Writen Testimony
By
Hilda R. Heady, MSW
Associate Vice President of Rural Health at the Robert C. Byrd Health Sciences Center
West Virginia University
National Rural Health Association, Past President
For the
United States Senate
Commitee on Veterans’ Affairs
April 22, 2009
 
Chairman Akaka, Ranking Member Burr, and Members of the Senate Commitee on Veterans' Affairs: thank you for the honor and the opportunity to speak to you today about the health care needs of our rural veterans. I am Hilda Heady, Associate Vice President of Rural Health at the Robert C. Byrd Health Sciences Center at West Virginia University, a commitee member of the VA Veterans Rural Health Advisory Commitee, and past president of the National Rural Health Association (NRHA). The NRHA provides leadership on the issues that affect the health of the 62 milion Americans who cal rural home and has long focused efforts on improving the physical and mental health of our rural veterans.
Since our nation’s founding, rural Americans have always responded when our nation has gone to war. Whether motivated by their values, patriotism, or economic concerns, the picture has not changed much in 230 years. Simply put, rural Americans serve at rates higher than their proportion of the population. Though only 19% of the nation lives in rural areas, 44% of U.S. Military recruits are from rural America. And, sadly, according to a 2006 study of the Carsey Institute, the death rate for rural soldiers in our current war in Iraq, is 60% higher than the death rate for those soldiers from cities and suburbs. Given this great commitment to service from our rural communities, we need to do more to resolve the health care barriers that face rural veterans.
There is a national misconception that al veterans have access to comprehensive care. Unfortunately, this is simply not true. Access to the most basic primary care is often difficult in rural America. Access for rural veterans can be daunting. Combat veterans returning to their rural homes in need of specialized care due to war injuries (both physical and mental) wil likely find access to that care extremely limited. Scarcity of mental health and family counseling services is also a problem for rural veterans in need of these services.
Simply put, because there are a disproportionate number of rural Americans serving in the military, there is a disproportionate need for veteran’s care in rural areas. While the VA has increased the number of Community Based Outpatient Clinics (CBOCs), Outreach Health Centers, Home Based Care, or other outreach service programs in rural communities, it is not reasonable to expect that the VA can put a CBOC or one of these other services in every community where our rural and highly rural veterans live. We can, however, increase access to approved sources of care to overcome the difficulty rural veterans experience in atempting to receive timely, appropriate care.
In West Virginia, more than half of al our veterans live in rural areas. Veterans represent over 14% of our population and that is growing: the state of West Virginia supports a military complex of Army and National Guard, Army and Air Reserve Components, plus Navy and Marine Reserve Units. Many of our soldiers in these units are serving their second or third tour of duty in Iraq or Afghanistan, but hopefuly wil return home soon. A vast number wil return home to rural communities scatered across the state, often several hours’ drive from veteran healthcare facilities. Many wil simply forego care because this access is so difficult.
 
The NRHA strongly supports specific solutions to meet the chalenges of providing quality care to our rural veterans. The NRHA believes that improving access to care for our nation’s rural veterans must be a priority for both the Administration and Congress, and submits the folowing recommendations:
1. Increase Access by Building on Current Successes
Community Based Outreach Centers (CBOCs) open the door for many veterans to obtain primary care services within or close to their home communities. Additionaly, Outreach Health Centers and mobile clinics meet the needs of many rural veterans. NRHA applauds the success of these programs as wel as recent increases in Federal appropriations. Expansion of these critical services is needed.
2. Increase Access by Colaborating with Non-VHA Facilities
Approximately 20% of veterans who enrol to receive health care through the VHA live in rural communities. In addition, the VA currently serves only 39% of al veterans, so we know that a number of rural veterans rely upon their local, civilian health care system for services and some may not receive any care. With an ever-growing number of veterans returning home to their rural communities after military service, these rural health care systems must be prepared to meet their needs. While CBOCs and Veteran Outreach Centers provide essential points of access, there are not enough of these facilities in rural communities. Furthermore, CBOCs do not provide a ful range of care and the low volume of veterans in some communities may never be able to support one of these centers. Simply put, more providers, specificaly trained in post deployment health conditions and care, are needed to serve the increasing number of rural veterans. Colaboration with existing rural health care facilities provides a cost-effective, timely and quality solution to this problem.
Linking the quality of VA services with rural civilian services can vastly improve access to quality health care for rural veterans. Our goal is not to mandate care to our veterans, but to provide them a choice, a local choice. As long as quality standards of care and evidence-based medicine guide treatment for rural veterans, the NRHA supports colaboration with:
• Community Health Centers. These centers serve milions of rural Americans and provide community-oriented, primary and preventive health care. More importantly, FQHCs are located where rural veterans live. A limited number of colaborations between the VHA and Community Health Centers already exist and have proven to be prudent and cost-effective solutions to serving eligible veterans in remote areas. These successful models should be expanded to reach al of rural America.
• Critical Access Hospitals and other rural hospitals. These facilities provide comprehensive and essential services to rural communities and are specific to rural states. If these facilities are linked with VHA services and models of quality, access to care would be greatly enhanced for thousands of rural veterans.
 
