[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]


                    RURAL ACCESS: IS VA MEETING ALL
                       VETERANS WHERE THEY LIVE?

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS

                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             SECOND SESSION

                               __________

                       THURSDAY, JANUARY 11, 2024

                               __________

                           Serial No. 118-45

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]


                    Available via http://govinfo.gov
                    
                               __________

                   U.S. GOVERNMENT PUBLISHING OFFICE                    
54-756                  WASHINGTON : 2024                    
          
-----------------------------------------------------------------------------------                     
                    
                     COMMITTEE ON VETERANS' AFFAIRS

                     MIKE BOST, Illinois, Chairman

AUMUA AMATA COLEMAN RADEWAGEN,       MARK TAKANO, California, Ranking 
    American Samoa, Vice-Chairwoman      Member
JACK BERGMAN, Michigan               JULIA BROWNLEY, California
NANCY MACE, South Carolina           MIKE LEVIN, California
MATTHEW M. ROSENDALE, SR., Montana   CHRIS PAPPAS, New Hampshire
MARIANNETTE MILLER-MEEKS, Iowa       FRANK J. MRVAN, Indiana
GREGORY F. MURPHY, North Carolina    SHEILA CHERFILUS-MCCORMICK, 
C. SCOTT FRANKLIN, Florida               Florida
DERRICK VAN ORDEN, Wisconsin         CHRISTOPHER R. DELUZIO, 
MORGAN LUTTRELL, Texas                   Pennsylvania
JUAN CISCOMANI, Arizona              MORGAN MCGARVEY, Kentucky
ELIJAH CRANE, Arizona                DELIA C. RAMIREZ, Illinois
KEITH SELF, Texas                    GREG LANDSMAN, Ohio
JENNIFER A. KIGGANS, Virginia        NIKKI BUDZINSKI, Illinois

                       Jon Clark, Staff Director
                  Matt Reel, 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

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                       THURSDAY, JANUARY 11, 2024

                                                                   Page

                           OPENING STATEMENTS

The Honorable Mike Bost, Chairman................................     1
The Honorable Mark Takano, Ranking Member........................     2

                               WITNESSES
                                Panel 1

The Honorable Shereef Elnahal, Under Secretary for Health, 
  Veterans Health Administration, U.S. Department of Veterans 
  Affairs........................................................     4

The Honorable Joshua Jacobs, Under Secretary for Benefits, 
  Veterans Benefits Administration, U.S. Department of Veteran 
  Affairs........................................................     5

        Accompanied by:

    Mr. John Boerstler, Chief Veterans Experience Officer, 
        Veterans Experience Office, U.S. Department of Veterans 
        Affairs

Ms. Alyssa Hundrup, Director, Health Care, U.S. Government 
  Accountability Office..........................................     7

                                Panel 2

Ms. Marisa Schultz, Illinois Veteran.............................    38

Dr. Buu Nygren, President, The Navajo Nation.....................    40

Mr. Jon Lovald, Chief Operating Officer, Minnesota Assistance 
  Council for Veterans...........................................    42

Dr. Mark Holmes, Director, Cecil G. Sheps Center for Health 
  Services Research and North Carolina Rural Health Research 
  Center, The University of North Carolina at Chapel Hill........    43

                                APPENDIX
                    Prepared Statements Of Witnesses

The Honorable Shereef Elnahal Prepared Statement.................    55
Ms. Alyssa Hundrup Prepared Statement............................    62
Ms. Marisa Schultz Prepared Statement............................    74
Dr. Buu Nygren Prepared Statement................................    77
Mr. Jon Lovald Prepared Statement................................    81
Dr. Mark Holmes Prepared Statement...............................    84

                       Statements For The Record

American Association of Nurse Anesthesiology.....................    89
American Nurses Association......................................    94
Center for Healthcare Quality and Payment Reform.................    96
NeuroFlow........................................................   100
OTC Health Services, a LEIDOS Company............................   102

                          APPENDIX--continued

U.S. VETS Prescott...............................................   106
ATA Action.......................................................   108
Western Governors' Association...................................   110
Alzheimer's Association and Alzheimer's Impact Movement..........   115
American Society of Anesthesiologists............................   117
Mr. John Mikelson................................................   121

 
       RURAL ACCESS: IS VA MEETING ALL VETERANS WHERE THEY LIVE?

                              ----------                              


                       THURSDAY, JANUARY 11, 2024

                    Committee on Veterans' Affairs,
                             U.S. House of Representatives,
                                                   Washington, D.C.
    The committee met, pursuant to notice, at 11:05 a.m., in 
room 360, Cannon House Office Building, Hon. Mike Bost 
(chairman of the committee) presiding.
    Present: Representatives Bost, Radewagen, Bergman, 
Rosendale, Miller-Meeks, Murphy, Franklin, Van Orden, Luttrell, 
Ciscomani, Crane, Self, Kiggans, Takano, Brownley, Cherfilus-
McCormick, Deluzio, and McGarvey.

            OPENING STATEMENT OF MIKE BOST, CHAIRMAN

    The Chairman. I appreciate everyone waiting for us to get 
through that business meeting but good morning. The committee 
will come to order.
    I want to welcome the witnesses here today. We are here 
today to discuss rural veterans and how VA is ensuring that 
they have access to health care and benefits they have earned.
    It is easy to forget that many Americans and many veterans 
live in flyover country, and that includes me. I am a rural 
veteran, as many members on this committee are. We understand 
the needs and challenges, and quite frankly, the frustration of 
our fellow rural veterans face because they live where they 
live.
    Now, my home is 30 miles from the nearest VA facility, and 
my constituents in the eastern part of Illinois drive some of 
them 60 miles or more to get to a VA facility. Veterans in 
other parts of the United States travel a whole lot further 
than that.
    Now, one of the witnesses we will hear from today with the 
Navajo Nation spans three states. Now, over 14,000 Native 
American veterans live on 27,000 square miles, and the 
challenges these men and women in rural America face cannot be 
overstated. Which is why others and I have fought so hard in 
2018 to get the Mission Act enacted. The Mission Act and the 
Community Care Provider Network have transformed VA's delivery 
of health care and services, especially in rural and remote 
parts of the country.
    Now, 5 years after the bill was signed into law by 
President Trump, I go home and my veterans are still saying the 
same thing. I cannot get health care and I cannot get my 
benefits. Whether it is a limited access to high-speed internet 
so the veterans cannot make their telehealth appointments, or 
driving over an hour for routine physical therapy, or the 
inability to find housing near employment opportunities, or 
having to travel long distances to attend a disability 
compensation and pension examination, rural veterans face 
daunting challenges. VA must meet these men and women's needs 
where they live.
    While VA has an entire office dedicated to serving rural 
and remote veterans, I am concerned that this office has not 
kept pace with the challenging veteran population. We must 
ensure that the 311,000,000 we have spent on this office and 
other rural veteran programs are providing real value and not 
just lip service.
    I look forward to hearing from our witnesses today about 
how we can pave the way for solutions and bridge the gaps and 
ensure the best quality of life for our rural veterans.
    I now recognize the ranking member for his opening 
statement.

        OPENING STATEMENT OF MARK TAKANO, RANKING MEMBER

    Mr. Takano. Thank you, Chairman Bost.
    Rural veterans and their families have long had to navigate 
the altogether different healthcare experience than their 
suburban and urban counterparts. From hours-long drives, to 
appointments, to housing shortages, to limited access to 
veteran service officers, to file claims, rural veterans 
experience a unique series of barriers. These barriers are 
likely to harden in the coming years as hospital closures and 
healthcare provider shortages in rural areas persist.
    When the VA Mission Act was passed in 2018, it sought to 
address some of the healthcare challenges facing rural veterans 
by creating the Veterans Community Care Program. Now, the goal 
was to better enable veterans to access care from community 
providers when such care was not readily available from VA.
    While necessary, it has not been the bridge to healthcare 
access for rural veterans that many had hoped. The healthcare 
infrastructure in rural America has proven too compromised, and 
in the wake of the COVID-19 pandemic, too fragile to meet the 
needs of civilians and veterans.
    The need for a robust VA presence in rural America remains. 
Since 2005, more than 100 rural civilian hospitals have closed 
according to research conducted by the North Carolina Rural 
Health Research Program at University of North Carolina (UNC) 
Chapel Hill.
    Another 87 rural hospitals have eliminated inpatient 
services. According to the Center for Healthcare Quality and 
Payment Reform, 600 rural hospitals, or about 30 percent of all 
rural hospitals in the country are at risk of closing in the 
near future. Over half of those are deemed at immediate risk of 
closing. Again, we are referring here to non-VA community 
hospitals. One only need look to the newspaper headlines from 
across the country to get a sense of how serious the closures 
are.
    Veterans cannot always rely on the community to be there 
but they should be able to rely on VA. We carry out this 
country's moral obligation to the men and women who have served 
in uniform in part by ensuring they have a healthcare system 
able to meet their needs no matter the state or territory they 
live in.
    There are some things that we simply cannot rely on the 
private sector to provide. Our postal service, for example, our 
national defense, our police and fire departments, these are 
services private industries simply cannot deliver in every 
place they are needed, especially as there are no profit 
opportunities or low profit opportunities.
    This is becoming increasingly true of healthcare. This was 
most acutely highlighted during the worst of the pandemic. We 
saw hundreds of private healthcare systems effectively buckle 
or shrink under the strain of public health emergencies and 
natural disasters, workforce shortages, and infrastructure 
challenges.
    The Veterans Health Administration (VHA) was largely able 
to avoid this. They delivered the highest quality care to 
veterans, provided world-class infection control, and delivered 
humanitarian care to thousands of civilians. They did so with a 
majority of elderly and rural patient population, and aged 
infrastructure, and an overworked workforce. That in and of 
itself was an achievement. They served us further by fulfilling 
VA's role as the backstop to the American healthcare system, 
aiding nearly every state and territory and dozens of tribal 
nations. More than 6,000 VHA employees volunteered to deploy to 
assist civilian or tribal health systems from March 2020 to 
July 2022.
    I am so pleased to have with us here the president of the 
Navajo Nation, Dr. Buu Nygren, to share with us the reality 
rural Native veterans are facing. Last September I visited 
Navajo Nation and discussed with the former president the 
myriad of ways VA can partner with tribes and the Indian Health 
Service (IHS) to better serve veterans. I am excited to 
continue that conversation today.
    Navajo Nation had extensive interaction with VHA during the 
worst of the pandemic. Dozens of Navajo citizens were 
transferred to VA hospitals and dozens of staff, particularly 
nurses, were deployed to IHS sites, Indian Health Service sites 
throughout Navajo Nation sometimes for months. This 
collaboration seems to have largely been successful and has 
prompted many of us to wonder how we might continue 
collaborations between VA tribes and the Indian Health Service.
    As communities continue to lose providers, often VA, tribal 
health programs, and the Indian Health Service are the only 
providers left. My staff have heard from several tribes over 
the years about their eagerness to explore collaboration 
between the two Federal health systems and tribes. Ideas such 
as dual-use hospitals for VA and IHS where infrastructure and 
staff would be shared. In situations where there is a need for 
care but a workforce shortage, providing care to both Federal 
patient populations could be the solution.
    Now, we must continue to provide robust support to VA in 
order to ensure that its workforce and infrastructure remain 
strong and truly accessible to veterans who need it.
    I also urge my colleagues to consider how we could really 
pursue creative solutions to rural access gaps. I believe there 
are opportunities before us if we are willing to do the hard 
work.
    With that, Mr. Chairman, I thank you, and I yield back.
    The Chairman. I thank the ranking member.
    We will now turn to our witnesses' testimony.
    Testifying before us today we have The Honorable Shereef 
Elnahal, the Under Secretary for Health at the Department of 
Veterans Affairs. We also welcome The Honorable Joshua Jacobs, 
the Under Secretary for Benefits for Department of Veterans 
Affairs, as well as Mr. John Boerstler, Chief Veterans 
Experience Office of the Department of Veterans Affairs. From 
the U.S. Government Accountability Office, Ms. Alyssa Hundrup, 
Director of Health Care.
    Dr. Elnahal, you are recognized for 5 minutes for your 
opening statement.

