[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]




   AN EXAMINATION OF RURAL AND NATIVE AMERICAN VETERAN ACCESS TO CARE

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

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                       WEDNESDAY, AUGUST 27, 2014

                               __________

                           Serial No. 113-85

                               __________

       Printed for the use of the Committee on Veterans' Affairs

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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               MICHAEL H. MICHAUD, Maine, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         CORRINE BROWN, Florida
DAVID P. ROE, Tennessee              MARK TAKANO, California
BILL FLORES, Texas                   JULIA BROWNLEY, California
JEFF DENHAM, California              DINA TITUS, Nevada
JON RUNYAN, New Jersey               ANN KIRKPATRICK, Arizona
DAN BENISHEK, Michigan               RAUL RUIZ, California
TIM HUELSKAMP, Kansas                GLORIA NEGRETE McLEOD, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
PAUL COOK, California                TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana
DAVID JOLLY, Florida
                       Jon Towers, Staff Director
                 Nancy Dolan, Democratic Staff Director

                         SUBCOMMITTEE ON HEALTH

                    DAN BENISHEK, Michigan, Chairman

DAVID P. ROE, Tennessee              JULIA BROWNLEY, California, 
JEFF DENHAM, California                  Ranking Member
TIM HUELSKAMP, Kansas                CORRINE BROWN, Florida
BRAD R. WENSTRUP, Ohio               RAUL RUIZ, California
JACKIE WALORSKI, Indiana             GLORIA NEGRETE McLEOD, California
DAVID JOLLY, Florida                 ANN M. KUSTER, New Hampshire

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.


























                            C O N T E N T S

                              ----------                              

                       Wednesday, August 27, 2014

                                                                   Page

An Examination of Rural and Native American Veteran Access to 
  Care...........................................................     1
Hon. Dan Benishek................................................     1

                               WITNESSES

Fred Kiogima, Tribal Chairman, Little Traverse Bay Band of Odawa 
  Indians........................................................     4
Curtis Chambers, Veteran.........................................     6
    Prepared Statement...........................................    36
Carl Archambeau, Commander, Veterans of Foreign Wars Post 2780...     7
    Prepared Statement...........................................    36
Linda Fletcher LTC (ret.), Executive Director, A Matter of Honor.     8
    Prepared Statement...........................................    37
Charles R. Lerchen, A.C.V.S.O., Director of Veterans Services, 
  Grand Traverse, Leelanau, and Benzie Counties..................    10
    Prepared Statement...........................................    38
Paul Bockelman, Director, Veterans Integrated Service Network 
  (VISN) 11, VHA, U.S. Department of Veterans Affairs............    20
    Prepared Statement...........................................    39

    Accompanied by:

        Peggy Kearns, Director, Aleda E. Lutz VA Medical Center, 
            (VISN) 11 , VHA, U.S. Department of Veterans Affairs
    and
        James Rice, Director, Oscar G. Johnson VA Medical Center, 
            (VISN), VHA, U.S. Department of Veterans Affairs

                             FOR THE RECORD

Grand Traverse Band of Ottawa and Chippewa Indians...............    42
Little River Band of Ottawa Indians..............................    44
Sault Ste. Marie Tribe of Chippewa Indians.......................    45
The American Legion..............................................    47

 
   AN EXAMINATION OF RURAL AND NATIVE AMERICAN VETERAN ACCESS TO CARE

                              ----------                              


                       Wednesday, August 27, 2014

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                   Washington, D.C.
    The subcommittee met, pursuant to notice, at 9:59 a.m., at 
the Veterans of Foreign Wars Post 2780, 3400 Veterans Drive, 
Traverse City, Michigan, Hon. Dan Benishek [chairman of the 
subcommittee] presiding.
    Present:  Representatives Benishek and Brownley.

        OPENING STATEMENT OF DR. DAN BENISHEK, CHAIRMAN

    Mr. Benishek. Thank you, gentlemen. The subcommittee will 
come to order. Good morning and thank you all for joining us 
today. I'm Dr. Dan Benishek, and it's my honor to be both your 
congressman and the Chairman of the Subcommittee on Health for 
the Committee on Veterans' Affairs of the United States House 
of Representatives.
    I'm joined here today by Congresswoman Julia Brownley, the 
ranking member of the Subcommittee on Health, Representative of 
the 26th District of California. Ranking Member Brownley is a 
steadfast leader and advocate for our service members and 
veterans. I am grateful to her for joining us today in Traverse 
City.
    Before I go any further, I would like to ask all of our 
veterans in the audience today to please stand, if you are 
able, or raise your hand and be recognized.
    [Applause.]
    Mr. Benishek. Thank you so very much for your service. We 
are here today for you and to make sure that the care that you 
and your fellow veterans in Michigan and around the country 
receive through the Department of Veterans Affairs is timely, 
accessible, convenient, and high quality.
    It is no secret that the VA is in crisis and has fallen far 
short of providing the care and services that our veterans have 
earned, deserve and should expect. Just five months ago a 
committee investigation, along with numerous whistleblower 
revelations from conscientious employees, exposed widespread 
corruption and systemic access delays and accountability 
failures across the VA Health Care System.
    As a result of VA's incompetence, thousands of veterans, 
including some right here in Michigan, were left waiting for 
weeks, months, and even years to receive the care they needed. 
I want to assure you all that my response to the scandal was 
swift and aggressive.
    I was honored to be joined by my colleagues in the House 
and the Senate from both sides of the aisle in a conference 
committee that just a few weeks ago created a bipartisan 
agreement that Congress passed, and the President signed into 
law, to improve accountability for VA employees, increase 
access to care for veteran patients, and pave the way for long-
term cultural and structural reforms throughout the VA Health 
Care System.
    This law is not perfect, and the problems at VA will not be 
solved overnight; however, this bill for the first time will 
allow veterans suffering long waiting times for care the option 
to be seen by local doctors. This effort is the best chance 
we've had in years to make fundamental changes to the way VA 
operates.
    Much more needs to be done. And my work will not be 
complete until all of our veterans receive the care and 
treatment they've earned and they deserve. The time for excuses 
is over. The time for action is now.
    For 20 years, it is my privilege to serve as a physician at 
the Oscar G. Johnson VA Medical Center in Iron Mountain, 
Michigan. From that experience I learned firsthand from veteran 
patients I treated and hard-working care providers I worked 
with about the many challenges and frustrations they face when 
attempting to access or provide healthcare throughout our 
nation's second largest bureaucracy.
    Our veterans fought for our freedom. They shouldn't have to 
fight bureaucrats when they return home. Those challenges and 
the frustrations are nowhere more apparent than where our 
Native American and rural veterans are concerned.
    During today's hearing we will discuss the issues these 
veterans face here in our community. We will hear testimony 
from tribal and local leaders, veterans, and VA employees. 
Their input, expertise, and advice is critical to informing the 
work we do in Washington, and I am grateful to each of them for 
agreeing to speak on the record here today and for all of you 
in the audience for joining us. Thank you so much for being 
here.
    Before I yield to Ranking Member Brownley, I would like to 
take a moment to recognize and thank the VFW Post 2780 for 
allowing us to use their hall this morning and for their 
assistance in preparing and setting up for the hearing. And, 
again, for the Honor Guard for their work and contribution, as 
well. Thank you for having us this morning.
    With that, I would like to recognize Ranking Member 
Brownley for any opening statement she may have.
    Ms. Brownley. Thank you, Mr. Chairman. You must not have 
had your microphone on. Thank you, Mr. Chairman, and thank you 
for your extraordinary leadership on this committee and the 
committee as a whole and for continuing to keep the issue of 
access to quality and timely services provided to our rural 
veterans and our Native American veterans at the forefront of 
this subcommittee.
    And thank you to all of our witnesses here today for coming 
and talking with us about the critical issues that have plagued 
the Department of Veterans Affairs. I hope that with your help 
and testimony we may find a better way to move forward.
    I'd also like to thank all of you in the audience who are 
here today in support of our veterans. Today's hearing will 
examine the progress VA has made in serving Native American 
veterans and rural veterans in Northern Michigan. We will 
particularly look at the issues of non-VA care, telehealth and 
transportation services. I am pleased to be here today to 
support the Chairman and look forward to hearing the testimony 
of all of the witnesses.
    Like Chairman Benishek, I believe caring for our veterans 
is an ongoing responsibility of our nation. As these brave men 
and women have sacrificed so much, the country must ensure 
resources are available and programs in place to address their 
needs during and after their transition to civilian life.
    The difficulty of providing care to rural veterans and 
Native American veterans is not new and presents some complex 
problems. Issues such as lack of transportation, lack of access 
to technology, and VA reluctance to turn to the community to 
help support our veterans through contracting of care closer to 
home are ones that this subcommittee has examined many, many 
times. And, in fact, we have passed legislation to address some 
of these concerns, but more needs to be done.
    While this hearing will focus on access to care in Northern 
Michigan, I meet regularly with veterans in my home district of 
Ventura County, California, who face similar challenges 
regarding the long drive times to get to our regional medical 
center and the long wait times for appointments.
    We all know about the current crisis that has embroiled the 
VA for months now: Untenable wait times, misleading and 
manipulation of data, gross mismanagement. I think we can agree 
that this crisis did not develop overnight and will not be 
fixed overnight; however, our committee also has a 
responsibility to assist the VA on the road to recovery.
    We want the VA to be viewed as an employer of choice and to 
be able to attract people who want to serve our veterans. The 
Department has allocated over 450 million--has allocated over 
450 million system-wide to implement the Access to Care 
Initiative. I look forward to hearing from the VA today just 
how much of that funding they have received here in VISN 11 and 
how it has been used to open up access and services to our 
deserving veterans.
    I would also like to hear from the VA what progress is 
being made in working with the Native American community 
through the memorandums of understanding that have been signed 
by VA and the Indian Health Service. I understand that the two 
agencies are working together, but could increase collaboration 
and oversight to ensure that Native American veterans have 
access to quality care closer to where they reside.
    I am hopeful that this will be an honest, open discussion 
on ways to provide the care needed such as more partnering with 
the public and private sector, increasing the pool of 
providers, and other creative ways to address the gaps in 
health treatment and services.
    And finally I would be remiss if I did not recognize the 
dedication of the VA employees who provide quality healthcare 
to our veterans every day. Thank you for all that you do for 
our nation's veterans.
    And, again, Mr. Chair, I thank you for your extraordinary 
leadership and being a great mentor to me as a new member of 
the Committee. I want all of your constituents here to know 
how--what an important member you are to this Committee, and 
clearly your leadership specifically on health issues for our 
veterans. Thank you, Mr. Chair, and I would yield back.
    Mr. Benishek. Thank you, Ms. Brownley. We are going to 
begin today's hearing with our first panel of witnesses who are 
already seated at the witness table. Before I introduce the 
panelists, I'm just going to gently remind you all how this all 
works. We have a 5-minute limit on the testimony. We ask you 
all to stay within that five minutes. The green light says 
you're good, the yellow light says you've got a minute left, 
and the red light means you hit the five minutes. So we want to 
have the opportunity for everyone to testify. And then we will 
take turns asking questions after you've all testified, and we 
have five minutes each, so it goes back and forth, we each have 
an opportunity to do questions. We may go back and forth two 
times depending how the time goes.
    Then we will allow the second panel to come up, and then 
they will testify, and then we will ask them questions as well. 
We typically have VA go up last. So thank you for that 
consideration.
    With us on the first panel this morning is Fred Kiogima, 
the Ogema of the Little Bay Traverse Band of Odawa Indians; 
Curtis Chambers, a veteran and a community leader in Cheboygan; 
Carl Archambeau, the Post Commander of the Veterans of Foreign 
Wars Post 2780 here; Lieutenant Colonel Retired Linda Fletcher 
of the U.S. Army Nurse Corps and Executive Director of a Matter 
of Honor; and Chuck Lerchen, a Veteran Service Officer for the 
Grand Traverse Region.
    I am so grateful to each of you for your willingness to be 
here this morning to speak candidly about the issues of 
importance to our veterans in our community. I'm honored and 
privileged to have you here.
    With that, we will begin with Ogema Kiogima. Mr. Chairman, 
you are recognized for five minutes.

 STATEMENTS OF FRED KIOGIMA, TRIBAL CHAIRMAN, LITTLE TRAVERSE 
   BAY BAND OF ODAWA INDIANS; CURTIS CHAMBERS, VETERAN; CARL 
  ARCHAMBEAU, COMMANDER, VETERANS OF FOREIGN WARS POST 2780; 
  LINDA FLETCHER LTC (RET.), EXECUTIVE DIRECTOR, A MATTER OF 
  HONOR; CHARLES R. LERCHEN, A.C.V.S.O., DIRECTOR OF VETERANS 
    SERVICES, GRAND TRAVERSE, LEELANAU, AND BENZIE COUNTIES

                   STATEMENT OF FRED KIOGIMA

    Mr. Kiogima. Good morning. I am Fred Kiogima, the Tribal 
Chairman of the Little Traverse Bay Bands of Odawa Indians in 
Harbor Springs, Michigan, and I respectfully submit this 
written testimony into the record for the House Committee on 
Veterans' Affairs hearing on August 27th, 2014.
    Mr. Benishek. Without objection, so entered.
    Mr. Kiogima. On behalf of the Little Traverse Bay Bands of 
Odawa Indians, I would like to thank all those responsible for 
inviting us to provide testimony at this hearing. We are most 
appreciative to have this opportunity to bring our concerns to 
light.
    To address every concern that is within our purview in our 
work with the local VA reps at the county, state and federal 
level would be an enormous task; however, what I will focus on 
today is a list of issues that are most critical to us at 
Little Traverse Bay Bands of Odawa Indians.
    We do have a Veterans Liaison Office established within our 
tribe; the coordinator was trained and certified by the VA reps 
and worked hand in hand with all the levels of the VA system.
    And I do thank Jim Alton, the Emmet County Vet Rep, who 
helped train our tribal liaison.
    We do have--we currently have in excess of 145 veterans 
within our tribe. Identifying all of our vets is an ongoing 
process. Some of our vets are from World War II, like my 
father; I'm a retired Gunnery Sergeant from the United States 
Marine Corps and a veteran of Central America, Desert Storm, 
Somalia and served in support of Iraqi Freedom. We also have 
active duty Ogichidaawok ``Warriors'' that are still deployed.
    Paramount to our Zhimaaganishak or veterans is the ability 
or inability to let them know about all the programming. What's 
available, what time frames, active, inactive, National Guard, 
retired.
    The second point is different wars are noted for different 
issues and concerns, and to clarify those, for example, would 
be the Vietnam--Agent Orange, Desert Storm--trying to get on; 
the registry, the current war in Iraq and Afghanistan--
traumatic brain injury, PTS.
    The third one is direct client assistance is a concern for 
us; i.e., emergency funding for vets in need, homelessness, job 
training.
    Four: Clarifying the difference between peacetime and 
combat times. It's confusing to many veterans that have served, 
why the distinction, and what category was the Cold War. It 
always leads to a conversation of the Cold War was an accepted 
war, but it's always listed as the Cold War.
    There needs to be a better PR effort sent out to the 
veterans to offset the impact of budget cuts, sequestration, 
and all the bureaucratic nightmares that are still being 
encountered on a daily basis.
    Six: For many veterans, they still seem to associate VA 
healthcare as substandard and cumbersome.
    Accessing VA care is a continuing journey for many, without 
a clear roadmap, and the rules and regulations seem to change 
on a whim.
    Number 8, there is always room for better cultural 
competency at VA clinics and hospitals.
    We have been working with our health clinic and the VA to 
iron out some details on reimbursement. There is such a long 
trail to walk with the VA to get movement on that, and we are 
continually and actively pursuing that.
    With that being said, we know that also in Alaska with the 
tribal village clinics out there, the VA does work hand in hand 
with them. And that is--I was up in Alaska about a month and a 
half ago, talking to their reps. It's a system that works, 
tribal and non-tribal access those clinics. And it's a very 
functional way to work.
    Why would a non-tribal veteran have to fly down to Seattle 
or some other place when they can do it in Alaska at a tribal 
village clinic. If the stickler is the reimbursement part of 
it, that is what needs to be fixed. Our veterans need access, 
whether they're tribal or non-tribal. It's a lot easier to get 
that if the clinic is right there in that same village.
    We are very rural nature here in Michigan. And we know 
that. But that's one of the things that we definitely need to 
look at, is working with the tribal clinics and the VA to iron 
out the reimbursement issues so we're servicing all veterans.
    Having had access to the VA Health System for minimal 
appointments myself, I can understand the frustration caused by 
the long wait for appointments and the long drive--3-plus 
hours--to Saginaw for follow-up appointments.
    And why I cite that is, I go to get some doctors' 
appointments done. I try to avoid it, but the system was not 
working the way it should. It took me, start to finish, about 
two years. But I'm also one of those that are able to get 
around by myself.
    And my theory is the veterans that do need the help, I feel 
that they need it more than I do, so they can access that care 
better than I can. They need those fundings, those issues. I'm 
a retired Marine, I can get those some other way or I can tap 
into my tribal clinic to an extent.
    In conclusion, we at LTBB have utilized the VA Health Care 
System to the extent reasonable given drive times, appointment 
times, and length of ongoing medical conditions. We are 
appreciative of the VA system, but it is so overrun with 
bureaucracy, consistently short-funded, and horribly short-
staffed. All of these are opportunities for improvement.
    This opens the door to actively pursue a consistent 
approach toward working with tribal clinics to alleviate some 
of that stress.
    Chi Megwetch.
    Semper Fi.
    Fred Kiogima, Little Traverse Bay Bands Tribal Chairman.

