[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]





  CHALLENGES IN RURAL AMERICA: INFRASTRUCTURE NEEDS AND ACCESS TO CARE

=======================================================================

                                HEARING

                               before the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                       THURSDAY, AUGUST 14, 2014

                               __________

                           Serial No. 113-84

                               __________

       Printed for the use of the Committee on Veterans' Affairs


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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               MICHAEL H. MICHAUD, Maine, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         CORRINE BROWN, Florida
DAVID P. ROE, Tennessee              MARK TAKANO, California
BILL FLORES, Texas                   JULIA BROWNLEY, California
JEFF DENHAM, California              DINA TITUS, Nevada
JON RUNYAN, New Jersey               ANN KIRKPATRICK, Arizona
DAN BENISHEK, Michigan               RAUL RUIZ, California
TIM HUELSKAMP, Kansas                GLORIA NEGRETE McLEOD, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
PAUL COOK, California                TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana
DAVID JOLLY, Florida
                       Jon Towers, Staff Director
                 Nancy Dolan, Democratic Staff Director

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.














                            C O N T E N T S

                              ----------                              

                       Thursday, August 14, 2014

                                                                   Page

Challenges in Rural America: Infrastructure Needs and Access to 
  Care...........................................................     1

                           OPENING STATEMENTS

Jeff Miller, Chairman............................................     1
    Prepared Statement...........................................    50
Gus Bilirakis, Vice Chairman.....................................     4
Kristi Noem, Congresswomen From: South Dakota....................     5

                               WITNESSES

Bryan Brewer, President, Oglala Sioux Tribe......................     8
    Prepared Statement...........................................    52

Tim Jurgens, Commander, American Legion Department of SD.........    10
    Prepared Statement...........................................    55

Robert Nelson, Veteran...........................................    12
    Prepared Statement...........................................    73

Amanda Campbell, Community Stakeholder...........................    14
    Prepared Statement...........................................    89

Patrick Russell, Co-Chair, Hot Springs Safe the VA Committee.....    15
    Prepared Statement...........................................    98

Larry Zimmerman, Secretary, Department of Veterans' Affairs, 
  State of SD....................................................    17
    Prepared Statement...........................................   116

Steven Julius M.D., Chief Medical Center and Acting Director, 
  Veterans Integrated Service Network 23, VHA, U.S. Department of 
  Veterans' Affairs..............................................    30
    Prepared Statement...........................................   116

    Accompanied by:
        Stephen DiStasio, Director, VA Black Hills Health Care 
            System, Veterans Integrated Service Network 23, VHA, 
            U.S. Department of Veterans' Affairs


 
  CHALLENGES IN RURAL AMERICA: INFRASTRUCTURE NEEDS AND ACCESS TO CARE

                              ----------                              


                       Thursday, August 14, 2014

            Committee on Veterans' Affairs,
                     U.S. House of Representatives,
                                                   Washington, D.C.
    The committee met, pursuant to notice, at 10:05 a.m., at 
the Mueller Civic Center, 801 South 6th Street, Hot Springs 
South Dakota, Hon. Jeff Miller [chairman of the committee] 
presiding.
    Present:  Representatives Miller and Bilirakis.
    Also Present: Representatives Noem and Smith.

           OPENING STATEMENT OF CHAIRMAN JEFF MILLER

    The Chairman. The committee will come to order.
    Before I begin, I'd like to take care of one minor 
procedural detail. I ask unanimous consent that Congresswoman 
Kristi Noem and Congressman Smith be allowed to sit at the dais 
today and participate in the hearing. Without objection, so 
ordered.
    Good morning, everybody, and thank you for joining us this 
morning. I am Jeff Miller, Chairman of the House Committee on 
Veterans' Affairs. I come from the panhandle of Florida where 
thousands live like millions wish they could.
    The Chairman. I have never been to South Dakota. What a 
beautiful State. Thank you so much for your warm hospitality. 
It is a pleasure to be here with you today.
    I am joined by the vice chairman of the full committee, 
another Floridian, Congress Gus Bilirakis, from the 12th 
district of Florida and, of course, I have already said 
Congressman Adrian Smith from the 3rd district of Nebraska and 
your Congresswoman and my good friend, Kristi Noem, from right 
here in South Dakota.
    The Chairman. I think it is important that you know that 
Kristi is known in Washington as a leader, and this field 
hearing is being held today because Kristi asked us to come 
here and hold this field hearing. It is important to note that 
she has been involved in the issue in regard to your facility 
here in Hot Springs from the very beginning, and when it comes 
to veterans affairs issues, she is not shy about coming up to 
me on the floor and talking about the issues that affect her 
constituents here in South Dakota.
    Earlier this morning, I was able to have a tour of the Hot 
Springs campus so we could see the facility. Firsthand I will 
tell you this--I had not heard about this facility until Kristi 
brought it to my attention several months ago. The first thing 
I did was go to the Internet and start looking at photographs. 
The photographs do not do it justice. What a beautiful and 
wonderful historic facility.
    The Chairman. It is very clear that this community and that 
facility have a storied past, taking care of those that have 
worn the uniform of this Nation, and it is our hope that some 
way, somehow we will find a way to continue that storied 
history that is held within the walls of that magnificent 
structure.
    So, again, thanks to you all for being here today. Thank 
you again. Let me say this before we start. If you are able to 
stand, please stand, anybody who has worn the uniform and is a 
veteran of this country. If you cannot stand, just wave to us, 
but I would like to recognize the veterans in this audience 
today.
    The Chairman. Thank you very much for your service. Again, 
we are here today to ensure that you receive the quality health 
care in a timely fashion that you have earned by wearing the 
uniform of this country. I know the Black Hills Health Care 
System, which has campuses in Fort Meade and here in Hot 
Springs, has the same desire, and that is to provide you the 
quality health care that you expect and certainly you have 
earned.
    I just want to give a little background, if I can. In 
April, you know that the House Committee on Veterans' Affairs 
was able to break open, unfortunately, what is probably one of 
the largest crises that has ever happened within the Department 
of Veterans Affairs and maybe even the Federal Government. We 
found that VA employees were actually manipulating wait time 
schedules. Unfortunately, we have had veterans who have died 
because of those manipulations. And unfortunately, VA still has 
a long way to go to correct that wrong that was perpetrated on 
you.
    I have pledged to the new Secretary, Secretary McDonald, 
that our committee will, in fact, work as a partner with him in 
trying to help restore the trust in VA that you would want to 
have and you would expect to have. But I have also told him 
that we will not give them a honeymoon period, if you will, 
because our oversight continues, oversight of the second 
largest agency in the Federal Government, over 330,000 
employees and a budget of over $150 billion a year.
    I think that it is important to understand that the veteran 
is sacred, not the VA. And that is what I think you would want 
us as Members of the United States Congress both in the House 
and the Senate to feel as we have conducted a very aggressive 
schedule of oversight hearings in the House in particular. You 
may have caught us on Monday evenings for some late night 
hearings that started at about 7:30. Some went to 1 o'clock in 
the morning trying to get VA to come forward and be as 
transparent as they possibly could in trying to get to the 
bottom of this issue. We wanted them to explain to us some of 
the initiatives that they have undertaken to try to fix the 
backlog that exists out there not only when it comes to 
provision of health care but also the process of disability 
claims and the processing problems that exist there.
    VA will claim that they have cut the backlog in half. To be 
very honest with you, I do not trust those numbers. I would 
certainly expect that there are many of you that would feel the 
very same way. While they may have rushed some things out the 
door in an attempt to cut that number down, what they did was 
they actually adjudicated some incorrectly and they also sent 
you into the appeals process which, of course, comes off of 
their books and does not count as a backlog claim, but for you 
the veteran, it is certainly claimed.
    You know that the President signed last week a landmark 
piece of legislation that for the first time I think will 
change the way that VA provides health care. They continue to 
try to provide it the way that they did in the 1950's and the 
1960's, but things have changed. Certainly the younger veterans 
of today from Iraq and Afghanistan understand that health care 
is delivered differently. Those of you from wars and conflicts 
prior to that or even in peacetime understand things are 
delivered in a different way. We have got to meld them together 
if we possibly can.
    We reformed in a very small way a couple of things. Number 
one, we gave VA the ability to hold managers accountable. If 
they do not do the right thing, they should be able to be 
fired.
    The Chairman. There are very few people, up until the law 
was signed, that the Secretary could actually fire at will. 
Now, out of the 330,000, we actually have added another 450. 
That is a first step. Accountability is important.
    Transparency is important. VA needs to tell the truth. 
There is no reason that they should hide news, even when it is 
bad. They should bring that news forward so that each and every 
one of us understands what is going on at VA.
    I think thirdly what this bill did was give the ability to 
look from the bottom up within VA, a true look at how VA 
delivers the services and the benefits that you have earned and 
from an outside perspective, not from within VA. VA is very 
good at trying to analyze itself and then putting forth the 
best picture possible that they can. This will be done by an 
independent group or groups over the next 9 months.
    I will tell you this. Not one law that Congress creates 
will change the culture within VA. That has to be done within 
individuals. They cannot continue to have a culture of what I 
call corruption, what the White House calls corrosive. Same 
thing. They have to do the right thing in serving the veterans 
of this country.
    Here in Hot Springs, I know that you have been faced with 
an issue now for a number of years, and we are going to take 
testimony this morning as to what the community thinks, what 
the veterans think, and certainly we will hear from VA this 
morning as well. We have heard from VA about the significant 
issues that they have to contend with. But in a community like 
yours, I will say this, that it is important for the community 
to be involved, and to see this many people turn out today is a 
true blessing for this community and to see the signs in all 
the local businesses. I have got to say thank you to Kristi and 
her staff and the other members that are here today.
    I would also ask unanimous consent before we begin. Both 
Senators have asked that they have statements entered into the 
record. So without objection, that will be done.
    The Chairman. You have a Senator who is the chairman of the 
Appropriations Committee that could help you in this issue. You 
should talk to him about it. It is very important. I would 
think he should be here, if he could, if not today, certainly 
at another time to talk to you about this issue that is so 
important.
    With that said, I want to recognize the vice chairman of 
the full committee, Mr. Bilirakis, for his opening statement.

    [The prepared statement of Jeff Miller Appears in the 
Appendix]

        OPENING STATEMENT OF VICE CHAIRMAN GUS BILIRAKIS

    Mr. Bilirakis. Thank you, Mr. Chairman. And I will be very 
brief.
    But I do want to thank you, Mr. Chairman, because you are 
responsible for these reforms. The bill that passed this last 
month came out of our committee.
    And I will tell you this. You have an outstanding 
Congressperson in Kristi Noem. She is so very well respected on 
both sides of the aisle in Washington, DC. And she is fighting 
for you, particularly for our true American heroes, our 
veterans.
    So I do have a brief statement, Mr. Chairman.
    Thank you, Mr. Chairman, for holding this important field 
hearing to ensure that VA has the capacity to provide veterans 
quality health care in the VA Black Hills Health Care System.
    I would also like to thank all of the members of the 
community who gather here today to address the concerns and 
challenges that veterans in rural areas face so we can work 
towards improving these issues. I look forward to hearing from 
local veterans and stakeholders in the community on their 
views, opinions, and concerns on the current VA health care 
system and how we can better provide quality health care for 
our veterans. That is the bottom line.
    And you know, we are U.S. Representatives. We not only 
represent our district but the entire United States. So we will 
fight on your behalf.
    It is my understanding that many veterans must travel 100 
miles or so to your nearest VA hospital, and once you arrive, 
you are troubled to find that the hospital does not provide the 
services you need. I want to address these issues today so that 
we can find effective solutions to provide for each of our 
veterans' unique needs and improving a system that can benefit 
each one of our Nation's true American heroes. South Dakota has 
a longstanding history of health care and support for our 
veterans, with facilities provided for over 107 years. What 
beautiful facilities they are too. I was very impressed with 
the services you provide here. We must keep them here. With the 
expectation for both rural and highly rural veterans to 
increase, it is imperative that veterans continue to have 
access to these facilities and services.
    I remain hopeful that through our hearing here today we can 
find the right path forward that best suits the needs of our 
veterans and this community. I look forward to hearing the 
testimonies, and I thank you very much. What a beautiful place 
this is. Thanks for having us here today.
    I yield back.
    The Chairman. I now recognize your Congresswoman, Kristi 
Noem, for a brief opening statement as well. Kristi?

             OPENING STATEMENT OF HON. KRISTI NOEM

    Ms. Noem. Well, thank you, Mr. Chairman. It is a good day. 
I am glad we are all here, and I am glad to see all of you here 
as well.
    I want to, first of all, thank the chairman for coming and 
for having this congressional hearing, Representative Bilirakis 
for coming and traveling so far as well, as well as 
Representative Smith who has constituents that are impacted by 
the proposed closure of this facility as well.
    Welcome to the veterans' town. Hot Springs has always been 
known in South Dakota as the veterans' town. The entire town 
wraps its arms around our veterans, cares for them, helps heal 
them. It is not just about buildings. It is not just about 
doctors and nurses. It is about coming to a place where 
everyone loves you, appreciates your service to this Nation, 
cares for you, and wants you to be healed and as well as you 
ever were at one point in your life.
    The Hot Springs VA Hospital has been slated for closure 
ever since the Department of Veterans Affairs announced a plan 
to realign the Black Hills Health Care System in 2011. For 
nearly 3 years, the tristate delegation has worked together and 
had a number of serious conversations and also serious 
reservations regarding that plan.
    I am very appreciative of your willingness to hear from the 
Hot Springs community, the veterans who are served from this 
hospital. We have some of them testifying today. Their 
perspective cannot be left out of this conversation.
    I have been very troubled by the VA's disregard of 
stakeholder grievances. I am also very concerned about the data 
that they have been using that has justified the hospital's 
closure, and I believe it is incorrect. I have seen 
overwhelming evidence of data discrepancies, including a very 
concerning cost-benefit analysis that was conducted last year. 
Additionally, there appears to be a systematic dismantling of 
services at the hospital.
    [Applause.]
    Ms. Noem. I believe that the true potential of this 
hospital has not been reached and that the services that our 
veterans deserve must return to Hot Springs immediately.
    [Applause.]
    Ms. Noem. Late last month, the VA released the findings of 
an audit that the VA conducted of the Black Hills Health Care 
System. I was very disappointed to see that the Black Hills 
Health Care System had considerably lower marks than other 
hospitals that were in the area and the national average. These 
numbers are unacceptable. I believe that the VA must address 
those numbers and those statistics by bringing services back to 
Hot Springs and ensuring that veterans are receiving the care 
that they deserve.
    I know that there are many other issues surrounding the Hot 
Springs VA, including the environmental impact statement 
process, the National Environmental Policy Act, or NEPA, 
compliance, costs for mothballing the facility, the restriction 
of access that Native American veterans would face if the Hot 
Springs facility were closed, and the potential for mental 
health treatment at the facility.
    I look forward to all of the witnesses and the wisdom and 
perspective that they will share with us throughout this 
committee hearing.
    I know in South Dakota that many veterans are satisfied 
with the care that they get because we have got good people 
here in South Dakota that grew up here helping to take care of 
them. We are very blessed to have them to care for those who 
have earned the distinction of being called a veteran. However, 
given recent reports of VA scandals and audit findings, I do 
not think it is appropriate to move forward with closing a 
facility that the veterans rely on.
    [Applause.]
    Ms. Noem. So ensuring that this facility is able to 
continue serving the men and women who have worn America's 
uniform is on my top priorities.
    I again thank Chairman Miller for holding this critical 
hearing as the community fights to restore the Hot Springs VA 
facility to full service so we can properly serve those 
veterans who have so honored us by serving us. Thank you.
    The Chairman. I now recognize Congressman Adrian Smith for 
his opening statement. Adrian.
    Mr. Smith. Thank you, Mr. Chairman. Thank you, Mr. Vice 
Chairman Bilirakis. Thank you to everyone who has shown up here 
today.
    I am grateful to have the opportunity to represent part of 
Nebraska in the United States House of Representatives and 
certainly representing more specifically the veterans who have 
so sacrificially served, as well as their families who have 
supported our veterans along the way as well.
    I want to thank our witnesses here. I appreciate the 
opportunity to work with you along this journey. It has been 
quite a journey, and I am grateful that we can interact so 
positively and hopefully bring about a positive result in 
standing behind I think not just the building, not just 
individuals one at a time, but perhaps that is the case too, 
but this community, this community of veterans. I have to think 
that the community--and when I say ``community,'' I actually 
kind of mean a three-State area, if you will, Mr. Chairman.
    In fact, how many are here today from Nebraska? Do you want 
to raise your hands?
    Mr. Smith. Very good.
    Maybe even some folks from Wyoming. Any folks from Wyoming 
as well? Okay. There we go.
    Mr. Smith. We know that there was an official announcement 
on December 12th, 2011 when the VA announced its plans to 
reduce the services at Hot Springs, moving all inpatient 
services to Rapid City. I immediately sent a letter to former 
Secretary Shinseki expressing disappointment and concern with 
the proposal. And, of course, we know that services have been 
changing in a less than positive fashion even prior to December 
of 2011. Specifically, I was concerned, following this 
announcement, it would jeopardize access to care of thousands 
of veterans, many of whom reside in the 3rd district of 
Nebraska.
    I have since sent or signed onto seven additional letters 
regarding this proposal. Reducing services at Hot Springs and 
requiring many rural veterans from Nebraska to drive upwards of 
6 hours round trip for care will cause many to not seek or 
delay seeking the services they need. It will put an 
unnecessary burden on their families who help transport and 
care for them. Rural veterans already find it increasingly 
difficult to access the care they require. Approximately 3.4 
million veterans, 41 percent of the total enrolled in the VA 
health care system, live in rural or highly rural areas of the 
country.
    I have appreciated the VA's cooperation with my and my 
colleagues' requests to hold additional meetings and delay any 
final decisions. And I appreciate former Secretary Shinseki 
agreeing to meet with the Save the VA Committee per our 
request.
    But I remain concerned that this is not enough and the VA 
has not fully and transparently addressed these concerns that 
we have expressed. Reducing services at Hot Springs will reduce 
services for our veterans who have already sacrificed so much. 
At a time when we are working so hard to improve access, 
increased transparency and accountability within the VA and 
improve the quality of care, this proposal simply does not make 
sense.
    Again, I appreciate the community support here today. I 
have to think that community support and accountability like 
this would prevent other problems in the VA that we have seen 
in other parts of our country.
    So, again, I want to thank Chairman Miller. Thank you for 
holding this hearing today and also everyone else who has 
worked so hard to preserve access to care here in Hot Springs, 
South Dakota. Thank you. I yield back.
    The Chairman. We are going to begin the hearing today with 
a group of witnesses that are already seated at the table, and 
in just a minute, I am going to recognize Kristi to introduce 
the witnesses at the table.
    But before, I would like to give you an idea of how a 
congressional hearing works. Each person will be given 5 
minutes for their opening statement. There is a little clock 
right in front of me. It has some lights on it. As long as that 
green light is on, you are good to go. When you get to the 
yellow light, some people say it is a minute. Some people say 
it is 30 seconds, but understand it is kind of time to wrap up. 
When it gets to red, that means, obviously, time is up. When it 
starts blinking, I have no idea what is going to happen.
    [Laughter.]
    The Chairman. Look, if it goes to red and it blinks a 
little bit and you have more to say, don't you worry about a 
thing. All right? We want to hear from you.
    Can I ask a favor? Do you mind if I take my coat off? Is 
that okay? All right. Guys, if you want to take your coats 
off----
    The Chairman. It is going to get hot.
    Kristi, you are recognized to introduce the folks that are 
here on our first panel. Thank you very much.
    Ms. Noem. Thank you, Mr. Chairman. I am very proud to have 
the witnesses here today seated at the first panel.
    First to testify will be President Bryan Brewer, who is 
President of the Oglala Sioux Tribe, who represents many 
veterans. And I appreciate his input throughout this entire 
process.
    We also have Commander Tim Jurgens here. He will be 
speaking on behalf of the American Legion, and we appreciate 
their leadership on this issue as well.
    Mr. Bob Nelson will be speaking as a veteran but also as an 
integral part of the Save the VA Committee. So I have always 
appreciated his candid conversations that he has had with me as 
well.
    Amanda Campbell will speak as well. She has been a very 
important part of the Save the VA Committee. She has worked 
through the EIS process and lends a lot of information and 
wisdom to that process, and we really appreciate her insight 
and ability of her to testify here today.
    Pat Russell will speak after Amanda. Pat has been a 
spokesperson for the Save the VA Committee, a very important 
one that has done a very fine job of coming to Washington, DC 
and articulating the concerns and the facts around the proposal 
that the VA has put forward and how the community feels and 
what their heart is on the issue.
    Last we have Larry Zimmerman who will be speaking as well. 
He is South Dakota's Secretary of Veterans Affairs, and if 
there are any veterans' issues going on in South Dakota, 
Larry's heart is there and he shows up and always gives us his 
perspective.
    So I would ask that all of you share your thoughts, your 
hearts, and your minds on this proposal and your perspective. 
It will be very beneficial to all of the members here today on 
the committee, and we certainly appreciate you being here.
    The Chairman. Thank you very much, Kristi.
    And again, all of your written comments will be entered 
into the record as is the custom of our committee. We are 
grateful that you would be here to testify today.
    Mr. President, President Brewer, you are recognized for 
your opening statement.

