[Senate Hearing 113-512]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 113-512

                    IMPROVING FEDERAL HEALTH CARE IN
   RURAL AMERICA: DEVELOPING THE WORKFORCE AND BUILDING PARTNERSHIPS

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

                                HEARING

                               before the

                   SUBCOMMITTEE ON THE EFFICIENCY AND
      EFFECTIVENESS OF FEDERAL PROGRAMS AND THE FEDERAL WORKFORCE

                                 of the

                              COMMITTEE ON
                         HOMELAND SECURITY AND
                          GOVERNMENTAL AFFAIRS
                          UNITED STATES SENATE


                    ONE HUNDRED THIRTEENTH CONGRESS

                             FIRST SESSION

                               __________

                              MAY 23, 2013

                               __________

         Available via the World Wide Web: http://www.fdsys.gov

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                        and Governmental Affairs
                        
   
   
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                          Washington, DC 20402-0001                      


        COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS

                  THOMAS R. CARPER, Delaware Chairman
CARL LEVIN, Michigan                 TOM COBURN, Oklahoma
MARK L. PRYOR, Arkansas              JOHN McCAIN, Arizona
MARY L. LANDRIEU, Louisiana          RON JOHNSON, Wisconsin
CLAIRE McCASKILL, Missouri           ROB PORTMAN, Ohio
JON TESTER, Montana                  RAND PAUL, Kentucky
MARK BEGICH, Alaska                  MICHAEL B. ENZI, Wyoming
TAMMY BALDWIN, Wisconsin             KELLY AYOTTE, New Hampshire
HEIDI HEIKAMP, North Dakota

                   Richard J. Kessler, Staff Director
               John P. Kilvington, Deputy Staff Director
               Keith B. Ashdown, Minority Staff Director
                     Laura W. Kilbride, Chief Clerk
                     Lauren Corcoran, Hearing Clerk


 SUBCOMMITTEE ON THE EFFICIENCY AND EFFECTIVENESS OF FEDERAL PROGRAMS 
                       AND THE FEDERAL WORKFORCE

                     JON TESTER, Montana, Chairman
MARK L. PRYOR, Arkansas              ROB PORTMAN, Ohio
CLAIRE McCASKILL, Missouri           RON JOHNSON, Wisconsin
MARK BEGICH, Alaska                  RAND PAUL, Kentucky
TAMMY BALDWIN, Wisconsin             MICHAEL B. ENZI, Wyoming
HEIDI HEITKAMP, North Dakota

                 Tony McClain, Majority Staff Director
                 Brent Bombach, Minority Staff Director
                       Kelsey Stroud, Chief Clerk
                       
                       
                            C O N T E N T S

                                 ------                                
Opening statement:
                                                                   Page
    Senator Tester...............................................     1
    Senator Portman..............................................     2
    Senator Begich...............................................    14
    Senator Heitkamp.............................................    17

                               WITNESSES
                         Thursday, May 23, 2013

Robert A. Petzel, M.D., Under Secretary for Health, Veterans 
  Health Administration, U.S. Department of Veterans Affairs.....     4
Yvette Roubideaux, M.D., Acting Director, Indian Health Service, 
  U.S. Department of Health and Human Services...................     6
Tom Morris, Associate Administrator, Office of Rural Health 
  Policy, Health Resources and Services Administration, U.S. 
  Department of Health and Human Services........................     8
Matt Kuntz, Executive Director, National Alliance on Mental 
  Illness for Montana............................................    22
Ralph Ibson, National Policy Director, Wounded Warrior Project...    24

                     Alphabetical List of Witnesses

Ibson, Ralph:
    Testimony....................................................    24
    Prepared statement...........................................    74
Kuntz, Matt:
    Testimony....................................................    22
    Prepared statement...........................................    63
Morris, Tom:
    Testimony....................................................     8
    Prepared statement...........................................    57
Petzel, Robert A. M.D.:
    Testimony....................................................     4
    Prepared statement...........................................    31
Roubideaux, Yvette M.D.:
    Testimony....................................................     6
    Prepared statement...........................................    48

                                APPENDIX

Responses to post-hearing questions for the Record:
    Mr. Petzel...................................................    83
    Ms. Roubideaux...............................................   113
    Mr. Morris...................................................   122
    Mr. Kuntz....................................................   138

 
                     IMPROVING FEDERAL HEALTH CARE

  IN RURAL AMERICA: DEVELOPING THE WORKFORCE AND BUILDING PARTNERSHIPS

                              ----------                              


                         THURSDAY, MAY 23, 2013

                                 U.S. Senate,      
        Subcommittee on the Efficiency and Effectiveness of
                Federal Programs and the Federal Workforce,
                      of the Committee on Homeland Security
                                        and Governmental Affairs,  
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 10:05 a.m., in 
room SD-342, Dirksen Senate Office Building, Hon. Jon Tester, 
Chairman of the Subcommittee, presiding.
    Present: Senators Tester, Begich, Heitkamp, and Portman.

              OPENING STATEMENT OF SENATOR TESTER

    Senator Tester. We will call to order this hearing of the 
Subcommittee on the Efficiency and Effectiveness of Federal 
Programs and the Federal Workforce. This morning's hearing is 
titled, ``Improving Federal Health Care in Rural America: 
Developing the Workforce and Building Partnerships.'' I look 
forward to hearing from our witnesses about efforts made by the 
Federal health care workforce to address the needs of rural 
America, including veterans and Native Americans.
    Today we will discuss some of the challenges of this task, 
including efforts to recruit and retain a quality Federal 
health care workforce, and we will highlight opportunities for 
collaboration, cost sharing and exploring stronger partnerships 
between agencies and local providers.
    As a Montanan and someone who has worked very closely with 
veterans and the Native American population, I am aware of the 
challenges in rural and frontier areas of accessing quality 
health care in a timely manner. Addressing these challenges 
will certainly require a multifaceted approach. We need to 
invest in technologies like telemedicine and bring health care 
closer to home. We need to expand the number of mobile clinics 
and Vet Centers and improve transportation options for folks 
that are forced to travel significant distances to receive the 
health care that they need.
    But we also need to address chronic health care workforce 
shortages in rural communities in agencies like the Veterans 
Administration (VA) and the Indian Health Service (IHS). Far 
too often we have seen new facilities sit idle because we 
cannot recruit enough mental health professionals to a 
particular area, or we have seen veterans diverted for care 
because of nursing shortages at a particular facility.
    But this is not a VA-specific problem. It is a rural 
problem, and it is a national problem. We need government 
agencies to aggressively and effectively work together to make 
progress and to ensure they are working in collaboration and 
not in competition. This collaboration should not only be 
happening between Federal agencies; it should be happening at 
the State level, and it needs to be happening in more rural 
areas.
    In these communities the Federal health care workforce 
needs to leverage its limited resources to empower local 
partners to more effectively increase access to care. Just 
because a veteran lives in a place like Havre, Montana, does 
not make him or her less deserving of timely and quality health 
care.
    We have some great witnesses with us here today, and as we 
discuss these critical issues in more detail, I look forward to 
hearing from each of them.
    I will now turn it over to Ranking Member Senator Portman 
for his opening statement.

