Senate Veterans Affairs Field Hearing on Rural Health Care Issues

 Talking Points:

Thank you for this opportunity to present The American Legion's views on access to quality health care for veterans in general and veterans in rural communities in particular. Research conducted by the Department of Veterans Affairs (VA) indicated that veterans residing in rural areas are in poorer health than their urban counterparts. It was further reported that nationwide, one in five veterans who enrolled to receive VA health care lives in rural areas. Providing quality health care in a rural setting has proven to be very challenging, given factors such as limited availability of skilled care providers and inadequate access to care. Even more challenging will be VA's ability to provide treatment and rehabilitation to rural veterans who suffer from the signature ailments of the on-going Global War on Terror-traumatic blast injuries and combat-related mental health conditions. VA's efforts need to be especially focused on these issues.

Community Based Outpatient Clinics (CBOC)
A vital element of VA's transformation in the 1990s, was the creation of CBOCs to move access closer to the veterans' community.   A recent VA study noted that access to care might be a key factor in why rural veterans appear to be in poorer health. CBOCs were designed to bring health care closer to where veterans reside. Over the last several years, VA has opened up hundreds of CBOCs throughout the system and today there are over 700 that provide health care to the nation's veterans. By and large, CBOCs have been pretty successful; however, of concern to The American Legion is that many of the CBOCs are at or near capacity and many still do not provide adequate mental health services to veterans in need.

One of the recommendations of the Capital Assets Realignment for Enhanced Services (CARES) recommendations was for more, not less, CBOCs across the nation.  The American Legion strongly supports this recommendation, especially those identified for rural areas; however, limited VA discretionary funding has limited the number of new CBOCs each fiscal year.

There is great difficulty serving veterans in rural areas. Veterans in states such as Nebraska, Iowa, North Dakota, South Dakota, Wyoming, and Montana face extremely long drives, a shortage of health care providers and bad weather. The Veterans Integrated Services Networks (VISNs) rely heavily upon CBOCs to close the gap.

The provision of mental health services in CBOCs is even more critical today with the ongoing wars in Iraq and Afghanistan. It has been estimated that nearly 30 percent of the veterans who are returning from combat suffer from some type of mental stress. Further, statistics show that mental health is one of the top three reasons a returning veteran seeks VA health care. The American Legion believes that VA needs to continue to emphasize to the facilities the importance of mental health services in CBOCs and we urge VA to ensure the adequate staffing of mental health providers in the CBOC setting.

CBOCs are not the only avenue with which VA can provide access to quality health care to rural veterans. Enhancing existing partnerships with communities and other Federal agencies, such as the Indian Health Service, will help to alleviate some of the barriers that exist such as the high cost of contracting for care in the rural setting. Coordinating services with Medicare or with other healthcare systems that are based in rural areas is another way to help provide quality care. 

The Presidential Task Force to Improve Health Care Delivery for Our Nation's Veterans made several recommendations for DoD and VA, one of which:  VA and DoD should declare that joint ventures are integral to the standard operations of both Departments.  (Recommendation 4.8)  Since this Task Force's final report in May 2003, none have materialized -- yet there are military bases in many rural communities.    

Traumatic Brain Injury Patients
In a July 2006 report entitled Health Status of and Services for Operation Enduring Freedom and Operation Iraqi Freedom Veterans after Traumatic Brain Injury Rehabilitation, the Department of Veterans Affairs Office of Inspector General examined the Veterans Health Administration's ability to meet the needs of OIF/OEF veterans who suffered from traumatic brain injury (TBI).  Fifty-two patients from around the country-including Montana, Colorado, North Dakota, and Washington state-were interviewed at least one year after completing inpatient rehabilitation from a Lead Center (Minneapolis, MN; Palo Alto, CA; Richmond, VA; and Tampa, FL) included those who lived in states with rural veteran populations. 

Many of the obstacles for the TBI veterans and their family members were similar. Forty-eight percent of the patients indicated that there were few resources in the community for brain injury-related problems.  Thirty-eight percent indicated that transportation was a major obstacle.  Seventeen percent indicated that they did not have money to pay for medical, rehabilitation, and injury-related services. 

Some of the challenges noted by family members who care for these veterans in rural settings include: the necessity for complicated special arrangements and the absence of VA rehabilitative care in their communities. 

Case managers working at Lead Centers and several secondary centers noted limited ability to follow patients after discharge to rural areas and lack of adequate transportation.

These limitations place undue hardship on the veterans' families as well.  Those contributing to the report, as well as veterans who have contacted The America Legion, have shared many examples of the manner in which families have been devastated by caring for TBI injured veterans.  They have sacrificed financially, have lost jobs that provided the sole income for the family, and have endured extended separations from children.  It is The American Legion's belief that VA needs to continue to improve access to quality primary and specialty heath care services for veterans residing in rural and highly rural areas.

Vet Centers
Vet Centers are another important resource, especially for combat veterans experiencing readjustment issues who do not live in close proximity to a VA medical facility.  Because Vet Centers are community based and veterans are assessed the day they seek services, they receive timely care and are not subjected to wait lists.  Some of the services provided include: individual and group counseling; family and marital counseling; military sexual trauma counseling; and, bereavement.

 The American Legion believes veterans should not be penalized or forced to travel long distances to access quality health care because of where they choose to live. We urge VA to improve access to quality primary and specialty health care services, using all available means at their disposal, for veterans living in rural and highly rural areas.

Again, thank you Mr. Chairman for giving The American Legion this opportunity to present its views on such important issues. We look forward to working with the Committee to bring an end to the disparities that exist in access to quality health care in rural areas.