call Centers, staffing a toll-
free benefits information line. In addition, the Cleveland RO houses 
VBA's Tiger Team, a special claims processing team dedicated to 
reducing the number of claims pending in three categories: veterans age 
70 and over with a claim pending over one year; claims pending over one 
year; and claims pending for veterans age 70 and over. The Cleveland 
RO's goal is to deliver benefits and services in a timely, accurate, 
and consistent manner. This is accomplished through the administration 
of comprehensive and diverse benefit programs.
    The Cleveland RO is responsible for delivering non-medical VA 
benefits and services to Ohio's 913,000 Veterans and their families. 
Approximately 108,000 Ohio Veterans receive disability compensation and 
pension benefits. VA benefits paid in compensation and pension to Ohio 
Veterans totaled nearly $1.1 billion in 2009.
    In fiscal year (FY) 2009, Cleveland completed nearly 25,400 
decisions on Veterans' disability claims, and the Cleveland Tiger Team 
completed nearly 20,000 additional decisions for Veterans from across 
the Nation. Cleveland RO employees conduct an average of 590 personal 
interviews per month and answer approximately 44,700 calls per month in 
its National Call Center. The RO conducted 24 Transitional Assistance 
Program briefings to 572 Servicemembers in FY 2009.
    The Cleveland Regional Loan Center (RLC) administers VA loan 
services to Ohio Veterans. VA has guaranteed over 766,500 loans in Ohio 
with a cumulative loan amount of over $29 billion. In FY 2009, the RLC 
guaranteed over 8,200 loans in Ohio worth over $1.3 billion, making 
homeownership in difficult economic times a reality for Ohio Veterans 
and their families.
    To increase access to benefits, the Cleveland RO oversees benefits 
offices in Columbus and Cincinnati. RO employees are also available to 
assist Veterans at the Cleveland, Cincinnati, Dayton, and Chillicothe 
VAMCs, the Columbus VA Outpatient Clinic, and Wright-Patterson AFB. All 
Veterans, including those in more rural areas, are now able to obtain 
payment and claim-status information (notification, development, 
decision, or closure) via the eBenefits Web site. This web portal, 
created in conjunction with the Department of Defense, allows Veterans 
everywhere immediate access to information provided by VA.

                                STAFFING

    The Cleveland RO currently has 573 employees. During FY 2009, the 
RO hired 60 employees, including 38 Veterans, as a result of the 
American Recovery and Reinvestment Act (ARRA). All ARRA employees 
directly contribute to improved benefits delivery by assisting with the 
development of claims and mail processing. The RO employees are very 
motivated and dedicated to making a difference in the lives of Ohio 
Veterans.

                    IMPROVEMENTS IN SERVICE DELIVERY

    The Cleveland RO is continuously seeking ways to improve its 
delivery of benefits and services to Ohio Veterans. During FY 2009, the 
Cleveland RO improved the accuracy of its rating-related decisions by 
over five percentage points to 88.4 percent. This accuracy rate, which 
is higher than the VBA national average, has been sustained this year. 
The Cleveland RO currently decides claims in an average of 161 days. 
This is comparable to the VBA national average of 160 days and is a 45-
day improvement over the Cleveland RO's average processing time in FY 
2008. Increased staffing, and improved proficiency of that staff as 
their training progresses, as well as the office's focus on workload 
management, are the principal contributors to that improved 
performance.
    The Cleveland RO's pending rating-related claims inventory 
currently averages approximately 10,800 claims. The RO has maintained 
this level of inventory even while the office's incoming claims volume, 
through February of this fiscal year, has increased nearly 6.8 percent 
over the comparable period in fiscal year 2009. This represents a 28 
percent reduction since the RO's record-high inventory of 15,123 at the 
end of FY 2006.
    Like you, I have been concerned about the well-publicized fact that 
Veterans in Ohio historically received lower disability compensation 
payments than Veterans residing in other states. I assure you that the 
Cleveland RO takes this issue seriously and understands the impact of 
accurate rating decisions on Ohio's Veterans and our stakeholders. 
Under the Veterans' Benefits Improvement Act of 2008, VA was required 
to provide a description of any differences regarding ratings for 
service-connected disabilities among various populations of Veterans. 
VA contracted with the Institute for Defense Analyses (IDA) to perform 
this study. As in a prior study, IDA concluded that there are many 
demographic and claim-specific reasons for variances among states. 
Factors such as the number of claims received for disability 
compensation based on Individual Unemployability and Veterans' military 
retiree status all play a part in state variances. Reports identifying 
Ohio as one of the historically lowest states in compensation payments 
are based on the totality of benefit awards to all Veterans currently 
receiving compensation, representing over 50 years of rating decisions. 
However, IDA's recent study showed that for initial claims decided in 
fiscal years 2006 through 2008, Ohio's average compensation ranked 30th 
of all states.
    To ensure that the Cleveland RO's decisionmakers are consistent 
with other offices, the Cleveland RO developed an extensive training 
plan for all employees. With a full-time training manager dedicated to 
employees' learning, each technical employee involved in the claims 
process receives a minimum of 80 hours of technical training annually. 
This training consists of 40 hours of Core Technical Training, 20 hours 
of standardized topics chosen by VBA, and 20 hours of training chosen 
by the RO for local issues and areas of concern. Such training includes 
having employees prepare mock decisions based on standard fact 
patterns. These mock exercises ensure that decisionmakers consistently 
review evidence and apply the law equitably.
    Furthermore, all new employees hired to work disability claims 
receive comprehensive training and a consistent foundation in claims 
processing through a centralized training program called Challenge. 
During FY 2009, the Cleveland RO had 35 newly hired or promoted 
employees attend centralized training under the Challenge program. The 
Challenge concept also includes extensive prerequisite courses prior to 
attending the centralized training segment and a standardized, rigorous 
training curriculum following it. Standardized computer-based tools 
have also been developed for training decisionmakers. Training letters 
and satellite broadcasts/NetMeetings on the proper approach to rating 
complex issues are also provided to all ROs.
    As a result of the Cleveland RO's training efforts, the office has 
historically high pass rates on employees' Skills Certification Tests, 
a standardized testing system used to promote employees.