              OPENING STATEMENT OF SENATOR PORTMAN

    Senator Portman. Thank you, Mr. Chairman, and thank you for 
having the hearing today on an incredibly important issue in 
Montana, in Ohio, and around the country. It is an important 
topic, and I think the testimony we are going to get today is 
going to shed light on some of these issues facing rural health 
care in particular. Thanks to the witnesses for being here, 
this panel and the coming panel.
    One of the most important functions that our Federal 
Government must fulfill, of course, is the care of our 
veterans. We need, as we are going to into Memorial Day, to 
think about that. They are out there defending us, in essence, 
and their mission continues, when they get home. We have to be 
sure we are there with them. And there are acute health care 
problems right now facing over 6 million veterans in rural 
communities, including a lack of sufficient health care 
providers and the need to travel, as the Chairman said, 
significant distances to seek care in many cases.
    Like our urban veterans, our rural veterans returning from 
Iraq and Afghanistan are coping every day with both the visible 
and the invisible wounds of war. But, unfortunately for those 
in rural areas, help is not as readily available.
    I would like to discuss these topics in the context of 
traumatic brain injury because it is often referred to as the 
signature wound, unfortunately, of the wars in Iraq and 
Afghanistan. The Department of Defense (DOD) now estimates that 
over 266,000 servicemembers have suffered traumatic brain 
injuries (TBIs), from 2000 to 2012. At the same time, the 
Congressional Research Service (CRS), has estimated that over 
100,000 servicemembers who have served since 2000 suffer from 
post-traumatic stress (PTSD). So it is one thing to be able to 
get our rural veterans treatment for an orthopedic issue or 
even help maybe on a diabetes management program, but often it 
is another thing entirely to present the full scope of 
treatment needed for a veteran suffering from the effects of 
TBI or post-traumatic stress.
    I know our witnesses recognize the scope of the problem, 
and each of your departments has embarked on a number of 
initiatives to address those problems. I look forward to 
hearing more about that today.
    I will say I am concerned that we are making internal 
adjustments and small steps forward, whereas the size of the 
problem is bigger than that. It is daunting. And the longer we 
take to address it, the worse it is going to become.
    I think the treatments that we are now providing for our 
veterans are not as effective as they could be, and I think the 
pilot projects and assessments are important. But I think we 
have a bigger problem that we need to address, and that is what 
we will talk about today.
    Tragically, we are now losing, we are told, 22 veterans a 
day to suicide. Fundamental changes are needed to occur from 
the way VA interacts with our veterans to the model for 
providing care, and we will talk about that.
    When I am back home in Ohio, I regularly talk to our 
veterans about their interactions with the VA. Some are very 
positive. Some of the stories I hear from our rural veterans 
are likely similar to what the Chairman hears in Montana: long 
drives, even longer drives in Montana probably; expensive 
drives sometimes to get the kind of treatment that they need; 
uncoordinated appointments; varying customer service. When a 
TBI patient who may find it difficult to remember his or her 
appointments, may find it difficult to follow directions, or 
even interact with other people, has to drive a couple hours to 
an appointment, and when he shows up a little late after 
driving through a blizzard and has to reschedule his 
appointment for weeks later, we are not setting that person up 
for success. And, unfortunately, the stories that I have heard 
are not isolated, and I know, again, in Montana some of the 
same stories are out there.
    So we have to leverage the resources of our Nation for 
these men and women who have given so much to us. We have 
providers throughout our country who stand ready to support 
this population of over 6 million rural veterans if given the 
opportunity to do so. And connecting our rural veterans with 
the right treatment I think is something we ought to be focused 
on, and we will talk about that today.
    So, again, thanks to our witnesses. Mr. Chairman, I look 
forward to the testimony today and discussing these issues.
    Senator Tester. Well, thank you, Senator Portman. I would 
just like to say thank you for your opening statement, and as 
we kick off the first hearing on this Subcommittee, I want to 
say I look forward to working with you to help improve issues, 
whether it is health care or something else. This is a pretty 
broad-based Subcommittee.
    Senator Portman. Yes, likewise.
    Senator Tester. So I look forward to working with you to 
get some good things done.
    I would like to welcome our first panel of witnesses who 
have all spent years in public service working to increase 
access to health care for rural Americans, and they have all 
dealt extensively with the challenges of recruiting and 
retaining a quality health care workforce.
    First of all, I would like to introduce Dr. Robert Petzel. 
He is the Under Secretary of Health in the Department of 
Veterans Affairs. He has served in that capacity since February 
18, 2010. In this position, he oversees the health care needs 
of some 8 million veterans currently enrolled in the Veterans 
Health Administration (VHA), the Nation's largest integrated 
health care system. VHA employs over 272,000 staff members at 
more than 1,700 sites across this country. Last year, the VA 
treated 6 million patients during 80 million outpatient visits 
and 692,000 inpatient admissions.
    Welcome, Dr. Petzel. It is great to see you, and we look 
forward to your testimony and look forward to getting you back 
in Montana.
    Next we have Dr. Yvette Roubideaux, who is the Director of 
Indian Health Service, IHS, at the U.S. Department of Health 
and Human Services (HHS). She has served in that capacity since 
2009. IHS provides a comprehensive health service delivery 
system for approximately 2.2 million American Indians and 
Alaska Natives from 566 federally recognized tribes in some 35 
States, and they serve a critical role in my State of Montana.
    Dr. Roubideaux, it is good to see you again. We look 
forward to your testimony.
    And last, but certainly not least, we have Tom Morris, who 
is the Associate Administrator for the Office of Rural Health 
Policy (ORHP) in the Health Resources and Services 
Administration (HRSA), an agency within the U.S. Department of 
Health and Human Services. Tom's office serves as a critical 
research and policy resource on rural health issues, and it 
administers a number of critical grant programs that enhance 
the delivery of rural health care. Additionally, his office 
works very closely with local partners to increase access and 
to build capacity within those communities. Tom also happens to 
serve on the Veterans Rural Health Advisory Committee (VRHAC).
    Welcome, Tom. It is good to have you here.
    OK. We will start with Dr. Petzel. You will have 5 minutes 
for your oral testimony. Know that your full written testimony 
will be made a part of the record, so with that, Dr. Petzel, 
you may proceed.

  TESTIMONY OF ROBERT A. PETZEL, M.D.,\1\ UNDER SECRETARY FOR 
  HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 
                        VETERANS AFFAIRS

    Dr. Petzel. Chairman Tester, Ranking Member Portman, and 
Members of the Subcommittee, thank you for the opportunity to 
speak with you today about how VA recruits, retains, and 
deploys a quality health care workforce to ensure that veterans 
can access the health care that they have earned and deserve.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Petzel appears in the Appendix on 
page 31.
---------------------------------------------------------------------------
    VA is committed to providing veterans with quality, timely, 
and accessible health care as close to their home as possible. 
Veterans' mental health is a top priority for VA. As a part of 
President Barack Obama's Executive Order (EO) to improve access 
to mental health services for veterans, servicemembers, and 
military families, VA has made significant progress to increase 
its mental health workforce to meet the needs of veterans.
    As of May 14, 2013, VA has hired 1,367 new mental health 
clinical providers. In addition to that, we have hired 2,063 
mental health providers to fill existing vacancies, so over the 
last 10 months, VA has hired almost 4,000 additional mental 
health providers. And in addition to that, we have begun hiring 
a new group of people called peer specialists, and today 261 of 
them have been hired.
    We are aware of the challenges to recruit and retain a 
quality health care workforce and are implementing a number of 
creative recruitment strategies to ensure access to care for 
all veterans. These efforts to increase the awareness of 
employment opportunities including national advertisements 
through television commercials, public service announcements. 
To meet the mental health needs of veterans and their families, 
VA has also begun to hold facility-based mental health summits 
with the purpose of building and expanding coalitions with 
community providers, organizations in the communities, and 
Federal and State agencies.
    VA is dedicated to improving access and quality of care for 
rural veterans by developing innovative practices to support 
the unique needs of veterans residing in geographically remote 
areas.
    VA has used a number of programs, including Project Access 
Received Closer to Home (ARCH) and Patient-Centered Care, in 
order to provide eligible veterans coordinated and timely 
access to care through a network of non-VA medical providers 
who meet VA quality standards.
    VA will continue to look for and implement new ways to 
broaden access through innovative approaches to bringing care 
to veterans.
    Telehealth enhances health care, especially in rural and 
geographically remote areas, where it can be difficult to 
recruit health care professionals and where travel distances 
are excessive.
    VA is a national leader in telehealth-based care. In fiscal 
year (FY) 2012, VHA provided care to half a million patients 
through video clinical conferencing, store-forward technology, 
telehealth, and tele-home health. This number is set to rise to 
830,000 in 2013.
    Specialty Care Access Network Extensions for Community 
Health Outcomes (SCAN-ECHO), is one initiative that VHA is 
using to ensure the delivery of specialty care services to 
improve access to specialists. SCAN-ECHO leverages telehealth 
to allow health care specialists from a regional center to 
offer expert advice to providers in rural health care settings.
    Another initiative is MyHealtheVet. This offers veterans 
online access to the VA health care system, and it is designed 
to give them greater control over their health and wellness. 
Features of the system include the ability to communicate with 
providers, refill prescriptions, and to access their electronic 
medical record.
    VA optimizes the delivery of treatments by using 
technologies and tools such as mobile applications. These 
mobile applications can help veterans build resilience and 
manage their daily challenges. The award-winning PTSD Coach 
mobile app, co-developed with the Department of Defense, 
provides an opportunity to better understand and manage the 
symptoms associated with PTSD.
    Prolonged exposure (PE) therapy coach, is a mobile 
application for patients to use with their therapist during 
prolonged exposure therapy as a treatment companion.
    VA maintains partnerships and continuously seeks to foster 
relationships with government and nongovernment organizations 
to bring value to veterans and expand access to the care they 
have earned and deserve.
    VA has a strong history of collaborating with community 
mental health clinics, including federally qualified centers. 
These locally developed community partnerships provide mental 
health services to veterans in areas where direct access to VA 
health care is limited by either geography or workload.
    In response to President Barack Obama's Executive Order, 
VA, working closely with the Department of Health and Human 
Services, initiated 15 pilot projects to evaluate how these 
partnerships can help bring mental health services in areas 
that are experiencing difficulty in providing direct care. We 
are committed to building an accessible system that is 
responsive to the needs of America's veterans. VA continues to 
implement its rural workforce strategy to recruit locally and 
utilize the necessary resources, including collaboration, 
technology, and partnerships, to achieve these goals.
    I thank the Subcommittee for the opportunity to appear 
before you to discuss this important issue, and I am prepared 
to answer any questions you may have.
    Senator Tester. Thank you for your testimony, Dr. Petzel.
    And we will move to Dr. Roubideaux.

   TESTIMONY OF YVETTE ROUBIDEAUX, M.D.,\1\ ACTING DIRECTOR, 
  INDIAN HEALTH SERVICE, U.S. DEPARTMENT OF HEALTH AND HUMAN 
                            SERVICES

    Dr. Roubideaux. Thank you, Chairman Tester, Ranking Member 
Portman, and Members of the Subcommittee. My name is Dr. Yvette 
Roubideaux, and I am the Acting Director of the Indian Health 
Service, and I am pleased to provide testimony on our efforts 
to develop and support the Federal health care workforce.
---------------------------------------------------------------------------
    \1\ The prepared statement of Ms. Roubideaux appears in the 
Appendix on page 48.
---------------------------------------------------------------------------
    IHS's workforce plays a critical role in supporting the 
overall mission of the IHS as a rural health care system 
addressing a population with significant disparities in health 
and access to care.
    IHS shares similar challenges faced by rural communities 
across the Nation. Many of our IHS facilities are in rural and 
remote locations where recruitment and retention of employees, 
especially health care providers, present unique challenges.
    IHS vacancy rates for health professionals have actually 
improved over the past few years, but they still remain an 
issue. For example, dental vacancies were greater than 30 
percent, but an increased focus on recruitment and retention 
reduced those vacancies to approximately 10 percent. However, 
continued efforts to improve recruitment, retention, and 
support of our Federal workforce are critical.
    Over the past few years, IHS has implemented a number of 
reforms to change and improve the agency, and many of these 
efforts have contributed to better support and strengthen IHS's 
workforce since many of our reforms were based on input and 
recommendations from our employees and our stakeholders.
    IHS also supports programs such as the American Indians 
Into Medicine, American Indians Into Psychology, and the 
Quentin N. Burdick American Indians Into Nursing Programs which 
help develop students' interest in health professions and 
encourage them to return to their communities and work for IHS 
in the future.
    The IHS Health Professions Scholarship Program is a key 
strategy for the agency in developing the future American 
Indian/Alaska Native (AI/ANs) workforce.
    The IHS Loan Repayment Program is one of our most effective 
recruitment and retention tools for the recruitment of a 
variety of positions in our workforce.
    The IHS has worked to strengthen our recruitment and 
retention strategies through gathering input from our workforce 
and our stakeholders to better understand the needs of our 
workforce. And another important strategy to improve 
recruitment and retention is to improve the workplace 
environment at IHS to better support our workforce.
    IHS has made improvements in background checks, the hiring 
process, and credentialing and privileging of providers to 
ensure that we have a quality Federal workforce.
    IHS has also worked to make our salaries more competitive 
with the private sector, which is especially important for 
health professional improvement.
    IHS has leveraged many partnerships to help develop and 
support its Federal workforce with other Federal agencies, 
academic institutions, and tribal communities.
    Our partnership with the Health Resources and Services 
Administration has helped us recruit more health professionals 
to work in IHS through their National Health Service Corps 
Scholarship and Loan Repayment Programs.
    Our partnership with the VA has helped us improve 
coordination of care for American Indian and Alaska Native 
veterans through implementation of our 2010 Memorandum of 
Understanding (MOU) and our 2012 VA-IHS National Reimbursement 
Agreement. Those are helping our workforce improve access to 
quality health care for American Indian and Alaska Native 
veterans.
    Our partnerships with academic institutions are extremely 
important to our recruitment and retention efforts because of 
the link it provides to students and new graduates seeking 
places to serve.
    One of our most powerful recruitment and retention 
strategies is our partnership with our communities. As more of 
our Federal workforce feels at home and supported by those 
communities, the likelihood that they will become a long-term 
member of that community will increase.
    In summary, the Federal workforce is essential to the core 
mission of the Indian Health Service and its delivery of 
accessible and quality health care services to American Indian 
and Alaska Native communities. While there is much more to do, 
we appreciate the opportunity to testify at this hearing to 
further discuss opportunities for improvement.
    Mr. Chairman, this concludes my testimony. I am happy to 
answer questions.
    Senator Tester. Thank you, Dr. Roubideaux. We appreciate 
your testimony.
    We will go to Mr. Morris.