    [The prepared statement of Fred Kiogima appears in the 
Appendix]

    Mr. Benishek. Thank you very much, Mr. Chairman.
    Mr. Chambers, you are recognized for five minutes.

                  STATEMENT OF CURTIS CHAMBERS

    Mr. Chambers. Thank you, Congressman. Thank you, 
Congressman Brownley, for being here today and holding this 
meeting.
    My name is Curtis Chambers. I am honored to appear before 
you today. I am equally honored to be seated with these great 
leaders here beside me today. I'm an Ottawa Indian and a Navy 
veteran. My father was a Navy veteran, and two of my sons are 
Navy veterans. We are all honored to serve this Great Nation as 
members of the greatest Navy this world's ever seen.
    And I would like to speak with you today about the need for 
transportation services, telehealth, and non-VA care. My son 
had planned to be here with me today, but he's on his way to 
Saginaw right now to have a consulting appointment for an end 
procedure he's going to have next week. He's going to travel 
twice in two weeks here.
    I have had the unfortunate opportunity to deal with our 
present system and to regale you with the failings would take 
you more time than we have allotted today. Such as the 18-month 
waiting time for an existing problem that one of my sons had, 
or medical records being lost not once, not twice, but three 
and four times and much more.
    I would prefer, however, to focus on the positive and 
possible fixes to the problems today. One: Non-VA healthcare. I 
don't understand why we can't just use our present doctors and 
send the bills to the VA.
    And then Number 2, some of our health concerns and 
questions--preferably like my son's going through today--could 
be done via Skype or some other sort of technology?
    Mr. Benishek. Telemedicine.
    Mr. Chambers. Yes, exactly. And then when it comes to 
travel problems and expenses, those would all be drastically 
reduced just by doing that. Certainly in the cases of my son 
and other people in Cheboygan.
    In my experience, the actual care a veteran receives is 
outstanding. The hospitals that my son has gone to, the care 
has been wonderful. Just caring, loving people. But the 
paperwork and the bureaucracy are mind-numbing. And when you 
add this to our Native cultures, you have a rural nightmare 
accessing VA care.
    I believe the percentage of able-bodied men in Indian 
Country who serve in the military is about 30 percent. That's 
higher than any other nationality and probably due to our 
warrior societies. We have hundreds, maybe thousands, of widows 
who probably qualify for pensions. There are hundreds of young 
vets not accessing any healthcare just because of the 
bureaucracy and the problems associated with that.
    According to the VA website, there are veterans homes and 
veterans trust funds available. I'd like to see more of an open 
dialogue between the VA and various societies in Indian 
Country. Perhaps we could have talking circles with vets and 
others associated with tribes and the VA itself.
    Mr. Chairman, I'm just a stump-jumping half-breed from 
Northern Michigan, and I realize that the devil is in the 
details. But it seems to me that in this Great Nation, and it 
is truly a Great Nation, that by working together, we can 
supply the veterans of the greatest military on earth, the 
greatest healthcare on earth. And they deserve no less. I thank 
you for your time. And thank you again for holding this 
hearing. We appreciate it.

    [The prepared statement of Curtis Chambers appears in the 
Appendix]

    Mr. Benishek. Thank you very much, Curt. And thanks a lot 
for staying within the time. Perfect.
    Let's see, who do we have? Oh, Commander Archambeau. You're 
up next. You have five minutes.

                  STATEMENT OF CARL ARCHAMBEAU

    Commander Archambeau. Yes. Thank you for having me here 
today. First of all, I am a U.S. Marine, retired, and CW--
combat veteran of U.S. Marine Corps, retired CW-4 of the United 
States Army.
    First of all, thank you for the testimony of the 
subcommittee on this health program. First of all, I would like 
to say that the Veterans Affairs Clinic in our area is doing an 
exceptional job for the veterans considering the space and 
equipment, personnel that they have to work with.
    Also, we have a Disabled American Veterans, DAV, 
transportation system in place to get some of our veterans to 
Saginaw, Ann Arbor or Detroit for hospital appointments, and 
that's a great thing to have that in our area.
    Having said that, the distances that we have to travel to 
get to the VA hospitals for an appointment are a problem. It is 
an all-day event to travel to and from the hospitals, plus 
waiting time at the hospitals, making it a hardship to our 
elderly veterans.
    After traveling the distance, like it's two and a half 
hours to three hours to Saginaw, and we start out like around 
3:30 in the morning to gather these gentlemen up, or ladies, 
and to get them down there. Plus Ann Arbor is another hour and 
a half. And Detroit's another two, two and a half hours from 
there, which is really a hardship on our elderly veterans.
    By the time they get home, they are--if they were really 
ill, they're going to be a lot worse.
    So Traverse City is more than 40 miles from the VA 
hospital. And I feel that the veterans should be allowed to use 
local doctors and hospitals for any medical needs that the 
local VA clinic cannot provide versus transporting these 
distances.
    The VA hospital in Saginaw is an old building. It needs to 
be redone. A new hospital in Gaylord area would better serve 
our veterans in Northern Michigan and Upper Peninsula area 
versus having them travel long distances. And that's basically 
all I have. And I appreciate you having me here.

    [The prepared statement of Carl Archambeau appears in the 
Appendix]

    Mr. Benishek. Thank you very much, Commander. Appreciate 
your testimony.
    Lieutenant Colonel Fletcher. You are recognized for five 
minutes. Hit the button.

                  STATEMENT OF LINDA FLETCHER

    Lieutenant Colonel Fletcher. Can you hear me now?
    Mr. Benishek. Yes, I've got you now.
    Lieutenant Colonel Fletcher. Well, I thank you, Chairman 
Benishek, for the opportunity to address this group today. I 
hope to provide an interesting perspective for the topics at 
hand. The recent events surrounding the VA have been very 
disturbing, to say the least, but it was Winston Churchill who 
said, ``Never fail to take advantage of a crisis.'' And that is 
what we have in the VA system today.
    Now is the time for problem identification, for opening to 
the consideration of conventional and unconventional ideas, and 
the formulation of bold steps to institute carefully conjured 
solutions.
    Abraham Lincoln eloquently captured the mission of this 
organization, which he created in 1865, with these words: ``To 
care for him who shall have borne the battle and for his widow 
and his orphan.''
    The structure and configuration of what we currently know 
as the Department of Veterans Affairs has changed through the 
centuries and our many wars, but the promise and the intent 
have not wavered, and the mission statement has remained the 
same.
    This nation has lately been generous with funding for our 
veterans: The FY 2014 budget is $152.7 billion. Approximately 
40 percent of that budget, or 61.1 billion, is directly related 
to the provision of healthcare. And due to the recent findings 
regarding administrative issues, an additional 16 billion is 
being added.
    There can be little doubt that America wants to take care 
of its veterans and we are willing to pay whatever it takes to 
do so. Unfortunately, sometimes pumping in money to patch a sag 
in the ceiling isn't the answer. Sometimes we have to start by 
fixing deeper foundational issues.
    I am in hopes that reformation of the VA system will begin 
with a review of the original mission statement so we can 
proceed to evaluate our existing organization in accordance 
with that guiding light.
    According to VA.gov, the VA is currently the largest 
healthcare system in the nation. In 2012, the VA provided 
healthcare for approximately 5.9 million Americans. That's 2 
percent of our entire population.
    Interestingly, of that group, some 1.6 million, or 26 
percent, qualify for care which the VA categorizes as not 
associated with war related illness or injury. In view of these 
numbers, perhaps the answer to the situation facing us is not 
what seems to be the foregone conclusion that we need to super-
size the VA; perhaps we need to consider streamlining the 
system in accordance with the mission statement by targeting 
care--by targeting care only for war related illness or injury.
    A restructuring that focuses specifically on that 
population would decrease the workload by 26 percent and 
provide a more focused approach to care for the remaining 
group.
    The care required by that smaller group could be provided 
in the local civilian sector by having the VA assume all costs 
associated with insurance provided by the Health Care Act. This 
mechanism may also be--might also be considered as an option 
for our many veterans located in rural areas where 
accessibility to VA facilities is geographically challenging. 
Perhaps we should consider allowing these veterans the option 
to receive equivalent local care funded by the VA through the 
HCA.
    From an administrative perspective, I would also like to 
recommend the VA revise their practice of hiring from within. 
The intellectual and cultural inbreeding that results from 
selection from the same pool chokes the breath of new ideas, 
perspectives and leadership that comes from selecting from a 
diverse assortment of potential employees.
    Lastly, care to veterans is restricted by more than just 
geography. There are some existing concepts emerging and/or 
reemerging regarding different psychotherapeutic techniques 
which target the resolution of cause, not just the current 
objective of mitigation of symptoms.
    Additionally, there's a wide variety of treatment 
methodologies from acupuncture to Zen meditation available in 
the alternative medicine communities that target stress 
reduction, a major component of PTSD care. In view of our less-
than-successful results in managing PTSD to date, we need to 
explore, not restrict, new possibilities in theory and 
treatment.
    I'm well aware that this is a superficial and limited 
overview of a very complex situation. I hope that some of these 
thoughts will be helpful as this nation struggles to provide 
better care for those who give--gave us so much. And let me--
let it be remembered that the VA may be stumbling, but with our 
help it can resume its revered and important position in our 
nation. They have a long and honorable history, and they can 
regain their glory with our support which includes 
constructive, not destructive, criticism.
    We are in crisis, and it presents the chance to take great 
strides in an abbreviated length of time. Let's take Winston 
Churchill's advice and not fail to take advantage of this 
opportunity to advance our systems for the good of our 
veterans. Thank you.

    [The prepared statement of Linda Fletcher appears in the 
appendix]

    Mr. Benishek. Thank you very much, Lieutenant Colonel 
Fletcher.
    Mr. Lerchen, you are recognized for five minutes.

                  STATEMENT OF CHARLES LERCHEN

    Mr. Lerchen. Thank you, Mr. Chairman.
    Good morning. My name is Chuck Lerchen. I am a Veterans 
Services Officer and Director of Veterans Affairs for a 3-
county area here in Northern Michigan. I would like to thank 
you for bringing the field committee together to gather 
information concerning the challenges confronted by veterans in 
rural areas in accessing and obtaining their healthcare needs.
    Speaking from the perspective of a local official who 
interacts with veterans daily, I believe I'll be able to 
provide you with some valuable insight as to the real world 
challenges rural veterans encounter after enrolling and 
choosing the VA to provide them with their healthcare services.
    What's become clear today and everybody knows is the VA is 
an agency in crisis. Both the Veterans Benefits Administration 
and the Veterans Health Administration struggle daily to 
accomplish their mission to our nation's veterans. Their 
congressional mandates routinely go unheeded.
    Billions of dollars continue to be thrown at these problems 
with little or no quantifiable results. And the biggest problem 
is that lack of accountability.
    The largest obstacle confronting the VA right now is the 
culture of the VA itself. Health care provision to the 
significant number of rural veterans is just another victim of 
this corrosive and obstinate culture. So while the VA and 
Congress continue to grapple with the core problems within the 
agency, the veteran continues to grapple with the effect it has 
on him or her.
    It is unreasonable to think that the VA can provide every 
veteran in the country easy access to every kind of healthcare 
they need in their own backyard. Since it was introduced over 
20 years ago, the clinic model for rural areas created by the 
VA has been a tremendous success. The need for rural veterans 
to have to travel great distances for primary care has been 
markedly reduced; however, the question now becomes, is how do 
we provide the specialty services a veteran needs while still 
addressing that need for the unreasonable travel and 
appointment times necessary to receive it.
    The answer to this question may lie in the authorization 
for rural veterans to receive certain care at non-VA providers. 
The VA has long held tightly to the notion that they and they 
alone will be the provider of all tertiary care. If your 
primary care provider at a clinic orders an MRI, the VA will do 
it, even if it means a 10-hour drive in the middle of a 
Northern Michigan winter and you're eighty-eight years old. The 
VA will still provide that service to you. This is the mindset 
of the VA, and it needs to be changed.
    The metropolitan VA medical centers have all the business 
they can handle. This is very clear. If the VA cannot provide 
the needed tertiary care to the rural veteran, then contract it 
out to the community. The military does this all the time. Our 
local Coast Guard Air Station is a good example of that. They 
do not fly their members down to Cleveland where a clinic or a 
hospital is. They are authorized to receive it in the 
community. Why can't the VA do this?
    The rural veteran clogs the wait list for these services 
unnecessarily. Equity and good conscience must come into play. 
None of us would find it acceptable to be required to drive 5 
hours one way to receive a needed medical service. Nor would we 
find it acceptable if our aging parent was required to make 
such trips.
    So, just as it is unreasonable to expect the VA to be able 
to provide all of these services to our rural veterans, it is 
likewise unreasonable to expect the veteran to endure the 
hardships currently required to receive their needed medical 
care.
    The rural veteran has entrusted their health and well being 
to the VA system. We are supposed to treat their ailments, not 
create more in doing so.
    We are beginning to see some progress in addressing these 
lingering deficiencies. VA's move to improve the method for 
identifying urban, rural and highly rural veterans by adopting 
a method used by other leading federal agencies is a major step 
in the right direction.
    It is also a step in the right direction in breaking down 
the core problem within the VA. The malignant culture that has 
existed in the VA for far too long must now be replaced with a 
culture of altruism and service to our nation's veterans.
    This concludes my testimony. Thank you for the opportunity 
to address your committee today.

