<DOC>
[109 Senate Hearings]
[From the U.S. Government Printing Office via GPO Access]
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S. Hrg. 109-376
FIELD HEARING ON THE STATE OF VA CARE IN HAWAII: PART I
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED NINTH CONGRESS
SECOND SESSION
__________
JANUARY 10, 2006
__________
Printed for the use of the Committee on Veterans' Affairs
Available via the World Wide Web: http://www.access.gpo.gov/congress/
senate
COMMITTEE ON VETERANS' AFFAIRS
Larry Craig, Idaho, Chairman
Arlen Specter, Pennsylvania Daniel K. Akaka, Ranking Member,
Kay Bailey Hutchison, Texas Hawaii
Lindsey O. Graham, South Carolina John D. Rockefeller IV, West
Richard Burr, North Carolina Virginia
John Ensign, Nevada James M. Jeffords, (I) Vermont
John Thune, South Dakota Patty Murray, Washington
Johnny Isakson, Georgia Barack Obama, Illinois
Ken Salazar, Colorado
Lupe Wissel, Majority Staff Director
D. Noelani Kalipi, Minority Staff Director
______
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WASHINGTON : 2006
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C O N T E N T S
----------
January 10, 2006
SENATORS
Page
Craig, Hon. Larry, Chairman, U.S. Senator from Idaho............. 1
Akaka, Hon. Daniel K., U.S. Senator from Hawaii.................. 3
WITNESSES
Evangelista, Rogelio, President, Maui Veterans Council........... 6
Prepared statement........................................... 9
Helm, Larry, President, Molokai Veterans Caring for Veterans..... 10
Prepared statement........................................... 12
Kekahuna, Roy W., PhD, District Director, Blinded Veterans
Association.................................................... 13
Prepared statement........................................... 15
Obado, Dwight ``Lui,'' Organizer, Lanai Veterans Organization.... 16
Prepared statement........................................... 18
Perlin, Hon. Jonathan A., MD, PhD, Under Secretary for Health,
Department of Veterans Affairs, accompanied by Robert Wiebe,
MD, VA Network Director, VISN 21, Sierra Pacific Network; James
Hastings, MD, Director, VA Pacific Islands Health Care System;
and Steven A. MacBride, MD, Chief of Staff, VA Pacific Islands
Health Care system............................................. 25
Prepared statement........................................... 28
APPENDIX 1
Prepared statements:
Atwell, Francine................................................. 43
Dickensheet, Don................................................. 42
Newsham, Sgt. Albert A........................................... 43
Ross, Patricia Absher, on behalf of husband, John William Ross,
Jr., LCDR, USN, Ret............................................ 41
APPENDIX 2
January 9, 2006--Hawaii Hearing, Kaui
Prepared statements:
Aylward-Bingman, Lynn M., Capt. (NC) USNR (Ret.) member, Veterans
Advisory Council to the Veterans Affairs Pacific Islands Health
Care System (VISN 21).......................................... 71
Browne, Colette V., professor, University of Hawaii School of
Social Work.................................................... 69
Cruz, Frank, President Kauai Veterans Council and Chairman for
the State Office of Veterans Service Governors Advisory Board.. 68
Driskill, Thomas M. Jr., President and Chief Executive Officer,
Hawaii Health Systems Corporation.............................. 68
Ekstrand, Laurie E., Director, Health Care, U.S. Government
Accountability Office.......................................... 53
Honjixo, William T............................................... 76
Kawamura, Edward, veteran........................................ 51
Perlin, Hon. Jonathan A., MD, PhD, Under Secretary for Health,
Department of Veterans Affairs................................. 45
Shaw Robert, National Legislative Chairman, National Association
of State Veterans Homes........................................ 49
Takamura, Ronald K............................................... 74
FIELD HEARING ON THE STATE OF VA
CARE IN HAWAII
----------
TUESDAY, JANUARY 10, 2006
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10:10 a.m., in
the J. Walter Cameron Center Auditorium, 95 Mahalani Street,
Kahului, Hawaii, Hon. Larry Craig (Chairman of the Committee)
presiding.
Present: Senators Craig and Akaka.
OPENING STATEMENT OF HON. LARRY CRAIG,
U.S. SENATOR FROM IDAHO
Chairman Craig. Good morning, ladies and gentlemen.
Audience Members. Good morning. Aloha.
Chairman Craig. Aloha. Thank you very much. It is a
tremendous pleasure of mine to bring the Senate Committee on
Veterans' Affairs to Maui, and to have an opportunity to visit
with many of you today on issues that affect all veterans. I
say that to receive testimony on the state of VA care here in
Hawaii and on the neighboring islands of this great State is
not only an opportunity for me, but an honor.
As some of you may know, we held hearings yesterday on the
island of--I always work on these names--Kauai----
Senator Akaka. Kauai.
Chairman Craig. Danny corrects me--that focused on VA's
long-term care programs nationally and here in Hawaii.
What a beautiful setting for a hearing, I said as we landed
this morning, and there was a rainbow. Is there always a
rainbow in Hawaii? I suspect so. Well, I'll tell you. It lifts
the spirit and the attitude. Rarely do you see a rainbow in
Washington, DC.
Yesterday after the hearing, we flew back to Oahu and spent
the afternoon out at the National Memorial Cemetery of the
Pacific. What a phenomenal and humbling experience. And, of
course, at Pearl Harbor. Spent some time, once again, looking
down into the waters of the Arizona.
I was truly awestruck when I saw these sights and the
events that drew our great country into World War II. Of
course, I was a very small child at that time. In fact, my
parents would suggest I hadn't even been thought of yet. But I
must tell you that it is that and your history, the history of
the people of this great State, that is so long and proud in
their defense of America's freedoms that you have always met
the challenge for. Of course, we, both Danny and I, in
understanding that, recognize our jobs as honoring America's
heroes.
I am pleased to be here with my friend, and I say that most
sincerely, Senator Danny Akaka. Senator Akaka and I came to
Congress at about the same time. We served in the House
together for a decade. We came to the Senate in 1990. Now we
find ourselves as the senior Members of the Veterans' Affairs
Committee.
Early on in that relationship, he invited me to Hawaii, and
of course, I invited him to Idaho. For some strange reason, he
wanted me to come here in August. I said, you know, we've got
these roles reversed. You come to Idaho in August. I'll come to
Hawaii in January or February. It snowed in Idaho yesterday,
and the skiing there is excellent at this moment. And it's
obvious why we're here now, and not there. But Danny has been
to my beautiful State before, and we hope to get him out there
again.
Senator Akaka has been vocal in his belief that Hawaii has
a unique geographic issue that other Members of Congress must
experience firsthand to understand this great State. I agree
with my colleague that there is no substitute for personal and
on-the-ground experience. That's why I'm here at Danny's
request. And that's why we're spending the time that we are
with the four hearings. This is the second of four scheduled
across the State.
For those in the audience who don't know much about Idaho,
Idaho and Hawaii are very similar in the sense of geography and
distance--difficulty of movement. You may have water; we have
high mountains. And at times, during this time of the year in
Idaho, it can be very, very difficult to move from one
community to the other.
Traveling the length of my State is a 500-mile journey.
Traveling the width of my State at one point is a near 500-mile
journey. So, there are great commonalities between our States
as it relates to the geographic issues. And therefore, how do
we service and how do we provide service to men and women who
choose to live, as they have the right to, in small rural
communities across our States?
That is an issue here. It is an issue in Idaho. It's why
we're here to see how we might improve those services, or offer
different types of services that meet certainly the
requirements of all of you and all of your needs. Mental health
treatment is often very difficult to come by, and extensive
travel, often measured in hundreds of miles, can be required to
receive complex surgical care.
I mention this because of our uniqueness as States and our
relationship as friends. I say to all of you that if all of our
country's Senators were as kind, as hardworking, and as
generous as Danny Akaka, the Senate would be an even better
place to work. I trust that you feel privileged to have him
serving you in the U.S. Senate because I feel privileged to
view him as one of my friends.
So I will turn to Danny now for his opening comments, and
then he's going to introduce the first panel. We have two
panels this morning. Our time is limited because we want to get
on and visit a CBOC and the Vets Center and get out on the
ground, after testimony and after listening to your concerns
and responding to some of the questions that we may have coming
out of our panels' testimony.
So with that, let me turn the microphone to Senator Akaka.
Danny.
[Applause.]
OPENING STATEMENT OF HON. DANIEL K. AKAKA,
U.S. SENATOR FROM HAWAII
Senator Akaka. Mahalo. Mahalo nui loa to all of you. And I
want to say an extra mahalo nui loa to the Chairman for coming
here to Hawaii to all these hearings. And I want to thank the
Chairman for his generous remarks this morning.
I want to tell you that as he mentioned, we've worked
together for many years. Larry Craig was a great Congressmen
and is a great Senator. He's inching up in leadership in the
Senate. So don't be surprised if you see Larry Craig from Idaho
as one of the leaders of the U.S. Senate one of these days.
And I really treasure his friendship. I must tell you that
since he took over and we became leaders of the Veterans'
Committee, that Committee is moving.
And I want to tell you that we share many of the same
ideas. There's no question that we want to do the best we can
to help the veterans. I think you know that there are limits,
but we want to do the best we can within the limits to give all
the services we can to the veterans of our country.
In Hawaii, we have, as the Chairman mentioned, unique
issues because of geography and because of our culture. Other
States have similar problems. This hearing will really help the
Committee to try to do a job that's great.
We have the top people here from VA, nationally, as well as
Statewide, and region-wide, too, here with us to testify. But
we are all here to try to see what we can do to help the
veterans. That's our effort here.
So I'm so glad. I also want you to know that this is the
first hearing where the Chairman of the Committee has traveled
to Hawaii in the history of our country.
[Applause.]
Senator Akaka. Thanks to the Chairman and our staffs, who
worked so hard to bring this about. I want to tell you that
normally the Committee doesn't leave Washington, DC. for
hearings. We have hearings in Washington. So this is very rare.
But we are very privileged to have the Committee out here. For
me, too, I mean, it's kind of a thrill to be able to bring the
Committee out here to Hawaii.
As I said, the Chairman has really had a busy schedule, at
home and in Washington. But I was so glad to have him, as he
said, suggest it: Hey, if not August, what about January? Oh,
that's all right with me. You know, whenever it is. And it
worked out beautifully because I feel great being home in
Hawaii whenever I can come home. And thanks to the Chairman for
all of this. And we are privileged and honored that all of you
have come to testify here and to listen to the testimony about
the needs of Hawaii's veterans.
You know, I want to mention--I'm taking long--but I want to
mention about what the Chairman said about the rainbow. You
know, the rainbow is very symbolic and important to Hawaii. I
come from a place on Oahu, and we always have rainbows. I
remember my mom, my father and mother, would always tell me,
``The rainbow is here.''
And it's a kind of symbol that is beautiful. It's spiritual
in a way because you can't touch it. It's there. It represents
hope. It's beautiful because it represents all the colors. It's
good for Hawaii because Hawaii is diverse. It has many, many
ethnic groups, and each ethnic group is in that rainbow. The
way I like to put it is that, whatever ethnic person you are,
it's good to know your tradition. When you do that, your color
is bright. But your color is better when it's side by side with
other colors.
That's why we're here. You know, we harmonize. We work
together. And that's a rainbow. There's a song that I call the
rainbow song, but it's really beautiful and it has lots of
meaning. I'm so glad the Chairman mentioned the rainbow because
it's significant. And that tells us our hearings are going to
be the best hearings, and it'll help the Committee do its work.
There's no question we have and we will, the Chairman and I and
the Committee, work together on veterans' issues.
I also want to thank Ernie Matsukawa from the Maui Vets
Center. Also, Terri Garcia from the Office of Veterans Services
in Maui, and Naomi Guardado from the J. Walter Cameron Center
which we are in now, who have been working with my staff to
coordinate these hearings. We greatly appreciate your hard
work. So mahalo nui loa for what you have done.
[Applause.]
Senator Akaka. My purpose in bringing the Committee to
Hawaii for field hearings is to find out more about the state
of VA care in Hawaii. I applaud the efforts of every VA
employee in Hawaii. I also applaud our officials of the VA who
have worked hard, in the region as well as nationally.
Secretary Nicholson is relatively new, but has worked real hard
in trying to do the best for our veterans across the country.
There are many things that the VA does well in Hawaii. However,
there is always room for improvement.
I want to hear about how we can help VA help Hawaii
veterans. Today, and over this entire week, the Committee will
examine the state of VA care in Hawaii. And I'm glad we're here
on beautiful Maui with representatives from Molokai, and Lanai.
As such, VA must tailor its strategy to reach all of Hawaii's
veterans.
We know that the access for care for those living on what
we call the neighbor islands--Kauai, Molokai, Lanai, Maui, and
the Big Island--could be improved. As such, I developed a bill
that would ensure a greater presence on the islands of Molokai
and Lanai, which currently lack VA facilities altogether. And
I'm sure we'll hear about that today.
A veteran living on either of these remote islands must
either wait for a VA provider to visit, which is only 9 to 10
times a year for Molokai and 4 times a year for Lanai, or take
it upon himself to get on Maui for clinical care, or to Oahu
for treatment for a more serious condition.
Filling up the car with a tank of gas and driving across
the State is obviously not even an option here. Inter-island
air fare is more than $200, and besides that, we don't have
bridges between the islands. So veterans have difficulty
getting reimbursed for these expenses, which also include
rental cars and hotels. Many veterans who cannot afford these
costs must choose to forgo care as a result.
Even when a VA provider finally comes to one of these
remote islands, they have no tele-medicine equipment--this from
a Department that is renowned for their computerized medical
records and technologies. I'm sure all of you know that
healthcare provided by VA is No. 1 in the Nation by the
Veterans Administration. That's a fact.
VA also needs to revamp its beneficiary travel program.
This benefit is one that is highly valued by many veterans,
especially those on fixed incomes. Unfortunately, there has not
been an increase in the benefit for some time. In 2001, VA
found that the current allowances under this program were not
sufficient to begin to deal with high gas prices. Yet 4 years
later, the increase was never put forward.
We are privileged to have all of our witnesses with us this
morning. We will hear first from veterans' representatives from
Maui, Lanai, and Molokai. It is vitally important that you
share your thoughts with us so that we know how to help VA help
you and the rest of Hawaii's veterans. VA officials will
respond to the concerns laid out by the previous panel. That's
a response not only on the national and regional level, but the
local level as well, State level, and on our congressional
level.
Finally, I want to address the fact that there are many
veterans who are here today and who want to testify. We want to
hear from you. And I'm glad to have met some of you before the
meeting outside, because some of you would have liked to
testify. But we can't hear everybody. Unfortunately, this is a
problem, and we cannot accommodate everyone's request.
However, we are accepting written testimony for the record.
So you can rest assured that we will read your written
testimony. If you have brought written testimony with you,
please give it to the Committee staff who are located in the
back of the room--they're raising their hands back there.
But if you do not have a written statement, but would like
to submit something, our staff is in the back of the room to
assist you with that also. In addition, the Committee staff is
joined by VA staff who can respond to the questions, concerns,
and comments that you raise, and will also be at that table.
Once again, mahalo nui loa to all of you who are in
attendance today, and I look forward to hearing from today's
witnesses.
Senator Akaka. We welcome the first panel here today. I'm
sure you're all familiar to the folks here in the tri-island
County, the three islands: The first one is Rogelio
Evangelista, who's the--as I call you, just raise your hand--
the President, Maui Veterans Council. Rogelio. I've got to tell
you, Rogelio was not supposed to be here today. He was supposed
to have an operation. But he postponed that to be here. Thank
you very much.
Also, Larry Helm, the well-known President, Molokai
Veterans Caring for Veterans.
Roy Kekahuna, Doctor, District Director, Blinded Veterans
Association. We're glad to have you, Roy.
Dwight ``Lui'' Obado, organizer of the Lanai Veterans
Organization, is here.
We're delighted to have you folks. We want to hear what you
have to say. You're welcome to come sit at the table. We're
delighted to have you folks here. You will testify in the order
you were introduced. So mahalo nui loa to you, and you can
begin.
STATEMENT OF ROGELIO EVANGELISTA, PRESIDENT,
MAUI VETERANS COUNCIL
Mr. Evangelista. Thank you, Senator. Before we go on, if we
can have a prayer first. Mario? Are you here? Can you lead us
in a prayer? And after that, maybe we can have a Pledge of
Allegiance. Will you stand.
[Opening prayer and Pledge of Allegiance.]
Chairman Craig. Please proceed.
Mr. Evangelista. Mr. Chairman, Larry Craig, Senator Akaka,
and distinguished Members of the Senate Veterans' Affairs
Committee, Veterans Administration Pacific Islands Healthcare
System Director General Hastings and staff, thank you for
giving me this opportunity to come before you today to discuss
the state of the VA care in Hawaii, home to more than 110,000
veterans, and especially for the more than 10,000 veterans
living in the county of Maui, which comprises the 3 islands of
Maui, Molokai, and Lanai out of the 8 islands that make up the
State of Hawaii, which are all separated by the ocean.
The excellent medical efforts of the Maui CBOC, the
Community Based Outreach Clinic, with the support of the Spark
Matsunaga Center on Oahu and the Tripler Army Medical Center,
have been extraordinary. I would at this time like to take a
moment to stress the unique nature of healthcare here on Maui,
Molokai, and Lanai, and to also include Kauai and Hawaii.
The first, by being on the State Veterans Advisory Board
for over 9 years and on the VAMROC, which is the Veterans
Administration Medical and Regional Office Center, Advisory
Board for over 5 years, and as a disabled veteran, I have
understood the stress and witness the bureaucracy the veterans
are faced when receiving healthcare from the Veterans
Administration.
They must be able to pass the means test by having limited
income jointly with their spouse so that if they need to go to
Oahu or the mainland for specialized care that is not service-
connected, they will be provided airline transportation. And
this is for any veteran with less than 30 percent disability
that uses the VA healthcare system as their primary healthcare.
If the veteran does not qualify on the means test and he or
she has a disability of less than 30 percent, then the veteran
must pay their own transportation to go to Oahu or the
mainland. Veterans on the mainland can drive to the VA
hospitals and not worry about passing any means test. VA states
it's cheaper to have the exam or procedure done on Oahu with
the veteran paying about $145 for a round-trip ticket instead
of having the veteran see a local provider on the island that
he or she resides on. Veterans' bills are even being sent to
collection agencies because the VA takes so long on paying for
services from outside providers.
Second, as I look at our aging veteran population, there
are 100 percent disabled veterans in nursing homes on Maui with
the families paying over $7,000 per month for their healthcare
at those nursing homes, plus their medications. It's hard for
the families to send them to Oahu to the Center for Aging, and
there will be no family support because they can't fly to Oahu
every day to see the veteran. Is it possible for VA to do a
partnership with Hale Makua, a nursing home on the island of
Maui, for the veterans living on Maui? Why is Hawaii and Alaska
the last two States that do not have any VA hospital? What
happened to a Federal mandate that states that there should be
a VA hospital in each State?
Third, our CBOCs on all the neighbor islands, even with the
experienced and dedicated staff, they are underpaid in
comparisom with the mainland VA staff. And they are also
overworked. We need more staffing and we need more office space
on Maui and on the other neighbor islands. On Maui, if the VA
can buy out the building that CBOC is located in and the vacant
lot next to the building and look at expanding services with
more staff we now have volunteers, but they are limited in the
scope off work that they can perform. And we need more
specialized equipment, especially for telemedicine.
There is now one full-time doctor 5 days a week, one part-
time doctor 4 days a week. We need to upgrade our staff to
provide the best possible care for our veterans. Right now it
takes so long to get an appointment to see the doctor for
routine or specialized care. The doctor has to come in from
Oahu or the mainland.
In order to provide ongoing care to veterans, first, the
Government must realize that veterans' healthcare is part of
the cost of war, and that the Government needs to provide
enough funding for VA healthcare to all veterans. Second, the
Veterans Administration, along with the Government, must
identify and develop programs and use today's technologies to
help veterans in their daily lives, especially for our disabled
veterans.
Combinations of advanced healthcare using new technologies
will greatly help all of our veterans, and make their
recoveries possible and the long-term relationship of being
accepted back into society. I ask you, why is VA funding always
the lowest priority in our Government, when we, the veterans,
made our country the greatest Nation in the world?
Fourth, many of our veterans are suffering from some sort
of physical or mental disability and would rather alienate
themselves from anything to do with the Veterans Administration
due to many contributing factors. All the red tape that they
must go through to even start to file their claim, something
that happened over 30 years ago, and it is just being addressed
today because of the veteran's health status, be it physical or
mental. And this is all due to different contributing factors
of the veteran's healthcare.
Veterans are being informed to get collaborating [sic]
evidence from other veterans that served with them and might
know something regarding the veteran's condition or of an
incident that occurred. Most of the veterans don't know where
these other veterans are now living, and some of them just
don't want to get involved. But there are records that the
military have, so why can't the Veterans Administration get
those records to collaborate [sic] the veteran's claim?
Fifth, veterans are now paying $7 co-payment on drugs and
medication, and the VA is also at this time exploring the idea
of raising the co-payment on drugs for veterans that are being
prescribed for non-service-connected medical problems. These
veterans are on very limited financial support due to their
physical and mental conditions being attributed to their
military career in one way or another.
They answered our Nation's call when they were needed. Why
can't our Nation now help them in their time of need? I ask and
plead with you, the Members of the Veterans' Affairs Committee,
to lobby your constituents and help our Nation's veterans lead
fruitful and dignified lives.
Sixth, the vocational rehab program that tried to help
veterans in training them for a vocation that they can excel in
is great. But now there are so much restraints being placed on
being able to qualify, and the approval all now comes from
Washington, DC and not done here locally like it used to be.
There is so much paperwork going back and forth, and it
takes such a long time, sometimes longer than 6 months for
approval if it does get approved, and by that time the veteran
has already lost interest and have given up on the system.
When you apply for vocational rehabilitation, you will need
specialized and long-term counseling and support from your case
worker here and not from somebody from Washington that knows
you only as a number, with no personal knowledge of all your
special needs as you continue with your studying. And this will
be due to the type of medications that you are being prescribed
by the doctor, so the doctors and your case worker need to be
informed on your physical and mental condition so that you can
be successful in pursuing your vocational training.
There are veterans here on Maui that don't even know of
certain benefits that they may be qualified to apply for due to
their physical and mental disabilities. Vocational
rehabilitation is a part of medical. It's due to your physical
condition.
Seventh, our veterans now from the Gulf War and those
returning from Iraq are now at this time being diagnosed with
illness not yet known. We need to expand our technology to help
these veterans and their families so they can cope with their
personal problems.
By extending our medical staff at our clinics, it won't
take 2 or 3 months or more for an x-ray, MRI, and other
specialized tests that need to be done to identify the cause of
the veteran's illness or his disabling injuries so the veteran
can be placed in various programs in mental, physical, or
vocational areas so the veteran can start to lead a fruitful
and normal life in our society.
Eighth, single veterans are being discharged from the
hospital, but still are not able to care for themselves, and
they can't get any home care since cases are so backlogged,
they have to go on a waiting period. We need a home care nurse
here on the island of Maui and Molokai and Lanai.
And also after hours, if you need to go to emergency and
use your VA card, about 2 or 3 months later you get a notice
from the VA that your emergency visit was not covered since it
was not related to a disability or since the attending
physician stated that you were OK on the checkup at emergency.