TESTIMONY OF TOM MORRIS,\1\ ASSOCIATE ADMINISTRATOR, OFFICE OF 
      RURAL HEALTH POLICY, HEALTH RESOURCES AND SERVICES 
  ADMINISTRATION, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Mr. Morris. Mr. Chairman, Ranking Member Portman, and 
Members of the Subcommittee, thank you for the opportunity to 
testify today on behalf of the Department of Health and Human 
Services, the Health Resources and Services Administration, 
about the Federal Office of Rural Health Policy.
----------------------------------------------------------------
    \1\ The prepared statement of Mr. Morris appears in the
    Appendix on page 57.
-----------------------------------------------------------------
    For 25 years, the office, which was created by Congress, 
has served as a focal point for rural health activities within 
HHS. We are charged with advising the Secretary on the impact 
of HHS policies, regulations, and programs on rural 
communities. This includes an ongoing focus on issues related 
to the training, recruitment, and retention of health care 
professionals in rural communities. We also administer several 
grant programs related to capacity building from community-
based pilot programs to State programs focused on improving the 
quality and financial performance of small rural hospitals. We 
welcome opportunities to discuss ways to help rural communities 
attract and retain needed health care providers. This is a 
priority for the office, for the Department, for HRSA, and for 
the Administration.
    There are nearly 50 million people living in rural areas. 
That represents about 16 percent of the population spread 
across 80 percent of the land mass of the United States. The 
rural health care system is heavily focused on primary care and 
chronic disease management, relies heavily on safety net 
providers like small rural hospitals, federally qualified 
health centers, and rural health clinics, as well as solo 
providers and small group practices.
    The Office of Rural Health Policy funds several initiatives 
that focus on building up that rural capacity. This ranges from 
our work with the 50 State Offices of Rural Health, which we 
provide grants to, as well as our work through the Rural 
Hospital Flexibility Grant Program and the Small Hospital 
Improvement Grant Program, which works to improve question and 
financial performance for small rural hospitals.
    HHS's investment in rural communities, though, goes far 
beyond the ORHP programs. For example, HRSA administers the 
National Service Corps, which offers a lifeline to rural 
communities. They support loan repayment and scholarships for 
health care providers, and almost half of those providers are 
in rural areas.
    HRSA training programs in primary care, behavioral health, 
dentistry, and nursing play a key role in training the next 
generation, and we are also heavily focused on investing in 
community-based residency training for physicians, whether that 
is through our teaching health center program in which 15 of 
the 22 grantees serve rural communities or through our work 
supporting the 23 rural training tracks across the country. Our 
studies indicate that 70 percent of the graduates of these 
rural training tracks stay in rural practice, and we are 
focused on increasing student interest in those programs and 
also working with communities to start new rural training 
tracks.
    Rural areas also benefit greatly from the HHS and State 
Conrad 30 J-1 visa waiver programs which place foreign-trained 
physicians in communities that need them the most. Our office 
also works with each of the States through the National Rural 
Recruitment and Retention Network, which placed 1,767 
clinicians in rural areas in the past year.
    Telehealth plays a key role in increasing the reach of the 
health care workforce. We have long supported grants to link 
urban specialists with rural communities in need, and yet we 
are seeing through our grant programs new and emerging 
technologies, such as E-emergency care, E-ICU, as well as tele-
home monitoring.
    Telehealth technology also plays a key role in extending 
the reach of the limited mental health workforce, particularly 
in rural areas where psychiatrists and psychologists are often 
scarce.
    We also currently are funding a three-State telehealth 
pilot that includes Montana and Alaska to link rural veterans 
to telehealth and health information exchange to enhance their 
care.
    At HRSA, we are also working within the range of Federal 
partners through the White House Rural Council to train the 
workers needed to operate and maintain these health information 
technology systems, whether we are talking about electronic 
health records, telemedicine, or health information exchange. 
We expect this to be a key job growth area in the coming years 
as these technologies continue to be deployed in health care.
    Thank you again for providing the opportunity to share 
HRSA's and the Office of Rural Health Policy's mission with you 
today and the efforts we have underway to focus on rural 
working challenges. I am pleased to respond to your questions.
    Senator Tester. Well, thank you, Mr. Morris, for your 
testimony.
    Around 10:30 there will be a vote called, and what we are 
going to do is stagger it out, so we are not going to adjourn. 
We will just stagger out, and then when Rob comes back, he can 
do it; otherwise, if we both have to be gone, we will kick it 
over to either Senator Begich or Senator Heitkamp. All right? 
Thank you. Could we put 7 minutes on the clock, please.
    Dr. Petzel, the VA has made a commitment to hire 1,600 new 
mental health care professionals and I think about 300 support 
staff. You correct me if my numbers are wrong. Where are we at 
on those hirings both for the clinicians and for the support 
staff?
    Dr. Petzel. The numbers are correct, Mr. Chairman. In terms 
of the clinical providers, we have two ways that we look at 
this. One is the actual positions that were identified that 
have been filled, and as of the 14th of May, we have filled 
about 1,356 of that 1,600 clinical mental health providers.
    Another way that we look at this is that every quarter we 
are able to assess the number of clinical providers providing 
direct care that we actually have on board. So we went back and 
looked at what we had on board in May 2012 when we began this 
effort, and now I have the most recent data from March 2013, 
and that indicates that we have an additional 1,556 people on 
board providing mental health care than we did back in May. So 
we believe that we are well on our way to meeting that goal. 
And we have basically hired almost all within a few short of 
the administrative personnel that were part of the 1,900.
    Senator Tester. What are the totals, the 1,556 additional 
from what they were, what are your total number of mental 
health----
    Dr. Petzel. I believe that the total mental health that we 
have on board providing direct patient care is about 18,600. So 
that would include psychiatrists, psychologists, mental health 
nurse, clinical mental health specialist nurses, psychiatric 
social workers, the master's trained counselors and master's 
trained family therapists.
    Senator Tester. As you well know, in Montana--and I think 
this could be said for all of rural/frontier America--we have 
struggled to overcome shortages in mental health professionals 
for years. So unless we are getting a healthy portion of new 
hires, which you have indicated we have, we are unable to make 
up ground with the impacts of PTSD and TBI and the issues of 
the unseen--we will just call them the ``unseen injuries'' 
coming back from war.
    You talked about where we are today. Moving into the future 
are there long-term efforts for assessment? And if so, are 
there long-term efforts for recruitment that go with those 
assessments as we move forward to help bring in more young 
folks into the eye of rural America?
    Dr. Petzel. Well, first of all, Mr. Chairman, there are 
ongoing recruitment efforts, and these will continue because we 
have continuing developing vacancies. I am pleased to say that 
the vacancy rate has actually dropped from slightly over 13 
percent amongst clinical mental health providers to a little 
bit below 11 percent, and that is a significant number when you 
are talking about almost 20,000 mental health professionals.
    We are assessing and will assess actually continuously 
whether or not we are meeting the access needs and the access 
standards that we have described. And if we discover that we 
are not able to do that because we do not have the personnel 
available, we will continue to add to the mental health 
workforce.
    But I think that it would be useful if I could take 1 
minute----
    Senator Tester. Sure.
    Dr. Petzel [continuing]. To describe the other things that 
we are doing that are relatively new efforts, the most 
important of which is the use of telehealth and telemental 
health to deal with the shortage of psychiatrists, which we and 
everybody has difficulty recruiting into rural areas. I know 
you are very familiar with that.
    We have set up regional centers of psychiatry that 
communicate with our community-based outpatient clinics and 
provide consultation and therapy by a telemental health from 
remote areas such as Spokane, Washington, where we are having 
difficulty recruiting psychiatrists, into one of these centers 
in an urban area where we are able to recruit psychiatrists. We 
have no difficulty recruiting psychiatrists to New York or 
Minneapolis or Houston or San Francisco. And these regional 
centers are proving to be very effective.
    The telemental health therapy is very well received by 
veterans. They like the idea that they do not have to travel 
great distances. They are not befuddled and frustrated by a 45-
minute drive, even across town in an urban area. And that is 
going to be a major effort in the next 2 years to help us 
provide the psychiatrist services in remote areas.
    Senator Tester. Well, thank you, and thank you for your 
work.
    Dr. Roubideaux, I want to talk about some of the challenges 
that may be unique to Indian country as you seek to recruit and 
to train and to retain quality health care folks. Time and 
again we hear about administrators who must bring in folks from 
outside the area as primary care docs, as specialists, as 
nurses. These are highly skilled but high-paying jobs, 
especially in Indian country.
    I had a group of eighth graders in my office yesterday from 
down at Crow, and one of the questions they asked me was: How 
do we get more doctors and nurses from Crow country in the Crow 
hospital? These are eighth graders, these are 12-, 13-year-old 
kids that understand what is going on.
    Can you talk about the challenges of recruiting in Indian 
country?
    Dr. Roubideaux. Well, our challenges are significant, and 
we certainly would like to recruit more individuals from our 
tribal communities to work in our facilities and to be health 
professionals. The challenges are of social and economic issues 
in the communities, schools, and things like that, and then 
they have to travel far away for their education, and sometimes 
they do not come back.
    So our health professions programs help us recruit and 
retain American Indians and Alaska Natives to work in our 
system.
    The Indian preference law helps us a lot because about, I 
would say, approximately three-quarters of our employees right 
now are American Indian/Alaska Native. The place where we have 
a difficulty recruiting American Indians and Alaska Natives is 
in some of the health professions that require training at a 
distance from the Indian reservation and so recruiting them 
back to work is a challenge, but our loan repayment programs 
really help with that.
    Senator Tester. OK. I am going to kick it over to Senator 
Portman.
    Senator Portman. [Presiding.] Thank you, Mr. Chairman,
    Dr. Petzel, I wanted to ask a little about using non-VA 
providers for rural veterans. I know that you have capacity 
issues--we just talked about that--despite hiring over 1,500 
new positions in the last year or so on the mental health side.
    Beyond capacity issues, where sometimes you do have to use 
a private or a fee service, what is the threshold? How far do 
you require a veteran to go to seek services? How do you define 
``geographic inaccessibility? '' Which I know is one of your 
criteria.
    Dr. Petzel. Thank you, Senator Portman. We have definitions 
of rurality that involve both distances--60 miles would be an 
example--and time--60 minutes--to services. But those are not 
really used in any great sense when we are evaluating whether 
somebody should be ``fee'd'' as we call it, or cared for in the 
community. Much of it has to do with the convenience of them 
being--or inconvenience of them being able to travel. If you 
have an 81-year-old gentleman who lives even 60 miles from a 
medical center, it is a burden to ask that individual to travel 
for a routine clinic appointment. And even for some individuals 
who are much closer but have to travel across an urban area, 
that can be a daunting task for somebody who is 81 years old.
    So we try to do two things. No. 1, an option is fee'ing 
that care, that is, providing the care in the local community, 
and we have two pilots that are running right now looking at 
that option. But another one that we are doing using in 
increasing numbers is what we call tele-home health, a video 
camera in the patient's home, instruments to monitor the 
patient's weight, electrocardiogram (EKG), blood pressure, and 
regular contacts with their primary care provider at their 
clinic or their medical center. It has proven very effective in 
taking care of patients with multiple chronic diseases, and in 
not--providing them with the opportunity to not travel to a 
clinic. We reduce emergency room visits by 40 percent in 
patients where we have done this and studied it. We have 
reduced clinic visits by 38 percent. And we have reduced 
hospitalizations by almost a third by providing this care in 
the home with constant communication.
    Senator Portman. For mental health treatment, is that as 
effective as it is for other kinds of treatment? We talked 
earlier about the fact that we have so many of our veterans 
with PTSD or TBI. So maybe for somebody who is, again, 
recovering from an orthopedic procedure or somebody who is on 
dialysis, maybe you can work through some of these issues using 
some of the telemedicine you are talking about. But how about 
for mental health? Is it more of a challenge?
    Dr. Petzel. Telemental health is remarkably well accepted. 
It began actually in the VA on an Indian reservation, on the 
Rosebud Indian Reservation in South Dakota, almost 10 years ago 
now, as a study, treating PTSD by telemental health, by a 
researcher at the University of Colorado. It proved to be very 
successful and was really the impetus for spreading telemental 
health around the country. The acceptance rate by this and the 
satisfaction rate by this is over 90 percent for the patients 
that use it.
    I will tell you an anecdote very quickly. A man lives in 
New Jersey, has to travel 45 minutes to get to his psychiatrist 
who works in one of the medical centers there, and he described 
live on the video camera the experience, 45 minutes through 
traffic, he is frustrated, he is angry, and he is not the same 
kind of person that he normally is by the time he shows up for 
that appointment.
    When he does a telemental health therapy episode, he is 
sitting in his own home. He is comfortable. He has not driven 
across urban traffic. He is relaxed, and he is an entirely 
different person. And the therapy session has a dramatically 
better effect.
    It works. It works very well, and we are going to be 
exploiting this to the maximum over the next several years.
    Senator Portman. Do you think that using non-VA providers, 
particularly for mental health and TBI, is something that you 
are doing adequately? I notice in the data that you provided 
the Committee that about 2 percent of VA mental health patients 
are seen by non-VA providers every year. DOD, as you know, has 
a policy with TRICARE that is a little different where they use 
non-DOD mental health providers for TRICARE recipients on a 
more regular basis. What is your policy? And, again, is only 
allowing 2 percent of our veterans to seek treatment by the 
many providers outside of the VA system appropriate?
    Dr. Petzel. Well, I think that should be expanded, Senator. 
I have no doubt that 2 percent is not as much as is needed and 
as could be, and we are, in fact, doing it. The new non-VA care 
arrangement called PC3 is going to have in it a mental health 
component, and we will be expanding that.
    The issues are making sure that those non-VA providers are 
facile with PTSD, particularly traumatic brain injury and 
depression and the things that we see as a result of combat. 
But we are expanding and we intend to expand our use of non-VA 
providers.
    The pilot that we are doing with the federally qualified 
health centers I think is an example of that. We have committed 
to piloting in 15 locations how this works when we have a 
contract with a federally qualified health care provider. Those 
are up and running, 15 of them. Five more are going to be added 
relatively shortly, and I have no doubt that the network is 
going to expand.
    Senator Portman. I notice the data you provided us goes up 
to 2010, and it does show an increase from 2007 to 2009, 
actually a decrease in 2010 from 2009. But are you suggesting 
that your data for 2011 and 2012 and 2013 would show an 
increase?
    Dr. Petzel. Certainly, Senator, 2012 will show an increase. 
I do not know about 2011 looks like, but 2012 should certainly 
show an increase.
    Senator Portman. On telehealth or telemedicine, you have 
given us some important information in your testimony and then 
in an answer to my earlier question, and I appreciate that. By 
your own count, you are seeing over a million mental health 
patients a year now. Clearly a lot more of our veterans need 
this service. If we assume these patients are dispersed like 
the veteran population as a whole, that is at least 300,000 
mental health patients will be in rural areas or highly rural 
areas already seeking treatment and likely just as many who 
need treatment who are not seeking it. Through these health 
programs that are telemedicine, telemental health programs, how 
many patients have been connected?
    Dr. Petzel. That is a very good question. Presently it is 
about 83,000 patients that we have delivered telemental health 
services to.
    Senator Portman. And how many of those 83,000 have to go to 
one of your community-based outpatient clinics (CBOC) in order 
to get that service?
    Dr. Petzel. Almost all of them, Senator, would be going to 
some location where we have telemental health services. There 
have been a few, but not many, that we have--as the gentleman I 
described in New Jersey, where we have set this up in their 
home. That is with the shrinking of----
    Senator Portman. That is a pilot program that you think 
should be expanded?
    Dr. Petzel. It is not a pilot. It is just in its infancy, 
and yes, it will be expanded. I think that we have 
demonstrated--these patients have demonstrated the fact that 
they are better therapy sessions, better therapy patients when 
we see them in the context of their home.
    Senator Portman. Anything we can do to help you expand that 
capacity into the home?
    Dr. Petzel. I think we have the resources, Senator. We have 
the money to buy the equipment. The price has shrunk 
dramatically, and it is basically just a Web cam now, a high-
quality Web cam on a computer. The thing that we need help with 
around the country, all of us do, is psychiatrists. There just 
are not enough psychiatrists in this country to meet the 
country's mental health needs, much less meet the needs of 
rural veterans, people that are being treated by the Indian 
Health Service. That is probably one of our largest issues.
    Senator Portman. Thank you, Dr. Petzel. I appreciate your 
testimony. Senator Begich.