                  STATEMENT OF SHEREEF ELNAHAL

    Mr. Elnahal. Thank you, Mr. Chairman, and Ranking Member 
Takano, and members of the committee.
    Thank you for the opportunity to appear before you today to 
discuss the Department of Veterans Affairs efforts to provide 
health care and benefits to veterans in rural areas.
    VA is committed to reaching to reaching veterans where they 
are. Lori Karvonen, a proud mother of a Marine corporal, is 
helping us do just that through the Veterans Coordination Pilot 
Program. Lori is proud to serve in her own way as a nurse in 
the Baraga County Memorial Hospital, a critical access hospital 
whose patients include many veterans from the local Keweenaw 
Bay Tribe.
    Through a partnership with VA, her hospital uses a 
standardized protocol to screen veterans for medical needs, 
including social determinants of health. Lori then helps 
eligible veterans enroll in VA care, schedule appointments, and 
connect to community services like food assistance, housing, 
and vocational training.
    Recently, the caregiver of a veteran identified through 
screening asked if they could obtain a backup battery for 
medical equipment as power outages are common in his rural 
community. Lori's team enrolled the veteran in VA care. Then, 
through collaboration with the Iron Mountain VA Medical Center 
and the local Veterans Service Organization (VSO), they 
obtained the medical equipment needed to manage his chronic 
lung disease and home blood pressure monitoring for his 
hypertension.
    When we spoke with this veteran, he was not only thrilled 
with his care at VA but asked if we could ``clone Lori'' so 
that all veterans may have the same experience.
    Almost a quarter of all veterans, or more than 4,400,000, 
resident in rural communities like Lori's and face unique 
challenges that differ widely from their urban counterparts. 
Geographical isolation creates challenges in accessing VA 
health care, and through new initiatives in this administration 
and a commitment to longstanding efforts, VA continues to 
bridge the gap between rural veterans and the world-class care 
that they deserve.
    Bridging that gap first requires enrolling veterans into VA 
care. Since the signing of the The Sergeant First Class Heath 
Robinson Honoring our Promise to Address Comprehensive Toxics 
(PACT) Act, VA has conducted an unprecedented outreach campaign 
encompassing direct mail, email, radio advertising, and over 
2,000 outreach events, including more than 1,000 in rural 
areas.
    Through December 2023, VA enrolled more than 500,000 new 
veterans, over 100,000 of whom through specific PACT Act 
authorities including 25,000 rural veterans, into VA health 
care.
    As part of implementation, VA also developed the Fiscal 
Year 2023 Rural Recruitment and Hiring Plan to ensure VA has 
the workforce it needs to meet our obligation. In Fiscal Year 
2023, thanks in part to the new authorities in the PACT Act, 
our healthcare system saw a 7.7 percent growth rate in the 
total employees onboard in rural facilities, which did exceed 
our overall growth rate.
    In addition to strengthening staffing in rural areas, VA 
meets even more needs for rural veterans with telehealth 
services, mobile clinics, and transportation services. In 
Fiscal Year 2023, VA delivered more telehealth services than in 
any previous fiscal year, including 2,900,000 million episodes 
of care delivered to more than 770,000 rural veterans.
    Further, VA launched 25 new mobile clinics to deliver 
medical services to homeless veterans in particular, many of 
whom are rural. VA has also made strides specifically in cancer 
care. Now, with 75 locations serving across the Nation, VA 
National Teleoncology offers state-of-the-art specialized 
cancer care across the country. Nearly half of the veterans 
seen through National Teleoncology reside in rural areas where 
they otherwise may struggle to have access to an oncologist.
    VA is also reaching rural veterans through the Close to Me 
infusion program which has infusion teams travel to clinics 
across rural areas where the live, reducing travel time and 
care continuity for veterans in rural areas. Our data has shown 
that veterans save 536 minutes of their own time on average due 
to this program and getting their cancer care.
    Many of the needs of rural veterans also means ensuring 
American Indian and Alaska Native veterans who are most likely 
to live in rural areas receive the care and benefits they 
deserve. In April 2023, VA implemented the Isakson-Rowe 
Veterans Health Care and Benefits Improvement Act, exempting 
eligible Native American veterans from copayments for their VA 
health care. That exemption honors our treaties with sovereign 
nations and addresses healthcare access and disparities for 
American Indian and Alaska Native veterans. As of December 8, 
2023, VA has canceled over $2,100,000 in copayments for over 
3,400 eligible American Indian and Alaska Native veterans. VA 
is also focused in suicide prevention for these veterans with 
an emphasis on culturally informed interventions.
    Chairman Bost, Ranking Member Takano, thank you for the 
opportunity to discuss our efforts to best serve veterans of 
rural communities. We appreciate your continued partnership as 
we embrace our collective responsibility to serve those who 
have served. Thank you.

    [The Prepared Statement Of Shereef Elnahal Appears In The 
Appendix]

    The Chairman. Thank you, Dr. Elnahal.
    Mr. Jacobs, you are recognized for 5 minutes.

                   STATEMENT OF JOSHUA JACOBS

    Mr. Jacobs. Thank you, Chairman Bost, Ranking Member 
Takano, and members of the committee for the opportunity to 
appear before you today to discuss how VA is working to 
increase access and improve outcomes for veterans living in 
rural or highly rural areas.
    VA believes all veterans deserve timely access to world-
class health care and earned benefits no matter what they look 
like, who they love, or where they live. Far too many veterans, 
and particularly those in rural areas, are unaware of the 
benefits that they have earned or lack trust in VA to deliver 
them.
    To better meet the needs of rural veterans where they are, 
VA has been engaged in the most aggressive, forward-leaning 
outreach campaign in the department's history over the past 
year. In Fiscal Year 2023, the department held over 13,000 
outreach events in communities across the country, relying 
heavily on our VSO state, county, and community partners to 
encourage every eligible veteran, family member, and survivor 
to apply for care and benefits that they earned.
    The results of that outreach can be seen in the historic 
number of disability claims that were submitted and approved, 
and in the individual stories of the veterans who have been 
positively impacted by this outreach, veterans like Rene 
Kendall, a retired police officer living on a fixed income in 
the small town of Otto, North Carolina, which is 3-1/2 hours 
away from VA's regional office in Winston-Salem.
    In an effort to meet veterans closer to where they live, 
the Winston-Salem regional office hosted an event in Franklin, 
North Carolina this June which enabled Rene to speak in person 
with a VA employee without spending 7 hours in the car. At this 
VA hosted event, Rene sat down with Misty Allen, a claims 
examiner from the Winston-Salem Regional Office (RO) to talk 
about his pending claim. While reviewing his file, Misty 
discovered there was an incomplete exam form provided by the 
medical examiner for review at the time of Rene's exam and that 
he had a recognized presumptive condition related to his 
service at Camp LeJeune.
    As a result of this rural outreach event and Misty's 
attentiveness, VA was able to award Rene retroactive benefits 
giving him and his wife a little more financial freedom each 
month on their fixed income. In his own words he said, ``Misty 
Allen is truly an advocate, and this extra money every month is 
a godsend. It has made an impact on our lives and helped us get 
by a little easier every month.''
    Though rural communities offer veterans like Rene multiple 
benefits, the approximately 4,500,000 veterans living in rural 
communities face unique challenges, like unreliable internet 
access and long travel distances that limit their awareness of 
and access to the benefits they have earned through service to 
this country.
    Addressing these challenges and others requires a 
collaborate approach involving Federal, state, and local 
government agencies, along with VSOs, nonprofit organizations, 
and local community partners to ensure veterans in rural areas 
receive the support they need to thrive.
    In collaboration with our partners, VA is also taking the 
following actions to better meet the needs of our rural 
veterans.
    First, we are keeping our foot on the gas, continuing our 
data driven, proactive outreach campaign.
    Second, we have changed the Transition Assistance Program 
(TAP) curriculum to add VSOs and State Departments of Veterans 
Affairs to brief transitioning service members at the end of 
every 1-day VA TAP class, increasing connections to the 
benefits and services available to them in the communities in 
which they will reside.
    Three, we are leveraging technology for more virtual 
Compensation and Pension (C&P) examinations, increasing 
utilization of mobile medical units to conduct C&P exams closer 
to where veterans live, expanding provider networks and the use 
of other modalities like the Acceptable Clinical Evidence 
Process, and utilizing automated decision support tools to 
minimize overdevelopment.
    Fourth, we have accredited our first two Native American 
VSOs, the Navajo Nation and the Gila River Indian communities 
to provide critical outreach and representation to an 
underserved population.
    VA is committed to addressing the unique challenges faced 
by rural veterans but we cannot do it alone. Through a 
collaborative approach we are working to bridge the 
geographical gaps that hinder access to health care and other 
earned benefits for our rural veterans. By utilizing proactive 
outreach, leveraging technology, expanding resources, and 
fostering partnerships, we are making significant strides in 
alleviating burdens faced by rural veterans ensuring every 
veteran is included in the VA process with a commitment to do 
more.
    Thank you for your continued support of veterans, their 
families, caregivers, and survivors. I look forward to 
answering any questions any members of the committee may have.
    The Chairman. Thank you, Mr. Jacobs.
    Ms. Hundrup, you are recognized for 5 minutes.

                  STATEMENT OF ALYSSA HUNDRUP

    Ms. Hundrup. Chairman Bost, Ranking Member Takano, and 
members of the committee, thank you for the opportunity to 
discuss our work on the Veterans Health Administration's Office 
of Rural Health.
    My testimony today covers findings and recommendations we 
made in our May 2023 report on the Office of Rural Health. Its 
mission is to improve the health and well-being of veterans 
living in rural areas through research, innovation, and the 
dissemination of best practices.
    Rural veterans represent a significant portion of our 
Nation's veterans with about 2,700,000 veterans enrolled to 
receive VA health care.
    As has already been noted, rural communities often have 
fewer resources compared to their urban counterparts which can 
result in rural residents experiencing challenges in accessing 
health care. In particular, rural communities often have fewer 
hospitals, face healthcare staffing shortages, and have limited 
transportation options as well as inadequate broadband access 
compared to their urban communities.
    VA's Office of Rural Health is one of the main offices 
responsible for taking actions to increase rural veterans' 
access to care. The office does this by two primary activities.
    First, it funds initiatives implemented by VA's various 
program offices. Initiatives expand existing services to 
medical facilities that serve rural veterans. For example, the 
office has provided funding to help provide transportation for 
veterans to VA facilities for medical appointments or ambulance 
services.
    Second, the office funds research projects that develop 
interventions to improve access to healthcare services for 
rural veterans and then disseminate those interventions more 
broadly. Research activities are managed by five resource 
centers which are field-based satellite offices that serve as 
hubs of rural health research. For example, several projects 
are looking into new uses for telehealth, such as programs for 
cardiac or knee rehabilitation.
    In our May report, we recommended that the resource centers 
communicate available research funding opportunities across VA. 
We found that each of the centers only communicated funding 
informally such as by word of mouth. For example, we heard that 
some researchers learn about funding opportunities through 
existing relationships with resource center staff. With only 
informal communication methods, many researchers may be unaware 
of funding resulting in missed opportunities for relevant 
research. By communicating more broadly, the office could reach 
a larger pool of applicants which in turn would help ensure the 
research projects the office funds best align with its mission. 
VA agreed with our recommendation and said that by May 2024, it 
plans to develop a standard procedure for communicating funding 
opportunities to researchers across VA.
    Also in our May 2023 report, we found the Office of Rural 
Health has taken steps to assess progress in meeting its 
mission. In particular, we found the office has identified 
broad outcomes it wants to achieve through strategic goals but 
it has not defined the specific level of performance that it 
aims to achieve to accomplish these goals. We recommended that 
the office develop performance goals that reflect leading 
practices identified in our prior work such as being objective, 
measurable, and quantifiable.
    For example, one of its strategic goals is to reduce rural 
healthcare workforce disparities. The office collects data on 
the number of clinicians trained on rural healthcare issues 
through its initiatives and research projects. In Fiscal Year 
2021, for example, it reported that 31,000 clinicians received 
training through its efforts. However, the office does not have 
a performance goal identifying how many clinicians it should 
train each year to help achieve its strategic goal of reducing 
workforce disparities.
    By developing performance goals, the Office of Rural Health 
would be better positioned to measure its performance and 
ultimately its progress in improving the health and well-being 
of rural veterans. Setting performance goals would also help 
inform the office's decision-making about funding for 
initiatives and research projects and help it determine if 
there are areas that may need additional focus.
    VA also agreed with this recommendation and stated that the 
office is developing a new strategic plan for 2025 through 2029 
that will include performance goals with annual growth targets. 
The office has estimated that it will finalize its strategic 
plan by this June.
    In closing, we are encouraged with VA's initial steps to 
implement our recommendations and will continue to monitor its 
efforts going forward.
    This concludes my prepared statement. I would be happy to 
answer any questions you may have. Thank you.