                       OUTREACH AND PARTNERSHIPS

    To help the Cleveland RO reach as many Veterans as possible, 
especially in the heart of Ohio's Appalachian Country, the Cleveland RO 
began providing VA benefits counseling services at the Chillicothe VAMC 
in January 2010. By partnering with the Medical Center, the RO now 
staffs a benefits office two days per week to assist Veterans and their 
families. Since the start of its on-site presence, the RO has served 
over 140 Veterans in Chillicothe. I am pleased that the RO is meeting a 
very real need to get information and assistance to these more 
difficult-to-reach areas of Ohio.
    I am also proud of the Cleveland RO's successful relations with 
VA's stakeholders. The RO provides office space to nine major Veterans' 
Service Organizations in the Cleveland facility. The RO recently 
welcomed the arrival of a permanent service officer of the Ohio 
Department of Veterans Services. The RO provides quarterly training to 
all of Ohio's 88 County Veterans Service Offices and recently completed 
a Congressional Liaison Seminar for local Congressional staffers.
    The Cleveland RO actively works with the Ohio Department of 
Veterans Services to identify and solicit claims from Ohio Veterans 
from all areas of the state, including Appalachia. The creation of this 
Ohio Cabinet-level department increased awareness of Veterans' needs in 
the state. The RO looks forward to further development of its working 
relationship with the Director, Bill Hartnett, and the Ohio Department 
of Veterans Services, as we work together to meet the needs of 
Veterans. As one of its first shared tasks, the Cleveland RO is working 
with the Ohio Department of Veterans Services to pilot the use of a 
checklist for claims submitted by Ohio's County Veterans Service 
Officers to ensure the timely submission of evidence to expedite claims 
processing.

                          HEALTH CARE SERVICES

    The VA Healthcare System of Ohio, Veterans Integrated Service 
Network (VISN) 10, consists of four VAMCs, one health care center, and 
30 community-based outpatient clinics (CBOC). VISN 10 provides mental 
health services at all 30 CBOC locations. The Louis Stokes Cleveland 
VAMC has a total of 13 Outpatient Clinics located throughout 
Northeastern Ohio.
    VISN 10's strategic plan of providing access to primary care and 
mental health services within 30 minutes or 30 miles, as well as access 
to tertiary care within 60 to 120 miles of all of Ohio's Veterans, has 
been accomplished. VISN 10 consistently ranks highest across the 
Department in access to clinical care with less than 0.4 percent of 
Veterans waiting more than 30 days for an appointment in FY 2009. These 
achievements are noteworthy, but there is always more we can do to 
improve the care Ohio Veterans receive.
    The Canton Outpatient Clinic is 25,000 square feet in size and 
serves over 12,200 Veterans. Current services offered at the Clinic 
include primary care, mental health, optometry, podiatry, laboratory 
services, pharmacy benefits, home-based primary care, women's health, 
and radiology. Two additional outpatient clinics located in Akron and 
New Philadelphia serve 12,380 and 2,800 Veterans, respectively. The 
Lorain CBOC is fully operational at the St. Joseph Community Center. 
Through the first five months of FY 2010, it has treated 6,152 
Veterans.
    VA is expanding the Middletown CBOC, more than doubling its size 
from 7,000 square feet to more than 18,500. The Middletown CBOC 
currently provides onsite primary care, preventive medicine, laboratory 
services, outpatient mental health, intensive case management for 
mental health, optometry, home-based primary care, and pharmacy 
benefits. By 2011, when the expansion is complete, the facility will 
also offer occupational and physical therapy, as well as radiology. 
VA's Office of Rural Health is awarding $1 million to establish an 
Outreach Clinic in Wilmington to provide primary and mental health care 
for rural Veterans. VA is working hard to establish this clinic, and 
the Department expects to activate the clinic by this summer. VISN 10 
continues to explore further options for enhancing care in rural Ohio, 
and to improve home-based primary care, tele-medicine, optometry, 
podiatry, and mental health care.

                               CONCLUSION

    VA has made significant improvements in delivery of health care and 
benefits to Ohio Veterans. Such improvements have helped prepare the RO 
to process approximately 5,000 claims anticipated to be received as a 
result of the recently announced new Agent Orange presumptive 
conditions of ischemic heart disease, Parkinson's disease, and certain 
leukemias. We have also improved the quality and availability of health 
care for Veterans across the state. VA is committed to providing the 
necessary resources to ensure the best possible service is available to 
Ohio Veterans and their families.

    Senator, this concludes my testimony. I greatly appreciate being 
here today and look forward to answering your questions.

    Senator Brown. Thank you Ms. Graves. Mr. Hartnett.