• Rural Health Clinics. These clinics serve populations in rural, medicaly¬underserved areas and comprise a vital piece of the safety-net system. In many rural and frontier communities, RHCs are the only source of primary care available.
The above rural health facilities are the cornerstone of primary and preventive quality health care in rural America. Each is required to meet federal requirements for quality, provider credentialing and the use of health information technology. Current colaborations with the VHA in Wisconsin, Missouri and Utah are strong examples of success. Expanding the levels of colaboration wil vastly increase access to care in a cost-effective manner.
The NRHA is pleased that the Rural Veterans Access to Care Act was signed into law last October. This act establishes a three-year pilot program in several rural regions of the country to alow the most underserved rural veterans to take advantage of existing quality rural health providers, such as Critical Access Hospitals, community health centers and rural health clinics. The pilot project is relatively smal and requirements to qualify are rigid - - a veteran must live at least 60 miles from a VA primary care facility like an outpatient clinic, 120 miles from a VA hospital or 240 miles from a VA specialized-care facility when seeking that care. Despite these defects, this legislation is an important step in the right direction, but so much more must be done.
S. 658, the Rural Veterans Healthcare Improvement Act, is an important next step because it wil alow even greater access to care or rural veterans. Specificaly, one section authorizes the Office of Rural Health to improve or expand care for rural veterans through a series of demonstration projects that includes coordination with Community Health Centers, Critical Access Hospitals and Indian Health Services. We thank Senator Tester for introducing this bil and for this Commitee’s examination of it.
Additionaly, S. 734, the Rural Veterans Health Care Access and Quality Act of 2009, is yet another crucial step. This Act establishes a pilot project that would provide financial incentives for physicians who serve in a Health Professional Shortage Area to provide primary care or mental health services to rural veterans. Such a program could go far in improving access to care for rural veterans, especialy meeting the great unmet mental health needs of our nation’s veterans. The NRHA applauds Chairman Akaka for introducing this important bil. Care must be taken that laudable efforts to increase provider care for our veterans does not exacerbate the current provider shortage in rural areas. Because access to primary care in rural America is at crisis levels for al both civilian and non-civilian patients, it is also important to be mindful that any incentives do not inadvertently reduce providers at non-VA facilities.
3. Increase Access to Mental Health and Brain Injury Care
Currently, it appears that Traumatic Brain Injury (TB I) wil most likely become the signature wound of the Afghanistan and Iraqi wars. Such wounds require highly
 