On behalf of the veterans of the State of Hawaii,
especially the county of Maui, and all their families, I would
like to ask all the Members of the Senate Committee on
Veterans' Affairs, along with the Veterans Administration
Pacific Islands Healthcare System Director and staff, for their
support of these men and women who committed a part of their
lives and well-being to defend and protect our great Nation,
the United States of America.
Will the Committee now, along with their constituents, give
their full support to our veterans and provide a healthcare
that is second to none and a budget to surpass the costs of
administering the greatest healthcare to all our veterans.
Thank you. May God bless America, its people, the armed
forces, and especially its veterans and their families.
[Applause.]
[The prepared statement of Mr. Evangelista follows:]
Prepared Statement of Rogelio Evangelista, President,
Maui Veterans Council
Mr. Chairman Larry Craig, Senator Akaka, and distinguished Members
of the Senate Veterans Affairs Committee, VAPIHCS Director Gen.
Hastings and Staff, thank you for giving me this opportunity to come
before you today to discuss the state of VA care in Hawaii, home to
more than 110,000 veterans and especially for the more than 10,000
veterans living in the County of Maui, which comprises the three
islands of Maui, Molokai, and Lanai out of the eight islands that make
up the State of Hawaii which are all separated by the ocean.
The excellent medical efforts of the Maui CBOC [Community Based
Outreach Clinic] with the support of the Spark Matsunaga Center on
Oahu, and the Tripler Army Medical Center have been extra ordinary. I
would at this time like to take a moment to stress the unique nature of
health care here on Maui, Molokai, Lanai, and to also include Kauai,
and Hawaii.
First, by being on the State Veterans Advisory Board for over 9
years and on the VAMROC [Veterans Administration Medical & Regional
Office Center] Advisory Board for over 5 years and as a Disabled
Veteran, I have understood the stress and witnessed the bureaucracy
that Veterans are faced when receiving health care from the Veterans
Administration. They must be able to pass the Means Test by having
limited income jointly with their spouse, so that if they need to go to
Oahu, or the Mainland for specialized care that is not service
connected, they will be provided airline transportation, and this are
for any Veteran with less than 30 percent disability that uses the VA
Health Care System as their Primary Health care. If the Veteran do not
qualify on the Means Test and he or she has a disability of less than
30 percent then the Veteran must pay their own transportation to go to
Oahu, or the mainland. Veterans on the Mainland can drive to the VA
hospitals and not worry about passing any Means Test. VA states it is
cheaper to have the exam or procedure done on Oahu with the Veteran
paying about $145.00 for a round trip ticket, instead of having the
Veteran see a local provider on the island that he resides on. Veteran
bills are even being sent to collection agencies because the VA takes
so long on paying for the services from outside providers.
Second, as I look at our aging Veteran population, there are 100
percent disabled veterans in Nursing homes on Maui with the families
paying over $7,000.00 per month for their health care at those Nursing
homes plus their medications and its hard for the families to send them
to Oahu to the Center for Aging and there will be no family support
because they can't fly to Oahu everyday to see the Veteran. Is it
possible for the VA to do a partnership with Hale Makua, a Nursing home
on the Island of Maui for the Veterans living on Maui. Why is Hawaii
and Alaska the last 2 states that do not have any VA hospital, what
happened to a Federal mandate that states that there should be a VA
hospital in each state.
Third, our CBOC's, on all the neighbor islands, even with the
experienced and dedicated staff, they are underpaid in comparing with
the mainland VA staff, and they are also overworked, we need more
staffing and we need more office space, on Maui, if the VA can buy out
the building that CBOC is located in and the vacant lot next to the
building and look at expanding services with more staff, we now have
volunteers but they are limited in the scope of work that they can
perform. There is now one full time doctor 5 days a week, one part time
doctor 4 days a week, we need to upgrade our staff to provide the best
possible care for our Veterans, right now it takes so long to get an
appointment to see the doctor, for routine or specialized care, the
doctor has to come in from Oahu or the mainland. In order to provide
ongoing care to Veterans, first, the government must realize that
Veterans health care are part of the cost of war and that the
government needs to provide enough funding for VA health care to all
Veterans, second, the Veterans Administration along with the government
must identify and develop programs and use today technologies to help
Veterans in their daily lives, especially for our disabled veterans.
Combinations of advanced health care using new technologies will
greatly help all of our veterans and make their recoveries possible and
the long term relationship of being accepted back into society. Why is
VA funding always the lowest priority in our government, when we the
Veterans made our country the greatest Nation in the world.
Fourth, many of our Veterans are suffering from some sort of
physical or mental disability and would rather alienate themselves from
anything to do with the Veterans Administration due to many
contributing factors. All the red tape that they must go through to
even start to file their claim, something that happened over 30 years
ago and it is just being addressed today because of the Veterans health
status, be it physical or mental, Veterans are being informed to get
collaborating evidence from other Veterans that served with them and
might know something regarding the Veterans conditions or of an
incident that occurred. Most of this Veterans don't know where these
other veterans are now living and some of them just don't want to get
involved, but there are records that the military have so why can't the
Veterans Administration get those records to collaborate the Veterans
claim.
Fifth, Veterans are now paying $7.00 co-payment on drugs and
medication and the VA is also at this time exploring the idea of
raising the co-payment on drugs for Veterans that are being prescribed
for non-service connected medical problems, and these Veterans are
living on very limited financial support due to their physical and
mental conditions being attributed to their military career in one way
or another. They answered our Nations call when they were needed, why
can't our Nation now help them in their time of need, I ask and plead
with you the members of the Veterans Affairs Committee to lobby your
constituents and help our Nation's Veterans lead fruitful and dignified
lives.
Sixth, the Vocational rehabilitation program that try to help
Veterans in training them for a Vocation that they can excel in is
great, but now there are so much restraints being placed on being able
to qualify and the approval all now comes from Washington D.C. and not
done here locally like it used to be. There is so much paper work going
back and forth and it takes such a long time sometimes longer than 6
months for approval if it does get approved and by that time the
Veteran has already lost interest and have given up on the system. When
you apply for Vocational rehabilitation you will need specialized and
long term counseling and support from your case worker here and not
from somebody from Washington that knows you only as a number with no
personal knowledge of all your special needs as you continue with your
studies. There are Veterans here on Maui that don't even know of
certain benefits that they may be qualified to apply for due to their
physical and mental disabilities.
On behalf of the Veterans of the State of Hawaii, especially the
County of Maui and all their Families, I would like to ask all the
Members of the Senate Committee on Veterans Affairs, along with the
VAPIHCS Director and Staff for their support of these men and women who
committed a part of their lives and well being to defend and protect
our great Nation, the United States of America. Will the committee now
along with their constituents give their full support to our Veterans
and provide a health care that is second to none and a budget to
surpass the costs of administering the greatest health care to our
heroes.
Thank you, may God Bless America, its people, the Armed Forces, and
especially its Veterans and their Families.
Senator Akaka. Thank you very much, Rogelio.
Larry.
STATEMENT OF LARRY HELM, PRESIDENT, MOLOKAI VETERANS CARING FOR
VETERANS
Mr. Helm. Good morning, fellow veterans. I'd also say a
special mahalo to our group from Molokai that got up at 4 this
morning to catch the ferry to come over here for this.
[Applause.]
Mr. Helm. Senator Larry Craig, Chairman, Honorable Senator
Danny Akaka, aloha kakahiaka to you and your staff. Welcome to
Hawaii nei and to the island Maui. My name is Larry Helm, a
heavy combat Vietnam veteran. I represent 345 Molokai veterans
from all wars and conflicts. From the vsn of a Patsy Bird, the
Molokai Veterans Caring for Veterans Center, Koa Kahiko, which
means ``strong, wise, ancient warrior,'' formed 4 years ago
mainly for veterans to have a voice and address concerns on the
island of Molokai.
Because we are an island in the Maui County surrounded by
water, we therefore have been many challenges to get services
for Molokai veterans. Today, the Veterans Administration is
doing a lot more for the Molokai veterans. I thank you and ask
you to please continue. I'm sure that there are a lot of rural
``Molokais'' throughout this country that face the challenges
of caring for veterans.
Molokai has many combat Vietnam veterans that are finally
getting help. The island has a population of 7,000 residents,
and has contributed to this country greatly. We have a memorial
stone in the middle of town naming 10 World War II, 6 Korean,
and 5 Vietnam veterans who lost their lives for this country.
There is a wall in Washington, DC with over 58,000 names of my
brothers and sisters killed in action in country in Vietnam,
but we do not have a wall for over 100,000 that prematurely
died from wounds related to combat--Agent Orange, chronic PTSD,
physical wounds, et cetera. This issue has been sanitized.
In the last year on Molokai, Koa Kahiko lost 5 Vietnam
veterans. Spencer Eldridge, 56 years old, died 3 weeks ago. He
handled Agent Orange on a ship outside the Tonkin Gulf. Three
of our deceased veterans had just started to receive their
service-connected disability benefits. The Molokai community
has over 40 men and women who have served and are serving today
in Afghanistan and Iraq.
I speak for past veterans, but essentially for those
veterans who will return from the Middle East to Molokai. I
emphasize the importance of continuing and improving the mental
and physical healthcare they deserve. All service-connected
claims must be efficiently and hastily processed sooner, not
later.
The Molokai veteran community says thank you. The VA has
certified Dr. Hafermann, a resident of Molokai, to practice on
Molokai alongside with the medical team from Maui. I'd just
like Dr. Hafermann to stand up. He's a colonel who used to be
in charge of Travis Air Force Base.
[Applause.]
Mr. Helm. I ask to have more psychological help for our
veterans on Molokai. It takes 6 months to get an appointment
with Dr. McNamara, who is the Mother Teresa for the veterans,
and her time is limited.
[Applause.]
Mr. Helm. We need more of her or hire two more Dr.
McNamaras. Dr. Springer, a psychiatrist, will start this month.
Mahalo.
To have an inpatient nurse help for older Molokai veterans.
We need a mini-honor guard burial service for service-
connected veterans. Every veteran deserves that honor.
To not repeat the process that led us to lose many of our
Vietnam veterans' lives, who did not get psychological help
because of PTSD--suicide, despondence, hopelessness,
deterioration of their body. In combat, one size does not fit
all. Why would you want to revisit the studying of PTSD when
the psychiatric community has studied this scientifically from
all wars and has agreed that is a serious, permanent disorder
that affects many veterans. I hope the Government does not
water down the treatment for this mental disorder because of
budget restraints, especially for our returning veterans.
To please continue providing veterans' organizations the
opportunity to testify for the veterans' affairs. We heard
Senator [sic] Buyer wanted to stop the VFW, DMV, the American
Legion, et cetera, from giving testimony. That is absolutely
not acceptable.
Starting a national--I suggest starting a national low
interest credit union and credit card service for service-
connected veterans and all other veterans, it could be a
profitable and honorable thing to do for the veterans.
That spouses of 100 percent service-connected veterans
qualify to receive their husband or wife's benefits 5 years
rather than 10 years. Many veterans die prematurely and leave
their spouse empty.
Senator Craig, Senator Akaka, mahalo for your time and the
opportunity to testify here this morning, and hope you consider
all that I have said. In my opinion, veterans are the soul of
this country. The American people required that it be mandatory
that the Congress provide whatever budget is needed to care for
the veterans.
May Akua bless you and the United States of America. Aloha,
aloha no.
[Applause.]
[The prepared statement of Mr. Helm follows:]
Prepared Statement of Larry Helm, President, Molokai Veterans
Caring for Veterans
Aloha Kakahiaka (Good Morning) to you and your staff. Welcome to
Hawaii nei and to the island of Maui. My name is Larry Helm, a heavy
combat Vietnam Veteran. I represent 345 Molokai Veterans from all wars
and conflict. From the vision of Patsy Bird, the Molokai Veterans
Caring for Veterans Center-Koa Kahiko (strong, wise, ancient warrior)
formed 4 years ago mainly for Veterans to have a voice and address
concerns on the island of Molokai.
Because we are an island in Maui County surrounded by water, there
have been many challenges to get services for Molokai Veterans. Today
the Veterans Administration is doing a lot more for the Molokai
Veterans. I thank you and ask you to please continue. I'm sure that
there are a lot of rural ``Molokais'' throughout this country that face
the challenges of caring for the veterans. Molokai has many combat
Vietnam veterans that are finally getting help. The island has a
population of 7,000 residents and has contributed to our country
greatly. We have a memorial stone in the middle of town naming ten
World War II, six Korean, and five Vietnam Veterans who lost their
lives for this country.
There is a wall in Washington DC with over 58,000 names of my
brothers and sisters killed in action in country in Vietnam but we do
no have a wall for over 100,000 that prematurely died from wounds
related to combat i.e. agent orange, chronic PTSD, physical wounds,
etc. This issue has been sanitized. In the last year on Molokai, Koa
Kahiko lost five Vietnam veterans. Eldridge Spencer, 56 years old, died
3 weeks ago from leukemia due to agent orange exposure. Three of the
deceased veterans had just started to receive their service connected
disability benefits. The Molokai Community has over 40 men/women who
have served and are serving today in Afghanistan and Iraq.
I speak for past Veterans but especially for those veterans who
will return from the Middle East to Molokai. I emphasize the importance
of continuing and improving the mental and physical health-care they
deserve. All service connected claims must be efficiently and hastily
processed sooner not later.
The Molokai Veteran Community says ``thank you''. The VA has
certified Dr. Havelman, a resident of Molokai, to practice on Molokai
along side the medical team from Maui.
I ask:
<bullet> to have more psychological help for veterans on Molokai.
It takes 6 months to get an appointment. Dr. McNamara is the Mother
Theresa for the veterans and her time is limited. We need more of her
or hire two more Dr. McNamaras. Dr. Springer, the psychiatrist will
start this month. Mahalo.
<bullet> to have inpatient nurse help for older Molokai veterans.
<bullet> for a mini honor guard burial service for service
connected veterans. Every veteran deserves the honor.
<bullet> to not repeat the process that led to the loss of many
Vietnam veteran lives who did not get psychological help because of
PTSD (suicide, despondence, hopelessness, and deterioration of their
body). In combat, one size does not fit all. Why would you want to
revisit the studying of PTSD when the psychiatric community has studied
this scientifically from all wars and has agreed that PTSD is a serious
permanent disorder that affects many veterans. I hope the government
does not water down the treatment for this mental disorder because of
budget restraints; especially for the returning Veterans.
<bullet> To please continue providing Veteran organizations the
opportunity to testify for veterans affairs. We heard Senator Buyer
wanted to stop VFW, DMV, etc. from giving testimony. That is absolutely
not acceptable.
I suggest:
<bullet> starting a national veteran low interest credit union and
credit card service for connected veterans and other veterans. It could
be a profitable and honorable thing to do for our veterans.
<bullet> that spouses of 100 percent service connected veterans
qualify to receive their husband/wife veteran benefits 5 years rather
than 10 years. Many veterans die prematurely and leave their spouse
empty.
Mahalo for your time and the opportunity to testify here this
morning and hope you consider all that I have said. In my opinion,
Veterans are the soul of this country. The American people require that
it be mandatory that Congress provide whatever budget is needed to care
for Veterans. May Akua bless you and the United States of America.
Aloha, aloha no.
Senator Akaka. Mahalo. Mahalo, Larry.
And now we'll hear from Dr. Kekahuna.
STATEMENT OF ROY W. KEKAHUNA, PhD, DISTRICT DIRECTOR, BLINDED
VETERANS ASSOCIATION
Dr. Kekahuna. Mr. Chairman and distinguished Members of the
Committee, thank you for the opportunity to come before you to
discuss the care of blinded veterans in general, and in
specific, the needs of the blinded veterans in the State of
Hawaii.
By way of introduction, I represent 10 Western States. In
August, I will represent Hawaii and Alaska. Idaho, Mr.
Chairman, happens to be one of the States in my District. I
have 18 regional groups. Hawaii's regional group is currently
defunct, so that's one of the reasons they asked me to come
back to Hawaii and put it together.
Showing my background, I was born and raised here in the
islands, originally from Molokai. My ancestor was the King of
Maui; is interred on the island of Maui. His name was Alapai
Nui in the ancient history of the Hawaiian islands. So there is
a lot here for me in the State. That's why I'm here today. I
have been to three blind centers, so I know what the blinded
veterans of the State of Hawaii really need and deserve. I
currently live in Las Vegas, and I have been to the Blind
Center, so I know what the blinded veterans of the State really
need.
I would like to take a moment to stress that blindness is a
catastrophic event in a veteran's life. Immediately, the
veteran loses his or her independence. The uniqueness of this
situation is that for the rest of this veteran's life, they
will need assistance during 25 to 80 percent of their daily
activities.
Another unique feature with a good percentage of the
blinded veterans is that they have dual sensory loss (for
example, hearing and visual loss). I have both hearing and eye
problems from my injuries in Vietnam. Besides having vision and
hearing problems, many of the blinded veterans have dual
disabilities, such as the loss of use of an arm. I'm sure
Senator Inouye could talk to that, as well as anybody else.
To give everybody an idea of what we have to go through in
our life, if you'll all close your eyes. Keep them closed.
Reach with your right hand for the left hand of the person next
to you. Pretty hard to do, isn't it? Well, welcome to my world.
I use the Veterans Administration healthcare facilities for
my medical services. Most area's of my medical experiences with
VA have been favorable. Veterans Administration's care for
their blinded veterans is behind the curve.
Veterans Administration in general is behind the curve in
care for their blinded veterans. Their care for the blinded
veterans of the State of Hawaii is in the dark ages. I cite
myself as an example. I came home from Vietnam totally blind.
There were no low vision services in the local Veterans
Administration. Today, there is still no low vision services in
VA, almost 40 years later. Blinded veterans of the State of
Hawaii are less than stepchildren. I believe that this is
criminal treatment of Hawaii blinded veterans.
Currently, the VA in Hawaii provides a part-time Vision
Impairment Services Team Coordinator, called a VIST. The
coordinator is responsible for case management of all blind and
legally blinded veterans. They do not train blinded veterans.
The VIST coordinator works only 5 percent of her work period on
blinded veterans. This is inefficient for the workload.
I'll give you an example because I did some research before
I got here. There currently 50 veterans in the vision program.
In the VA, there are 200 blinded veterans registered with eye
clinic in the State of Hawaii. In the area of high risk, there
are 700 veterans currently enrolled in the VA Eye Clinic. These
numbers only reflect the veterans who have come out of the
woodwork, and realize that they are due these benefits.
Ho'opono, the State of Hawaii's vocational rehabilitation,
is the only low vision/blind service currently available to
veterans. It is VA's responsibility to care for the veterans as
it promised. The blinded veterans of the State of Hawaii need
your support to gain equal treatment, which their brother and
sister veterans of the other 49 States have.
As an example--some more research--VA outlying clinics are
not equipped to assist visual impairment. State Rehab for the
Blind is a 9-month program, where the VA has better programs
located on the continent. There are no housing facilities to go
with this. Our island veterans, such as people on Maui,
Molokai, and Lanai have an expense that is insurmountable just
to get there. The non-service-connected veterans have no chance
unless they pay for it out of their pocket presently.
I applaud the VA and the Department of Defense, DoD,
partnership that they have here in Hawaii. Together they have
the makings of a perfect harmony to service the blinded
veterans. In this opportunity scenario, the Army Medical
Detachment, AMMED, at Tripler Army Medical Center, TAMC, as
it's called, can provide a full-time low vision doctor, while
would provide a full-time VIST/Blind Rehabilitation Outreach
Specialist, BROS.
The State of Hawaii's geographical island makeup supports
the need of a VIST/BROS full-time specialist. The individual
who operates from this position can provide both casework and
training for the blinded veteran while on the different
islands. I would highly recommend the creation of this position
as soon as possible.
In the best of times and the best of situations, the
blinded veteran should attend a VA Blind Rehabilitation Center.
I notice that we have people here from Palo Alto, California
who work at the Blind Rehab Center, and I applaud you. I am a
graduate.
Ho'opono's program is 9 months long. Anybody on the outer
islands, on all of the islands, who just have the
transportation costs, make it almost inaccessible for them to
attend. Blinded veterans on the island of Oahu currently have a
place they can go for training. The VA should send other
blinded veterans to the Blind Rehab Centers, or they should
have specialists on each and every island to take care of these
veterans.
I have experienced the excellent medical services provided
at TAMC. I have been to four sessions at different Blind
Rehabilitation Centers and received excellent training. I
believe that it is important to fund the VA, Department of
Defense medical facilities, and staff them properly. I don't
care how good your facility is; if you are not staffed properly
it will not work.
On behalf of blinded veterans and their families, the
people of Hawaii, I thank the Members of this great institution
for providing us with the funding and resources to take care of
the finest men and women that I've had the pleasure to
represent today. Thank you.
[Applause.]
[The prepared statement of Mr. Kekahuna follows:]
Prepared Statement of Roy W. Kekahuna, PhD, District Director,
Blinded Veterans Association
Mister Chairman and distinguished members of the committee, thank
you for the opportunity to come before you today to discuss the care of
blinded veterans in general, and in specific the needs of the blinded
veterans in the State of Hawaii.
I would like to take a moment to stress that blindness is a
catastrophic event in a veterans' life. Immediately the veteran loses
his or her independence. The uniqueness of this situation is that for
the rest of those veterans' lives, they will need assistance during 25
to 85 percent of their daily activities.
Another unique feature with a good percentage of the blinded
veterans, is that they have dual sensory loss (for example, hearing and
vision). Many of the blinded veterans have multiple disabilities (an
example, loss of limbs).
A BRIEF DEMONSTRATION OF WHAT A BLIND VETERAN HAS TO GO THROUGH
TO DO A SIMPLE TASK
I use the Veterans Administration (VA) Health Care Facilities for
my medical services. Most areas of my medical experiences with VA have
been favorable; Veterans Administration's care for their blinded
veterans is behind the curve.
Veterans Administration in general is behind the curve in care for
their blinded veterans; their care for the blinded veterans of the
State of Hawaii is in the dark ages. I cite myself as an example. I
came home from Vietnam totally blind. There were no low vision services
at the local Veterans Administration. Today, there is still no low
vision specialist at the VA. Almost 40 years later, the blinded
veterans of the State of Hawaii are less than a stepchild. I believe
that this is criminal treatment of our Hawaii Blinded Veterans.
Currently the VA in Hawaii provides a part-time Vision Impairment
Services Team Coordinator (VIST). The coordinator is responsible for
the case management for all blind and legally blinded veterans. They do
not train blinded veterans. The VIST coordinator in Hawaii works only 5
percent of her work period on blinded veterans cases. This is
inefficient for the caseload.
Ho'opono, the state of Hawaii's vocational rehabilitation is the
only low vision/blind service currently available to veterans. It is
VA's responsibility to care for its veterans as promised. The blinded
veterans of the State Hawaii need your support to gain equal treatment,
which their brother and sister blinded veterans of the other 49 States
receive.
I applaud the VA and the Department of Defense (DOD) partnership
that they have here in Hawaii. Together they have the makings for a
perfect harmony to service the blinded veterans. In this opportune
scenario the Army Medical Department (AMMED) at Tripler Army Medical
Center (TAMC) can provide a full time low vision doctor while VA would
provide a full time VIST/Blind Rehabilitation Outreach Specialist
(BROS).
The State of Hawaii's geographical island makeup supports the need
of a VIST-BROS full time specialist. The individual who operates from
this position can provide both casework and training for the blinded
veteran while on the different islands. I would highly recommend the
creation of this position as soon as possible.