   STATEMENT OF BILL HARTNETT, DIRECTOR, OHIO DEPARTMENT OF 
                       VETERANS SERVICES

    Mr. Hartnett. Thank you, Senator. Thanks for being here and 
joining with us in this field hearing that you have called. 
Your letter invited me to discuss the benefits and services 
available to Appalachian veterans. I also want to tell you 
about the efforts being made throughout all of Central Ohio, 
and especially our efforts to find veterans.
    An interesting comment made earlier was a lot of veterans 
don't know they're veterans. When the department was 
established 18 months ago Governor Strickland made it very 
clear that our primary objective is to find our veterans and 
make them aware of the benefits they've earned. That's why our 
State mission is likely to be identified to connect and 
advocate for veterans and their families. If we translate that 
mission into numbers from the VA and the Department of Defense 
we're looking at 935,000 Ohio veterans. That vast majority of 
these veterans have never applied for State and Federal 
benefits, so we have no database as to where those veterans 
are; so how can we find them? Unfortunately, it's very 
difficult to identify them; we just know they're there. So we 
reasonably can't contact all of the veterans. Let's find a way 
for them to contact us. To that end we have carefully launched 
a marketing campaign to all veterans in Ohio inviting them to 
call 1-877-OHIO-VET to learn about the benefits they have 
earned. Our message is very simple: ``Veterans! Your service 
may be worth more than you think. Call 1-877-OHIO-VET.''
    But first, it is important to define what person is a 
veteran. It's important because there are thousands of veterans 
in Ohio, perhaps tens of thousands, who do not know that they 
are veterans. Let me explain that. These veterans see veterans 
only as people who are retired from the military. Or they think 
that people on active duty are not retired so they're not yet 
veterans. So let's define what a veteran is. A veteran is any 
person who honorably wears or has worn a United States military 
uniform, or is a member of the uniformed services of the 
National Oceanic and Atmospheric Administration or the Public 
Health Commission Corps.
    So our mission is two-fold. First, we have to tell a lot of 
veterans they're veterans and that their service may be worth 
more than they think. Second, we have to tell them to contact 
us, 1-877-OHIO-VET. Earlier I said that we launched this 
marketing campaign to get those veterans into our database. I 
say carefully because we have to move deliberately because we 
don't want to overwhelm the County Veterans Service Officers. 
Many of them are understaffed and underfunded.
    The Appalachian Counties here in Eastern Ohio are good 
examples. They do great work, great work, as do the other 88 of 
our County Service Offices. But if we suddenly invite tens of 
thousands of veterans to call them for benefit information, 
they would simply be overwhelmed. We would have a few thousand 
very upset veterans making unanswered or unreturned telephone 
calls.
    Hire more people to take the calls? Well, that's not easy. 
The county offices are funded by a half-mill of the county's 
property tax receipts. Of course, property taxes differ 
dramatically from county to county and the less affluent 
counties get the least money.
    It's no secret that Ohio's Appalachian Counties are at a 
geographic disadvantage when it comes to connecting our 
veterans to extensive health care. Although the area is placed 
under Ohio for the most beautiful landscape, medical treatment 
for our veterans is a cross-country venture. A veteran in 
Marietta, for example, must travel 80 miles for treatment at a 
VA medical center in Clarksburg, WV. I address this issue 
carefully in my written testimony.
    We're also doing some groundbreaking work with the VA 
Regional Office in Cleveland so that communication between our 
department and the VA is faster, easier, and clearer. How are 
we doing that? Well, we're putting the Ohio Department of 
Veterans Services staff in the Cleveland Regional VA Office 
right now. I mean, literally, in the VA office and literally, 
right beside the VA staffers.
    With your permission I would like to recognize two people 
that are with us who are the primary movers in the efforts to 
get the veterans connected to get the benefits and services 
they have earned. First, Director Cange, who is my all time 
hero, and my second all time hero, Mickey Volkman, who is our 
person at the VA. I think that you will find that their work is 
going to do a great deal. You see, I told you that Ohio and VA 
are now side by side. I will also tell you that other States 
are watching Ohio pretty closely and that the VA in Washington 
is also watching. If this type of project works, and we have 
evidence that it is already working, other States I think will 
launch similar efforts.
    I want to emphasize something very, very important. We 
could not have established this cooperative relationship 
without the VA and the Cleveland Director Joyce Cange. Director 
Cange gets it. She recognizes the problem and she understands 
the solutions. The objective here is to speed up the front end 
of the application process. That's the time between the 
veterans initial request for benefits and the time when they 
receive a decision from the VA. Simply stated, very simply 
stated, the VA needs additional information in order to make 
that funding decision. It's easier for somebody to walk 15 
steps and ask one of his or her associates for help than it is 
to communicate with strangers 250 miles away.
    The backlog you heard about is real. But we can attack it 
with higher training standards at all levels. The Ohio County 
Commissioners, the County Veteran Service Commissioners and 
their offices are championing this additional training. We are 
excited every time we hear that Secretary Shinseki recognizes 
that the disability claim backlog could be eliminated from one 
key step, going paperless.
    Twelve days ago in Baltimore he said he wants the quantity 
resolved by 2012 when a modern system is expected to start 
rolling out. It's all about computers, computers, computers, 
and when it comes to the backlog of disability claims, it's 
time to leap into the nineties. Improved procedures can be 
adopted and identified and developed. Why do we have to wait 
for the veteran to make the first contact with the VA? Why 
can't the Department of Defense automatically place veterans in 
the VA system the moment they enlist or when they are 
discharged or separated from service? If we did that, we would 
have veterans on file even though they have never applied for 
benefits. We could tell them about such things as the diseases 
that are presumed to be caused by their service in Vietnam, and 
now Afghanistan, Iraq, and the Persian Gulf.
    I hope that my point is clear, Senator. We acknowledge that 
our system is flawed, but we are not stuck in decades old time 
and tradition. Not only are we looking for new, more effective 
policies and procedures, we are finding them and implementing 
them all to improve our service to the veterans that have 
served us. We are actively identifying and connecting with and 
advocating for our veterans and their families and will never 
be satisfied until they're all served. Thank you for your time.
    [The prepared statement of Mr. Hartnett follows:]

   Prepared Statement of Bill Hartnett; Director, Ohio Department of 
                           Veterans Services.