specialized care. The current VHA TBI Case Managers Network is vital, but access to it is extremely limited for rural veterans -- expansion is needed.
Additionaly, mental health needs of combat veterans deserve special atention and advocacy as wel. Access to mental health services is a problem in many smal rural communities. In fact, 85% of al mental health shortages are found in rural America. A lack of qualified mental health professionals, shortage of psychiatric hospital beds and the negative stigma of mental ilness, often result in many rural residents not geting the care they so desperately need. These problems are exacerbated for veterans who live in rural communities - - too often members of our military return home to a civilian community where the cultural expectation is self-reliance and to solve one’s own problems. In a civilian health care system where few may understand military experience or the special needs of combat veterans, we need to do more to prepare our primary care providers who wil serve these veterans..
Although Vet Centers provide mental health services, they are not consistently available at the local, rural level. More resources are needed in order to contract with local mental health providers, hire additional mental health providers and/or contract with Critical Access Hospitals (CAHs) and other smal rural hospitals. The provisions in S. 658 that give the VA the clear authority to contract-out mental health services for certain rural veterans is strongly supported by the NRHA. However, without addressing the national need for more mental health providers in rural areas and include post deployment and/or combat related mental health disorders, the greater impact of S. 658 may be hampered.
4. Target Care to Rural Veterans
A. Needs of the Rural Family. Rural veterans have an especialy strong bond with their families. Returning veterans adjusting to disabilities and the stresses of combat need the security and support of their families in making their transitions back into civilian life. The Vet Centers do a tremendous job of assisting veterans, but their resources are limited. The NRHA supports increases in funding for counseling services for veterans’ and their families.
B. Needs of Rural Women Veterans. More women serve in active duty than at any other time in our nation’s history. And more women are wounded or are war casualties than ever before in our nation’s history.
Targeted and culturaly competent care for today’s women veterans is needed. Rural providers should also be trained to meet the unique needs of rural, minority, and female veterans.
5. Improving the VA Office of Rural Health
The NRHA cals on Congress and the VA to fuly implement the functions of the newly created VA Office of Rural Health to develop and support an on-going mechanism to study and articulate the needs of rural veterans and their families.
 
Additionaly, efforts to increase service points for rural veterans have, in large part, not been fuly supported by the VA Administration itself. The VA has not consistently supported atempts to colaborate with rural health. It is my hope that with a new Administration and the newly formed VA Rural Health Advisory Commitee, previous barriers wil be eradicated and the VA Office of Rural Health wil lead the way in expanding access options for rural veterans. Furthermore, the NRHA strongly encourages greater coordination between the Rural Health Consultants housed in each VISN and state-level rural health officials in their region. Specificaly, quarterly meetings with State Office of Rural Health and State Rural Health Association officials would be prudent.
S. 734 provides important direction for the VA Office of Rural Health. The requirement of establishing a strategic plan to implement specific workforce recruitment and retention goals is imperative for increasing access to care for rural veterans. However, we must again be mindful that any strategic plan to increase providers at VA facilities does not inadvertently increase the current shortage crisis at non-VA facilities. To this end, colaboration between the Federal Office of Rural Health Policy within HRSA and the VA Office of Rural Health is critical and must be established to best take advantage of the many efforts to reduce provider shortages in rural areas already underway within HRSA.
6. Explore ways to coordinate benefits for dual eligible veterans
As the veteran population ages, a growing number of veterans are eligible for both VHA health benefits and Medicare. The combination of two partial benefits packages should ensure the best possible care for our veterans, but the co-payments and Medicare Part D requirements may not be affordable for many veterans. Coordination of benefits would alow veterans to utilize the different resources offered to them effectively to receive high quality care close to home.
7. Increase research on defining the rural veteran population
Without good research about the rural veteran population, we cannot possibly expect to ensure their good health. Epidemiological studies are needed to identify the locations and populations of veterans in various rural areas of the country. These studies must provide information about race, gender, place of residence, health care needs, service-related health issues and service utilization. With only 39 percent of veterans enroled in VA health care benefits, and most VA research conducted on secondary bases of enrolees, we know that non-enrolees who may be rural, less than honorably discharged, and other veterans in need, are not included in this research. We need to broaden avenues for quality research which would provide information about how to best serve the veteran population who are currently not enroled. The NRHA would encourage the VA to colaborate with the six Federal Office of Rural Health Policy/HRSA-funded Rural Health Research Centers to explore this research.
 
Conclusion
While many opportunities for improvement exist in providing care to veterans in rural communities, the VA is to be commended for the excelent service provided in many of its facilities. However, we must never forget that many veterans forgo care entirely because of access difficulties to VA facilities. Providing health care in rural communities requires unique solutions, whether it is to veterans and their families or the general population. Additionaly, we must al be mindful of long-term needs and costs of our sailors and soldiers. The wounded veterans who return today won’t need care for just the next few fiscal years; they wil need care for the next half century.
Both S. 734 and S.658 are crucial pieces of legislation that wil vastly improve the access to health care for our nation’s rural veterans. Adopting the legislation and other strategies referenced in this writen testimony wil vastly improve the lives of the milions of veterans who live in rural America. Their service to their nation affords them no less.
Thank you again for this opportunity.