In the best of times and in the best situation the blinded veteran
should attend a VA Blind Rehabilitation Centers (BRC). The closest BRC
for Hawaii's' blinded veterans is Palo Alto, CA. The current
configuration of the blind services training at Ho'opono only works for
those veterans residing on the island of Oahu. There are no resident
facilities for the other island veterans.
I have experienced the excellent medical services provided at TAMC.
I have been to four sessions at different BRC's and received excellent
training. I believe that it is important to fund the VA, DOD Medical
facilities, and staff them properly to support our current blinded
veteran population and the next generation of blinded veteran that is
already here from the conflicts/wars that we fight. This means keeping
the promise.
On behalf of the blinded veterans and their families, I thank the
members of this great institution for providing us with the funding and
resources to take care of the finest men and women that I have had the
honor to represent here today.
Senator Akaka. Before I call on Lui, I just want to say
something about what Larry mentioned while he was testifying,
and that was he said aloha kakahiaka. And for those of you who
don't know Hawaiian, what he said was good morning. Kakahiaka
is ``morning.'' Thank you, Larry.
And now we'll hear from Lui, Lui Obado.
STATEMENT OF DWIGHT ``LUI'' OBADO, ORGANIZER, LANAI VETERANS
ORGANIZATION
Mr. Obado. Hello. Thank you, everybody. Thank you for
attending. I appreciate your calling--bringing Lanai over here.
Welcome all to Lanai.
I know the weather in Washington. I was stationed in
Aberdeen Proving Ground, and I also was stationed in Fort Lee,
Virginia. I know your weather, and I love being away from it.
[Laughter.]
Mr. Obado. So welcome to Lanai. This is a good day to be
coming to Hawaii. This is a good day to be in Hawaii.
Now, let me tell you how it is where the rubber meets the
road. We are the ones--Molokai and Lanai are the ones--that are
really hurting. OK? Let me tell you about how we're really
hurting.
First off, we have post-traumatic syndrome cases in Lanai.
They affect our wives. Our wives is affected by getting wife
abuse. And they don't want to come to Lanai because they don't
have their money reimbursed.
We make an arrangement. We pay our own arrangement for our
boat from Lanai to Lahaina. Then from Lahaina, we should catch
that DAV van. All right? But if we get the DAV van, the DAV van
supposedly picks us up at Lahaina and bring us to Kahului. But
the DAV van shows up only 40 percent of the time, and we have
to wait a whole hour at Lahaina Airport--I mean, Lahaina
Harbor--for us to make an arrangement and get a taxi if they
don't show up. The taxi costs us, again, the average of $47
from Lahaina to Kahului.
Now, the DAV van driver hang up the keys at 1. If our
appointment going to keep us after 1, then we've got to go
through the people again and find a taxi and cost another $47
from Kahului back to Lahaina, and another $30 from Lahaina to
Lanai. That's money out of our pockets that we can't claim.
Right there. And that's [inaudible] to me, but [inaudible] and
VA. And he gets there all the time. All the time. But it's
money out of our pockets that we cannot claim.
And we're VA. We signed the dotted line to join the
military. When we sign that dotted line, we put our lives on
the line and we put our families on hold. And when we did that,
we gave that 100--more than 110 percent. Now we've got to have
the 110 percent back. We need that.
In Lanai, it's out of sight, out of mind. I wrote a
Committee to say, reimburse us for our trip here to make this
appointment. They said, no. You get a--make a fund-raising to
support your trip to Maui, and [inaudible] or not. You know, I
don't understand. You explain that to me. OK? If I am
[inaudible], then this is the [inaudible] function, then you
should be reimbursing us for our vote. But money out of our
pockets.
I pay the dues for this organization. Money out of my own
personal pocket for our organization. I don't have money back.
None. OK? It's a lot of stuff that Lanai people pay out our
pocket, and we don't have--we can't claim it back. Period.
Another one we can't claim it back is another health
insurance, which is TRICARE. The VA clinic over here tells me--
I'm going to give you my experience--tells me that they won't
service me because I have health insurance. So I use my health
insurance, which is TRICARE, because I'm a retired military. I
use the TRICARE, and I get the bill. So I sent the bill to VA.
VA said, no. You pay your bill.
All I wanted was a B-12 shot. That's all I wanted. All I
want is them to bring a syringe to Lanai and use the medication
that I brought from the mainland and give me a shot. And their
answer, the VA answer, is no. Use your insurance. And I did,
and did I claim it? I mean, did I get the money back? No. This
is where the rubber meets the road.
Lanai, we all have the problem. The problem is sitting
right there, too. You see all of us have come. We're all 100
percent disabled. We're all a Category 1. And for the VA clinic
to tell us, Category 1 personnel, who is more than 100 percent
disabled, tell me that they're not going to service me and for
me to use my insurance? No. My insurance is for my wife and my
son. I use the VA clinic system.
And now I come over here and they says, no. We won't
service you. I'm a Category 1 personnel. What are you doing,
you know? Don't you know your own regulations? So I am called--
this VA hospital called me a troublemaker. I am not a
troublemaker. I'm just asking you to read the regulation,
understand your regulation, and do what you're supposed to be
doing. That's what I am doing. So I'm a troublemaker. Oh well,
you know?
I'm trying to stay on schedule here. I don't want to go
over. So that's fine. I didn't bring any write-up.
Anyway, back--oh, I am dyslexic, ADD, and brain-injured.
So--and I also wear a hearing aid. I don't have it on today
because I didn't bring my spare with me. So I'm very
dysfunctional. You see? I got a dysfunctional veteran hat:
``Leave me alone.''
[Laughter.]
Mr. Obado. [Inaudible.] My permanent VA clinic is in
Vancouver, Washington. When I come to Hawaii, I'm a visitor to
Hawaii. But I'm helping all the veterans in Lanai because they
are not getting the care I'm getting from the mainland. OK?
My care, I get it all from the mainland. And I come over
here and I see Lanai don't have any kind of care. We have care
once a month. OK? We have [inaudible] officer, which is Bill,
come over here once a month. Once a month is not going to cut
it for Lanai because Lanai, we need the veterans--like Bill, we
need a veteran to sit down with Bill and do our claim.
[Inaudible.] Once a month.
You know, if you live in Maui, just run down to the clinic.
Make an appointment and run down to the clinic. What's it going
to cost you? It costs you gas money. That's all. It costs us a
boat trip, which is $60, a taxi fare, which is $47 one way, and
they hang up the keys at 1, and then it costs us another $47
back this way. OK?
I'm 3 minutes over. Anyway, I want to let you guys know
that I am the only one in all of Hawaii that [inaudible] the
United States Army [inaudible]. And that's why I am so eager to
help the veterans in Lanai to get something what is they
deserve when they sign that dotted line. Thank you.
[Applause.]
[The prepared statement of Mr. Obado follows:]
Prepared Statement of Dwight ``LUI'' Obado, Organizer,
Lanai Veterans Organization
We respectfully call to your attention to the seriousness of the
problem of Veterans medical care in Lanai Hawaii. We wish to emphasize
the importance of the Veteran's Medical care of one of the most needed
health benefit and vital to those veterans residing in Lanai.
Federal policymakers are unaware of the many challenges faced by
Lanai veterans due to geography of our State. We would need to
introduce a Bill to provide a new satellite clinics in both health-care
and mental health service.
The agency also would have to improve mental health and substance
abuse services in Lanai. We have a few veterans who are not right in
their heads because of their war experiences. You would call this
chronic sickness (PTSD). They have spaced out thoughts and attitudes.
Even to a point of blacking out and getting an attack. Loosing tempers
and yelling at their families and friends. One of our Veteran wife had
to lock her self in the bedroom because her husband was yelling at her
and stabbing the door with a knife. He is a Korean veterans and a
Purple Heart recipient. I always have to go to his house when his wife
calls me when he has his attacks and he always tells me he doesn't know
what he was doing. He doesn't want to go to Maui for treatment because
it costs him too much money and he had problems in the past of
collecting his travel expense back from VA. See VA letter pertaining to
his case and my travel case. The ``red tape and bureaucracy'' involve
in obtaining any kind of medical care here in Lanai can be tough and
frustrating to cope with.
I can readily appreciate the strain on the Federal budget;
nevertheless, we ask that you consider giving us your consideration of
a satellite clinics with both health-care and mental health service.
On behalf of the veterans' in Lanai Hawaii, We would like to thank
you for helping us work together to accomplish our goal and what we
cannot do alone. God Bless the United States of America for the U.S.
Senate, Committee on Veterans' Affairs to helping us. Please show your
patriotism and that you care for our veteran's. Please make the
deference and love the country we veterans' kept free and great.
Chairman Craig. Lui, thank you very much for your
testimony. I have a couple of questions, but I want to make a
couple of observations prior to those questions.
First and foremost to all of you, we believe your testimony
to be heartfelt and directed appropriately. Part of the reason
we're here is to not only understand where there are problems,
but also to create, where we can, a greater evenness of
coverage and healthcare access.
And we also know that there are challenges. We can't have a
veterans hospital everywhere. In fact, today, quite the
opposite is happening across the country. Today, with
technology, we're not building bricks and concrete any more as
much as we used to. And no one else in the healthcare field is
because of the use of technology.
I think, Larry, you mentioned, possibly you, Larry,
telemedicine as an approach. That is only one of many that are
allowing healthcare professionals to outreach in ways that
heretofore have not--we've not been able to do in rural
environments of the kind that you live in here or that my
veterans live in Idaho.
There is no question we are being able to extend healthcare
in areas where we could not before, or facilitate those who, as
you said, have to travel by boat. In situations in my State, we
have people who get in cars and drive 250 and 300 miles to gain
access to VA healthcare.
So there are similar kinds of problems, and I think it's
important that we hear those and that we attempt to resolve,
where we can, those kinds of difficulties that do exist.
Let me say this because I am extremely proud of the work
that has been done over time. There are a variety of illusions,
and I use that word, illusion, as to what taxpayers and
Congress are or are not doing for America's veterans.
But here's a reality: Of all the budgets that I look at,
the one budget that has consistently had higher rates of
increase over the last decade, over any other budget, has been
the veterans' budget. Why? Because of the direct and open and
obvious commitment that not only the Congress has, but we think
Congress is reflective of America's concern.
You watched, I think, with great interest the debate we
went through this past year. And we nearly doubled the budget
as it was once proposed. It isn't a partisan issue. President
Bush proposed a budget. President Clinton proposed different
budgets. Congress disagreed, and put more money into it. And
that is consistently the case.
Over the last decade, we've seen a near-average increase of
9 percent, on the whole, on an annualized basis, in the
veterans' healthcare. If you'll notice today's press,
healthcare costs this year inflated at a lower rate of about 9
percent.
We are not able to meet all of the needs or all of the
perceived needs. We do have to establish priority. We do have
to look at those who are in greater need and have less means
within the veterans population to do so.
It is difficult for most who look at our Government who
think, well, if you can spend money over there, why can't you
spend money over here in a different area? Veterans' budgets,
the VA budget, versus Health and Human Services, versus
Agriculture, versus Defense, are very clear and separate
budgets, and they are viewed as that. And they don't commingle.
And as much as we are--and I believe that to be--Danny and
I, advocates for veterans, we have advocates there in Congress
for all other areas of expenditures. And they fight as
aggressively for their money as we do for your money.
And as a result, we're about to go through another budget
cycle. The President will propose a budget. The Congress will
look at it. This authorizing Committee that Danny and I serve
on will look at the VA budget very, very closely. We will make
recommendations to the Budget Committee. The Budget Committee
will be looking at it. The Budget Committee will then lay out a
level of expenditure based on what they think is necessary, and
we will work the process down.
But there is a bottom line, and I'm very proud of that
bottom line. That is that VA has been extremely well funded for
the last decade as it compares to other areas of our
Government. The only other area that we see larger increases is
defense, and it's obvious to most of us why that's occurred,
since 9/11, at least, in the last good number of years.
So as we work these issues through, and we will continue to
do so. Not only do we work to get the money, but we also work
to re-establish priorities or to look at where there are
greater needs, to see if older services once offered are still
legitimate, or if we opt to shift money to other areas and
categories within VA healthcare, to do so.
Having said all that, Danny mentioned in his opening
comments something that, again, both he and I are extremely
proud of. Over the last several years, in numerous write-ups in
national journals across the country, as a result of an
analysis of quality care delivery, VA has come out No. 1.
I think if we think back just a few years, that was not the
case. VA, when you as a veteran might have had alternative
healthcare access, might have chosen that over VA. Today, that
is simply not the case. As a result of us investing in VA
healthcare and upping its overall quality, we've also
accelerated the demand. Veterans have looked at it, when
available, as an option or a selection of first choice in their
healthcare.
Those are some of my observations as we work through this,
that we are very proud of the VA healthcare system. We do
recognize it as a quality healthcare delivery system. But
gaining access, gaining service, rural environments, difficult
geography, all of that complicates. There's no question about
it.
And I must say that where it cannot be delivered in one
location, is delivered in another, in a greater populated area,
trying to therefore facilitate cost of transportation and
movement so that veterans can get to those facilities. I don't
think you can expect in remote environments comprehensive
levels of care that oftentimes we experience in the more urban
environments. It is simply a reality, although it's changing
because of the technologies that are being allowed to us today.
Let me ask you, Dr. Roy, with your blind--your experience
as an injured veteran and a blind veteran, you mentioned in
your testimony that you've been to a number of VA blind
rehabilitation facilities for training, or BRCs, as they are
generally residential programs which require long stays away
from family.
Dr. Kekahuna. Right.
Chairman Craig. And I'm sure you would agree that many
veterans do not want to spend long days away from their
families. That's a difficulty.
So the question would be: Do you believe that blind
rehabilitation outpatient specialists are an adequate
substitute to a residential program ? Or is the residential
program of more benefit?
Dr. Kekahuna. I believe that the outreach program here in
Hawaii would be most beneficial. In most instances, those
veterans that can go to the Blind Rehabilitation Center should
go there because it gives you the opportunity to become who you
can be, all you can be, all in one place.
But because of the situation and the geographical location,
blind outreach specialists would be most beneficial here
immediately. Getting the veterans then onto the program to go
forward to the BRC would be the next step because even after
they get the basic training--at least they can survive at
home--with the outreach program, then the VA should get them to
the blind center so that they can get all of the equipment and
the education that's needed to facilitate their lives.
I went to Hines in 1968. I went to Palo Alto because,
through the grace of God and medical science, I've had vision
back in one eye, and in 1988 I became legally blind again. And
becoming legally blind, I was able to go to--to Palo Alto
because they had good computer access to get my PhD. So that's
why I went to Palo Alto, because at that time, even that was a
scary place. Let me tell you why.
[Inaudible]. So by the time I went back to college and 6
months later, my computer was out of date. It's no longer that
way, and that's a blessing for the veterans that go there now
because they get the latest equipment and help them do what
they need to do for their lives.
But outreach, yes, by far in this State.
Chairman Craig. Well, I thank you for that. I will disagree
with that observation. I think that clearly to gain those
course skills that you need, you need that clinical/student/
classroom environment that, by the nature of its costs and
realities, can only be put in certain locations. And we simply
have to take the veteran to that location instead of expect
that kind of facility in others.
Danny, let me turn to you. And again, gentlemen, your
statements have become a part of the official record of the
Committee. We thank you for your time and your commitment. Your
work as advocates of veterans, that's greatly appreciated.
You've been loudly heard today. Thank you.
[Applause.]
Senator Akaka. Thank you very much, Mr. Chairman, for your
remarks about the system. And I want to tell you that, as I
mentioned, that working with Larry has been great. We together
have been looking at better ways to try to service the
veterans.
And with your kind of help, with your testimony in Hawaii
and elsewhere, this will help us do that, as I mentioned in my
remarks. You can help us to help you. This is what we're trying
to do here. So Larry and I will continue to work hard on this
Committee and try to take care of some of the problems that we
hear, not only in Hawaii but across the country.
I'd like to ask a question of Mr. Helm, of Larry. In your
testimony, you state that Molokai's veterans must wait 6 months
to receive psychiatric care. Can you tell me about some of the
problems that arise when veterans have to wait so long for
care?
Mr. Helm. Senator, we do have a large population of Vietnam
veterans, and because for many years the VA is finally catching
up getting these veterans on line to get mental health, there's
quite a few of them.
And Dr. McNamara just has so much time. She comes up there
twice a month now. She used to come up once a month. So to see
5, 6, 7, 10 patients a day in an 8-hour or how many hours she's
out on the island--she's got to come back in the afternoon; she
comes in the morning--there's not enough. So sometimes it
causes problems. The veterans get impatient. There's, you know,
some problems at home and stuff like that. But it's been an
ongoing thing for many years.
So if we could get Dr. McNamara a little bit more, it
probably could fill the void. It's, I think, 5 months? If a guy
goes to you, 3 months to 5 months? Yeah. It's down to 3 months
now that she's coming twice a month. So if we could get her
three times a month, that might mean more guys could get the
help that they need.
Senator Akaka. Mahalo for your response.
Mr. Obado, Lui, I was especially concerned to hear that
veterans may not travel from Lanai to Maui for treatment
because of what you said and issues they have collecting back
money from travel reimbursement. And you have covered this
pretty well.
My only question to you would be: Do you have an idea on
how that could be done better?
Mr. Obado. I think that ideally it would be better to have
a satellite clinic in Lanai so they can, even through
television, talk to another veteran doctor, and use our Straub
Clinic, our doctor in the Straub Clinic, to have a satellite
clinic, and they can talk to a VA clinic through a satellite.
We have a doctor, Dr. Gasper. He used to be a doctor to a
VA clinic. So he knows what it takes to help a veteran. And we
have one on there. But he can't do it, because now he's a
doctor for the Straub Clinic. But if he had the camera to talk
to another veteran doctor, then we can go to the clinic
ourselves. Instead of coming all the way to Maui, we can go
straight to the Straub Clinic and the doctor there can just go
to the television and discuss with another veteran doctor, and
then that veteran will be helped.
Senator Akaka. Thank you. Mahalo for your mana'o.
[Applause.]
Senator Akaka. Larry, to buildupon Lui's statement, can you
please explain the obstacles that a veteran must overcome to
travel from Molokai to Maui for care? I understand that the
ferry runs during the morning and evening rush hours and
arrives on the western side of Maui near Lahaina town. So can
you----
Mr. Helm. Yes, Senator. We do have a ferry that comes every
day. We do have Island Air that flies from an airport. And the
cost of Island Air is $216 round trip for us to come over here
for care.
But very difficult sometimes to get the VA to tie in with
the veterans' timeframe to get a flight and coordinate the
appointment here. That's been the difficulty [inaudible].
Paperwork. Sometimes the paperwork did not get in, or the
VA thought that they are going to Honolulu when he's supposed
to come to Maui. And there's a lot of mix-ups like that. That
could be solved if there was a little bit more efficiency there
for the Molokai vets.
Also, now that we are having a doctor from on island there,
and now that we're having or supposedly getting a psychiatrist,
we also need an outreach counselor. We lost Robert Lewis, so we
need an outreach counselor to come to Molokai on a regular
basis. That would help the Molokai veterans a lot. We need a
lot more, but that would help us a lot.
We also need about $3 million to build our veterans center.
[Laughter and applause.]
Senator Akaka. Mahalo. Mahalo, Larry.
Dr. Kekahuna, thank you for providing us with that
demonstration of what a blinded veteran endures to complete
simple tasks. Can you tell us what you mean exactly by ``low
vision services''? What does that encompass?
Dr. Kekahuna. Low vision, in the VA vernacular, is people
that are not legally blind or blind. But when administering the
test for the low vision test like I go through, they use a lot
of different types of equipment, equipment that's needed here
in the VA in Honolulu, that tests your eyes to see what your
peripheral vision will be and what your central vision will be.
It lets, you look deep into the depths of your eyes and how
clearly you can see.
I believe that with the equipment and with trained
personnel, especially at the medical doctor's level, an MD,
that, you know, it would really help the veterans here.
Senator Akaka. Thank you. Mahalo.
Mr. Helm, Larry, I noted in your testimony that you
expressed the need for support of young returning war veterans.
Can you tell us what can be done to ease their transition from
the military to civilian life?
But before you answer that, let me tell you that one day I
was on Maui, and this would have been last year, and there was
a Hawaiian father who was hanging around outside. And so when I
was ready to leave, he was in a parking lot waiting for me. And
he wanted to talk to me.
And he told me the story. He said, you know, my son, before
he joined the Army, he used to go surfing. He used to go with
his friends. He was always out of the house. And he said, he
joined up. He got sent to Iraq when the Iraq War broke out. He
served in that war. And then following that, he retired and
came home.
And he told me, he said, what can you do to help my son? He
said, I can't even get him to surf. He said, he comes home and
he sits in the house. And, he said, that's not like him. So he
told me, visit with your friends. He said, [inaudible]. And
for, I don't know how many months since then, and he saw me, he
said, what can I do with my boy? You know, [inaudible].
And I thought I'd mention that. And I don't know what we
ought to say. Mahalo.
Mr. Helm. Yes, Senator. Unfortunately, that's the cost of
war, that returning young veterans, you're going to have a lot
of these kind of situations going on. But there is an asset in
every community in this country that if it was to be malama'd
or massaged or used, it's the combat veteran that is disabled
in every place.
If the VA could put these young guys in touch with these
veteran organizations or combat veterans, they know the talk.
They know the walk. They've been there, done that, and they
could be of great help to these young veterans. That should be
one way, besides the VA and the mental health department.
Of course, you need more people in mental health because we
have a lot of these young guys coming back. But that's an asset
that this country has, is the Vietnam veteran, combat vets, you
know, the Korean vets, have been there, have done that, know
how to respond to these guys and can help them.
Senator Akaka. Mahalo, Larry.
Rogelio Evangelista, in your testimony you mentioned that
although some veterans live on limited financial support, VA
continues to explore raising the co-payments for drugs
prescribed for non-service-connected patients. You also
mentioned that these same veterans may have limited resources
because of physical or mental conditions that can be attributed
to their service.
Can you please elaborate on that?
Mr. Evangelista. Well, Senator, in regards to that, I have
seen a lot of veterans suffering from PTSD. And because of
their physical and mental condition, they work menial jobs and
they don't last in those jobs long enough to be fruitful and so
forth. So they end up getting laid off. They end up getting in
trouble.
And the part is, if we can look at the veteran himself and
see how we can retrain him to get, you know, a different type
of profession other than just the low, menial type of jobs
like, for example, a computer expert, that part, it's something
that we can get in regards to this mentality, use it, and we
can be accepted back into society by that aspect.
Senator Akaka. Thank you. Mahalo. Thank you very much.
Before I say mahalo nui loa to this panel, I want to thank
all the veterans from Molokai, from Lanai, and of course from
Maui, those who traveled here today. It's not very easy--to
wake up, to catch the ferry, it's not easy, and I thank you all
for making such an effort to get here to testify and to be part
of this hearing.
So mahalo nui loa, and I'll turn it over to the Chairman.
Chairman Craig. Well, gentlemen, thank you again for your
testimony. It's great [inaudible]. Thank you. We'll excuse this
panel, and ask our second and last panel to come forward,
please. Thank you very much.
[Applause.]