    The mission of the Ohio Department of Veterans Services (ODVS) is 
``to actively identify, connect with and advocate for Veterans and 
their Families.'' Since the department was established 18 months ago, 
we have concentrated on finding the 935,000 Veterans that VA says are 
Ohioans.
    We started with a list of only 4000 names and addresses of Veterans 
18 months ago and now we are up to 400,000 and adding approximately 
20,000 new Vets each month. We are doing this with the help of our 
partnership, with the Ohio Bureau of Motor Vehicles and the Ohio 
Department of Jobs and Family Services. They are providing contact 
information from Veterans who renew their driver licenses, register 
their vehicles with military license plates or, seek assistance about 
jobs and family services.
    The VA has a list of Veterans in its database. These are Vets 
seeking help for challenges that are extremely private and their 
privacy is, of course, protected by VA.
    If we can't contact those Vets, let's find a way for the Veterans 
to contact us. To that end, we have carefully launched a marketing 
campaign to all Veterans in Ohio; inviting them to call 877-OHIO-VET to 
learn about the benefits they have earned. Our message is very simple:

        ``Veterans! Your service may be worth more than you think. Call 
        1-877-OHIO-VET.''

    But first, it is important that we define, ``who is a Veteran.'' It 
is important, because there are thousands of Veterans in Ohio--perhaps 
tens of thousands--who do not know they are Veterans. Let me explain.
    These Veterans see Veterans only as people who are ``retired'' from 
the military. They incorrectly think that if they are on active duty, 
they are not Veterans; they incorrectly think that if they did not 
serve at least 20 years of active duty, they are not Veterans.
    They think: ``I was in the military for only four years so I'm not 
a Veteran.'' Or, ``I'm still on active duty so I'm not a Veteran.''
    A Veteran is any person who honorably wears or has worn a United 
States military uniform, or is a member of the uniformed services of 
the National Oceanic and Atmospheric Administration (NOAA) or the 
Public Health Commission Corps (PHCC).
    So, our mission is two-fold:

    First, we have to tell a lot of Veterans that they are Veterans and 
that they may be eligible for benefits.
    Second, we have to tell them how to contact us.

    Earlier, I said that we have carefully launched a marketing 
campaign to get those Veterans into our database. I say carefully 
because we have to move deliberately but slowly. Slowly, because we 
don't want to overwhelm the County Veterans Service Offices (CVSO) 
which will be the primary agency that the veteran is to contact. Many 
of them are under staffed and underfunded.
    Most of the Appalachian counties here in Southeast Ohio are good 
examples. They do great work . . . great work . . . as do all 88 of our 
CVSOs. But, if we suddenly invite tens of thousands of Veterans to call 
them for benefit information, they will be overwhelmed. And, we would 
have a few thousand very upset Veterans making unanswered or unreturned 
telephone calls.
    Hire more people to handle the calls? Well, that's not as easy as 
it may sound. As you know, the county offices are funded by a half-mill 
of the county's property tax receipts. Of course, property taxes differ 
dramatically from county to county and the less affluent counties get 
the least money.
    So, we're moving carefully . . . 
    With posters promoting our message and the 877 OHIO Vet number. 
Right now, they're hanging in places where people walk and wait; at 
barbershops and beauty salons . . . at state parks . . . BMV offices . 
. . rehabilitation services commission offices . . . county one-stop 
centers and so on.
    We know that many Veterans gravitate to jobs that require uniforms. 
So, our posters are going to every fire department in Ohio . . . police 
departments and FOP lodges . . . Natural Resources and the Highway 
Patrol barracks.
    We're working with the Ohio Council of Retail Merchants so that 
their member stores can give customers a pre-paid post card that they 
can fill out and mail back to us. That's Kroger, Giant Eagle, Walmart, 
Best Buy, Target, Meijer and other retailers throughout Ohio.
    That's how we're working ``to actively identify, connect with and 
advocate for Veterans and their families.
    We're also doing groundbreaking work with the VA regional office in 
Cleveland so that communication between my department and the VA is 
faster, easier and clearer. How are we doing that? We have Ohio 
Department of Veterans Services staff in the Cleveland Regional VA 
office. I mean, literally, in the VA office and literally, right beside 
the VA staffers.
    A big thank you goes to the Director of the VA Regional Office in 
Cleveland, Joyce Cange for her partnership with our department. Our 
Deputy Director, Mickey Volkman, now works from the VA office in 
Cleveland.
    On her very first day, Mickey started working with the VA staff to 
implement a compensation check sheet for CVSO's. This sheet not only 
helps the counties to submit a complete claim for VA Compensation, but 
it also helps the VA to identify and recognize a compensation claim 
that is ready to process. This can speed the processing time 
considerably. Just last month, two new claims were filed, they were 
processed within 30 days and given a rating decision.
    Not only are we working side by side with the VA but also with the 
military service organizations, such as the VFW, to assist with claims. 
Mickey, operating as a mediator in the VA, is helping to open the 
communications between the VA, CVSO's and the veterans organizations. 
By establishing these relationships, we are building a strong teamwork 
attitude to help reduce the gaps between claims preparers and the 
claims processors and to speed up the process. The bottom line is 
better service for the Veterans of Ohio.
    I can also tell you that other states are watching Ohio very 
closely and the VA in Washington also is watching. If this project 
works . . . and we have evidence that it already is working . . . other 
states could launch similar efforts.
    As the VA and the Ohio DVS learn more and more about each other, 
new ideas are born, new procedures are being developed, and new 
questions are being asked and answered.
    The backlog you've heard about is real but we can attack it with 
higher training standards at all levels. Several approaches are 
underway.
    Ohio has a well-positioned system of CVSO's throughout the state 
with more than 180 county Veterans service officers who are accredited 
by our Department of Veterans Services. However, all of them are not 
accredited with the Veterans organizations that do business at the 
Cleveland Regional office. When they are accredited, they can 
communication directly with VA to discuss a Veteran's claim. Through 
those accreditations we are hopeful that our CVSO's will be better able 
to follow the processing of the veterans' claim and to keep the veteran 
informed of its progress.
    In Addition, if the Department of Defense would automatically place 
Veterans in the VA system the moment they are discharged or separated 
from the service, we would have Veterans on file even though they never 
have applied for benefits. And, we could tell them new benefits such as 
the diseases that now are presumed to be caused by their service in 
Vietnam . . . or Afghanistan . . . or Iraq . . . or the Persian Gulf.
    We have more great programs and initiatives that Ohio has 
implemented to better serve our Veterans:

    The Ohio GI Promise represents the most significant expansion of 
benefits and services for veterans in Ohio since the end of World War 
II. The creation of the GI Promise ensures that veterans in Ohio are 
given every opportunity to achieve the promise of a higher education. 
The Board of Regents, Ohio institutions of higher education, the Ohio 
DVS, and many others invite America's veterans and their dependents to 
earn their college degrees here in Ohio, and ensure that they have the 
resources they need to succeed. In doing so, veterans and their 
families will make significant and important contributions to the state 
of Ohio in many ways: They will help expand Ohio's skilled work force 
with their knowledge and education; they will bring their maturity and 
motivation to Ohio's higher education classrooms; and, they will enrich 
Ohio's communities through their leadership, selfless-service, and 
dedication.
    On election day 2009, 72 percent of Ohio voters went to the poles 
to say thank you to our Ohio veterans with the passing of Issue One, a 
bonus for Veterans of wars in the Persian Gulf, Iraq and Afghanistan. 
The passing of the bonus is expressing the gratitude to Ohio veterans 
for all they have done for us. Our department is working diligently on 
several crucial steps that must be in place before dispersing the 
checks. We want the bonus application and approval process to be easily 
understood, accurate and efficient. The department's goal is to be 
mailing the first checks in November, one year from voter approval.
    Last April, our department partnered with the VA Healthcare System 
of Ohio to host the largest Women Veterans Conference in the Nation. We 
had almost 700 women in attendance. The one-day conference was geared 
toward informing women Vets of the many benefits they may be entitled 
to. Our department is committed to continuing our efforts to reach 
women Veterans through various outreach initiatives.
    We also are very proud of the excellent care our State Veterans 
Homes provide to Ohio's heroes. Both the nursing home and domiciliary 
in Sandusky as well as the newer home right here in Appalachia, over in 
Brown county, continue to provide much needed care for more than 750 
residents. Our residents come from all walks of life but have a common 
bond of serving our Nation during our past and present conflicts and 
wars overseas.
    The homes also provide significant employment opportunities in the 
areas where they are located. Our home in Brown County has added nearly 
200 good paying jobs to the Appalachian region and is now the 5th 
largest employer in Brown County.
    In the most recent Veterans Health Administration surveys conducted 
at both locations, the nursing home in Sandusky experienced just one 
minor citation, while the domiciliary in Sandusky and the Nursing home 
in Georgetown received perfect zero deficiency surveys. This 
performance is on par with the best state veterans facilities in the 
Nation. Surveys conducted by the Ohio Department of Health also 
substantiate the excellent care provided by the dedicated professionals 
who are caring for our residents.
    A program started nationally is being implemented here in Ohio by 
Supreme Court Justice Evelyn Lundberg Stratton. She is establishing 
Veterans courts to help returning Veterans with PTSD and other issues, 
whose problems may lead to involvement in the criminal justice system. 
The veteran will be given the opportunity to be assessed for required 
treatment including alcohol, drug, mental health and/or medical 
assistance. They will also be assessed for housing and/or job 
referrals. The Vet will have a rehabilitation plan for treatment and 
assistance with the VA. This is an opportunity to prevent Veterans 
charged with misdemeanors from falling into a life of crime.
    The Ohio Department of Rehabilitations and Corrections is working 
with the U.S. Department of Labor, Veterans Employment and Training 
Service on the Incarcerated Veterans Transition Program. This program 
is designed to help ex-offender Veterans who are at risk of 
homelessness to re-enter the workforce. It provides direct services--
through a case management approach--to link incarcerated Veterans with 
appropriate employment and life skills support as they transition from 
a correctional facility into the community.
    The Ohio Military Injury Relief Fund (MIRF) was created by House 
Bill 66 in June 2005. The purpose of the MIRF is to grant money to 
servicemembers injured while serving in country under Operation 
Enduring Freedom and Operation Iraqi Freedom. The grant money paid to 
the servicemember will vary year to year, based on the amount of funds 
collected for the tax year. The application process is simple and 
usually it takes only four to six weeks to receive a check. This 
program has been very helpful to Vets and their family members.
    As you can see all our efforts are focused on better serving all 
Veterans of Ohio and continuing to build and enhance our partnerships. 
We acknowledge that our system is flawed but we are not stuck in 
decades old time and tradition. Not only are we looking for new and 
more effective policies and procedures, we are finding them and 
implementing them . . . all to improve our service to the Veterans who 
served us.
    We are ``actively identifying . . . connecting with . . . and 
advocating for our Veterans and their families.'' And never will we be 
satisfied.