    [The prepared statement of Charles Lerchen appears in the 
Appendix]

    Mr. Benishek. Thank you very much, Mr. Lerchen. I truly 
appreciate your efforts and your testimony here today.
    We've heard some of the issues that you've talked about 
here today. And I'll yield myself five minutes to ask a few 
questions. The issues that you all brought up, many of us have 
heard them before in this committee and also from veterans 
groups around the country and around the district.
    It's the same problems that come up over and over again. 
It's been very frustrating to me to hear the people from the VA 
say, ``yes, well, we understand and we're working on it.'' And 
yet, at times thirty years will go by and nothing changes, even 
though we get the answer, ``We're working on it.'' So they are 
not working very effectively on it.
    Let me just ask a couple of questions that we've thought of 
here. In VISN 11, which includes all Michigan except for the 
UP, they were awarded $8 million in Fiscal Year 2014 to 
increase access to care for rural veterans. Anyone seen any new 
programs or initiatives put into place? To improve access to 
care this year? Anyone can answer that question. They got an 
extra 8 million bucks. Has anything happened that you've seen 
as a change in care in this year?
    [No response.]
    Mr. Benishek. Mr. Kiogima, have you seen anything new?
    Mr. Kiogima. I have not seen anything new. And, like I say, 
the intent of how the--my Tribal Nation would like to see more 
local care.
    Mr. Benishek. That's not happening. Mr. Chambers, have you 
seen any change?
    Mr. Chambers. No, sir. My son is still driving to Saginaw 
for consulting problems.
    Mr. Benishek. Not even for the procedure, just to get the--
--
    Mr. Chambers. Just to talk about setting up the procedure.
    Mr. Benishek. Right, right.
    Commander Archambeau.
    Commander Archambeau. I agree with the other two gentlemen. 
I haven't seen anything.
    Mr. Benishek. Lieutenant Colonel Fletcher.
    Lieutenant Colonel Fletcher. Yes, sir, I have.
    Mr. Benishek. What have you seen?
    Lieutenant Colonel Fletcher. I've had the distinct pleasure 
and opportunity to be able to address a lot of different groups 
with regard to post traumatic stress disorder in the Traverse 
area. And, I'm not a counselor. I guess I'm really more of an 
epidemiologist than anything.
    And when I talk to groups, I bring up things that are 
important and--and sometimes they are destabilizing to people 
who have PTSD. I frequently have people who come to me after 
the talks in tears and needing counseling.
    So I went to the VA and I said, I need somebody here. 
Somebody here to support me with counseling so that I can say: 
``Here's the VA, they're right here in the community, and they 
want to help you.'' That has happened. I have that support now. 
And I'm very appreciative of it, as are the people who are 
falling apart after I talk. So I think that's a step in the 
direction--the right direction. And I think it's representative 
of something that we probably need to target, and that is the 
confluence of the efforts of the VA and the community. We need 
to work together. Not in the--not within the halls of the VA, 
but in the community itself.
    Mr. Benishek. Thank you. Mr. Lerchen, do you have an answer 
to that question? Have you seen anything new in the last year 
as a result of this $8 million that the VISN got?
    Mr. Lerchen. We have been informed--keeping in mind that 
they don't talk to us very much, whether at the medical center 
level or the VISN level, so nothing formal has been related to 
us.
    I do hear back from the veterans that there has been maybe 
a slight increase in authorizations to receive some local care. 
But nothing formal, nothing official, nothing that we've been 
asked to participate in any way, shape or form. So I can't 
answer your question.
    Mr. Benishek. Quickly, I have a few more seconds left. Do 
any of you have any examples of what you think could be changed 
in the way that we take care of rural veterans other than, 
getting people to local clinics? Is there something else that 
VA should be doing as far as any of you think?
    Voice. I have just recently had four procedures at the Ann 
Arbor VA. I've had to make 12 trips, some days they were 18-
hour days. One trip was to have a preop examination. I had just 
had my complete physical about a week or so with my primary 
care here in Traverse City.
    But I had to go to Ann Arbor and have my heart listened to 
and have an EKG because they said that they could not accept 
what was done here in Traverse City. Again, surprisingly, the 
EKG came up abnormal. I asked the--and I'm an RN, and I asked 
the nurse practitioner what is--what is going on with this EKG? 
``Oh,'' she says, ``I get that reading all the time. It's an 
old machine.'' So I had to make a 12-hour trip to go down and 
have my heart and lungs listened to, have an EKG that wasn't--
wasn't good, and I had just had the care done here in Traverse 
City a week or so before. So there needs to be some consistency 
across the board. It's all the same.
    Mr. Benishek. Right.
    Voice. It was wasteful. Totally wasteful.
    Mr. Benishek. Thank you. I'm out of time. I'm going to 
yield five minutes to Congresswoman Brownley from California 
for her questions.
    Ms. Brownley. Thank you. Thank you, Mr. Chairman. So, I 
wanted to ask a few questions around our service to veterans 
who are Native Americans. And it was in your testimony, Mr. 
Chairman, you talked about knowing the programs--I think Mr. 
Chambers here talked about a--how did you describe it--a 
talking circle with tribes and the VA.
    What form of communication is happening now so that your 
veterans are well aware of all of the services that are 
available to them?
    Mr. Kiogima. Okay. Speaking for my tribe, we had initiated 
a Veterans Liaison Office, which we staffed as I came into 
office last year. It's has a more administrative approach to 
it.
    We also transcend, the non-tribal and the tribal lands. We 
work hand in hand with the Emmet County Veterans person, point 
of contact, and he helped us get trained up all the way through 
the VA system.
    But that in itself, we don't have a traditional approach as 
per se. Those are something that tribal nations, tribal people 
are kind of reluctant to do unless it's just strictly tribal. 
Because that's what--one of the uphill struggles we have with 
the Native veterans are there--it is not that they are afraid. 
It's just the way we're raised. You don't go out and seek help 
and bring it to attention that you have a problem. And that's 
across the board. But it's more so on Native--in Indian 
Country.
    I think if you talk to any of the veteran reps in this 
room, they will tell you almost all veterans are that way. They 
almost have to be falling apart before they raise their hand 
and say, ``Help me.'' That old mantra of no pain/no gain kind 
of kicks us in the butt when we're in the military, and it 
catches up to us years later.
    But just in itself in the Indian Country, that's one of the 
biggest problems we have, is the outreach. And we're scattered 
into very rural areas. And then after that, it just kind of 
rolls into a big ball of not having access to get to the VA 
clinic, which is--up in the UP, it's over in the Congressman's 
area; down here, it's in Saginaw. There is a lack of funding 
all the way across the board with transportation issues. But --
--
    Ms. Brownley. So do you think if there were talking circles 
and the VA came, would--would your folks also come? Or is it--
or is it something that you're going to gather for one purpose, 
and a VA person or someone who can, communicate to your folks 
be there? So I guess when you're talking about some of the 
cultural issues, about not speaking up and needing help or 
asking for help ----
    Mr. Kiogima. When we say a talking circle, it's more 
along--I guess here it would be called group therapy or 
something else. But it's not to exclude anybody, but it's 
almost like the veterans have their own world to be in. Even 
within that circle of veterans, for some reason we've built up 
a wall between combat veterans and noncombat. I don't know 
where that came from because to me we're all the same. But even 
when we get in our talking circle, that seems to be a wall 
there. And it shouldn't be there.
    But a talking circle, in and of itself, on a cultural 
level, is for the tribal people. But that's not to negate 
anybody could come to a talking circle because a warrior is a 
warrior. Ogichidaawok is Ogichidaawok, whether they're tribal 
or not, and it's a healing circle.
    But having somebody from the VA staff to sit in on one 
would probably be most appreciative so you could actually see 
some of the things that are going on and some of the concerns. 
Because that's where you get the vocalness is within those 
circles, where they feel safe within that circle, because they 
are talking back and forth with other veterans, people who have 
experienced the same thing.
    Ms. Brownley. So it's not an issue, tribal and non-tribal? 
Together, it's fine.
    Mr. Kiogima. Yes.
    Ms. Brownley. Okay. Very good. And Commander, you talked 
about the transportation system here. And I think you were 
saying that you thought the transportation system was 
relatively successful and relatively positive. Is there 
something--can you describe the transportation system?
    Commander Archambeau. Basically we have--I believe it's two 
vans that we utilize, and we basically transport the patients. 
We pick them up at their homes or wherever they need to be 
picked up at, and then we deliver them to--usually Grayling. 
And from Grayling, then they are transported down from a bus 
that comes out of Grayling, and then they have to ride this bus 
down there.
    But there is times that we'll actually transport them also 
all the way down to their appointments. Depends on how many we 
have. And I'm not really up on that as much as I should be due 
to the fact that's--the coalition basically--I mean, the DAV 
people handle that a lot, but I do drive for them.
    But I guess it's a good system. It works. But the thing is 
that they--we start out like 3:30 in the morning, and they 
don't get back till sometimes till 8:30 at night, and that's a 
long time for a veteran to be sitting around.
    Plus once they get to the hospital, if they would get 
priority as soon as they hit the hospital. Instead of the 
people in the local area that could drive to the hospital to be 
taken care of, these veterans, when they come in, should be 
taken care of immediately so they could turn them around and 
try to get them home in their earlier part of the day versus 
going into the evening.
    And then they don't get to eat properly. Because the food 
isn't, given to them while they're there, if I am not mistaken. 
And, so the veterans have to fend for themselves while they're 
there. So it's a hardship on elderly veterans.
    Voice. The VA doesn't pay for it. It's mostly volunteer 
organizations and local people in communities that pony up the 
money to pay for the vans, the fuel, the maintenance. And the 
drivers are 99 percent volunteers. And these are guys that go 
above and beyond all the time to make sure these guys get to 
their appointments.
    The VA has not contributed a dime of money that I'm aware 
of to anything in Manistee County as far as transportation of 
veterans to appointments. It's all been volunteer and people in 
the local area donating money to pay for it.
    Commander Archambeau. That's true what he's saying, is like 
we have a fund going now, trying to make money to raise X 
amount of dollars so we could get a new DAV van. And that's 
being done by the local people donating that $15,000. Then the 
rest of the funds are coming in--I don't know where they're 
coming from, but--I'm not up on that myself. But what he's 
saying is true. The local people are supplying that money for 
that DAV van. And I cannot believe that the DAV--I mean, the VA 
can't support that cost.
    Mr. Lerchen. Ms. Brownley? For clarity, I'm sorry.
    Ms. Brownley. Yes.
    Mr. Lerchen. Just to be sure we're accurate here, I ran 
that program locally for about 17 years. I have now turned it 
over to another coordinator.
    But the VA does participate with that program. It's a 
collaboration between the national DAV and the VA and Ford 
Motor Company. It's been going on for quite some time.
    Essentially the DAV chapters in the state and national 
organization raise the funds to buy vehicles; 100, 140 of them 
annually nation-wide. At reduced rates from the Ford Motor 
Company.
    They then donate those vehicles to the VA. The VA accepts 
ownership of those. The VA pays all of the expenses associated 
with gas and oil and maintenance, feeding the drivers, all of 
that. So it's a collaborative effort between the VA and the 
DAV, and then--which filters down to the local--the 
coordinators. Those are all volunteers.
    It's still not a perfect system. But I did want to make 
sure that--to stand corrected--the VA participates actively 
with that program nation-wide.
    Ms. Brownley. So if we were going to improve upon it, would 
more vans improve upon it? Or----
    Mr. Lerchen. We're asking volunteers--where we live, we're 
asking a volunteer, typically a retired person themselves, who 
may be looking for a volunteer gig--instead of working the 
information desk at the local hospital for a couple hours, 
we're asking them to get up at 3:00 o'clock in the morning, in 
the middle of February, travel on interstate and rural roads 
for 5 hours one way, with a van load of veterans needing 
appointments, wait at the hospital for 5 and 6 hours, and turn 
around and drive it all back.
    It's hard to get volunteers willing to do that. And then 
the VA, you know--because of liability reasons, the VA owning 
the van and accepting all the liability associated with that, 
they have to pass a physical. The VA has to clear them to drive 
the vehicle. So it becomes a logistical problem. It's hard to 
get and maintain drivers. Up here.
    Voice. Background searches, fingerprints.
    Mr. Lerchen. Up here we lose a lot of drivers in the 
winter. They go down to Florida and Alabama and whatever. So 
it's a logistical problem. So.
    Voice. Can I throw in things?
    Ms. Brownley. I yield back, Mr. Chairman. I don't want to 
go over my time.
    Mr. Benishek. We're trying to go back and forth a little 
bit. I want to ask another question on the tribal issue.
    According to the statement of VA, they have done extensive 
outreach to all 13 tribes in Lower Michigan. Would you agree 
that the VA's outreach to Native American veterans in the Lower 
Peninsula has been extensive?
    Mr. Kiogima. You can define `extensive' probably with four 
or five e-mails a day, Congressman. There's a difference 
between outreach and consultation. That's one of the biggest 
problems that we do have in Indian Country. The determination 
that they call of outreach is what pops up on my computer.
    That is to me a function. It is not an outreach. That is a 
notification of something. An outreach is literally what we're 
doing here or at the VA level to have the representatives up 
here in Northern Michigan occasionally so we can see one-on-one 
what the problems are and how it's doing. So, no, that would be 
a negative as far as an outreach--workable outreach program 
being handled up here.
    Mr. Benishek. Mr. Chambers.
    Mr. Chambers. I'd agree with the Chairman. You could define 
that in different ways. I would challenge anybody in the VA to 
show me a list of tribal representatives for each tribe that is 
connected with the VA. I don't know that there is such a list. 
I've tried to put one together myself and haven't been able to 
do so.
    Mr. Benishek. Okay. Do you have any ideas about how they 
could improve the outreach? Some of the things you've already 
said, I guess. I mean, having somebody actually come up here.
    Mr. Kiogima. To reiterate, that was the intent of our 
Tribal Liaison Office, was to make direct contact. Because it 
is a different scenario with the Tribal Nation. The one-on-one 
should be at a higher level. But the VA reps, that was the 
intent of our Tribal Liaison Office, was to work hand in hand 
with the county reps and with the state reps and keep it going. 
That to me is an open communication and an outreach program. If 
it is not being done that way, then it's just another blip on 
the radar.
    Good consultation with the VA, whether it's semi-annually, 
quarterly, from Saginaw or even up at the hospital in Escanaba, 
somewhere needs to be. Rural America is caught in between up 
north/Escanaba and Saginaw; everything in between seems to be 
rural to an extent that's hard to get to the system. So 
outreach has to be preeminent in how they get out there and 
talk to the people.
    Mr. Benishek. Curt.
    Mr. Chambers. And also they don't necessarily just have to 
outreach to the veterans. outreach to the community itself can 
include just letters in our local bulletins. Newsletters. The 
widow's fund that we have. There are just so--hundreds of 
people would be eligible for this if they knew that it existed. 
But they don't.
    These things are on the web site. There's quite a few--you 
need to search through them. I wouldn't know about them myself 
except Jason Allen pointed them out to me.
    Mr. Benishek. Let me ask all of you this question. Is there 
some type of care for our veterans that you think can only be 
provided by VA itself? And not provided by the out--by, local 
community Lieutenant Colonel, do you have any thoughts toward 
that?
    Lieutenant Colonel Fletcher. I do.
    Mr. Benishek. These microphones are something, I know.
    Lieutenant Colonel Fletcher. Am I on now?
    Mr. Benishek. Yes.
    Lieutenant Colonel Fletcher. Well, I really don't think 
that there is anything special that the VA can offer that can't 
be done in the community. And--if that's what you're asking me.
    Mr. Benishek. Yes.
    Lieutenant Colonel Fletcher. And, actually, I don't see any 
reason why we have to limit healthcare for veterans to the 
Veterans Administration. I mean, it--when I hear about the 
transportation issues and everything else, it looks to me like 
the ancillary--the answer is localize this stuff.
    I mean, instead of trying to make a cumbersome 
transportation system and everything else work, why don't we 
just authorize a mechanism so that people can get their care on 
the local economy. I think that mechanism may be available 
through the HCA. I don't know, I made that up. I have to tell 
you, I am not an expert on that. But it seems to me that for 
the first time there may be a fiduciary tool that we could use 
to, expedite that. So, no, I don't think there's anything that 
has to happen in the VA.
    Mr. Benishek. Does anyone else have a different answer than 
that?
    Mr. Lerchen. Real quickly, and this is my perspective on 
it, but there's nothing that the VA does that can't be handled 
locally. I mean, it's healthcare. The culture of veterans being 
former military members, there is a certain understanding of 
that at the VA facilities. And that's important.
    In my opinion, you have to look back historically. The VA 
system, is--is needed for this country. During World War II, 
Korea, Vietnam, the VA was responsible for treating returning 
casualties. We have to have some--we don't have that right now. 
Will we ever have that in the future. Hopefully not again.
    But if we do, doesn't that system have to be up and 
running? Don't we need that system to be able to handle that if 
we ever need that again?
    In the meantime, what do we do with it? So I'm--I think 
it's a bigger question than whether or not it can be handled. 
It's the need and the national security, whatever you want to 
call it. Do we need that system? And history has told us, yes, 
we've needed it in the past. And if we need it in the future, 
it's hard to get it back up and running again.
    So, but, keeping the focus on rural veterans, I think it 
was in my testimony, where these VA hospitals are that service. 
The rural veterans, they are already full. Why are we making 
the rural veterans come in there and further clogging that up, 
and then we have the incidences like Phoenix. I'm sure they 
were bringing rural veterans from Arizona in there. So a hybrid 
answer is probably the answer.
    Mr. Benishek. Thank you. I'm out of time here. Let's ask 
Representative Brownley if she has any further questions of the 
panel.
    Ms. Brownley. I wanted to----
    Mr. Benishek. And then we'll get to the next.
    Ms. Brownley. Thank you, Mr. Chairman. And I just wanted to 
follow up with the Lieutenant Colonel on her testimony around 
alternative therapies for mental health.
    Lieutenant Colonel Fletcher. Yes.
    Ms. Brownley. I'm just curious to know, are there 
acknowledged alternative therapies for veterans here in this 
VISN for mental health?
    Lieutenant Colonel Fletcher. If there are, there are very 
few of them. And the VA in general is reticent to embrace 
those. I think, across the nation, they are becoming more and 
more embraced.
    But the VA is being very cautious to ensure that 
appropriate standards are available for each one of those 
disciplines. And so that's difficult, because these are 
sometimes ancient practices that don't have those kinds of 
fundamental disciplines.
    The possible answer to that is to have the VA come up with 
some ideas about what it is that they would require from each 
one of those different sectors. And instead of them--those 
providers coming to them with the answers, the VA say: This is 
what we demand of you. And that way they could access that 
care.
    Ms. Brownley. Well, I've been an advocate for the 
alternative therapies--as a matter of fact, the hearing that we 
had in California that the Chairman joined me on was focused on 
that. So I'm hoping very, very much that the VA will take 
another step towards that.
    Because I think, therapy through telemedicine, talk 
therapy, one-on-one, group sessions, these are all good. And 
not one method is going to work for every single veteran. And I 
know in my district we have equine therapy that works----
    Lieutenant Colonel Fletcher. Yes, we have that here.
    Ms. Brownley [continuing]. Very, very well.
    Lieutenant Colonel Fletcher. And we--I think you're--I 
applaud your efforts in that regard. We need--at this juncture, 
we need every single tool we can probably gather. We're not in 
a position to be able to show--to shut the door on any sort of 
option whatsoever. We just need to explore everything.
    Ms. Brownley. Thank you. And, one question for all of you 
is--that I would like to ask. every time I speak to a veteran, 
all of the testimony that we've had back in Washington--and 
believe me we've had hundreds of hours worth--one thing that is 
always consistent is veterans believe once they're in the 
system, they're getting good quality healthcare. It's accessing 
the system is where the problems reside. So in this discussion 
about using local facilities and local doctors and--I 
understand the travel time and the elderly, and I'm sure in the 
wintertime here it's--it must be really onerous. And----
    But I guess the question is, if you were going to survey 
all of your veterans that are serviced here, would they all 
choose to go to a local doctor versus travel to--to the VA? 
Understanding that the one thing that I've heard that is true 
is that the healthcare is of good quality once they're inside 
the system. So I'm just curious to hear generally what you 
might think.
    Lieutenant Colonel Fletcher. I don't think you can say 100 
percent of the population would go with that.
    Ms. Brownley. The majority?
    Lieutenant Colonel Fletcher. Yes, I would certainly expect 
that.
    Voice. I have a comment. I've rode down several times with 
gentlemen who were receiving radiation therapy. It was a 5-
minute radiation therapy treatment, but they would have to go 
down on Monday, stay through the week, and come home on a 
Friday. For a 5-minute-a-day treatment that could definitely be 
rendered here in--within the community. Or closer to their 
home.
    Ms. Brownley. Mr. Chairman, I am going to let you respond 
to that.
    Mr. Benishek. Well, I think if you and I are out of 
questions, I think that will get VA up in the next panel and 
let them give their testimony and I'll ask them a few 
questions.
    Voice. I thank you all for spending time with us here this 
morning. I want to tell the audience that we will have time and 
staff to answer questions and take comments after the hearing. 
But in view of the time situation, we want to keep the ball 
rolling.
    So please don't think that we don't want to hear what you 
have to say. But in the format of the hearing, we have to keep 
moving. So please talk to the staff. We will have staff here 
staying afterwards that you can speak with. So I appreciate 
everyone being here and their wish to comment.
    The first panel is excused. And then we'll ask the second 
panel to come up forward.
    [Pause.]
    Mr. Benishek. I would like to welcome the second panel to 
the table. Joining us today from the Department of Veterans 
Affairs is Paul Bockelman, the Director of Veterans Integrated 
Service Network ``VISN'' 11.
    He's accompanied by Peggy Kearns, the Director of the Aleda 
E. Lutz VA Medical Center in Saginaw; and James Rice, the 
Director of the Oscar G. Johnson VA Medical Center in my town 
that I practiced medicine in, Iron Mountain. I want to thank 
you all for being here today.
    Mr. Bockelman, will you please proceed with your testimony.