              OPENING STATEMENT OF SENATOR BEGICH

    Senator Begich. [Presiding.] Thank you very much. And, Dr. 
Petzel, thank you very much for your work and your times to 
Alaska and other work your agency has done, especially around--
we call it the ``Heroes Card,'' but the work you have been 
doing with Indian Health Services and delivering health care 
services to rural veterans, especially in roadless areas in 
Alaska where it is very difficult, as you know, to get access.
    I want to ask you a general question, but first I again 
want to commend you for moving forward. I know our tribes have 
been very motivated, and hopefully--I have given them the task, 
after a period of time, to be working with us on any issues 
that may come up to make sure we continue that process so that 
a veteran, no matter where they live in rural Alaska, will have 
access to health care and not worry about having to fly all the 
way to Anchorage or Seattle, depending on the service they 
need.
    Can you just give me a quick update on how that is working 
and how you feel the success of that is?
    Dr. Petzel. Thank you, Senator Begich. I want to just 
mention that I had dinner last night with Katherine Gottlieb 
from the Southcentral, and I mentioned we were having the 
hearing, and she said to send her regards.
    Senator Begich. Very good. Thank you.
    Dr. Petzel. We have had great success, I think, in working 
with Southcentral and the other tribes in Alaska. The contract 
that we have for sharing services with Southcentral has been 
very effective in providing specialty services. We also have 
some instances where in more remote areas veteran patients are 
being seen in tribal facilities, obviating the need to travel 
back to either Fairbanks or to Anchorage.
    Then the second issue, the number of people that are having 
to travel out of Alaska down to Seattle or to Portland for 
services has shrunk dramatically, and I would say that with 
very few exceptions we are going to eliminate that need in the 
not too distant future. I mean, there are some quaternary 
things such as bone marrow transplants, et cetera, which 
Seattle is the obvious place to go.
    Senator Begich. Right, sure.
    Dr. Petzel. But, otherwise, our goal is to not have 
veterans in Alaska traveling out of Alaska in order to receive 
care. I think we are making progress, sir.
    Senator Begich. Fantastic. Let me ask you on the mental 
health, because, since I have been here, that has been an 
issue, and I appreciate I think the regulatory change you made 
to eliminate copays on mental health providers on mental health 
services. Alaska has been--and you know this, and so it is kind 
of repeating the obvious--that we have been on the forefront of 
telehealth and many different avenues from health care to 
mental health to delivery of just about everything you can 
imagine through telehealth.
    If, let us say, I am an Alaskan who needs services through 
telemedicine, and my doctor is in Idaho, does that doctor that 
I am doing telemedicine have to be licensed in Alaska?
    Dr. Petzel. The short answer is no.
    Senator Begich. OK.
    Dr. Petzel. First of all, in the VA, as in I think every 
Federal health care entity, you need to have a license in a 
State, but you do not have to have a license in the State in 
which you are practicing. So the licensure issue is really not 
a problem. What you need--the problem, if it arises, is not the 
credentialing, which is what licensing is about.
    Senator Begich. Right.
    Dr. Petzel. It is the privileging. You need to have that 
individual have the right kind of privileges in the right 
organization. So if a doctor in Boise was doing specialty care 
for somebody at the Anchorage facility, they would have to be 
privileged at both Anchorage and at Boise.
    We are working to try and smooth out this process of 
privileging.
    Senator Begich. Good.
    Dr. Petzel. Credentialing is not an issue. It is----
    Senator Begich. Thank you for kind of splitting the two 
issues. I knew there was an issue here, and it is on the 
privileging situation.
    Dr. Petzel. Correct.
    Senator Begich. Is there anything legislatively we need to 
do. I know we did some stuff with DOD on their end, on active, 
that Senator Kelly Ayotte and I did in an authorization bill a 
couple of years ago to fix that problem. There were a few more 
issues they had, but to make sure no matter where an active 
military member would go, they could get their mental health 
services delivered from whatever doctor they had at any time. 
Is there anything legislatively we need to do?
    Dr. Petzel. Senator Begich, I do not know.
    Senator Begich. OK.
    Dr. Petzel. The privileging issue is something that has to 
do with the regulating bodies in medical care, the Joint 
Commission. So the Joint Commission requires that an individual 
be privileged at the point where they are delivering the care. 
There is no law, there is not even a Federal regulation that 
has anything to do with privileging. It is basically a 
requirement that the Joint Commission has, and we have been 
working with them to try and find ways to make it easier to 
have people privileged at various places. But right now 
privileged is the right of the medical center or the clinic 
that is delivering the care.
    Senator Begich. OK. Very good. Let me again say thank you 
for all the work that you guys have done in regards to getting 
what I called the ``Heroes Card,'' but really delivery for 
health care for veterans no matter where they live, the 
services they have earned and deserve. So thank you for that.
    Dr. Petzel. I would like to also just comment on the fact 
that working with the IHS and tribes in Alaska has just been 
wonderful. That has been a very good example of Federal 
collaboration. Thank you.
    Senator Begich. They are a great group up there.
    Let me ask you, Dr. Roubideaux, if I can--again, Dr. 
Petzel, thank you very much for that.
    As you know, we have a significant problem--and, again, I 
want to echo what Dr. Petzel said. I think our Indian Health 
Services tribes are doing fantastic work in the delivery of 
health care. I would argue that we have the best, if not, the 
top in the country when it comes to delivery in the most harsh 
climates, conditions, and situations. So I agree that we have 
some incredible and very innovative approaches that we are 
making headway in.
    But one of the issues--and you have heard me talk about 
this before, and that is this consistent problem of staffing 
packages and how do you make sure that you have a vacancy rate 
of 30 percent in some of your categories, as you described. But 
the bigger issue is we have, as you know, a hospital in Barrow, 
one being developed in Kenai, Nome is completed, Matsu, a 
beautiful facility, the whole top floor is empty because they 
do not have a staffing package. They cannot deliver the 
services that the Federal Government contracted with them to 
do.
    You got about $53 million last year in the CR nationwide. 
Just the one in Fairbanks TCC will take $8 million of that.
    How are we going to solve this? Because, it is one thing to 
have a clinic in an urban area, but to get someone hired in a 
rural area like in Alaska, you cannot do it the day they are 
open. It does not make any sense.
    How are we going to solve this? Because this is honestly 
unacceptable. We have invested lots of money in these 
facilities, and then we do not staff them. What is the answer 
here? Because these are in rural areas.
    Dr. Roubideaux. Well, the answer is for us to work together 
on the appropriations that will help us get the staffing 
packages, and I am pleased to report that the President's 
budget for 2014 in terms of staffing packages for new and 
replacement facilities, including joint venture facilities and 
Federal facilities in Alaska and in Oklahoma, helps us catch up 
to the amounts that we need to catch up. It has been a 
difficult budget climate over the past few years, but 
fortunately through our colleagues and through our working with 
the tribes, our proposal for $77 million in new staffing really 
helps us catch up.
    Senator Begich. Is that enough?
    Dr. Roubideaux. That is enough to catch up with the need 
for the facilities that are planned to be open in 2014. And so 
right now we are doing our 2015 budget formulation and trying 
to estimate which ones will be open then as well.
    Senator Begich. OK. Let me ask one last question, and then 
I have to go vote. This one, I will use the Matsu facility. 
They have a top floor that is available. They are going to fill 
it up. VA has a clinic down the street that is at capacity. It 
does not have full service, but it is a clinic. Why don't we 
just take the clinic that the VA has, take the space that is 
beautiful space, put it in there and have a collaborative 
effort? It is all Federal money.
    Dr. Roubideaux. Well, the great thing about our----
    Senator Begich. Is that a good idea?
    Dr. Roubideaux. Because the VA-IHS MOU allows us to do that 
through sharing of facilities and staff, we have started to do 
that, and we hope to do more.
    Senator Begich. VA, good idea?
    Dr. Petzel. Absolutely. We would be delighted if that kind 
of arrangement worked for both parties.
    Senator Begich. Fantastic. We want to work with you 
specifically on that project, so I think that is a huge 
opportunity to create a great model.
    Thank you. I have to go vote.
    Senator Tester. [Presiding.] Yes, you do. Senator Heitkamp.