    [The Prepared Statement Of Alyssa Hundrup Appears In The 
Appendix]

    The Chairman. Thank you, Ms. Hundrup.
    We will now turn to questions. I will recognize myself for 
5 minutes.
    Dr. Elnahal, last year we discovered that about 9,700,000 
of PACT Act money for critical skills incentives was paid to VA 
senior executives as bonus. Now, that money could make a big 
difference in attracting providers to rural areas. Has the 
money been fully recouped?
    Mr. Elnahal. Mr. Chairman, the money is in the process of 
being recouped from the executives who received it.
    The Chairman. Are there safeguards in place to make sure we 
do not do that again?
    Mr. Elnahal. Well, one of the first things the secretary 
did was ask the Office of the Inspector General to do a full 
lookback on how those decisions were made in error. That is 
ongoing and we will work closely with the Inspector General on 
that.
    The Chairman. Thank you.
    Mr. Elnahal. That will then, of course, inform our policies 
to make sure that all of these things are transparent to senior 
leadership and that we make decisions according to policy and 
the law.
    The Chairman. Thank you.
    Also I need to ask, between 2016 and 2022, the budget for 
the Office of Rural Health (ORH) grew about 68 percent, and 
that is about $311,000,000 today mentioned in the opening 
statement. What meaningful impacts have been made with that 
$311,000,000 in 2022?
    Mr. Elnahal. Mr. Chairman, the Office of Rural Health 
really plays an important role in two main ways--making sure 
rural veterans benefit from appropriated funds. The first is 
actually funding research initiatives but also operational 
initiatives that extend our care to veterans across the 
country. In multiple ways the Rural Health Office has done 
that. For example, they have coordinated with our health 
informatics team and our field leaders to distribute almost 
200,000 tablets to veterans across the country to be able to 
make sure they can have access to telehealth in the convenience 
of their own home. That also speaks to a partnership we have in 
the interagency with the Federal Communications Commission 
(FCC).
    We also have commissioned many studies to figure out what 
disparities exist as Ms. Hundrup mentioned among rural veterans 
so that we can bring more resources and more care available.
    The second main function rural health does is coordinate 
the actual execution of those funding, of those funds, and make 
sure that program is benefiting veterans. Everything between 
our minority veteran coordinators who reach out to American 
Indian and Alaska Native veterans to our Rural Access Network 
Growth Enhancement (RANGE) and Enhanced Rural Access Network 
for Growth enhancement (E-RANGE) programs for mental health are 
assisted by the Office of Rural Health.
    The Chairman. I think you have probably in your statement 
there answered this part of my questions as well but maybe you 
want to expand on it. What ORH initiatives have the VA adopted 
across the enterprise as a program model of care or best 
practices?
    Mr. Elnahal. Another example, Mr. Chairman, that I have not 
mentioned yet is the Women's Health Mini Residency Program 
which has done now over 200 events and trained more than 500 
providers refreshing the unique aspects of women healthcare 
needs and making sure our clinicians are read up on those. In 
fact, women's health is an increasingly important focus and 
that is a close collaboration between the Office of Women's 
Health and the Office of Rural Health. That on top of multiple 
initiatives to get care as conveniently close to veterans in 
rural areas as possible really underlies their focus.
    The Chairman. None of the Offices of Rural Health 35 
initiatives placed more providers in the rural areas; is that 
right?
    Mr. Elnahal. Well, we have enterprise-wide initiatives that 
are trying to bring care closer to veterans in rural areas. The 
Office of Rural Health assists in multiple ways in extending 
access but we have hired a record number in just one year of 
providers in rural areas just last year. In fact, the growth 
rate of rural health--of rural employees rather within our 
healthcare system exceeded our overall growth rate at 7.7 
percent.
    That is an operational priority that I sent as my first 
priority last fiscal year, and thankfully, we have seen better 
staffing in rural areas.
    The Chairman. I know that a lot of the problems with 
telehealth is no connectivity. Okay? Would we be better off 
budgeting and be better spent on facilities and providing like 
more mobile facilities as well?
    Mr. Elnahal. Mobile medical units are a very important part 
of what we do as well. In fact, we just announced in August 
that we are deploying 25 mobile medical units to assist with 
homeless veterans including in rural areas. That is just one of 
many examples.
    I also mentioned in my opening testimony our Close to Me 
infusion service and National Teleoncology where we bring 
providers, you know, over a certain period of frequency to 
veterans who need chemotherapy in clinics that are closer to 
them. Normally, chemotherapy infusion services are offered at 
our larger tertiary centers, our larger medical centers. We 
know that increasing the convenience and reducing the travel 
time is just a more reliable way to deliver care for rural 
veterans.
    The Chairman. Thank you.
    My time is expired. Ranking Member, you are recognized for 
5 minutes.
    Mr. Takano. Thank you, Mr. Chairman.
    Dr. Elnahal, can you talk about some concrete efforts at VA 
to hire healthcare workers in rural areas, particularly in the 
area of mental health? What have you been able to achieve?
    Mr. Elnahal. Yes. Mental health is a major focus of our 
hiring efforts. We hired thousands of mental health providers 
and mental health staff last Fiscal Year alone as part of my 
broader priority of hiring faster and more competitively. We 
also have programs that are specifically related to veteran 
outreach and care delivery in rural areas. One of them is 
RANGE. RANGE is a program that allows for more intensive care 
coordination for veterans in rural areas who need intensive 
outpatient mental health services and helps connect them to 
inpatient services like residential rehabilitation treatment 
programs when they need it. We recognize that more intensive 
care coordination could benefit rural veterans and those two 
programs are just a couple of examples.
    Mr. Takano. Well, great. Would you agree that Congress has 
given the department a range of tools, a lot of tools, a lot of 
authorities to be able to recruit and retain employees? I mean, 
do we need to give you any more?
    Mr. Elnahal. Well, I will tell you, the PACT Act 
authorities, Title IX of the PACT Act helped us significantly 
in increasing our total employees onboard to the tune of us now 
having more employees onboard in the healthcare system than at 
any point in history. More than 410,000 employees in the 
healthcare system. Everything from recruitment and retention 
incentives to better loan repayment, to the ability to pay 
retention incentives up front when people come in has made us 
that much more competitive.
    We do have a legislative proposal called the VA Careers Act 
that would help us be much more competitive with physicians. We 
were only able to increase physicians onboard by about 2.3 
percent last year. That did exceed our previous years because 
of these enhanced authorities but relieving us of the $400,000 
cap, especially for specialty physicians who far exceed on 
average that amount for many specialties would be extremely 
helpful.
    Mr. Takano. We do have a need to increase the specialty 
physicians. We need to really get serious about that. This 
hearing is about rural areas. It is especially challenging to 
get specialty care into rural areas, is it not?
    Mr. Elnahal. It is, Congressman. In fact, the salaries that 
folks command in specialty care areas, in rural areas are much, 
much higher than often we are able to pay. It is why we have 
had this as our first legislative priority proposal coming out 
of the administration for veterans for a couple of years now. 
We know that this will just better enhance access to care for 
veterans, reduce wait times, and make care better.
    Mr. Takano. I mentioned in my opening statement, Dr. 
Elnahal, that rural hospital closures have been accelerating in 
recent years. How is VA factoring the shrinking footprint of 
community providers in rural areas into its long-term 
infrastructure and workforce planning?
    Mr. Elnahal. Mr. Ranking Member, I completely agree that 
the degree of closures of critical access hospitals and other 
healthcare infrastructure in rural areas is highly concerning, 
especially because of the disproportionate number of rural 
veterans who need care in our system. In fact, for inpatient 
care we often rely on these institutions as it stands to be 
able to meet that care. In response, we have to invest in our 
direct care system. We are often the only healthcare providers 
for particular specialties for veterans in rural communities 
and we absolutely have to hire but also create more 
infrastructure and be able to get appropriated funds to create 
that infrastructure especially with this concerning trend of 
closures.
    Mr. Takano. Especially with specialty care, being absent 
even in the private sector, I mean, it is clear to me that care 
in the community, it does not solve the problem of access to 
care in these rural communities. I mean, might we have to 
consider solutions like somehow getting VA's specialty 
physicians into these areas and possibly sharing them with 
others in the community that need them? Might we be thinking 
the other way around instead of thinking, open it up to 
community. Maybe the communities in these rural areas need VA 
specialists that can be shared with Medicare and Medicaid and 
whoever at the Indian Health Service?
    Mr. Elnahal. Well, the first thing I will say is veterans 
do disproportionately in rural areas rely on community care, so 
I do not want to undercut in any way the importance of our 
Community Care program. These are critical partners for us to 
deliver timely care for rural veterans. You are right in that 
there often are not good options in the community for veterans 
to receive the care that they need. Again, doubling down on our 
need to build infrastructure.
    We have a partnership similar to what you are talking about 
here with the Public Health Service Corps, Admiral Levine 
recently communicated to us that she intends to have now 200 
Public Health Service Corps officers deployed within VA for 
their healthcare experiences. We will disproportionately deploy 
them to rural areas. Thinking about other Federal healthcare 
systems like the Indian Health Service with whom we just 
renewed a Memorandum of Understanding (MOU) for reimbursement 
for their services for American Indian and Alaska Native 
veterans, looking at our partners at Department of Defense 
(DOD) for enhanced staffing, all of that is on the table for 
consideration.
    Mr. Takano. Thank you.
    I yield back. I am sorry for going over.
    The Chairman. Representative Van Orden.
    Mr. Van Orden. Thank you, Mr. Chairman.
    Mr. Elnahal, I want to start by thanking you personally. We 
spoke quite a while ago and I gave you a copy of a letter 
written by one of my constituents about their brother 
committing suicide because they could not get an appointment at 
the VA. I know you have done personal follow up with that widow 
and that is a standup thing to do. That really speaks to your 
level of commitment as a public servant. I appreciate that 
greatly.
    I live in a very rural district. I mean, this committee 
hearing is perfect for us. The big complaints that I get from 
my constituents and it sounds so simple is the removal of a 
kiosk so that folks could get their travel claims. I guess, Mr. 
Jacobs, is a travel claim, that payment, is that considered a 
benefit?
    Mr. Jacobs. We provide travel reimbursements in instances 
of C&P exams. If you are talking about reimbursement for 
medical care that would be handled in the health system.
    Mr. Van Orden. Okay. Like when I go to the optometrist at 
the La Crosse VA which is awesome, you are supposed to be able 
to file for reimbursement for travel. Well, here is the 
problem. Before you used to be able to just push a couple 
buttons and it would be your birthday, your Social Security 
number, and your name, and then it would say, here it is. You 
would sign it with your finger, direct deposit, done. Now 
because these kiosks are gone, and it is my understanding that 
someone forgot to renew the contract during COVID, you have got 
to do this first. This is a 40-page document about how to do 
ID.me. You have got to follow all these steps on a computer in 
order to get an ID.me identification number and then when you 
are done with that there is this 16-page step-by-step document 
for people to fill out a travel claim.
    My concern is this. We have Korean War veterans that have a 
flip phone that do not understand the technologies involved. We 
have folks that it has been addressed already that do not have 
broadband internet. Are you guys taking concrete steps to 
either get these kiosks back or to radically streamline this 
process?
    Mr. Elnahal. Yes, Congressman. I will tell you, I will not 
mince words on this. We did not do well with this transition 
with the beneficiary travel online system. We should have 
codesigned that better with veterans and we should have rolled 
it out much more carefully. Certainly before decommissioning a 
process like the kiosks that veterans were used to. It should 
have been deployed better. I take ownership of that. That has 
happened over the last several years as you mentioned 
throughout the pandemic. We will do better.
    One way that I am ensuring that any veteran has the option 
if they are not able to use the online system for various 
reasons they do have the option to file a paper claim to be 
able to get reimbursed.
    Mr. Van Orden. I did not bring a copy of that but it is an 
extensive thing also. My point being this, sir, is that we had 
something that was incredibly efficient for the veteran. It was 
perfect. It even could tell you your appointments for the day. 
We spent so much time deriding a bureaucracy as we should 
because you were here for the business meeting. You saw that we 
have an oversight responsibility assigned to us by the 
Constitution. We had like one thing that really worked and then 
we got rid of it. That is part of our frustration.
    Maybe as opposed to redoing this. It is like 70 pages worth 
of stuff for people that, I mean, I am old, too. He was right. 
