July 19, 2010


JULY 19, 2010

Mr. Chairman and Members of the Subcommittee: Thank you for this opportunity to submit The American Legion's views on this pressing issue concerning the quality of health care provided to veterans in rural areas and in particular those in rural Virginia. The American Legion, a long time advocate for America's veterans and their families, has noted the change in demographics of veterans and also the recent trend of veterans moving to rural and extremely rural areas of this nation. Even with that conscious decision, these veterans have earned the right to receive access to "The Best Care Anywhere." The Veterans' Health Administration (VHA) has endeavored to provide the required patient services, particularly gender-specific services, regardless of location, but there is still much to be done. The American Legion has passed a national resolution supporting enhancements to VHA's Rural Health Care programs to ensure veterans receive the timely and quality health care they have earned, regardless of where the veteran chooses to live. The American Legion's primary health care evaluation tool is a program called "A System Worth Saving." This Task Force, first established in 2003, annually conducts site visits at VA Medical Centers nationwide to assess the quality and timeliness of VA healthcare. In preparing for these visits, The American Legion team researches General Accountability Office (GAO) reports, VA's Office of Inspector General (VAOIG) reports, and news articles relating to potential breakdowns in a system that we consider, "The Best Care Anywhere." This task force, we believe, is valuable on a national level to identify trends and improvements made in the VA Health Care System, as well as identify local issues and areas for improvements.During the 2010 "System Worth Saving" Task Force visits to 32 VA Medical Centers across the country, a commonly repeated theme regarding rural areas was the shortage and turnover of personnel, especially nurses and personnel with specialty training. One of the reasons reported during Task Force visits for turnover and shortage is a lack of competitive compensation.Of the 23.4 million veterans in this country, nearly eight million veterans are enrolled in the VA Health care system, of which approximately three million are from rural areas. Rural veterans comprise about 40 percent of all enrolled veterans, or one of out of every three enrolled veterans. For many of the three million veterans living in rural areas, access to health care remains problematic, as they simply live too far away from the nearest VA Medical Center or Community Based Outpatient Clinic (CBOC). VA defines urban, rural and highly rural veterans with the following definitions: urban: any enrollee located in a census area defined as urbanized; rural: enrollees not designated as urban; highly rural: those enrollees defined as rural and reside in counties with less than seven individuals per square mile. Only two-thirds of rural and highly rural veterans enrolled in the health care system received VA medical services in FY 2008. Unfortunately, for many this means that rural veterans cannot see a doctor or a health care worker to receive the care that they need due to their geographical limitations. Given these barriers, it is no surprise that our rural veterans have poorer health outcomes compared to the general population.

In VHA's Office of Rural Health Strategic Plan for 2010-2014, VA's strategic goals are to: improve rural access and quality of care, enhance technologies, improve research studies and analyses, improve education and training, improve collaboration of service options and recruiting and retaining medical professionals. VA provides care to more than 5.5 million veterans each year at over 1,100 locations, including inpatient hospitals and CBOCs. Demographic shifts and changes in where veterans live call for continued realignment of the delivery system with the needs of all veterans enrolled in mind. One of the continued challenges for VA is determining the locations to build a major medical center or where it is more feasible to construction CBOCs, contract services, or telehealth programs.

Men and woman from geographically rural and highly rural areas make up a disproportionate share of service members and comprise about one-third (31.9) of the enrolled Veterans who served in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF); many of these service members are returning to their rural communities. This is due to the high number of Reserve Component service members who deploy from and return to their hometowns. This trend of veterans returning to rural communities will continue and VA must ensure that it is prepared to meet the increased demand for rural health care services.

The VA relies heavily on the CBOCs to serve the rural veteran populations. For example, the Marion VA Medical Center in Illinois has seven CBOCs located in Illinois, Indiana, and Kentucky that provide services to veterans in 52 counties in three states. Currently there are 42,000 veterans enrolled in rural CBOCs. The challenge of rural health care is a national issue. According to the National Rural Health Association (NRHA), many of the issues are a result of population size, age structure, health risk factors, economic development, ethnic composition, technology, and mix of health care providers, all impacting the health care needs of rural veterans and how they access health care services.