Chairman Craig. All right. Let's get started with the
second panel. I'm very pleased today that we have--I suspect
it's a first on this island--the Under Secretary for Health,
Department of Veterans Affairs. This gentleman that I am about
to introduce is in charge. It doesn't mean you can blame him
for everything. But you can blame him for most. How's that?
[Laughter.]
Chairman Craig. Let me introduce to you the Honorable
Jonathan A. Perlin, MD, PhD, Under Secretary for Veterans
Affairs. He is accompanied by Dr. Robert Wiebe, VA Network
Director, VISN 21, Sierra Pacific Network. That's the greater
region of the Pacific area. Dr. James Hastings, Director of VA
Pacific Islands Health Care Services; and Dr. Steven MacBride,
Chief of Staff, Honolulu VA Hospital.
So all four are doctors. I don't know whether that's good
or bad.
[Laughter.]
Chairman Craig. I suspect in this business it's good. If
they were all four lawyers----
[Laughter.]
Chairman Craig. I'll let that speak for itself. Somebody
said, ``We'd be here longer.'' That's a reasonable observation.
Well, anyway, we thank these gentlemen very much for
accompanying us and being with us today. Sitting and listening
to your concerns is extremely important for those who make the
system work as well as it does, both from the Washington level
or from the regional or area level. So we thank you all for
being here, and I'll turn the testimony over to Dr. Perlin.
Doctor.
[Applause.]
STATEMENT OF THE HONORABLE JONATHAN A. PERLIN, MD, PhD, UNDER
SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS,
ACCOMPANIED BY ROBERT WIEBE, MD, VA NETWORK DIRECTOR, VISN 21,
SIERRA PACIFIC NETWORK; JAMES HASTINGS, MD, DIRECTOR, VA
PACIFIC ISLANDS HEALTH CARE SYSTEM; AND STEVEN A. MacBRIDE, MD,
CHIEF OF STAFF, VA PACIFIC ISLANDS HEALTH CARE SYSTEM
Dr. Perlin. Aloha, Chairman Craig, Senator Akaka. Mahalo
nui loa for the opportunity to be here with you all today to
provide testimony, and especially for the opportunity to hear
from the men and women of this great State and the veterans who
do in fact use VA for what Chairman Craig and you, with your
fine support and advocacy, have helped to shape as the world's
best healthcare.
I appreciate the opportunity to hear about ways in which we
can improve healthcare here in Maui and on Lanai and on
Molokai. And I think today that you will be pleased to hear of
a number of improvements that will in fact go a long way toward
addressing some of the issues that have been brought to our
attention.
It doesn't mean that we'll solve all issues today, but it
does mean that I think you will be very pleased to hear some of
the progress, and I think I heard in your testimony what I
experienced this morning when I had the great honor and
privilege of visiting the CBOC here at Maui.
What I saw this morning were a team of dedicated healthcare
professionals, staff also, from the Veterans Benefits
Administration who not only were technically excellent in their
delivery of healthcare services, but in fact, were absolutely
passionate and compassionate and really creative in the
delivery of those services to individuals that they felt were
nothing less than family, part of the community.
There were two doctors, a nurse practitioner. Everyone
knows the psychologist, Captain McNamara. In fact, a
psychiatrist will soon be joining the team who's also well-
known to the residents and veterans of Maui and Molokai and
Lanai, Dr. Springer.
And so in that vein, sir, I'm very pleased to be able to
report that the VA finds exceptional service to veterans of
Maui County through our VA Pacific healthcare system, which is
part of the Sierra Pacific Network, one of our 21 Veterans
Integrated Service Networks or VISNs.
We're proud to tell you that last year more than 80 percent
of our patients at the Maui Outpatient Clinic in fact rated
their care as, overall, very good or excellent. We made
investments in this clinic 3 years ago, spending more than
$200,000 to renovate this clinic into really one of the very
nicest.
The clinic staffing complement, as mentioned, includes a
full-time primary care physician, a part-time family practice
physician. It will include a psychiatrist shortly, the
psychologist I mentioned, a nurse practitioner. And we need to
extend these services to veterans with specialty care by
clinicians who actually rotate to the clinic, such as my
colleague, who is not only director of the VA Pacific Islands
Healthcare Care System, Dr. James Hastings, but also a
cardiologist who is well-known to both the patients and staff,
who comes to deliver cardiac care services at this particular
clinic.
To further serve the veterans of Maui County, we regularly
send VA staff not only from Honolulu, but also as far away as
California to bring in the most specialized expertise in all
areas. And if veterans services are not available here, then we
will make care available in the community, pay for care, in
places like Maui Memorial Hospital or in fact Tripler Medical
Center as well.
The facts are that last year we spent nearly $3.4 million
for non-VA care in the private sector to residents of Maui. I'm
also pleased to note that Maui Clinic has--in fact, very
shortly--plans for new patients, and it's very rare that
patients ever wait more than 30 days for their first
appointment.
Senators, the Islands of Molokai and Lanai are also, as all
know here, a part of our Maui County service area. And I
understand and heard loudly this morning that you've asked us
to improve services to those islands. Our staff do visit from
Maui, and while we don't operate formal outpatient clinics
there, we do provide service to an area which does have a
number of veterans.
The island of Molokai, approximately 260 square miles in
area, is home to 144 veterans among its population of 649
veterans who use VA for care. We currently send a primary care
physician to Molokai once a month, a nurse practitioner once a
month, a psychologist twice a month, and we lease space in the
community to provide these services.
In addition, we spent more than $250,000 last year to
purchase care in the community for eligible veterans living in
Molokai at places such as Molokai General Hospital. And we are
absolutely thrilled to welcome Dr. Hafermann, a retired Air
Force physician, to really be part of the VA community in
extending continuity of care on Molokai, supported by what
we'll discuss later, I'm sure, increased tele-health services.
I want to thank Senator Akaka for his help in helping to
bring Dr. Hafermann to VA as part of our community, and for his
support with Chairman Craig of veterans and VA in general. I
think it's really important that all here understand the degree
of passion and advocacy and courage that you, sir, Senator
Akaka and Chairman Craig, show not only for all veterans, but
in support of the Department of Veterans Affairs providing
services.
VA is working to establish additional tele-health
capabilities on Molokai, and has designated our presence there
as an outreach clinic. This allows us to establish an
electronic link between Molokai and Maui so that electronic
health records will also support the clinical care on Molokai.
The island of Lanai is approximately 140 square miles, and
VA estimates that the veteran population on the island is 229,
of whom 34 veterans use VA for healthcare or used VA for
healthcare last year. Similarly, we send a nurse practitioner
from the Maui CBOC to Lanai every few months to provide needed
primary care services. I believe this can be enhanced in part
through care in the community, and last year we spent $35,000
paying for care for veterans in the community, mostly for
services through Lanai Community Hospital.
Now, on Lanai, we are not planning to activate a formal
community-based outpatient clinic. Instead, we are looking at
other options to improve access. We're talking with the Hawaii
Health Systems Corporation, the Native Hawaiian Health System,
and local providers to potentially establish a federally
Qualified Health Center.
Since healthcare is currently limited to residents of
Lanai--for example, there are no mental health services on the
entire island--we're very excited about the possibilities that
this offers to improve healthcare, not just for veterans, but
for all residents of the island.
We're also looking at the feasibility of establishing tele-
health capabilities on Lanai, and are considering developing
contracts with other clinicians to provide care for veterans,
much like we're doing on Molokai.
And so in conclusion, with the support of Congress, but in
particular with your leadership, Chairman Craig, Ranking Member
Akaka, VA is providing unprecedented levels of healthcare
services to veterans residing in Maui County, and we look
forward to augmenting those with not only new staff such as Dr.
Hafermann, but additional tele-health capabilities, and look
forward to discussing some of the issues that were raised this
morning. Mahalo nui loa.
[Applause.]
[The Prepared statement of Dr. Perlin follows:]
Prepared Statement of Hon. Jonathan A. Perlin, MD, PhD, Under Secretary
for Health, Department of Veterans Affairs
Mr. Chairman and Members of the Committee, mahalo nui loa for the
opportunity to appear before you today to discuss the state of VA care
in Hawaii. It is a privilege to be here on Maui--the Valley Isle--to
speak and answer questions about issues important to veterans residing
in Hawaii.
First, Mr. Chairman, I would like to thank you for your outstanding
leadership and advocacy on behalf of our Nation's veterans. During your
tenure as Chairman of this Committee, you have clearly demonstrated
your commitment to veterans by acting decisively to ensure the needs of
veterans are met. In addition, I appreciate your interest in and
support of the Department of Veterans Affairs (VA).
I also would like to express my appreciation and respect for
Senator Akaka, Ranking Member of this Committee. Along with his
colleague, Senator Inouye, Senator Akaka has done so much for the
veterans residing in Hawaii and other islands in the Pacific region. As
I will highlight later, his vision, guidance and assistance have
directly led to an unprecedented level of health care services for
veterans, construction of state-of-the-art facilities in Honolulu and
remarkable improvements in access to health care services for veterans
residing on neighbor islands, including Maui.
Today, I will briefly review the VA Sierra Pacific Network that
includes Hawaii and the Pacific region; provide an overview of the VA
Pacific Islands Health Care System (VAPIHCS) and the VA clinic here in
Maui; highlight issues of particular interest to veterans residing in
Maui County, including VA services on the nearby islands of Molokai and
Lanai and access to specialty care; and address any questions posed by
Members of the Committee.
VA SIERRA PACIFIC NETWORK (VISN 21)
The VA Sierra Pacific Network (Veterans Integrated Service Network
[VISN] 21) is one of 21 integrated health care networks in the Veterans
Health Administration (VHA). The VA Sierra Pacific Network provides
services to veterans residing in Hawaii and the Pacific Basin
(including the Philippines, Guam, American Samoa and Commonwealth of
the Northern Marianas Islands), northern Nevada and central/northern
California. There are an estimated 1.25 million veterans living within
the boundaries of the VA Sierra Pacific Network.
The VA Sierra Pacific Network includes six major health care
systems based in Honolulu, HI; Palo Alto, CA; San Francisco, CA;
Sacramento, CA; Fresno, CA and Reno, NV. Dr. Robert Wiebe serves as
director and oversees clinical and administrative operations throughout
the Network. In Fiscal Year 2005 (FY05), the Network provided services
to 227,000 veterans. There were about 2.8 million clinic stops and
24,000 inpatient admissions. . The cumulative full-time employment
equivalents (FTEE) level was 8,200 and the operating budget was about
$1.3 billion, which is an increase of $378 million since 2001.
The VA Sierra Pacific Network is remarkable in several ways. In
fiscal year 2005, the Network was the only VISN in VHA to meet the
performance targets for all six Clinical Interventions that directly
address adherence to evidence-based clinical practice. The Network
hosts 11 (out of 65) VHA Centers of Excellence--the most in VHA. The VA
Sierra Pacific Network also has the highest funded research programs in
VHA. Finally, VISN 21 operates one of four Polytrauma units that are
dedicated to addressing the clinical needs of the most severely wounded
Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans.
VA PACIFIC ISLANDS HEALTH CARE SYSTEM (VAPIHCS)
As noted above, VAPIHCS is one of six major health care systems in
VISN 21. VAPIHCS is unique in several important aspects: its vast
catchment area covering 2.6 million square-miles (including Hawaii,
Guam, American Samoa and Commonwealth of the Northern Marianas); island
topography and the challenges to access it creates; richness of the
culture of Pacific Islanders; and the ethnic diversity of patients and
staff. In fiscal year 2005, there were an estimated 113,000 veterans
living in Hawaii (9 percent of Network total).
VAPIHCS provides care in six locations: Ambulatory Care Center
(ACC) and Center for Aging (CFA) on the campus of the Tripler Army
Medical Center (AMC) in Honolulu; and community-based outpatient
clinics (CBOCs) in Lihue (Kauai), Kahului (Maui), Kailua-Kona (Hawaii),
Hilo (Hawaii) and Agana (Guam). VAPIHCS also sends clinicians and
support staff from these locations to provide services on Lanai,
Molokai and American Samoa. The inpatient post-traumatic stress
disorder (PTSD) unit formerly in Hilo is in the process of relocating
to Honolulu. In addition to VAPIHCS, VHA operates five Readjustment
Counseling Centers (Vet Centers) in Honolulu, Lihue, Wailuku, Kailua-
Kona and Hilo that provide counseling, psychosocial support and
outreach.
Dr. James Hastings was recently appointed Director, VAPIHCS. Dr.
Hastings has impressive credentials, including tenure as Chair,
Department of Medicine, John A. Burns School of Medicine, University of
Hawaii, and Commanding General at Walter Reed AMC and Tripler AMC. I am
excited about the possibilities that his tenure as Director at VAPIHCS
brings.
In fiscal year 2005, VAPIHCS provided services to 18,300 veterans
in Hawaii (8 percent of Network total). There were 194,000 clinic stops
in Hawaii during fiscal year 2005 (7 percent of Network total), an
increase of 36 percent since fiscal year 2000. The cumulative FTEE for
the health care system was 478 employees. The budget for VAPIHCS
(including General Purpose, Specific Purpose and Medical Care Cost
Funds [MCCF]) has increased from $53 million in fiscal year 1999 to
$102 million in fiscal year 2005 (about 8 percent of Network total). In
addition, VISN 21 provided over $20 million in supplemental funds to
VAPIHCS over the past two Fiscal Years to ensure VAPIHCS met its
financial obligations.
VAPIHCS provides or contracts for a comprehensive array of health
care services. VAPIHCS directly provides primary care, including
preventive services and health screenings, and mental health services
at all locations. Selected specialty services are also currently
provided at the Honolulu campus and to a lesser extent, at CBOCs.
VAPIHCS recently hired specialists in gero-psychiatry,
gastroenterology, ophthalmology and radiology. VAPIHCS is actively
recruiting additional specialists in cardiology, orthopedic surgery and
urology. Inpatient long-term care is available at the 60-bed Center for
Aging. Inpatient mental health services are provided by VA staff on a
20-bed ward within Tripler AMC and at the 16-bed PTSD Residential
Rehabilitation Program (PRRP) that was formerly in Hilo (now relocating
to Honolulu). VAPIHCS contracts for care with DoD (at Tripler AMC and
Guam Naval Hospital) and community facilities for inpatient medical-
surgical care.
The current constellation of VA facilities and services represents
a remarkable transformation over the past several years. Previously,
the VAPIHCS (formerly known as the VA Medical and Regional Office
Center [VAMROC] Honolulu) operated primary care and mental health
clinics based in the Prince Kuhio Federal Building in downtown Honolulu
and CBOCs on the neighbor islands that were staffed primarily with
nurse practitioners. Senator Akaka and his colleagues in Congress
approved $83 million in Major Construction funds to build a state-of-
the-art ambulatory care center and nursing home care unit on the
Tripler AMC campus and these facilities were activated in 2000 and
1997, respectively. VISN 21 allocated nearly $17 million from FY98-FY00
to activate these projects. VISN 21 also provided dedicated funds
(e.g., $2 million in fiscal year 2001) to enhance care on the neighbor
islands by expanding/renovating clinic space and adding additional
staff to ensure there are primary care physicians and psychiatrists at
all CBOCs.
MAUI CBOC
VA operates a CBOC, located in Kahului (203 Ho'ohana, Suite 303,
Kahului, HI, 96732). In fiscal year 2002, VAPIHCS spent $208,000 to
renovate the clinic. The Maui Vet Center is located in nearby Wailuku.
The veterans treated at the Maui CBOC appear to be very satisfied
with their care. For example, a Vietnam veteran recently remarked, ``I
chose VA when I had opportunities to use other health care. My medical
care from the Maui CBOC has been superb in every respect. There is
genuine concern for my health and well-being and I could not hope for
better care.'' With comments like this, it is not surprising that in
fiscal year 2005, VAPIHCS achieved an exceptional level of performance
in the national VHA measure of outpatient satisfaction with over 80
percent of patients rating their overall care as ``very good'' or
``excellent.''
The Maui CBOC serves an estimated island veteran population in
fiscal year 2005 of 10,787. In fiscal year 2005, 2,769 veterans were
enrolled for care and 1,464 veterans received care (``users'') at the
Maui CBOC. The market penetrations for enrollees and ``users'' are 26
percent and 14 percent, respectively, and compare favorably with rates
within VISN 21 and VHA.
The current authorized full-time employment equivalents (FTEE)
level is 12.4, including a full-time primary care physician, part-time
family practice physician, psychiatrist, psychologist and nurse
practitioner. With this staff, the Maui CBOC provides a broad range of
primary care and mental health services. In addition, VAPIHCS provides
specialty care services at the clinic by sending VA staff from Honolulu
and other VA facilities in California. Services provided by clinicians
traveling to Maui include cardiology, geriatrics, nephrology,
neurology, optometry, orthopedics, rheumatology and urology. If
veterans need services not available at the clinic, VAPIHCS arranges
and pays for care in the local community (e.g., Maui Memorial
Hospital), Honolulu (including Tripler AMC) or VA facilities in
California. In fiscal year 2005, VA spent nearly $3.4 million for non-
VA care in the private sector (i.e., not including costs at other VA or
DoD facilities) for residents of Maui.
In fiscal year 2005, the Maui CBOC recorded 9,135 clinic stops,
representing a 41 percent increase from fiscal year 2000 (i.e., 6,499
stops). The clinic has short waiting times for new patients with very
few veterans waiting more than 30 days for their first primary care
appointment.
SPECIAL ISSUES
The islands of Molokai and Lanai are part of Maui County. Although
VA provides limited services on these islands by VA staff visiting from
Maui, VA does not operate formal CBOCs in these locations. Veterans and
their advocates have asked VA to increase services in these underserved
areas.
Molokai. The area of the island of Molokai is approximately 260
square miles. VA estimates the veteran population to be 649. In fiscal
year 2005, 202 veterans were enrolled for VA care and 144 veterans
received VA services. VA currently sends a primary care physician to
Molokai once a month, a nurse practitioner once a month and a
psychologist twice a month. VA leases space in the community to provide
these services. In addition, VA purchased non-VA care in the community
(e.g., Molokai General Hospital) for eligible veterans residing in
Molokai (e.g., $254 thousand in fiscal year 2005). Veterans residing in
Molokai also are seen at DoD and VA facilities in other locations.
In fiscal year 2005, VHA formally designated the VA presence in
Maui as an outreach clinic. This allowed VAPIHCS to establish an
electronic link between the outreach clinic in Molokai and the Maui
CBOC so that the VA electronic medical record can be used in Molokai.
At present, due to the relatively small number of veterans residing in
Molokai, VA does not plan to establish a formal CBOC in Molokai.
However, VA does plan to improve access to health care services on the
island.
Based on information provided by Senator Akaka and his staff, VA
has identified a former Air Force physician (i.e., Dr. Hafermann) who
resides in Molokai and is interested in providing medical care to
veterans on a part-time basis. VAPIHCS recently credentialed and
privileged this physician and is working with him to establish a
regular clinic schedule in early 2006. VA is also working to establish
telehealth capabilities from Molokai. VA will place an order for
telehealth equipment and is working to identify the location for the
telehealth activities. VA will also explore the possibility of sharing
telehealth capabilities with non-VA providers in exchange for local
services for veterans.
Lanai. The island of Lanai is approximately 140 square-miles. VA
estimates the veteran population to be 229. In fiscal year 2005, 57
veterans were enrolled for VA care and 34 veterans received VA
services. VA currently sends a nurse practitioner from the Maui CBOC to
Lanai every couple of months to provide needed primary care services.
In addition, VA purchased non-VA care in the community (e.g., Lanai
Community Hospital) for eligible veterans residing in Lanai (e.g., $35
thousand in fiscal year 2005). Veterans residing in Lanai also are seen
at DoD and VA facilities in other locations.
Due to the small number of veterans residing in Lanai, VA does not
plan to activate a formal CBOC. Instead, VA is exploring other options
to improve access. VA is talking with the Hawaii Health Systems
Corporation (HHSC), Native Hawaiian Health System and local providers
(i.e., Straub Clinic) to potentially establish a federally Qualified
Health Center (FQHC). Since health care is limited to all residents of
Lanai (e.g., there are no mental health services in Lanai), a FQHC
offers exciting possibilities. VA is also exploring the feasibility of
establishing telehealth capabilities in Lanai. Finally, VA will also
consider establishing a contract with local clinicians to provide care
for veterans, based on the availability of resources and local
interest.
Specialty services. The size of the veteran population and number
of VA patients limit the feasibility of having a large cadre of medical
and surgical specialists based in the Maui CBOC. Nonetheless, VA
recognizes that some veterans in Maui County have needs that go beyond
primary care and mental health. As I noted earlier, VA sends
specialists from Honolulu and California to the clinic on a regular
basis. Services provided by clinicians traveling to Maui include
cardiology, geriatrics, nephrology, neurology, optometry, orthopedics,
rheumatology and urology. VAPIHCS also refers patients to the local
community for care at VA expense (when eligibility criteria are met)
and transports (also at VA expense when eligibility criteria are met)
patients to the VA facility in Honolulu.
VAPIHCS is utilizing telehealth technology to expand access to
specialty care (e.g., dermatology). VAPIHCS estimates that telehealth
services are provided more than 15 hours per week at the Maui CBOC. As
additional specialists are hired at the VA facility based in Honolulu,
these clinicians will be able to travel to Maui County and further
utilize telehealth technologies. For the past several years, veterans
in Maui have been invited to participate in research studies designed
to test if telehealth could be used effectively to extend mental health
services (e.g., treatment for PTSD) to a culturally diverse population.
The willingness of Maui veterans to participate reflects their trust in
VAPIHCS, Maui Vet Center and VHA National Center for PTSD.
As noted before, VAPIHCS staff occasionally refers patients to VA
facilities in California. Access to other VA facilities was especially
important to a veteran who wrote, ``The veteran's health center in Kona
[Kailua-Kona CBOC] has not only helped me get my prescription drugs at
a lower cost, but last year they helped me go to the Western Blind
Rehabilitation Center in Palo Alto to learn how to cope with my
blindness. For the first time in many years, I have confidence to do
things I never thought I could do without sight.''
CONCLUSION
In summary, with the support of Senator Akaka and other Members of
Congress, VA is providing an unprecedented level of health care
services to veterans residing in Hawaii and the Pacific Region. VA now
has state-of-the-art facilities and enhanced services in Honolulu, as
well as robust staffing on the neighbor islands and has expanded or
renovated clinics in many locations. VA is bringing more specialists on
board and preparing for the newest generation of veterans-those who
bravely served in southwest Asia.
VAPIHCS still faces several challenges, in part due to the
topography of its catchment area. VAPIHCS will meet these challenges by
utilizing telehealth technologies, sharing specialists, developing new
delivery models and opening new clinics as demographics suggest and
resources allow. I am proud of the improvements in VA services in
Hawaii, but recognize that our job is not done.
Again, Mr. Chairman and other Members of the Committee, mahalo nui
loa for the opportunity to testify at this hearing. I would be
delighted to address any questions you may have for me or other members
of the panel.
Chairman Craig. Thank you very much, Dr. Perlin. You
mentioned in your testimony that VA does send a primary care
physician and a nurse practitioner to Molokai once per month,
and a psychologist to the island twice per month, to provide
service to veterans who reside there.
What kind of service does the traveling staff generally
provide? Is there an advance schedule of their travel published
so that all veterans on the island know of the staff's
impending arrival?
Dr. Perlin. Thank you, Chairman Craig, for the question. In
fact, I asked that question this morning when we had the chance
to visit the Maui CBOC. In fact, the nurse practitioner and the
primary care physician provide just that, general medical care.