                   STATEMENT OF BRYAN BREWER

    Mr. Brewer. Good morning. [Speaking native language.] My 
name is [speaking native language.] My English name is Bryan 
Brewer, and I am President of the Oglala Sioux Tribe and I 
represent approximately 40,000 people on our reservation. Today 
I am also speaking for the Sicangu Nation of Rosebud and also 
the Cheyenne River Sioux Tribe.
    I am also a veteran. I served in Vietnam from--I was in the 
service from 1965 to 1969. I served three tours as a Navy 
Seabee. I am a combat veteran. And I am also a disabled 
American, and I use the facilities here at Hot Springs. I have 
been using the facilities here for over 15 years, and it is 
something that we all cherish our times when we come up here.
    I am aware of the recent concerns nationally regarding the 
VA health care system. You know, most of the health care that I 
needed--they all have been provided. Everything that I needed I 
could get here. There is a specific care that could not be 
handled here. I was sent to various other places, to Sturgis. I 
went to Omaha once and they flew me to Minneapolis one time. So 
the care is here. We need to utilize it.
    While it maybe seems isolated, it serves veterans beyond 
South Dakota and many from our sister Lakota tribes of the 
Cheyenne River and Rosebud. Over the years, I have met veterans 
from Wyoming, Montana, Nebraska, North Dakota, and sometimes 
beyond depending on what services they have come to receive. So 
this facility is crucial to the veterans in this entire region.
    One of my big concerns is that the numbers of the Lakota 
veterans--and I seen a letter that was sent to Senator Tim 
Johnson, and our numbers were not included in that, the Lakota 
veterans.
    As you are aware, there is a current memorandum of 
understanding between the VA and the Indian Health Service to 
encourage cooperation and resources between the two 
departments. While this partnership has been shown to work well 
for our sister tribes in other parts of the country, the 
preference for local American Indian veterans is to get their 
health care from the Hot Springs VA. Here we are consistent 
with our health care providers, quick responsiveness to our 
arising health issues, trust in confidentiality in our provider 
and patient exchanges, and for the most part, appointments are 
timely and prompt.
    As outlined in the 2010 report on IHS by former Senator 
Byron Dorgan, IHS in the Aberdeen area struggles and has a 
difficult time to meet the basic health needs of its patients. 
The VA recognizes that we as veterans have very unique health 
care needs and works hard to provide services to address those 
needs. For many reasons, IHS is an overwhelmed system and is 
not equipped to address the very precise and delicate nature 
and delivery of care that veterans require.
    One example of care veterans require is the treatment of 
post traumatic stress disorder. The PTSD treatment center here 
at the Hot Springs VA has the reputation of being one of the 
best treatment programs in the country. You know, we need to 
expand this.
    I appreciate the cultural competency and sensitivity of the 
staff and leadership here at the Hot Springs VA. It is one 
place I can come and I feel I am treated the same as my non-
Indian counterparts. We are all treated with professionalism. 
We are all treated with dignity and respect. We are all treated 
as all American veterans.
    Over the years, I have seen many American Indians join the 
staff here. The Hot Springs VA supports and encourages the use 
of traditional Lakota practices. We are allowed to use a smudge 
with our medicines, sing our prayer songs, and are supported 
with our inipi, our sweat lodge ceremonies. These are conducted 
by local tribal members. The PTSD treatment program has 
components specifically tailored to the American Indian 
veterans. And I would like to thank Richard Galliani for all 
that he has done with our Lakota patients here.
    Culturally for the Lakota, the Hot Springs area has 
significance in regards to the healing properties and being a 
place to collect some of our traditional Lakota herbs and 
medicines. Located near Hot Springs, Wind Cave is a sacred site 
to us Lakota. It marks the place where we emerged from Mother 
Earth to the outside world. In a recent letter written to newly 
appointed Secretary Robert McDonald, delegates stated in that 
letter, ``For more than 100 years, veterans however been coming 
to Hot Springs to receive health care.'' We can appreciate this 
historical significance, as our ancestors have been coming to 
the Hot Springs area for thousands of years. For us Lakota, it 
makes sense that this area with is beauty and healing powers 
would be where a VA facility would be built.
    To date, there has never been a census of the veterans on 
our reservation. We estimate that there are over 3,500 Oglala 
Lakota veterans on our reservation. And we know that not all 
these veterans currently utilize the VA. Some are unaware of 
the services that they have a right to access. Locally we have 
partnered with the Disabled American Veterans and the American 
Legion to help inform and recruit veterans to use the VA. Our 
hope is by increasing the amount of veterans to the VA, revenue 
to the Hot Springs VA and overall area will also increase.
    In conclusion, the Hot Springs VA has a long history, 
strong cultural ties, and an undeniable commitment to veterans' 
health. As I sit here today, I think of all the veterans, the 
warriors, the heroes from our communities who passed through 
the walls of the Hot Springs VA. They came here for care, for 
healing, for camaraderie, and some came here for the final 
days. Closing the VA in Hot Springs not only changes the 
landscape of Hot Springs and western South Dakota, it robs 
veterans of the unique and specialized care that have received 
for decades and should receive for decades to come.
    I want to thank all of you. Mr. Miller, Chairman, I really 
want to thank you for coming to South Dakota. Mr. Bilirakis, 
Mr. Smith, and Kristi, I really want to thank you for making 
this all happen today. [Speaking in Native Language.]

    [The prepared statement of Mr. Brewer appears in the 
Appendix]

    The Chairman. Thank you very much, Mr. President.
    The Chairman. I wanted to say thank you in Lakota. I tried 
to look it up on my iPhone but I am not even going to try.
    [Laughter.]
    Mr. Brewer. Pilamiya.
    The Chairman. Thank you.
    Commander Jurgens, you are recognized for 5 minutes.

                    STATEMENT OF TIM JURGENS

    Mr. Jurgens. Thank you, Chairman Miller and members of the 
committee.
    Forty one veterans. That is the projected decline in 
veteran population between now and the year 2020 according to 
VA's own data. 41 veterans.
    With a market penetration 20 percent higher than the 
national average, the Black Hills VA medical service should be 
championed as a model of efficiency, not targeted for 
dismantling. It is clear that veterans in the Black Hills 
catchment area value the use of the VA. Reducing services and 
making VA treatment options more difficult to access violates 
the agreement our Federal Government has made with our Nation's 
veterans.
    Chairman Miller and members of the committee, on behalf of 
our National Commander, Dan Dellinger, and the 2.4 million 
members of the American Legion, thank you for holding this 
important hearing to help the VA and our Government understand 
how critically important it is to maintain the services we have 
here in Hot Springs and not degrade the services our veterans 
have relied on since 1909.
    Last week, the President signed the VA Health Care Access 
and Accountability Act into law. Our National Commander was 
present at the bill signing, and our national staff worked 
closely with your staff over the course of several months to 
ensure that the bill addressed the immediate needs of this 
country's veterans. As you know, that bill contains a provision 
that mandates VA to release veterans from VA-provided care and 
further burdens the Federal Government to absorb the additional 
expense of contracting that same care that the VA is incapable 
of providing in a timely manner.
    The proposed realignment transfers several services 
currently offered at Hot Springs to the Rapid City facility 
while relying on the Fall River civilian community facility for 
additional support at a contracted rate. While the American 
Legion opposes closing the Hot Springs hospital anyway, it was 
interesting and telling that after the VA announced this new 
proposed partnership, the American Legion met with the board of 
directors of the Fall River hospital, and as we have noted in 
our written testimony, no such agreement had been worked out 
and that as of March of this year, they have repeatedly asked 
VA for details regarding any proposed arrangement. But VA never 
responded.
    Realignment of Hot Springs services will disenfranchise 
more than 4,000 veterans. Rapid City is more than 60 miles one 
way from Hot Springs, which means that the vast majority of 
veterans who have services transferred from Hot Springs to 
Rapid City will immediately qualify for and be issued choice 
cards and leave the VA system.
    The American Legion spends tens of thousands of dollars 
annually conducting site visits to VA hospitals around the 
country. Our staff and members have hundreds of years of 
experience working with and for VA. Our members rely on us for 
accurate, meaningful, and timely information, which we 
painstakingly provide. As such, the American Legion has 
presented VA with a list of recommendations that we believe 
will best support our local veteran community and is in the 
best interest of VA.
    VA should not relocate and/or close medical services until 
a new facility is in place or in order to accommodate the 
health care needs of the veterans in Hot Springs catchment and/
or surrounding areas.
    VA should maintain the same level of care and/or services 
and provide equal understanding of veterans' health care needs 
if contracted to non-VA medical facilities.
    If the VA medical center was to be closed, VA should plan 
to open a super CBOC to provide both primary and specialty care 
services.
    VA should keep the domiciliary on the Hot Springs campus to 
provide long-term extended care to meet veterans' long-term 
care needs.
    The VAMC should search opportunities to make use of the 
State Veterans Home in Hot Springs.
    Future plans should reflect necessary services that 
veterans in the Hot Springs catchment and surrounding areas 
need.
    And finally, without viewing a finalized contract with the 
local hospital in Hot Springs, the American Legion at this time 
cannot ensure reconfiguration of inpatient services will 
provide the same quality care that veterans are currently 
receiving at Hot Springs.
    Every day in America, 82 people take their own life. That 
is one every 17 and a half minutes. 26 percent of suicides are 
veterans. And yet, only 7 percent make up the population. The 
stakes could not be higher. Any degradation of services for 
veterans in this area, especially services associated with 
mental health, would be tantamount to reckless endangerment. 
The mental health of veterans is something the American Legion 
takes very seriously, and we adamantly oppose by resolution 
eliminating or reducing services to veterans in the Hot Springs 
area in any way.
    Thank you. Thank you, Mr. Chairman and the members of the 
committee.

    [The prepared statement of Mr. Jurgens appears in the 
Appendix]

    The Chairman. Thank you, Commander.
    Mr. Nelson, you are now recognized.

                   STATEMENT OF ROBERT NELSON

    Mr. Nelson. Chairman Miller, Vice Chairman Bilirakis, 
Congresswoman Noem, Congressman Smith, welcome and thank you 
for taking the time to come to Hot Springs to hear our concerns 
about the VA's proposed closure of the Hot Springs VA.
    My name is Bob Nelson. I served 4 years in the Navy and 
after my discharge in 1974, I began working at the Hot Springs 
VA Medical Center. After 36 years of serving America's 
veterans, I retired in December of 2012.
    Eighteen years ago, the VA merged two rural VA hospitals 
into the Black Hills Health Care System. That decision has 
eroded medical services and in many cases eliminated available 
services and, as a result, access to care for veterans wanting 
to use the Hot Springs VA. Some of these veterans travel 150 
miles one way from rural and highly rural America and from 
medically under-served areas in southwestern South Dakota, 
northwestern Nebraska, and eastern Wyoming.
    The VA insists the current domiciliary in Hot Springs and 
its associated substance abuse and PTS programs should be moved 
to Rapid City because Rapid City has the largest majority of 
veterans. In fiscal year 2010 and in fiscal year 2011, over 90 
percent of the domiciliary patients came from locations other 
than Rapid City.
    From 2008 through 2011, a total of 448 veterans were in a 
homeless shelter in Rapid City despite an average daily census 
in the Hot Springs domiciliary of only 76 veterans. A daily 
census that is 24 veterans under the authorized daily census 
for the domiciliary. The wait times to get into treatment 
programs in the domiciliary grew from 92 days in fiscal year 
2010 to 157 days in fiscal year 2011. If there is a wait time 
to get into the domiciliary, should it not be because the 
domiciliary is full?
    The cost to have veterans in that----
    Mr. Nelson. The cost to have veterans in that homeless 
shelter from 2008 through 2013 was $3.3 million.
    The VA has said publicly Hot Springs averages five hospital 
inpatients daily, which is insufficient to maintain staff 
proficiency over time and stresses recruitment and retention. 
The number is actually six inpatients, and the VA always 
neglects to mention the four nursing home care unit patients 
that are also on the same ward as the inpatients. The medical 
staff is not taking care of only five patients per day. They 
are taking care of 10 patients per day, twice the number the VA 
uses publicly.
    The VA's own internal audit of the Black Hills Health Care 
System found 14 percent of schedulers at the Black Hills Health 
Care System said they were instructed to change the waiting 
times after a veteran first requested an appointment.
    In December of 2011, the VA's announcement of the proposed 
Hot Springs closure was seen by many veterans as an attempt to 
marginalizes us. They had reduced us to green dots on a Power 
Point slide.
    In spite of these criticisms, veterans that are still able 
to use the Hot Springs hospital echo what other veterans across 
the country are saying. The quality of care they receive is 
excellent. The proposed closure of the Hot Springs VA, their 
access point to health care, is what angers them.
    The employees of the Hot Springs VA who work every day 
under difficult circumstances to provide care to America's 
veterans are victims of friendly fire, wounded by the very 
administrators entrusted to care for America's veterans.
    Chairman Miller, on behalf of the veterans who want to 
continue to use the Hot Springs VA, we need your committee's 
help. This has never been a proposal by the VA. The VA is 
moving forward with their plan. Without congressional 
intervention, the VA will likely close the Hot Springs 
hospital. Local management for 2 and a half years has 
repeatedly heard from the veterans that use the Hot Springs 
hospital, and the VA continues to turn a deaf ear to those 
veterans' concerns. Black Hills management is either unable or 
unwilling to stand up for the veterans they are charged to 
serve. Maybe they just do not know how.
    It is time to follow the lead of the national American 
Legion and call for a change in the current management of the 
Hot Springs VA. Veterans who want to continue to receive their 
care at Hot Springs and Hot Springs employees deserve better 
than an administration that has taken what was once a fully 
functional hospital and reduced it to little more than a 
transfer station to other hospitals.
    Mr. Nelson. Veterans who depend on Hot Springs VA for their 
care deserve administrators who understand the needs of rural 
veterans.
    And finally, Chairman Miller, Save the VA is asking you to 
support South Dakota's congressional delegation to have 
Secretary McDonald personally visit the Hot Springs VA. The 
first facility in the VA system to provide medical care for our 
country's veterans, Hot Springs is the granddaddy in the VA 
system, and we are proud to say also a national landmark.
    This concludes my oral testimony. Again, thank you for the 
opportunity to speak to you today. I will be happy to answer 
any questions you may have.

    [The prepared statement of Mr. Nelson appears in the 
Appendix]

    The Chairman. Thank you, Mr. Nelson.
    Ms. Campbell, you are recognized.

                  STATEMENT OF AMANDA CAMPBELL

    Ms. Campbell. Good morning and thank you. Welcome to Hot 
Springs and thank you for coming.
    We have said in the past that what has happened to the Hot 
Springs VA is a local example of a national problem. A toxic 
cocktail of four things has brought us to this current point: 
negligent management lacking integrity, poor and manipulated 
data, bad decisions based on that poor data, and agency 
inertia.
    We have recently seen a change in Washington, DC with the 
removal of Dr. Petzel and Secretary Shinseki.
    Ms. Campbell. In his final remarks, the Secretary said that 
the problems that this agency faced can be fixed. I believe 
that to be true 100 percent. We are hopeful and we are anxious 
to see how the new VA leadership in DC continues to heal this 
broken system.
    I ask you folks to hold onto your hats because I am going 
to say something that you probably never heard before. What has 
happened in DC in the last few months is exactly what needs to 
happen in the Black Hills.
    Ms. Campbell. We are calling for the immediate removal of 
the Black Hills VA Health Care System Director.
    Ms. Campbell. We are calling for the implementation of a 
leadership with national support for that leadership that does 
not reduce the National Environmental Policy Act to a 
predetermined process and an exercise in box-checking.
    We are calling for a leadership that does not violate the 
National Historic Preservation Act by neglecting to consult 
with the Advisory Council on Historic Preservation, the South 
Dakota State Historic Preservation Office, or the Tribal 
historic preservation officers.
    In 2010 and in 2011, the VA made the following statements.
    Number one, the Hot Springs facility is in poor physical 
condition.
    Number two, the Hot Springs facility has outlived its 
useful life.
    Number three, the Hot Springs facility is not ADA 
compliant.
    Number four, rehabilitating an old facility to meet 
historic preservation standards is too costly.
    And last but not least, quality care cannot be offered in 
the historic layout of the Hot Springs facility.
    We are calling for a leadership that does not decide to 
decommission a national historic landmark, a sacred site, and a 
national treasure with a legacy of care based on an uneducated 
and an unqualified opinion of two administrative staff and 
agency inertia. We are calling for a leadership that does not 
make those statements without first conducting a valid 
structural assessment, a feasibility study into the 
rehabilitation of that structure, and an adequate consultation 
with the required partners, and last but not least, a common 
sense discussion about what is best for rural veterans.
    I will tell you that a structural assessment was finally 
conducted by a qualified architectural firm with the 
experience. The words used to describe that facility were not 
poor. It was not unuseful. The words were excellent condition, 
very good condition, good condition, constructed of inexpensive 
and readily available materials, and no historic preservation 
premium should be anticipated.
    We are calling for a leadership that does not manipulate 
the interpretation of ADA regulations to insist on new costly 
construction versus economical rehabilitation of a facility 
that is already 100 percent ADA compliant and has been since 
the 1970's in areas where the patients receive care and reside.
    We are calling for a leadership that recognizes the 
outstanding level of care offered here because of that legacy 
of healing over the last 107 years and because of the 
nationally recognized care in that existing facility.
    We are calling for leadership that does not violate its own 
handbook and directive 7545 of the VA handbook.
    We are calling for leadership that does not instill fear of 
reprisal in hundreds of its employees.
    We are calling for leadership that does not employ a real 
estate firm to offer major repurposing options of a national 
historic landmark without even setting foot onto the campus. 
Mind you, this is the same firm that the VA OIG found to be off 
by $49 million regarding the consolidation of the Brecksville 
and the Wade Park facilities--$49 million annually.
    We are calling for a leadership that does not violate five 
executive orders with its intention to close, one of those 
being the removing of the access of Native Americans to sacred 
sites, another being the impact on low-income and minority 
populations, and yet another to consider the location of agency 
operations within historic districts.
    In closing, we have provided you with volumes of data that 
we cannot summarize in 5 minutes, but all of this data points 
towards a restoration of services here in Hot Springs. We are 
calling for a leadership that recognizes the legacy of healing, 
the potential, the advocate community, and rural and 
therapeutic setting, a healing environment, and bottom line, 
the desires and the needs of our veterans.
    Thank you.

