April 21, 2012

Members of the Committee:

Thank you for the opportunity to provide The American Legion’s views on improving access to quality healthcare for rural veterans. I commend the committee for traveling to Montana to see firsthand what challenges veterans living in rural areas face with accessing Department of Veterans Affairs (VA) health care. While my testimony will focus on challenges Montana veterans have with receiving quality health care in remote areas, these same concerns can also be found with rural veterans from other states across the country.


The American Legion’s National Executive Committee created the “System Worth Saving Task Force” in 2003 to continue conducting site visits of VA Medical Centers, on behalf of The American Legion’s National Commander. The purpose of the site visits are to assess the quality and timeliness of VA health care and to provide feedback from veterans on their level of care. In the fall of 2011, the System Worth Saving Task Force focused on rural health amid many concerns The American Legion received from veterans across the country, such as the lack of primary and specialty providers and increased time and distance veterans have to travel to VA health care facilities.

As part of these site visits, the task force visited the Veteran Integrated Service Network (VISN) 19 Director, VISN Rural Consultant, Project Access Received Closer to Home (ARCH) pilot site in Billings, MT, VA Montana Health Care System in Ft. Harrison, MT and community based outpatient clinics in Anaconda and Billings.

The Ft. Harrison VA Medical Center in Helena, Montana is a full service VA Medical Center providing acute, chronic and specialized inpatient and outpatient services. The VA Medical Center oversees 12 community based outpatient clinics throughout the state of Montana in Billings, Miles City, Bozeman, Glendive, Glasgow, Cut Bank, Great Falls, Anaconda, Missoula, Lewistown, Havre and Kalispell. Additionally, there are primary care telehealth outpatient clinics in Hamilton and Plentywood.


The major concerns we have heard from VA and members in Montana, as well as in other states, are how VA defines rural health care, the long distances and travel to receive medical care and lack of primary and specialty care.

Rural Health Definition

One the first problems the System Worth Saving Task Force found across the country was how VA defines rural veterans. VA accepts the US Census Bureau’s definition for urban areas and defines rural areas for any individuals not living in an urban cluster. Furthermore, VA also defined rurality further by designating a highly rural criterion for a veteran that lives in a county with fewer than seven people per square mile. So, when VA says one out of every three enrolled veterans lives in a rural area, they are not basing this definition on travel time and distance to VA Medical Facilities, but rather on the US Census Bureau’s definition. Under this definition, a veteran could reside in a rural area in close proximity to a VA Medical Center facility or community based outpatient clinic while others do not.

Long Distances/Travel

While The American Legion and many of the veterans of Montana applaud VA’s adoption and expansion of Community Based Outpatient Clinics, these clinics only provide primary care. For veterans living in rural communities that need specialty care, they have to drive several hours or from out of state to the VA Medical Center in Ft. Harrison, MT. For many older and seriously injured veterans, traveling these long distances is a disincentive for them to receiving timely and quality health care. As a result, their medical condition could worsen or these veterans are seen by a private doctor who may not have the specialized training needed to provide care for military and veteran health conditions. Furthermore, the care they receive by a private doctor may not be the same level of quality that VA requires, and often times treatment records from private doctor visits are sent back to VA to input into the veteran’s VA medical record.

The American Legion believes veterans should not be penalized by where they choose to live and VA services must be enhanced and accessible for veterans living in rural areas. While VA cannot open a clinic or hospital in every rural community, contracts with local providers should be considered on a case-by-case basis by the VA Medical Center facility’s chief of staff. A non-VA appointment should not be considered a first resort as The American Legion believes VA is a health care system designed to meet veterans’ unique health care needs. However, The American Legion urges VA to reconsider its national non-VA purchased care policies to allow VA Medical Center Chiefs of Staff to use their best judgment and discretion to prevent veterans from being forced to drive hours to a facility for several routine and reoccurring appointments. If care is provided in the private sector, VA should have incentives built into the contract or fee-episode to ensure the same quality of care is maintained and that the documentation of that clinical visit is sent back to VA to be inputted into the veteran’s medical record.

VA Medical Center facilities primarily rely on veteran volunteer transportation drivers to bring veterans to and from their VA medical appointments through Voluntary Service Offices at the medical centers. Veterans are also able to be reimbursed for travel to and from their medical appointments if they qualify for the Beneficiary Travel program. Within the last two years, VA has launched a Volunteer Transportation Service initiative to provide VA-paid transportation for veterans with special needs and do not have transportation to and from outpatient appointments. The pilot VA Medical Centers are in Anchorage, AK; Phoenix, AZ; Prescott, AZ; Tucson, AZ; Loma Linda, CA; Denver, CO; Washington, DC; Lake City, FL; Atlanta, GA; Hines, IL; Marion, IL; Alexandria, LA; Boston, MA; Baltimore, MD and Cambridge, MD. The program is expected to be deployed across all VA Medical Centers by 2014 and is a great option for veterans that may not be able to drive or rely on a volunteer veteran transportation driver. Each VA Medical Center should conduct a catchment area transportation needs analysis so it can identify areas where transportation is available and what additional needs can be added. Better communication and coordination is needed within VA Medical Centers’ volunteer transportation drivers, beneficiary travel and the volunteer transportation service initiative.

Lack of Primary/Specialty Care Providers

Across the country, VA has several challenges in recruiting and retaining quality primary and specialty care providers. In an effort to close the disparity between federal and private sector salaries and to recruit and retain employees in rural areas, VA offers recruitment and retention bonuses, student loan repayment opportunities and retention incentives. During the System Worth Saving site visit to Ft. Harrison on February 7, 2012, facility leadership stated that they are recruiting for physicians, nurses and pharmacists. Additionally, the VA Director said there is a need for mental health personnel, but space is limited. In order to meet these mental health hiring needs, the director was forced to cut other areas of service such as nursing home beds. The facility director stated that additional mental health funding from the Veteran Integrated Service Network (VISN) and VA Central Office in Washington, DC is needed in order to recruit mental health personnel.

The VA Office of the Inspector General (OIG) is conducting a federal review of Ft. Harrison’s inability to hire mental health psychiatrists. A $7 million dollar mental health facility at the Ft. Harrison Medical Center has remained closed over the last 12 months due to the inability of the medical center director to hire the needed staff. The VA Director, Robin Korogi, has subsequently resigned from her current position and transferred to a Denver Regional Office.

The American Legion remains concerned about unfilled vacancies in the mental health sector nationwide throughout VA and urges Congress to utilize their oversight to help ensure these positions are being filled.


Recommendation 1
The American Legion recommends that VA should develop its own definition of rural and highly rural veterans, and not be based on the US Census Bureau, but based on access and driving times to VA facilities.

Recommendation 2

The American Legion urges VA to swiftly hire and fill all provider critical shortages and vacancies in VA Medical Centers and rural communities; especially within Mental Health.

Recommendation 3

The American Legion recommends VA improve their incentive programs to recruit and retain top talent in rural facilities.

Recommendation 4

The American Legion urges VA Medical Centers to develop fully functioning transportation departments in each medical center to oversee volunteer transportation driver programs, beneficiary travel and the VA transportation service initiative.


The American Legion thanks this committee for the opportunity to provide this testimony today and I would be happy to answer any questions the committee might have.