             OPENING STATEMENT OF SENATOR HEITKAMP

    Senator Heitkamp. Thank you, Mr. Chairman, and thanks to 
all the Members of the panel. Lest you think that this is an 
unimportant issue to North Dakota, I want to point out that the 
two Senators whose names were invoked in the testimony were 
Senator Conrad and Senator Burdick, both from North Dakota and 
both deeply concerned over a long period of time about the 
issue of rural health delivery. Whether it is veterans, whether 
it is our Native Americans, or whether it is just mom and dad 
on the farm, this is a critical issue for us, and it is a 
critical infrastructure issue for the development and the 
continued viability of rural America.
    And so I thank the Chairman for bringing this very 
important issue to the forefront, and I have obviously more 
questions than what I have time for, and so I would ask for an 
opportunity to submit some additional questions going forward.
    But I want to first make a point. We have heard every bit 
of your testimony across the board, talking about telemedicine, 
talking about the need to do things a little differently, 
expand your capacity by using the technology. Are you so 
convinced that the technology is available in Indian country or 
in rural America? The kinds of things that you think you can do 
in Washington, DC, do you really believe you can do in Hoople, 
North Dakota? Is there the infrastructure backbone, the amount 
of technology? And have you looked at those issues going 
forward when you are promoting telemedicine as a solution?
    Dr. Petzel. Senator, I will take a crack at that first. Ten 
years ago, the technology was clunky. It required special 
telephone lines that were often difficult to get into in terms 
of remote areas. But that whole technology landscape is 
changing dramatically.
    No. 1 is that we can now use a high-resolution Web camera 
to provide the same kind of fidelity of image, et cetera, that 
we----
    Senator Heitkamp. I do not mean to interrupt, but is that 
true in every remote location in the United States?
    Dr. Petzel. Well, we can put that technology anyplace, and 
we can then use the Internet in order to----
    Senator Heitkamp. What happens if the Internet is 
intermittent and dial-up?
    Dr. Petzel. If it is dial-up, it works. We have not run 
into those kinds of difficulties really any place. We have been 
on Rosebud. We have been providing services of this nature on 
Pine Ridge. We are going to be providing those services in 
Devils Lake in North Dakota. And every place we have used it, 
it has been, No. 1, reliable but I think more importantly it is 
very well accepted by the patients. When they see that as an 
alternative to driving 100 miles to Fargo, they will take it in 
a minute. And they like it, and they get good care with it.
    So, yes, I am convinced that this is going to be the wave 
of the future.
    Senator Heitkamp. Mr. Morris, I would like to hear your 
response to that, because you are beyond--I mean, your umbrella 
is a little broader.
    Mr. Morris. Yes, ma'am. I think there are some challenges 
in terms of broadband access, which I think is what you are 
trying to get at, is there enough capacity to use the full 
extent of the technology that I agree with Dr. Petzel works 
very well. And we can get back to you for the record with 
some--I know there has been some analysis of where there are 
some broadband gaps.
    The Federal Communications Commission (FCC) has done some 
revisions to its universal service program for rural health 
care that we think is going to be a key tool in sort of that 
last mile and expanded capacity for those areas, and that was 
just announced I think within the last couple months.
    In addition to that, some of the investments in the 
Recovery Act through both the Department of Commerce and the 
Department of Agriculture helped close some of that gap, but 
there are areas still that are not accessible.
    Senator Heitkamp. I do not think there is any doubt there 
is still a digital divide in this country, and that is my 
point. My point is we cannot offer a solution to the remoteness 
in rural health care and say we are going to solve it with 
telemedicine, and then not have the highway that is going to 
take you there. And so I will pledge this. I am chairing on the 
Ag Committee the Rural Development Subcommittee, and this is an 
area that goes beyond telemedicine, but this is obviously an 
absolute critical component of rural development in my opinion.
    I have a question for Dr. Roubideaux as well. Obviously 
Senator Begich and the work that has been done in Alaska is 
very intriguing to us in North Dakota. We think we have remote 
locations. We think that we have a great deal of difficulty. 
And I would tell you that where you hear a lot of praise from 
him in terms of Indian Health Service, that is not what I hear 
in my State. What I hear is intermittent services. I hear about 
clinics shutting down because they do not have the capacity and 
do not have the staff to even open up on a Friday. That 
overflow goes to other hospitals.
    And so I am very concerned about the long-term commitment 
and appreciation that you have about the concern that Native 
Americans in my State have about the quality of their health 
care.
    Dr. Roubideaux. I want to reassure you that we are 
absolutely committed to providing health care services to the 
best of our ability to the American Indians and Alaska Natives 
throughout the country, including in different areas. And you 
are absolutely right. There are differences among areas. It 
tends to track around the difference between the proportion of 
more direct service programs versus more tribally managed 
programs. And there are flexibilities around tribal management 
that are really helping Alaska do some really innovative 
things. But we still have the Federal trust responsibility and 
our commitment to the direct service programs in North Dakota 
and throughout the regions in the country. And so we are still 
working very hard to try to get these same types of 
improvements in those programs.
    Senator Heitkamp. And not to prolong it, but I will tell 
you this: That there are concerns about squashing innovation, 
especially in the mental health area, within the Indian Health 
Service because it does not fit with what people may see as 
traditional models. And I would like to have a longer 
conversation with you about that going into the future. But we 
need to be innovative in Indian country in order to provide 
these services. We need to continue to develop the workforce 
and the technical expertise of anyone who wants to offer their 
services, but particularly the programs that we have at the 
University of North Dakota (UND) to train Indian doctors and 
Indian nurses.
    And if I can just indulge just one additional question on 
Heroes, I am very interested in looking at modeling the Heroes 
Health Card program that Senator Begich has been able to get a 
pilot on. I am very interested in modeling that in North 
Dakota, and particularly as it relates to Native American 
veterans. I think anyone who understands Indian country knows 
that very many Native Americans in terms of a percentage of 
their population serve in really double, triple, quadruple 
numbers in the armed services. When they come home, they have 
access to Indian Health, they have access to Veterans, but 
neither one seems to work for them.
    And so we do not want people who have chemotherapy who are 
entitled to veterans services to have to get on a bus and drive 
10 hours and literally wait in Fargo another 8 hours while the 
other patients on the bus get their services. As somebody who 
understands chemotherapy, that is not a healthy thing to do to 
people.
    And so we really believe that North Dakota would be a great 
additional site, Dr. Petzel, for modeling a Heroes Health Card 
in the Lower 48.
    Dr. Petzel. We would be delighted to talk with you about 
that.
    Senator Heitkamp. Terrific.
    Dr. Petzel. And I would just make a comment. In North 
Dakota and South Dakota, which is where I used to work, 50 
percent of the Native American adult males are veterans. That 
is a huge number.
    Senator Heitkamp. Yes.
    Senator Tester. Thank you, Senator.
    I have a question for Tom Morris. Tom, you are 
Administrator of the Office of Rural Health Policy, and you are 
a member of the Veterans Rural Health Advisory Committee. You 
have an informed perspective on a lot of the issues we have 
talked about today. Could you tell me what the biggest 
challenges to greater collaboration between agencies like the 
VA and HHS might be?
    Mr. Morris. Well, we have had a good partnership with the 
VA, and their Office of Rural Health I think was created in 
2007, and they reached out to us very early on to sort of learn 
the lessons we learned over the last 25 years about what it is 
like to sort of be a voice for rural within a large 
organization. And that collaboration has continued, as you 
mentioned. I am on the VA Rural Advisory Committee. And I think 
it has taken a little time for us to understand the unique 
challenges that the VA has and how that intersection takes 
place between the VA providers and private providers. But, I 
think the fact remains that so often veterans who are returning 
from the previous two wars especially are predominantly rural, 
and they are coming back to their towns, and they are seeing 
care both from their local providers and then they may also be 
going to the VA for some more specialized care.
    And so the challenge but also I think the opportunity is 
how we can both, the private sector and the VA, dually care for 
those patients, and part of it involves making sure that, as 
you share patient information or you do telehealth, you meet 
the privacy and security challenges of the VA's firewall. But I 
think there is progress being made there through an initiative 
they have around Blue Button, which is a form of health 
information exchange.
    We have a veterans pilot program right now--and one of the 
grantees is in your State of Montana, and also Alaska and 
Virginia--in which we are putting money in to put telehealth 
equipment into hospitals and clinics, and then reaching out to 
the VA so that, for instance, a veteran might be able to get 
their PTSD treatment from a VA provider without having to leave 
their home community, even if there is not a CBOC or a veterans 
clinic in that location. And so that program is really still in 
its infancy. We are recompeting it right now to award another 3 
years of grants. And our hope is that that can serve as a pilot 
for ways that the private providers that care for veterans can 
also reach out to the VA in their regions and dually care for 
those patients as effectively as possible.
    And then we are in conversations with the VA Office of 
Rural Health about looking at a number of pilot sites really to 
focus on this whole notion of health information exchange so 
that as the veteran sees care in both places, the patient 
information, the medical record, goes back and forth between 
both groups.
    Senator Tester. Very good. I would be remiss if I did not 
ask this question that Senator Begich alluded to, because I 
have Dr. Roubideaux here and Dr. Petzel here, and it is the 
collaboration between the VA and the IHS. I would expect you 
both, since you are sitting side by side, to say it is working 
great. But what are the challenges that you faced with the 
collaboration that you have done together? That is the first 
question to each of you.
    And the second question is: Do you have all the policy 
flexibility you need to be able to do collaboration? In many 
cases you are serving the same group of people. So if you could 
talk about what the challenges have been and then talk about 
if, in fact, from a policy standpoint if you have the 
flexibility you need. Whoever wants to go first, go ahead.
    Dr. Roubideaux. Well, I think that we really appreciate our 
partnership with the VA and their willingness to try to dig in 
and deal with some of the challenges we face. We are two 
different systems with two different authorities, and sometimes 
we have to work through those issues.
    There is also the enormous need and the distances that 
really challenge us as we work together, but I have been 
requiring my area directors and my Chief Executive Officers 
(CEOs) to work with the VA over the past 2 years and meet with 
them, and that is actually going really well. So we are 
starting to have the conversations we need to have to work 
through some of the challenging issues. So that relates to the 
policy issues, and I think the reimbursement agreement was a 
great opportunity for us to understand each other's authorities 
and understand some of the innovative ways that we could 
collaborate and innovative things that we could do. And so I 
really appreciate our partnership with the VA because they are 
willing to dig at some of the hardest challenges we are facing.
    Senator Tester. From your perspective, Dr. Petzel?
    Dr. Petzel. I would say that in terms of Washington, and 
here the collaboration is excellent, the attitude, the desire 
to make this work for both of us, the desire particularly from 
our perspective to serve veterans wherever they might be is 
unparalleled.
    The issue for me is generally how this is executed locally, 
and on both sides. I am not saying it is either the VA or the 
IHS or the tribes. But it works better in some areas than it 
does in others. Alaska I think is an example of where it works 
wonderfully. We have sharing agreements with every tribal 
organization in Alaska. We are going to have reimbursement 
pilots in almost all of the State.
    In other parts of the country, we have difficulty with our 
people getting together with the IHS people, and I think that 
my responsibility is to be sure that the attitude that we 
evince in Washington is transmitted down to the level where the 
work is being done.
    But I would also agree with Dr. Roubideaux. It is, as I 
would look at it in the main, working very well. We have a 
number of places around the country where we do sharing. We 
have clinics located from the VA's perspective on tribal 
grounds. The reimbursement agreement I think was a huge step 
forward, ten pilots piloting that reimbursement agreement to 
work out the kinks in terms of charges and how bills are paid 
and patients move back and forth.
    There is always room for improvement, Mr. Chairman, and 
that is in my mind at the local level where we need to be sure 
that people are doing everything they can do to develop these 
cooperative relationships in places like Devils Lake, in places 
like the Crow Reservation, in the Billings clinic, et cetera.
    Senator Tester. Right. OK. Thank you all very much.
    Did you have any further questions, Senator Heitkamp?
    [No response.]
    Senator Tester. OK. I just wanted to thank you all for your 
testimony and thank you for the question-and-answer session we 
have had. This record is going to be open for 15 days, so if 
there are additional questions--and I know there will be 
because I will have some myself, and I am sure the others will, 
too--or additional comments that you want to be put in the 
record, you certainly can do it over the next 15 days. Thank 
you all for your service, and thanks for being here this 
morning.
    Now we will go to the second panel, so, Matt Kuntz and 
Ralph Ibson, if you would come up, and we will get the name 
tags changed.
    I would like to welcome our second panel of witnesses who 
both have worked tirelessly over the years to advocate on 
behalf of policies that improve health outcomes and increase 
access to care for more folks.
    We have, first of all, Matt Kuntz. I have known Matt for a 
while now. He is from the great State of Montana and represents 
the best of Montana. Born and raised in Helena, Matt graduated 
from West Point, served with distinction as an Army infantry 
officer. Matt's advocacy on behalf of our veterans, which is 
spurred by personal loss, has been recognized by President 
Obama. Currently he practices law and serves as executive 
director of the National Alliance on Mental Illness for 
Montana. Matt took on this role to support, educate, and 
advocate for all Montanans suffering from serious mental 
illness and their families. He has done a tremendous job in 
that capacity, and I am proud of his work and the work of the 
National Alliance on Mental Illness. Welcome, Matt.
    Next we have Ralph Ibson. Ralph is the national policy 
director of the Wounded Warrior Project (WWP). In that 
capacity, he heads up research and policy development on 
health, benefits, and economic empowerment issues for the 
Wounded Warrior Project. He formerly served as general counsel 
at the Department of Veterans Affairs and is also a veteran of 
the United States Army.
    Thank you for your service, and welcome, Ralph.
    Each of you will have 5 minutes for oral testimony. Know 
that your entire written testimony will be made a part of the 
record. So we will start with you, Matt, with your oral 
testimony.