Scott was right. I did not appreciate it but, you know, the 
truth hurts sometimes. Maybe we could think about 
reimplementing the system that we absolutely know works.
    Mr. Jacobs. Well, I commit to you, Congressman, that we 
will make this better. For the kiosks that do exist, we are not 
going to be decommissioning them so that at least the veterans 
who are used to using that process will have that. There are a 
total of four ways now for veterans to get reimbursed. We just 
have to do better in redesigning them to making them easier and 
to be able to do a personal touch with veterans, especially 
veterans like Korean War vets who are on average less able to 
use this type of technology. We have to bring a better process 
to them. That is VA's responsibility and you have my 
commitment.
    Mr. Van Orden. Excellent. I would like to continue to 
follow up with your office because, again, that is like the 
number one complaint I get from my constituents.
    I would like to thank you guys for letting me jump ahead. I 
appreciate it greatly.
    Mr. Chairman, I yield back.
    The Chairman. Representative Brownley.
    Ms. Brownley. Thank you, Mr. Chairman. Thank you, Mr. 
Secretary. It is nice to see you.
    It is my understanding that VA estimated that only 8 
percent of enrolled rural veterans are women. Why? I mean, that 
seemed low to me. I am curious to know if there are rationales 
or reasons for why that is.
    Mr. Elnahal. I will always start, Congresswoman, by saying 
that it is VA's responsibility to increase enrollment and 
increase access to care for veterans no matter where they live 
or what their gender is. I think the first and most important 
reason is that we need to do more outreach and we need to reach 
more veterans in rural communities who are women. We take that 
very seriously. We have a collaboration between the Office of 
Rural Health and our Office of Women's Health to be able to do 
much more outreach. I will pass the baton quickly to Mr. 
Boerstler to help talk about ways that we are going to reach 
more rural women veterans.
    Mr. Boerstler. Thank you, Dr. Elnahal, and thank you, 
Congresswoman.
    I absolutely agree. We do have a lot of really great 
programs to reach more women veterans. As you know, as this 
committee knows, women veterans are our fastest growing 
customer population at VA, and we are, especially in the last 
year and a half, since we have implemented the PACT Act, we 
have been able to reach more women veterans and increasing 
their access to benefits and care.
    In particular, reaching women veterans, and all veterans in 
rural areas, has become a big focus for us especially as we 
roll out our VA radio outreach program which has been able to 
record 60 different public service announcements for different 
personas like women veterans and Native American veterans and 
other minority veterans that are in rural areas to be able to 
reach them if they do not have access to broadband internet or 
they are not able to go to their nearest facility. We have been 
able to partner with 150 different syndicates in these rural 
areas. There is a lot of work being done.
    We are also proactively text messaging lots of veterans 
including more women veterans in these areas so that they can 
have better access to care and benefits.
    Ms. Brownley. Very good.
    Mr. Jacobs, you talked about historic outreach. I am just 
curious to know of the outreach that you did was historic. How 
many more veterans who are now qualified to receive benefits? 
Did you capture that number?
    Mr. Jacobs. In Fiscal Year 2023, we had a 40 percent 
increase in the total number of claims we received relative to 
last year which was an all-time high. We also delivered more 
benefits to more veterans than we ever had in our history.
    Ms. Brownley. How many more veterans just, you know, who 
are new to the VA who qualified to receive benefits?
    Mr. Jacobs. I do not have that number but I will get back 
to you for the record.
    Ms. Brownley. Did you have a breakdown at all in terms of 
men versus women?
    Mr. Jacobs. I would have to get back to you on that. We do 
proactively try to conduct outreach targeted to encourage more 
women veterans to file claims. I do not have those numbers in 
front of me.
    Ms. Brownley. If you would provide them I would appreciate 
it.
    Mr. Jacobs. Absolutely. Yep.
    Ms. Brownley. That would be great.
    Mr. Secretary, you mentioned IHS and the MOU. When was that 
finalized?
    Mr. Elnahal. Congresswoman, we announced it at the White 
House Tribal Nation Summit just last month.
    Ms. Brownley. Just last month. I am curious because as 
chair of the Health Committee, a couple years ago we had a 
couple of hearings on this and I am curious to know, because I 
know one of the issues was that veterans would use IHS for 
general health care and then they would use the VA for 
specialty health care. Then when they went to the VA for 
specialty health care, the VA repeated a lot of the different 
tests and assessments that were done with IHS. I am just 
wondering if the MOU addressed that so that the VA is not doing 
more tests than they need to do in order to prescribe what a 
veteran may need in terms of their health care.
    Mr. Elnahal. Yes. You are describing a frustrating 
experience, Congresswoman, that I hear all the time for 
veterans who have to often repeat their histories and where 
clinicians do not have the information available to them. The 
MOU was mostly focused on how we will reimburse the Indian 
Health Service and better coordinate with them to be able to 
deliver a comprehensive care plan for American Indian and 
Alaska Native veterans. We have a lot of collaborative work 
going on to make that process as seamless as possible. 
Especially in rural areas and for tribal veterans in 
particular, they often have to go to different systems because 
of the general lack of healthcare infrastructure. That is why 
the relationship with IHS is so important. It is why, for 
example, we opened a couple of more contract-based clinics in 
the Navajo Nation alone to be able to bring, you know, care 
closer to the veterans. All of that happened just over the last 
several months but us working better and more seamlessly with 
IHS on the ground is extremely important to prevent what you 
are talking about.
    Ms. Brownley. Thank you, sir.
    I yield back.
    The Chairman. Representative Radewagen.
    Ms. Radewagen. Thank you, Chairman Bost, and Ranking Member 
Takano, for holding this hearing. Talofa lava. Thank you to the 
witnesses for your testimony.
    This issue is very important to my home district as our 
veterans must fly thousands of miles to receive anything more 
than the most basic care. Our veterans in the rural and remote 
areas deserve the same level of treatment as the rest of the 
country. Telehealth and other initiatives have come a long way 
in improving access but there are still gaps to be filled.
    Dr. Elnahal, Government Accountability Office (GAO) 
recommended that VHA update its guidelines for establishing 
outpatient intensive mental health care programs. How is VHA 
planning to revise these guidelines to improve access to mental 
health services for our rural veterans, particularly those with 
serious mental illness?
    Mr. Elnahal. One of the main ways we do that, 
Congresswoman, is through our RANGE program, which is 
essentially an intensive case management program that makes 
sure that rural veterans in particular, including veterans in 
our territories, are getting the care that they need. You know, 
an extra hand to be able to coordinate that care, canvass all 
options including not only VA care but also community care, and 
making sure the dots are connected for veterans so that the 
care is both timely and effective is the focus of that program. 
It is, in fact, focused exactly on what you mentioned, the 
veterans who need intensive outpatient and in some cases 
inpatient services for mental health and we are very focused on 
it.
    Ms. Radewagen. Thank you.
    You know, a GAO report from last year indicated that VHA 
does not analyze mental healthcare data by virality. How does 
VHA plan to incorporate virality in its data analysis to better 
understand and address the disparities in mental healthcare 
utilization between rural and urban veterans?
    Mr. Elnahal. That effort is more than possible, 
Congresswoman. The way that we are approaching that is 
essentially by using this very specific geolocation information 
for both veterans and our infrastructure to better understand 
who needs what no matter where they live, including, of course, 
rural veterans. That report was very helpful to us. It helps us 
really be able to try to slice the data in the way that is 
helpful. By the way, helpful not just to folks at headquarters 
but more importantly, folks who are at the clinics and in the 
infrastructure in rural areas to better target the veterans 
they can serve.
    Ms. Radewagen. Dr. Elnahal, we noticed many of the 
initiative's Office of Rural Health funds are related to 
telehealth. How is ORH coordinating with relevant VA offices, 
such as the Offices of Connected Care, Primary Care, and 
Specialty Care?
    Mr. Elnahal. One of the main ways that you see that 
collaboration is through our clinical resource hubs. Every 
network in the system, including Veterans Intergrated Service 
Network (VISN) 21, which serves the Pacific, has a clinical 
resource hub. Across our system we have about 800 tele-mental 
health providers in particular that are able to--and in fact, 
spend all of their time coordinating and providing care to 
rural veterans via telehealth. That is a collaborative effort 
between rural health, Connected Care, and the Integrated 
Veteran Care program. Of course, our operators in the field who 
execute on that.
    Ms. Radewagen. What are you doing for veterans that lack 
broadband internet access or prefer to see providers in person?
    Mr. Elnahal. We have a collaboration with the Federal 
Communications Commission that helps us essentially cover the 
costs vis-a-vis FCC's authority. For much of the broadband and 
wi-fi services, you know, total bill that veterans need. That 
number continues to grow for veterans served. Of course, 
veterans also have to have the devices to be able to use 
broadband. That really underlies our effort to hand tablets to 
a vast majority of them are rural veterans, almost 200,000 we 
have distributed.
    We calculate that almost 100 percent. About 97 percent of 
the encounters that we are seeing with telehealth for rural 
communities is delivered in the convenience of the veteran's 
home. We will keep trying to expand those programs. We know 
that rural veterans will continue to meet them.
    Ms. Radewagen. VA talks about expanding access through 
telehealth, but 27 percent of veterans do not access the 
internet at home as you have mentioned and lack of broadband 
connectivity is still a major issue in much of rural America. 
Yet, one-third of Office of Rural Health's initiatives are 
focused on telehealth. What is VA doing to address 
infrastructure issues?
    Mr. Elnahal. We have that program with the Federal 
Communications Commission, Congresswoman, that helps us offer, 
you know, the ability for veterans to cover the costs of 
broadband and wi-fi services. Our task is to just make sure 
every veteran who needs this and who qualifies for it knows 
about it and that our local teams are letting veterans know 
about it. We will not know unless we ask the question to 
veterans when they come in for care, and we just have to do 
that with every opportunity we have, especially for our 
facilities in rural areas.
    Ms. Radewagen. Thank you, Mr. Chairman. I yield back.
    The Chairman. Representative Cherfilus-McCormick.
    Ms. Cherfilus-McCormick. Thank you, Mr. Chairman.
    I want to say thank you to Dr. Elnahal for visiting my 
office, Under Secretary. Visiting our district, actually, and 
speaking to the mental health services that are available to 
our veterans.
    I wanted to pick up on the question of the tablets that you 
handed out. One of my first community projects was to actually 
hand out tablets to connected people to telehealth. One of the 
things we got back was some people did not know how to use the 
tablets because they were not digitally savvy. Have you come 
across that with our veterans who are receiving them?
    Mr. Elnahal. Yes. I have heard that personally, and we have 
also had oversight reports, including from the Office of the 
Inspector General that talked about that and a number of other 
issues. We are working to change that. We really need to be 
helping veterans not only, you know, get these tablets but know 
how to use them and know how to use our applications, like My 
Healthy Vet and the VA.gov global application. That really 
needs to be a close, you know, veteran centered education that 
happens.
    We are working on that. We are trying to improve the way 
that we educate veterans on this and provide a helping hand. I 
view that as VA's responsibility.
    Ms. Cherfilus-McCormick. How big of a problem is it? Is it 
a huge problem or a very small problem that you are running 
into?
    Mr. Elnahal. Well, the problem varies depending, of course, 
on the service area and the age of the veteran. We know that 
rural veterans on average are older. Again, it is really the 
responsibility of VA in my view to take a full comprehensive 
approach in helping veterans through that process to learn how 
to do it.
    Ms. Cherfilus-McCormick. Now, I have a question about best 
practices as was mentioned by Ms. Hendrup. What steps are you 
taking to make sure that best practices are being established 
especially for our rural veterans. When I go throughout my 
district I see there is a huge difference with the VA in West 
Palm Beach, in Miami, and even outside my district. What steps 
are you guys taking to ensure that they are getting the best 
services available to them?
    Mr. Elnahal. Yes. We are addressing the issue of best 
practices through our Office of Rural Health Promising Practice 
program.
    I will just give you one example that was unique to rural 
veterans. I served in VA. This is my second time serving in VA. 
My first time I focused on the very topic of spreading best 
practices. Collaborated with the Office of Rural Health 
extensively. One of the best practices to get more advanced 
care directives for rural veterans filed, better to be able to 
define what they would like to receive in terms of end-of-life 
care. That should be the veteran's decision and should be a 
plan well in advance of them needing end-of-life care. They 
were a really innovative practice where it was essentially 
group classes and group visits. Rural veterans obviously have 