  STATEMENT OF PAUL BOCKELMAN, DIRECTOR, VETERANS INTEGRATED 
SERVICE NETWORK (VISN) 11, VETERANS HEALTH ADMINISTRATION, U.S. 
 DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY PEGGY KEARNS, 
 DIRECTOR, ALEDA E. LUTZ VA MEDICAL CENTER, VISN 11, VETERANS 
HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND 
JAMES RICE, DIRECTOR, OSCAR G. JOHNSON VA MEDICAL CENTER, VISN 
12, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
                            AFFAIRS

                  STATEMENT OF PAUL BOCKELMAN

    Mr. Bockelman. Good morning, Chairman Benishek and Ranking 
Member Brownley.
    First, I would like to thank the first panelists for their 
candid conversations. We are all about learning. We are all 
about looking for opportunities to increase our services to 
veterans that will improve their experience with us. That is so 
important to us, so we appreciate their comments.
    Thank you for the opportunity to be here at VFW Post 2780 
to discuss VA's commitment in providing accessible, high 
quality, patient-centered care.
    Today, we are here to discuss VHA's care for rural veterans 
and Native American veterans in Northern Michigan and the Upper 
Peninsula. I am accompanied this morning by Ms. Peggy Kearns, 
Director of the Saginaw VA, and Mr. Jim Rice, Director of Iron 
Mountain.
    We sincerely appreciate the assistance we have received 
from our partners at local veteran service organizations, 
Native American Tribes and key non-profit stakeholder groups. 
We would not be able to provide the necessary care to our rural 
and Native American veterans without the support of our 
partners who are dedicated to ensure our nation's veterans are 
receiving the services they have earned.
    The VA's committed to enhancing the care rural veterans 
receive. Approximately 43 percent of Michigan's veterans 
enrolled in the VHA live in rural areas. In Michigan, we have 
multiple projects and programs in place to increase access to 
rural areas. These include telehealth; home-based primary care; 
our mobile prosthetics van, which brings prosthetic services to 
the CBOCs or the clinics; clinical training opportunities for 
providers in rural areas; and our program to provide mental 
health support to veterans living in rural areas.
    We also partner with the Escanaba mobile vet center to 
provide ready access to returning service members during the 
mobilization events.
    Throughout Northern Michigan, we use innovative methods to 
meet the healthcare needs of veterans in rural areas. One of 
the ways we accomplish this is through telehealth technology. 
Our telehealth program ensures veterans get the right care in 
the right place at the right time very much an issue with our 
panelists this morning.
    In Fiscal Year 2013, Michigan's telehealth programs 
conducted roughly 62,400 visits using telehealth modalities.
    Transportation is a challenge unique to the highly rural 
areas we serve. We continue to look for opportunities to expand 
access to care for rural veterans and we look forward to 
talking to the folks that spoke earlier about any opportunities 
they may see for us to expand our transportation system.
    For example, our transportation program and network of 
volunteer drivers--which we so much appreciate--assist veterans 
in rural communities with their rural transportation needs. 
Transportation is provided to the Saginaw Medical VA Center as 
well as Ann Arbor and Detroit. The Iron Mountain Medical Center 
also has a bus that travels to Milwaukee twice a week.
    Veterans have expressed satisfaction and appreciation with 
the transportation program. I would add we continually are 
looking for drivers. This is a wonderful volunteer opportunity 
for them, and it is so much appreciated by the veterans and the 
employees that enable them to see the veterans, as well.
    VHA has done outreach to Native American Tribes in Michigan 
to build closer relations with tribal governments and promote 
awareness of VHA services. Our efforts include charting an 
outreach team to connect with Native American veterans in order 
to increase awareness of benefits and services, promote VA's 
high quality of care, receive feedback from veterans, and 
address access gaps.
    Working with local veteran service officers and tribal and 
community representatives, local outreach teams coordinated and 
participated in numerous outreach events in Fiscal Years '13 
and '14, including over 20 at area Tribal Nations.
    Through collaboration, the Iron Mountain VA Medical Center 
established a satellite, home-based, primary care team located 
at the Lac Vieux Desert Tribal Health Clinic to provide care to 
our veterans living in that area.
    In addition the Saginaw, Battle Creek and Iron Mountain 
Medical Centers held the Third Annual Tribal Veterans 
Representative Training. This training promotes the practice of 
having a tribal veteran representative in federally recognized 
tribes throughout Michigan.
    VA's goal is to provide care to veterans directly in a VA 
medical facility; however, when we cannot provide the necessary 
services at one of our facilities, we are authorized to provide 
that care through our community providers.
    We recognize that in Michigan, travel distance and the 
number of available providers is a challenge in our efforts to 
provide non-VA care. VA is committed to providing the high 
quality care that our veterans have earned and deserve.
    We appreciate the opportunity to appear today before you 
and we appreciate the resources Congress provides VA to care 
for veterans throughout Northern Michigan and the UP. We are 
prepared to answer questions you may have for us. Thank you.

    [The prepared statement of Paul Bockelman appears in the 
Appendix]