    [The prepared statement of Ms. Campbell appears in the 
Appendix]

    The Chairman. Thank you, Ms. Campbell.
    Mr. Russell, you are recognized.

                  STATEMENT OF PATRICK RUSSELL

    Mr. Russell. Representative Miller, Representative 
Bilirakis, Representative Noem, Representative Smith, I am 
Patrick Russell, Army veteran, a medical technologist at the 
Hot Springs VA, President of the American Federation of 
Government Employees Local 1539, and co-chair of the Save the 
VA Committee in Hot Springs.
    On behalf of the Save the VA Committee, I would like to 
welcome you to Hot Springs, and we appreciate the opportunity 
to share our concerns about the proposal to close the Hot 
Springs VA Medical Center.
    There are many issues that need to be taken into 
consideration on this proposal, but I will limit my oral 
statements to the loss of services and personnel and the impact 
to the loyal employees and the veterans that we serve.
    Management of the Black Hills Health Care System has 
systematically been dismantling the Hot Springs VA since 1996. 
This was an observation made by Senator John Thune on January 
28, 2013 in a meeting with Secretary Shinseki, Senators Enzi, 
Barrasso, Johanns, Johnson, and Government Dennis Daugaard and 
Representative Noem. This systematic dismantling has caused 
undue hardships on the veterans and lowered the morale of the 
employees who have been bearing the brunt of a greater 
workload.
    Since 1996, we have seen the complete loss of surgery 
services to include orthopedic surgery, colonoscopy, and upper 
GI endoscopy, cataract surgery, and general surgery and 
anesthesia services. We have seen the loss of radiologists and 
fluoroscopy and other onsite radiologist-assisted procedures. 
We have lost our ICU unit. The emergency room is now downgraded 
to urgent care. We have lost our cardiac rehab clinic. We have 
lost the ability to ventilate patients in respiratory distress. 
We have lost the sleep lab. We have lost the pacemaker clinic, 
nuclear medicine, stress tests, a cardiology clinic, and a 
neurology clinic. The list continues to grow, and as these 
clinics and services are lost, our veterans are forced to 
travel longer distances for services they once received here. 
Many of the veterans we serve come from rural and highly rural 
areas where these services are not available in their local 
community hospitals and clinics.
    In March of 2004, in a hearing before the Senate Veterans 
Affairs Committee, the CARES Commission recommended that the 
Hot Springs VA Medical Center retain its current mission to 
provide acute in patient medical, domiciliary, and outpatient 
services. The commission did not concur with designating this 
facility as a critical access hospital.
    During the recent scoping meetings for the environmental 
impact statements, we heard from veterans in Pine Ridge, South 
Dakota; Chadron, Nebraska; Alliance, Nebraska; and Scottsbluff, 
Nebraska saying they now travel farther for their treatment, 
and they have all commented on the great quality of care they 
have received from the employees at the Hot Springs VA. Closing 
this facility will further reduce access into the VA system. 
The veterans we serve will be put into longer lines or perhaps 
waiting lists at VA medical centers where they will be 
referred.
    In the Black Hills proposal to close this facility, they 
state that they will absorb the 300 Hot Springs employees and 
nobody will lose a job. However, they go on to state that over 
a 5 to 10 year period, they will eliminate 300 positions 
throughout the system through attrition.t a time that the House 
Veterans' Affairs Committee is looking at access and waiting 
times, much of which is attributable to not having enough staff 
to handle the workload, Black Hills management wants to close 
an access point and reduce the staff. This will only make the 
issues worse. As a taxpayer, I feel my taxes will be wasted on 
building a domiciliary we already have. As a veteran receiving 
care at the Hot Springs VA, I have had to travel to Fort Meade 
to undergo procedures that were once available in Hot Springs.
    Veterans have paid for their care by service to their 
country. We should not have to beg to retain that care.
    Mr. Russell. But as a representative of the employees who 
work at the Hot Springs VA Medical Center, I see the pain and 
anguish as they are being pushed to their physical, mental, and 
emotional limits by a management that has cut their numbers and 
limited what they can do for the heroes that we serve every 
day.
    Mr. Russell. The VA's entire plan does not do justice to 
the veterans, the taxpayers, or the employees of the Hot 
Springs VA. What our veterans earned we deliver.
    This concludes my oral statement. I thank you for your time 
and willingness to hear our statements.

    [The prepared statement of Mr. Russell appears in the 
Appendix]

    The Chairman. Thank you, Mr. Russell.
    Secretary Zimmerman, you are recognized.

                  STATEMENT OF LARRY ZIMMERMAN

    Mr. Zimmerman. Thank you, sir. Good morning, Chairman 
Miller, Vice Chairman Bilirakis, Representative Noem, and our 
Representative from the State of Nebraska, and members of the 
committee. I am pleased to be here today to present our concern 
for the health care challenges faced by veterans in rural 
America.
    My name is Larry D. Zimmerman. I serve as Governor 
Daugaard's Secretary of the South Dakota Department of Veterans 
Affairs. Our department is the voice for South Dakota's 75,000 
veterans. I served active duty from 1973 to 1976 in the 4th 
Infantry Division at Ft. Carson, Colorado and served 29 years 
in the South Dakota National Guard, most recently serving as 
the State Command Sergeant Major. I had the distinct honor to 
complete a tour of duty in Afghanistan in support of Operation 
Enduring Freedom as the Operations Sergeant Major for the nine 
northern provinces in that country.
    South Dakota is fortunate to have three VA health care 
facilities in our State, 12 community-based outpatient clinics, 
and three vet centers. We are fortunate to have 66 county 
veterans service officers and seven tribal veterans service 
officers and over 20 service organizations that are committed 
to enhancing the lives of our veterans.
    In 1889, the Grand Army of the Republic secured territorial 
legislation to construct a veterans home. It is our 
understanding the Dakota Territory was the first of all 
territories to provide a home for their veterans. In 1907, the 
Battle Mountain Sanitarium opened its doors in Hot Springs to 
focus on short-term medical needs of veterans. All through over 
the years, both facilities have changed their names--although 
they have, the VA Black Hills Health Care System and the 
Michael J. Fitzmaurice State Veterans Home have worked together 
to provide care for the veterans for over 107 years.
    I give you some numbers that reflect the State veterans 
home use of the VA here in Hot Springs in the past year.
    Veterans health care is a critical issue and is important 
we honor the promise to take care of those individuals who 
secured and protected our freedoms. During a 1-year window, the 
Michael J. Fitzmaurice State Veterans Home transported our 
heroes to the VA health care facilities here in Hot Springs 
1,272 times for urgent care, eye care, dental care, dialysis, 
respiratory care, x-rays, urology, podiatry, and mental health 
care. In addition, during that same 1-year time frame, 40 of 
our heroes from the home were admitted to acute care at the VA 
Black Hills Health Care System here in Hot Springs, and 108 
times for higher level care they were transported to Rapid City 
via the VA. Additionally, thousands of veterans drive from 
other States, tribal lands, and many of South Dakota's most 
rural areas to receive that medical care here.
    Our heroes deserve the opportunity to enjoy the rest of 
their lives and being assured they will have access to quality 
health care. South Dakota has a strong legacy of taking care of 
our veterans, and we at Michael J. Fitzmaurice State Veterans 
Home will guarantee that our heroes' needs will be taken care 
of no matter what the decisions.
    In closing, I appreciate the support that your committee 
has given and to all the issues relating to veterans. I 
appreciate the invitation to present this information to you 
and will be pleased to answer any questions you may have.
    On a personal note, I just had knee replacement 7 weeks ago 
at our VA facilities in the Hills. The care and giving that 
those people from the VA gave me was outstanding.
    We do have issues. I totally understand that. We need our 
health care facilities. But I want everybody to please remember 
that the representatives and/or employees of these great VA 
facilities have a heart and a mind to take care of our heroes, 
and they do that with every ounce of their ability. They do 
take care of us. Change is not good sometimes. We want to 
represent the veterans of the State. I hope that you as a 
committee can understand the need and see the crowd that 
represents the veterans of this great State.
    Thank you for your time, Mr. Chairman.

    [The prepared statement of Mr. Zimmerman appears in the 
Appendix]