more difficulty getting to our brick and mortal infrastructure 
and so to hold classes like this when we know rural veterans 
are coming in for care, to educate about advanced directives 
and on the spot offer the opportunity for rural veterans when 
they are ready to file their advanced directive. It is one of 
many best practices that just gets a very needed piece of their 
care delivered.
    The Office of Rural Health works with our Innovation team 
and other members of our team at headquarters to make every 
corner of our system know what is working for veterans.
    Ms. Cherfilus-McCormick. Thank you so much. I yield back.
    The Chairman. Representative Rosendale.
    Oh, I am sorry.
    Ms. Kiggans. Thank you. Thank you, Mr. Chair. Thank you.
    It has been great to hear about some of the improvements 
for expanding access to rural health care since I think that is 
what we are here to discuss. Rural access and VA. Are we 
meeting veterans where they live? I think there is some room 
for improvement. We have done good things that you all have 
mentioned--telehealth, mobile clinics, improving transportation 
service. That is great but I, as a nurse practitioner, I want 
to talk about an issue near and dear to my heart, and that is 
expanding the scope of practice for advanced practice 
Registered Nurses (APRNs), nurse practitioners, nurse 
anesthetists. A lot of midwives. There are so many of us that 
feel such a void for health care, especially for rural health. 
I know that the VA provided guidance for APRNs in 2016 and you 
published that report. Certified Registered Nurse Anesthetist 
(CRNAs), specifically, were left out of that. Nurse 
anesthetists were not allowed to practice to the full scope of 
their potential. I wanted to just note some things from the 
guidance talked about expanding full practice authority for 
CRNAs would not harm Team Base Care. That anesthesia care 
provided by CRNA would not harm team-based care and the 
anesthesia care provided by CRNAs is equally safe with other 
physician supervision.
    This was from that 2016 report. Also in that report the VA 
believes that a significant shortage of anesthesiologists exist 
and that this leads to cancellation, delays of surgery in rural 
settings. I know that after that time the VA partnered with 
Temple University Beasley School of Law in 2022 for a VA 
commission duty which concluded, the policy, about the CRNA's, 
decisions on their standards should be guided by current 
available data. The data provided in the study shows that 
removing restrictions on CRNA's had no negative impact on 
patients. Maybe a cost effective solution to physician 
shortages and may increase access to care. In the wake of 
reports on canceled surgeries and acknowledgement that 25 
percent of VA facility chiefs of staff reported problems 
recruiting or hiring anesthesiologists, it is of the utmost 
importance that the VA reconsider their exclusion of CRNA's 
from their 2016 rule on the APRNs. Additionally, APRNs, 
including CRNAs, are typically more accessible to historically 
underserved populations in geographic areas. For instance, 
rural facilities which are more heavily reliant on CRNAs for 
anesthesiology and surgical practices.
    I guess my question is to Mr. Elnahal. Can you just tell me 
why? Why are we leaving CRNAs out of the picture? This is a 
time when we need advanced practice nurses more than ever to 
fill those voids. They are capable. All of this data, I know I 
could go on and on about providing that their outcomes are just 
as good, if sometimes not better than some of the physicians we 
employ. Why are they left out of the equation?
    Mr. Elnahal. Well, the first thing I will do, 
Congresswoman, is identify yourself with your support for 
advanced practice nurses. More generally, they have been some 
of my best colleagues in healthcare delivery personally as a 
physician.
    I also want to clarify that our current policy is one where 
advanced practice nurses, and CRNAs in particular, where our 
medical centers are in states that allow full practice 
authority for CRNAs. Medical centers do have the authority to 
extend privileges for full practice authorities in those 
states. We have many medical centers already doing this 
consistent with that policy and consistent with state licensing 
guidelines.
    The question at hand with the National Standards of 
Practice is whether or not through our Federal supremacy 
authority potentially override state licensing restrictions on 
those professions. That is the question at hand as we look at 
the national standard for CRNAs.
    My team tells me that just over the next year or two we are 
going to see more data that would help in our final decision-
making on what that national standard should look like. We want 
to make sure we have the most up-to-date and important 
information for us to be able to take that extra step and say 
VA through its Federal supremacy will grant that authority 
regardless of what its state licensing regime says. That right 
now is still deliberative. I have not made a decision on that. 
My team has not recommended a decision on that yet.
    Ms. Kiggans. Yes. I do not know how much more information 
you need to have the outcomes be very obvious that we need 
these guys. We need them now because we are not providing the 
care to our veterans especially in those rural health settings 
again.
    You know, I come from Virginia, and we recently, only in 
the past few years allowed for nurse practitioners statewide to 
have full practice authority. VA led the way. You guys did it 
first. You were brave. You went out there. You filled that 
void. I think you can do it in this instance, too.
    I will be watching as a member of this committee, as a 
nurse practitioner, and watching and waiting for you all to 
approve full practice authority for our CRNAs.
    I know I am running out of time. Actually, I only have 5 
seconds. I will yield. Thank you very much.
    The Chairman. Representative McGarvey.
    Mr. McGarvey. Thank you very much, Mr. Chairman. Thank you 
all for being here today. I appreciate you all's testimony.
    Dr. Elnahal, thank you for your testimony and for sharing 
the great work the VA is doing to address the needs of rural 
veterans and their families. I am thinking particularly of 
Appalachia and Eastern Kentucky, the state where I am from, 
where my grandfather is from in that area, and all of the other 
rural areas that really struggle with access to care and how we 
better reach them.
    I am excited to see the telehealth visits are expanding. 
Two point four veterans have made 11,600,000 million telehealth 
visits but only 770,000 of the 2,700,000 enrolled, rural 
veterans, or 29 percent are using telehealth.
    My colleague, Ms. Radewagen asked a little bit about this, 
and obviously, we have got to see some more access to 
broadband, what we can be doing now. Appreciative of the 
American Rescue Plan and the infrastructure laws that are going 
into place. I know you guys addressed that a little bit.
    I am going to talk a little bit about the programs 
themselves because obviously, we all share the commitment and 
passion to get health care to our veterans because they have 
earned it. They have earned it and they deserve it.
    You have got the at-home screening for colorectal cancer. 
You have got the remote monitoring for prevention of diabetic 
amputation. These types of programs.
    Dr. Elnahal, how does the VA determine how to design these 
programs, whether a program is working, and how to quickly 
scale it up?
    Mr. Elnahal. The best programs, Congressman, in this area 
have really come organically from our field leaders and field 
clinicians who understand what veterans need close to the 
ground as they serve them. You know, a lot of our home 
monitoring programs for things like congestive heart failure, 
the diabetes amputation program that you mentioned, started in 
one or two or more of our medical centers. We are discovering 
it and lift it up as a best practice and then it becomes 
supported better and better through our infrastructure. I think 
that is the best way that we service these really effective 
programs.
    Mr. McGarvey. I know you are setting up a new Office of 
Digital Health as well. Can you tell me about how the VA plans 
to untether veterans, especially our rural veterans, from just 
solely relying on the brick and mortar model of care?
    Mr. Elnahal. The impetus for this office, Congressman, I am 
glad you mentioned it, is a recognition that digital health 
will just become more and more of a part of the expectation of 
patients, not just veterans, but across the country. We have to 
be leading on this as we have historically with telehealth. The 
best way to do it in my view is through human center design. 
That is an office that will have the infrastructure in 
collaboration with the Veterans Experience Office to be able to 
work with veterans to understand how technologies can be 
accessible, how much education are we offering, but how are we 
designing the programs up front to be able to make it as easy 
and effective as possible to receive that care. I am happy to 
pass to Mr. Boerstler for more insights on that.
    Mr. Boerstler. Well, thank you, Dr. Elnahal. As he pointed 
out, the human center design or veteran center design in this 
case is really understanding the pain points, the bright spots, 
the moments that matter along each customer journey, whether it 
is a specialty care journey or an outpatient care journey for 
rural veterans and non-rural veterans alike. We continue to do 
that in almost every business line.
    We also consistently monitor on the quantitative side. 
Through our Veteran Signal or V Signal survey platform we are 
able to see and monitor the increase in trust in ease, 
effectiveness, and emotion. I am happy to report there are 
great scores for veteran access to care for outpatient services 
in particular which are higher among rural veterans. More rural 
veterans trust VHA outpatient services than non-rural veterans, 
as well as emergency medicine, vet centers, and community care. 
There is a lot of great quantitative data there as well.
    Mr. McGarvey. Thank you. Just in closing in the time we 
have left, in you all's opinion, what is the best action we 
could take now to help veterans get this type of care?
    Mr. Elnahal. I think, Congressman, ensuring that we have 
the resources to be able to not only extend the best and most 
modern technology but also that we have the right workforce in 
place to be able to lead what is really the digital revolution, 
especially with the advent of generative Artificial 
Intelligence (AI) would be extremely helpful. We are going to 
out of our Digital Health Office lift up our AI program to make 
sure that we are following the trustworthy AI principles that 
the president outlined in a recent executive order but then put 
as much potential forward in a safe and secure way to be able 
to meet veteran needs. Of course that means telehealth. It 
means as much home monitoring as possible to make things more 
convenient for rural veterans. Really, everything that we can 
do to make the daily job, the daily work easier for our 
clinicians to be able to deliver that care.
    Mr. McGarvey. Thank you very much, Mr. Chairman. I yield 
back.
    The Chairman. Representative Rosendale.
    Mr. Rosendale. Thank you very much, Mr. Chair. Thank you 
for holding this hearing.
    I want to start off this afternoon by thanking publicly Dr. 
Elnahal. I am known to hold people accountable and raise hell 
on occasion when things are not being done the way that I would 
like to see, and I do that publicly. I want to make sure that 
everyone is aware of the great job that we are seeing right 
now.
    Before too long, ineffective leadership oversaw poor hiring 
procedures and tolerated serious medical malpractice. Veterans 
suffered as a result, and while there is still work to be done, 
I am very encouraged with the new leadership at the Montana VA 
at Fort Harrison. It started to implement changes leading to 
improve care for our Nation's heroes. I appreciate you and 
Secretary McDonough for being responsive to my initial letter 
conducting the preliminary investigation, requiring a 
comprehensive review, and keeping my office thoroughly 
informed. Hiring an interim executive director and bringing in 
the outside help. I made it my mission to fix the Montana VA to 
ensure veterans receive the best health care possible. I am 
thankful for your role in this department and these efforts. 
Again, I want to say that publicly because we have had many 
conversations over the last several months and the work is 
bearing fruit. It has really been turning out good.
    Mr. Elnahal. Thank you, Congressman.
    Mr. Rosendale. I am passionate about ensuring veterans have 
easy access to effective healthcare services and believe 
telehealth is an essential component. In Montana specifically, 
patients who otherwise would have to spend hours driving to an 
appointment often having to take time off of work have come to 
rely on these telehealth services. We saw them expand it 
dramatically during COVID, obviously, but in Montana it is just 
a way of life without COVID.
    Dr. Elnahal, in your testimony you mentioned that for the 
Fiscal Year 2023, the VA delivered 11,600,000 telehealth 
episodes to over 2,400,000 veterans. This number was the 
highest for the VA in any fiscal year. What do you anticipate 
the demand for telehealth to be for the Fiscal Year 2024? What 
steps is the VA taking to meet that demand?
    Mr. Elnahal. Well, Congressman, I appreciate your 
recognition that we are providing more telehealth than we ever 
have in history. I can tell you we plan on offering more and 
more of it because the expectations of veterans in all 
generations frankly are to receive more and more convenient 
care. Not only are post-911, Iraq, Afghanistan veterans who are 
pursuing modern and convenient care, but we have data that also 
shows that more than 50 percent of rural veterans prefer 
telehealth as the primary modality. I am going to see if we 
have modeled what the expected volume should be this fiscal 
year. I do not have that in front of me right now but we will 
be sure to get that back to you. I can almost guarantee it will 
be more telehealth than we have ever done before.
    Mr. Rosendale. Great. If you could get those numbers to me 
and then just some kind of summary of how you plan to address 
that increase, that would be greatly appreciated.
    As you can imagine, we are challenged with both the 
broadband and technology issues. In Montana because the state 
is so rural, some of these areas just are not able to get it, 
with the travel.
    That being said, I want to dive into the travel issues. 