    Mr. Benishek. Thank you very much, Mr. Bockelman. I'm going 
to start and I'm going to yield myself five minutes to ask some 
questions. I'm going to start with something that Fred talked 
about when he mentioned the tribal outreach in his testimony. 
The way he related it, it was basically some e-mails he was 
getting. I appreciate that they have had this outreach at the 
Lac Vieux Desert Tribe, but I was hoping maybe we could use 
this meeting here this morning to encourage you to actually get 
somebody to talk to Fred on a regular basis rather than an e-
mail. Because I think he's feeling as if there's--could be 
better communication. Don't you think he felt that way?
    Mr. Bockelman. Always willing to look for opportunities. We 
do have some face-to-face. I think the recognition, hearing his 
testimony that the more face-to-face, the better. For that 
culture, written communication/oral communication is not as 
good as face-to-face communication. There's a great nugget for 
us to take home and work to increase our outreach efforts.
    Mr. Benishek. I think in our culture, as well----
    Mr. Bockelman. Sure.
    Mr. Benishek [continuing]. That works out well. I mean, 
we're trying to develop a better relationship with Ms. Kearns 
here, and I think my office has a good relationship with Mr. 
Rice. And regular communication tends to help things go. And I 
was hoping I could get your commitment today to try to make 
that happen better.
    Mr. Bockelman. You do.
    Mr. Benishek. Good. I have another question about--
something that's come up talking to veterans in the district. 
Is there a registry for people who have been subject to these 
burn pits that were present in the Gulf War? The people that 
have been exposed to these burn pits, and they are now starting 
to report medical conditions related to that? Are you familiar 
with that?
    [No response.]
    Mr. Benishek. It's similar to Agent Orange, but in the Gulf 
War they had these burn pits in some of the camps, that people 
were exposed to ash and chemicals for a long period of time. I 
am beginning to hear now that those veterans are developing 
medical illnesses, which they feel as if it's related to the 
burn pits. Is there anything like that going on, developing a 
registry of people exposed to these burn pits?
    Mr. Bockelman. We will get back to you on the exact nature 
of the registry. I know there's been a lot of outreach to folks 
that have been exposed to make sure we understand what kind of 
symptoms they are having.
    Mr. Benishek. You are not doing that now, though?
    Mr. Bockelman. I need to find out if there is a registry.
    Mr. Benishek. Okay. All right. Another thing that keeps 
coming up, too, then, that was mentioned today by Mr. Chambers 
is the lost records issue. This is something that I hear all 
the time. I sent my records in not once, not twice, but three 
times and they are lost. How exactly does that happen? You must 
have heard this. Have you ever heard this before, I hear it a 
lot.
    Mr. Bockelman. I know within the VA now that we have a well 
established electronic medical record, we don't have those 
problems within the agency like we've had in the years gone by.
    When we do have records that come in, it is very difficult 
to keep hands on them. We do want to make sure that we've got 
that system figured out so that it does get included in the 
patient's electronic record.
    Knowing that we are going to continue to do non-VA care and 
expanding that in the future, this is critical. One of the 
concerns we have about expansion of non-VA care is will we lose 
continuity of care. And we will have to work very diligently to 
make sure we don't lose that consistency.
    As a physician, the concept of knowing what other 
physicians have provided or think is important is just critical 
to ensuring we are not going off on the wrong track. So if we 
have opportunity for----
    Mr. Benishek. So you don't have an answer for that story, 
then?
    Mr. Bockelman. I don't have an--not for that specific 
question.
    Mr. Benishek. I still have a few minutes left. The other 
thing that I want to talk about is this $8 million that the 
VISN received for increased access to care for rural veterans. 
What exactly have you spent that $8 million on this year?
    Mr. Bockelman. Within Michigan, Northern Michigan, we have 
spent 3 and a half million on the CBOCs that are rural up in 
this area. This was a way for us to get the CBOCs established. 
This is the third year for several of those, and after three 
years the funding should be within the regular budget. We've 
spent the money on the transportation system, several other 
outreach-specific--and I can get you the exact details on 
those.
    Mr. Benishek. That would be great, if you just sent me how 
you spent 8 million bucks.
    Mr. Bockelman. I can do that.
    Mr. Benishek. The other thing is I know there is a bus that 
the VA provides in Iron Mountain that transports the guys back 
and forth to Milwaukee. And Madison, too, I think. I've heard 
about this transportation issue that these volunteers, they are 
getting a little bit older, tougher to pass the physical.
    What is the long-term plan for continuing decent 
transportation? Is there anything beyond the volunteers? Is 
there any other plan that you're trying to implement Because it 
doesn't seem to me like this is a very good system. Are there 
buses that you provide similar to the ones in Iron Mountain, 
here, down below the bridge?
    Mr. Bockelman. Yes, we do. And I will have Ms. Kearns 
describe that. But, again, I just need to say how crucial it is 
to have the volunteers. They are wonderful. It is amazing to 
see, on the worst weather days, the volunteer drivers do get 
the veterans to care. And that is appreciated.
    Ms. Kearns, can you describe the transportation within the 
district.
    Ms. Kearns. Yes, in addition to our volunteer network--
which they service about 90 veterans a month that they are 
transporting back and forth in their vans--we also have a 
program through the Rural Health Transportation Program that we 
were given funding for. That is VA employees that drive 
patients down to Saginaw, Detroit, and Ann Arbor. And this 
starts at Gaylord, stops at West Branch, Grayling, Standish, 
picks people up, takes them down to Saginaw. And then we take 
them to wherever they need to go, whether they need to go to 
Detroit or Ann Arbor.
    Mr. Benishek. This is separate from the volunteers?
    Ms. Kearns. That is separate from the volunteers. That's 
our bus that goes back and forth, and it's run--it's funded 
through Rural Health Initiative money and it's VA employees 
doing that. So we have two programs: The volunteer program 
and--our own bus, which has serviced about 1,200 veterans in 
the past year.
    Mr. Benishek. I see I'm running over time. I am going to 
allow my colleague, Representative Brownley, to ask questions 
for five minutes.
    Ms. Brownley. Thank you, Mr. Chairman.
    Mr. Bockelman, thanks for your testimony, and I really 
appreciate your introductory comment saying that you 
appreciated the candid conversation from the first panel and 
always looking to learn and to grow. Because I honestly am a 
firm, firm believer that in order for us to really improve the 
VA and change culture, we really need to be in a mindset of 
continuous improvement, always--always trying to improve.
    And I also really believe that there's not--one size 
doesn't fit all. So, we go across the country, in different 
areas there are different needs, and we're going to have to 
solve those issues differently. So I appreciate those comments.
    And I guess my first question to you--and after all of the 
crisis that we have had within the VA, I am convinced that 
communities need to be having ongoing conversations with one 
another. Just like we're having today. And--but to have a 
process and a system set up where veterans in the community can 
talk to you and you can talk to the veterans and have that 
communication sort of back and forth.
    And so I'm just wondering, do you have a system like that, 
where you are, on an ongoing basis, talking to the veterans in 
Northern Michigan to make sure that you, as the VISN director, 
can do absolutely everything possible to sort of meet the 
individual needs throughout the area?
    Mr. Bockelman. A couple things. One, within our VISN 11 
organizational structure, our governing structure, we 
recognized last year at our strategic planning, a year ago, 
that this is something that we needed to crank up is how do we 
get more veterans' input? So we've tasked ourselves with 
getting more veterans as members on our facility level 
committees.
    We value their input. They surely present different things, 
different perspectives of the same issue, and it always adds 
value to our discussions. So we've been doing that with great 
success. And with great eye-opening input from these members. 
So that's something that we've been doing as an organization as 
the leaders felt that we needed to do that.
    As the new Secretary has identified, we will be holding 
town halls in all of our facilities over the next couple of 
weeks to make sure we look for opportunities. Typically the 
facilities have regular and routine outreach or opportunities 
to speak to veteran services officers, the congressional 
delegations. Most of the facilities do that at least quarterly 
and most are in conversations with your offices much more 
frequently than that for all sorts of reasons, and we look for 
any opportunity to get input from the congressional staff. The 
veteran service organizations do simple things like suggestion 
boxes, as well.
    One of the things that we've heard this morning that we 
look forward to helping is some of the discussion on just basic 
information eligibility. It's always tough to get that message 
out to everybody. But we can improve on that if that's seen as 
a real need. We would look forward to reaching out and seeing 
if we can get that into any local publications. And we would 
ask for input from the community on what kind of publications 
would best suit the needs of them to hear more about the VA.
    Ms. Brownley. Thank you. I appreciate that. And I think in 
all of our conversations and hearings that we've had back in 
Washington--the committee is unanimous on this--is, we want 
change and we want the VA to be veteran-centric, service-
focused. And the veterans are at--are at the core here.
    And I think the only way that we will become a veteran-
centric, veteran-centered organization is if we are constantly 
talking to the folks that we serve and knowing what their needs 
are and--and having a nimble enough organization to be able to 
bend and flex to meet our veterans' local needs. So I 
appreciate your comments on that.
    And I see that I'm running out of time, so I will yield 
back.
    Mr. Benishek. When are the town halls going to be?
    Mr. Bockelman. We will get you the exact schedule. Each 
facility is having one of those.
    Ms. Kearns, do you have yours scheduled?
    Ms. Kearns. Ours is September 18th at the Saginaw VA.
    Mr. Benishek. So on September 18th you are having a town 
hall at the Saginaw VA. What time is that?
    Ms. Kearns. It's at 5:00 p.m.
    Mr. Benishek. 5:00 p.m.
    Mr. Bockelman. Mr. Rice.
    Mr. Rice. Ours is September 24th and 25th.
    Mr. Benishek. How about here at the CBOC?
    Ms. Kearns. That is something we are going to be planning 
in the future. We need to find a spot that is kind of central 
to----
    Mr. Benishek. Is every CBOC going to have a town hall?
    Ms. Kearns. We hadn't planned on doing it at present. We 
were trying to have an area in between, so we could have two or 
three of the CBOCs come to the one spot. But we could end up 
having them at the CBOC.
    Mr. Benishek. That's what we're talking about, the 
difficulty with driving.
    Ms. Kearns. The transportation, yes.
    Mr. Benishek. Can we use the CBOC as well?
    Ms. Kearns. Yes, if we could get space like--something like 
this, we could certainly have a town hall in here.
    Mr. Benishek. I'm sure the communities would just be more 
than happy to be able to have a town hall meeting. There's a 
lot of people with questions about--and it would be really 
helpful, I think. Just think what you learned here today----
    Mr. Bockelman. Sure.
    Mr. Benishek. Mr. Bockelman, just from the testimony we've 
had my view of the leadership is you've got to be out there, 
hearing for yourself what's actually going on, because 
sometimes the leadership gets a different view from the people 
that work for them than when they actually go out and hear what 
people have to say.
    So I would encourage you and Ms. Kearns also to be 
participating in this town hall so that you really learn from 
the front and not just lead the division from the rear. But 
lead the division from the front and see what people on the 
ground are actually seeing. So thank you for that.
    How are we going to change the culture in your VISN, Mr. 
Bockelman? I mean, frankly, Ms. Brownley and I have heard 
testimony--and frankly, had the Secretary tell me that we've 
increased the waiting list by 40 percent. And then we find out 
that those numbers have all been fudged. So we members of the 
committee, we've sort of become very jaded when the VA tells 
us, ``We're doing great. We're really improving.'' So, I think 
communication on your part, being out there and being at the 
front of things, is very, very important. Because, frankly, 
we've stopped believing most of the things VA says. Because 
their actions, haven't--you've fouled up from what you're 
saying. So I would encourage you to really focus on getting out 
there and doing outreach and that.
    I have a couple questions for Mr. Rice. What can we do, Mr. 
Rice, because you and I have talked in the past about the 
difficulties in getting providers. And, we've worked at the 
committee level--the Inspector General has told the VA eight 
different times over the last 30 years they need a central plan 
for hiring providers.
    And one of the biggest problems we have in Northern 
Michigan is having each individual VA find enough providers to 
provide care, continuity of care, so you're not seeing a 
different doctor every time, as doctors don't stay long.
    You and I have talked about the various challenges you've 
had. How can this system be changed, other than with central 
planning and more evident recruitment, to make sure that you 
have the providers you need to provide care?
    Mr. Rice. That's a great question. I think one of the 
things we've been working on lately is really trying to recruit 
providers that want to live in Northern Michigan. We hired 
recently 4 new primary care providers that had a background, 
they grew up in the UP and then left.
    One of the things we've also started for other providers is 
a college program where we hired 15 kids while they're going to 
school, and the hope is that when they graduate and they want 
to come back and raise their families they'll think about us. 
But it gives them the exposure to the VA, so they are familiar 
with the VA culture.
    Personally, we had a vacancy in Sault Ste. Marie for about 
a year and a half, so I personally outreached to every provider 
in the Soo area and sent them a personal letter asking them if 
they would consider coming to work for the VA. So it's a 
challenge, and we struggle with that every day in Iron 
Mountain, recruiting.
    Mr. Benishek. You would agree it would be better if the VA 
had a central plan to hire physicians nation-wide to get a 
pipeline of people in the system?
    Mr. Rice. Yes.
    Mr. Benishek. Mr. Bockelman, do you have any more thoughts 
on that?
    Mr. Bockelman. A lot of thought has gone into recruitment 
and retention. Once they get them----
    Mr. Benishek. See, the problem is, it's all happening at 
each individual medical center.
    Mr. Bockelman. And I think there's some value to having 
some local medical center responsibilities for that. The 
efforts that Mr. Rice has got are going to be a whole lot 
different than an urban setting, so it's nice to have that 
opportunity to fine tune the recruitment.
    One of the things that came out in the law that was just 
passed was the ability for us to pay up to $120,000, I think 
for the amount, for education debt reduction. That will make us 
much more competitive.
    One of the things that Mrs. Kearns has brought in since her 
arrival a year ago is to actually use some of the recruitment 
incentive funding that has been available, some tools that just 
have not been used.
    VISN 11 is having in November a recruitment and retention 
training session. I want to make sure our providers, the 
leaders that have areas where there are critical shortages, 
know all the tricks of the trade and all the tools that are 
available to do them.
    We've got to make sure that we get as many available. We 
recognize not everybody is a good candidate for the VA, but 
we've got to get folks in the door. We do find once they come 
to the VA, get a feel for the mission, they do stay. So the 
recruitment, getting them there, is significant.
    Mr. Benishek. I'm over time. I'll yield to Ms. Brownley.
    Ms. Brownley. Thank you. I wanted to know--you had 
mentioned in your testimony identifying access gaps, I think is 
how you termed it. So what are they?
    Mr. Bockelman. I think we've talked about the distance. I 
think if we look at gaps being the limitation to healthcare, is 
going to be the distance. The winter weather is a serious gap. 
Can't do much about that.
    We have worked hard on the telehealth domain to get that. 
We've now got the capability to start to go into veterans' 
homes to do it directly. We're working hard to find providers 
that are willing to do that. This is new for them, too. That's 
important.
    And some veterans aren't too excited about having a screen 
in front of them. We recognize that for some it will work and 
some it won't. But we're expanding those products wherever we 
can.
    And a good example is in Beaver Island, which is an island 
off the coast here that I think we have 90 permanent residents. 
And I will share with you a picture of that island in the 
middle of the winter, and you'll understand how difficult it is 
to access.
    We now have an arrangement with the local, state and rural 
health facility there to provide primary care for those 
veterans there so they don't have to travel. They would have to 
fly to get to the mainland, and then travel through normal 
ground methods to get there.
    We are also providing telehealth equipment that we'll be 
able to use to work with the veterans; specifically, for mental 
health services that that clinic is not able to provide. As we 
know, much of healthcare is done in primary care, and so if we 
can avoid them having to come off the island except only for 
specialty care, which everybody on the island does have to come 
off to do, that's the kind of efforts we're making. So we're 
looking for those kind of points.
    Ms. Brownley. Thank you. So, before this--before we passed 
this law that's in place now that hopefully is going to help in 
terms of access, before the law was passed, VISNs and the VA 
had the opportunity to use community partners or private 
practitioners when they couldn't meet wait times and so forth. 
So in terms--were you utilizing that? Were you utilizing--
sending your veterans, at least in this area, to--to community 
partners and utilizing that before the law was passed?
    Mr. Bockelman. Yes. I will pass to Ms. Kearns to discuss 
the budget. But this is a significant portion of our budget. 
And just to give you a flavor of what it--the impact it has on 
Saginaw.
    Ms. Brownley. Is using private practice for--is it a 
significant part of your budget?
    Ms. Kearns. For the--this year--well, of our overall 
budget, for all nine clinics and the hospital this year we've 
spent almost $20 million on non-VA care. In this particular----
    Ms. Brownley. What percentage is that?
    Ms. Kearns. It's about 17 percent of our budget.
    Ms. Brownley. Okay.
    Ms. Kearns. Is being sent out. In this particular district, 
this year we've spent over $3 million. We've sent out over 
2,200 veterans to care in the community.
    Ms. Brownley. And do you know their satisfaction levels?
    Ms. Kearns. We--they are happy when we can send them out 
closer to home. That's the answer.
    Ms. Brownley. Do you survey the veterans that you're 
sending out so you get a sense of the kind of care they're 
getting and their level of satisfaction?
    Ms. Kearns. We have not surveyed them. That's probably 
something that can be done. Oftentimes getting the records back 
and finding those things out--but, yes, we could do that.
    Ms. Brownley. And for the local CBOC here that I had the 
opportunity and pleasure to visit, what's your average wait 
time for primary care and specialty care at this moment in 
time?
    Ms. Kearns. Our average wait time for primary care is about 
12 days. Specialty care, depends on what the specialty care is, 
it can be up to 30 days.
    Ms. Brownley. But it's not--you don't have--you're not 
beyond 30 days?
    Ms. Kearns. No, we are not beyond 30 days in most of our 
areas. There are a few little pockets that could be--like 
neurosurgery is a difficult one to get anywhere. But in general 
about 30 days.
    Ms. Brownley. I was very impressed with the fact that the--
speaking to your RNs this morning, before they got into their 
cars to travel today, to have in-home care. And so that was 