    The Chairman. Thank you very much to all of you for your 
testimony.
    Before I recognize Kristi for questions, I just want to 
make one quick comment. If there is one single employee that is 
singled out for reprisal for speaking the truth, I hope you 
will contact me directly because that is not acceptable. The 
men and women in this room fought for the ability for people in 
this country to speak their minds, even if their government 
disagrees with it, and if that happens, please let me know.
    And with that, Kristi, you are recognized for any 
questions.
    Ms. Noem. I wanted to start with Bob. I would like you to 
expand a little bit. The VA has continuously used demographic 
data to justify the closure of the VA facility. I would like 
you to expand on what the Save the VA Committee has done to 
refute some of the data that VA is currently using and how you 
arrived at some of the numbers that you did and how that is 
different than what you feel the VA system is using to justify 
closure of this facility here.
    Mr. Nelson. Thank you. After the VA made the announcement 
in 2011, we got together to try to figure out how we are going 
to make some sense of this. Pat is employed there. I am a 
former employee. There are a lot of folks that were saying this 
just does not make any sense. So through the Freedom of 
Information process, we started asking all kinds of data of the 
VA, the number of veterans that were on wait lists for 
domiciliary, just all the stuff that is in my written 
testimony. And time after time, the Freedom of Information 
requests confirmed what the employees were telling us, is that 
the numbers that the VA is putting out there are to put a spin 
on their proposal. It is my own personal belief that the VA did 
not expect to find themselves in this situation.
    In the summer of 2011, veterans and employees were starting 
to get a sense that something was happening up there that the 
VA was not telling us about. So it is when we approached South 
Dakota's congressional offices and started expressing the 
concerns that we need to have somebody look into this. And at 
the time, South Dakota's congressional offices got on board 
with us, as they have been from 2011, and they asked Secretary 
Shinseki to come to Hot Springs and talk about what was going 
on. He was not willing to do that. So we ended up in 
Washington.
    But consistently the VA, I think, has tried to defend a 
decision after they made it, and they have done a poor job of 
doing it because when they go back and they try to scramble and 
put a spin on what the true data is, they just cannot do it.
    Yesterday I gave to your staff, Chairman Miller, a little 
thumb drive that has all of the data that we have collected, 
the Freedom of Information Act requests. So I encourage you to 
interpret that data, have your staff and interpret it on your 
own. The resolutions that have come from the Native American 
tribes, just all the supporting documents. But what we have 
found is that consistently everybody that has used that 
facility disagrees with the presentation--the icing that the VA 
has put on their proposal. They did not expect to have to 
defend it.
    In so many other cases--New Orleans was a good example that 
we found. They just went through the process. Nobody called 
them on it. We called them on it, and they have been struggling 
for 2 and a half years to make sense of it.
    Ms. Noem. I wanted to follow up with President Brewer. I 
wanted you to speak a little bit about the veterans that we 
have currently living on Pine Ridge. And some of the 
suggestions by the VA have been that they could receive care 
through IHS. Now, you know and I know the challenges that IHS 
faces and how the contract dollars run out so early in the 
year. But I would like you to go into a little bit more detail 
about how that is not really feasible to transfer veteran care 
over to IHS services because of the lack of funds that are 
there.
    Mr. Brewer. You know, the people on the Pine Ridge 
reservation--they cannot meet the needs of our people. Our 
people are dying every day. They cannot afford to send them 
out. They cannot afford to pay their bills. They may transfer 
them out, and yet that person will be responsible for paying 
for their bills. And what happens to the people that are sent 
out? Their credit is ruined and everything else. IHS--they just 
cannot do it. They cannot meet the needs. They do not have the 
money. They do not have the facilities. Yet, now they are going 
to make an MOA to take on the 3,500 veterans just from Pine 
Ridge on. And with our special needs, they will never meet 
them.
    Kristi, it is not only Pine Ridge, but it is also the other 
reservations, Rosebud, Cheyenne Eagle Butte. The veterans are 
going to start dying because they are not going to get any 
services. They will not be able to do it.
    And one of the problems is that the VA does not pay its 
bills. So if they do send us someplace, we are going to have a 
difficult time there also.
    Ms. Noem. Thank you. I have run out of time. We will move 
on.
    The Chairman. Mr. Smith, I would like to recognize you for 
your questions.
    Mr. Smith. Thank you.
    Number one, I appreciate, again, your insight and certainly 
the remarks shared here today.
    Perhaps some of my questions are better suited for our next 
panel, but I do want to point out also that Senator Fischer and 
Senator Johanns have also worked on this issue from Nebraska.
    I am glad that the facility here does not know a State 
boundary. I say that as a Representative on another side of the 
State line. So I say thank you.
    But more specifically here, I guess, Mr. Nelson, as a 
former employee, looking at the big picture here, how do you 
feel like perhaps a bureaucracy in Washington, DC perhaps 
unintentionally--there is just a big disconnect there. I co-
chair the Rural Veterans Caucus, this effort that we have in 
the House to focus on the needs that are unique to rural 
America, rural veterans most specifically. Certainly limiting 
the services in various facilities or closing or reducing, 
however anyone wants to call it--how much do you think might be 
an unintentional disconnect, nonetheless a disconnect, between 
the bureaucracy in Washington and what is really happening here 
in middle America?
    Mr. Nelson. I am not confident it is an intentional 
disconnect, other than at the cabinet level position, the 
Secretary's position. Dr. Petzel came from VISN 23. He came 
from Minneapolis, Sioux Falls, Sturgis, Hot Springs. He knows 
the situation out here. What frustrates us in this whole 
argument and one thing that we have tried to not focus on 
because it would seem to be pitting us against foreign aid, but 
the reality is we are--I say ``we''--it is tough to move away 
from 36 years of service out there.
    Fort Meade and Hot Springs are part of one system. But in 
this whole presentation, the VA continues talking about Rapid 
City and what needs to happen up there. And they should know 
their own system well enough to know that Fort Meade up around 
Rapid City and Hot Springs serve geographically different areas 
of veterans. The veterans that are in the Rapid City area did 
not historically come to Rapid City for the majority of their 
care. Prior to the CBOC being placed in Rapid City, they went 
up to Fort Meade. The veterans that come to Hot Springs have 
always come from the reservations. They have come from 
southwestern South Dakota. They have come from northwestern 
Nebraska, your area, your veterans. They have come from 
Wyoming.
    And in this whole proposal, the VA is willing to sacrifice 
those veterans who have traditionally used Hot Springs in my 
opinion. The VA is going to say we are not sacrificing them. We 
are going to provide them with CBOC's all over the place, and 
they can go to private health care. CBOC's are fine. CBOC's are 
necessary. For a veteran to travel 150 miles, if you can put a 
CBOC out there for an occasional visit, that is fine. But 
CBOC's are doctors' offices. They are open 9:00 to 5:00 Monday 
through Friday, excluding Government holidays. They should not 
be a feeder system into private health care.
    Mr. Smith. And perhaps not every day either. Right.
    Mr. Nelson. CBOC's should not be a feeder system into 
private health care. Veterans have unique medical conditions 
that they need to be taken care of that the private health care 
does not deal with on a daily basis. Folks within the VA system 
understand how to recognize those things that veterans present 
with.
    So I personally do not think in this particular case that 
there is a disconnect--there was a disconnect at the Washington 
bureaucracy level other than with Secretary Shinseki. I 
personally think Secretary Shinseki is an honorable man. I 
think he got lousy advice. His people failed him and they knew 
better.
    Mr. Smith. Thank you.
    And perhaps briefly before my time runs out, could you Bob 
or Pat elaborate on the capacity for Hot Springs to be a mental 
health care hub? We know that the needs of veterans are 
changing over time due to various impacts. But can you speak to 
that?
    Mr. Nelson. Pat, would you like to do that?
    Mr. Russell. I believe that Hot Springs has the capacity to 
take back many of the services that have been discontinued. 
They currently have lots of room in the domiciliary, and staff 
have even requested in the PTSD program that they create more 
cohorts so they can get more veterans through the PTSD program. 
Of course, with that, you are going to need staffing. Perhaps 
they need more room.
    But the problem that I have seen is that the VA, rather 
than creating administrative offices in the domiciliary and 
patient care areas--they should be leasing or buying the 
historical properties in Hot Springs per executive order 
several years ago that the President said the VA should be 
utilizing these properties. We have the Carnegie Library. We 
have several other buildings where they could be moving places 
like the call center and telehealth off of the hill, creating 
more rooms for exam rooms or patient care areas. We have the 
capacity. There is room up there if things were done right.
    I feel the biggest problem is in recruitment. We keep 
hearing from our current administration that nobody wants to 
live in Hot Springs and they cannot recruit people. All I know 
is that in 1995 this facility had five surgeons. We had two 
certified nurse anesthetists. We had a complete staff of 
doctors. There was no problem getting a professional to live in 
Hot Springs. But suddenly we hear on the news people from the 
VA saying that we cannot get anybody who wants to live in Hot 
Springs. I do not believe that. We have the capacity, and if 
things are done right, this could be a very viable medical 
center providing the care that our veterans earned.
    Mr. Smith. Thank you.
    The Chairman. Mr. Bilirakis.
    Mr. Bilirakis. Thank you, Mr. Chairman.
    I would like to hear from Mr. Nelson or Mr. Russell or 
anyone else who wants to comment on this particular question. 
We were visiting the dialysis unit at Hot Springs this morning, 
and again, the patients seemed to be very satisfied. I was very 
impressed with the unit. Where are these patients going to go 
if they do not have family? How are they going to travel to 
Rapid City or other locations? I mean, what is going to happen 
to these patients? Can you elaborate on that, sir? Why do we 
not start with Mr. Nelson?
    Mr. Nelson. I am not sure how many years ago, but the Hot 
Springs dialysis unit became the first dialysis unit within the 
VA system to be able to accept Medicare patients. They did that 
not to exclude veterans. And I do not know what the capacity is 
today, but for conversation purposes, let us say that they have 
a capacity of being able to do 20 patients a day, 20 dialysis 
patients a day. As long as the need for veterans are under that 
20, if there is extra capacity there, 15 veterans need 
dialysis, then the Hot Springs VA can provide care to five 
Medicare patients. Unique. It does not happen anywhere else in 
the country.
    So prior to that, those dialysis patients were traveling to 
Rapid City typically, and when you are on dialysis, one of the 
things that I experienced when I was up there is that people 
walk into dialysis or people that see patients walk into 
dialysis and walk out of dialysis think those people are not 
very sick. They walked in, they walked out. These people are on 
the fine edge. If they do not get their dialysis, they are in 
trouble quick. So they are not in good health. So to ask them 
to get on the road and travel somewhere else and spend 2 and a 
half to 3 hours in a dialysis treatment and then go back home 
when they are whipped anyway, it is a concern we have had all 
along. We talk about that. Dialysis--it is one of the proud 
things that Black Hills has hung onto.
    But I am not sure where they are going to go, and I do not 
know what all the resources are. Rapid City is the closest. I 
think if you would talk with Dr. Birch I believe is the 
consultant that comes down, I think he will tell you that there 
is not a lot of extra capacity in this area. And he has always 
appreciated coming down here. So it is a question that troubles 
us.
    Mr. Bilirakis. Mr. Russell, would you like to comment on 
that?
    Mr. Russell. I am thinking in the original proposal, they 
were talking about establishing a dialysis clinic adjacent to 
the Fall River Hospital. However, but nobody ever talked to the 
president of Fall River Hospital about it. I think another 
thing they mentioned was putting a dialysis unit up at the 
State home. I do not know if there have been further 
discussions on that. That is all talk.
    All I know is I do not think the veterans are being taken 
into consideration because the other alternative is them either 
traveling more often to get their dialysis or having to 
relocate to Rapid City or someplace that would have dialysis 
available. It serves a great need because the unused capacity 
is used for Medicare patients who are not veterans. So it is a 
good use of VA resources to help recoup some of the costs the 
VA is expending in maintaining that dialysis unit. I do know 
that the employees up there are very, very dedicated to what 
they do, serving not only the veterans but also the Medicare 
patients that they do see.
    Mr. Bilirakis. Thank you.
    I do not want to take too much time, but Mr. Brewer, can 
you elaborate? I understand that this is a very exceptional, 
special PTSD treatment center at Hot Springs, and I am very 
interested in this issue. What is so unique? Why do veterans 
travel across country to get to Hot Springs for treatment of 
PTSD? I want to know myself, but also tell me what is so unique 
about this and how can we bring even more veterans, expand the 
services here at Hot Springs with regard to PTSD? Thank you.
    Mr. Brewer. I have to say that I have not been through the 
program yet. Time has not allowed it. My physician has asked me 
to go to it, tried to get me into it, but I have not had the 
time yet.
    You know, people come from all over the country. I have 
heard of stories where guys have hitchhiked in here, veterans 
from back East, hitchhiked to Hot Springs, South Dakota hoping 
to get into the PTSD program here. It has that reputation of 
helping and healing people. You cannot cure anyone with PTSD. 
We know that, but they can give you things that will help you, 
things to do. And I cannot tell you what they do here, but they 
do a great job.
    And I think it would be nice to visit with some of the 
staff here because it needs to be expanded. I know there is a 
number of people that want to come through our program. This 
program here should be for our veterans nationwide to be able 
to travel to Hot Springs, South Dakota to get it because it is 
the best here in Hot Springs.
    Mr. Bilirakis. Thank you, Mr. Chairman. I yield back.
    The Chairman. Thank you very much.
    Mr. Nelson, in your testimony, you said overwhelmingly 
veterans have told Black Hills management that they want the 
Hot Springs VA to remain open. Tell me what the reaction has 
been to you and the veterans in this community from the 
management in regard to your pleas and the information that you 
have provided to them regarding keeping this facility open.
    Mr. Nelson. When I referred to veterans have overwhelmingly 
told them, that has been over the 2 and a half year span. When 
the VA first made the announcement, veterans were telling them 
no, do not do this. They would give their individual stories 
why that would not happen. That has been consistent from the 
original announcement in 2011 to today's meeting.
    You have seen the turnout that we get when we talk about 
closing the VA. And what we get from the VA are respectful 
smiles, nodding of the head, and then going about business as 
usual. They have done nothing to indicate to us that they have 
heard the veterans' pleas to keep this facility open. What they 
did was agree to enter into--Secretary Shinseki said, well, we 
will do an EIS process. But there is not anything about that 
process in the way it was presented that leads any of us to 
believe that there is not a predetermined decision here. What 
they are doing now they should have done 3 to 4 years ago. It 
should have been a question. The EIS process is about a Federal 
agency saying we think we have a problem here. Let us take a 
look at it and see if we are right and then let the public 
provide input and arrive at a conclusion. The VA never did 
that.
    As I have stated earlier, they made their decision and they 
will not honestly tell anybody what is behind that decision 
because I do not think they can defend it. They are going to 
tell you today that we have looked at the numbers and it makes 
sense to do this.
    I provide a lot of data in my written testimony. But I do 
not think we have gotten through to the VA. That is just 
another example of why you folks are out here. We are grabbing 
at straws, anything we can do to try to keep this facility 
here. I am not convinced the VA still gets it.
    The Chairman. Mr. Secretary, you had said in your testimony 
that there had been 1,272 different times that people had been 
transported from the State home. How many patients? Can you 
break it down to individuals?
    Mr. Zimmerman. Yes, sir. We have capacity for 135. We have 
52 skilled nursing care rooms and 48 residential. And that 52/
48 is what we are building and putting in the new facility. I 
also have a larger residential capacity in one. But that is 
just that 135 resident and nursing care capacity. And we as a 
State veteran home have a level of care, and so when someone 
has a heart attack, they are brought to the VA, as the VA has 
levels of care that they have to go out of that facility maybe 
to the Rapid City regional hospital, and I mentioned some 
transports of that. But it is the 114 to 120 daily census 
capacity that does those visits, and that is daily appointments 
and/or high level of care needed, a patient fall or a nursing 
care resident in our dementia unit or something and bring him 
down. So the 1,272 is daily appointments and others.
    The Chairman. So if this facility were to close, where 
would those residents have to go?
    Mr. Zimmerman. I would have to yield to some of the Save VA 
Committee not to answer but in their answers they have given. 
It is kind of unsure. I mean, right now it would be the Hot 
Springs hospital which we take some of our residents' spouses 
to or Rapid City, minus there being a facility that we can 
transport them to here in town.
    The Chairman. Mr. Russell, you said in 1995 things were 
going very well in regard to the number of surgeons and people 
that were employed. Then all of a sudden, something happened. 
What happened?
    Mr. Russell. There was a shotgun wedding they call a 
merger, a consolidation of Fort Meade and Hot Springs. 1995 our 
center director was Daniel Marsh and Fort Meade was a separate 
facility. And for 2 years, they had been having discussions 
about collaboration between Hot Springs and Fort Meade about 
doing certain things to lower the costs, such as if you are 
going to order supplies, let us make it one big order instead 
of two separate smaller orders. What can we do to collaborate 
working with each other? After 2 years, they came out and 
announced the consolidation, the consolidation of Fort Meade 
and Hot Springs.
    And from that period on, it was not too long after that, 
the first thing we lost was our laundry services. We had a 
laundry that was doing not only the work for our facility but 
we were doing the laundry for Pine Ridge, Ellsworth Air Force 
Base, Sioux San Hospital up in Rapid City. We were contracting 
out the services in order to help recoup some of the costs for 
laundry. That was gone. That was closed up. Everything was 
moved up to Fort Meade.
    And shortly after that, our surgery department became 
ambulatory surgery only, no more inpatient surgery. And over 
the last several years, they have gradually eliminated surgeons 
and programs. And as of last April, the last surgeon to leave 
was the ophthalmologist who would do the eye surgery, cataract 
surgery. They would not renew his contract down here. They 
renewed his contract at Fort Meade, but not in Hot Springs. 
That was the last surgery we had in Hot Springs.
    So 1995, whether it is the cardiac rehab clinic, the 
radiologists, the pathologists, the histology lab, all these 
things have been taken out a brick at a time. They realized in 
1995 you cannot wreck that facility with a wrecking ball. If 
you cannot wreck it with a wrecking ball, you take out a brick 
at a time. Every program is a brick. Every employee is a brick. 
Pretty soon, the wall is so unstable, it crumbles. That is that 
they are doing by reducing the programs and services, hoping 
the wall crumbles and they can close it up.
    The Chairman. We will do a quick second round of questions 
if the members have them. Kristi, you are recognized.
    Ms. Noem. Pat, at any point in your conversations with the 
VA, did they indicate to you that they were considering what 
would be best for our veterans' health care needs?
    Mr. Russell. Using their logic, perhaps. But I do not think 
they are listening to the veterans themselves.
    Mr. Russell. The original announcement was made down here 
on December 12th, 2011, and that week there were meetings in 
Rapid City and Kyle, Pine Ridge, Chadron, Scottsbluff, 
Alliance, and overwhelmingly, from the very beginning, veterans 
were saying we do not want to go to the local community 
hospital. There was a veteran in Scottsbluff that stood up and 
said we will not go to that hospital because they will kill us 
there. I want to go to the Hot Springs VA.
    Mr. Russell. And on April 12th, 2012, Representative Noem, 
Senator Johnson, and Senator Thune were at the American Legion 
here in Hot Springs, standing room only. People were standing 
outside the doors on a Thursday morning for a 1-hour meeting. 
And they expressed their opinions. People talked. Veterans came 
to the mike, and not one of them advocated closing down our VA.
    And we have just completed the scoping meetings for the 
environmental impact statement, and I attended the ones in Pine 
Ridge, Chadron, Alliance, and Scottsbluff. Not one veteran 
advocated closing the VA. Every one of them said keep it open. 
We want our health care. We do not want to have to drive more.
    I do not think they are listening. It is we have made up 
our mind. We are not going to listen to the data. We have 
already made up our mind and that is what is very troubling to 
me is that they are not listening to the veterans. They are not 
listening to the taxpayers. And by God, I do not think they are 
listening to our Senators or our Representatives either because 
they feel----
    Mr. Russell. It appears that being a cabinet Department, 
they are above all of our congressional people that have been 
elected.
    Ms. Noem. Well, you are right. I came down here. The 
announcement was made in December. I came here first February 
4th, and I told you I would come back with the whole delegation 
and we did. We came back in April. After they continued down 
the process of continuing to follow through with closure of the 
facility, the delegation together sent a list of questions to 
the VA and asked them to answer these questions that we 
specifically were asking of them, cost-benefit analysis, 
consideration of care for veterans, the facility, the 
compliance with ADA requirements, a list of questions. It took 
them 134 days to answer our questions. 134 days. When we 
finally did get the answer, it was not a clear consensus with 
their data, what they were using, compared to what your data, 
what you were using. So I will say absolutely. It has been a 
very frustrating process.
    We did ask the Secretary to come here as well. He did not. 
When we did finally meet with him, I called his office many, 
many times. Never once received a return phone call from him. I 
could pick up the phone, call the Secretary of Agriculture, and 
he is on the phone 30 seconds later, but the Secretary of the 
VA--cannot get him to return a phone call. So I will tell you 
that has been my frustration through the process as well.
    But I want you to talk a little bit today so the committee 
has a full understanding of how they have treated the employees 
and especially, Pat, I want you to speak about how they offer 
openings for employment, how they offer temporary openings, not 
permanent placement, and then how long the openings exist. I 
was downtown this morning, had a man tell me that he believes 
one position was only open for 8 hours and closed again, and 
they said they could not find any applicants. Well, it was only 
open for 8 hours.
    So I would like you to speak to that because I think it 
shows some of the process where they justify not being able to 
find somebody to live in Hot Springs, how they conducted that 
led to the result of not getting people who could fill those 
positions.
    Mr. Russell. Thank you for asking that question because it 
is somewhat of a game they play. When they talk about not being 
able to recruit people to work in Hot Springs, they will open 
up a nursing position and they will open it up as a temporary 
job not to exceed 2 years. Not many people, especially if they 
have families, are going to relocate for a temporary position 
that may not be there in 2 years.
    The other example. We had a medical technology position 
that was open up in the laboratory. The announcement was open 
for 8 hours and closed. The vacancy is still there. It still 
has not been filled.
    They are creating new position descriptions of jobs. It is 
inconceivable. They have recently created four positions for 
medical technologists in the Black Hills Health Care System, 
but as a requirement for that job, you may be working at Fort 
Meade one day, you may be working at Hot Springs the following 
day. You do not know where you are going to work. The travel--I 
do not know whether that would be on company time or a company 
car, but part of that would be pulling call in Hot Springs. So 
if you have a person from Sturgis that accepted the job 
thinking they are working at Fort Meade and they say you are 
going to work now in Hot Springs and you are pulling call, 
where do you stay for call? They do not have anyplace for them 
to stay. They will have to rent a hotel room. So the 
requirements they are putting out for these jobs are totally 
unrealistic.
    And besides that, problems I see having employees driving 
back and forth between Fort Meade and Hot Springs. You are 
talking about an hour and a half one way, 3 hours for a total 
day. That is windshield time. You are not behind the bench. You 
are not producing results. What measurable workload have you 
done by commuting back and forth? It is a waste of taxpayer 
money. It is a waste of professional time.
    The jobs that are being eliminated--they are telling other 
employees just work harder--work smarter not harder. We have 
been hearing that since 1995, and that is why in my statement I 
said that the people are physically, mentally, and emotionally 
drained and exhausted because they have been working harder.
    The Chairman. Mr. Smith, any more questions?
    Mr. Smith. Yes.
    President Brewer, you mentioned briefly that the VA does 
not pay its bills. Could you elaborate on that?
    Mr. Brewer. I am very concerned that they do not. They do 
not pay their bills on time. And I am very concerned that if we 
are sent to a facility and that facility is aware--and they 
probably are--that the VA does not pay its bills in a timely 
manner, we are going to be put on the bottom of the list. We 
are not going to become a priority. So this is a big concern 
for us.
    Mr. Smith. You mentioned, I think, the population that you 
represent is about 41,000. How many veterans would you say are 
in that population?
    Mr. Brewer. On our reservation, we estimate we have over 
3,500 veterans alone in Pine Ridge. That is not counting 
Rosebud or Cheyenne Eagle Butte.
    Mr. Smith. Any rough estimate what those other reservations 
and tribes would----
    Mr. Brewer. Less than Pine Ridge. Pine Ridge is the 
largest. I do not have those figures with me.
    Mr. Smith. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Mr. Bilirakis.
    Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it.
    Just one question for Ms. Campbell. In your testimony, you 
state that the DoD conducted a study released in February of 
2013. The report supported the fact that rehabilitation of 
masonry buildings constructed prior to World War II is more 
cost-effective as opposed to new construction options. Are you 
aware of the costs to update the Hot Springs facility? And do 
they fall in line with this study's conclusions?
    Ms. Campbell. Bottom line--we do not know a bottom line 
figure mainly because the VA has neglected--despite the fact 
that they have moved forward with their planned decommission, 
they have not conducted a feasibility study to determine if, 
indeed, it is feasible to rehabilitate the facility. Based on 
past projections, based on past estimates, construction 
estimates and rehabilitation estimates, at the VA, the VA at 
Hot Springs specifically, I think we tossed around a number of 
right around $20 million to bring the facility into 100 percent 
full compliance and a variety of other issues and elements.
    The report about the masonry structures, about how easy 
those are to rehabilitate fall directly in line with reports 
from the National Trust for Historic Preservation, also from 
the Tenor report and a variety of others that say that it is 10 
times easier and significantly more cost-effective to 
rehabilitate historic structures, as directed by several 
Federal regulations, than it is for new construction.
    Another cost that we did not talk about that has not been 
considered is the cost of mothballing a national historic 
landmark. I believe--and this is data that has been rattling 
around in my mind for quite a while, but I believe we were 
looking at a figure of about $128 million over the course of 
several years it would require to abandon and mothball a 
national historic landmark. That would be money that would be 
mandatory and required in conjunction with new construction and 
staffing and filling those new buildings.
    Mr. Bilirakis. Thank you very much.
    Would anyone else on the panel----
    Mr. Bilirakis. Can you please elaborate on this issue? 
Thank you.
    Mr. Nelson. Yes. I would just like to add to what Amanda 
has said. The frustration with this whole thing--and she has 
referred to the Treanor report. The Treanor report shreds 
everything that the VA has said about what is not possible with 
that facility. As she alluded to earlier in one of her 
comments, the firm that the VA has based their numbers on never 
even stepped site on the VA here to make the assessment. That 
company used data that was provided to them by the VA.
    Thanks to Representative Noem, Senator Johnson, and Senator 
Thune pressing Secretary Shinseki about coming to Hot Springs. 
When he declined to do that, what he did is he said what I am 
going to do is I am going to instruct the VISN 23 in Black 
Hills to sit down with Save the VA folks, congressional staff, 
the veterans service officers--I talked a little bit about that 
in my written testimony--to figure out where do we disagree. 
And it became apparent very quickly that, again, the VA was 
working with their own data that I do not think they 
understood. So we pressed them to have a historic preservation 
specialist come in and assess that property. That is the result 
of the Treanor report.
    And what he talks about in there is that until the VA comes 
out with how they would redesign the buildings there, what they 
would want, what kind of medical facilities, it is very tough 
to come up with an estimate of what it is going to take to do 
it.
    So for us, it is just another example of if the VA was 
sincere in wanting to honestly look at this and see if they had 
made the right decision, they would not have resisted coming up 
with alternate plans. They should have gone back to an 
architect and said, okay, here is how we think it would look if 
we do not abandon the facility. Just another example of that is 
not the direction they want to go, so that is not what they are 
going to do. They want out of Hot Springs.
    Mr. Bilirakis. Thank you so much. Appreciate it.
    The Chairman. Thank you, Mr. Bilirakis.
    Mr. President, it has been said a couple of times that 
there is a zero number for veterans on Pine Ridge, that VA does 
not include those numbers. Could you explain to me if there are 
no veterans on Pine Ridge, why you just opened a veterans 
cemetery there in July?
    [Laughter and applause.]
    Mr. Brewer. We have a very beautiful cemetery now, and I 
would like to thank the Veterans Administration for that. I 
would like to invite all of you to come see it sometime. It is 
very beautiful.
    But, yes, a good question. And if they close up Hot 
Springs, we will probably be filling it up pretty fast too.
    [Applause.]
    The Chairman. Mr. President, Kristi will tell you that that 
was one of the places that I desperately wanted to visit while 
I was here, and unfortunately, time will not allow it. But 
after landing in Rapid City--and I am not going to stay in 
Rapid City anymore. I am going to come and spend the night in 
Hot Springs. All right?
    [Applause.]
    The Chairman. I love old hotels and look forward to coming 
back.
    But let me also say, Ms. Campbell, your $20 million number 
may be right, may not be right. We do not know. But it is the 
only number that we have to deal with. And I just would make 
this closing comment to you.
    We are spending $60 million to restore the dome on the 
United States Capitol Building. Now, it needs to be done. It 
really does. It needs to be done. But it is a historic 
landmark. And so is this facility.
    [Applause.]
    The Chairman. In the bill that was signed by the President 
last week that was passed jointly by the House and the Senate 
in the conference committee, we appropriated $5 billion, with a 
B, and within that $5 billion, there is an allocation for minor 
construction and also delayed care on facilities. So there is 
money that is now available for VA, should they choose to use 
it. The fact that they will say that there is no money does not 
hold water because it is available.
    I just want to say thank you. I wish we had a little more 
time for another round of questions, but we have a second round 
of panelists that have come here to speak today. I just want to 
say from the bottom of my heart thank you for fighting so hard 
to save not only the history of this town, but some of the 
history of the United States of America. We appreciate your 
fight. Thank you.
    [Applause.]
    The Chairman. And with that, we will excuse the first panel 
and say thank you very much for being here.
    We will call the second panel to come forward.
    And I want to ask a favor of everybody, if you would. 
Everybody in this room that wore the uniform of this country 
wore it to allow other people to speak, even when you may 
disagree with what they have to say. So I would beg your 
indulgence as to the two gentlemen that are here today speak. 
We are here to get information from them. We will continue to 
press for answers to questions that have not been answered. But 
again, I would ask that you treat them with the same respect 
that you treated the first panel because they are here 
representing the Department of Veterans Affairs.
    So, again, joining us from the Department is Dr. Steven 
Julius, Acting Network Director and Chief Medical Officer for 
Veterans Integrated Service Network 23. He is accompanied by 
Stephen DiStasio, Director of the VA Black Hills Health Care 
System. I appreciate them being here today.
    Dr. Julius, you are recognized for your opening statement. 
Thank you, sir.