Veterans across Montana have told me about the difficulties 
with the Beneficiary Travel Self-Service System, especially for 
some veterans who are not as proficient in technology. This has 
led some veterans to give up in frustration and not to obtain 
the reimbursement they have earned. When you are traveling 
literally hundreds of miles that is a large financial impact.
    The veterans liked the old kiosk system. I know that you 
spoke to that a little bit earlier but I was not here. Why is 
it that we cannot bring back the kiosk system that worked 
better for veterans? I know that there was fraud and waste 
involved in it. With the investments that we could make there, 
we could make improvements for the security of that if that is 
the problem, and make sure that we still eliminate the waste 
and fraud while keeping those consumers and veterans happy.
    Mr. Elnahal. I will just say, Congressman, we have to do a 
lot better with that system. I will say that up front and admit 
it to you as I have admitted it to my team. I will tell you 
that our process for instituting this new system was not done 
correctly. We did not design it with veterans. That is why we 
are collaborating more than ever with Mr. Boerstler and his 
team with the Veterans Experience Office. We are going to keep 
the kiosks we have but we have to maximize and make the options 
easier to use for veterans.
    There are four options now. The VA.gov patient check-in is 
a new one that we just introduced. We are going to try to 
educate veterans on that and see if they respond well to it. 
Similar to my comments before about the Office of Digital 
Health, we will make sure that we focus on this and make the 
design much easier to use and better. It is a major focus of 
ours.
    Mr. Rosendale. Very good. Thank you so much.
    I see my time has expired. I would yield back. Thank you.
    The Chairman. Thank you.
    Representative Deluzio.
    Mr. Deluzio. Good morning, Mr. Chairman. Good afternoon, 
everyone. Thanks for being here.
    I want to pick back up on some of the telehealth discussion 
Mr. Rosendale and you were having, Dr. Elnahal. I recently was 
at the Beaver County Clinic in my district and saw some 
technology there for veterans who come in who may not be able, 
because of internet access or technology, do it from home or do 
it from where else. I encourage more of that so that veterans 
can do those appointments perhaps with a specialist. In my case 
it might be University Drive or Heinz in Pittsburgh, PA.
    My question though, if VA is unable to offer an appointment 
that makes someone eligible for fee-for-service care out in the 
community, they might receive virtual care out in the 
community. Why should we not consider virtual care as an access 
standard if VA can provide a virtual appointment?
    Mr. Elnahal. That is exactly our intention, Congressman. 
The secretary announced that last year that if we are able to 
deliver an appointment via telehealth and the veteran agrees 
and our clinicians think that that is an acceptable modality of 
care for what they need that that should count toward our 
ability to fulfill an appointment according to our wait time 
standards.
    We are working on that through rulemaking. There will be a 
number of other elements that help us factor in the importance 
of telehealth. We strongly believe that again, if the veteran 
agrees and our clinicians think it is acceptable, we can offer 
that as satisfactory in meeting the standards.
    Mr. Deluzio. Thank you. Please proceed as best you can 
there. I mean, one of my overarching concerns, I mentioned this 
to Secretary McDonough when he was here last year. It was the 
ballooning cost for fee for service care side of the ledger 
relative to what we are seeing at VHA. I am not going to cite 
you every study but, of course, VA's own systemic review study 
which I think now is looked at 57 studies itself continually 
shows the bulk of the findings of the VA is doing as well, if 
not better than care, a free for service. They are out in the 
community. I mean, even on wait times in particular that was 
stark to me how much better VA is doing, what that stark to me 
how much better VA is doing, what that trend looks like 
relative to providers out in the community. My great fear is we 
are not investing in VA's ability to give and relying on a 
community care fee-for-service network that there are provider 
shortages that many of us see in our district and communities 
that we should be strengthening VA. Would love to hear your 
perspective of, you know, can VA scale up? Should we be? What 
are your thoughts here?
    Mr. Elnahal. I agree with your perspective, Congressman. 
You mentioned the studies. We also participated in Centers for 
Medicare and Medicaid's (CMS's) overall hospital quality start 
rating system for the first time just this past fall. When we 
released our results, 67 percent of our medical centers score 
either four or five stars on that rating compared to fewer than 
50 percent of hospitals in the private sector. Overall, our 
direct care system provides exception care. These are people 
who focus squarely and only on veteran care by definition. We 
have some of the best researchers expanding the pie of 
knowledge and the services that we can offer, new treatments, 
effective treatment. We do rely on the community though when we 
cannot offer timely care to veterans. That is a backstop. That 
is still important specially for rural veterans. Investing in a 
direct care system has been among my top priorities to include 
more than 61,000 people we hired just in Fiscal Year 2023 alone 
to make sure we have the team in as many areas of the country 
as possible and growing our healthcare workforce in rural areas 
by 7.7 percent in just one year.
    Mr. Deluzio. Well, and I will point to a couple of these 
findings. I know I do not have a ton of time but one about a 
study of veterans who live within 20 miles of VHA facility and 
comparing those sent to private hospitals for emergency 
treatment. The mortality rate was much worse than the private 
hospitals. That gives me cause for alarm. I think we should get 
veterans we should be investing in VA so the veterans are 
getting that better care.
    I also point to the Office of Inspector General (OIG) 
report last year on prescription of opioids.
    Then the lack of oversight we were seeing in the feel for 
service community care providers. The ranking member and some 
of my colleagues and I sent a letter to VA, which we await a 
response. One, any update on when we will hear that response, 
and two, I will urge that we have at least scrutiny you are 
seeing in VA on those prescriptions when it is happening out in 
the community as well.
    Mr. Elnahal. It is an extremely important issue, 
Congressman, and I regret that we have not gotten that response 
back to you yet. I will ensure that is our top priority and 
correspondence to get that back to you. What I will say is, you 
know, we have an oversight responsibility over this. We know 
that there are some levels of redundancy on this. You know, 
there are a lot of states and there are to some extent Federal 
oversight requirements on opioid prescribing. We require folks 
to look at essentially what is a public data base, patient by 
patient, on what opioids they have been prescribed 
historically. The prescription drug monitoring programs that we 
engage in. Our responsibility is to veterans no matter where 
they get their care. If they are being too many opioids, VA has 
to be on first in identifying that and holding our community 
provider partners accountable.
    Mr. Deluzio. Mr. Chairman, thank you. I yield back.
    The Chairman. Dr. Miller-Meeks.
    Ms. Miller-Meeks. Thank you very much, Chair Bost, and 
thank you for holding this hearing.
    Quite honestly, it has been apparent to me so I am both a 
physician and a veteran, married to a veteran who is also a 
nurse, and I was a nurse prior to becoming a physician. It is 
very apparent to me when I talk to veterans in my community and 
as a physician providing care that the Mission Act is not being 
fully implemented by the VA. That became readily apparent when 
we had our Health Statement of Benefits (SOB) on residential 
mental health and substance use disorder where the VA did not 
even think that residential mental health and substance use 
disorder fell into the parameters of the Mission Act. 
Therefore, getting a patient in within 30 days was not part of 
that type of care.
    I am just going to be blunt here. Color me unimpressed. You 
can take accountability for the fact that you got rid of a 
kiosk system to me is bureaucrats deciding this would be a 
great idea. We are going to do this. Guess what? Just like 
Electronic Health Records (EHRs), we are not going to talk to 
the people that use these systems. We are not going to talk to 
veterans to find out what they want, what makes it easier. You 
have had multiple complaints. You know about the complaints. 
Veterans complain about it but we have not done anything. 
Whatever money we thought we were going to save by getting rid 
of the kiosk, that money is now invested into increasing VA 
employees to train people how to do stuff instead of, and this 
is the same for the Office of Rural Health Care, and believe 
me, I have done this as a physician, we need people who deliver 
care. Not people who study care. It is great that you are 
talking about advanced directives. All patients should have 
advanced directives. Do we have to set up a training program, 
go out into rural areas to make sure veterans have access to 
knowledge about advanced directives rather than when they are 
at the facility it is done?
    I do not care to increase the bureaucracy of the VA with 
people who are not delivering care. What I want is for people 
to receive care. We should not have to do a bill that says if 
you need residential mental health care and you need substance 
use disorder treatment that that has to be within 10 days 
because the VA does not see it within their parameters to 
deliver that care. Or that you go to another VISN that is 200 
to 300 miles away from your home. Or that we are going to call 
you the day before your appointment to make an appointment 
which we get under the 30-day timeline because we do not want 
people going out to the community. Absolutely there should be 
oversight of care wherever that care is delivered. Fully 
supportive of that. I am not supportive of people who know what 
their problems are, know that there are access of care issues 
because people can get into the VA, but yet do not want them to 
receive community care in a timely fashion.
    I think this is both for Dr. Elnahal and for Mr. Jacobs. 
Has there been a decrease in veterans filing for travel claims?
    Mr. Elnahal. To my knowledge, Congresswoman, that is not 
the case. I think we are seeing more travel claims but I have 
to get that back to you for the record.
    Ms. Miller-Meeks. Yes. I know veterans who are not filing 
for travel claims because of the difficulty of doing that.
    Dr. Elnahal, how is the VA ensuring optimal diabetes 
management for rural at-risk veterans to prevent foot ulcers 
and amputations?
    Mr. Elnahal. Yes. It is a really important program that we 
have, not only care that we provide in-person for wound care 
and ultimately diabetes management to prevent the need for 
amputations. We also have a remote monitoring program and a 
telehealth program specific to that, again, supported by the 
Office of Rural Health. We have seen some really promising 
results that I am happy to send to you and your team, 
Congresswoman. We want to expand that offering as much as we 
can.
    Ms. Miller-Meeks. I certainly think technology can truly 
help to get access, especially with cameras, our digital 
ability to do things that we have not had in medicine. I am 
just going to say, it is one thing to take ownership of 
problems that you know about but one of the things that very 
frustrates our veterans and our constituents is that there is 
never accountability. You still have your job despite 
developing a program, rolling out a program that has been 
extraordinarily cumbersome for veterans. Our Rural Health Care 
Office, it is great to study whether or not veterans can have 
access to studies, especially if their study is cutting edge on 
medications to treat disease. What I want to know is are 
outcomes improved? Do we have less veterans committing suicide? 
How are we treating Post-Traumatic Stress Disorder (PTSD)? What 
is our cancer cure rate? What is our amputation rate for our 
diabetes?
    I have volunteer organizations in my district, volunteer, 
receive no money from the VA, are not VA employees, who 
actually do a job, a better job of reaching out to veterans and 
taking them down from a suicide risk and treating their PTSD 
only because they are just there to serve veterans. That should 
be our goal and our mission.
    Thank you very much. I yield back my time.
    The Chairman. Representative Budzinski, you are recognized 
for 5 minutes.
    Ms. Budzinski. Thank you, Mr. Chairman. Thank you, Ranking 
Member, for this opportunity. Good morning everyone. Thank you 
to all my colleagues and the witnesses for your time today to 
discuss the urgent issues around rural healthcare access in 
particular.
    I represent a very rural district in central and southern 
Illinois, and I have heard concerns from veterans back home 
about the need to expand health care. I have especially heard 
this concern from our women veterans.
    In September, I hosted my first Women Veterans Roundtable 
in the district, and among the issues mentioned was a lack of 
awareness of women specific services provided by the VA in 
rural areas. I would like to use my time to focus on our women 
veterans in particular which leads me to my first question for 
Dr. Elnahal.
    What are some examples of initiatives and research projects 
funded by the Office of Rural Health that focus on women 
veterans living in rural areas and their access to health care? 
How is that office helping to disseminate information about 
services and resources to our women veterans in rural areas? 
Thank you.
    Mr. Elnahal. Yes. It is a mandate that we take very 
seriously, Congresswoman, to make sure that we are the ones 
getting women veterans connected to care, enrolling more women 
veterans. The fastest growing demographic by far is women 
veterans. Of course, for women veterans in rural areas to make 
sure they get the care they need.
    The first program is the Women's Health Rural Mini-
Residency program which really primes our providers in rural 
areas to understand the unique needs of women veterans. Our 
Office of Women's Health leads that. We have already trained 