very impressive, and it sounds like you're going to look 
further into--to the degree of, how much more of in-home care 
we can do.
    And I really think in the long term, with telehealth and 
sort of in-home care, too, that the combination, if we can 
bring telehealth into the home, in essence, is probably a 
good--a good, longer-term solution as well. So I'll yield back 
my time.
    Mr. Benishek. I just want to touch on one of the things 
that was brought up in the previous panel again. Mr. Lerchen 
said that no one of us would find it acceptable to be required 
to drive 5 hours to receive a needed medical service, nor would 
we find it acceptable for our aging parent to be required to 
make such a trip. And Mr. Chambers also mentioned his son, not 
elderly, but driving apparently for a preop visit for an 
endoscopy to Saginaw.
    This is a pretty huge issue. I'm surprised that there's not 
more local care being done or why, like, somebody has to travel 
preop to Saginaw for an endoscopy. I did endoscopy at the VA. 
They didn't do that. I am not exactly sure what he's getting 
done.
    But this--this 5-hour trip--or 3-and-a-half or whatever it 
is to Saginaw, that's a pretty big deal for up here. And it's a 
common theme that you hear. Why aren't we doing more of this 
care here now? I know that the bill that we did is supposed to 
make it easier, but it's already been within the realm of VA to 
make it happen. And don't you think there should be more local 
care being given here so people don't have to make that drive 
to Saginaw? What are we doing? Are you doing anything specific 
now to make that happen easier?
    Ms. Kearns. One of the things that I've done since I've 
gotten there is ease up who can go out and have care if they're 
eligible to go out and have care. We've spent almost $4 million 
more than last year already on non-VA care because we're 
finding pockets of people that we can send out.
    For example, a good example I had was, it was brought to my 
attention an 88-year-old veteran who they wanted to travel to 
Ann Arbor. And when it was brought to my attention, I said, 
``No, he will go local,'' and we paid for him to go local. So 
those are the kind of things that, I agree, we need to try to 
do those things like that.
    Mr. Benishek. So what is happening to make it be better? 
Because these are questions I've asked for three years--and, I 
see that--you say $4 million more this year than last year. And 
is it going up that fast, then, every year, then? Is it going 
to continue to improve?
    Ms. Kearns. I would guess with the new law that's been put 
into place, yes, it will continue to.
    Mr. Benishek. What about the PC-3 thing? This is something 
I've spoken to people in DC, about where they are to provide 
more of a tri-care like network for veterans. Where are you 
with that?
    Mr. Bockelman, do you have any idea where that is at? 
Because my experience is that--I was concerned, number one, 
what they were going to pay providers. And, number two is 
what--how many providers are actually signing up and when will 
that network be complete?
    Mr. Bockelman. This has been a challenge in VISN 11, 
especially in Michigan where there is not an existing network 
by this company. They are working hard, they are scrambling to 
get providers signed up. We have had some early communication--
I would call them start-up problems with recognition of 
territories. Is this town closer than this town? And they might 
be sending veterans to the farther-away town than a closer one.
    Mr. Benishek. It's not very good, it sounds like.
    Mr. Bockelman. We are still struggling to get this program 
up and running.
    Mr. Benishek. I'm concerned about this piece of legislation 
that we passed is supposed to be able to give an access card to 
veterans from this area basically. I mean, people that live 
more than 40 miles from a VA facility that provide their care.
    I mean, how are we going to--I know you probably don't have 
the answer for that because you're the VISN director and not 
the big wheel in Washington. But, we're hoping for something to 
happen fast. So we're not waiting two years to implement 
something that is supposed to happen right away for the people 
who are suffering. Do you have any comment on that?
    Mr. Bockelman. I know they are working vigorously to get a 
full understanding of the law to make sure we're able to carry 
it out as intended. We look forward to the opportunity to 
expedite the care. Especially with the choice card.
    We are concerned about the continuity of care like we 
discussed. That's always going to be a concern, knowing in the 
back of our heads as healthcare providers that we don't want to 
lose that, because that is so critical.
    There will be new rules that we will have to learn on how 
we're going to handle that. We will have the horsepower ready 
to go as it comes to implementation so that we could do this. 
There will--I'm recognizing that any new program like this will 
have some start-up time. We will do whatever we can to expedite 
that and not be in a position to wait for action.
    Mr. Benishek. But do you agree that 5 hours is excessive?
    Mr. Bockelman. That's a long time. A long time, yes.
    Mr. Benishek. A long time to be traveling.
    Mr. Bockelman. I do.
    Mr. Benishek. Thank you. I will yield to Ms. Brownley.
    Ms. Brownley. Thank you, Mr. Chair. Mr. Bockelman, I wanted 
to ask, so how much funding did your VISN receive from the 
Access to Care Initiative? Do you know the number?
    Mr. Bockelman. We have about $11 million earmarked for 
that. 2 million of that came from the Washington component. We 
drained our reserves to put up the additional 8.8 million 
approximately.
    We're on target to get all this spent in the next 5 weeks. 
We've been working hard to monitor our progress, to make sure 
that we got that done. If there comes a time, if we were so 
lucky as to have funds that weren't spent, we would sure be 
ready to share those with other parts of the country that have 
a need that we don't. But to this point----
    Ms. Brownley. So what was your criteria for disbursement?
    Mr. Bockelman. We went to the facilities and asked them 
what are their needs. Where do you find delays? Where are you 
having problems meeting that within house? Come up with a 
budget and let's look at it. And we've been adjusting it a 
little bit more here, a little less there as we do find that.
    Ms. Brownley. So what were the needs here?
    Mr. Bockelman. Across our network, we had a lot of 
optometry.
    Ms. Kearns. Audiology
    Mr. Bockelman. Audiology was another area.
    Ms. Brownley. So how was money going to solve those issues? 
We talked a little bit about that earlier today, but----
    Mr. Bockelman. A couple things. That will help with the 
backlog to get those done.
    Ms. Brownley. Yes.
    Mr. Bockelman. I think one of the things--a good example 
might be optometry, which is--plain optometry is a rather low 
risk/high volume. That is something that we should be looking 
at our contract for, because that can be done locally.
    We've been doing some work with teleaudiology, which will 
now enable us to do work at the CBOCs; not just helping 
veterans adjust hearing aids, but actually able to plug into 
the computer system that will allow the audiologist back at the 
main facility. We are rolling that out over the next year.
    Ms. Brownley. Very good. And then also I think in your 
testimony you said that the--your VISN had received $8 million 
from the Veterans Health Administrative Office----
    Mr. Bockelman. Yes.
    Ms. Brownley [continuing]. Of Rural Health to support 25 
projects and programs to increase access to care for rural 
veterans. So, can you tell us what the process is to receive 
that funding? And do you--do you have to provide measurable 
outcomes at the end of the project?
    Mr. Bockelman. Yes, we do. A couple things. One--the nice 
part about this program is the rural health office keeps a 
running list of all the successful programs, so we can look to 
see if there's something that we just hadn't thought of that we 
can go pick right off the list.
    At the same time we do ask the facilities, go and look and 
see what might work at your facility. What's the deficit there. 
Maybe we've got something unique. We've got a lot of rural 
health transportation dollars coming to Saginaw because of the 
transportation.
    So it can come either way. We could look for projects that 
have been successful or the ground up.
    We then have a coordinator, Mr. DeLoof, who does a 
wonderful job getting these packages put together at the 
network level, bundled up, making sure that they're sound, 
making sure that we do have metrics or understanding of what 
would be a recognition of success. And then they do go forward 
to Washington where we hope they compete well because there's a 
lot of folks.
    Ms. Brownley. Can you give me some examples of some of the 
measurable outcomes that you've set in place?
    Mr. Bockelman. A good one that we've done lately, in the 
last couple years, is our prosthetics vans. Recognizing that a 
veteran might go a long way just to get a brace adjustment or 
an orthotic shoe adjustment, we now have mobile vans that go 
out to the CBOCs routinely, on schedule, that allows the 
veterans to get that work done at the CBOCs.
    We have monitored that. We can now show you conclusively: 
Here is the cost. Here's the gaps. Here's the maintenance for 
the vehicle versus what we would pay for beneficiated travel to 
come to the medical center.
    Not even counting or trying to put a dollar value to the 
veteran for not losing a whole day of work. That has saved us 
money.
    And I think it also probably enables the veterans to be 
more comfortable in their orthosis. If it fits well, and 
therefore they will wear it more often and have better clinical 
successes.
    Ms. Brownley. Thank you. I yield back.
    Mr. Benishek. While preparing--I'm going to yield myself 
five more minutes for questioning. While preparing for the 
hearing today, my office received a call from a Northern 
Michigan VA employee who, due to fear of retribution did not 
want to be identified, but did want to alert me to his concern 
regarding the alleged use of no call/no show lists at the 
Saginaw VA Medical Center.
    According to this person, some veterans are scheduled for 
VA appointments without being made aware of the appointment 
time or the date. When that veteran then misses the 
appointment, which he or she was never advised of, the veteran 
is then placed on a no call/no show list, and VA's access 
number looks better than they really are.
    Needless to say this is an allegation from someone. But we 
are going to be investigating it further.
    Is there a no call list for people who have a history of 
not showing up at their appointments and then they get put on a 
list of--a no show list?
    Ms. Kearns. Well, when somebody no shows for an 
appointment, it comes up in the computer when they don't show 
up. It shows that they're--that they didn't show up for the 
appointment. So you would be able to track that by no shows, 
and we do keep track of how many no shows we do, so that we 
have access for other veterans.
    So when somebody doesn't show up, then we can put somebody 
in that slot to see. If they--if we have somebody available at 
that point in time. But as far as a list that--I am not aware 
of any list that we put people's names on other than we can 
show who no showed for the day. That's part of the computer 
system that all VAs have.
    Mr. Benishek. Right, right, right. Is there a--consistent 
way of reminding people of their appointments?
    Ms. Kearns. Definitely. We make phone calls. We have 
letters. We have cards. In fact, the comment we get most often 
is, ``Quit calling us, quit telling us I have an appointment.'' 
It's a very good system with multiple reminders to people.
    I had somebody tell me just recently that they got three 
reminders about an appointment in the same week. So we do have 
a system for that, plus a calling system that goes out. So.
    Mr. Benishek. Right. That's been a complaint elsewhere in 
the country. Of veterans, not being told when their appointment 
is, and then the appointment is made for them, but nobody 
actually spoke to the veteran prior to making the appointment. 
So that they may have been off to a funeral or--you know what I 
mean, something like that. So you're saying that that does not 
occur, then.
    Ms. Kearns. No, no, what I'm saying is we--when somebody 
has an appointment, we remind them of the appointment. I was 
talking about reminders.
    Mr. Benishek. When people's appointment is scheduled, are 
they usually spoken to, then, when you schedule the 
appointment?
    Ms. Kearns. Generally, yes. I mean, I would have to have an 
example of what you're speaking of.
    Mr. Benishek. We've heard at other testimony that VA would 
make somebody an appointment without speaking to them, so that 
they may have had other plans than the appointment. They didn't 
speak to the veteran when they made the appointment. They just 
made the appointment and told the veteran when the appointment 
was later, and the veteran may not have been available at that 
time. You know what I mean? So you're saying that doesn't 
happen that way?
    Ms. Kearns. That can happen when a consult is done, and we 
send out the consult to another facility. They may make the 
appointment then.
    Mr. Benishek. They speak to the veteran, then, when they 
make the appointment?
    Ms. Kearns. I would hope that they speak to the veteran.
    Mr. Benishek. You don't know that for sure?
    Ms. Kearns. I don't know that for sure when we send out the 
consult, to another facility.
    Mr. Benishek. Is that the standard method, then, of 
actually speaking to the patient when they make an appointment?
    Ms. Kearns. Well, that's what we endeavor to do every day, 
if we can actually speak with them. I----
    Mr. Benishek. What I'm trying to get to is the point is 
that when a veteran is scheduled for an appointment, do they 
speak to the veteran as they schedule the appointment----
    Ms. Kearns. Yes.
    Mr. Benishek [continuing]. Or prior to scheduling the 
appointment, so they know the patient is going to be available 
that day? Not just: Well, the appointment is going to be on 
three weeks from Tuesday. Send the letter to the veteran that 
the appointment is three weeks from Tuesday. Do you understand?
    Ms. Kearns. Generally a follow-up appointment is made, it's 
made right with the veteran when they're standing in front of 
us.
    Mr. Benishek. Right. That's what I want to make sure 
happens.
    Mr. Bockelman. One thing that happened after the access 
issue became so apparent, I went out and met with the 
scheduling people at the medical centers. And I know Ms. Kearns 
and Mr. Rice have done the same thing. To make sure we 
understood what issues they were facing that we might not know 
about, we don't know about.
    One of the questions is how come these are not filtering 
up? And I think that's the cultural question that we really 
need to address.
    But one of their toughest parts of their job is getting 
ahold of veterans for appointments. They might call. No answer. 
They call a number that's listed, it's not current. All those 
kinds of things.
    They are very reluctant, very reluctant to settle for 
sending a letter to a patient saying we've been trying to get 
ahold of you, can't get ahold of you, now we're going to go 
ahead and schedule and get this ball rolling, we hope you can 
make it.
    The clerks know that is not ideal. They do not want to do 
it. They are really anxious to try to capture that appointment 
information before the veteran leaves in front of them if at 
all possible.
    Mr. Benishek. Thank you.
    Ms. Brownley.
    Ms. Brownley. I just wanted to follow up on the no shows. 
So it sounds to me like you have a methodology, though, that if 
you do have a no show, you can fill that slot.
    Because we've heard some testimony in Washington that some 
folks no show, no appointment, the appointment just stands open 
and is never filled. So, in some places a doctor may see--in a 
clinic or a CBOC might see two patients. Ten were scheduled, 
but, because of no shows and other kinds of things, only two 
were seen.
    But--so there were suggestions about different systems, I 
guess that private practices utilize. And one of them being 
just a series of open appointments every single day so that if 
you do have no shows and so forth, you can fill them. And 
that's what you're doing?
    Ms. Kearns. We have open slots that people can walk in.
    Ms. Brownley. So what's your average amount of--what's your 
average--how many patients does a doctor see in a given day?
    Ms. Kearns. Generally at the clinic here in Traverse City 
they see about 10 patients a day.
    Ms. Brownley. Thank you.
    Mr. Benishek. I've got a couple more questions. In a 
statement for the record, the Sault Ste. Marie Tribe of the 
Chippewa Indians stated that they are seeking an agreement with 
VA to allow members who are veterans as well as non-Native 
veterans to receive care at one of the tribal clinics in the 7-
county service area that they have. And to receive 
reimbursement payments from the VA to provide care for those 
veterans. Without the burden of travel and financial stress 
created by the long distance between reservations and VA 
clinics. Would you be supportive of such an arrangement?
    Mr. Rice. Actually, my facility has been working with them. 
We do have--we've already set up one clinic, optometry, because 
we needed access over in the Manistique area. So the clinic--
the tribal clinic in Manistique is now seeing our optometry 
patients. It's a veteran's choice that's put out on fee.
    But we have been working with them for a while to try to 
get the issue--the issue is treating non-Native Americans at 
their clinic. So we've been working at that for about 12 months 
to get that resolved.
    Mr. Benishek. So are you still working on individual 
contracts with clinics rather than the PC-3 thing? Because that 
obviously is a problem, it sounds like.
    From what you said, that that's not going as well as it 
could. So you're still contracting on an individual basis to 
get care for veterans at local clinics like this?
    Mr. Rice. Yes.
    Mr. Benishek. Can you keep me informed as to how that 
continues to go.
    Mr. Rice. Yes.
    Mr. Benishek. I want to keep up to speed on that.
    Do you have any further questions?
    Ms. Brownley. No further questions.
    Mr. Benishek. Well, I know that we haven't covered all the 
aspects of VA's problems that we've heard in Washington. I know 
that in your positions, from where you're at, you can't solve 
the problems of how the whole management of the system works.
    For the audience we passed a pretty major veteran reform 
bill this past time that, frankly, it's going to come down to 
implementation. And is VA going to be able to implement the 
changes that we've made in the law to allow veterans better and 
easier access to care locally. That's pretty much the gist of 
the bill.
    And the bill also demands reform of VA with outside third 
party evaluation of the entire management scheme of VA. So, 
this crisis that's come up has led to a new secretary. It's led 
to the changes that we made for access for care. And it's made 
for an evaluations of the system and an ability for management 
to demand more accountability out of its people.
    So hearings like this help develop a communication between 
our committee and my office to VA staff. I hope that you all 
learned something from the conversation that we had with the 
first panel, and that we'll be reaching out to members of the 
first panel to continue to work with them in a constructive 
fashion rather than adversarial fashion to improve care for our 
local veterans.
    So I appreciate you all being here today, and I know I'm 
going to continue to work on it, as will Ms. Brownley.
    If you have any closing comments, Ms. Brownley.
    Ms. Brownley. Well, I would just say, thank you to 
everybody who has participated. And I know I don't represent 
your area, but your concerns here have been expressed is of 
great interest to me and not only Dr. Benishek, but it's 
important to the committee.
    And I know I can say with great certainty that our--the VA 
committee back in Washington had many, many meetings around 
this crisis. And I think it was pretty clear that we identified 
what the problems were. And this bill is a beginning step. But 
we know the most important work for us to do at this particular 
point in time now is to make sure that we provide--the 
committee provides the oversight and making sure that the 
execution is taking place and making sure that the 
accountability and so forth that we all want and believe we 
need is in place, so that we are improving--and as I said 
earlier, continuously improving--our services to our veterans, 
not only here but across the country.
    And so this is just, in my mind, a--a beginning, and we've 
got a long way to go. And I think--and I am not talking about 
VISN 11 specifically here. I am talking about the VA in 
general. there's got to be a major, major sort of cultural 
shift that has to take place. And cultural change is hard. And 
it's hard work. And I think it's our responsibility to make 
sure that we move forward with those changes.
    And at the end of the day, we want to provide high quality, 