The American Legion conducted a site visit at the Salem VA Medical Center in Salem, VA in FY 2004, and at that time patients traveled an average of 80 miles and waited 30 minutes for specialty care. In FY 2009, there were 23,169 unique users veterans in the Salem VA Medical Center catchment area with 33,094 enrolled. The rural area of Bedford is approximately 30 miles from the nearest CBOC and 80 miles away from the Salem VA Medical Center. Bedford, Virginia has 1,524 veterans enrolled with only 770 users. There is currently one veteran in Bedford, VA that is enrolled in the Home Based Primary Care program and eight veterans that reside in Bedford, VA enrolled in the Care Coordination Home Tele-health program. The most common fee basis service for veterans living in the rural areas of Virginia is physical therapy and neurosurgery. There is an assigned Rural Health Team that provides outreach and patient education to veterans.

Another example of the difficulty to service rural and highly rural veterans is the Sheridan VA Medical Center in Wyoming and whose closest CBOC is 9 hours away. Some of the issues at this and other VAMCs are that when the roads are affected by rain or snow, the VA Medical Center's Volunteer Transportation Network vans are unable to go pick up veterans for their appointments. In some cases, travel times are nearly 20 hours each way to pick up a veteran and the veteran and volunteer driver must sleep in a homeless shelter each way on the trip. Also, many veterans who live in rural areas of the United States do not wish to make the long and tedious drive to the VAMC, even if a volunteer driver is willing to take them. Some veterans have gone over 30 years without seeing their primary care provider, but decide to see a doctor when it is usually too late, such as when cancer or other serious medical conditions worsen.

At some VA facilities unique approaches are being developed for assisting veterans and their caregivers. At the Iron Mountain Veteran Affairs Medical Center in Michigan, management reported that they do not have an adult day center because of the rural density. The VA is developing a voucher program so family and friends are able to receive payment and training to take care of their veterans. This will allow the veteran to be able to stay out of the VAMC and get the best care possible.

The American Legion applauded Congress and the Administration's passage of the Caregivers and Veterans Omnibus Health Services Act this year. One of the provisions in the law is to increase housing and transportation assistance for veterans living in rural communities. In addition, under VA's current mental health strategic plan mental health services have been expanded to primary care settings in VAMCs and CBOCs, something The American Legion has called for. The American Legion continues to 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. Veterans should not be penalized or forced to travel long distances to access quality health care because of where they choose to live.

Mr. Chairman, while VA is making continued improvements to the access and delivery of health care to rural veterans, more still needs to be done. We commend the committee for holding this field hearing in our community to witness first hand some of the challenges we and other rural veterans continue to face across America today.

Mr. Chairman and Members of the Committee that concludes my testimony.




MICHAEL F. MITRIONEDepartment Commander of VirginiaThe American Legion

Mr. Mitrione's eligibility in the American Legion results from 20 plus years in the US Army, where he retired as a Lieutenant Colonel in April 1984. While in the service he served in various command and staff positions from unit level to Headquarters, Department of the Army. His awards include the Legion of Merit, Bronze Star, 2 Meritorious Service Medals, 3 Air Medals, 5 Army Commendation Medals, and the Combat Infantry Badge.

Mr. Mitrione has been an active member of the American Legion for the past 22 years. At the Post level he has been a commander, chairman and member of numerous committees. He served as District Commander in two different Districts and was recognized by the State organization as the District Commander of the Year in both cases. At the State level he served two years as membership chairman and has been a member of the Finance Committee for the past six years. In the year he was the State Vice Commander, he was recognized by the State organization as the Vice Commander of the year. At the National level he has been serving as a member of the National Security subcommittee on Naval Affairs. In July 2010, he was elected as the State Commander.