more than 500 providers using this over 200 events. We continue 
to grow that offering.
    We also have the Women's Health Care Rural Coordination 
Program for essential screening that is gender specific, so 
breast cancer and cervical cancer screening. We have seen an 
uptick in screening as a result of that program thankfully and 
we continue to want to expand that.
    We also have specific offerings for women veterans in 
tribal areas. American Indian and Alaska Native veterans 
through just offering better cultural care. I will ask Mr. 
Boerstler to help supplement the outreach we are doing for 
women veterans as well.
    Mr. Boerstler. Thank you, Dr. Elnahal. Thank you, 
Congresswoman. I actually wanted to mention this earlier but we 
did not have enough time. We hosted our first Women Veterans 
Experience Action Center last fall. It was a national program 
really focused on increasing access to VA Benefits Care, 
Appeals, Cemetery Memorial Affairs services is really 
successful in partnership with all the offices and many of the 
women veteran service organizations in the country.
    Another great example is in South Dakota, which is a highly 
rural state, we have about eight Community Veteran Engagement 
Boards. It is all run by a one woman veteran, an Army veteran 
named Jill Baker. She has been hosting listening sessions 
throughout the state focused on women veterans and outreach and 
access to VA care and benefits in partnership with 
representatives from our VA facilities in the state and 
surrounding areas.
    There are a lot of best practices out there that we are 
really anxious to share and continue to increase access for 
benefits and care for women veterans across the country.
    Ms. Budzinski. That is really great. I would love to find 
an opportunity to build something out like that within my own 
district to help specifically women veterans and maybe we could 
lean on you and follow up with your office specifically about 
how we can get tapped into kind of those best practices that 
you mentioned. I would really appreciate that.
    My next question is for Ms. Hundrup. I know the GAO has 
looked into VA health care for rural vets. Do you have any 
input based on what you have found on how health care for women 
veterans in rural areas can be improved as well?
    Ms. Hundrup. I would just underscore what has already been 
stated. I mean, I think just the first is the recognition and 
the acknowledgement and having the awareness and really looking 
at the data first and foremost. We have got to understand and 
analyze it by rurality, by gender to know, and then recognize 
the unique needs.
    For instance, we have talked a lot about hospital closures. 
I think the VA pays for maternity care. It does not offer those 
services and we are seeing obstetric units closing as with 
other hospital closures around the country. Just having that 
awareness and then being proactive and taking action in terms 
of outreach and getting those services.
    Ms. Budzinski. Okay. That is great.
    Can I just go back to Mr. Elnahal, maybe just giving an 
opportunity to further elaborate on some of this work? If at 
all, are women veterans represented as an area of focus within 
the Office of Rural Health Strategic Plan or its research 
agenda in particular? I have heard from women veterans and 
their organizations specifically the research side is sometimes 
kind of lacking as it relates to specific outcomes related to 
women veterans. I am just curious if you could speak to that, 
too.
    Mr. Elnahal. I would say, Congresswoman, that our Office of 
Women's Health, which by the way reports directly to the Under 
Secretary for Health, is taking the lead on research for 
women's health services. In fact, we have an incredible leader 
over that area. She has done incredible work over the last many 
years, Dr. Becky Yano, who really commissions health service 
researchers across the country, helps fund those studies, and 
supports them.
    I had a chance to address our women's health researchers 
just a few months ago and they continue to develop insights on 
where we are seeing inequity, where we need to place more 
services. What I am trying to do is make sure that our 
operation responds to those findings swiftly and that informs 
our infrastructure planning, our hiring planning. Women 
veterans, especially in rural areas deserve that.
    Ms. Budzinski. Okay. Yes, I would love to follow up with 
your office and those offices and folks just to hear more about 
how I can integrate some of those ideas into the work we are 
doing.
    Thank you very much. I yield back.
    The Chairman. Representative Ciscomani.
    Mr. Ciscomani. Thank you, Mr. Chairman. Thank you to all 
our witnesses also for coming before the committee to lend 
their perspective on the issues facing rural veterans.
    With over 70,000 veterans in my district, in District 6 of 
Arizona which encompasses large sections of rural areas, I am 
constantly looking for ways to identify gaps of discrepancies 
in access to housing, medical examinations, and care. I have 
worked hard to address barriers to access to care for our 
veterans, specifically disability exams for our rural veterans. 
Through two different pieces of legislation I have aimed to 
increase the number of exams conducted and ease in which our 
veterans can access exam providers. My bills tackle these 
challenges by not only expanding the pool of providers who can 
conduct exams but also expanding the ability for providers who 
provide care across state lines.
    Further, I worked with Chairman Tom Cole to introduce H.R. 
4155, the Tribal Department of Housing and Urban Development-
Veterans Affairs Supportive Housing (HUD-VASH) Act of 2023, 
which would make permanent the HUD-VASH program, a critical 
effort that ensures our tribal veterans have access to quality 
housing as well. Veterans of all walks of life deserve a safe 
place to call home.
    Now, ensuring those who sacrifice have the opportunity to 
receive the care and respect they were promised is one of my 
top priorities here in Congress. The Federal Government has a 
solemn duty to ensure our duties have the care and respect they 
were promised. This is a responsibility I do not take lightly.
    Now, as my first question here to Dr. Elnahal, to your 
knowledge are there any steps being taken to specifically reach 
and inform female veterans in rural communities about relevant 
VA healthcare services, especially in regard to maternal 
health?
    Mr. Elnahal. Yes, Congressman. We take very seriously the 
need to focus very closely on the care coordination for women 
veterans. Every medical center in the country to include our 
rural facilities has a women's health coordinator to be able to 
guide the care and make sure that we are not seeing lapses in 
care or unanswered phone calls or missed appointments. These 
coordinators have a very busy plate. They are some of the best 
professionals we have. That is just part of our standard work 
every day.
    For example, if a woman needs maternity care if she becomes 
pregnant we have a very intensive care coordination program 
that helps guide that care in the community because we do not 
provide direct obstetrical services in our direct care system.
    Those are just a couple of examples. Mr. Boerstler also 
mentioned our Community Veteran Engagement Boards. I am not 
sure if you have further comments on outreach.
    Mr. Boerstler. Especially in the Veteran Experience Action 
Centers we have hosted successful engagement in American Samoa, 
other Pacific Islands, Michigan, Indiana, Montana, other highly 
rural states, and we would love to do the same in Arizona in 
the coming months and years, Congressman. These Veteran 
Experience Action Centers are essentially 3-day enrollment 
sprints where veterans will have access to the Veterans 
Benefits Administration, Health Administration, Cemetery 
Administration, and the Board of Veterans Appeals to solve 
their issues. In many cases they are talking to multiple 
administrations about multiple issues they have. The experience 
scores that we are seeing from these events are in the 90th 
percentile. We do a specific outreach to women veterans and 
minority veterans and Native American veterans so that we can 
increase the enrollment in those events from those populations.
    Mr. Ciscomani. Well, I definitely want to know more about 
that. That actually leads into my next question. That is 
directed to you, Doctor, but either one of you could answer.
    How does the office of Rural Health measure, you guys 
measure the impact and the effectiveness of the mobile medical 
units, as well as mobile vet centers in improving healthcare 
access and outcomes for rural veterans? Also, if you could 
mention what steps are taken to adapt these services based on 
the feedback and needs of our rural veteran communities?
    Mr. Elnahal. Our mobile medical units, Congressman, just 
have an incredible infrastructure that can travel around very 
flexibly. They have areas for being able to draw labs within 
the vehicle. They often have the ability to beam in, to have 
any provider through telehealth who might be a specialist to 
come in and serve veterans, and so just really important 
assets.
    We have seen from the GAO, but also other oversight bodies 
the need for us to better track where these mobile medical 
units are going, how they are being used, and what the outcomes 
are. Candidly, that is something we need to work on and better 
develop in order to meet those recommendations. We have 
concurred with all of them. We just want to make sure that we 
are making maximum use of these assets to reach as many, 
especially rural veterans as possible who could most benefit.
    Mr. Ciscomani. Well, it is definitely the goal. Also back 
to your point also, Mr. Boerstler, regarding expanding this to 
Arizona and those services, I think that is critical. I look 
forward to working with you on all this.
    Thank you so much. Chairman, I yield back.
    The Chairman. Dr. Murphy.
    Mr. Murphy. Thank you, Mr. Chairman. Thank you all for 
coming. I appreciate what you all are doing on the work on 
behalf of veterans.
    I am very blessed to be in a district in eastern North 
Carolina where about 10 percent of my constituents are 
veterans. Camp LeJeune is there, Cherry Point, New River Air 
Station. Multiple other military communities that are there. It 
is a huge, huge aspect for us.
    On the other hand, we are also an extremely rural area. 
When practicing full time, I still practice some, we had a 29 
catchment rural area, one major hospital. It is a huge burden, 
difficult.
    One of my colleagues mentioned earlier that he thought, he 
read one study where veterans got worse care at a private 
institution. I want to read that study and pick it apart 
because as you guys well know, most of our literature is 
nonsense. I would love to see what that means because that is 
just the opposite of the experience I have had.
    One thing before I want to get into some of my questions. 
Dr. Elnahal, can you tell me what these executive bonus things 
we started out the committee meeting was about? I am going to 
just preface it by saying I am appalled by the hospital 
administrator bonuses that go on across this Nation when the 
people who are actually taking care of the patients, doctors 
and nurses do not get them and all these other things. The 
administrators getting the money frankly pisses me off. If you 
will go ahead with that.
    Mr. Elnahal. Well in short, Congressman, we discovered that 
bonuses occurred that were outside what we thought was 
legislative intent and outside of our policy. Upon discovery of 
that we made the decision to retract those bonuses for 
headquarters executives.
    Mr. Murphy. I get the whole thing about competition in this 
country but it is also, it is something that is played 
explicitly, well, we are going to lose somebody who is 
competitive. That is nonsense. Anyway, let me get back to 
actually the meat of what I would like to ask.
    I think it is becoming more and more and more apparent to 
the country that we are experiencing an overall shortage of 
physicians and it is going to be apocalyptical in the next 3 to 
5 years with a shortage of surgeons, especially those who, we 
are getting Medicare cuts day in and day out.
    I know that the VA has sometimes a hard job in competing 
with hospitals who get extra money now because of some of the 
subsidies they get and everything. I understand the pressures 
that you guys have in recruiting. I really do, because it is a 
real world situation and some of the previous administrations, 
some of the laws put into place make it so much more difficult. 
If you look at tertiary consequences down the road and what has 
happened to our physician community, it has turned into, and I 
will just say it this way, just with so much employment of 
physicians it has turned into so much of a transitory physician 
market rather than ones who come down and put their roots in 
communities. That is even worse I think affected with the VA.
    I would really love to know, you know, the VA cannot do it 
all. As you and I talked on the phone the other night, the fact 
that you thought that the VA efficiency was 60 percent compared 
to medical centers which compare to private practice is 
normally about 60 percent. We are really looking at a depletion 
in efficiency how you are, one, going to fix that, and two, how 
are you going to use the private community and the private 
world to assist our veterans? I do not believe that nonsense 
about getting worse care at a private institution than at the 
VA. I really want to know your strategy for fixing it.
    Mr. Elnahal. Well, Congressman, I appreciate you asking 
that because we are here to provide the best quality but also 
the most timely access possible to veterans. Access really just 
means how many veterans we are able to bring through the door 
in a timely way through our clinics across the country. That is 
why the first thing I announced as a major priority was to hire 
enough clinicians to be able to do the job. The more clinicians 
we have on board, the more timely we will be able to see 
veterans.
    The second thing we did was double down on a strategy that 
we call bookability, which is to really make sure that every 
provider uses the time that they are booked as clinical, to 
fill that time by at least 80 percent with veterans scheduled 
into their clinic. The rest of the time should be for walk-ins, 
for same day care when needed on an urgent basis, and to take 
care of some of the important documentation work and other 
tasks that physicians have to do. That 80 percent standard now 
we are enforcing across the country. We did see an improvement 