                   STATEMENT OF STEVEN JULIUS

    Dr. Julius. Thank you, Chairman Miller. Good morning--or I 
guess in a couple minutes it is good afternoon--Chairman 
Miller, Congressman Bilirakis, Congressman Smith, and 
Congresswoman Noem. Thank you for the opportunity to discuss 
the VA Black Hills Health Care System's commitment to providing 
veterans high quality, patient-centered care and to address 
rural health care and access to care.
    I am accompanied today by Mr. Stephen DiStasio, Director of 
the VA Black Hills Health Care System.
    VA Black Hills provides primary and specialty medicine, 
extended care and rehabilitation services, surgical and mental 
health services, as well as residential rehabilitation 
treatment programs. VA Black Hills consists of two medical 
centers located at Hot Springs and Fort Meade, South Dakota, 
and VA-staffed community-based outpatient clinics located in 
Rapid City and Pine Ridge, South Dakota and Newcastle, Wyoming. 
In addition, six contract CBOC's are located in South Dakota 
and two are located in Nebraska.
    In fiscal year 2013, there were approximately 35,000 total 
veterans within the VA Black Hills service area. Of the 
approximately 35,000, approximately 21,000 were enrolled for 
health care services, and 19,207 of the enrolled unique 
veterans were served. This reflects an enrolled penetration 
rate of 60 percent in fiscal year 2013, one of the highest in 
VHA.
    The Hot Springs and Fort Meade campuses are particularly 
noteworthy as sites of historical significance. Hot Springs is 
the Battle Mountain Sanitarium National Historic Landmark with 
a proud history of caring for veterans extending back to the 
early 1900's. The Fort Meade cavalry post is known for its 
substantial military presence, extending back to the 1880's. We 
understand the significance of these sites and we appreciate 
the rich history they bring to the community.
    Maintaining and improving the aging buildings, ranging from 
40 to over 100 years old, significantly increases the cost of 
operation at both facilities. Existing operating rooms at both 
hospitals are reaching 40 years of age. The current residential 
rehabilitation treatment program building at Hot Springs is 
over 100 years old, and the structure is not compliant with the 
Architectural Barriers Act. For these and other reasons, VA 
Black Hills has the highest costs per unique patient of all 
VISN 23 facilities and one of the highest in all of VHA.
    VA Black Hills is committed to meeting veterans' needs in 
western South Dakota, Nebraska, Wyoming, and North Dakota. We 
have conducted a review of the services provided and the 
Department has determined that improvements and 
reconfigurations to VA Black Hills operations are needed to 
maintain the safety and quality of care it provides. We believe 
this will increase the scope of services available to veterans 
closer to their homes while being good stewards of public 
funds.
    VHA is concerned about its ability to preserve the quality 
and safety of care at Hot Springs, given that the volume of 
inpatient activity is so low. In these circumstances, it is 
difficult to recruit and retain skilled providers, as well as 
maintain their competencies. Surgical procedures at Hot Springs 
have been curtailed due to an inability to recruit and retain 
surgeons and anesthesia providers. In addition, all of the 
hospitalists and after-hours physicians are temporary staff 
hired on contract to fill staffing needs.
    The most significant changes proposed by the Department 
involve replacing the current medical center in Hot Springs 
with a new community-based outpatient clinic and relocating the 
residential rehabilitation treatment program to Rapid City, 
South Dakota. The overall goal of the reconfiguration is to 
realign services and resources to provide safe, high quality, 
accessible, and cost-effective care closer to where veterans 
live.
    To be transparent and make optimal decisions regarding 
veteran care, VA has openly shared access and quality data with 
stakeholders. VA Black Hills sites of care are insufficient to 
provide ready access to care to all veterans within the large, 
highly rural service area. The limited availability of 
specialists is also a barrier, requiring some veterans to 
travel to VA sites in Minneapolis or Omaha for needed specialty 
care. The recruitment and retention of physicians, nurses, and 
other health care providers has also been difficult with 
physician specialists particularly problematic.
    VA Black Hills has addressed these challenges by expanding 
the use of non-VA care to provide access to services locally 
and shorten waiting times. Major benefits for veterans and 
their families have been the reduction of travel to VA tertiary 
care sites and of out-of-pocket travel expenses, as well as the 
opportunity to be close to home and receiving medical care. VA 
Black Hills has also steadily increased the utilization of 
telehealth services. Through the end of fiscal year 2014's 
third quarter, over 1,100 clinical video telehealth encounters 
have been completed.
    In conclusion, the VA Black Hills Health Care System, in 
conjunction with health care providers throughout its service 
area, is committed to providing high quality care and services 
for our veterans. Our location in a highly rural landscape 
presents VA with some challenges, the most significant of which 
is the ability to recruit and retain highly skilled physicians 
and nurses. Despite these challenges, we continue to focus on 
improving veterans' access to care.
    We sincerely appreciate the opportunity today to appear 
before this distinguished panel to share with you the great 
service that the VA Black Hills Health Care System provides to 
our Nation's heroes every day.
    We are pleased to respond to any questions or comments you 
may have.

    [The prepared statement of Dr. Julius appears in the 
Appendix]