   TESTIMONY OF MATT KUNTZ,\1\ EXECUTIVE DIRECTOR, NATIONAL 
             ALLIANCE ON MENTAL ILLNESS FOR MONTANA

    Mr. Kuntz. Thank you, sir. Good morning, Chairman Tester, 
Ranking Member Portman, and Members of the Committee. I am 
really honored to be here to testify. As you mentioned, I came 
into the National Alliance on Mental Illness (NAMI) line of 
work the hard way, like most of us do, but I am really honored 
to try to help out as many people as possible, especially our 
rural vets.
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    \1\ The prepared statement of Mr. Kuntz appears in the Appendix on 
page 63.
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    I would like to start out by just saying what the view from 
Montana is. As you know, it is a very big State with 147,000 
square miles, just over 1 million people, with roughly six 
people per square mile. We have one of the Nation's highest per 
capita rates of military service, and we are home to over 
108,000 veterans, which is about 16.2 percent of the 
population. Our Indian Health Services needs, we have 12 tribes 
and 7 reservations with over 66,000 Montanans of Native 
American heritage.
    The scarcity of mental health professionals in Montana is 
pretty hard to comprehend, and it really is a major difficulty 
for our families. But the best way to describe it is we have 
one psychiatrist between Billings and Bismarck, North Dakota. 
That is a stretch of about 400 miles on the interstate, which 
is roughly the distance between Boston and D.C. One 
psychiatrist to cover all that area. There are fill-ins by 
psychiatric nurses and telepsychiatry, but one warm body.
    And I think the other thing that needs to be mentioned 
because it underlies everything in Montana is the oil 
development in the Bakken, and our eastern Montana and western 
North Dakota is overtaxed with pretty much all infrastructure 
issues, but especially mental health. And it is taking what was 
a crisis and turning it into something really terrifying.
    So I just wanted to give some quick realities of what 
happens in Montana, especially with our vets, to show 
interlinked all of these different agencies are. For instance, 
if there is a veteran in Darby, Montana, who goes into crisis, 
he would probably be moved 16 miles to Hamilton to stay at 
Western Montana's private inpatient crisis center. After being 
there for a day or two, he will then be transported to Helena 
where the VA's inpatient unit is--that is 100 miles--and then 
will eventually return to his home community where he will be 
treated either by the VA through telepsychiatry or by the 
private health contractor. And that is just how it looks from 
us.
    Some of the things that I think that are really good that 
are happening in Montana is that the contracting system with 
the private providers is absolutely essential. The psychiatric 
nursing program at Montana State is really helping us fill the 
needs, and telepsychiatry has hit almost a critical mass in 
Montana, especially with the Centers for Medicare and Medicaid 
Service (CMS) grant for $7.7 million for Montana and Wyoming.
    Peer services is developing well, and I guess one of the 
things that I would really like to see more is a residency 
program. I think that we all talk about how bad we need 
psychiatrists, but the fact is every State that needs 
psychiatrists also needs a psychiatric residency program. And 
if they are able to do some of these things, if they are able 
to provide the services through telemedicine, maybe there is a 
way to structure those residency programs a little bit more 
flexibly as well.
    Also, the loan repayment programs, our Nation really relies 
on our inpatient psychiatrists, and how they should be taken 
care of in loan repayment is a little bit different than 
outpatient psychiatrists.
    Thank you, Senator Tester, and I am willing to answer any 
questions.
    Senator Tester. Thank you, Matt. I appreciate your 
testimony.
    Next we have Ralph Ibson.