They make appropriate referrals where that is necessary.
Captain McNamara, the psychologist, provides individual
psychotherapy and support services, outreach counseling, across
the range of mental health diagnoses. Again, she also makes
appropriate referrals. I know, as was alluded to here, she also
looks forward to Dr. Springer coming back to the Maui CBOC to
be part of the mental health team.
We realize that that is one way of extending our outreach,
is to provide the services with physicians, psychologists, who
travel. But we also look forward to extending the reach of
telehealth as one of the important ways to help provide
additional support.
We do publish a schedule annually of the times that the
medical team is there. But one of the other things that we also
discussed that the clinic does is that they send a letter
individually to each patient to just reaffirm particular
appointment times.
Chairman Craig. Well, thank you. One of the gentlemen who
testified on the first panel mentioned that there were some
difficulties experienced by some of his friends in obtaining
quick and accurate travel reimbursement from VA for his visit
to--I think this was to Honolulu for services.
Can you or someone else on the panel here give me an idea
of what the process of beneficiary travel reimbursement is
like, and what turnaround time there is on these claims?
Dr. Perlin. Let me just note that, in fact, the backlog of
claims has been worked down so that once the claim is received,
it should be less than 30 days. But let me ask Dr. MacBride to
elaborate on the current process.
Dr. MacBride. Thank you very much. Thank you, Dr. Perlin.
Patients who have had authorization for travel then have
the opportunity to submit travel claims for reimbursement.
Typically, we receive those requests for reimbursement anywhere
from 6 to 8 weeks after the travel has occurred, sometimes
sooner.
From that point on, it takes us about 30 days in
processing. As Dr. Perlin mentioned, we did have a backlog for
a while in our claims processing. So once we are in receipt of
completed claim with a receipt, we are able to refund the
veteran within 30 days.
Chairman Craig. Dr. MacBride, if you would explain to me,
and maybe to the audience, what designates--I believe you used
the word certified travel--or authorized travel. Yes. How is
that established?
Dr. MacBride. Well, travel for veterans that is going to be
reimbursed by the VA is authorized ahead of time. Typically,
our travel benefits include travel for service-connected
conditions.
Chairman Craig. So in other words, that's known in advance
by the veteran who's traveling to seek services, whether he or
she has been authorized----
Dr. MacBride. That's correct.
Chairman T4raig [Continuing]. To receive reimbursement?
Dr. MacBride. That's correct, sir.
Chairman Craig. Dr. Perlin, you mentioned in your testimony
that VA purchased approximately $250,000 worth of care and
services from Molokai General Hospital for veterans residing
there.
What criteria governs the decision to purchase care locally
on the island as opposed to having veterans travel to other
places for care, and are those standards for Hawaii any
different than any of the other States?
Dr. Perlin. Mr. Chairman, that is a great question. And in
fact, there's absolutely no difference in the way that one
makes a purchase or provides service decision or [inaudible]
decision. It comes down to this. If the veteran has an
emergency situation, and those are emergencies to a reasonable
person--someone who has chest pain--then we buy those services.
You know, when there is some time there, we really do
appreciate when the veteran calls to make sure that we can
coordinate services as well as possible. These are small
communities. Doctors and nurses and psychologists and others
know each other. So that if there's an urgent situation or
emergency, we will purchase those services.
We won't purchase the services, A, if they're not available
because they're not available of the island of Molokai, for
example, itself; or when in fact we know that it's not an
emergency or urgent situation, and we not only have the
services, but by virtue of the electronic health record and the
continuity and quality that both you and Senator Akaka alluded
to, we can provide those services within VA. So emergency or
urgent, we purchase otherwise services that we would provide
ourselves.
Senator Akaka. Dr. Hastings and Dr. MacBride, as you know,
last year I introduced legislation to formalize what VA is
already doing on Molokai and to increase access to VA care.
I understand that VA sent a team to Molokai to review
certain options. Will you please describe those options? Have
there been any attempts to coordinate with Mr. Helm's group,
Molokai Veterans Caring for Veterans, as they have identified
land to build a center for veterans on the island that could
potentially house a part-time clinic or, at the very least,
space to house tele-ealth equipment? Please make your remarks
on this.
Dr. Hastings. Senator, Dr. MacBride is part of that group.
So I've asked him to respond to your question.
Senator Akaka. Dr. MacBride?
Dr. MacBride. Thank you, Dr. Hastings. Thank you, Senator
Akaka. I want to thank also Mr. Larry Helm and Mr. Manny Garcia
and Dr. Dave Hafermann and several other Molokai veterans who
not only joined us on that day, but provided us with some very
interesting insights into care and conditions on Molokai that
helped us enormously.
As was mentioned earlier, for a number of years now staff
from the Maui CBOC have been traveling to Molokai to provide
services in a rural health clinic located on the grounds of
Molokai General Hospital. I think that it's worth mentioning--
some of them haven't been mentioned today--a person who really
went forward first was Kathy Haas, CNS who at the time was our
nurse practitioner in the CBOC in Maui and now coordinates the
management of all of our CBOCS.
[Applause.]
Dr. MacBride. And then in addition, we have heard so many
nice things said about Kathy McNamara, Dr. Jim Santoro, Rita
Webb, and previously, Dr. Richard Rose, the psychiatrist.
There on Molokai, what we did in fiscal year 2005, as Dr.
Perlin testified, was to designate our presence at the Rural
Health Clinic as an outreach of the Maui CBOC, an outreach
clinic. With that official designation in VA, it allowed us to
provide the electronic links to establish connectivity to the
VA electronic patient record.
This is extremely important because, in fact, this is
really the lifeblood of our care, to be able to have the
electronic record throughout VA so that the record is present
wherever veterans travel. Veterans don't travel with the
record. With that established, we have now gone forward, and
Dr. Dave Hafermann, who was introduced earlier, a retired Air
Force internist/pulmonologist--that's a lung specialist--will
begin seeing veteran patients in the Rural Health Clinic using
our electronic record in February of this year.
In addition, VA, with its partnerships with Queen's Medical
Center and the administration of Molokai General Hospital, will
be using tele-health equipment that is in existence at the
Molokai General Hospital. Further, we will augmenting that
equipment with VA tele-health equipment.
Now, it's fortunate that the Molokai General Hospital is
linked to the State Tele-health Access Network, the STAN. That
allows us to have the broadband that is necessary to do tele-
health transmissions.
We were fortunate that day to review several other options
and availabilities, and meet several of the physicians on the
island. There is a federally Qualified Health Center in
Kaunakakai, and there is Hui Malama with the Native Hawaiian
Health Care System. We plan to work more closely with the
Native Hawaiian Health Care System because they are expert at
providing education for chronic diseases. We, in addition, are
expert at providing tele-mental health for mental health
services in general.
So, in addition to our traveling people to Molokai, we
intend to work with our new physician, Dr. Hafermann,
physicians in the community hopefully by contract, and to
augment services using telehealth.
I also want to thank Larry Helms and Manny Garcia and Dr.
Dave Hafermann for their service to veterans, and not only
through the insights they provided to VA leadership, but also
in showing us their plans for the veterans center. Our mission,
of course, is to provide healthcare services to the 144
veterans who Dr. Perlin mentioned have enrolled for care with
us and are actively receiving VA services. We look forward to
working closely with Mr. Helm and Mr. Garcia and the Koa Kahiko
to explore and establish the best possible options for enhanced
care for Molokai's veterans.
Senator Akaka. Thank you very much for that response, Dr.
MacBride.
Dr. Perlin, your testimony indicates that VA does not plan
to activate a formal clinic on Lanai. Can you explain some
other ways that VA can improve access to care for veterans on
Lanai? I am especially interested in hearing more about a
federally Qualified Health Center that could benefit all
veterans on Lanai.
Dr. Perlin. Thank you, Senator Akaka, for that question. As
with Molokai, the ability to improve services for the residents
of that island occurs through more regularly scheduled visits
and additional visits of staff, better coordination with the
local providers in the community, and the use of telehealth,
which we're exploring.
All that said, I'm very excited, as well of its acceptance
for a federally Qualified Health Center, and I would again ask
to turn the microphone back to Dr. MacBride to elaborate on
that discussion.
Dr. MacBride. Well, thank you, Dr. Perlin. And before I
forget, I would like to take the opportunity to thank you,
Senator Craig, for coming all the way out to Hawaii in January,
and Senator Akaka, for your remarkable leadership and
assistance here with veterans here and the VA.
The VA is very fortunate again on the island of Lanai to
have discovered recently that we have the opportunity to work
together with partners and friends. Mr. Tom Driskill, who
testified yesterday in Kauai and who is the CEO for the Hawaii
Health Systems Corporation, and Mr. Ray Vera from Straub Clinic
and Hospital, recently discussed with us the opportunity to
collaborate together.
On Lanai, the hospital is administered by Hawaii Health
Systems Corporation, and they have the outpatient building in
which Straub Clinic houses two physicians who practice medicine
and also do emergency services at the hospital.
There is a plan, with VA in collaboration, to apply for a
federally Qualified Health Clinic and to add much-needed
women's services to the island--and I think Mr. Obado testified
to the importance of having services for women as well--and
also to partner with Native Hawaiian Health Care System in
their remarkable ability to provide education for chronic
diseases.
We very much want to partner with these individuals
amenities. We want to be able work with physicians onsite who
can see our VA patients and take care of VA patients in the
event of an emergency. But we also want to augment mental
health services in which VA is so outstanding. So we intend to
provide tele-mental health services for patients of this
consortium with whom we work. In addition, our partners have
spoken with us about the possibility of supplementing some of
the specialty care, and we will study that as well.
Senator Akaka. Thank you very much for your response, Dr.
MacBride.
Dr. Wiebe, I have concerns about the Maui clinic and other
clinics around Hawaii restricting specific healthcare services
such as home care, based upon disabilities status rather than
clinical need. I am glad that VA is reviewing this situation. I
know they are.
I need a commitment from you that when these restrictions
are lifted, that new dollars will flow from the network to
Hawaii to cover these costs. But we'd like to hear your
thoughts about this.
Dr. Wiebe. Thank you, Senator Akaka. As you know, the
Pacific Islands Health Care System is one of six healthcare
systems that comprise the VA Sierra Pacific Network. One of my
responsibilities as network director is to make an allocation
to each facility at the beginning of each fiscal year.
Since I have been network director and have had the
privilege of doing so since 1998, budget at the VA Pacific
Island Health Care System has increased from approximately $53
million to, last year, about $105 million. The portion of that
budget that is allocated by my office to Hawaii, has increased
over this period of time by 85 percent, while the network
budget, as a whole, has increased about 70 percent.
I expect that the budget here in Hawaii for fiscal year
2006--that allocation has not been made yet--that the
allocation will be higher than the previous year. In general,
we do not allocate money for individual programs, but instead
rely on each individual medical center and healthcare system to
make those choices based upon what they know the local
conditions and the local needs to be.
You're absolutely correct in that we were, here,
incorrectly and inappropriately restricting care. That since
has been corrected, and I fully expect that additional
resources will be spent on non-institutional care specifically
in the home healthcare programs.
Senator Akaka. Thank you very much, Dr. Wiebe, for your
response.
Dr. Perlin, vision impairment, as you heard from Dr.
Kekahuna, services provided veterans are below par in Hawaii,
and he compared some services he received on the mainland.
What can be done to improve this situation?
Dr. Perlin. Well, thank you, Senator Akaka, for that
question on care for veterans with blindness or low vision. I
need to tell you that this is not a theoretical question for
me. My grandfather was a blinded veteran, and something I feel
very passionately about. This is also not the first opportunity
that I've had the privilege of meeting Dr. Kekahuna or some of
his colleagues.
I think the opportunities to improve care here in Hawaii
are not significantly different than some of the opportunities
to advance for the care for veterans with blindness and low
vision. There are really two things that I think we need to
think about in caring for veterans with blindness or low
vision.
First is the proximity, but the second is the mode in which
the veteran acquired blindness. The veteran who experienced the
immediate, traumatic loss of vision is one circumstance. The
other circumstance is one that's becoming all too prevalent
today: Older veterans, or even some veterans who aren't all
that old, who have the ravages of diabetes or macular
degeneration.
And in fact, for the veteran who's had a sudden and
catastrophic loss of vision, a very intensive inpatient setting
which has a great deal of experience, such as in a Blind Rehab
Center, is really the best way to reorient them to higher
function, given the trauma of recent blindness.
I'm pleased that Dr. Kekahuna had such a good experience at
the Western Blind Rehabilitation Center, which is one of 10
national referral centers for veterans that are scattered
around the country. We just opened a brand-new Blind Rehab
Center at Hines where Dr. Kekahuna has also experienced their
care. This is a shining example of the promise of the Cares
program and the best we can offer veterans. It is a premier
facility anywhere in the world.
That doesn't answer the mail, though, for the veteran who
has the gradual loss of vision and needs some support in his or
her community. In fact, Ms. Cynthia Yosuda is dual-hatted right
now. She is the visual impairment coordinator, and she in fact
needs to be given more time to provide services and outreach.
This is one of the areas where I think we can improve care
here in Hawaii, which is to provide that dedicated time and
those important services. I've become aware that there are some
equipment needs that are actually fairly modest, and we can
provide that as well.
The optometrists do travel, not only to Maui, but Kona and
Hilo and Kauai as well. And we do hope to coordinate with the
wonderful program that is here in the State that provides
services for all residents of the State. But that's not enough.
We're also hiring an ophthalmologist who will begin to make
rounds, and I'm pleased to report that that individual will be
part of the team here in VA Pacific Islands Health Care Systems
in 60 days.
Finally, sir, I think one of the best ways to address
blindness is to prevent it. I couldn't be more proud of the
high-quality care provided by VA in terms of treating diabetes
so well and preventing the really horrific complications, such
as loss of vision.
Senator Akaka. Thank you very much, Dr. Perlin, for that
response. And I noted in your testimony that VA is working to
establish telehealth capabilities on Molokai. Do you have an
idea about the timeframe on that?
Dr. Perlin. We look forward to seeing the telehealth in
operation in April. And I'm also pleased to report that VISN 21
and the VA Pacific Islands Healthcare System applied for some
funding for telehealth and its support of tele-mental health--
and I'm pleased to share a little bit before the announcement,
but I want to thank Chairman Craig and Senator Akaka for their
support of the mental health initiatives to make this
possible--$200,000 to support personnel to operate that
equipment in such areas as tele-mental health.
Senator Akaka. Thank you. I have two more questions, Dr.
Perlin.
VA in Hawaii falls under the Sierra Pacific Health Care
Network, which includes some very large tertiary facilities in
California. Given the competing demands for resources, how do
you believe VA Hawaii is faring?
Dr. Perlin. Well, Senator, I think Dr. Wiebe mentioned that
the budgets for the VA Pacific Islands Health Care System
increased from $53 million to nearly $105 million over this
last 5-year period, roughly doubling. And so it's fairly clear
to me that Dr. Wiebe, in making allocation decisions,
understands and appreciates the needs for services here in
Hawaii and neighbor islands.
I think the budget is good. As both you and Chairman Craig
and Secretary Nicholson challenge us, our goal is to make sure
that those resources go as far as possible in treating as many
veterans as possible, as well as possible.
Senator Akaka. Thank you. And my final question is one
about long-term care needs. Testimony given at yesterday's
hearing on Kauai pointed to the significant gaps in long-term
care services provided to Hawaii's veterans due to the
geography of our State.
What is the VA doing to meet long-term care needs on Maui
and throughout all of Hawaii, both in terms of nursing home
care and home-based care?
Dr. Perlin. We appreciate the opportunity to discuss the
long-term care. And clearly there are here some veterans who
are not safe or don't have social support and need
institutional long-term care.
I recall your support and that of this Committee for
building the Center for Aging on the Tripler campus, and it's
really a remarkable institution. It provides care for up to 60
veterans. And I know that it's been running very full, 56
veterans on average.
I'm very, very excited, again, about the leadership that's
been shown in the State of Hawaii to build the new State
Veterans Home in Hilo. This is a very exciting proposition.
It's a partnership with the State. VA provides two-thirds of
the funding for up to $20 million, and we look forward to this
facility opening in the spring of 2007, again providing 95
additional beds.
VA contracts for care in a couple of other community
nursing homes. We do have some challenges in terms of the
institutional care in that any of facilities either don't meet
VA's life safety standards, which we consider absolutely
critical, or they haven't been willing to contract with us.
We really hope to get Dr. Michael Carrithers, who was here
yesterday and is the Associate Chief of Staff of the Pacific
Islands Health Care Systems for Geriatric and Extended Care,
together with Mr. Driskill, to see what sorts of discussions
might bear.
Turning to the non-institutional care, this is really such
an important area. It's an area where we've had to preserve not
only community relationships but, as in the case of so many
World War II veterans, spousal relationships of 50 or 60 years.
The use of technologies that allow us to make sure that the
veteran is doing OK, that their breathing is OK, that their
weight is OK, that their blood sugar is OK, that they're taking
their medicines, that they're not hungry, are technologies that
are not science fiction. They're technologies that we use
today.
They're technologies that preserve that spousal and
community relationship under technologies which also extend the
dollars. And I'm very proud of the tremendous increases that
are being shown here in Hawaii, which not only offer all of the
social advantages, but also transcend and get beyond the
barrier of that great ocean that separates the islands.
Senator Akaka. Thank you so much for your response. I want
to especially thank Dr. Hastings and Dr. MacBride for
responding to my repeated, really repeated requests for
addressing access to care, and those issues on Maui and on
Molokai and Lanai. I really am happy to have learned of your
efforts to include access to care for rural veterans as well.
I appreciate Dr. Perlin's and Dr. Wiebe's response to these
needs as well. I also thank Cathy Haas and Dr. McNamara for
what you do every day to help the veterans of Maui County. And
I want to thank this panel very much for coming to Hawaii and
responding as you have to our questions here. That without
question will make a huge difference for all veterans in
Hawaii.
I also want to remind you that we have a table in the back
of the room where we have staff, both from the VA, as well as
our staff, who are there to take any questions or concerns that
you may have. Remember that if you're wanting to testify and we
don't have it on the agenda, you are welcome to give us a
statement or arrange to give a statement to us. And we'll be
glad to direct it.
So again, I want to say thank you so much to this
distinguished panel that's before us. Also, before I quit here,
I want to say mahalo nui loa to Lupe Wissel, who sits on this
side of the Chairman, and to Noe Kalipi, who sits on this side,
on my side. I also want to thank the Committee staff, Kim
Lipsky, Dahlia Melendrez, and Alex Sardegna, who organized this
morning's hearing. Thank you so much because it really went
well.
And mahalo nui loa for making this a great hearing, Mr.
Chairman.
Chairman Craig. Well, Danny, thank you very much.
Ladies and gentlemen, my fellow citizens, I am here today
and the Committee is here today because of Danny Akaka. He is a
gentleman and a soft-spoken person, but one of the loudest
advocates you have in Washington, DC.
[Applause.]
Chairman Craig. And you watched a classic case this morning
of Senator Akaka working with this panel to get them to assure
you and him that the services he has consistently requested for
you are being looked at and/or are en route toward being
supplied. That role he plays on behalf of all of you in the
State of Hawaii is a very active one, and I congratulate Danny
for his advocacy.
Let me also mention one of you in your testimony of the
first panel. You referred to him as a Senator. He is not. He is
a Congressman, Congressman Buyer, who is Chairman of the
Veterans Affairs Committee in the House. He's been in a bit of
controversy of late in discussing how he would handle what had
been traditional hearings by the service organizations who come
to Washington annually to advocate on your behalf, but also to
examine the budgets as proposed by the administrations and the
Veterans Administration itself as it relates to its adequacy.
He and I disagree as to how those hearings ought to be
held. Please understand me very directly: All veterans service
organizations will be heard. We will hold those hearings on the
Senate side. Other hearings will be held on the House side. But
rest assured, all veterans service organizations who come to
Washington to testify before the appropriate authorizing
Committee--that's this Committee--will be heard in complete
forum as to the record they want to build.
[Applause.]
Chairman Craig. Let me also thank this panel, Dr. Perlin
and his associates, for being here, for the work they do. I've
had the privilege of getting to know these gentlemen, work very
closely with Dr. Perlin and of course Robert Wiebe, and I'm
getting to know these other gentlemen. And they live their
profession on a day-to-day basis. They are without question
your greatest advocates.
While there may be times when they make tough choices,
that's also their job as it relates to how resources get
allocated and where resources go. They live with you on a day-
to-day basis. They are committed as no other professionals I
have ever met as to the services they provide and the
responsibilities they've undertaken with the titles of the
positions that they hold. I honor them for that. They should be
recognized for that quality of work.
Let me also recognize, as Danny did, Lupe Whistle, who's
the staff director for the Veterans' Affairs Committee to my
immediate right; Billy Cahill in the back, an associate who,
between us all, keep these folks on their toes; because the
relationship of Government is a lot of oversight and checks and
balances. That's the character of our system and why it works,
frankly, as well as it does.
The administrative side, the legislative side, the
policymaking side, the budget-shaping side. That's Danny's
responsibility. That's my responsibility. The administrative
side is to take that policy and the resources and bring it to
the ground to provide the services for us to oversight and to
view and to correct or adjust as time goes on and the
situations occur, and as you react to us, as you should in a
representative republic, in the way you have with your presence
here today.
We thank you all very much for coming out and spending your
morning and early afternoon with us. And again, Danny, let me
thank you for inviting me and the Committee to your great
State.
[Applause.]
Senator Akaka. Mahalo. Mahalo nui loa, Mr. Chairman. Larry
and I, as you can tell, work very well together. And many of
our successes in the Committee are due to him. And so he has
done well for the veterans across the country.
But I want to particularly thank him for sacrificing the
few days that he has to come to Hawaii and join us with this
hearing. He has made a huge difference. And I want to thank him
for his generous remarks and wish him a safe trip, and his
staff also, when they finally go back to Washington, DC. Larry,
I can't thank you enough for helping us out here. Mahalo.
[Applause.]
Chairman Craig. Thank you. The Committee will stand
adjourned.
[Whereupon, at 12:28 p.m., the Committee was adjourned.]
A P P E N D I X 1
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Prepared Statement of Patricia Absher Ross on Behalf of Her Husband
John William Ross, Jr., LCDR, USN, Ret.
I, Patricia Ross, am a Veteran of the United States Cadet Nurse
Corps, sworn into service March, 1944. I received tuition, maintenance,
textbooks, Summer and Winter uniforms and stipends, and signed to stay
in essential nursing until the war crisis was over. I was released from
that commitment in March, 1947, the nursing shortage declared over.
We are registered and included in the Women Veterans' Memorial,
Arlington National Cemetery, Washington D.C., the only Congressionally
mandated memorial to honor all military women-all wars--all grades--all
periods of time from the Revolutionary War to present day and beyond.
It is with that service background that I rise to speak-up for my
husband, John Ross, and thank you for allowing me the opportunity and
honor to do so.
Specifically, I would like to address the issue of the inequity of
access to care for the many underserved veterans needing care, in Maui
County so they can be supported and be with family and friends, at a
critical, frightening, stressful time in their lives.
John has numerous health problems that require Specialists' care
and monitoring. We have chosen to pay for Kaiser Permanente Senior
Advantage program and use them as our primary care. Because of
moderately severe Dementia and being blind, John must stay in familiar
surroundings to avoid panic and air travel is not for him. What we seek
from the Veterans Health Care System, is help with expenses for
Intermediate Day Care and Long-term Care, when it will be needed at
home, here on the Island of Maui, where we have been for 29 years.