    Thank you for your time and this opportunity to speak with you.

    Senator Brown. Thank you, Director Hartnett. I appreciate 
your comments as always.
    Ms. Graves, Director Hartnett said that we can't find all 
the vets in the State and across the country so we are making 
it easier for them to find us. Why can't we, with technology, 
why can't we correspond with virtually every veteran? We have 
military records that they've served, we have, in many cases, 
Social Security numbers and we have the technology. Maybe the 
better question is maybe not why, why can't we, but what are we 
doing so we can? What are we doing nationally?
    Ms. Graves. Over the past several years there has been a 
significant effort from both the DOD and the VA to work much 
closer together to improve that transition, that seamless 
transition, from servicemember to veteran. I see a couple of 
improvements in that area. We are now receiving basically a 
direct feed from the DOD that tells us information about those 
who are serving. One of the ways we get information to process 
some of our claims is that direct feed of information from the 
DOD.
    Senator Brown. I'm sorry to interrupt you. I know we're 
doing better. One of the first conversations I had with 
Secretary Gates was in January, or whenever it was in 2009. I 
was urging him, as our Committee has, and he was beginning to 
interface between the DOD and VA so that when people leave the 
service they don't go back to Belmont County or Jefferson 
County or Guernsey County or Muskingum County never to be seen. 
So they are doing better and helping veterans ultimately have a 
seamless transition with medical records beginning when they 
join the service.
    But for all those veterans that are older, that have served 
in other wars--I think we're making significant progress and 
doing the right thing for those that are the soldiers, Marines, 
and sailors now--but what about those that fought in World War 
II or Korea or served during the fifties or the sixties or what 
have you? What are we doing about them?
    Ms. Graves. I think, sir, the thing that we're trying to 
do, just as they are at the State level and the county level, 
is the outreach, getting our people, along with the county and 
State, out in the community reaching out to veterans, being in 
places where veterans go.
    Senator Brown. But we're not doing any kind of systemic 
outreach to the Korean War veteran that never goes to the VA. 
My dad served in World War II, he served in several countries, 
though he didn't talk about it a lot. Most veterans don't. I 
wish they would talk more. We could learn a lot from them, but 
that's their choice. They don't go into the veterans 
organizations.
    There are ways of using technology. I appreciate all those 
things like what Director Hartnett is doing. It's very, very, 
very important that VA work with them and get the posters 
around. What are we doing to find those that don't go to these 
organizations?
    Ms. Cange. Let me just speak about Cleveland and the 
veterans in the State of Ohio. Again, our partnership with the 
Ohio Department of Veterans Services is very key and critical 
to reaching out to these veterans in the State of Ohio. What 
Director Hartnett has started to do, which you might want to 
speak to the Director, is he's reaching out and asking veterans 
through the State licensing board, ``Check a box if you're a 
veteran.'' Then that information gets back to Director 
Hartnett. Then our next step is to work to reach out to those 
veterans that have identified themselves so we can go out and 
tell them what the benefits are that they're entitled to. Doing 
that outreach is essential. So that's what we're doing in Ohio.
    Senator Brown. I appreciate that, and I'm not in any way 
belittling or demeaning that, but isn't there a way when DOD 
has some records--I would imagine Social Security numbers of 
many, many, many of the Korean and Vietnam War vets and others 
for example. We have a way from all kinds of databases from the 
Department of Motor Vehicles, hunting licenses, fishing 
licenses, and all of that; isn't there a way to--and the State 
can't do this, but isn't there a way for the VA to find--and 
maybe this is a huge problem, it seems like it probably is--but 
isn't there a way to use technology like e-mail or to direct 
mail notifications or something to reach veterans?
    Ms. Graves. Secretary Shinseki is bringing a culture of 
advocacy to the VA and, that is, definitely taking this 
information back and ensuring that we haven't done these type 
of things, that we haven't done that. I would be happy to 
report that back through your staff.
    Senator Brown. Let me go to two of the problems that we've 
identified over and over. I encourage any of the five of you, 
the three in the middle, to speak up at any point to some of 
the things that Ms. Maupin brought up and Ms. Neutzling or Dr. 
Greenlee, but especially the two more specific problems. One is 
the backlog and the second is the level of--you know, that fact 
that we rank fifth in the Nation in the level of benefits. 
Maybe I'm dense about this, but I can't still understand why 
Ohio seems to have a backlog that's larger than most States and 
why our benefits are lower than most States. You represent more 
than one State, so why is it worse in Ohio than in Michigan? 
What do we tell these people and what do we do about those? Do 
you know?
    Ms. Graves. You're absolutely right. Those are intense 
problems that we're dealing with on a daily basis. One of the 
things through Secretary Shinseki's leadership is we are now 
looking at all kinds of ways that we can work in our regional 
offices to cut the backlog. This means looking for unique and 
innovative ways to use the staff that we have.
    We have been very fortunate to be able to hire many new 
staff, but it does take time, a significant amount of time, to 
get those folks to a very proficient level. We are trying to 
use those individuals in the most effective manner that we can 
while they're still training and learning to have the most 
impact on improving the process. We are looking at unique and 
innovative ways to streamline the process all the way from 
looking at things we can individually do in our regional 