TESTIMONY OF RALPH IBSON,\1\ NATIONAL POLICY DIRECTOR, WOUNDED 
                        WARRIOR PROJECT

    Mr. Ibson. Chairman Tester, thank you for inviting Wounded 
Warrior Project to testify this morning. With our mission of 
honoring and empowering those wounded in Iraq and Afghanistan, 
the mental health of our returning veterans is among our very 
highest priorities, and I am honored to be here with Matt.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Ibson appears in the Appendix on 
page 74.
---------------------------------------------------------------------------
    With our focus we see that, despite extensive Federal 
efforts there remain wide gaps in meeting the mental health 
needs of this generation of warriors. Let me highlight one 
critical concern.
    Many who served in Iraq and Afghanistan remain reluctant to 
receive mental health care. Research indicates that half of 
those who need care are not getting it, and a high percentage 
of those who elect to pursue care drop out prematurely. Much 
more progress is needed to reverse these trends, in our view.
    Many factors play a role in that process, but in some 
cases, it also appears to be a function of family issues. And 
while current law, law that you helped enact, Mr. Chairman 
directs VA to provide needed mental health services to 
immediate family members of the Operation Enduring Freedom and 
Operation Iraqi Freedom (OEF/OIF) veterans, VA has not 
implemented that provision.
    To your focus this morning, Mr. Chairman, nowhere are the 
gaps in meeting warriors' mental health needs wider than in 
rural America. VA policy says in essence, and as discussed 
earlier, that VA facilities must be able to provide veterans 
needed mental health care, and if they cannot because of lack 
of onsite staff or geographical inaccessibility, other options 
must be used, including telehealth or contract arrangements.
    But even veterans who live in remote areas often encounter 
local VA reluctance or even resistance to authorizing 
community-based care. With limited exceptions, we see only 
modest VA use of contract arrangements to overcome access gaps. 
And as indicated, with 55 percent of U.S. counties, all rural, 
having no practicing mental health clinicians and situations as 
Matt described in Montana, VA's policy of providing contract 
care is hardly a comprehensive answer. And with the drawdown of 
forces in Afghanistan, the access challenge will only grow.
    We do see promise in programs mentioned this morning. VA's 
telemental health capability has seen exponential growth, and 
we certainly see room for VA to greatly expand use of 
telemental health to engage more warriors and are pleased that 
Dr. Petzel agrees, as reflected in his testimony.
    A second important programmatic effort was sparked by the 
directive in the President's Executive Order of last August, 
that VA hire and train 800 veterans to serve as peer-to-peer 
counselors. We see that as a model for winning warriors' trust 
in entering into mental health treatment and staying in 
treatment. And we also see it as having potential in rural 
areas. Our one concern is that the initiative is not really 
targeted at supporting OEF/OIF veterans, where the need is 
greatest, in our view. That, Senators, as you know, also 
incorporate a peer-to-peer model, and we see that as a key 
aspect of the success of that program and are pleased, again, 
at Dr. Petzel's acknowledgment that this is a program that 
needs to expand.
    Finally, let me suggest that many OEF/OIF warriors with 
PTSD and other mental health conditions are also struggling to 
readjust to a new normal, to uncertainties about finances, 
career, education, employment. And no single VA program 
necessarily addresses that full range of issues that many young 
warriors face. Few, if any, VA programs are embedded in a 
veteran's community, and yet VA and community each has a 
distinct role to play. For some veterans, as we see it, 
community reintegration may take a community-wide effort, and 
we see a role here for VA. But as yet we see no real 
centralized effort to harness such partnerships.
    With limited exceptions, VA mental health programs are 
generally not focused or integrated with the adjacent 
community, and while VA has broad authority to enter into 
partnership with community providers and Congress just last 
year in the National Defense Authorization Act (NDAA) strongly 
encouraged that, we do not see much happening on that front.
    Finally, we believe VA should work with communities in 
providing needed mental health services to wounded warriors. 
This should include providing training to clinicians on 
military culture and the combat experience. Simply having more 
providers or access to providers who do not really understand 
the experience veterans have been through or PTSD is not itself 
a real answer.
    We look forward to working with the Subcommittee on the 
important issues discussed this morning, and thank you for 
consideration of our views. I am happy to answer questions.
    Senator Tester. Well, thank you, Ralph. Thank you both for 
your testimony. I appreciate it very much.
    I am going to start with you, Ralph, on what you just last 
said, because I think it is an issue that I have heard from the 
veterans themselves, and that is the training of the 
clinicians, making sure that when a veteran who has some issues 
goes and sees a clinician, that they actually have an 
understanding of what got that person to the point where they 
are.
    How do we best do this? It seems to me that there are 
several steps involved, and, by the way, you correct me if I am 
wrong. First you have to build the partnership, and then you 
have to make sure the folks who are dealing with the veterans 
understand what the veteran has been through. How is the best 
way to move forward with that from a VA perspective? Because I 
think you are spot on, quite frankly.
    Mr. Ibson. Well, Mr. Chairman, I think you have really put 
your finger on an important point or emphasized an important 
point, and that is that the treatment process has to begin with 
developing a relationship of trust, and I think essential to 
that is that the veteran perceive that the provider understands 
his or her problems, understands where he or she has been. And, 
the VA has done a heroic job of training its clinicians on 
evidence-based therapies. I do not purport to be an educator 
or, to have insight on the best way of training, but I do not 
see the equivalent focus on helping ensure that those providers 
really understand veterans. And I do see that even as VA has 
expanded and has filled many of those vacancies, hiring 1,300-
plus, when veterans encounter a clinician who they perceive 
does not understand them, they leave.
    Senator Tester. Yes, I agree with that, and that is the 
worst possible outcome, quite frankly, as far as care goes.
    Matt, despite significant investments that have been made 
to address the complex wounds of war, we continue to see--and 
you deal with this firsthand--high rates of depression, 
divorce, domestic abuse, an unacceptably high number of 
servicemembers, as has already been pointed out today, commit 
suicide every day. It is overwhelming and at times it is 
difficult to tell whether we are actually making progress, 
making a significant impact on what is going on out there.
    We need to ensure that the VA is able to identify and treat 
these folks with their issues in a meaningful way, and we need 
to ensure that they are appropriately staffed in a rural area 
like Montana. You talked about Billings and Bismarck, 400 miles 
away. We have a training staff, but sometimes there is no staff 
to train in certain areas because there are not mental health 
professionals there.
    As an advocate you have been personally involved with this 
epidemic. You have seen the investments that have been made. 
You talked about telemedicine. Are there other things out there 
that are working besides telemedicine? And is telemedicine 
working well?
    Mr. Kuntz. Sir, I think telemedicine is working well. It is 
a great, wonderful thing, and the Tribal Veterans Rep program 
was one of the first ones that brought it to Montana, and it is 
valuable. There is no question. I think that one of the other 
things that I thought was really good was, as you know well, 
the VA really struggled to staff its inpatient facility in 
Helena, and it just sat open, and they could not run it due to 
lack of psychiatrists. And I think that the way that they were 
able to change their staffing structure to use it with one 
inpatient psychiatrist, one outpatient, and a couple of nurse 
practitioners, like that willingness to adapt to what actually 
happens on the ground in Montana, we do not have three 
inpatient psychiatrists to run a facility like that. And the VA 
learned. It took them awhile.
    But one of the other things I think is--like the peer 
support is critical and important, and it also provides much 
needed jobs for veterans that struggle with these kind of 
issues. But the retention of the counselors I think in some 
ways is a bigger issue than actually whether or not they have 
served. I know many veterans that I talk to just say it is a 
matter of kind of changing bodies in front of them. And if they 
open up their soul and describe their combat needs, describe 
all of their issues going on with them, and then the person is 
gone, I mean, I talked to one vet that works across the street, 
and he had three counselors in a year. I think that while we 
need to focus on getting the perfect, right training and 
everything----
    Senator Tester. Sure, yes. multifaceted. So what is the 
issue on retention? Why are they leaving? Is it salary? Quality 
of life? Are they burning out, getting out of the business? Why 
are they leaving? Why are we seeing turnover?
    Mr. Kuntz. It is really hard to tell, sir. I think it is 
different for every one of them. But what shocks me is I guess 
how in the box and how constrained they are, I mean, and the 
limits of what they are given to work with. I do think that 
they are pretty heavily worked. Hopefully they will be working 
with peer specialists, but also like they do not even give them 
business cards sometimes, no voicemail for some of these 
counselors. And how do you----
    Senator Tester. Right. I got you.