Medical expenses have been very high this year, with needing to
have full time care for John' while his wife was hospitalized with four
cardiac surgeries, (February to mid-July). John cannot be left alone.
This was an unplanned expense for an exhausted wife, Caregiver!
Nearly 300, Disabled Veterans in Maui County face similar problems.
BRIEF HISTORY
John entered service in the U.S. Navy on March 31, 1941 and was
honorably discharged on July 31, 1961. He served in the Navy as a
career Engineering Officer (EDO) for over 20 years. He was classified
as 100 percent, service-connected disabled effective February 26, 2002,
based on diagnosed Asbestosis some years ago, as John developed a
malignant lesion in his lung.
------------------------------------------------------------------------
Cause Problem Medical Monitoring
------------------------------------------------------------------------
Ship repair, inspection, Lung cancer....... Pulmonary
construction, mothballing specialist
constant exposure to asbestos.
Dry-docked radioactive Ships at Skin Cancers, Dermatologist
SFNaval Shipyard from atomic colon cancer. Surgeon/Oncologist
tests at Bikini Atoll, 1948.
Numerous head injuries Normal Normal pressure, Neurologist to
Pressure Starting with 2 falls hydrocephalus. monitor shunt
down Hydrocephalus Darkened placed in brain.
submarine Hatches.
Knee deterioration <greek-e> 2.. Knee Replacements Orthopedic checks
(2).
Vision: Aging................... Blindness due to Ophthalmologist,
Ophthalmologist, checks
Q2mos.
Prostate problems............... Elevated psa (28). Urologist
------------------------------------------------------------------------
The cost for the medical care was covered by the Kaiser Insurance
we have held for many years and will keep as our Primary Care.
difficulties encountered with maui veterans health care
Full access for Veterans to have VA Health Care on Maui, Lanai and
Molokai, and provisions for intermediate and long term care, at home or
in facilities ON ISLAND does not exist. Numerous agencies and qualified
medical personnel are present and could provide much of the care if the
VA would contract with them.
John's greatest fear expressed to the VA Gerontologists on 12/15/
05, was what would happen to him if something happened to his wife,
first! The doctors assured him that he would be taken care of, but in
HONOLULU.
It is hard to accept that John would be sent off island, away from
his home, friends, and familiar surroundings to a more confusing,
unfamiliar place, blind, with mobility problems, worried about his wife
of 58 years and no way to keep in touch. He is very frightened.
Reasons given for not contracting on each island vary from:
(1) Excessive pages of redundant paper work required by the VA
(2) The VA is slow in paying and the care facilities cannot carry
the debt.
(3) The Veterans are not organized to demand change.
(4) The Veterans are considered a ``sub-group'' among the numerous
health Agencies planning long-term care for Seniors and Disabled.
There re over 13,000 veterans in Maui County.
(5) Permission needed from the VA to participate and there is a
lack of funds.
(6) ``SPEND DOWN your assets and apply for MEDICAID, as that system
is being used and in place and easier to administer.
INTERMEDIATE CARE
A plea for VA to contract with Maui Adult Day Care Center. John has
found an incentive to do more than stay in his recliner despairing over
his loss of vision. He attends MADCC 5 days a week where he has found
new friends, activities, exercise and new interests. It is a safe
environment where his self-worth has been restored as he helps others.
``Health'' is more than physical rehabilitation, the mental, emotional
social and psychological aspect is so important and present at MADCC.
John has found a second home. MADCC have centers in Kahului, Lahaina,
and Hana . Add ``Health'' to their name.
In conclusion:
Maui County's service members serving in Iraq and elsewhere are
contacted and made aware of their Veteran Rights. Included is the Dept.
of the Army's (DS3) disabled Soldiers Support System for the severely
disabled. Soldiers include Reservists and National Guard and their
families. Support is offered throughout notification, treatment and
eventual return to home station and home destination. It is the home
destination segment we should be concerned with. How and where will
these veterans fit into the health care systems of the outer islands?
Where will the funds come from to support on or islands, the VA
Health Care that is available only on Oahu? You should not provide for
the outer islands at the expense of care on Oahu, but you must find
ways to provide better VA Health Care in Maui County. WE PLEAD FOR
COMPASSIONATE SOLUTIONS!
Mahalo for listening and for your caring.
Prepared Statement of Don Dickensheet
Howzit from the island of Lanai and yesterday I got a copy of a
letter from Mr. Obado about a hearing well please allow me to throw my
2 cents in if I may as my name is Don Dickensheet and I have lived on
Lanai since retiring from the Navy after 21 years in 1992 and let me
first tell you that the only thing you can do successfully on Lanai
when it comes to medical is die! Almost everything else you have to go
to Honolulu for, don't get me wrong those of us who live here realize
this and the pleasure we gain from living on this island outweighs a
lot of the alternatives.
In August of 2000 I like Mr. Obado suffered a cerebral aneurysm and
have since then been stumbling along and in this day of the internet I
don't feel I should have to sell my home here and move to some squalid
apartment in San Diego to get my benefits, as we here on Lanai realize
we are ALWAYS on the low end of the pecking order as they have vans in
Honolulu to whisk all the guys living in the bushes on Nimitz highway
up to the Sparky VA center to dry out for a few weeks most folks here
just give up after awhile and I can understand their frustration
getting up at 0 dark thirty to dial 1-800 numbers and talk to machine
during normal working hours in DC. After my aneurysm I started thinking
now that my life was ruined. Why had this happened and it took me 3
years to prove to the VA that it was service connected because unknown
to me the whole time I was on active duty I was growing a brain tumor
which they failed to detect as it caused a hearing loss in my left ear
and they never bothered to fully investigate the cause on my retirement
physical so with only Bill Station to help me once a month I got busy
and it took 3 years but I got it done and am now in the process of
trying to get a grant to have a new bathroom made as when I first came
home from the hospital I spent out of my own pocket for grab bars a new
toilet etc. only to find out later on that the VA will provide it. To
this date, we are still working on this and all I ever seem to get is
forms requesting more forms? My rating decision has already been made
and I don't know what the hang up is but since I refuse to play the
Press 1 for English and press 2 to listen to goofy music game I guess
it will take me another 3 years at least to get what I am entitled to.
My heart goes out to the old timers here whose families would have to
play these games when they pass away to get them buried here in our
veterans cemetery.
We NEED a central place here on Lanai where vets can go and
actually speak to a human being who knows how to get their benefits.
For example, I would like to see someone get hold of NALCO in Honolulu
and see if regular logistic flights could be scheduled to all islands
utilizing the C-12 aircraft which Navy pilots utilize while on shore
duty to maintain flight quals and instead of flying in circles around
the runway doing touch and goes how about flying to Molokai, Lanai Maui
and the Big Island to pick up vets for their appointments in Honolulu
saving the $200 plus. There are many ways that already exist within the
system to accommodate us and in my case being retired military it
really burnt me up to HAVE to spend $400 to go re-new my wife's ID card
in Honolulu bet Dan doesn't do this? Also let me get back to the
retired thing we military retirees give up a lot to live on outer
islands as we don't get to buy cheap gas, food, and clothing and we all
know this when we make the decision to live where we do but it really
smarts when we cant even get the basic entitlements which we were
promised and there are probably less than a dozen military retirees on
this island but each one of us has to do something different to try to
get our benefits as we know so much more how the system works than
those vets who only were in for one hitch, they earned these benefits
many paid with their own blood and to act as if they don't exist
because they chose to live in a place that doesn't fit in the required
block, example one form I use to get repaid my co-payments for
Medication has DO NOT USE PO BOX on it for address guess the bean
counters don't know that zip code 96763 is PO BOX ONLY I think I got
that through their heads by telling them to dial 1-800- ASK-USPS its
stupid stuff like this that cause delays for months! I for one would
like to get all Vets on the same page here so we can get what we
earned.
Prepared Statement of Francine Atwell
I am the wife of a disabled vet and I have recently become disabled
myself, due in part to my husband's severing PTSD.
The VA provides very little support to veterans' families. On Maui,
there is a women's/spouse group primarily focused on understanding our
veterans PTSD but it is not enough, even though the meeting has been a
very good start.
First families pay the high-test emotional price sometimes even
higher than veterans themselves for the veteran's injuries and illness.
We need more help to withstand the stress that comes with long-term
conditions.
Second, the families are true first responders to our veterans.
Given the opportunities to lean assertive training/communications
skills or anger management techniques not for ourselves and for our
vets. We can deal with our vets more effectively and as caregivers
reinforce VA care.
Supporting the families supports the vet in very cost effective
way. Group meeting and classes are very expensive compared to the costs
of hospital treatment and the effects of abuse and violence which is
very real to many of us.
Prepared Statement oF Sgt. Albert A. Newsham
I want to know why the thousands of combat veterans are not
permitted to collect ``combat related special compensation.'' I was
forced to retired from the Army because of my wounds. I spent my time
in combat. I spent 2 and half years in Army hospitals and I am 100
percent disabled.
Let's be fair, we did what you asked us to do. We went when you
said Vietnam and our country needed us. Now it is time for you to step
up and do the correct and honorable thing. Show us you can keep your
word. Pass the legislation so men and women like me can receive the
compensation we earned with our blood and tears and honor.
A P E N D I X 2
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January 9, 2006--Hawaii Hearing, Kauai
Prepared Statement of Jonathan A. Perlin, MD, PHD, MSHA, FACP, Under
Secretary for Health Department of Veterans Affairs
Mr. Chairman and Members of the Committee, mahalo nui loa for the
opportunity to appear before you today to discuss the state of VA care
in Hawaii. It is a privilege to be here on Kauai--the Garden Isle--to
speak and answer questions about issues important to veterans residing
in Hawaii.
First, Mr. Chairman, I would like to thank you for your outstanding
leadership and advocacy on behalf of our Nation's veterans. During your
tenure as Chairman of this Committee, you have clearly demonstrated
your commitment to veterans by acting decisively to ensure the needs of
veterans are met. In addition, I appreciate your interest in and
support of the Department of Veterans Affairs (VA).
I also would like to express my appreciation and respect for
Senator Akaka, Ranking Member of this Committee. Along with his
colleague, Senator Inouye, Senator Akaka has done so much for the
veterans residing in Hawaii and other islands in the Pacific region. As
I will highlight later, his vision, guidance and assistance have
directly led to an unprecedented level of health care services for
veterans, construction of state-of-the-art facilities in Honolulu and
remarkable improvements in access to health care services for veterans
residing on neighbor islands, including Kauai.
Today, I will briefly review the VA Sierra Pacific Network that
includes Hawaii and the Pacific region; provide an overview of the VA
Pacific Islands Health Care System (VAPIHCS) and the VA clinic here in
Kauai; highlight issues of particular interest to veterans residing in
Kauai, including the availability of long-term care services, specialty
care and access to the VA clinic from the west side of Kauai; and
address any questions posed by Members of the Committee.
VA SIERRA PACIFIC NETWORK (VISN 21)
The VA Sierra Pacific Network (Veterans Integrated Service Network
[VISN] 21) is one of 21 integrated health care networks in the Veterans
Health Administration (VHA). The VA Sierra Pacific Network provides
services to veterans residing in Hawaii and the Pacific Basin
(including the Philippines, Guam, American Samoa and Commonwealth of
the Northern Marianas Islands), northern Nevada and central/northern
California. There are an estimated 1.25 million veterans living within
the boundaries of the VA Sierra Pacific Network.
The VA Sierra Pacific Network includes six major health care
systems based in Honolulu, HI; Palo Alto, CA; San Francisco, CA;
Sacramento, CA; Fresno, CA and Reno, NV. Dr. Robert Wiebe serves as
director and oversees clinical and administrative operations throughout
the Network. In Fiscal Year 2005 (FY05), the Network provided services
to 227,000 veterans. There were about 2.8 million clinic stops and
24,000 inpatient admissions. The cumulative full-time employment
equivalents (FTEE) level was 8,200 and the operating budget was about
$1.3 billion, which is an increase of $378 million since 2001.
The VA Sierra Pacific Network is remarkable in several ways. In
fiscal year 2005, the Network was the only VISN in VHA to meet the
performance targets for all six Clinical Interventions that directly
address adherence to evidence-based clinical practice. The Network
hosts 11 (out of 65) VHA Centers of Excellence-the most in VHA. The VA
Sierra Pacific Network also has the highest funded research programs in
VHA. Finally, VISN 21 operates one of four Polytrauma units that are
dedicated to addressing the clinical needs of the most severely wounded
Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans.
VA PACIFIC ISLANDS HEALTH CARE SYSTEM (VAPIHCS)
As noted above, VAPIHCS is one of six major health care systems in
VISN 21. VAPIHCS is unique in several important aspects: its vast
catchment area covering 2.6 million square-miles (including Hawaii,
Guam, American Samoa and Commonwealth of the Northern Marianas); island
topography and the challenges to access it creates; richness of the
culture of Pacific Islanders; and the ethnic diversity of patients and
staff. In fiscal year 2005, there were an estimated 113,000 veterans
living in Hawaii (9 percent of Network total).
VAPIHCS provides care in six locations: Ambulatory Care Center
(ACC) and Center for Aging (CFA) on the campus of the Tripler Army
Medical Center (AMC) in Honolulu; and community-based outpatient
clinics (CBOCs) in Lihue (Kauai), Kahului (Maui), Kailua-Kona (Hawaii),
Hilo (Hawaii) and Agana (Guam). VAPIHCS also sends clinicians and
support staff from these locations to provide services on Lanai,
Molokai and American Samoa. The inpatient post-traumatic stress
disorder (PTSD) unit formerly in Hilo is in the process of relocating
to Honolulu. In addition to VAPIHCS, VHA operates five Readjustment
Counseling Centers (Vet Centers) in Honolulu, Lihue, Wailuku, Kailua-
Kona and Hilo that provide counseling, psychosocial support and
outreach.
Dr. James Hastings was recently appointed Director, VAPIHCS. Dr.
Hastings has impressive credentials, including tenure as Chair,
Department of Medicine, John A. Burns School of Medicine, University of
Hawaii, and Commanding General at Walter Reed AMC and Tripler AMC. I am
excited about the possibilities that his tenure as Director at VAPIHCS
brings.
In fiscal year 2005, VAPIHCS provided services to 18,300 veterans
in Hawaii (8 percent of Network total). There were 194,000 clinic stops
in Hawaii during fiscal year 2005 (7 percent of Network total), an
increase of 36 percent since fiscal year 00. The cumulative FTEE for
the health care system was 478 employees. The budget for VAPIHCS
(including General Purpose, Specific Purpose and Medical Care Cost
Funds [MCCF]) has increased from $53 million in fiscal year 1999 to
$102 million in fiscal year 2005 (about 8 percent of Network total). In
addition, VISN 21 provided over $20 million in supplemental funds to
VAPIHCS over the past two Fiscal Years to ensure VAPIHCS met its
financial obligations.
VAPIHCS provides or contracts for a comprehensive array of health
care services. VAPIHCS directly provides primary care, including
preventive services and health screenings, and mental health services
at all locations. Selected specialty services are also currently
provided at the Honolulu campus and to a lesser extent, at CBOCs.
VAPIHCS recently hired specialists in gero-psychiatry,
gastroenterology, ophthalmology and radiology. VAPIHCS is actively
recruiting additional specialists in cardiology, orthopedic surgery and
urology. Inpatient long-term care is available at the 60-bed Center for
Aging. Inpatient mental health services are provided by VA staff on a
20-bed ward within Tripler AMC and at the 16-bed PTSD Residential
Rehabilitation Program (PRRP) that was formerly in Hilo (now relocating
to Honolulu). VAPIHCS contracts for care with DoD (at Tripler AMC and
Guam Naval Hospital) and community facilities for inpatient medical-
surgical care.
The current constellation of VA facilities and services represents
a remarkable transformation over the past several years. Previously,
the VAPIHCS (formerly known as the VA Medical and Regional Office
Center [VAMROC] Honolulu) operated primary care and mental health
clinics based in the Prince Kuhio Federal Building in downtown Honolulu
and CBOCs on the neighbor islands that were staffed primarily with
nurse practitioners. Senator Akaka and his colleagues in Congress
approved $83 million in Major Construction funds to build a state-of-
the-art ambulatory care center and nursing home care unit on the
Tripler AMC campus and these facilities were activated in 2000 and
1997, respectively. VISN 21 allocated nearly $17 million from FY98-FY00
to activate these projects. VISN 21 also provided dedicated funds
(e.g., $2 million in fiscal year 2001) to enhance care on the neighbor
islands by expanding/renovating clinic space and adding additional
staff to ensure there are primary care physicians and psychiatrists at
all CBOCs.
KAUAI CBOC
VA operates a community-based outpatient clinic (CBOC), located in
Lihue (3-3367 Kuhio Highway, Suite 200, Lihue, HI, 96766-1061). In
fiscal year 2003, VAPIHCS spent $470,000 to renovate the clinic. The
Kauai Vet Center is co-located with the clinic in Lihue.
CBOCs, like the one here in Kauai, play a crucial role in the care
of veterans in Hawaii. Since they are located in small communities,
CBOCs have the feel of an old-fashioned doctor's office. Patients get
to know their caregivers (in ways not possible in a large medical
center) and clinic staff gets to know their patients, including their
friends, military stories and even their grandchildren's names. Staff
at the Kauai CBOC sees its role as not just caregiver, but also as an
active participant in the local community. On its own time, staff
participates in community events like Veterans Day, Fourth of July
celebrations and December holiday festivities.
The Kauai CBOC serves an estimated island veteran population in
fiscal year 2005 of 5,420. In fiscal year 2005, 1,518 veterans were
enrolled for care and 1,016 veterans received care (``users'') at the
Kauai CBOC. The market penetrations for enrollees and ``users'' are 28
percent and 18 percent, respectively, and compare favorably with rates
within VISN 21 and VHA.
The current authorized full-time employment equivalents (FTEE)
level is 9.0, including a full-time primary care physician,
psychiatrist and nurse practitioner, and all positions are filled. With
this staff, the Kauai CBOC provides a broad range of primary care and
mental health services. In addition, VAPIHCS provides specialty care
services at the clinic by sending VA staff from Honolulu and other VA
facilities in California. Services provided by clinicians traveling to
Kauai include cardiology, nephrology, neurology, optometry,
orthopedics, rheumatology and urology. If veterans need services not
available at the clinic, VAPIHCS arranges and pays for care in the
local community (e.g., Wilcox Hospital), Honolulu (including Tripler
AMC) or VA facilities in California. In fiscal year 2005, VA spent more
than $2.1 million for non-VA care in the private sector (i.e., not
including costs at other VA or DoD facilities) for residents of Kauai.
In fiscal year 2005, the Kauai CBOC recorded 6,024 clinic stops,
representing a 35 percent increase from fiscal year 2000 (i.e., 4,457
stops). The clinic has short waiting times for new patients with very
few veterans waiting more than 30 days for their first primary care
appointment.
SPECIAL ISSUES
Long-term care. As a group, the veteran population is aging.
Consequently, long-term care (LTC) services are a very important
component of the continuum of care provided by VA. VA provides both
inpatient LTC (i.e., institutional care) and non-institutional care
(NIC). VA's approach to LTC is to provide extended care services in the
least restrictive setting that is appropriate for the clinical
condition of the veteran and his/her personal circumstances.
As an alternative to inpatient LTC, VA has developed and fostered a
variety of NIC programs. NIC includes Adult Day Health Care (ADHC),
Contract Adult Day Health Care (CADHC), Home-based Primary Care (HBPC),
Contract Home Health Care (CHHC), Homemaker/Home Health Aid (H/HHA),
Home Hospice, Home Respite, Geriatric Evaluation and Management (GEM)
Program and Spinal Cord Injury (SCI) Home Program. Secretary Nicholson
and his predecessors authorized the expansion of VA's NIC services. The
capacity of these programs has grown rapidly since fiscal year 1998 and
VA is expecting a further increase of 18 percent in fiscal year 2006.
This trend is also present in Hawaii. In fiscal year 2005, VAPIHCS
recorded a NIC ADC of 108 patients, representing an increase of 38
percent compared to fiscal year 2004 (i.e., NIC ADC 78.2 patients). In
some locations in Hawaii, VA directly provides NIC services. In other
venues, including Kauai, VA contracts for these services. The following
table displays trend in VAPIHCS obligations for LTC services in the
community.
Trend in Non-VA Expenditures at VAPIHCS
[$000]
------------------------------------------------------------------------
Change FY 2002-
FY 2002 FY 2003 FY 2004 FY 2005 FY 2005
------------------------------------------------------------------------
Comunity nursing home (CNH)
------------------------------------------------------------------------
$93 $280 $661 $1,047 442%
------------------------------------------------------------------------
Non-institutional care (NIC)
------------------------------------------------------------------------
$97 $126 $191 $716 638%
------------------------------------------------------------------------
The decision to ``make or buy'' is based on the clinical need for
and availability of these services in the local community. These
decisions are re-evaluated based on changes in workload and
availability of resources. As an example, VAPIHCS currently operates
HBPC programs in the Big Island (i.e., at its CBOCs in Hilo and Kailua-
Kona, but not in Kauai or Maui. VAPIHCS is currently reassessing the
feasibility of adding staff at its CBOCs here in Kauai and Maui to
provide HBPC.
At the request of Senator Akaka, the Office of Inspector General
recently began a review of access to NIC in VHA. Although its findings
and recommendations are not yet available, I am already taking actions
in Hawaii to ensure clinical and eligibility criteria are correctly
applied. As an example, VAPIHCS had been inappropriately restricting H/
HHA services to veterans meeting the eligibility requirements for
mandatory inpatient LTC as set forth in the Veterans Millennium Health
Care and Benefits Act (Millennium Act), Public Law 106-117 (1999).
These local eligibility restrictions have been rescinded.
Nursing home care is reserved for situations in which the veteran
can no longer safely be cared for at home. VA is committed to providing
nursing home care to all veterans for whom such care is mandated by the
Millennium Act (i.e., 70 percent or more service-connected rating or
requiring nursing home care because of a service-connected disability).
VA will continue to provide long-term maintenance care to other
veterans on a discretionary basis as resources permit. VA provides
inpatient LTC services directly in its nursing home care facilities,
pays for nursing home care in communities and supports State Veterans
Homes (with construction funds and per diem reimbursements).
As noted earlier, VAPIHCS operates a long-term care inpatient unit
in Honolulu. Recently, this 60-bed unit operates close to its capacity
(e.g., in fiscal year 2005, the average daily census [ADC] was 56
patients). VA has contracts with and places veterans in two community
nursing home care units in Oahu. In fiscal year 2005, VAPIHCS spent
more than $1 million in community nursing home (CNH) care-nearly
quadruple the amount spent in fiscal year 2003 (i.e., $280 thousand).
VAPIHCS is interested in expanding its CNH program, but unfortunately,
the other community facilities (including those on Neighbor Islands)
VAPIHCS has contacted do not meet VA's life and safety codes or are
unwilling to fulfill the requirements of VA's CNH contract.
VA is also providing funding and working with the State of Hawaii
to build and activate the first State Veterans Home in Hawaii. The 95-
bed nursing home facility will be built in Hilo at the site of the
former Hilo Hospital on the Hilo Medical Center Campus. The cost
estimate for the project is $31 million and VA is contributing 65
percent (i.e., $20 million).