timely healthcare to our veterans in every single corner of our 
country. And that's our goal and that's our mission. And what 
you have provided for us here is helpful to us. And we take 
that information back, and it will be helpful in terms of our 
next steps. So thank you.
    And I--you live in a wonderful, beautiful place. And I've 
enjoyed my stay here very much. Thank you, Chairman.
    Mr. Benishek. Once again, I want to thank all the witnesses 
and the audience members for participating in today's 
conversation. It's been a pleasure for me to be here and spend 
the morning with you.
    With that, I ask unanimous consent that all members have 
five legislative days to revise and extend their remarks, and 
include extraneous materials without objection.
    Mr. Benishek. So ordered. The hearing is now adjourned.
    [Whereupon, at 11:07 a.m., the subcommittee was adjourned.]

                                APPENDIX

                Prepared Statement of Curtis P. Chambers

    My name is Curtis P. Chambers, I am honored to appear before you 
today, and I am equally honored to be seated with these great Tribal 
Leaders. I am an Ottawa Indian and Navy Veteran, my father was a Navy 
Veteran, and two of my sons are Navy Veterans. We were all honored to 
serve this great nation as members of the greatest Navy this world has 
ever seen. I would like to speak with you today about the need for 
transportation services, telehealth, and non-VA care.
    I have had the unfortunate opportunity to deal with our present 
system and regaling you with the failings would take more time than we 
have allotted today. Such as an eighteen month waiting period for an 
existing problem one of my sons had, or travel records being lost not 
once, not twice, but three and four times . . . and much more. I would 
however prefer to focus on the positive and possible fixes to the 
problems facing us today.
    1. Non-VA healthcare, why can't we just use our present Doctors and 
healthcare providers and then send the bill to the VA.
    2. Some of our health concerns and questions could probably be 
answered via skype and some other such device which could be done at 
various VA Clinics
    3. The above ideas will both decrease travel expenses.
    I/my experience, the actual care our veterans receive is 
outstanding however, the paper work and bureaucracy are mind numbing.
    Mister Chairman, I am just a stump jumping half breed from Northern 
Michigan and I realize that the devil is in the details but I'm sure 
that by working together we can supply the Veterans of the greatest 
Military on earth the greatest healthcare on earth.
    I would like to thank Congressman Benishek and everyone involved in 
the efforts to improve our present VA care system.
    Respectfully,
    Curtis P. Chambers

                                 

                 Prepared Statement of Carl Archambeau

    August 25, 2014

    Dan Benishek

    U.S. House of Representatives
    Committee on Veterans Affairs
    Subcommittee on Health
    Washington DC 20515

    Re: Testimony before Subcommittee on Health

    First of all, I would like to say that the Veterans Affairs (VA) 
clinic in our area is doing an exceptional job for the veterans 
considering the space, equipment and personnel they have to work with. 
Also, we have a Disabled American Veterans (DAV) transportation system 
in place to get some of our veterans to Saginaw, Ann Arbor, or Detroit 
for their hospital appointments.
    Having said that, the distances we have to travel to get to a VA 
hospital for an appointment are a problem. It is an all day event to 
travel to and from the hospitals plus the waiting time at the hospital 
making it a hardship on our elderly veterans. Traverse City is more 
than 40 miles from any VA hospital and veterans should be allowed to 
use local doctors and hospitals for any medical needs that the local VA 
clinic cannot provide.
    The VA hospital in Saginaw is in an old building and needs 
renovation. A new hospital in the Gaylord area would better serve 
veterans in Northern Michigan and the Upper Peninsula.
    Commander, VFW Post 2780


                                 

         Prepared Statement of Linda L. Fletcher LTC/ANC (ret)

    I thank you, Congressman Benishek, for the opportunity to address 
this group today. I hope to provide an interesting perspective on the 
topics at hand.
    The recent events surrounding the VA have been very disturbing to 
say the least. But . . . it was Winston Churchill who said ``Never fail 
to take advantage of a crisis'' . . . and that is what we have in the 
VA system today. Now is the time for problem identification, for 
opening to the consideration of conventional and unconventional ideas 
and formulation of bold steps to institute carefully conjured 
solutions.
    Abraham Lincoln eloquently captured the mission of this 
organization that he created in 1865 with these words . . . ``to care 
for him who shall have borne the battle and for his widow and his 
orphan''. The structure and configuration of what we currently know as 
The Department of Veterans Affairs has changed through the centuries 
and our many wars but the promise and the intent have not wavered and 
the mission statement has remained the same.
    This nation has lately been generous with funding for our veterans. 
The FY 2014 budget is $152.7 billion. Approximately 40% of that budget 
($61.1 billion) is directly related to provision of health care. And, 
due to the recent findings regarding administrative issues, an 
additional $17 billion is being added. There can be little doubt that 
America wants to take care of our veterans and we are willing to pay 
whatever it takes to do so. Unfortunately, sometimes pumping in money 
to patch a sag in the ceiling isn't the answer. Sometimes we have to 
start by fixing deeper foundational problems. I am in hopes that 
reformation of the VA system will begin with a review of the original 
mission statement so we can proceed to evaluate our existing 
organization in accordance with that guiding light.
    According to www.va.gov the VA is currently the largest health care 
system in the nation. In 2012 the VA provided health care for 
approximately 5.9 million Americans. . . . 2% of our entire population. 
Interestingly, of that group some 1.6 million (26%) qualified for care 
which the VA categorizes as not associated with war related illness or 
injury.
    In view of these numbers perhaps the answer to the situation facing 
us is not what seems to be the foregone conclusion that we need to 
supersize the VA. Perhaps we need to consider streamlining the system 
in accordance with the mission statement by targeting caring only for 
war related illness or injury. A restructuring that focuses 
specifically on that population would decrease the workload by 26% and 
provide a more focused approach to care for the remaining group. The 
care required by that smaller group could be provided in the local 
civilian sector by having the VA assume all costs associated with 
insurance provided by the Health Care Act.
    This mechanism might also be considered as an option for our many 
veterans located in rural areas where accessibility to VA facilities is 
geographically challenging. Perhaps we should consider allowing these 
veterans the option to receive equivalent local care funded by the VA 
through the HCA.
    From an administrative perspective I would also like to recommend 
that the VA revise their practice of hiring from within. The 
intellectual and cultural inbreeding that results from selection from 
the same pool chokes the breath of new ideas, perspectives and 
leadership that comes of selecting from a diverse assortment of 
potential employees.
    Lastly, care to veterans is restricted by more than just geography. 
There are some exciting concepts emerging and/or re-emerging regarding 
different psychotherapeutic techniques which target resolution of cause 
not just the current objective of mitigation of symptoms. Additionally, 
there is a wide variety of treatment methodologies, from acupuncture to 
Zen meditation, available in the alternative medicine communities that 
target stress reduction, a major component of PTSD care. In view of our 
less than successful results in managing PTSD to date we need to 
explore, not restrict new possibilities in theory and treatment.
    I am well aware that this is a superficial and limited overview of 
a very complex situation. I hope that some of these thoughts will be 
helpful as this nation struggles to provide better care for those who 
gave so much for us. And let it be remembered that the VA may be 
stumbling but with our help it can resume it's revered and important 
position in our nation. They have a long and honorable history and they 
can regain their glory with our support which includes constructive, 
not destructive, criticism. We are in crisis and it presents the chance 
to take great strides in an abbreviated length of time. Let's take 
Winston Churchill's advice and not fail to take advantage of this 
opportunity to advance our systems for the good of our veterans.
    Thank you and God Bless America

                                 

               Prepared Statement of Charles R. Lerchen,

    Good Morning, Mr. Chairman. I would like to thank you for bringing 
the Field Committee together to gather information concerning the 
challenges confronted by veterans in rural areas in accessing and 
obtaining their health care needs. Speaking from the perspective of a 
local official who interacts daily with veterans, I believe I will be 
able to provide you with some valuable insight as to the real world 
challenges rural veterans encounter after enrolling and choosing to 
have the VA provide them with their healthcare services.
    As we all know, the VA is an agency in crisis. Both the Veterans 
Benefits Administration and the Veterans Health Administration struggle 
daily to accomplish their missions to our nation's veterans. Their 
Congressional mandates routinely go unheeded. Billions of dollars 
continue to be thrown at the problems with little or no quantifiable 
results; and the biggest problem is the lack of accountability. The 
largest obstacle confronting the VA right now is the culture of the VA 
itself. Health care provision to the significant number of rural 
veterans is just another victim of this corrosive and obstinate 
culture.
    So while the VA and Congress continue to grapple with the core 
problems within the agency; the veteran continues to grapple with the 
affect it has on him or her. It is unreasonable to think the VA can 
provide every veteran in the country easy access to every kind of 
health care they need in their own back yard. Since it was introduced 
over 20 years ago, the clinic model for rural areas has been a 
tremendous success. The need for rural veterans to have to travel great 
distances for primary care has been markedly reduced. However, the 
question now becomes is how do we provide the specialty services a 
veteran needs while still addressing the need for the unreasonable 
travel and appointment times necessary to receive it? The answer to 
this question may lie in the authorization for rural veterans to 
receive certain care at non-VA providers.
    The VA has long held tightly to the notion that they and they alone 
will be the provider of all tertiary care. ``If your primary care 
provider at the clinic orders an MRI--we will do it even if it means a 
10 hour drive in the middle of the winter, a six month wait to have it 
scheduled and OH . . . by the way we don't care if your 88 years old''. 
This is the mind set of the VA and it needs to be changed. The 
metropolitan VA Medical Centers have all the business they can handle . 
. . this is clear. If the VA cannot provide the needed tertiary care to 
the rural veteran than contract it out to the community. The military 
does this routinely, why can't the VA? The rural veteran clogs the wait 
lists for these services unnecessarily. Equity and good conscious must 
come into play. None of us would find it acceptable to be required to 
drive 5 hours one way to receive a needed medical service; nor would we 
find it acceptable if our ageing parent was required to make such 
trips.
    So, just as it is unreasonable to expect the VA to be able to 
provide all of these services to our rural veterans; it is likewise 
unreasonable to expect the veteran to endure the hardships currently 
required to receive their needed healthcare. The rural veteran has 
entrusted their health and well being to the VA system. We are supposed 
to treat their ailments, not create more in doing so.
    We are beginning to see some progress in addressing these lingering 
deficiencies. VA's move to improve the method for identifying urban, 
rural and highly rural Veterans by adopting a method used by other 
leading Federal agencies is a major step in the right direction. It is 
also a step in the right direction in breaking down the core problem 
within the VA. The malignant culture of oppugnancy that has existed in 
the VA for far too long must now be replaced with a culture of altruism 
and service to our Nations veterans.
    This concludes my testimony. Thank you for the opportunity to 
address the committee today.

                  Prepared Statement of Paul Bockelman

    Good morning, Chairman Benishek, Ranking Member Brownley Thank you 
for the opportunity to discuss rural healthcare and healthcare 
specifically for American Indian Veterans within the Veterans 
Integrated Service Network (VISN) 11. I am accompanied today by Ms. 
Peggy Kearns, Director of the Aleda E. Lutz VA Medical Center (VAMC) 
and Mr. James Rice, Director of the Oscar G. Johnson VAMC.

VISN 11 and Aleda E. Lutz VA Medical Center (VAMC) Overview

    The employees of VISN 11 proudly provide patient-centered care to 
the approximately 386,000 Veterans living in portions of Michigan, 
Ohio, Indiana, and Illinois. VISN 11 consists of 30 Community-Based 
Outpatient Clinics (CBOC) and healthcare system main campuses located 
in: Ann Arbor, Battle Creek, Detroit, and Saginaw in Michigan; 
Indianapolis and Ft. Wayne in Indiana; and Danville in Illinois.
    With a budget exceeding $2.1 billion, we are in a position to 
provide our Nation's heroes with high quality care through traditional 
and innovative methods. VISN 11 also has a collaborative relationship 
with the Vet Centers located in Macomb County, Dearborn, Detroit, 
Escanaba, Grand Rapids, Saginaw, and Traverse City.
    The Aleda E. Lutz VAMC, located in Saginaw, Michigan, is accredited 
by the Joint Commission and consists of the Medical Center with a 
Community Living Center (CLC) and Annex in Saginaw and CBOCs in Alpena, 
Bad Axe, Cadillac, Cheboygan County (Mackinaw City), Clare, Gaylord, 
Grayling, Oscoda, and Traverse City. These facilities provide care to 
Veterans in the 35 counties of Central and Northern Michigan's Lower 
Peninsula. On April 21, 2014, the Aleda E. Lutz VAMC was awarded 
Planetree Bronze Recognition for Meaningful Progress in Patient-
Centered Care. The Aleda E. Lutz VAMC is the first healthcare 
organization in Michigan to be awarded Bronze-level recognition since 
Planetree first introduced the recognition level in 2012.
    The Aleda E. Lutz VAMC provides primary and specialty medical 
services, ambulatory surgical services, mental health services, 
inpatient medical care, rehabilitation, dentistry, audiology, 
optometry, blind rehabilitation, pain management, geriatrics, and 
extended care.
    Expanded mental health programs include: Operation Enduring 
Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) case 
outreach, Mental Health Intensive Case Management (MHICM), 
Posttraumatic Stress Disorder (PTSD) Clinical Care, Home-Based Primary 
Care (HBPC) psychology services, Compensated Work Therapy (CWT), 
recovery-based programs, suicide prevention, outpatient substance abuse 
programs, evidenced-based therapies, VA Caregiver Support, and Homeless 
Veterans Program, including Veterans Justice Outreach.

Focus on Access

    No Veteran should have to wait for the care and services that they 
deserve. We remain committed to ensuring Veterans have access to the 
highest quality care that they have earned through their service to 
this country. Patients at the Aleda E. Lutz VAMC can consistently 
access primary care, specialty, and mental health services within 
thirty days. Access is monitored daily to assure availability.
    The Aleda E. Lutz VAMC has implemented the Accelerating Care 
Initiative along several different tracks. Approaches to assure timely 
access include:
    1. Increasing the use of Non-VA care;
    2. Use of Saturday clinics;
    3. Hiring a substitute provider (known as a locum tenens provider) 
for Primary Care, and;
    4. Ongoing recruitment of staff.
    There have been reductions in the number of patients waiting both 
on the Electronic Wait List (EWL) and the New Enrollee Appointment 
Request (NEAR) list. From May 15, 2014, to August 1, 2014, the Aleda E. 
Lutz VAMC EWL dropped from 61 to 34. From June 1, 2014 to August 1, 
2014 its NEAR list dropped from 110 to 9. .
    As part of our commitment to transparency, VA is posting regular 
data updates showing progress on our efforts to accelerate access to 
quality healthcare for Veterans who have been waiting for appointments. 
These access data updates are posted at the middle and end of each 
month at the following link: http://www.va.gov/health/access-audit.asp.

VA Rural Health Care Program--State of Michigan

    There are approximately 660,800 Veterans in the state of Michigan, 
of which an estimated 31 percent or 207,200 live in rural areas. 
Approximately 227,400 Veterans in Michigan are enrolled in VA, and 43 
percent or 97,300 enrolled Veterans live in rural areas. An estimated 
34 percent of all Veterans living in Michigan are enrolled in the VA 
healthcare system.
    In addition to funding allocated to VISN 11 through the Veterans 
Equitable Resource Allocation (VERA) system for Veterans' healthcare, 
in Fiscal Year (FY) 2014, VISN 11 received $8 million from the Veterans 
Health Administration's (VHA) Office of Rural Health to support 25 
projects and programs to increase access to care for rural Veterans. 
The programs specific to Michigan include our Mobile Prosthetics Van, 
which brings prosthetic services typically found only at the main 
campus to the CBOCs; clinical training opportunities for providers in 
rural locations; telehealth; and HBPC which currently serves around 300 
Veterans. Since the telehealth and HBPC services are co-located within 
the community Veterans Service Office, such as the American Legion 
building, in Ludington, MI, we are able to facilitate Veterans' needs 
by working closely on Veterans Benefits Administration and claims 
issues and providing community-based services. This program is made 
available to Veterans in the Mason, Lake, Newaygo, Mecosta, and Oceana 
counties by the Battle Creek VAMC Northern Rural Expansion Team.
    We continue to look for opportunities to expand our care via 
telehealth technology. VHA is in the early stages of developing a 
collaborative effort with community providers to be able to exchange 
health information. We now have the capability to provide Clinical 
Video Telehealth (CVT) in the home, which will improve access to care 
for rural Veterans and mitigate the need for travel to a VHA site of 
care. We are also establishing additional Mental Health services via 
telehealth to Veterans at the Patriot House in Gaylord in 2014.
    The Battle Creek VAMC has taken the lead on several Veteran 
outreach projects in the rural areas of Michigan. To address low 
utilization rates, the Battle Creek VAMC signed a Memorandum of 
Understanding (MOU) with local Veteran Service Organizations, such as 
Veterans of Foreign War (VFW) and American Veterans (AMVETS), to allow 
VA to use their space to deliver care to rural Veterans. Additionally, 
the facility started delivering care in Veterans' homes. The care 
provided included access to a nurse practitioner, psychologist, social 
worker, registered nurse, pharmacist, occupational therapist, 
registered dietitian and a telehealth clinical technician. The use of 
home telehealth, as well as utilization of tele-dermatology and tele-
retinal services, has been incorporated into this team.
    These services enable rural Veterans to access VA care without long 
drives to one of the Battle Creek CBOCs. The psychologist has initiated 
some mental health groups in addition to utilizing clinical video 
telehealth to connect Veterans with other providers at the main medical 
center. To date, this motivated team of Federal employees has provided 
VA services and care to over 560 Veterans, with the numbers growing 
weekly.

Rural Health Outreach Transportation Program

    The Aleda E. Lutz VAMC's Rural Health Transportation Program is 
well developed, averaging nearly 1,200 patients per year, over 80 
percent of whom reside in rural communities. Patient satisfaction has 
increased with this program. Many of the users of the transportation 
program may not otherwise get to appointments and are repeat customers. 
Veterans requiring transportation assistance have pick-up sites in 
Gaylord, Grayling, West Branch, and Standish. Transportation is 
provided to the Aleda E. Lutz VAMC, as well as the Ann Arbor and 
Detroit Medical Centers.