    The Chairman. Thank you very much, Doctor.
    Kristi, you are recognized for opening questions.
    Ms. Noem. You spoke specifically just now about the Hot 
Springs facility being the highest cost operating facility 
within VISN 23. Is that correct?
    Dr. Julius. That is correct.
    Ms. Noem. Can tell me how you evaluated that cost?
    Dr. Julius. Well, it has to do with the total cost per 
unique patient.
    Ms. Noem. Per patient. Okay. Just hold on there 1 second.
    So when you remove services, do you remove the ability to 
service patients? If you are offering less services at a 
facility, these patients then have to go to other facilities to 
get treatment if they needed service. Is that correct?
    Dr. Julius. That is correct.
    Ms. Noem. So after you have removed services the past 
several years, when did you evaluate the cost of running the 
facility and the number of patients that are served? What date 
did you run the cost of that?
    Dr. Julius. The high cost per patient for VA Black Hills as 
an entire system----
    Ms. Noem. Well, I am concerned specifically about how you 
evaluated that the Hot Springs facility was the highest cost 
operating facility within VISN 23.
    Dr. Julius. If I said that, that was incorrect. The VA 
Black Hills Health Care System----
    Ms. Noem. As a whole is the highest cost.
    Dr. Julius. As a whole.
    Ms. Noem. So you are not laying the blame on the Hot 
Springs facility, that this facility for some reason is the 
anchor that is dragging down the rest of the system?
    Dr. Julius. No. There are challenges in a highly rural 
environment for all VA healthcare. So Fort Meade shares some of 
that as well.
    Ms. Noem. Thank you for that clarification. That is what I 
was concerned about is that you were evaluating the cost based 
on per patient served at the facility, which I do not think is 
a fair assessment considering the services that have been 
removed from there. Obviously, patients are going to have to go 
get treated somewhere else, and it would obviously increase the 
cost per patient served.
    Other questions that I have for you is tell me why you do 
not offer permanent positions to employees at the Hot Springs 
facility. You said in your statement that you were offering 
temporary ones. Why do you not open it up for permanent 
positions?
    Dr. Julius. I am not aware of that. I would refer that to 
Mr. DiStasio. I am not aware that I mentioned in the 
statement----
    Ms. Noem. Well, you talked about people that were employed 
at Hot Springs and that there were some temporary positions 
that were employed at a certain time. It was in your statement. 
I could look it up for you too, if you do not remember.
    [Applause.]
    Ms. Noem But you talked about----
    Dr. Julius. No. I think----
    Ms. Noem [continuing]. Temporary positions. Tell me about 
your hiring processes. Maybe that would be--for over the last 5 
years your hiring processes.
    Dr. Julius. To answer your question specifically, we were 
talking about the after-hours physicians, locum tenens 
providers. VA Black Hills for a long time has been attempting 
to recruit permanent positions for those people, the 
hospitalists that we have in the hospital, the people who are 
there after hours. Due to an inability to do that, we have had 
to rely on what are called locum tenens physicians, or 
contracted physicians, temporary physicians, that are hired and 
come in for the weekend or for a week to cover the hospital.
    Ms. Noem. So tell me what your ideal hiring process would 
look like. How do you traditionally--if you were to fill 
positions, how long would the job position be open? How would 
you advertise? So that everybody is aware what the normal 
process is.
    Dr. Julius. Well, typically we would post an opening saying 
that we have an opening for a hospitalist, for a critical care 
physician, for a surgeon. We would publish it in various places 
in which doctors view that. It would be open. We would be 
asking for resumes. People would submit them. We would look at 
them. We would interview them if we felt it was appropriate and 
hire them as permanent staff. That would be the ideal goal, and 
that is what we have tried to do all along. That leads to a 
stable medical staff in which you can be assured of the quality 
of the care that you are getting rather than the situation 
where you have new doctors coming in all the time, which also 
may be qualified but you do not know.
    Ms. Noem. And you followed that process here in Hot Springs 
at this facility within the last several years. You have gone 
through that entire process you just laid out.
    Dr. Julius. As far as I know we have. I will defer to Mr. 
DiStasio if he knows differently.
    Ms. Noem. There is some discrepancy in that. We have had 
Save the VA Committee members that have come to us and told us 
it has been very different. So I would love to have you, Mr. 
DiStasio, talk a little bit about the hiring processes and tell 
me if you disagree with them. Do you disagree with them in what 
has happened here at Hot Springs in how vacant positions have 
been filled and if permanent positions have been offered?
    Mr. DiStasio. Just to add to Dr. Julius' comment about 
providers, he described very accurately what we call a 
continuous and open announcement for physicians, and that is 
across the entire system. And the fact that we are using locum 
tenens is a commitment to keep the services open.
    There are, indeed, within the system some positions that 
are advertised as permanent and some that are temporary. We 
make management decisions every day about how are we going to 
structure the workforce, where do we need in fact temporary 
help because we perhaps have an employee who is out for an 
extended illness, if you will.
    I did listen carefully, as there were some descriptions and 
I believe you used the example of 8 days or 8 hours. I 
encourage people to bring those to my personal attention, and 
if they bring it to yours, please share it with me. I would 
like to understand----
    Ms. Noem. Well, I heard it this morning and that is why I 
brought it to you today at the hearing.
    Mr. DiStasio. I cannot say that is true in my system. I 
would share that we have about 140 positions at any time in 
some sort of phase of recruitment. We share that with our union 
partners so that they see the same information. And it is a way 
of making a partnership because we are all responsible for 
recruiting.
    Ms. Noem. Has a permanent position been offered at this 
facility in the last 2 years?
    Mr. DiStasio. Yes, ma'am.
    Ms. Noem. All right. I am out of time. I will have more 
questions later.
    The Chairman. Mr. Smith.
    Mr. Smith. Thank you, Mr. Chairman.
    And to our panel, I realize you are probably messengers 
here today. I imagine you might find parts of your job 
frustrating. But we are at a position here that I know has 
frustrated many. Can you tell me, as briefly as you can, what 
kind of veteran input you gathered from affected veterans that 
would lead to the December 2012 decision?
    Dr. Julius. The input that we got was--it was not a 
decision. It was basically a proposal. Obviously, 
administrators within VA, hospital administrators we have are 
always looking at the future and need to do due diligence as 
far as planning, planning for changes as far as the 
demographics, planning for changes in availability of services, 
those things. And so as part of this ongoing process then, the 
initial suggested proposal came out in December of 2011.
    We were instructed by the Secretary at the time, after it 
had already been discussed with the Secretary, that we needed 
to and wanted to--and we did--held multiple town hall meetings 
which were discussed earlier by the earlier panel all over the 
area, starting in Hot Springs and going to Rapid City and going 
to various places. The purpose of those town hall meetings was 
to get the very thing that you are saying, to say this is what 
VA is thinking. These are the problems that we anticipate in 
the future that we are going to have in order to ensure that 
you have reliable healthcare. This is what we are proposing. 
This is what we have heard. We can see that people have to 
travel a long ways for care. Perhaps this is a better solution 
that we could purchase care.
    Anyway, we presented it. Steve and I went around to--and 
the network director, Jan Murphy, went around to all of these 
various town halls in the different States, presented the 
proposal and asked for feedback. And we got a lot of feedback, 
as people have mentioned before. Most of it was negative but 
not all of it.
    Mr. Smith. And I think you can appreciate the dynamics in 
play here today.
    Now, you mentioned that it is difficult to recruit medical 
professionals. I would say that is not unique to any town, 
large city in America. There are various challenges. I will not 
get into some of the other healthcare distractions we have at 
the Federal level these days. But I will say at least my sense 
of it is there has been a question about VA commitment to this 
facility for some years now, even prior to December 2012. And 
so was that taken into account in terms of evaluating the 
difficulty of recruiting various professionals, providers?
    Dr. Julius. I missed your question. The fact that there 
appeared to lack of support for----
    Mr. Smith. Lack of commitment to the facility by the VA in 
general. I mean, there is a list here of discontinued clinical 
services beginning in 1996. Now, was that ever taken into 
account in terms of--I do not want to get ahead of myself here. 
But I would think if there were a decision made by the VA that 
would outline the commitment that the VA would make to this 
facility, if that were definitively announced, would it not 
lead to perhaps a better position to recruiting professionals?
    Dr. Julius. Oh, I think absolutely.
    Dr. Julius. I would comment, yes, I think absolutely. I 
think the uncertainty and the lengthy uncertainty of the 
process that has gone on now for this many years without a 
decision has definitely adversely affected our ability to 
recruit to Hot Springs. If you are a young professional and 
realize that the situation that you are coming to might change 
in the future, you are going to be more reluctant. So I would 
agree.
    Mr. Smith. Now, in terms of reimbursement, we heard 
concerns about delayed reimbursement to non-VA facilities. 
Would you say that that is a concern?
    Dr. Julius. I am not aware that it is. I certainly trust 
what President Brewer was saying. We track that now. That has 
been a problem in VA that has been an irritant to the former 
Secretary about why VA does not pay its bills, and so we have 
been tracking payment for non-VA care. We want to get 90 
percent of it paid within 30 days. Black Hills Health Care 
System, the last time that I checked, was paying 89 and a 
certain percentage, so almost 90 percent within the required 
goal of 30 days.
    Mr. Smith. Let us talk about reimbursement--oh, my time has 
expired.
    The Chairman. We will come back.
    Mr. Bilirakis.
    Mr. Bilirakis. Thank you, Mr. Chairman.
    Dr. Julius, what are the current primary specialty and 
healthcare wait times for, let us say, mental healthcare as 
well, wait times for veterans within the VA Black Hills Health 
Care System service area? Currently.
    Dr. Julius. I would like to allow Mr. DiStasio to answer 
for his facility.
    Mr. DiStasio. Thank you for the question.
    For actual wait times--and this is to completion of 
appointment--in primary care in June, which is the last 
released data that we have, it is about 17 days for a new 
patient--excuse me--primary care patient. For an established 
primary care patient, it is about 3 days.
    Mr. Bilirakis. Can you say that again?
    Mr. DiStasio. I'd be glad to repeat that. Thank you.
    For a new primary care patient, it is about 17 days.
    The Chairman. Will the gentleman yield?
    Mr. Bilirakis. Yes.
    The Chairman. I heard this for the first time in Roswell, 
New Mexico last weekend that there is a new metric now that VA 
is using. It is called prospective primary care patient. Why 
did you change the measurement? All we want to know is how long 
does it take a patient to receive an appointment and get their 
primary care taken care of. After all of this stuff that hit 
the fan, somebody somewhere has come up with a new metric to 
measure by. Why?
    Wait, wait, wait, wait.
    The Chairman. And I promise you that it did not come from 
the Black Hills Health Care System. It came down from the 
mountain in Washington. Why?
    Mr. DiStasio. You know, in my experience as a healthcare 
leader, one of the things a bureaucracy can do is try to 
standardize the operational definitions of the data they use so 
that you can make, if you will, apples-to-apples comparisons 
between facilities.
    What I have in front of me is the objective data for the 
time it actually takes us to complete an appointment in primary 
care, specialty care, and mental health for new and established 
patients.
    The Chairman. All right. Established patients. What is that 
number? What is that number?
    Mr. DiStasio. The number for primary care is about 3 days.
    The Chairman. All right. Ladies and gentlemen, turn around 
and watch this. Anybody in here get your primary care 
appointment within 3 days?
    [Chorus of noes.]
    The Chairman. One hand. One hand. I just do not get it. 
Your numbers still do not add up. I yield back.
    Mr. Bilirakis. I will go ahead and take the next question 
in the second round. I will yield to Ms. Noem or the chairman.
    The Chairman. You are yielding to me.
    Mr. Bilirakis. Sounds good.
    The Chairman. All right. Thank you.
    Mr. Bilirakis. Since you are the chairman.
    The Chairman. Dr. Julius, Kristi asked about the 
discrepancy in cost of unique patients within the system. If 
you know that number for the system, certainly you know the 
number for Fort Meade and you know the number for Hot Springs. 
So what is the cost for a unique at Hot Springs and the number 
at Fort Meade?
    Dr. Julius. I am sorry, Mr. Chairman. I do not have that 
information with me. We will be glad to take that for the 
record. I do not have it broken out because it is an integrated 
healthcare system. Now, we can talk to our CFO, and I am sure 
we can come up with something close to what you are asking for. 
But the two systems do not operate entirely independently. So 
there are things that are shared costs and those things.
    The Chairman. This is not unique to this health system 
because when we asked Dr. Lynch in a hearing in Washington what 
it costs to see a patient at VA, they have no idea. None. It is 
beyond me. If you go into the private sector, I guarantee you 
every CFO or CEO will tell you to the penny what it costs to 
see a patient. And yet, you have known for quite some time that 
we were going to come and have this hearing and that one of the 
biggest questions was going to be how much it costs to see a 
patient at this facility. And you do not have the answer. So 
for the record, if you would, please get that number to us as 
soon as possible. When I say as soon as possible, a week is 
sufficient, not the 2 years.
    The Chairman. How much of the $35 million that is estimated 
to be spent on non-VA care in this region--I guess that is the 
number that you are talking about--will be allocated to the PC3 
program?
    Mr. DiStasio. Very little of those funds will go to PC3.
    The Chairman. And the reason is?
    Mr. DiStasio. Still a developing market. Our landscape here 
in the Black Hills is that the contractors or the providers 
that PC3 is approaching are the same ones, if you will, that we 
use already as part of our non-VA care network. So it is fair 
to say there is not a lot of competition in this market, and I 
am sure their conversations are ongoing about trying to 
establish a robust PC3 contract.
    The Chairman. So can you tell me how many? You said not 
much. But can you tell me how many authorizations have been 
issued through PC3? Close. It does not have to be exact.
    Mr. DiStasio. No. I would never estimate for you, but I am 
glad to come back with a better number in the near future.
    The Chairman. You did not give me any number.
    Mr. DiStasio. No number.
    The Chairman. Okay. I was going to say do not come back 
with a better one. Come back with a number.
    Mr. DiStasio. A number.
    The Chairman. The accuracy of the data that VA has used to 
support closing the Hot Springs campus has been called into 
question. You heard that this morning. Could you respond to 
some of those numbers and the criticism that you heard this 
morning? Because I think it is important. We heard them. We 
need to hear what your numbers are. So, Mr. DiStasio or Dr. 
Julius, either one.
    Mr. DiStasio. I think we always have an opportunity to 
check with each other when you have two parties that, if you 
will, have numbers that, if you will, differ. One of the things 
that is striking about the data we collect is that we have to 
make sure that we are both looking at the same site and the 
same currency date and the same operational definition for the 
numbers.
    I know there has been a lot of dialogue about the cost of 
renovation. When we in VA estimated what it would cost to 
rework the Dom, we had to make sure that we were fully 
compliant with various laws and access. We wanted to have a 
model of care that was better for our veterans. And we were 
required to show that those costs--what they extrapolated over 
30 years of operation. So our number was much beyond just the 
renovation portion of it, if you will.
    You know, I do agree with Save the VA's point, though. That 
is a grand old building. It is not going to blow down. It is 
not going to fall down. It is not going to flood. But in my 
estimation, it is not appropriate for healthcare services for 
the next generation of veterans. Thank you.
    The Chairman. Wait, wait, wait. Come on, everybody.
    What is it appropriately ready for?
    Mr. DiStasio. My largest concern about the Dom is, of 
course, the setting for our veterans, the privacy that they 
have or do not have, restroom access, those sorts of things.
    I think there could be some alternative uses for that 
building that would help bring better things for the community 
and VA. We are currently conducting an alternative use study, 
which gives us the ability to begin looking nationwide and 
seeing what opportunities could be available.
    I hope you are aware we received last week a proposal under 
the environmental impact statement process from an Iowa group 
that in fact prepared a rather lengthy prospectus on another 
possible use for some of those buildings at least.
    The Chairman. Ms. Noem?
    Ms. Noem. Dr. Julius, how many veterans do you say you 
service on Pine Ridge? Or how many veterans do you say are 
there that the VA actually counts?
    Dr. Julius. We have it and I am looking right now.
    The Chairman. Pause the clock for a minute while they are 
looking it up so Ms. Noem does not lose her time.
    Mr. DiStasio. So I have some data in front of me that was 
prepared in May of 2013 trying to get to the root of this. And 
we used a number of different sources. Let me just run through 
them very quickly.
    Ms. Noem. What do you use when you are evaluating whether 
to keep this facility open or not? I just want that number. 
What number do you say that you have on Pine Ridge that would 
use this facility?
    Mr. DiStasio. Our records show that we serve 1,370 Native 
Americans.
    Ms. Noem. 1,370.
    Mr. DiStasio. But there is a caveat. The Native American 
veterans are not required in our system to identify themselves 
as such. So there could be more.
    Ms. Noem. But I will tell you that I have been going 
through this for the last 2 and a half years with the Hot 
Springs community and with you, and the entire time the Pine 
Ridge reservation and the Oglala Tribe have told us that they 
believe they have 3,500 veterans. Tell me what you have done to 
try to reconcile the numbers so that you can identify the 
veterans that they have and reconcile the numbers and come to 
some kind of conclusion on how many veterans really are 
represented by that tribe.
    Mr. DiStasio. Thank you for the question.
    My personal effort has been to communicate with Chairman 
Brewer on a personal level and a letter to his office 
describing if you have more veterans, names, lists, whatever, 
we would gladly take a copy. We have also done that with our 
county veterans service officers and our tribal veterans 
service officers. We are also waiting to see what happens with 
Secretary Zimmerman's Reach All Veterans initiative, which I 
think will be an important part of----
    Ms. Noem. So have you come closer together in number? Have 
you reconciled after you wrote these letters? I know there was 
ongoing dialogue over the past 2 and a half years. Have you 
come closer together at agreement on how many veterans are 
actually served? What number are you currently using to 
evaluate how many are serviced by this facility?
    Mr. DiStasio. The 1,370 number is----
    Ms. Noem. You have not moved off your number at all.
    Mr. DiStasio. That is the best number we have to date.
    Ms. Noem. Does the sole responsibility of counting those 
veterans on Pine Ridge rest on them and not on you?
    Mr. DiStasio. It does not. We took another few steps and we 
went to the Census facts and then we went to the National 
Center for Veterans Analysis. They gave us a number of the vet 
population of about 2,435.
    Ms. Noem. So that might be a good number to use.
    Mr. DiStasio. It may be. Again, the caveat was these were 
for veterans who resided in the counties that encompassed the 
reservations and they include known non-Native American 
veterans. But if we use that range of 1,370 to 2,400, we hope 
we have got the best math possible at this moment.
    Ms. Noem. Did you do any kind of outreach to the tribe or 
go down there and try to register veterans? You did?
    Mr. DiStasio. We did.
    Ms. Noem. You had meetings down there and invited all the 
veterans to come in and get signed up for care through the VA 
facility?
    Mr. DiStasio. That is correct.
    Ms. Noem. How many veterans did you gain during that 
process? Because you are using the same number that you used 2 
and a half years ago. Are you saying a single veteran did not 
show up and say, hey, you were not counting me before?
    Mr. DiStasio. Well, I personally have been down there a few 
times each year over the last 5 or 6 years, and in my personal 
observations, we have enrolled one or two at each event. There 
could be others of similar numbers at other events, but I can 
capture that data for you and bring it back.
    Ms. Noem. That would be great.
    Dr. Julius, I would like you to speak to the recent audit. 
In late July, the VA released the results of their internal 
audit for all of the VISN's in the country. Out of the all the 
hospitals within VISN 23, Black Hills Health Care System had 
the worst results. Rapid City staff was instructed to not use 
the electronic wait list required by the VA for scheduling. The 
staff was also instructed to manipulate data throughout the 
Black Hills Health Care System. This is an audit that was done 
internally by the VA. I would like you to speak to that audit 
and tell me how those results impact you personally and what 
you are doing to change the delivery of healthcare to veterans 
in this area and how closing down the Hot Springs facility will 
help you better serve the veterans within your system.
    Dr. Julius. Congresswoman Noem, thank you for the question.
    Concerning the audit results, yes. I mean, this was 
obviously a crisis for VHA when the news from the Phoenix VA 
came out and the Secretary then tasked senior leadership to 
audit the scheduling practices at all of the 128 medical 
centers and all CBOC's more than 10,000 veterans. And I was a 
part of that group. I went to another VISN. I took part in 
these very audits.
    What I would say is obviously if we get any scheduler that 
says they felt that they were instructed to manipulate the 
data, that is unacceptable. And from the data, like I said, we 
tried to meet with maybe 10 schedulers. And so it is often 
difficult to tell. If one scheduler said that they were feeling 
they were encouraged to do that, we would put it down. And that 
would be a certain percentage that had answered yes to that 
question. I do not know how pervasive that is. But like I said, 
anytime any one of our scheduling people are feeling that they 
have been instructed, implied or 
overtly, to manipulate the scheduling package, that is 
unacceptable.
    As a result of that, then we have also been instructed--so 
me as the acting network director, Steve as a center director, 
we have been meeting regularly with the schedulers at all sites 
of care and having this very discussion and saying, you know, 
this is a crisis for VHA. We have been accused of losing our 
integrity. We have to earn our credibility back. We cannot earn 
it back if we are having stuff like this going on. And I 
realize these schedulers are the front line folks, but we as 
senior leaders need to be giving them the message that, no, you 
know, the wait times are the wait times. Whatever they are you 
are putting in. The desired date is what the veteran says. And 
we do not want anybody to feel that they are in any pressure to 
do something that they----
    Ms. Noem. So who has been fired?
    Dr. Julius. I am not sure we have anybody that needs to be 
fired for that within the VA Black Hills or VISN 23.
    Ms. Noem. So you do not trust what your schedulers have 
told you. That is the discrepancy that we have is this is an 
internal audit done by the VA, and your schedulers felt they 
were told to manipulate data, that they were instructed by 
staff to not use the electronic wait list. We had a discussion 
earlier here about your wait list, that the veterans largely in 
the room did not agree with the waiting times. So we do have a 
problem here in the Black Hills Health Care System, which our 
veterans are certainly paying the consequences. I want to know 
if there have been any actions taken within the healthcare 
system in the Black Hills in regards to this audit.
    Dr. Julius. Well, plenty of actions of what I just said. No 
personnel actions that I am aware of because, again, these were 
comments that we solicited from schedulers without attribution. 
We wanted them to be as candid as they could possibly be. It 
was also instructed we are not trying to get anybody in 
trouble. We want to know what is actually going on. And so in 
trying to create an environment of psychological safety, they 
answered candidly about the way that they felt things were 
going. Now we are going back and saying--I think in the data 
you have to interpret it again that not all schedulers said 
that.
    Ms. Noem. No. I agree. I do not believe every scheduler 
said that. But I would like to know what changes you are 
implementing. As a leader, as a manager, as a director of this 
healthcare system, I want to know how you personally are taking 
action to make sure this does not happen again and that our 
veterans are not having long wait times.
    Dr. Julius. Well, one of the first things I think that 
nationally they realized that contributed to this was our 
performance metric of--performance goal of getting people in 
within 14 days of their desired date. That was a good stretch 
goal. That was a good aspirational goal. That is something that 
we strive to do. All of us would like to have an appointment as 
near our desired date as possible. But I think when that goal 
was put into place, it was an unrealistic goal and we did not 
have the infrastructure as a system to actually meet that. But 
then it went from an aspirational goal into a performance 
measure where all of a sudden it was put into people's annual 
performance plans. And I think the unintended consequence of 
that is that was then viewed as a stringent, more serious 
thing. I am going to be judged whether my performance this year 
was satisfactory.
    And for whatever reason--like I said, I do not believe any 
of our senior leaders are telling schedulers to cheat, to 
change the data, but somewhere in the system, in mid-managers 
or somewhere, they were hearing the message or it was implied 
that we need to meet this metric, and they did the things that 
they should not have done.
    So the Secretary immediately ordered that any reference in 
anybody's performance plan to a 14-day metric be removed. They 
have all been removed. The other things that we have talked 
about is, like I said, that facility directors now will meet 
with schedulers at all sites of care every 30 days and have 
listening sessions to discuss what their life is like, what are 
they hearing, what are the barriers, what are their challenges. 
Then the VISN director is instructed to every 90 days visit 
every medical center and do the same thing, meet with the 
schedulers representing the VISN now and again reiterating our 
core values and that we do not want this behavior in VHA. We 
cannot have it. And like I said, we are rightfully accused of 
having lost our integrity, and we now need to spend time 
earning that back.
    The Chairman. Mr. Smith.
    Mr. Smith. Thank you.
    Let us discuss reimbursement levels if indeed it would come 
to the point where other entities outside the VA would be 
reimbursed for the care of veterans. Has that reimbursement 
schedule been established?
    Dr. Julius. On the new veterans' access act you mean?
    Mr. Smith. Well, on the premise that there would be 
veterans cared for outside the VA system, has a reimbursement 
level plan been established?
    Dr. Julius. I am obviously not an expert in the intricacies 
of the new law that was passed. It was my understanding that 
the reimbursement rate would be at Medicare rates, but if 
needed, higher rates could be negotiated locally if that were 
necessary to obtain care.
    Mr. Smith. Because we have veterans who would come from 
Scottsbluff, for example. We have veterans who would come from 
Gordon, who would come from Chadron, who would come from 
Alliance, among other places. So we have got critical access 
hospitals in some of these communities, not all of them, but 
critical access hospitals that have a level of reimbursement. 
Would that level of reimbursement be similar? Would it be the 
same? Could you guarantee that? Has there been any groundwork 
done to establish those reimbursement levels?
    Dr. Julius. To that specific question, I guess I cannot 
answer that. Steve, do you have any additional information?
    Mr. DiStasio. Thank you, Congressman Smith.
    We have had some preliminary discussions with them about 
their approachability about taking care of veterans. We are 
well aware of the reimbursement rates for critical access 
hospitals. But at this point in the process, it is really 
premature for us to enter into any contracts, but at the point 
that would be done, I think that conversation is possible, what 
will be the rate for what services that are provided.
    Mr. Smith. And I can appreciate that.
    And I actually misspoke earlier when I said December 2012. 
It is actually December 2011, as many in the room full well are 
familiar with that.
    Now, it would seem to me that as major of a decision as it 
would be--the proposal--and I hope that the VA will abandon its 
proposal to reduce its services in Hot Springs. And this is not 
about saving an historic building. I love old buildings. I love 
old architecture. And I think we have a very unique situation 
here, though, where we have got, yes, an historic location with 
a very unique mission, and I hope that we can combine those 
missions because I happen to think that if there is a will, 
there is a way to get this done. And I think it can be done 
without adding a greater burden on rural veterans who already 
travel a good ways to get to Hot Springs. It is even further, 
we know, to Rapid City or Fort Meade.
    So I think it is vital that we enter the decision with eyes 
wide open in terms of what reimbursement levels are. I struggle 
to think that the 3 years has not been enough time to 
investigate what reimbursement levels would be. We have heard 
that there are delays in payments. That has been a consistent 
concern within the VA over time. I am frustrated as someone who 
has voted to continually increase funding to the VA, and we 
hear about various situations throughout public policy where 
agencies are expected to do more with less, and yet, we have 
significantly increased the funding and again a few weeks ago. 
And I would hope that the funds could be utilized to maintain 
the mission and objective in Hot Springs.
    Thank you.
    The Chairman. Mr. Bilirakis.
    Mr. Bilirakis. Thank you. That applause was not for me.
    We have increased the funding by 40 percent in the last few 
years, and then we have given another $5 billion for additional 
healthcare providers.
    I am going to get back to the building for Dr. Julius. In 
your testimony, you state that the current residential 
rehabilitation treatment program--the building at Hot Springs 
is not compliant with the Architectural Barriers Act. Can you 
elaborate on which section of the act that the building is 
violating and how long has it been in violation?
    Dr. Julius. No. I am sorry I do not have the particulars as 
far as----
    [Laughter.]
    Dr. Julius [continuing]. What is involved with the 
Architectural Barriers Act. We had talked previously about the 
Americans with Disabilities Act, but I was informed by my 
highers-up in VACO that Federal buildings are not subject to 
that, but we are subject to the Architectural Barriers Act.
    Mr. Bilirakis. Excuse me, sir. I do not want to interrupt. 
But I do want to state that you are aware that there is a 
violation or a couple violations. This is what was stated by 
the VA. Are you not?
    Dr. Julius. That is my understanding, yes.
    Mr. Bilirakis. Now, have any of these violations--have any 
steps been taken to correct these violations, if there are 
violations?
    Dr. Julius. Well, again, without knowing exactly what was 
going on--I mean, certainly some things are. You know, the 
ramps that we talked about--typically they are too steep. And 
so we have made some corrections as you saw this morning. And 
elevators have been installed to mitigate some of the 
deficiencies of the building. But what specific parts of the 
act are in violation I cannot answer it accurately.
    Mr. Bilirakis. Mr. DiStasio, please.
    Mr. DiStasio. No, sir. I am unable to cite a specific 
chapter. But our folks in construction and facility management 
at VACO who have looked at the building and helped us clarify 
what standards we are required to meet by law consistently 
point out emergency exits and the angle of the ramps that you 
saw this morning.
    Mr. Bilirakis. Do you not think it would be more efficient, 
less costly to actually take care of any of these violations, 
bring them up to code, if there are any, than the 
reconfiguration plan proposed by the VA?
    Mr. DiStasio. I think this is a key point that needs 
ongoing discussion is which is the most viable cost, renovation 
or new construction. And of course, I am including operating 
costs over a number of years.
    We also have to look at something bigger than the Americans 
Barriers Act. We have to look at whether or not the veterans 
can have privacy, can they have a private bathroom versus a 
communal bathroom down the hall.
    Mr. Bilirakis. Well, the thing is that you guys are pleased 
with this building, are you not? Are you pleased with the 
services?
    Mr. Bilirakis. I mean, that is what should matter. In my 
opinion, Washington should not be making these decisions. Our 
veterans should be making these decisions.
    Well, thank you very much. I yield back. Thank you.
    The Chairman. If you would excuse me, sir. Thank you very 
much for your service. Thank you for your service.
    If you would, tell me exactly how stakeholder and 
congressional delegation feedback has been incorporated in your 
proposal.
    Mr. DiStasio. Through the initial hearing period that 
occurred in late 2011 and 2012, we took comments from almost 
3,000 people, as I recall, and we took it in emails and 
letters. We handed out comment cards. All of that was collected 
and then summarized.
    In our ongoing conversations with VA central office, we 
shared what we were hearing in terms of thematics. And it is 
accurate to say that the very largest majority of people were 
saying do not do this.
    Nonetheless, my concern has always been about conserving 
quality and safety of care. And so we have discussed very 
carefully with our VA leadership how do we balance these two 
things, if you will, a very heartfelt request from the 
veterans, do not take away this building, with the challenge of 
making sure that we do not harm a veteran.
    The Chairman. If I could, Doctor, this is a little off 
topic, but are you credentialed? Are you currently 
credentialed? Do you see patients within the VA system?
    Dr. Julius. Not currently, no.
    The Chairman. No.
    Dr. Julius. I did until 5 years ago, yes.
    The Chairman. I have a little bit of a problem with the way 
VA does this because when we had the backlog that erupted--
actually it was back to April 9th, but there are physicians 
within the system that could not see patients. Are you paid for 
one job? Are you paid for more than one job in your current 
position?
    Dr. Julius. I assume I am paid for one job, being the Chief 
Medical Officer of the network.
    The Chairman. Well, certain pay scales are set. If you are 
a physician, then you get paid for being a doctor. You get paid 
for being Chief Medical Officer. You get paid for being the 
VISN Director. Can you explain----
    Dr. Julius. My salary is determined by the fact that I am a 
physician.
    The Chairman. Despite the fact that some of the most 
serious problems within South Dakota in regard to wait times 
were here, did either of you receive a bonus in the last 
several years?
    Dr. Julius. I received a performance award for last year's 
performance, yes.
    Mr. DiStasio. And I did also, the first time during my 
period as a Director for about 3 years now.
    The Chairman. Can you tell us how much it would cost, 
because I think there has to be some type of an idea, to bring 
the facility to the ADA compliance? How much money are we 
talking about?
    Mr. DiStasio. The financial analysis that was done included 
a significant focus on those costs. I did not bring that with 
me. Certainly the Members of Congress from this district have 
those figures, and of course, we are glad to provide them also 
as a question for the record.
    The Chairman. And also for the committee, if you would 
provide that for us as well. I think it is pretty important 
that we figure it out.
    I do not know if we have a failure to communicate.
    The Chairman. But let me ask you this. You talked about Hot 
Springs being a difficult place to recruit physicians to come 
to and live. Rapid City--a little easier?
    Mr. DiStasio. Yes, sir.
    The Chairman. How much easier is it to get a physician to 
go to Rapid City?
    Mr. DiStasio. We have no physician vacancies in our 
operations in Rapid City.
    The Chairman. Here is something that I am wondering because 
you pay veterans to travel from here, and you are talking about 
hundreds of veterans having to travel to Rapid City, but one 
doc, two docs, three docs. Why can they not live there and you 
pay them to travel down here?
    Mr. DiStasio. We do that already. Our specialists that come 
down here may be assigned to Fort Meade, may be in Rapid City. 
Some are assigned here. So they may often serve patients in 
both locations.
    I would offer to you that sometimes when we are in 
negotiation with a high value asset, a specialist, if you will, 
in medicine and we discuss with them that we would like them to 
travel to serve our patient population, that can be a 
disincentive to them.
    The Chairman. That is unfortunate because it calls into 
question whether they are working for the right reason. Are 
they working for a buck or are they working to serve America's 
heroes?
    [Applause.]
    The Chairman. And I would wonder if they are not willing to 
sacrifice, do we need them?
    [Applause.]
    The Chairman. I want to give Ms. Noem and Mr. Smith the 
opportunity to do another round of questions, if you have one, 
because we are scheduled to wrap up in about 11 minutes. So, 
Ms. Noem, you are recognized.
    Ms. Noem. You cannot remember what your original proposal 
of moving the facility to Rapid City was, how much that would 
cost moving care services to Rapid City, putting clinics in. 
What was your original proposal? What was the cost of that?
    Mr. DiStasio. It is never a good idea to try to recall off 
the top of your head----
    Ms. Noem. Well, the thing that is really unfortunate about 
the situation is that one of the biggest reasons you have used 
for closing down the Hot Springs facility has been cost and to 
the detriment of our veterans. So I would like to have a 
general conversation because the proposal has been around for 
years now. And it took a long time to get a cost analysis from 
the VA on what the investment would be to bring this facility 
up to what they would think would be something they could 
approve of, but you cannot remember that either. And so I do 
not need it to be down to the penny. Maybe just within $10 
million of where it was would be good because it is your 
proposals and it is your analysis.
    And the Save the VA Committee--not once--not once--during 
their testimony did they not have an answer that we asked them. 
They had every single answer for everything. They had their 
data. They had their numbers. They had their facts. They were 
prepared. Their heart and guts is invested in this thing. And 
you have sat here over and over today and said you do not know. 
You will have to get us the information. That is not 
acceptable.
    [Applause.]
    Ms. Noem. So at this point, I do not care if you are wrong. 
I really do not care if you are wrong. I want you to say 
something other than I will get that for you or I do not know.
    So what was your cost to get this facility up to where you 
would deem it--if that investment choice was made and what was 
your approximate cost for your original proposal of shutting 
down this facility and moving to the Rapid City area and Fort 
Meade?
    Mr. DiStasio. Congresswoman, I care about being accurate. I 
care about what is happening to veterans. I have those numbers. 
We have put them into the hands of your staff. We are glad to 
do that again.
    Ms. Noem. They did not realize they were responsible to 
bring your numbers. But we are getting them right now. 
Hopefully by the end of the hearing, we will have them.
    Mr. DiStasio. That is more than fair. I am always glad to 
continue this dialogue whether it is again in another hearing 
or perhaps in a visit in your office or mine. You deserve those 
answers. We will get them for you.
    Ms. Noem. Okay.
    Secretary Shinseki, when we had a meeting with him in 
Washington, DC and talked about his decision to move forward 
with the EIS process--he promised that there would be no more 
reduction in services at this facility while we went through 
that process. However, I have heard from many veterans in the 
area, the Save the VA Committee, that we have continued to lose 
services. And you will have to clarify for me if this is 
accurate or not. I believe one of them--it was a conversation 
that happened several months ago about checkups for pacemakers 
no longer being done here in Hot Springs, stress tests being 
moved to different facilities. And so is it true that services 
throughout this process, even though the Secretary of the VA 
told us in that meeting he would not degrade the services here 
any more--is it is true that it has continued to happen 
throughout the process?
    Mr. DiStasio. There are certainly episodic changes in 
services. And if I could address very simply the one about 
cardiac pacemakers. Our process in the past had been to have a 
primary care physician, if you will, oversee that program. The 
standard of care has exceeded that and it requires a 
cardiologist. We have no such person on staff. So we made a 
contract with a regional cardiology group. There really is only 
one in the Black Hills. And so we have been able to meet that 
standard of care which is more important to us than, if you 
will, not. That service is provided by those cardiologists at 
many locations in the Black Hills and then also remotely.
    Ms. Noem. So you are saying the standard of care changed 
and that is why that service can no longer be offered here at 
Hot Springs. Is that a standard of care that is set within the 
VA or within the American Medical Association? That standard of 
care--where did that come from?
    Mr. DiStasio. Those are generally set by the professional 
associations, for instance, cardiology. The American Medical 
Association certainly may sign onto that.
    Ms. Noem. And then the VA makes the decision whether they 
choose to adopt those standards of care?
    Mr. DiStasio. Generally speaking, we make every effort to 
meet the community standard of care, and in this case, that is 
how that is done here.
    Ms. Noem. I anticipated that when the Secretary told us he 
would not reduce services, he would do everything in his power 
to make sure that services were not reduced throughout this 
process. And that is what is disappointing about it is that I 
felt as though he should have made the investment to make sure 
we could deliver those services here and continue to see 
patients here while we went through the EIS process so it could 
be credible at the end of the day.
    Thank you. I am out of time.
    The Chairman. Mr. Smith.
    Mr. Smith. Just in the interest of time, I do want to 
respect the limits of time. But I would highly discourage using 
the information that you say is driving the decision that it is 
so difficult to recruit professionals because there is 
seemingly abundant data that there is an eager reduction in 
services, and it would be very difficult to recruit anyone to a 
facility that does not seem to have a commitment behind it.
    [Applause.]
    Mr. Smith. So I would humbly ask that you refrain from 
using many of these driving factors, seemingly driving factors 
in the decision because I just do not think it can be relevant 
and especially when perhaps any other facility, rural or urban, 
would be facing a similar challenge. So if you wish to respond, 
go ahead.
    Dr. Julius. Yes, thank you, Congressman.
    I totally agree. I totally agree that it is difficult to 
recruit when there is the uncertainty about what is going on. I 
think everybody has the same goal in mind, though, and that is 
that we are all trying to figure out how can we ensure that we 
are providing safe, quality, evidence-based care to our 
veterans. Standards of care change over time. We have noticed 
that in the surgical arena. We did a lot of surgeries in small 
hospitals in the past, and then there was a very famous bad 
example in VA in which we had terrible surgical outcomes as a 
result of that facility sort of overextending what the support 
the staff that they had to do that. That caused VA to reassess 
our surgical complexity models. All these things are 
continually evolving, and so it is not just a standard that 
just says, well, the way it was 20 years ago or 15 years ago or 
5 years ago is the way it is going to be 2 years from now.
    Mr. Smith. I fully understand the need for agility and 
flexibility and the ease of operation. But when there seems to 
be a self-fulfilling prophecy here, it is frustrating as a 
policymaker. It is frustrating as we do engage in how much 
money to spend--taxpayer dollars--to maintain the commitment 
that I think we can all agree we have to stand behind our 
veterans and their care.
    Dr. Julius. The reality is it is difficult to recruit and 
retain providers here. To your point--I grant that--the 
uncertainty of the situation exacerbates that.
    Mr. Smith. I think that is an understatement.
    But I yield back. Thank you.
    The Chairman. Mr. Bilirakis.
    Mr. Bilirakis. No further questions.
    The Chairman. Ms. Noem.
    Ms. Noem. Is it not true that you have justified the 
closing of this facility based on more veterans seeking 
services in Rapid City? I know that we have had conversations 
before, and I think, Mr. DiStasio, you and I have had that 
conversation before where you have said more and more veterans 
are choosing to go to Rapid City for their care and for their 
services.
    Mr. DiStasio. I would clarify that as the phenomenon we are 
seeing with distribution of the veterans. More and more of them 
live there. By nature of the kind of care they may need, 
regional health is our tertiary referral center. So they have 
to go to Rapid City. And then in addition, our specific effort 
to expand the spending of non-VA to save veterans from 
traveling to Minneapolis, Omaha, and so on has allowed them to 
seek care in Rapid City. And Congressman Smith also in 
Scottsbluff, Gordon, Alliance and so on.
    Ms. Noem. But as we lose services here, it obviously would 
cause more veterans to seek care in Rapid City as well. You 
would agree to that.
    Mr. DiStasio. Or some other local healthcare facility 
closer to their home.
    Ms. Noem. Can you elaborate--well, no. I am going to pass.
    Mr. Chairman, I am very concerned. As a representative of 
the VA, do you believe that you are carrying out the mission of 
the VA? What is the mission of the VA, and do you believe that 
you are carrying out that mission when the decision is being 
made to go forward with vacating the Hot Springs campus?
    Mr. DiStasio. There is no decision----
    Ms. Noem. Is there a mission of the VA?
    Mr. DiStasio. There is.
    Ms. Noem. What is that?
    Mr. DiStasio. To care for those who have borne the battle.
    There is no decision to close this campus. And in fact, the 
proposal is to certainly change our inpatient footprint but to 
maintain, as someone requested, a specialty community-based 
outpatient clinic to serve veterans here locally and then any 
that choose to travel to this location.
    Ms. Noem. You know, that reminds me. Have you had a 
conversation with the Fall River Hospital yet about caring for 
people in this area if this facility were to close?
    Mr. DiStasio. I met personally with the board of the 
hospital twice.
    Ms. Noem. What did they say to you? Do they have the 
capacity to----
    Mr. DiStasio. Their approach to the conversation was that 
essentially they did not want to have it at that time, that we 
would continue it at some later time.
    Ms. Noem. Okay. Continue on. I am sorry I interrupted you.
    Mr. DiStasio. Thank you. That was all.
    Ms. Noem. The last question I have then is when you are 
looking at evaluating a facility, whether for closure or to 
continue to operate it, what are the factors that you consider? 
I know cost is a factor. What else are the considerations? Is 
it desires of the veterans or the best service and care of the 
veterans? Is that one of the factors as well?
    Mr. DiStasio. First and foremost, it has been about 
delivery of care to the veterans. And it is focused almost 
entirely on quality and safety. Can we preserve that for our 
veterans? To be the leader of a healthcare organization or to 
be a physician or a nurse or a technician in a health care 
organization that might injure a veteran would just be a 
nightmare in our lives and certainly a nightmare for----
    Ms. Noem. Do you think that would happen here at Hot 
Springs?
    Mr. DiStasio. I am concerned that that could happen here.
    Ms. Noem. How could that happen here at Hot Springs?
    Mr. DiStasio. When you look at trying to recruit and retain 
people that have a full range of competencies, you have both 
the issue of them maintaining their competencies. Just as 
important for support staff is gaining the competency. So you 
might, in fact, have a nurse who does not have the depth of 
skill to recognize when a patient is getting in trouble and 
know when to notify a provider or to suggest that a transfer to 
a higher level of care be made.
    Ms. Noem. So you believe they are not treating enough 
patients to maintain the competency levels that they need to 
properly care for the veterans?
    Mr. DiStasio. That is part of the issue we are trying to 
deal with, yes.
    Ms. Noem. So could you tell me what consideration you gave 
to the Save the VA's proposal on the PTSD establishment of a 
center here in Hot Springs? And did it have potential, and did 
you consider using it as that kind of a facility as well?
    Mr. DiStasio. I did consider it. I still consider it. I 
think one of the very strong strengths of their proposal was 
also the veteran industry concept. I was a little surprised, 
though, that we have not heard much from Save the VA on either 
of those two proposals over about the last year, and I was 
expecting them to comment on it in the environmental impact 
statement process. They chose not to.
    Ms. Noem. Well, I think it might be because they have not 
gotten answers to their original questions. We are still 
arguing on----
    Ms. Noem. You have not been able to reconcile the data on 
number of veterans served in the area. You have not been able 
to reconcile the data on wait times. Then the audit came out 
which obviously showed we were not caring for our veterans in 
this healthcare system properly. So I think because they have 
never received clear answers from the VA on any of their 
original questions, why were they to put more work into a 
proposal they have already submitted to you that you have given 
them no feedback on and continue to push that when we still 
have all these unresolved issues? I do not fault them one bit 
for not bringing that up during this process because from the 
very beginning when they have been told something from the VA 
or from the Secretary, it has not been followed through on.
    With that, Mr. Chairman, I will yield back.
    The Chairman. Gentlemen, thank you very much for being part 
of the second panel. We appreciate you being here to answer our 
questions. We would ask that you continue to be open and 
transparent and listen to what the people in this community are 
saying. This is a very unique situation. We are not talking 
about a facility that was built 30 years ago. We are definitely 
talking about the heart of a community. I would not want to be 
on the watch when that heart quit beating. I think that the 
veterans here today are serious about trying to come up with 
solutions. We will do what we can.
    And I want the folks in the audience to understand too that 
VA is not perfect and the private sector is not perfect. There 
will always be errors that will be made by both. We will not be 
able to please everybody. Lord knows, we in the political arena 
understand that probably better than most. But we will try.
    We are here today at Kristi Noem's request to try to come 
to a resolution that is satisfactory to those that have borne 
the battle, their widows, and their orphans. That is the most 
important thing that we should all remember. As I said in my 
opening statement, the veteran is sacred. VA is not. We will 
continue to watch as these Members who have come here today and 
others within their delegation try to come to a resolution. I 
have got some ideas that I will share with Kristi offline when 
we get back in September.
    But, again, ladies and gentlemen, thank you for being here 
today. It has been an honor to be in Hot Springs. And next time 
I come, I will be spending the night here not in Rapid City.
    The Chairman. This hearing is adjourned.
    [Whereupon, at 1:06 p.m., the committee was adjourned.]