Specialty services. The size of the veteran population and number
of VA patients limit the feasibility of having a large cadre of medical
and surgical specialists based in the Kauai CBOC. Nonetheless, VA
recognizes that some veterans in Kauai have needs that go beyond
primary care and mental health. As I noted earlier, VA sends
specialists from Honolulu and California to the clinic on a regular
basis. Services provided by clinicians traveling to Kauai include
cardiology, nephrology, neurology, optometry, orthopedics, rheumatology
and urology. VAPIHCS also refers patients to the local community for
care at VA expense (when eligibility criteria are met) and transports
(also at VA expense when eligibility criteria are met) patients to the
VA facility in Honolulu.
VAPIHCS is utilizing telehealth technology to expand access to
specialty care (e.g., dermatology). VAPIHCS estimates that telehealth
services are provided more than 10 hours per week at the Kauai CBOC. As
additional specialists are hired at the VA facility based in Honolulu,
these clinicians will be able to travel to Kauai and further utilize
telehealth technologies.
West Kauai. Although Kauai is a relatively small island (i.e., 550
square-miles), transportation on the island can be problematic. As an
example, the driving time from the west side of Kauai to the VA clinic
can be up to an hour. VAPIHCS estimates approximately 190 existing
patients (i.e., ``current users'') live on the west side of Kauai.
Consequently, it is not practical to establish a new clinic on the west
side or rotate staff from the existing clinic. Instead, VA will work
with community organizations, such as veterans' service organizations,
and local government to enhance transportation options for veterans.
CONCLUSION
In summary, with the support of Senator Akaka and other Members of
Congress, VA is providing an unprecedented level of health care
services to veterans residing in Hawaii and the Pacific Region. VA now
has state-of-the-art facilities and enhanced services in Honolulu, as
well as robust staffing on the neighbor islands and has expanded or
renovated clinics in many locations. VA is bringing more specialists on
board and preparing for the newest generation of veterans-those who
bravely served in southwest Asia.
VAPIHCS still faces several challenges, in part due to the
topography of its catchment area. VAPIHCS will meet these challenges by
utilizing telehealth technologies, sharing specialists, developing new
delivery models and opening new clinics as demographics suggest and
resources allow. I am proud of the improvements in VA services in
Hawaii, but recognize that our job is not done.
Again, Mr. Chairman and other members of the Committee, mahalo nui
loa for the opportunity to testify at this hearing. I would be
delighted to address any questions you may have for me or other members
of the panel.
Prepared Statement of Robert Shaw, National Legislative Chairman
National Association of State Veterans Homes
Chairman Craig, Senator Akaka and other Distinguished Members:
Thank you for the opportunity given to me to present the views of
the National Association of State Veterans Homes before this hearing of
the Committee on Veterans' Affairs. It is an honor to join you today on
this beautiful island of Kauai to explore ideas and seek methods to
better serve Hawaii's aging veterans with long-term care services they
need and have earned through their service.
I am presenting testimony today on behalf of the National
Association of State Veterans Homes (NASVH), an all-volunteer, non-
profit organization founded over a half century ago to promote the
common interests of State veterans homes and the deserving elderly
veterans and their families that we serve. The membership of NASVH
consists of the administrators and senior staffs of State-operated
veterans homes throughout the United States. Our current membership
includes 119 homes in 47 States and the Commonwealth of Puerto Rico. We
provide nursing home care in 114 homes, domiciliary care in 52 of those
locations, and hospital-type care in five of our homes. Our State homes
presently provide over 27,500 resident beds for veterans, of which more
than 21,000 are nursing home beds. I am here today as both the National
Legislative Chairman of NASVH, an elected position I have held since
the year 2000, and also as the Administrator of the State Veterans
Center in Rifle, Colorado, where we provide skilled nursing care to 100
veterans and family members each day.
The State home program dates back to the post-Civil War era when
several States established homes in which to provide domicile, shelter
and care to homeless, sick and maimed Union soldiers and sailors. In
1888 Congress first authorized Federal grants-in-aid to States that
maintained these homes, including a per diem allowance for each veteran
of twenty-seven cents ($100 per year per veteran). Over the years since
that time, the State home program has been expanded and refined to
reflect the improvements in standards of medical practice, including
the advent of nursing home, domiciliary, adult day health, and other
specialized geriatric care for veterans. For example, the facility that
I manage in Colorado now includes a Special Care Unit for Alzheimer's
and dementia patients, a growing need in this population. There are
also now two State homes providing adult day health care, and a number
of others are developing programs in this new discipline and other
emerging approaches to delivering care in less restrictive settings.
Today, the State home program is supported in two ways by the
Federal Government: through per diem subsidy payments that help States
cover daily costs, and construction grants to keep our homes up-to-date
and safe for our patients and staffs. Subject to appropriations, VA
provides construction matching-grant funding for up to 65 percent of
the cost of constructing or rehabilitating homes, with at least 35
percent covered by State funding commitments. The per diem program
provides reimbursement to State homes, currently $63.40 for nursing
home care, which is about 30 percent of the average cost to the States.
Section 1741 of Title 38, United States Code, authorizes VA to provide
a per diem rate of up to 50 percent of the States' average daily cost,
but VA has not been able to bring the actual rate paid to our homes
near this statutory cost ceiling.
Mr. Chairman, as you well know, the last budget debate for fiscal
year 2006 was a crucial one for the State home program. We want to
thank this Committee, and especially you, Mr. Chairman and Senator
Akaka, for the vital role you both played in defending the State home
program during the budget and appropriations cycle just concluded for
fiscal year 2006. Thanks to your leadership, as well as tremendous
support and leadership from Senators Hutchison, Feinstein and others,
the Administration's proposals to dramatically restrict per diem
payments to only a small portion of the veterans currently in our
homes, and to impose a moratorium on further construction funding, were
soundly rejected. We are grateful that Congress spoke clearly and
forcefully on theses matters in the Joint Explanatory Statement
accompanying the Act:
The conferees do not agree with the proposal contained in the
budget to alter the long-term care policies, including a policy
of priority care in nursing homes. The conferees have provided
with this total appropriation, sufficient resources to maintain
a policy of providing long-term care to all veterans, utilizing
VA-owned facilities, community nursing homes, State nursing
homes, and other non-institutional venues. The conferees expect
there to be no change from the policies in existence prior to
fiscal year 2005.
We look forward to working closely with you in this New Year should
we again face budgetary and legislative challenges during the Second
Session of the 109th Congress.
Today, however, we are focusing on how best to provide long term
care services to Hawaii's veterans who need and deserve this care. As I
stated previously, 47 States already have at least one state veterans
home in operation, leaving just three states--Hawaii, Alaska and
Delaware--which do not. Of course, as you well know, there is a new 95-
bed State veterans' home under construction in Hilo on the Big Island
scheduled to open later this year that will substantially meet the
needs of veterans residing on that island. In addition, long-term care
and transitional rehabilitative services are being provided now on Oahu
by a VA-operated, 60-bed Center for Aging, located at Tripler Army
Medical Center. The VA Center for Aging will partially meet Honolulu-
area veterans' long term care needs, but additional resources will
probably be needed on that island as the elderly Oahu veteran
population continues to grow.
There remain, however, significant gaps in long term care services
to Hawaii's veterans due to the nature and geography of this great
State. In particular, the Neighbor Islands, with their smaller overall
veteran populations and physical separation, face a much more difficult
challenge in trying to meet the needs of their frail, elderly veterans.
For those living on Kauai, Molokai, Maui and other Neighbor Islands,
the facilities at Hilo and Oahu simply are not realistic options. The
question before this panel today is how best to meet these needs given
the challenges we have identified and the inevitable budgetary
constraints faced by VA and Congress.
Under current law, as set forth in Public Law 106-117, the Veterans
Millennium Health Care and Benefits Act, Congress established specific
criteria for authorizing construction of new State homes. It is
possible under VA criteria that Hawaii, in addition to building the new
home at Hilo, could justify building another State home with about 120
beds based upon its State-wide veteran population. However, given the
unique island geography of Hawaii, with vast seas separating islands,
as well as their rich cultural traditions, it would not be practical to
expect veterans from close-knit families and communities on one island
to leave their families and travel great distances to another island
for long-term care. While the construction of a second State veterans'
home somewhere in Hawaii might solve one island's problem for aging
veterans, it would not adequately address their lack of long-term care
services on other islands.
For better or for worse, Mr. Chairman, Hawaii is not alone in
trying to address the challenge of meeting the needs of geographically
dispersed populations. Other large rural States, including, Alaska,
Wyoming, Montana and Idaho, among others, face similar problems in
trying to provide high quality and convenient long term care for
veterans who live at great distances from larger population centers and
major VA facilities. As Congress and VA seek to address this problem,
it could prove beneficial for this Committee to look at how Alaska, our
largest State, has managed this challenge.
Over the years, Alaska's State government, Congress and Alaska's
veterans' organizations have considered numerous proposals for that
State to seek VA matching grants for the construction of State homes
for veterans, but no concrete proposal was ever approved by the
Governor or the State legislature. This is not to suggest that Alaska
has no facilities serving older veterans in need of long-term care.
Beginning in 1913 in the city of Sitka, the State of Alaska began
operating what are called ``Pioneer Homes.'' Today, Alaska operates six
of these homes providing more than 500 total long term care beds in
Sitka, Anchorage, Fairbanks, Juneau, Ketchikan and Palmer. These homes
provide nursing and residential care to ``Alaska Pioneers'' -- any
Alaska citizen over age 65, in declining health, and in need of
significant care for activities of daily living. These homes are
supported by State funds, insurance reimbursements and private
payments, very similar to the mixed financing arrangements of State
veterans' homes. Although these homes are not solely reserved for
veterans, about one-quarter of the residents are veterans of military
service.
In the past decade, Alaska's ``Pioneer Homes'' also have become
licensed assisted living facilities, offering a comprehensive range of
services to meet the needs of the elderly residents. Professional
services cover the full range of needed care, including assistance with
activities of daily living, skilled nursing, and compassionate end-of-
life services. Many Pioneer residents receive a level of service that
would otherwise be delivered in a hospital, a traditional nursing home,
a hospice, or in a home-based elder program under a Medicaid waiver
arrangement Alaska reached with the Center for Medicare and Medicaid
Services (CMS).
In May 2004, Congress passed legislation to define the Alaska
``Pioneer Homes'' as a single State veterans home for purposes of
establishing eligibility for participation in VA's State home programs.
Based upon this legislation, Alaska submitted a request for, and was
approved for, the construction of a 79-bed veterans' domiciliary as a
new wing to the existing Pioneer Home in Palmer, Alaska. Construction
of this new wing began this past summer and is expected to be completed
late this year.
Similar to Alaska, Hawaii's dispersed veteran population on the
smaller islands generally cannot justify construction of veterans'
homes on each island. However, using the Alaska Pioneer Home concept as
a foundation, it may be feasible to advance legislation deeming a
similar status to the Hawaii Health Systems Corporation (HHSC)--as one
``State veterans' home'' for purposes of HHSC's participation in the VA
State veterans' home programs. The HHSC, a public benefit corporation,
is an extensive hospital system of 12 facilities on five islands, and
is the largest health provider in the Neighbor Islands. Under this
scenario, smaller bed units--perhaps ten to thirty beds each, depending
on local circumstances--could be justified under existing VA criteria
in a manner similar to the Alaska model. Such projects could be
developed as separate facilities within these existing State-owned and
operated hospitals to accommodate the needs of elder and disabled
Hawaii veterans in rural and remote locations.
Mr. Chairman, like you, NASVH is committed to meeting the long-term
care needs of veterans, whether they live in major metropolitan areas
or in geographically dispersed areas such as these Neighbor Islands of
Hawaii. Although Hawaii may not be able to cost-effectively justify the
establishment of large, stand-alone State veterans' nursing homes on
each of the Neighbor Islands, other creative solutions such as the
Pioneer Homes model may be worth pursuing. NASVH stands ready to work
with you, this Committee, Congress and VA to meet the diverse needs of
veterans living throughout Hawaii, as well as other veterans living in
large States such as Alaska, Wyoming, Montana, and Idaho.
Mr. Chairman, Senator Akaka, and other Members the Committee, once
again I want to thank you for allowing me to testify here today on
behalf of the National Association of State Veterans Homes. We look
forward to working with you and the Congress to strengthen, rather than
weaken, this foundation of veterans' long-term care. The care provided
by our member homes is an indispensable, cost-effective, and successful
element in VA's provision of comprehensive health care. We are grateful
for your past support and hope that should we see a repetition of the
misguided budget proposals submitted by the Administration last year,
that we can again count on your support. Millions of veterans are going
to need long-term care in the years ahead. We want to be sure that the
State home program is there to support them.
Mr. Chairman, this concludes my testimony. I would be pleased to
answer any questions you may have on this or other topics in which I
might be helpful to the Committee.
Prepared Statement of Edward Kawamura, Veteran
To: Senator Craig, Ranking Member, Senator Akaka, and Members of
this hearing.
My name is Edward M. Kawamura. I am a Vietnam Veteran who retired
from the U.S. Army in 1978. I have been involved with veterans and
families as Department of Hawaii, Disabled American Veteran Commander,
Kauai Veteran's Council President, Board Member Office of Veterans
Services, and current Board member to the VA Advisory Board.
The services that are provided by our VA are ``No. 1.'' The
personnel at the Kauai Community Based Outpatient Clinic (CBOC) are the
best. Their professionalism, dedication, and willingness to help, make
them the best. Their rating by JACCO reflects their No. 1 rating. I
applaud all the workers involved at the CBOC and VET Center.
There are some improvements and visions that I would like to share
as improvements and new programs for Kauai Veterans. They are as
follows:
a. Manpower. More manpower is needed. A Home Healthcare Nurse is
needed. Our aging population, coupled with problems of getting veterans
to the medical clinic, mandates the need to provide the care and
services at the homes. This nurse would help in reducing time now
serviced by our doctor and nurse practitioner so more veterans can be
served and reduce scheduling time for appointments. Outreach programs
are needed, and can be accomplished with more manpower. Increased
manpower and services are needed also due to the increased veteran
population returning from the Iraqi War.
b. Facility. The CBOC has outgrown itself. The size and space for
the waiting room, screening rooms, prescription vault and conference
rooms needs to be increased. Parking is another area that needs to be
increased. Recommendation: A new CBOC be constructed at the Kauai
Veterans Center site. Parking is adequate and space is available for
new building. This would make for a ``One-Stop'' veterans operation.
c. Funding. More funds should be made available for travel as our
VA has a huge geographic area to cover. All of these travels must be by
air. Care servers, care givers, and patients are often required to
travel to provide or receive services.
d. Kauai Veterans Cemetery. Phase I expansion by the VA doubled the
size of the cemetery. They did not provide for increase in manpower or
equipment. This should be a factor included in future plans.
e. Vision. The vision is that there should be an Old Soldiers Home
of the Pacific here on Kauai. The aged veterans who have nowhere to go
should be afforded a place to live out their lives. This is so we can
accommodate the Pacific Rim veterans to provide for an environment
similar to their lifestyles. The site location at Sam Mahelona Hospital
has the ideal view and environmental elements for a good soldier's
home.
The Spark M. Matsunaga Medical Center is a perfect example that
reflects the dedication by our congressional and your committee to our
fellow veterans. This facility is ``No. 1.''
I would like to thank each and everyone on your committee for
taking time to hear our concerns. This is truly the only way to hear
first hand the needs of our fellow veterans and their families. Thank
you very much.
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Prepared Statement of Thomas M. Driskill, Jr., President and Chief
Executive Officer Hawaii Health Systems Corporation
Senator Akaka, and other distinguished Members of this Committee,
thank you for this opportunity to testify before you in strong support
of healthcare programs, services, and facilities that serve the
approximately 118,000 Veterans living in Hawaii. Hawaii Health Systems
Corporation (HHSC) is grateful for the opportunities to provide high
quality healthcare services to Veterans at all 12 of our existing
facilities located on five islands of Hawaii. The more than 3,400
employees of Hawaii Health Services Corporation take great pride in
caring for our State's Veterans. Soon, our role in caring for Hawaii's
Veterans will be expanding to new heights when the 95-bed State
Veterans Home is opened for operation and occupancy in 2007.
As Hawaii's Veteran population continues to both grow and age,
there is an even more critical need for long-term care services such as
will be available in the state-of-the-art State Veterans Home that
Hawaii Health Systems Corporation is building in Hilo. This 95-bed
facility will significantly increase the number of long-term care (LTC)
beds in east Hawaii and because they are earmarked specifically for
Veterans and other eligible beneficiaries, we will be measurably
improving the LTC access and capacity for our Veterans.
Over the last 8 years, HHSC has enjoyed an outstanding,
collaborative and very successful working relationship with the
Department of Veterans Affairs-Hawaii, Washington, D.C., the VA Medical
& Regional Office Center-Hawaii, the Office of Veterans Services, and
multiple Veterans organizations across the State. Since 2001, HHSC has
intensively worked with our VA partners to attain the first ever State
Veterans Home for Hawaii, and now the fruits of that arduous labor will
soon pay off with the opening of the State Home.
We have recently selected and contracted with a nationally
acclaimed management company to operate the State Home for HHSC.
Community support both in East Hawaii and across the State for our new
State Home has been strong and steadfast over the past several years,
and we anticipate that this support will continue to grow as we get
closer to opening the State Home. The synergy of a combined Federal and
State funding of the Home has been the catalyst for making this dream a
reality. We deeply appreciate Senator Akaka's tremendous support, as
well as the tremendous support we received from Senator Inouye,
Representative Abercrombie, Representative Case, Governor Lingle, our
Hawaii State legislators, and our Hawaii Veterans organizations in
making this State Home possible for Hawaii's Veterans.
We would like to ask for one additional element of support from
this Committee and that is to help ensure that the per diem rate for
State Veterans Homes is NOT decreased at the Federal level. Decrements
to the per diem rate of reimbursement to the State Veterans Home will
have serious adverse financial consequences to the viability and
sustainability of all State Veterans Home's operations.
Thank you, Senator Akaka, for the tremendous support you continue
to give to all of Hawaii's Veterans, and thank you for your sage
leadership and the warm Aloha that you bring to our great State.
Mahalo Nui Loa.
Prepared Statement by Frank Cruz, President Kauai Veterans Counicl
Chairman for the State Office of Veterans Service Governors Advisory
Board
Chairman Craig, Ranking Member, Senator Akaka, and Members of this
Hearing: My name is Frank Cruz. I am a Vietnam Veteran and currently
the President of the Kauai Veterans Council and Chairman for the State
Office of Veterans Service Governors Advisory Board.
The 95 bed Long Term Care Facility being build in Hilo is a welcome
and long awaited project for our veterans living in the State of
Hawaii. This Facility will help our veterans especially the World War
II, Korean, Vietnam and our 100 percent disabled veterans here in
Hawaii a much needed long term care place. However there are some
question and information that needs to be decimated to all veterans
wanting to apply for this facility.
1. What are the criteria for any veterans applying for long term
care?
2. What will be the cost for the veteran and their family?
3. This facility needs professional and trained caretakers, how
will this facility be able to be self sufficient without putting the
burden on the veterans staying in this facility?
The Kauai Community Based Outpatient Clinic (CBOC) has provided top
notch services to our veterans here on Kauai. There are some areas
where much needed improvements are needed.
1. Parking for this clinic is inadequate to accommodate for
patients having appointment.
2. How will this clinic be able to handle the influx of veterans
coming from Iraq and elsewhere?
3. The medical equipment must be up-graded to current standard.
4. There is a need for qualified female to handle the needs for our
women coming from Iraq and elsewhere.
5. There is a need to increase manpower and services due to the
increased of veteran population returning form the Gulf war.
On behalf of the veterans on Kauai, I thank the members of this
Committee for the time you have taken to listen to the concerns of our
Island. Your commitment and efforts to our Veteran Community is greatly
appreciated. Thank you very much.
Prepared Statement of Colette V. Browne Professor, University of
Hawaii School of Social Work
Mr. Chairman and Members of the Senate Committee on Veterans
Affairs:
Thank you for the opportunity to participate in this hearing on
long term care in Hawai'i, and the role of the Department of Veterans
Affairs in providing this care.
Mr. Chairman, we at the School of Social Work join in welcoming you
to Hawaii. We appreciate your leadership and your commitment to working
in a bipartisan manner to better understand how to ensure that the
needs of older adults, specifically veterans, are met with accessible
and affordable quality of care. I am professor and Chair of the School
of Social Work's gerontology program. For more than fifteen years, I
have served as a gubernatorial appointment to the State's Policy
Advisory Board for Elderly Affairs. In this capacity, I learned a great
deal from the older adults in our great State. I also speak to you
today as the proud daughter of a World War II veteran. I will speak
specifically about the availability of long-term care services in
Hawaii.
Long-term care refers to a range of support services provided in a
variety of home, community, and institutional settings, and coordinated
to meet the needs of people of all ages with disabilities or serious or
chronic illnesses. Examples of these services range from personal
assistance, transportation, home health, meals, nursing care, case
management, and adult day care. Although these services are age-
irrelevant, research informs us that the primary consumers are older
adults. Nationally, nearly 45 million Americans, or one in every six,
are 60 years of age and over. Most older Americans are healthy,
contributory members of society. Others, especially those over the age
of 85 who compose the fastest growing cohort within the aging
population, have become frail and are dependent on others for care.
This dramatic shift in our nation's population has clear implications
for long-term care, in part because older adults have more chronic
ailments than do younger adults. Older citizens account for almost one-
quarter of hospital days in 2001, have a higher physician and hospital
utilization rate, use 69 percent of home health services, and represent
83 percent of nursing home residents.
Mr. Chairman, Hawaii has one of the Nation's fastest growing aging
populations. Today, there are 120,000 citizens who are 60 and over, or
17 percent of our State's population. To put this in perspective,
between 1970 and 2000, the older adult population increased by 207
percent while the total population increased by 57 percent. Our life
expectancy is greater than any other State--an average of 80 years
compared to the Nation as a whole at 77 years. By 2020, an estimated
400,000 residents will be over the age of 60, composing 25 percent of
the State's population.
To determine what the State's needs are and may be for long-term
care, researchers estimate that 15 percent of citizens have limitations
or disabilities that require some form of long term care. In Hawaii,
this is estimated to be 31,000 people. It is important to note that of
this population, 82 percent have annual incomes of less than $20,000.
These are individuals most at-risk of needing public support for long-
term care.
Similar to her sister States, Hawaii provides for its disabled and
elderly citizens with a wide array of health and supportive care
services provided in institutions, health care and social service
sites, community based programs and in the home. Over the past twenty
years, numerous reports and studies conducted by public and private
entities have examined this issue of long term care for Hawaii. A
review of these reports finds a great deal of agreement that the long
term care system in general is: complex and fragmented, institutionally
biased, lacking in its capacity for critical services, limited in its
efforts to maximize Federal funding for programs for special needs,
supports and services; limited in its agency awareness; and
experiencing a shortage of adequately trained professional and direct
support workers, especially in rural areas of the State.