offices to ensure that we have a smooth transition to looking 
at procedural and regulatory areas that might be improved upon 
to increase our efficiency in providing services.
    As Director Hartnett noted earlier, technology is 
significant, but it won't be everything that we need. With 
improved processes and increased capitol, again, those are 
areas where Secretary Shinseki has been very up front about 
maybe trying to take advantage of all of these types of 
technologies.
    With the impending regulation for--regarding Post Traumatic 
Stress Disorder, we are working to ensure that those claims 
come in and we can begin to address them as effectively as we 
can. At my level, I have responsibility for 16 offices. I work 
with them to look at individual components in the regional 
offices to make sure that we have the resources where 
appropriate and we take appropriate action to hold our staff 
accountable for improving service. As Director Hartnett said, 
it is key when looking at individual States, that we are 
getting out in into the community and reaching out to veterans 
and doing everything that we can to improve the services that 
we provide.
    Senator Brown. Thank you. Director Hartnett.
    Mr. Hartnett. Thank you, Senator. I think that I look at 
this kind of from a veteran in my era or Vietnam. But the issue 
is that right now I think one of the VSOs' most difficult 
problems is to prove a medical claim. Because we have nothing--
we don't know anything about them. When they got out, I bet 
most of their physical exam was, ``How do you feel?'' ``You 
know, I want to get home.'' So to go back to connecting a 
current disability with something that happened to them while 
they were serving is very difficult. I think that, you know, 
the VA deals with billions of dollars. Obviously I think they 
want to preserve the treasury, but there are times with the 
senior veterans where it's a little different than the current 
veteran who hopefully will have that medical record and make it 
much easier for them to attach a future problem to something 
that was verified when they get out.
    The issue that you bring up I think is real important and 
that is about how all of these 135,000 veterans we have in Ohio 
have the problem of proof. It seems to me that, I don't know 
what all of the standards are for approving it, but I know that 
it takes a long time. I think the length of time is something 
we have to look at. I mean, we have a backlog not because we 
have too many to serve at any one time, but we're serving all 
of those that are ready at one time, plus all of those that 
we've put away because we haven't been able to verify or to get 
an appropriate answer back to the veteran.
    So I think that there's two things that can happen. Going 
forward we should understand that we, as an office, being in a 
place for a long time should have a better handle on this. When 
we started we knew 4,000 veterans, their names and addresses. 
That's all we could verify, and it came from a women's veterans 
group that met in Ohio. We are at 435,000, and we still have to 
protect those names. What we're trying to do is not only use 
the 1-877-OHIO-VET, but we're also partnering with the retail 
merchants in Ohio to give a guy, or a woman, a postcard that 
says, ``If you're a veteran, send this in.''
    So we're going to build a better bank of veterans, but we 
still, especially in Southeast Ohio, I think it's very 
difficult as the doctor said before. We need to tell them they 
are a veteran. We need to be using our Veterans Service Offices 
and the director's office to get people to tell us they're 
veterans so we can help them.
    Senator Brown. Mr. Gering, I was in Chillicothe a few days 
ago. I think you're in charge of five CBOCs?
    Mr. Gering. That's correct. One of them we're just opening 
in Wilmington, so we have five and one-half.
    Senator Brown. Just down the road in Southgate Parkway is 
the Cambridge CBOC which has a new mental health program I 
understand with a psychiatrist specialist in house. Are there 
more plans or programs so that the CBOCs will all have that 
specialty, at least among your area, Mr. Gering, or Ms. Graves 
or Mr. Hetrick, that will be available multiple days of the 
week?
    Mr. Gering. I really think under Secretary Shinseki's 
leadership our relationship will increase with Ohioans and the 
VA in putting mental health out there in CBOCs, and the 
clinics. I know last year we put mental health presence in 
CBOCs. We have a mental health social worker.
    Senator Brown. Beyond the five?
    Mr. Gering. I can speak for our five. We have a mental 
health social worker in each one of ours. We have a mental 
health psychologist at each one of those clinics. And starting 
next week we will have a psychiatrist at each one of those 
clinics as well. So if you go--like in Cambridge here you will 
be able to see a psychiatrist on site. In Athens, we have, 
again, a mental health social worker, a psychologist full time. 
She has a practice in Athens. She's been on board about a year. 
So we've done an awful lot of outreach for getting access to 
mental health services for veterans in Appalachia, in 
Southeastern Ohio.
    Senator Brown. Mr. Hetrick, do you want to respond?
    Mr. Hetrick. Actually in Ohio we've had more mental health 
and we've only been enhancing it over the past couple of years. 
But in addition to that, I think it's important to note, as was 
appropriately noted earlier, it's difficult to fill a void 
every place we might perceive it to be needed, but on the CBOC 
system of 30 CBOCs around our State that we are responsible 
for, we have been adding additional specialty services as well, 
based on the number of patients that have visited them. These 
kind of services keep veterans from traveling to a large city 
where they generally don't like to go to.
    In addition to that, I believe that at Mr. Gering's 
location last week we had the first telemedicine connection 
between--or specialty service between surgery with a specialist 
in Cincinnati to keep a female veteran from having to travel 2 
hours to Cincinnati. During that live consultation he 
determined that while she was actually being prepared for 
surgery that it was not really the right procedure, so there 