                                APPENDIX

              Prepared Statement of Jeff Miller, Chairman

    Good morning and thank you for joining us today.
    I am Jeff Miller, Chairman of the Committee on Veterans' Affairs 
for the United States House of Representatives and Congressman from the 
First District of Florida, where--as we like to say--thousands live 
like millions wish they could.
    I am joined today by Congressman Gus Bilirakis, Committee Vice 
Chairman from the Twelfth District of Florida; by Congressman Adrian 
Smith from the Third District of Nebraska; and, by your Congresswoman 
and my friend, Kristi Noem, from right here in South Dakota.
    Rep. Noem (Kristi) is known in Washington for her hard work, 
steadfast leadership, and strong voice--particularly where the needs of 
servicemembers and veterans in South Dakota and around the nation are 
concerned.
    Earlier this morning, she led us on a tour of the Hot Springs 
campus so that we could see first-hand the services that are provided 
and the impact closure of that facility would have on the hard-working 
employees who work there and the deserving veterans who receive care 
there.
    During that visit, it became even more apparent to me what an 
ardent and impassioned advocate she is for her fellow South Dakotans.
    This community has a long and storied history of coming together to 
care for its military and veteran populations and, looking out on this 
audience, it is clear that passion and enthusiasm has never been more 
alive.
    Thank you all for taking time out of your day to join us and for 
the work that you do to support and honor our nation's veterans.
    It is a honor to be in Hot Springs and I am grateful to Rep. Noem 
(Kristi) for inviting us here.
    Before I go any further, I would like to ask all of the veterans in 
our audience to please stand if you are able or raise your hand and be 
recognized?
    Thank you for your service.
    We are here today on your behalf to ensure that the care you 
receive is timely, convenient, accessible, and high-quality.
    The Department of Veterans Affairs (VA) Black Hills Health Care 
System--which has campuses in Fort Meade and Hot Springs--covers a 
service area of approximately one-hundred thousand (100,000) square 
miles across four states and has one of the highest enrolled veteran 
penetration rates in the country.
    As you all know, in April, a Committee investigation and 
whistleblower revelations exposed widespread corruption and systemic 
access delays and accountability failures across the VA healthcare 
system that left thousands of veterans--including some right here in 
your state--waiting for weeks, months, and even years for the health 
care they earned through honorable service to our nation.
    The Committee has conducted aggressive and historic oversight in 
the four months since the depth of VA's many deficiencies has come to 
light; VA senior leaders at all levels have resigned and been replaced; 
and, nationwide initiatives have been put undertaken.
    Just two weeks ago today, Congress passed a bipartisan Conference 
agreement that will improve accountability for VA employees; increase 
access to care for veterans facing lengthy waiting times for VA 
patients or residing far from the nearest VA facility; and pave the way 
for long-term reforms that will dramatically improve the Department for 
veterans today and for generations to come.
    However, no single law by itself will create the large scale 
cultural and structural reform that is truly needed in our nation's 
second largest bureaucracy or address all of numerous and varied issues 
our veterans and those who care for them experience every day.
    Here in Hot Springs you have faced your fair share of obstacles 
with the Department of Veterans Affairs.
    Recently, VA has told us that one significant factor impacting 
access to care for veterans is the lack of clinical and administrative 
space across the VA healthcare system.
    Yet, here in Hot Springs, VA has a historic campus that the 
Department claims it can no longer use. In a community such as yours 
open communication is vital, particularly when an agency is considering 
an action that could have a significant impact on the very livelihood 
of that community.
    I share your concerns about the quality of the data VA has provided 
to support the Department's proposal to close the Hot Springs campus 
while building new facilities and your frustration about the lack of 
transparency that seems to have characterized VA's response to your 
concerns.
    Unfortunately, data integrity issues and lack of transparency 
characterize much more than just VA's responses here.
    I am also concerned that VA's nationwide access audit found 
troubling scheduling practices were been in place in South Dakota, 
including instructions--against VA policy--to manipulate appointment 
waiting times.
    If VA leaders are so concerned about being unable to make the 
Department's access goals that they would resort to manipulating data, 
why is VA not making full use of its existing facilities--in this case, 
Hot Springs--to ensure access to care for veterans across South Dakota?
    I look forwarding to hearing from today's witnesses--local 
veterans, local stakeholders, and local VA officials--about what VA 
what actions have been taken and still need to be taken to improve 
access to care for veterans throughout the Black Hills and what need to 
be done to provide the highest level of care to those veterans who rely 
on services here in Hot Springs.
    As citizens and active community members, you are the true experts 
and I look forward to listening to your thoughts, ideas, and proposals.
    I thank you all once again for being here this morning.
    