Long-term care is not only nursing home beds, although the very
frail can be found needing this level of care. According to the Health
Care Association of Hawaii, in 2003 Hawaii had fewer than half the
national average of long term care beds per 1,000 population aged 65
and over even though we have the fastest growing population in the 85
and over group. The State's nursing facility median occupancy was 93.7
percent. This same report found that Hawai has the most dependent
nursing facility residents as measured by higher acuity in areas such
as activities of daily living, mobility and medical support
requirements. This results in the need for more resources to be
utilized in these patients' care. Because of this higher acuity level
of Hawaii's nursing facility resident, the average total nursing hours
per patient day in Hawaii is 4.57 compared to 3.24 hours per day on the
mainland.
To finance existing services, Hawai'i relies on a mix of public and
private funders and agencies, together with private and family
resources. This is similar to the rest of the nation. Projecting into
the future, the Hawaii Health Information Corporation's recent report
on forecasting long-term care bed days in Hawaii found that Hawaii's
aging population is and will continue to be a challenge for long term
care service delivery as baby boomers age. This is because older adults
are much more likely to require acute care hospitalization, long-term
care, home care and hospice, placing heavy demands on the Medicare and
Medicaid programs. This same report found that in both rural and urban
settings in Hawaii, the increases in health care utilization are for
age related disorders, such as heart disease, diabetes, cancer and
stroke. In short, Hawaii 's citizens have the greatest longevity, one
of the nation's most rapidly aging populations, the most ethnically
diverse population, and, looking at Hawai'i's most frail--the oldest,
sickest and most dependent nursing home population in the United
States.
Here in Hawaii, the Department of Veterans Affairs (VA) is a key
government agency that provides services to veterans on all major
islands. Nationally, the Department of Veterans Affairs is responsible
for providing Federal benefits to veterans and their families. The most
visible of all VA benefits and services is health care, providing a
wide spectrum of medical, surgical, and rehabilitative care.
Similar to all public and private agencies, the VA is challenged to
meet the needs of this growing population. Unlike other States, Hawaii
has two unique characteristics that impact the delivery of care. First,
Hawaii's island geography compounds challenges related to access and
utilization of services. As an island State, travel must be by plane or
boat. Second, our multicultural population is unlike any other State,
with a mix of 22 percent Caucasian, 22.8 percent Hawaiian, 11.7 percent
Filipino, 16.4 percent Japanese, 16.3 percent mixed, 3.1 percent
Chinese, and the category of ``other'' equal to 7.7 percent.
Preferences, cultural values, and practices all influence health status
and choice of care. Furthermore, 80 percent of our population resides
on the island of Oahu, where most of our main government programs are
provided. The State is challenged to ensure that all of its citizens
receive equal care. In summary, Hawaii is one of the most ethnically
diverse States, has one of the fastest growing aging populations in the
nation, and its unique geography lends itself to specific challenges
related to access and quality care issues.
As the Nation grows older, Congress is presented with the needs of
those who so well have served our nation. In turn, the VA works to meet
the needs of its constituencies by responding to recent Congressional
laws and mandates within its budgeted resources. This typically results
in the prioritization of services. Inpatient rehabilitation, community
care, respite services, palliative care and nursing home care are some
of the long-term care services offered to veterans through the VA. On
our neighbor islands, the VA operates community-based outpatient
clinics in their attempts to meet needs. Some services, like homemaker
and adult day care, are provided under the Uniform Health benefit to
all veterans. Other services, such as nursing home care, are provided
under the Millennium Law by contracted community institutions to those
with service-connected disabilities.
What we have learned is that veterans and non veterans appear to
want the same thing when it comes to long-term care. A recent AARP
study found that most adults prefer to receive care in their own home,
are not confident about being able to pay for nursing home care; feel
it is important for the government to help pay for long term care
services, and support being able to decide about the kind of care they
want to purchase. It is worth pointing out that it is not only the
needs of veterans that must be considered, but those of their families,
who have and continue to provide the bulk of long term care. Services
to support families, then, must be part of our mix of long-term care.
A critical need in which we at the University see the VA taking a
key leadership role is the education and training of new professionals
in geriatrics and gerontology. This is no small task, as the
recruitment of new professionals continues to be a challenge. The
Veterans Administration fulfills a critical and valued community need
in its training of future geriatricians, geriatric psychiatrists, and
geriatric social workers.
Mr. Chairman, the problems around long-term care are huge, and
clearly no one agency can do it alone. Long-term care requires
collaboration. Throughout the nation, aging networks, health care
providers and community services are joining together to promote and
improve the well-being of older adults. A recent report, A Strategic
Plan: On Achieving Outcomes on Creating a Legacy: Healthy Aging Project
(2005-2009), a partnership among the Aging Network, Department of
Health, and public and private agencies here in Hawaii, offered a
blueprint for improving health of na kupuna--our elders. This report
recommended that any venture to improve the health of our elders must
be community driven, inclusive, community-owned, built upon existing
community assets and infrastructure to ensure long term sustainability,
and use evidence-based strategies. Ensuring the adequacy of the State's
infrastructure to provide long-term care requires skilled and
knowledgeable professionals and paraprofessionals committed to quality
care. From a university perspective, we remain concerned about meeting
future long-term care workforce needs. We therefore respectfully
request Congressional support for the training and education of future
professionals in medicine, nursing, social work and other related
fields.
In closing, a recent Summit on Long-Term Care organized by the
Hawaii Institute for Public Affairs analyzed previous reports and
studies, plans and data, and arrived at the following conclusion. The
need exists to build the political will and gain greater community
support for the issue of long term care. This hearing can hopefully be
seen as a concrete step toward building both.
The VA provides a number of critically important services for our
veterans. Nonetheless, they face similar challenges that our State and
private entities face: a growing aging population with increasing
fiscal restraint. We are all here today because we understand the
enormous sacrifice that our soldiers and their families make everyday
to serve their country. The question is: Will the Nation be there for
our veterans with the necessary long term care services when they need
us? The mission of the VA is clear. Have we, in turn, provided them
with the requisite resources to meet this need?
I thank you for this opportunity to speak with you today, and I am
happy to answer any questions.
Prepared Statement by Lynn M. Aylward-Bingman, Capt (NC) USNR (Ret)
Member, Veterans Advisory Council to the Veterans Affairs Pacific
Islands Health Care System (VISN 21)
Chairman Craig, Ranking Member, Senator Akaka, and Members of this
Hearing: I am Lynn Aylward-Bingman. I am a retired US Navy Nurse Corps
Captain. Among other duty stations, I served at the Naval Hospital Guam
in 1968--1969 caring for the air-evaced wounded from Viet Nam.
Subsequently, while stationed in San Diego, I received my law degree
and was a trial attorney for 23 years. I became involved with the
Hawaii Veteran community when I came to Kauai, from California, nearly
5 years ago. I am proud to represent our veterans as a member of the
Veterans Advisory Council to the VA Pacific Islands Health Care System.
In that capacity, my colleagues and I communicate to, and address,
concerns of our Hawaii veterans with the Director of the VAPIHCS and
the Regional VISN Director. We also liaison with the individual Island
Veterans Councils. I am honored to speak on behalf of our veterans,
particularly the Kauai veterans, at today's hearing, and to express
some of our concerns with the State of veterans' health care in Hawaii.
The citizens of Hawaii are the most patriotic and generous people
I've ever known. This is exemplified by the fact that there are several
Medal of Honor recipients among our Hawaii veteran community; and by
the spirit of ``ohana,'' which is particularly strong in our veteran
community. The ohana spirit is very important given the unique
disparate and geographic nature of our Islands and the Pacific Region.
It is far more difficult for our veterans to obtain full health care
services than it is for our fellow veterans on the Mainland.
We are very proud of the strides that have been made by the VA in
Hawaii over the last few years, especially those on the Outer Islands
such as establishment of Community Based Outpatient Clinics or
``CBOCs''. Our Kauai CBOC staff are outstanding and do their best to
provide a high quality of care to our veteran patient community.
However, they are limited in the care they can provide by limited
funding. We lack ``on Island'' VA specialists, certain equipment, and
adequate staffing, among other things. There are three areas of concern
I would like to address today.
SPECIALIZED TREATMENT/SURGICAL CARE
At present, when a veteran needs specialized care for a cardiac,
orthopedic, or serious dermatologic condition, for example, one of
three situations will occur after being evaluated by our CBOC staff.
The veteran will either: (a) be flown to Honolulu to see a specialist;
(b) have to wait several months to get an appointment with one of the
specialists who come to the CBOCs intermittently; or (c) obtain
authorization to be seen by a local health care provider in the
community. Telemedicine greatly assists our CBOC staff in evaluating
some health issues, but does not eliminate the need for the veteran to
actually be seen and treated by a specialist. Each of the above
scenarios costs the VA money and, in the first two, also costs the
veteran valuable time.
We recognize that it is not practical, nor possible, to have a full
complement of specialists on each Island to see veterans when needed.
However, it is also not acceptable to have to wait months, in pain,
before a veteran is seen by a specialist who only comes to Kauai for a
single day once every 3 or 4 months. Nor is it acceptable to wait
several months before the veteran is flown to the Mainland for hip
replacement surgery.
When a veteran is flown to the Mainland for surgery, more problems
are created. First the VA incurs the transportation costs. Second a
sick or disabled veteran is forced to travel alone to a location where
he, or she, has no friends nor family support, and undergo, again
alone, what is frequently serious or even life threatening surgery or
treatment. Following the surgery or treatment, the veteran then travels
alone again to return home. He is not followed by his surgeon, nor is
his post operative care or recovery monitored, or modified if needed,
by anyone who actually did the surgery. This is far from optimal care
and, in some instances, would be considered negligent. If post
operative problems occur, other healthcare providers, who have no first
hand knowledge of the surgery, are involved in the veteran's care. The
more providers involved, the greater the chance recovery problems will
arise. Additionally, it doesn't make good medical sense, or good care,
to expect a person who has just been through major surgery to travel
long distances. Just navigating a large airport these days is stressful
to a healthy person.
One solution to this problem, and to obviate the VA incurring the
costs of the local health care provider on a fee basis, is to increase
and implement more long term arrangements with the local healthcare
providers on Kauai, and the other Islands. Through the use of Memoranda
of Understanding (MOU), or other long term contracts, more veterans
could receive care locally, at a reduced cost to the VA. This would
also benefit the veteran in that he would not have to leave his home
Island, or family, for surgeries. It would also improve the overall
quality of the care rendered as the veteran's progress would be
monitored by the provider performing the surgery. If adequate
facilities exist at Tripler, another alternative is for the VA to hire
board certified specialists who can treat and/or perform surgery on
veterans as inpatients at Tripler.
Funding for the VA needs to be significantly increased to meet the
increased demand for care, not just by our older veterans, but also to
ensure that good care is available to our service men and women who
are, and will be, returning from the middle East. We also want to
ensure that the VA obtains maximum value for the monies budgeted for
healthcare. MOUs with local providers will help accomplish this goal.
STAFFING
Interrelated with the above is our concern that the CBOCs have
sufficient staff. Adding another physician would allow for more
diagnostic evaluations to be done ``in house.'' In turn, some of the
fee based costs incurred by the VA for referrals to local providers
would be eliminated or, at least, reduced.
At present, we still have a need for at least one more clinic
staff, preferably an LVN or person certified to draw blood. The Kauai
CBOC does have a part time person who is in the clinic 3 days a week to
draw blood, and collect other specimens, which are then sent off Island
for processing. Obviously, this creates a delay in getting results, and
in treatment when indicated. It also requires a return visit by the
veteran if they come on a day the ``lab'' person isn't there. Emergency
laboratory work is done locally on a fee basis. Again, use of an MOU
would be useful in reducing the costs to the VA.
The individual who does the tele-medicine support at the CBOC is,
inaccurately, ``counted'' as Kauai CBOC ``staff;'' but is, in fact, a
Honolulu staff person who could be recalled at any time. If any one of
the current staff become ill, or are even on vacation, it creates an
immediate staff shortage. The Kauai CBOC staff is very devoted to
providing optimal care to the veterans they serve, and they do an
excellent job. However, insufficient staff translates into delays for
patients, and the inability to see more patients.
One problem with determination of staff needs is that an outdated
model, based solely on the numbers of patients, is utilized to assess
physician, nursing, and support staff needs. Our CNP not only sees
patients and assists our physician. She also is responsible for all the
patient education, supervision of the staff, dispensing medications,
doing follow-up phone evaluations and many other duties. However, the
CBOCs needs for additional nursing personnel are based only on the
number of patients she sees. All the other hours she expends on the
care of our veterans, including preventative care through education,
are not counted. The methods used to evaluate the healthcare needs and,
hence, determine the amount of funds needed and allocated requires
immediate revision and updating.
Of equal import is the long time need for a Home Health nurse.
Monies for this position were budgeted and approved; but the monies
were utilized for other health care matters. However, the need for a
Home Health care nurse still exists. Hawaii, and the Pacific Islands in
general, have significant numbers of elderly veterans. Many of these
veterans have reached the age when they can no longer drive or tolerate
the trip from their homes to the CBOC. The obligation to these aged
veterans cannot be ignored or forgotten. Once again the inability to
meet these healthcare needs is due to lack of adequate funding to
provide these services. Long term care facilities are non existent, but
greatly needed, for Kauai veterans. Similarly, Kauai's homeless
veterans are in need of attention. Extension of the O'ahu outreach and
other programs, even on a part time basis, is needed.
FUNDING
As noted at the outset, VA Pacific Islands Healthcare System
encompasses a vast, and disparate, geographic area. The very
composition of the System mandates additional monies be allocated for
rendering health care, and other, services simply to meet the costs of
transportation and the necessity of utilizing community resources more
frequently than a similar Mainland veteran population. Our healthcare
providers primary goal is to render quality care for our veterans.
Although some increases have occurred, the VA budget is still seriously
short of it's needs. Providers are doing the best they can, but cannot
work miracles . . . with limited staff, resources and equipment, the
care rendered is also limited.
On behalf of the veterans we represent, I thank the Members of this
Committee for the time you have taken to hold these hearings and listen
to the concerns of our Islands. Your efforts and commitment to our
Veteran community is greatly appreciated. Mahalo, and Aloha.
Prepared Statement of Laurie Makaneole
I would like to take this opportunity to express my concern
regarding our returning military personnel from Iraq and Afghanistan.
Kauai will be having over 100 reservists but in addition we have many
Kauai people who have also served in the active military and will also
be returning from Iraq and Afghanistan.
I have a son who is a Captain out of the Stryker Brigade Combat
Team from Fort Lewis-Washington--who just recently returned from Iraq.
I am concerned that these military persons and their families need
access to Post Traumatic Stress counseling- that is appropriate for
them. These young people returning are not the same persons who left us
a year ago--and we all need help with this serious issue.
I am concerned about their successful re-entry into our world.
These young persons gave so much of themselves and now need our help to
assist with a successful re-entry and a good future life. Their
difficulties are also a spouse and child concern- it affects the entire
family unit.
Please provide funds to appropriately educate families and provide
appropriate treatment for this concern.
Prepared Statement of Martin T. Rice
In the summer of 1966 I joined the U.S. Army and served two tours
in Vietnam which just so happened to span three successive Tet
Offensives: 1967 and `68 in Nha Trang, on the central coast, and 1969
at Long Binh, just outside of Saigon.
I was told that one of the benefits of joining the service was
life-long health care coverage. Some administrations have whittled away
at the promise. It is an alarming trend.
However, I am grateful for the partial coverage that has been
provided to me. The Government has admitted and taken responsibility
for the diabetes and colon cancer that was diagnosed in August of 1999,
probably as a result of exposure to Agent Orange during one or both of
those two tours. The emphysema that was simultaneously diagnosed in
August 1999 is currently not a problem, however, it continues to be
monitored and is a result of the cheap tobacco products offered to
young soldiers, such as myself, at PX's. I was able to stop smoking,
with the help of hypnotherapy, in November 1988, 22 years after
entering the service. The emphysema appears to be in check. The
diabetes is likewise under control, thanks to the monitoring by Dr.
Duvachelle and the Kauai Clinic staff, however, to keep it under
control requires the attention and time-frame of a part-time job. I
currently spend about 18 hours a week, including drive time, at the gym
in order to maintain blood sugar levels. I've found that 6 days a week
of cardio-vascular exercise coupled with weight training has done the
trick. I am able to forgo medicine, most days, and of course, I watch
my diet. I have, over the years, seen the number of per-year visits at
the Kauai Cluuc, whittled down, due in part to my exercising regimen,
but also due in part to a heavier patient load carried by the staff.
Be that as it may, the lasting effects of the Agent Orange-induced
colon cancer are ever-pervasive. I had what's known as a total
proctocolonectomy, basically Tripler Army doctors in Honolulu took
everything ``south'' of the small intestine: the appendix, colon and
most of the rectum, and reattach the small intestine to what was left
of the rectum. The procedure was innovative at the time, and required a
4-month period with a colonectomy bag while the lower third of my small
intestine was trained to function, somewhat, as a colon.
I do own my own home-based business, however it requires one day of
delivery, from Kekaha to Hanalei--a day of complete fasting until the
deliveries are done. Usually that means from the preceding evening
until 7pm that day, at the earliest, about 24 hours.
I'm also lucky to have started this business in 1990, as I've been
able to adapt it, somewhat, to my current medical condition. Otherwise,
I would be unemployable, as the absence of the storage capacity that a
colon provides requires many daily restroom visits. By way of
measurement, I usually use seven to ten rolls of toilet paper weekly.
Literally, I know my way around this island from restroom to restroom.
Additionally, I have not slept more than 4 hours uninterrupted at
any given time since the April 2000 surgery, due to the need to use the
restroom at all hours, giving rise to what has been diagnosed as acute
sleep deprivation.
I'm not complaining. I know many people have it a lot worse than I.
I feel lucky to be here, as the cancer surgery, which took place almost
8 months after diagnosis, again due to the heavy patient load, this
time at Tripler, came just in time. It became negated as the cancer had
spread quite dramatically; a total proctocolonectomy became necessary.
It was luckily performed before the cancer penetrated the outer wall of
the colon, from which it usually spreads to the liver, a sure death
sentence.
I have presented all of the preceding to demonstrate how precarious
my current situation is. Without the promise of medical help of the
government, I would not have even limited health coverage. In fact, I
probably would have been dead already.
I feel that this promise of limited health care is in further
jeopardy, for main two reasons. (1) there's a need for increased
staffing at the local clinic as the load will be increasing due to
returning servicemembers from Iraq and Afghanistan, and (2) there's the
ongoing threat that the current administration will cut health services
to people such as myself as a matter of fact.
Those who know me, know that I remain active in spite of my
service-connected diseases. In addition to my main business and the 6
days-a-week gym workouts, I am starting a second business. I'm also a
lobbyist at the State legislature for a civil rights organization, I'm
the current chair of the local Democratic Party and I serve as
treasurer for a local non-profit.
My story is but one of a hundred thousand in this small State, and
one of but millions upon millions nationwide. My dream of public
service at the State legislature will probably remain just that, due to
the aftermath of my service-connected diseases as I feel that although
my country wouldn't abandon me or my health care needs, this
Administration will.
Prepared Statement of Ronald K. Takamura
Mr. Chairman, Senator Akaka and other distinguished members of the
panel. My name is Ronald K. Takamura. I am a medically retired US Army
Captain. I am presently involved with the Hawaii Veterans Community and
especially on affairs concerning the Veterans of Kauai.
First of all, let me give you a broad insight of just where this
island stands within the entire United States. Our little island has a
population count of approximately 54,000 people of which approximately
5,700 are veterans; this is equal to 10 percent of the population which
is the highest pro-capita ratio in the entire United States. Our CBOC
technical staff which consists of only one Doctor, one Nurse
Practitioner and one Psychologist see and treat approximately 30+
patients per day out of a registered count of approximately 1,850
veterans. With the returning veterans from the Middle-East who will be
coming home very shortly, our facility will be greatly under-staffed
and will be very strained to deliver the best care and services to the
total number of veterans.
As a proposed remedy to this situation, the following idea is
presented to you for your consideration:
A. Facts:
1. The CBOC and the VA office located at its present location will
have outgrown its space for which the sum of $ 15,000.00 plus utilities
is paid for rent on a monthly basis.
2. There is only adequate parking space for 17 cars including those
that belong to the staff.
3. Cost to the VA each time a veteran is sent t Honolulu runs over
$200.00 per visit for transportation alone.
4. It takes the veteran approximately 3 hours of travel time to get
to Honolulu and another 3 hours for him to return.
5. In addition to the above, the State of Hawaii Office of
Veterans' Affairs (OVS) pays approximately $1,850.00 rent for the area
it occupies in the present Veterans Center.
B. Proposal:
1. The Kauai Veterans Council has acquired enough additional land
at the rear of the present center to construct a two or possibly three
story building in which it would be ideal to house the CBOC, VA Office
and the OVS Office.
2. This building would be customized to house an expanded CBOC as
well as the other offices. By doing so, would create a one-stop
Veterans Complex with ample parking and technical facilities to better
serve our veterans in the long run.
3. The monies paid for rent/utilities would be better utilized as
the facilities located within this complex will be owned by our
veterans, and would contribute toward any costs incurred like mortgage,
etc.
4. The CBOC would then be expanded to handle a larger technical
staff as well as up-to-date equipment and programs which would be
classified a State-of-the-Art.
5. The cost of flying specialists to Kauai from Oahu would be
cheaper than flying patients from Kauai to Oahu due to the following
accepted procedures presently in effect:
a. Time saved on patient travel time which would be an equivalent
to approximately 3 hours to and from Oahu for a total of 6 hours.
b. Each time a patient goes there to Oahu, he is first interviewed
by interns from the University. The interns then consult with the
specialist and only after all of this, he gets to see the specialist
for approximately fifteen minutes if lucky. If the specialist flew over
to Kauai, there would be no interns and then he would be able to
service at least three to four times as many veterans for the same
amount of time.
c. Transportation for patients would be much simpler with the
utilization of the DAV Transportation Network and the Kauai Bus
services.
d. By increasing the technical staff of the CBOC, i.e. one Doctor,
one Laboratory Technician, one administrative clerk and one records
management clerk, much better services could be provided the veterans
and the waiting periods between appointments would be greatly reduced.
As for my comments on Long-Term Care Facilities, I personally do
not think that the operation of one on this island would be
economically practical. In addition, to have the facility on another
island would not for practical purposes sufficiently or efficiently
service our veterans due to travel and other cost restrictions.
The cost factors to operate such a facility have not been spelled
out to the veterans in black and white which leaves many loop holes in
the true benefits that a veteran would gain over the civilian type of
care facilities now in operation.
For example, if the administration would only accept the VA
benefits check, the Social Security check and maybe \1/2\ of the
retired military pay check, then the veteran may be able to benefit
some provided that his personal property not be touched. If his
personal property and assets are included into the cost factor, then I
contend that there would be no different than the present operating
Long-Term Care Centers presently in operation and the veteran would
lose in the long run.
Judging from the panel members in attendance of his hearing, all of
the operational bodies would belong to a profit making organization or
company and would be out there to make money instead of trying to do
what would be best for the veteran. Therefore, I contend that there
would be better ways to utilize our monies, such as building a center
as proposed above.
Thank you for giving me this opportunity of testifying before this
Committee.
Prepared Statement of William T. Honjixo
A hearing as this is great appreciated by veterans on this island
of Kauai. IT certainly demonstrates that our nation cares about
veterans. The caliber of participants and speakers were outstanding and
impressive. It was not ``eye wash,'' but a serious attempt to solve
problems facing the veterans here on Kauai and the State of Hawaii.
Mahalo for your effort and the caring of veterans.
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