Beaver Island Outreach Project

    The Aleda E. Lutz VAMC, the VISN 11 Rural Health Consultant, and 
the VISN 11 Planner have worked with the Beaver Island Rural Health 
Clinic to bring VA healthcare services to Beaver Island Veterans using 
non-VA Care authorizations. This partnership enables eligible Veterans 
to receive primary care, laboratory, and general radiology services 
from the Beaver Island Rural Health Center instead of traveling to a VA 
facility. To be eligible for services, Veterans must be enrolled in the 
VA Health Care System and meet VA eligibility requirements. VA and the 
Beaver Island Rural Health Clinic held a VA Day on June 13, 2014, to 
provide information for Beaver Island Veterans on VA healthcare as well 
as listen for additional opportunities to meet their healthcare needs. 
As a result of the information collected, we will establish a VA 
telehealth clinic to provide these Veterans access to VA healthcare. 
This service will be established by October 1, 2014.

Readjustment Counseling Service

    VA's Vet Centers present a unique service environment--a personally 
engaging setting that goes beyond the medical model--in which Veterans, 
Servicemembers, and their families receive professional and 
confidential care in a convenient and safe community location. Vet 
Centers are community-based counseling centers, within Readjustment 
Counseling Service (RCS), that provide a wide range of social and 
psychological services including professional readjustment counseling 
to eligible Veterans, Servicemembers, and their families; military 
sexual trauma counseling; and bereavement counseling for eligible 
family members who have experienced an Active-Duty Death.
    The Saginaw and Traverse City Vet Centers, like those throughout 
the country, also provide community outreach, education, and 
coordination of services with community agencies to link Veterans and 
Servicemembers with other VA and non-VA services. A core value of the 
Vet Center is to promote access to care by helping those who served and 
their families overcome barriers that may impede them from using those 
services. All Vet Centers have scheduled evening and/or weekend hours 
to help accommodate the schedules of those seeking services.

VISN 11 Telehealth Clinic Expansion in FY 2013

    In FY 2013, VISN 11's Telehealth program conducted 109,806 visits 
using telehealth modalities, reaching 12.4 percent of Veterans in VISN 
11 who use the VA system. The Aleda E. Lutz VAMC led VISN 11 in 
telehealth performance targets. In the past 12 months, this VAMC has 
achieved a 20 percent increase in virtual visits and 28 percent 
increase in the number of Veterans using telehealth programs.
    Recognizing the Aleda E. Lutz VAMC is not a tertiary healthcare 
site, VISN 11 is developing virtual capabilities to link Veterans with 
specialty care found in our tertiary facilities in Ann Arbor and 
Detroit, including care for substance abuse; and also provide pharmacy 
clinical video health services to a Veteran's home. Utilizing 
telehealth for follow-up care helps eliminate travel and ensures 
Veterans receive the appropriate follow-up consultation. The Aleda E. 
Lutz VAMC is also working with the National Telemental Health Center to 
provide mental health services for patients with chronic pain--an area 
of growing demand and concern.
    The Battle Creek VAMC expanded their healthcare reach by placing 
telehealth equipment at the rural Volunteers of America (VOA) site. 
Telehealth equipment was purchased for the VOA site in Lansing to 
provide telehealth services for homeless Veterans. Some of the services 
for homeless Veterans include, telemental health counseling, substance 
abuse treatment, and case management. Future services to be provided 
will be primary care basic visits, diagnostic visits, mental health 
visits, and mental health case management. We are in the planning 
stages for a project that will allow for small, county mental health 
offices to have telehealth equipment to connect with providers located 
within the Battle Creek VAMC.
    Obesity is a significant problem impacting the healthcare of many 
in the United States. VA has enthusiastically engaged in weight 
management programs, such as our MOVE! weight management program. We 
have and continue to expand these services by adding TeleMOVE! to our 
CBOCs. The goal of the TeleMOVE! Program is to assist with weight 
management in the comfort and convenience of the Veterans home through 
a home messaging device. Time spent with our registered dietitians 
assisting and motivating Veterans has proven to be an effective 
component--of a Veterans weight loss plan.

FY 2014 Expansion Goals

    As we learn about additional opportunities or tools related to 
telehealth we have been aggressive in investigating them for 
utilization within VA. We still have opportunities to expand mental 
health programs in such areas as OEF/OIF/OND case outreach, outpatient 
substance abuse programs, evidence-based therapies, the VA Caregiver 
Support Program, telehealth for the homeless Veteran, and the Veterans 
Justice Outreach. Aleda E. Lutz VAMC is participating in a VA national 
tele-spirometry project to provide spirometry testing to patients at 
the CBOCs. We know that addressing hearing aid deficiencies is a big 
need for Veterans. We have learned there are components of such care 
that we can provide virtually through tele-audiology. We will be 
expanding this program in four additional CBOCs in Michigan.

Homeless Veterans and the Veterans Justice Outreach Programs

    Homelessness is not just an urban issue - homeless Veterans are in 
rural areas too. We provide direct help daily through our homeless 
staff and programs such as HUD-VASH wherein HUD provides Housing Choice 
vouchers and VA provides case management services. We also recognize 
that it is important to create and maintain access points within 
Veterans Affairs Offices and/or local community partners where the 
homeless congregate. Our goal is to identify homeless Veterans and 
introduce them into the continuum of care we have available to serve 
them. We continue to combat homelessness proactively by working to 
identify Veterans who are incarcerated or at risk for incarceration and 
working with the court systems to intercede where possible. Working 
proactively before an incarcerated Veteran is released has been 
instrumental in avoiding Veterans instantly becoming homeless. We have 
Veterans Justice Outreach Coordinators located throughout the state and 
have strong relationships with seven Veterans Courts in Michigan. We 
have experience with utilizing telehealth to link our Veterans and the 
judges involved with their care and we look forward to expanding this 
capability where possible.

VISN 11 American Indian/Alaskan Native Veterans Overview

    The VA and Indian Health Service (IHS) Memorandum of Understanding 
was signed in 2010 to increase access and quality of care for American 
Indian and Alaskan Native Veterans across the Nation. VISN 11 has done 
extensive outreach to all tribes in Lower Michigan, particularly with 
the Little Traverse Bay Bands of Odawa, Grand Traverse Bay of Ottawa 
and Chippewa Indians, and the Pokagon Band of Potawatomi in Dowagiac, 
Michigan.
    Over the past 3 years, VHA personnel attended Pow Wows, American 
Indian health fairs, annual meetings with IHS, and VHA presentations at 
tribal chair meetings.
    In April 2014, Battle Creek VAMC entered into MOUs with the Pokagon 
Potawatomi and the Nottawasippi Huron Potawatomi to provide telemental 
health for tribal Veterans at the Tribal offices via telehealth 
technology through the Battle Creek VAMC. The MOUs provide for a part-
time VA Tribal Outreach Worker for each tribe location to assist in 
connecting tribal Veterans to VA's mental health providers. This new 
telemental health project currently has a small number of newly-
enrolled, younger American Indian Veterans utilizing their VA benefits 
for their healthcare needs. It is anticipated that 130 Tribal Veterans 
within the Nottawaseppi Huron and Pokagon Band of the Potawatomi Nation 
will benefit from this project to bring access to mental health 
services to them in a location that is easily accessible and acceptable 
for them.
    In addition, the Grand Traverse Bay Band of Ottawa and Chippewa 
Indians and VA are working on a Reimbursement Agreement, under which VA 
will reimburse the tribe for direct care services provided by the tribe 
to eligible American Indian Veterans. Aleda E. Lutz VAMC will be 
representing VHA at health fairs held during 2014 at the Little 
Traverse Bay Bands of Odawa Indians and Grand Traverse Bay Band of 
Ottawa and Chippewa Indians. In addition, the Aleda E. Lutz VAMC is 
beginning a new partnership collaboration with Little River Band of 
Ottawa Indians and will be attending the Veterans' Warrior Society 
meeting in August to expand outreach to tribal Veterans.

American Indian Outreach Tribal Veteran Representative (TVR) Training

    The Battle Creek VAMC and Aleda E. Lutz VAMC, along with VISN 12's 
Oscar G. Johnson VAMC, held the third annual Tribal Veteran 
Representative (TVR) Training. VISN 11 also conducted two TVR Trainings 
in 2013 for tribal members and another was held July 21-24, 2014, in 
Farwell, Michigan.
    TVR training in Michigan promotes the practice of having an 
American Indian TVR in Federally recognized tribes throughout Michigan. 
The representative assists Veterans in understanding how to access 
benefits while also allowing VA to develop positive relationships with 
American Indian tribes in Michigan. The value in tribal members 
participating in the training is that many tribal customs are shared 
during discussions. This enhances the healthcare team members' cultural 
understanding and appreciation of American Indian Veterans' 
contributions to our country.

Conclusion

    VHA, VISN 11, the Aleda E. Lutz VAMC, and the Battle Creek VAMC are 
committed to providing the high-quality care that our Veterans have 
earned and deserve. We appreciate the opportunity to appear before you 
today, and we appreciate the resources Congress provides VA to care for 
Veterans. We are prepared to answer questions you may have for us.

                                 

                             FOR THE RECORD

  Tribal Chairman, Grand Traverse Band Of Ottawa And Chippewa Indians

                     Written by Alvin V. Pedwaydon,

    My name is Alvin Pedwaydon and I am the Chairman of the Grand 
Traverse Band of Ottawa and Chippewa Indians (GTB or Grand Traverse 
Band). I am a Vietnam-era veteran and a resident of Northwest Michigan 
who has directly encountered healthcare issues, both as a provider in 
my capacity as Chairman of Grand Traverse Band, and as a recipient as a 
veteran and tribal member. Grand Traverse Band has 4,100 members or 
which 1,500 reside in rural Northwest Michigan. My testimony reflects 
both my position as Chairman of GTB and my individual position as a 
Vietnam-era veteran and resident of rural Northwest Michigan.
    Grand Traverse Band has a storied and turbulent history of military 
service against and for the United States. Based on our sovereign 
status as an Indian Nation, like other Indian Nations in the United 
States, we have fought against the United States and we have fought for 
the United States. The last hostile encounter between GTB and the 
United States was the war of 1812; and our resistance to the United 
States' attempted Indian removal of our ancestors to Kansas and 
Oklahoma in the 1830s and 40s. Our ancestors have nevertheless 
willingly and gratefully served with honor in the United States armed 
forces since the Civil War. Members of our Tribal Council, for example, 
have great-great grandparents who were participants in Company K, 
Michigan Ottawa Indian Sharpshooters, a total Ottawa Indian Company 
from our area that fought on the Union side in the Civil War. Our 
ancestors have also served proudly and honorably in World War I and II, 
Korea and Vietnam, Gulf (Operation Desert Storm) and the Iraq and 
Afghanistan wars. GTB also honors its members who participated in the 
``Siege of Wounded Knee'' in 1973 as warriors for Indian Country.
    It is this historical complex relationship between Indian Tribes 
and the United States that defines the scope of our healthcare problems 
as manifested in our healthcare delivery systems. The history of 
federal Indian law and the relationships of the Tribes to the United 
States is a quagmire of complexity that represents both the pain and 
promise of federal Indian law and our historical relationship with the 
United States. Clearly Indian Tribes want to maintain their sovereign 
status as indigenous inhabitants to this continent and we have fought 
ferociously over the years to maintain this sovereign status. The 
United States has recognized this sovereign status in the 
implementation of a complex federal statutory system of federal 
domestic services.
    In the area of healthcare we must content with the Indian Self-
Determination and Educational Assistant Act (ISDEA); the Indian 
Healthcare Improvement Act; and services offered to veterans under 
Veterans Administration (VA) delivery systems. The Indian Healthcare 
Improvement Act (IHCIA) achieved permanency status in the landmark 
legislation, the Patient Protection and Affordable Care Act (ACA), 
signed by President Obama in March of 2010. We applaud this permanency 
and recognition of tribal sovereign status in the ACA. The defining 
concept of the ISDEA and the IHCIA is self-determination for Indian 
Tribes. We administer a comprehensive and expensive healthcare delivery 
system for our tribal members in Northwest Michigan. Indeed, we are 
probably the second biggest healthcare payor and provider in Northwest 
Michigan. The defining characteristic of ISDEA and IHCIA is 
administration by the tribes under a well-defined self-governance 
concepts and processes that have had the opportunity to develop 
detailed and complex federal regulations governing healthcare delivery 
to tribal members. In a thumbnail, those regulations consist of 
approximately 1,000 pages of CFR regulations, or more appropriately, 
digital screen images, which the tribes have had the opportunity to 
implement and develop by negotiated rule-making.
    By any measure of modern bureaucracy, both the ISDEA and IHCIA have 
been a resounding success nationwide for Indian Country. We still argue 
with the Health and Human Services Department (HHSD) over the scope of 
the costs and associated indirect costs, but the Tribes have generally 
prevailed on the merits in requiring HHSD to fully fund indirect costs. 
We are now confronting and coordinating a MOU agreement with the VA to 
deliver reimbursement costs for eligible veterans who access our tribal 
healthcare system. This effectively melds two systems of healthcare 
delivery, and as expected, we have had problems in fully implementing 
all of the VA eligible activities into our existing Indian healthcare 
system.
    In particular, the VA system does not have statutory authority 
similar to the HHSD that permits an Indian tribe to negotiate a 638 
self-governance contract under ISDEA to ultimately culminate in a 
totally administered tribal program. We would suggest that such 
statutory authority would provide opportunities for Indian tribes and 
the VA to work out alternative delivery systems for rural-based Indian 
veterans. Presently, the VA uses an MOU agreement on the model of a 
``one size fits all'' regardless of the individual circumstances of the 
demographic picture of the service population. For example, it has been 
GTB's experience that it is cost-effective for us to bring dental and 
eye care services directly in-house at our healthcare clinic, but that 
it is not cost-effective to bring auditory services in-house. 
Therefore, our service population generally has quick turn-around time 
for dental and eye care services and delayed service for auditory 
benefits.
    In my own personal experience, because of the remoteness of our 
location and the necessity of my application to go through a 
centralized processing VA system, I had to wait eight months to receive 
my hearing aid. In my position as Tribal Chairman, a very public 
position, this was extremely frustrating and detrimental to me in 
effectively administering my office, which requires participation in 
public meetings. I would suggest that VA statutory authority to 
negotiate with a Tribe, beyond a simple MOU agreement for direct in-
house service, might be a solution for rural Native veterans who do not 
have access to a VA hospital but do have access to an Indian health 
clinic.
    We applaud the efforts of the VA to have a tribal liaison office 
and we would suggest that VA services follow the Indian Health Services 
to have native-specific care modalities, like the Indian Health Service 
and tribal clinics. Currently, the VA does not make any concessions in 
services to Native-based beliefs. Though the VA is subject to Indian 
preference hiring, the VA has not implemented an active Indian 
preference hiring system for our area. Finally, because of the last 
decade of war, we unfortunately have a whole generation of wounded 
warriors suffering from PTSD. This population should receive special 
attention by the VA and the focus for rural Native Americans should be 
on establishing pilot PTSD programs for rural Native Americans directly 
serviced by existing Indian healthcare clinics.
    I want to thank you for this opportunity to present these views of 
the Grand Traverse Band and my personal experience individually and to 
personally commend you for taking the time to address this important 
issue for rural Native American veterans and their healthcare.

                                 _______

             From: The Little River Band of Ottawa Indians

    Good Morning,
    I am Larry Romanelli, Ogema or Chief and the elected leader of the 
Little River Band of Ottawa Indians in Manistee Michigan.
    I am unable to attend in person due to conflicts in scheduling but 
want to offer my support for efforts of the House Veteran's Affairs 
Committee in looking at services to Native American's in rural areas.
    It is a well-known fact that Native Americans have the highest 
record of service per capita when compared to other ethnic groups in 
serving the United States and have since the war of 1812.
    A little known fact is that the U.S. Government used other Native 
Americans from other tribes besides the Navajo to secretly communicate 
during World War II. While Navajo Code Talkers are the most notable and 
deservedly respected, members of our own Tribe were documented as 
``Code Talkers'' including members of my own family who spoke in the 
Odawa or Ottawa language to keep the enemy from being able to 
understand the communications.
    It is a great thing that healthcare for veterans has made major 
improvements over the years however for many Native American veterans, 
access to such healthcare remains a roadblock. Again, Native American 
veterans represent the largest number of those rural vets.
    I thank the efforts of the House Veteran's Affairs Committee for 
taking the time and effort to address this issue. Migwetch (Thank you)


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