was a revisit of the treatment plan. I think those are the 
kinds of things we want to do more of. Our telemedicine program 
right now is serving more veterans in the State of Ohio than 
most other CBOCs that I'm aware of. We've been fortunate to 
have the technology and the resources to do that.
    In addition, we're competing for VA funding that would 
expand additional home-based health care teams in all the rural 
areas that we serve in Ohio. So that would play to the kind of 
services and enhancements that we need. We're waiting to hear; 
it's a competitive process. We don't have as many rural areas 
as other areas of the country, but we certainly are trying our 
hardest to get those closer.
    Senator Brown. Thank you. I have one question to ask all of 
you fairly, and I prefer you use about 1 minute, if you can. 
The question is: on Wednesday I'm going to see Secretary 
Shinseki in Cincinnati. If you could ask him one question, or 
tell him or give him one piece of advice anonymously, even 
though this is a Congressional Committee Record, if you would 
like to tell me one thing that you would either ask him or tell 
him and I know I'm not giving you much time to think about it. 
Mr. Hartnett has more time than Ms. Graves because I'm starting 
with you and working down there. Tell me what I should say to 
him or ask him?
    Ms. Graves. I think that with Secretary Shinseki's 
leadership we are approaching a new day at the VA and I would 
encourage him to continue to push us to do better and ensure 
that we are providing services to our veterans.
    Senator Brown. A little less commercial, but thank you. 
Thank you for your services, Kim.
    Ms. Cange. I echo Kim's comment that it is a new day in the 
VA, and more important, it is a new day for veterans. Secretary 
Shinseki met with all of the directors of the regional offices 
in Louisville probably 3 weeks ago now and he wants to break 
the backlog, break the back of the backlog. He said it over and 
over again. He has inspired us and gotten us motivated. I have 
drilled it down to my employees. Last week I went to the 
Congressional Liaison Summit Seminar. Director Hartnett and I 
were there with a variety of other staffers and I emphasized 
that, you know, we have a backlog and we have more claims 
coming. With the presumptive Agent Orange that are coming, we 
need to figure out a way to do something different. We cannot 
keep doing the same work over and over. We're going to need 
your help; if we can change laws to streamline it. We ask for 
your support. But I would say Secretary Shinseki has energized 
me and I believe in my staff and my entire staff is ready for 
the change. They are up for it. We want to make a difference 
for veterans.
    Senator Brown. Thank you.
    Mr. Hetrick. Well, I may be at the same place you are, so 
you might know where this is coming from. I would say that the 
Secretary has spent more time talking to the leadership in the 
field than I have ever experienced before and I would encourage 
him to continue to encourage others to do the same thing. I 
think that he has learned from us and we have learned from him. 
With that kind of support, we want to go out and challenge 
assumptions that we've all lived by in the past that has 
created an environment where we really think we can go forward 
and are supported to do the right thing for the people.
    Senator Brown. If I had thought and done this question a 
little better I would have asked Ms. Neutzling this question. 
What do you think she would say?
    Mr. Hetrick. I think we go back to what Dr. Greenlee said.
    Senator Brown. I understand what her grandfather told her.
    Mr. Gering. In rural America and Appalachia we have a 
unique challenge. Like Dr. Greenlee and the faculty at Ohio 
University talked about, the issues with mental health access 
in rural America which is different. It's different than 
Pittsburgh, and it's different than Cleveland. You can have a 
generation which has had intentions and hopes with the 
government to serve their needs and has been let down. How do 
we deal with that? How do we reconnect? Outreach is essential. 
Getting in touch with the family is essential. We need to 
regain that trust and keep that trust. That's critically 
important, probably more so, again, in rural American and 
Appalachia than in urban America.
    Senator Brown. I would like to ask you to assign one person 
from Chillicothe to work directly from the VA to deal with the 
issues specifically of Ms. Neutzling. Is Andrea still here?
    Mr. Hartnett, close it by just--you're the only one that 
doesn't technically work for General Shinseki. I think he's 
done a terrific job and I appreciate all that. I love what the 
VA does 97 percent of the time. If you want to say something 
about the other three you can.
    Mr. Hartnett. Well, I've waited 78 years for a second class 
petty officer to advise a general. You know, Senator, I would 
encourage him to do what he is doing. I think he's radically 
changed. I don't think he's fit into the culture yet, and I 
hope he never does. I think that the fact that he's out talking 
to people, that he is pushing his troops. I think that's--I 
think General Shinseki has the opportunity to change the 
culture that we all operate under, whether it's at a State 
level or Federal level, by simply saying we owe it to them and 
have to find ways of doing it.
    Senator Brown. OK. Thank you, all five of you, very much 
for your service to veterans and your services to Americans. 
Thank you very much. Ms. Neutzling, Ms. Maupin, and Dr. 
Greenlee, thank you.
    Thanks again to Regina Bryant behind me; to Tom fisher, 
Carl Lambert, Troy Simmons, and David Moyer for their work in 
making this run smoothly today. Thanks to this panel and all of 
you in the audience that are serving veterans, the VSOs, and 
other places.
    There will be 1 week for anyone to amend or add to the 
statements, including those of Ms. Neutzling, Ms. Maupin, and 
Dr. Greenlee. If you want to add anything to the statements or 
submit anything else that will be part of the record, you have 
1 week from today to do that.
    Again, thank you. This hearing is closed.
    [The hearing concluded at 12:57 p.m.]
      

                                  
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