UNITED STATES SENATE
COMMITTEE ON VETERANS’ AFFAIRS

OVERSIGHT HEARING ON
“VA HEALTH CARE IN RURAL AREAS”

TESTIMONY OF
DAN WINKELMAN
VICE PRESIDENT FOR ADMINISTRATION & GENERAL COUNSEL OF
THE YUKON-KUSKOKWIM HEALTH CORPORATION
BETHEL, ALASKA

JUNE 16, 2010

 Good morning, Mr. Chairman and members of the Committee:

I. INTRODUCTION
 The Yukon-Kuskokwim Health Corporation (YKHC) has been contracting with the Indian Health Service (IHS) to provide health care services for over twenty years.  Today in remote Western Alaska we provide comprehensive health care to 28,000 people, largely Yupik Eskimo across a roadless area the size of Oregon, where the average per capita income is $15,000.  Our unemployment rate in our villages is over 20%.  Gas in our main hub city of Bethel is $5.34 per gallon, and in our villages it is $6-8 per gallon, the same price we pay for a gallon of milk.   Many homes in our region are without piped water and sewer and over 6,000 homes in rural Alaska do not have safe drinking water.  When considering the high energy, food and personnel costs against an IHS appropriation that does not allow for mandatory medical inflation costs, providing health care for our 58 tribes is a daily and extraordinary challenge.

 Especially, when considering the enormous health disparities our region faces.  For example, Alaska Natives’ leading cause of death is cancer.  The Alaska Native cancer mortality rate is approximately 26% higher than U.S. Caucasians.  While cancer mortality for the rest of Americans is decreasing, it is increasing dramatically for Alaska Natives.  Particularly disturbing is our region’s high suicide rates.  Our age-adjusted suicide rate for 15-19 year olds is 17 times the national average.

 This is the environment where many Alaska Native veterans were born and raised and then return to after serving our great Country.  For Alaska Native/American Indian veterans, who serve at the highest per capita rate of any U.S. race, to lack access upon their return from duty to culturally appropriate and quality health care services by the Veterans Administration (VA) is a shame. 

 In Alaska, highly rural veterans must break through several barriers in order to receive care.  There are almost no VA facilities in rural Alaska.  The existing IHS and tribal facilities, managed by tribal health organizations like YKHC, are underfunded according to the IHS by approximately 50%.  Lastly, the Alaska VA Health System’s, “Rural Health Pilot Project” is not statewide and needs improvement. 

II.  RECOMMENDATIONS
 I have three recommendations.

1. Establish a VA Clinical Encounter Rate for IHS and Tribal Facilities.
 Instead of building new VA health care infrastructure in rural Alaska, the VA should increase its collaboration with tribal health organizations and use the existing Alaska Tribal Health System infrastructure for rural veterans care.
 The Alaska Tribal Health System provides quality services and our facilities are nationally accredited by the Joint Commission.  However, due to the IHS’s chronic underfunding, it is important that the VA reimburse tribal facilities that provide care to veterans and their families.
 A VA clinical encounter rate is needed.  The creation of a VA clinical encounter rate to reimburse IHS and tribally operated facilities should include multiple types of services, such as primary, emergent, behavioral health and telemedicine.  Non-native veterans should also be able to access care through this encounter rate since tribal facilities are often the only provider available in rural Alaska.

2. In the Alternative of Establishing a VA Clinical Encounter Rate for IHS and   Tribal Facilities, the Committee Should Review, Redesign with Tribal Input and Redeploy Statewide the Alaska Rural Health Pilot Project.
 
 I ask the Committee to review, redesign with tribal input and redeploy statewide the Alaska Rural Health Pilot Project.  The Committee should review how the Pilot was developed, the extent of tribal participation in the Pilot’s design prior to deployment, its scope of services offered versus actual need, whether the Pilot was effectively communicated to highly rural veterans and tribal partners, its billing process and the number of veterans who “opted-in” and utilized services.

 The Pilot could have been designed and deployed more effectively, instead it seemed to be an after-thought.  For example, although care is rendered in tribal facilities, veterans must first self-enroll with a different agency, the VA.  This process is called “opt-in”.  Why are veterans required to fill out additional paperwork in order to participate in the Pilot when they should already be deemed eligible by virtue of their service record?  Our veterans deserve better than having to research how they and their family members can “opt-in” for health care services.  After all, our veterans “opted-in” when they signed over their lives to serve our Country. 

 Another opportunity for improvement is to do away with limiting the scope of health care services a veteran may utilize within a six-month period.  I do not know anyone who can plan ahead of time when to have their illnesses take place, let alone in a six-month time period.  To require our highly rural veterans to jump through additional barriers to receive limited health care services is bureaucratic and ineffective to improve access to care. 

3. Monitor Appropriations to the Office of Rural Health to Ensure All Rural                
 and Highly Rural Veterans are Adequately Served.

 According to a June 3, 2009 letter by Senator Murkowski to VA Secretary Shinseki, Alaska’s highly rural veterans were initially going to receive zero dollars of last year’s historic $215 million appropriation to the Office of Rural Health (ORH).  Senator Murkowski wrote:
I first learned of this project on Friday May 22 after I expressed concern that none of $215 million in Office of Rural Health projects announced that week would have any significant effect on Alaska’s access problems.

 It is unacceptable for America’s most remote rural veterans living in roadless Bush Alaska to be forgotten by the VA and the ORH whose mission is to ensure highly rural veterans have adequate access to quality health care resources, especially with such an historic appropriation.   

III. CONCLUSION
 Any rural or highly rural veteran should be able to go to any IHS or tribal facility and receive the care they need and that facility should be fully reimbursed by the VA for providing service.  In the words of Senator Begich, “it’s all federal monies” regardless of which federal agency provides the care, the VA or the IHS.

 Unfortunately, since last year’s appropriation of $215 million in Office of Rural Health projects, little has changed for Alaska’s highly rural veterans.  Hopefully Chairman Akaka’s recent landmark legislation, the Caregivers and Veterans Omnibus Health Services Act will be able to address some of these concerns. 

 Ultimately, for tribal organizations like YKHC, being able to systematically improve access to quality services for our highly rural veterans is more than a priority, access can dramatically improve the lives of our veterans and their families. 
 
 The reality for a highly rural veteran seeking behavioral health services is that it might mean waking in the early morning hours to leave their home in the coastal community of Kotlik via a small single-engine plane and flying a half-hour to Emmonak located near the mouth of the Yukon River.  Transferring to another small plane and flying another hour and a half to Bethel.  Then transferring to a regional airline to fly the last 400 air miles to Anchorage that evening.  The round-trip ticket cost alone is currently over $1,000.  All to make an appointment the following day at a VA facility in Anchorage.  Whew!

 Instead, improving access could mean the veteran not having to leave their community at all.  That same veteran could wake-up and walk from his or her house to YKHC’s Kotlik Village Clinic, and receive quality telepsychiatric care via high-definition video.  It is obviously far more efficient and less costly for the VA to use existing IHS and tribal facilities for serving rural and highly rural veterans.  Ultimately, it is simply the ability for a highly rural veteran to receive quality care closer to home and it is a matter entirely within Congress’s power to address!
 Thank you for the opportunity and honor to address your Committee today.
      Sincerely,
      Dan Winkelman
VP for Admin. & General Counsel