    Ralph, do you want to add anything to that as far as what 
is working and what is not working?
    Mr. Ibson. Well, I have seen that same telemental health 
demonstration that Dr. Petzel alluded to, and I would agree 
with his assessment, and I would agree as well with Matt's 
perspective on the retention issue, which I think is not 
limited to counselors. We attempted about a year and a half ago 
to survey VA mental health clinicians, across the country and 
while I would not want to suggest it was a scientific survey, 
but it was disturbing to see results that suggested serious 
morale problems at many facilities.
    Now, this reflected a period of understaffing, and so I 
acknowledge that as well.
    Senator Tester. Right.
    Mr. Ibson. But many spoke of the system as top-down, as 
failing to appreciate the importance of allowing clinicians to 
build that trust relationship, and of imposing performance 
requirements that were highly focused on evidence-based 
exposure therapies, which, while having solid evidence base, 
were not appealing to the veterans. Many of the veterans could 
not handle dealing on a weekly basis with re-exposure to the 
trauma they had experienced, and yet that was the directive 
from on high.
    VA has done a survey of its own mental health staff last 
September on clinician attitudes. I think it would be helpful 
to see the results of that survey. It would be helpful to 
understand the factors that drive the 10-percent vacancy data 
that Dr. Petzel cited. I think a system that honored its 
clinicians from those peer-to-peer counselors on up would be a 
system that would be a more successful one.
    Senator Tester. I am going to ask you guys a question that 
I was going to ask Dr. Petzel, but I did not want to keep him 
here all day. But I think you guys can answer it in maybe a 
better way than he could because you are driving the bus at the 
other end of the experience here.
    Licensed professional mental health counselors, marriage 
and family therapists, they make up about 40 percent of the 
overall mental health independent practice workforce. In the 
VA, they make up less than 1 percent. Is there a reason for 
that? Are they less desirable as counselors? Or is there 
something out there I am missing?
    Mr. Kuntz. Sir, there may be a reason for that, but I will 
just say flat out it is not a valid one.
    Senator Tester. OK.
    Mr. Kuntz. We need them.
    Senator Tester. OK. Ralph, do you want to add anything to 
that?
    Mr. Ibson. I would not disagree with that perspective.
    Senator Tester. OK. Good. I want to talk about the gaps 
that you talked about a little bit, Ralph, in your testimony. 
There are some real inhibiting things in our society about 
people who go in for mental health treatment. There is a stigma 
attached to it. There can be employment problems afterwards, 
not because they have issues with mental health, but it is 
because the employer might not want them to begin with.
    What can we do to minimize the stigma, so these folks are 
more likely to go in and get help when they need it? Because it 
is curable. We know it is curable. It can be fixed. Or is there 
anything we can do about it?
    Mr. Ibson. Well, I do think there has been a probably 20-
year or longer effort to address stigma. I think organizations 
like NAMI have played an important part in that. But there is 
evidence that suggests that veterans themselves, warriors of 
this generation, still are distrustful of mental health care. 
It is not solely a stigma issue. And I think the peer-to-peer 
counselors can play an enormously important part in belying 
those views and drawing warriors into treatment and helping 
sustain them in treatment.
    I agree with, again, Matt's point that we have to honor 
those warrior employees, make them feel they are an important 
part of the team and make their working conditions appropriate. 
But I do think the infrastructure and the policies are in place 
to close those gaps.
    Senator Tester. OK. Matt, do you have anything to add to 
that?
    Mr. Kuntz. Sir, I have, I guess, two things. One is I think 
we need to take the magic out of what this is through research. 
I mean, a really big problem with the lack of understanding. 
And we do not understand the brain well enough, and especially 
these diagnostic patterns. With the Diagnostic and Statistical 
Manual (DSMs) changing and everything, the best clinicians 
really struggle to identify what a person has and, I mean, I 
think because we do not have valid scientific instruments to 
measure whether or not people have these conditions, they are 
measured by behavioral health surveys, it just leads to a level 
of distrust, and people do not have a way of saying, OK, my 
neuro circuitry is disrupted, so I get help for this.
    Senator Tester. I understand.
    Mr. Kuntz. Anything that we could do to improve that.
    The other thing, I think, is we have a lot of different 
anti-stigma efforts, but they do not really highlight people 
that had PTSD and depression in the past. We do not read 
about--or we do not see the anti-stigma things that talk about 
Winston Churchill's depression, that talk about Abraham 
Lincoln's depression. Some of the greatest Americans struggled 
with these conditions, and why don't we bring them up? So I 
would love to see a little bit more of that.
    Senator Tester. OK, good. I want to talk about 
partnerships, particularly between the VA and the Wounded 
Warrior Project, and there may be partnerships between NAMI and 
the VA that I am unaware of, or maybe there are some 
opportunities for partnerships that we could make them aware 
of.
    I have been aware of and, quite frankly, been out on some 
programs like Healing Waters in Montana, and you mentioned a 
project, Project Odyssey, in your testimony, which is maybe 
classified in the peer-to-peer program, or maybe it is 
separate----
    Mr. Ibson. Yes, sir, it has a strong element of peer-to-
peer support.
    Senator Tester. Yes. If you guys could shed light on 
programs like that, their effectiveness, and how we might be 
able to expand on other programs that could--there are programs 
out there working with animals, horses in particular, dogs, and 
just kind of talk about opportunities out there to collaborate 
on peer activities related to the outdoors to relieve stress.
    Mr. Ibson. Well, if I could followup, Mr. Chairman, Project 
Odyssey is one of 18 different programs our organization 
operates. It is a program that takes warriors out in retreat-
like settings. It might be to Montana for an outdoor activity 
or mountains in Vermont, wherever. But it takes them out in 
groups that include a trained therapist and focuses on building 
peer-to-peer relationships to confront in some cases for the 
first time their post-traumatic stress disorder or other 
combat-related mental health conditions. It has been very 
successful in helping veterans confront those issues and get 
into treatment, to overcome the stigma and barriers. And it is 
a program that we have run for a number of years and ran in 
collaboration with VA Vet Center program, and to our 
disappointment, VA pulled out of it in about 2010. The 
suggestion was they lacked the authority or felt they lacked 
the authority to continue.
    Since then, Congress last year enacted legislation making 
it crystal clear that authority exists, and we had hoped that 
would lead to reinstitution of that partnership. That has not 
happened yet.
    Senator Tester. Matt, do you have anything to add?
    Mr. Kuntz. Yes, sir. My favorite program for this--I am 
totally biased because I was involved in helping start it. My 
sister, Dr. Janna Sherrill, and a veteran from Missoula, Jesse 
Scollin, started it up. It is called X Sports 4 Vets in 
Missoula. What it is, they take--it was based on taking 
veterans river boarding--I believe it was a 6-week program--and 
it engages them in an extremely high adrenalin activity, and 
then it was tied in with counseling afterwards, and the level 
of success in what I saw from that program was just 
astonishing. And the veteran participation, they not only 
joined it and they got involved in it, but they took it over 
themselves and run it. It really is amazing, and it is done in 
partnership with the Missoula Vet Center, and I know it is a 
model that could be expanded to other sports and stuff. But the 
neat thing about this in comparison to some of the other ones 
is it is not a retreat. It is kind of--it takes them in their 
community in a sport or something that they can do afterwards 
and gets them involved with a group of men and women that they 
eventually form bonds and friendships with, and it also 
introduces them to civilians like the rafting guide that helped 
start it.
    That was the first civilian that some of these vets have 
bonded with, and they respected him because he takes a little 
tiny raft on the Lochsa River, and it really is remarkable. But 
I have not seen any efforts from the top to try to expand that 
beyond Montana.
    Senator Tester. Last question, and this is going to be a 
quick one for you, Ralph. Who funds your Project Odyssey now?
    Mr. Ibson. We get donations, typically small donations 
around the country.
    Senator Tester. All private----
    Mr. Ibson. Yes, it is all private sector, no Federal.
    Senator Tester. All right.
    Mr. Ibson. We do not take Federal money.
    Senator Tester. All right. Thank you, guys, very much. I 
want to thank you again for your testimony this morning. I very 
much appreciate it. I think overall this hearing has 
underscored some of the important progress that I think we have 
made, but it also highlighted some additional efforts that we 
need to make. And I look forward to working with Ranking Member 
Portman and our witnesses here today on these issues to make 
sure we address the health care needs of our citizens and they 
are met regardless of where they live. And in that regard, I 
just want to thank you two fellows for being here this morning. 
Again, I appreciate your work.
    This hearing record will remain open for 15 days for any 
additional comments or questions that may be submitted to the 
record. And with that, the hearing is adjourned.

    [Whereupon, at 11:45 a.m., the Subcommittee was adjourned.]
    
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