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                 Prepared Statement of Larry Zimmerman

    Good morning Chairman Miller, Vice Chairman Bilirakis, 
Representative Noem, and members of the committee. I am pleased to be 
here today to present our concern with the healthcare challenges faced 
by veterans in rural America.
    My name is Larry D. Zimmerman and I serve as Governor Daugaard's 
Secretary of the South Dakota Department of Veterans Affairs. Our 
Department is the voice for South Dakota's 75,000 veterans. I served 
active duty Army from 1973-1976 in the 4th Infantry Division at Ft 
Carson, Colorado, and served 29 years in the South Dakota National 
Guard, most recently serving at the State Command Sergeant Major. I had 
the distinct honor to complete a tour of duty in Afghanistan in support 
of Operation Enduring Freed as the Operations SGM for the nine Northern 
provinces in that country.
    South Dakota is fortunate to have three VA healthcare facilities in 
our state, 12 community based outpatient clinics and three vet centers. 
We are fortunate to have 66 county veterans service officers and seven 
tribal veterans service officers and over 20 veterans service 
organizations that are committed to enhancing the lives of our 
veterans.
    In 1889 the Grand Army of the Republic secured territorial 
legislation to construct a veterans home. It's our understanding that 
Dakota Territory was the first of all territories to provide a home for 
their veterans. In 1907 the Battle Mountain Sanitarium opened its doors 
in Hot Springs to focus on short term medical needs of veterans. 
Although over the years, both facilities have changed names, the VA 
Black Hills Health Care System and the Michael J. Fitzmaurice State 
Veterans Home have worked together to provide care for our veterans for 
over 107 years.
    Veteran's healthcare is a critical issue and it is important that 
we honor the promise to take care of those individuals who secured and 
protected our freedoms. During a one-year window, Michael J. 
Fitzmaurice State Veterans Home transported our heroes to the VA 
healthcare facilities in Hot Springs 1,272 times for urgent care, eye-
care, dental care, dialysis, respiratory care, x-rays, urology, 
podiatry, and mental healthcare. In addition, during that same one-year 
time frame, 40 heroes were admitted to acute care at the VABHHCS in Hot 
Springs and 108 were transported to Rapid City via the VA. 
Additionally, thousands of veterans drive from other states, tribal 
lands and many of South Dakota's most rural areas to receive medical 
care.
    Our heroes deserve the opportunity to enjoy the rest of their lives 
and be assured that they will have access to quality healthcare. South 
Dakota has a strong legacy of taking care of our veterans and we at the 
Michael J. Fitzmaurice State Veterans Home will guarantee that our 
heroes needs will be taken care of no matter what decisions are made 
of.
    In closing, I appreciate the support that your Committee has given 
us on all issues relating to veterans and I appreciate the invitation 
to present this information with you and I will be pleased to answer 
any questions you may have.

                                 

                Prepared Statement of Dr. Steven Julius

    Good afternoon Chairman Miller and distinguished members of the 
panel. Thank you for the opportunity to discuss the VA Black Hills 
Health Care System's (VA BHHCS) commitment and accomplishments in 
providing Veterans accessible, high quality, patient-centered care and 
to specifically address rural healthcare and access to care in western 
South Dakota, northwestern Nebraska, eastern Wyoming, and a portion of 
southwestern North Dakota. I am accompanied today by Mr. Stephen 
DiStasio, Director of the VA BHHCS.

VA Black Hills Health Care System Overview

    VA BHHCS provides primary and specialty medicine, extended care and 
rehabilitation services, surgical and other specialty care, and mental 
health services, as well as residential rehabilitation treatment 
programs. VA BHHCS is a part of Veterans Integrated Service Network 
(VISN) 23, the VA Midwest Health Care Network, which includes 
facilities in South Dakota, North Dakota, Nebraska, Iowa, Minnesota, 
and portions of neighboring states.
    VA BHHCS consists of two medical centers located at Hot Springs and 
Fort Meade, South Dakota (approximately 90 miles apart); and VA staffed 
Community-Based Outpatient Clinics (CBOC) located in Rapid City and 
Pine Ridge, South Dakota, and Newcastle, Wyoming. Contract CBOCs are 
located in Pierre, Winner, Mission, Eagle Butte, Isabel, and Faith, 
South Dakota, and Gordon and Scottsbluff, Nebraska. Compensated Work 
Therapy (CWT) programs are located in McLaughlin, Eagle Butte, and Pine 
Ridge, South Dakota, serving Veterans on the Standing Rock, Cheyenne 
River, and Pine Ridge Indian Reservations. In addition, Transitional 
Residences are located in Rapid City, Sturgis, Pine Ridge and Hot 
Springs, South Dakota. VA BHHCS also has collaborative relationships 
with the Vet Centers in Rapid City and Martin, South Dakota.
    The VA BHHCS--Fort Meade Campus is identified as a rural medical 
center and the VA BHHCS--Hot Springs Campus is recognized as a highly 
rural medical center. The VA BHHCS has a service area of approximately 
100,000 square miles covering parts of four states. The Hot Springs VA 
Medical Center is located in a community of approximately 3,900 
residents. The Fort Meade VA Medical Center is located in the community 
of Sturgis with approximately 6,300 total residents.
    In FY13, based on calculations by VA's National Center for Veterans 
Analysis and Statistics for Veteran Population, there were 
approximately 35,000 total Veterans within the VA BHHCS service area. 
Of the 35,000, approximately 21,000 were enrolled for healthcare 
services, and 19,207 of the enrolled unique Veterans were served. This 
reflects an enrolled penetration rate of almost 60 percent in FY13, one 
of the highest in VHA.
    There are approximately 1,033 dedicated VA staff members at the VA 
BHHCS who demonstrate their commitment to the care of Veterans every 
day. Often, employees travel to remote locations throughout the area to 
provide primary care, mental health, and other services to Veterans.
    VA BHHCS maintains 459,000 square feet and 77 acres of property at 
Hot Springs and 821,000 square feet and 220 acres at Fort Meade. 
Maintaining and improving the aging buildings at the Fort Meade and Hot 
Springs Medical Centers, ranging from 40 to over 100 years old, 
significantly increases the cost of operation at both facilities.

          Existing operating rooms at the Fort Meade and Hot 
        Springs VA hospitals are reaching 40 years of age.
          The current Residential Rehabilitation Treatment 
        Program (RRTP) building at Hot Springs is over 100 years old, 
        and the structure is not compliant with the Architectural 
        Barriers Act.
          The Hot Springs and Fort Meade campuses are both 
        sites of historical significance. Hot Springs is the Battle 
        Mountain Sanitarium National Historic Landmark, with a proud 
        history of caring for Veterans extending back to the early 
        1900s. The Fort Meade cavalry post is known for its significant 
        military presence, extending back to the 1880s.

    VA BHHCS has the highest costs, per unique patient, of all VISN 23 
facilities and one of the highest unit costs in all of VHA. In addition 
to the factors previously mentioned, this cost derives from a number of 
operational and infrastructure variables, the ratio of staff to 
Veterans served, and utility and maintenance costs of extensive 
buildings/acreage.

VA Black Hills' Proposal for Reconfiguration

    VA BHHCS is committed to providing safe, high-quality, and 
accessible healthcare to the Veterans in western South Dakota and areas 
of the bordering states of Nebraska, Wyoming, and North Dakota. We have 
conducted a review of the services provided in this region. The 
Department has determined that improvements and reconfigurations to VA 
BHHCS operations are needed to maintain the safety and quality of care 
it provides. We also believe this will increase the scope of services 
available to Veterans closer to their homes, while being good stewards 
of public funds.
    VHA is concerned about its ability to preserve the quality and 
safety of care at Hot Springs. The Hot Springs Inpatient Medicine Unit 
(1East) has maintained a cumulative Average Daily Census (ADC) of 
approximately 5 patients per day from FY 2010 to present. In these 
circumstances, it is difficult to recruit and retain skilled providers 
as well as maintain their competencies. As a result, surgical 
procedures at Hot Springs have been curtailed due to an inability to 
recruit and retain surgeons and anesthesia providers. In addition, all 
of the hospitalists and after-hours physicians are currently locum 
tenens providers, or temporary staff hired on contract to fill staffing 
needs.
    The most significant change proposed by VA BHHCS involves replacing 
the current medical center in Hot Springs with a new CBOC, and 
relocating the residential rehabilitation treatment program from Hot 
Springs to Rapid City, South Dakota. The overall goal of the 
reconfiguration is to realign services and resources, to provide safe, 
high quality, accessible, and cost-effective care, closer to where 
Veterans live.
    In 2011, VA BHHCS began holding stakeholder meetings with Veterans, 
Veteran advocates, congressional offices, employees, community and 
business leaders, and the general public. VA conducted these meetings 
to answer questions, address concerns, and seek feedback to the 
proposals. On October 10, 2012, the Network and Facility Director 
briefed VA's Secretary and his staff on the feedback received, 
alternative proposals received, and potential alternatives for 
consideration. At the invitation of South Dakota Senator Tim Johnson, 
the Secretary met with representatives from the community of Hot 
Springs, and staff from the offices of Senator John Thune and 
Congresswoman Kristi Noem, in Washington, DC on January 28, 2013. A 
follow-up meeting was held on May 6, 2013, with VA Central Office 
subject matter experts and community representatives to provide those 
representatives with a better understanding of the data VA used to 
develop and support the reconfiguration proposal.
    VA BHHCS initiated an Environmental Impact Statement (EIS) in early 
2014, to evaluate the impact of the proposed reconfiguration of care in 
the Black Hills service area. VA has contracted Labat Environmental, 
Inc. through the required federal contracting process to assist VA with 
conducting the EIS process, including scoping, consultation, public 
involvement, EIS preparation, and finalization. In June 2014, ten 
public scoping meetings were held during this process at locations in 
South Dakota, Nebraska, and Wyoming. Additional public meetings will be 
conducted as the process continues. The EIS process is expected to take 
approximately 10-18 months, with a current completion date targeted for 
late 2015. Once the EIS is complete, the VA Secretary can make a 
decision regarding the proposed reconfiguration.

Focus on Access

    VA BHHCS leadership is committed to preserving access to healthcare 
services. To be transparent and make optimal decisions regarding 
Veteran care, VA has openly shared access and quality data with 
stakeholders. Access is a challenge for a variety of reasons. VA BHHCS 
sites of care are insufficient to provide ready access to care for all 
Veterans within the large, highly rural service area. The limited 
availability of specialists is also a barrier, requiring some Veterans 
to travel to VA sites in Minneapolis, Minnesota, or Omaha, Nebraska, 
for needed specialty care. The recruitment and retention of physicians, 
nurses, and other healthcare providers has also been difficult, with 
physician specialists in orthopedics, urology, psychiatry, internal 
medicine, and inpatient hospitalists particularly problematic.
    To address these challenges, VA BHHCS has expanded the use of non-
VA care to provide access to services locally and shorten waiting 
times. This year, VA BHHCS is estimated to spend thirty-five million 
dollars for non-VA care, including inpatient, outpatient, and long-term 
care. A major benefit to Veterans has been the reduction of travel to 
VA tertiary care sites in Minneapolis, Minnesota, and Omaha, Nebraska; 
the reduction of out-of-pocket travel expenses for Veterans and their 
families; and the opportunity to be close to home when receiving 
medical care and services.
    In addition, VA BHHCS has steadily increased the utilization of 
telehealth services. Mental health, clinical pharmacy, cardiology, 
oncology, infectious disease, pulmonary, neurology, and other specialty 
services are provided to Veterans in Hot Springs via Clinical Video 
Telehealth. Through the end of FY 2014's third quarter, 1,153 Clinical 
Video Telehealth encounters have been completed.
    We are also working to improve communication with Veterans about 
appointment scheduling. VA BHHCS' efforts to bundle appointments for 
Veterans, ensure that appointment letters are accurate, and that the 
telephone reminder system is used, are helping to reduce the current 10 
percent no-show rate.
    The opening of a system-wide call center is providing Veterans the 
opportunity to get timely help with appointments, medication 
management, billing questions, and other matters. The center has been 
so successful that it now provides similar services for the Veterans 
served by the Fargo VA Healthcare System. In addition, other VA 
facilities have inquired about VA BHHCS providing call center support 
to their Veterans. Repeatedly, Veterans tell me how the call center 
makes it easier for them to conduct business with VA BHHCS.
    We consider an important part of access to be outreach to Veterans 
who may be unaware of the scope of services for which they might be 
eligible. VA BHHCS conducts numerous outreach events throughout our 
service area, with particular emphasis on the four Native American 
reservations, Cheyenne River, Pine Ridge, Rosebud, and Standing Rock. 
Special attention is also given to Veterans of Operation Enduring 
Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND). 
Due to the large geographic service area, VA collaborates with other 
military, Veteran, and community service providers, to ensure Veterans 
and their families receive the care they need. Specialty OEF/OIF/OND 
case managers are assigned to provide outreach to Veterans who live 
great distances from our main medical facilities, including those who 
are assigned to an outlying CBOC. Additionally, a Transition Patient 
Advocate works with the OEF/OIF/OND team assisting in an array of 
outreach efforts that facilitate integration of care for all 
generations of Veterans. Post deployment integrated care is available 
through the Patient Aligned Care Team Transition Clinic, a mobile team 
providing care at Fort Meade, Hot Springs, and the Rapid City Clinic. 
This team is staffed by a mid-level provider and a licensed practical 
nurse and is supported with a Medical Support Assistant for scheduling 
duties. As of this year, this clinic continues to serve the ongoing 
primary care needs of about 1,100 combat Veterans.
    As a result of the many actions taken to improve timely access to 
care:

          Ninety one percent of new and established Veteran 
        patients receiving direct care from VA BHHCS get an appointment 
        within 30 days.
          As of August 4, 2014, there are only four Veterans on 
        the Electronic Wait List (EWL). The EWL count is the total 
        number of all new patients (i.e., those who have not been seen 
        in a specific clinic in the previous 24 months) for whom 
        appointments cannot be scheduled in 90 days or less.
          As of August 2, 2014, there are no Veterans on the 
        New Enrollee Appointment Request (NEAR) List. The NEAR List is 
        the total number of newly-enrolled Veterans, who have asked for 
        an appointment during the enrollment process for whom an 
        appointment has not yet been scheduled.

VA Department of Defense (DoD) Sharing Agreement

    The VA BHHCS' sharing program with DoD helps support a strong 
collaboration with VA and Ellsworth Air Force Base (AFB) leadership. VA 
continues to search for additional opportunities to share resources 
with DoD while improving cost effectiveness and efficiency in the 
provision of patient care. We are concentrating on the areas of 
radiology, dermatology, chronic pain management, and mental health. In 
2005, VA BHHCS and Ellsworth AFB successfully submitted a Joint 
Incentive Fund (JIF) proposal to purchase a Magnetic Resonance Imaging 
(MRI) system for VA and DoD to share. The agencies received $2 million 
from the JIF, to use for this purpose. In 2007, VA BHHCS and Ellsworth 
AFB successfully completed a JIF proposal for a Sleep Lab, and received 
$443,000 for this purpose. In June 2011, VA BHHCS, Ellsworth AFB, and 
VA Dakota's Regional Office initiated disability examinations for 
active duty service members, through the Integrated Disability 
Examination System. More recently VA BHHCS is providing some surgical 
care and inpatient mental health services for active-duty military 
members through a local sharing agreement with Ellsworth AFB.
    Projects in development include more robust provision of 
dermatology, pain management, physical therapy, and laboratory 
services. When a new Rapid City CBOC is opened, co-locating some VA and 
DoD services will provide improved access and services for Veterans, 
active-duty members, and their family members.

VA Indian Health Services (IHS) Sharing Opportunities

    VA BHHCS has taken the leadership role in the VISN 23 
implementation of the national VA IHS Reimbursement Agreement, under 
which VA reimburses IHS for direct care services provided to eligible 
Native American Veterans in IHS facilities. VA BHHCS has developed 
strong relationships with the IHS and Tribal Health entities in Pine 
Ridge, Rosebud, Eagle Butte, and Rapid City, South Dakota, within the 
guidelines of the Reimbursement Agreement and is a leading VA facility 
in the amount of direct reimbursement to IHS facilities. A local 
sharing agreement with IHS supports non-Veteran Native American access 
to MRI services at Hot Springs. VA BHHCS also supports the direct 
referral of Native American Veterans seen in IHS facilities to VA 
specialty clinics, saving the Veteran an additional appointment with 
their primary care provider.
    Projects under consideration include the provision of mobile MRI/
Computerized Tomography services to multiple IHS hospital sites, a 
jointly operated telehealth network for access to scarce medical 
specialists, and a potential fee-for-service arrangement for a Tribal 
Health-operated mobile clinic.

Other Sharing Opportunities

    VA BHHCS enjoys positive relationships with other governmental 
agencies in the surrounding areas, and actively participates in the 
local community. VA BHHCS is the largest employer in both Sturgis and 
Hot Springs, South Dakota. VA BHHCS has strong relationships with the 
South Dakota State Veterans Home in Hot Springs; the Veterans Outreach 
Center in Rapid City, South Dakota; the Ellsworth AFB outside Rapid 
City, South Dakota; and the South Dakota and Nebraska Army National 
Guards. Through a lease agreement, the Fort Meade VA Medical Center 
campus hosts the South Dakota Army National Guard 196th Regiment, which 
serves as a nationwide training center for hundreds of National Guard 
leaders every year.
    In addition, VA BHHCS has a positive and mutually supportive 
relationship with the single non-profit hospital system in western 
South Dakota, the Regional Health System, and its affiliated healthcare 
centers.
    There have been preliminary discussions with multiple community 
hospitals in South Dakota, Nebraska, and Wyoming, about establishing 
sharing agreements to care for Veterans. To date no sharing agreements 
have been completed; pending the decision on the reconfiguration 
proposal.

Conclusion

    VA BHHCS is committed to providing high-quality care and services 
for our Veterans. We continue to focus on improving Veterans' access to 
care. Our location in a highly rural landscape presents VA with some of 
the same challenges faced by other healthcare systems in highly rural 
areas. The most significant of these is the ability to recruit and 
retain highly-skilled physicians and nurses. Throughout our service 
area, the scarcity of primary care providers and hospitalists is acute.
    We sincerely appreciate the opportunity to appear before this 
distinguished panel to share with you the great work that the VA BHHCS 
provides to our Nation's heroes every day. We are pleased to respond to 
any questions or comments that you may have.

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