in clinician productivity overall in Fiscal Year 2023. We are 
going to continue to double down on that and make sure that we 
make most use of the direct care system as possible.
    Your second question on community care, when we are not 
able to meet timeliness standards or when we have 
infrastructure that is too far for veterans, we do offer 
community care as required by us under the Mission Act. That 
will continue to be a critical piece of what we do. In fact, we 
are now as of last Fiscal Year nearly a $30,000,000,000 payer 
for care. Especially in rural communities we will need to be 
relying on community care for at least a portion of a lot of 
veterans' care.
    Mr. Murphy. I appreciate that. I would ask that you look at 
actually Community Care actually paying people because I took 
care of veterans for so long and we never got paid in Community 
Care. It is a difficult job with turnover and I am not asking 
you guys to be slave drivers because there is competition that 
goes out there. Asking somebody to do 80 percent of 100 percent 
of a job with allowing for work-ins is not asking too much.
    One quick question and I will just maybe follow up with 
somebody else because I know my time is overdone, is the VA 
part of the Civil Service Retirement System (CSRS) system, the 
drug reporting system?
    Mr. Elnahal. I am not aware of that, Congressman.
    Mr. Murphy. The reason why I ask this is because different 
states, North Carolina, we have a system which some idiot in 
the State House wrote, that was me, that just looking at drug 
usage and everything before you prescribe an opioid or 
anxiolytic you have to query. The thing is it has to be 
nationwide because some people can jump right across borders. 
If you are not interfacing with the private community system 
also there are people that are going to be gaming that system.
    Mr. Elnahal. Now I am tracking, Congressman. We do have 
what we call the Prescription Drug Monitoring Program and we 
participate, the last I checked with at least 49 states' 
programs to be able to query that.
    Mr. Murphy. Okay. Thank you, Mr. Chairman. I yield back.
    The Chairman. Mr. Crane, you are recognized for 5 minutes.
    Mr. Crane. Thank you, Mr. Chairman.
    Mr. Jacobs, your testimony stated that VA held 436 claims 
clinics across the country. What is VA's plan for ensuring that 
rural veterans, rural community, and Native American tribes are 
aware of the options to request a claims clinic?
    Mr. Jacobs. Yes, Congressman, thanks very much for that 
question.
    What we have identified at a national level is that we are 
serving rural veterans at a slightly higher percentage than 
urban veterans in terms of benefits utilization but that highly 
rural veterans are being served at a slightly lower percentage. 
Now, that varies in community by community. As an example, I 
was talking with our regional office director in Oakland 
earlier this week, and he shared with me that the rural 
communities that he serves are having a lower benefits 
utilization rate--or actually, they have a higher benefits 
utilization rate than their urban counterparts. If you go to 
other parts of the country the inverse is true. The way that we 
are getting at that is we are utilizing a population mapping 
tool so we can look state by state and county by county to 
determine where we have penetrated the communities where we are 
appropriately serving veterans and we can target those areas 
that are underserved. We are using that tool to drive the 
decisions about where we go to conduct claims clinics and we 
are doing that in partnership with the State Department of 
Veterans Affairs, with county veteran service organizations and 
officers, with our VSO partners, and increasingly with the 
tribes.
    Mr. Crane. On that, Mr. Jacobs, why do you think that is? 
Why do you think in rural communities our veterans are 
accessing these facilities more?
    Mr. Jacobs. I think they are accessing benefits in some 
cases because they have got incredible local resources. We have 
incredible partners in the county VSOs who do wonderful work in 
educating veterans about their earned benefits and helping 
connect them to those earned benefits through the filing of 
their disability claims. I think in some cases it is network 
and word of mouth, and so understanding where there are 
opportunities and community members and friends helping one 
another. I also realize that is not true in every part of this 
country.
    Mr. Crane. Thank you. I have got to follow up on that real 
quick, sir. Which program office should Native American tribes 
contact or request a claims clinic? Can you assure me that 
their request will be fully considered?
    Mr. Jacobs. They can contact my office and certainly I 
would be happy to work with you.
    One of the things that we have done is we are now for the 
first time ever accrediting tribal veteran representatives.
    Mr. Crane. How do they contact your office, Mr. Jacobs?
    Mr. Jacobs. My email is Joshua.jacobs@va.gov. Send me an 
email. We also have a veteran service organization liaison that 
will help, and every single regional office director would be 
happy to help as well. Through partnership with the local 
regional offices, through the contact at the national level, 
through our VSO liaison, we can help identify where there are 
opportunities to pursue in collaboration with local tribes 
additional claims clinics.
    Mr. Crane. How does the VA prioritize these claims clinics 
from rural and some of the tribal nations?
    Mr. Jacobs. We are looking at the more broadly. As an 
example, the three of us were in Nashville late last week for 
the Student Veterans of America conference. While we were there 
we had staff who were there to help veterans file and process 
claims. We had folks from our Medical Disability Examination 
Office, from our Education Service Office, and we had mobile 
medical units from our four vendors who conduct the C&P exams 
on the ground to help with veterans. We were able to help 
hundreds of veterans on the ground. We identify events like 
that, large VSO conferences, but we are also identifying using 
that tool that I mentioned where there is great unmet need. We 
do it both from a data driven perspective, but also based on 
the input that we are getting from our partners where they are 
hearing anecdotally where there may be unmet need.
    Mr. Crane. Is it geographical distance to a facility? Is 
that how you guys prioritize? Let us say you have got 10 
requests but you only have five resources, who gets priority? 
That is what I am asking.
    Mr. Jacobs. It really is case by case. I cannot provide a 
uniform answer but what we are doing is looking where can we 
get the most bang for the buck. In some cases we have very low 
percentage utilization in a small population. We are still 
going to have to make that decision. I think there is value in 
going there even if we are not able to serve as many veterans 
because we have identified an area where there is not enough 
benefits being utilized. In other cases, we are going to make a 
different decision and it really just depends on the 
circumstances.
    Mr. Crane. Thank you, Mr. Jacobs.
    Mr. Jacobs. Yes, sir.
    Mr. Crane. I yield back.
    The Chairman. Representative Self.
    Mr. Self. Thank you, Mr. Chairman.
    This is for pretty much the entire panel. I continue to be 
frustrated with the VA solution to everything is more inputs. 
We never see health outcomes. You all believe that you solve a 
problem by throwing more money at it, a new organization, a new 
position. I never hear that we have had a decrease in diabetes. 
We have had a decrease in heart conditions. We have had 
certainly suicides. I just ask you, Ms. Hundrup, I would ask 
you to start measuring that because in your testimony the 
300,000,000 that was totally uncontrolled or accounted for 
formally, I would ask you to start measuring health outcomes 
because all of this process, all of this infrastructure that we 
are discussing today, what is the benefit? Not that they use a 
benefit the way you term it but what is the health outcome 
benefit to our veterans? I do not see it in any of these 
testimonies written. I continue to be frustrated with how much 
better off are our veterans because of VA, as opposed to just 
throwing another process, another organization and some more 
money at it.
    While I am on money, I have already told the VSOs that we 
need to get a better handle on offsets. The only offset that 
this committee has is charging veterans additional home 
financing fees for a new program. We are charging veterans for 
every new program that we put into the VA. That is not an 
offset to me. An offset to me is when we say this is a very 
noble program. We must have this program. It is vital that we 
have this program. What less noble program are we going to find 
an offset in? Every program is noble but a less noble program, 
what are we going to find an offset in? That is the rules of 
the road here. We find an offset. I do not think the housing 
finance fee that we charge veterans is an offset because it 
adds to it. I have got the Congressional Budget Office (CBO) is 
a problem. I understand the scoring issue. Those are two issues 
that I wanted to highlight.
    I am not sure which of you is going to answer this but what 
percentage of claims is actually filed by an outside 
organization? My rural VSOs tell me that they believe that it 
is like 90 percent of all claims are not started within VA. 
They are started by some VSO. Is that true or not?
    Mr. Jacobs. Yes. I do not have the exact numbers. I will 
follow up and get them so I am not misstating. We rely very 
heavily on accredited representatives like VSOs and county VSOs 
to help veterans. They do that for free. We are increasingly 
concerned about other actors coming in and trying to charge 
veterans for something that they have earned through their 
military service, but we do rely on outside entities to help 
veterans pull together, explain information. We are available 
at all of our 56 regional offices. We have got a national 
contact center. We have got a website, other public outreach 
events where we go and try to explain it but we rely on and we 
value very much----
    Mr. Self. Okay. I would like that figure if you can get it 
to me.
    My rural VSOs also say that when they go onto your 
website--this may have been covered by one of my colleagues in 
a different format--they bring up their current claim. One of 
them showed me his current claim that shows the documents that 
supposedly have been put in to justify that claim. They are not 
live linked anymore. They are dead documents. When you copy the 
PDF and you put it in it goes nowhere. That is concerning to my 
rural veterans because they cannot get a true picture of the 
status of their claim. I would just ask you to look at that and 
I would like a response on that as well.
    Mr. Jacobs. Yes, Congressman, I would ask if they are rural 
VSOs that you have been talking to, I would like to meet with 
them to talk about the issue and I will bring in my team and we 
will make sure we go through that directly.
    Mr. Self. Absolutely. We will set it up. Hunt County, 
Texas. Hunt County, Texas is where you are going.
    Mr. Jacobs. Love it.
    Mr. Self. I want to just ask you a general question. I have 
got 30 seconds so my question is, how do our rural veterans' 
health care compare to the rural citizens who are not veterans? 
Do we have a feeling for how they compare?
    Mr. Elnahal. Well, Congressman, you know, we could do 
analyses on healthcare outcomes per your previous comment. I 
can tell you that our medical centers do score very highly 
whether rural or not on CMS's overall hospital quality star 
rating. That is actually a pound for pound comparison between 
VA Medical Centers and private sector medical centers. More 
than two-thirds of our medical centers score at the top two 
ratings compared to only about 42 percent of the private 
sector. Many of our four and five star medical centers are in 
rural areas.
    Mr. Self. Okay. Very good.
    Thank you, Chairman.
    The Chairman. General Bergman, you are recognized.
    Mr. Bergman. Thank you, Mr. Chairman.
    Dr. Elnahal, I saw that you called a few days ago. I am 
sorry I was not able to take your call. I was driving so I was 
not doing anything illegal or would get me a ticket.
    Mr. Elnahal. No problem, Congressman.
    Mr. Bergman. The point is I understand you were talking 
about one of my constituents when Secretary McDonough and I 
were up in Baraga.
    Mr. Elnahal. Thank you for correcting me.
    Mr. Bergman. Just think of, we have a lot of black bear in 
the area. It is a wonderful part of our environment. Just think 
of coming into that little town and seeing a bear looking you 
in the eye. It is Baraga.
    Mr. Elnahal. I will not get that wrong again.
    Mr. Bergman. I had the same conversation with Secretary 
McDonough when he had the same challenge and we laughed about 
it. They are good folks up there.
    Let me ask you a quick question here. You know, in your 
testimony you describe how it is consistently more difficult to 
recruit physicians in rural areas, probably other healthcare 
providers as well. It is my understanding that the VA allows 
for independent certified registered nurse anesthetists--that 
is a tough one for me. Maybe Baraga for you but anesthetist for 
me--practice in about 40 VA facilities typically in more rural 
areas. Does the VA see a difference in either outcomes or 
patient satisfaction at those facilities compared to others 
where you are, you know, not so rural or not so remote?
    Mr. Elnahal. That is exactly the question, General Bergman, 
that our team is deeply analyzing now with our own data, to 
understand whether there are differences in outcomes. I have 
not seen data that has shown worse outcomes, whether it is 
rural or urban areas. The question we are trying to answer with 
the National Standards of Practice is whether we override state 
licensing restrictions on CRNAs. As you mentioned, we do 
authorize CRNAs independent practice in states that allow that 
under their licensing system.
    Mr. Bergman. Okay. To discuss one specific program, last 
month GAO found that VA was not reliably collecting or 
reporting performance data on its MMUs, Mobile Medical Units, 
which provide a wide variety of care to veterans that literally 
cannot--they do not have internet. They cannot get out of their 
house to get to a provider. How does the Office of Rural Health 
measure the impact and effectiveness of mobile medical units 
for rural veterans? What steps are being taken to adapt these 
services based on the feedback, so the loop? Service provided, 
feedback loop, modifications. Any comments on that?
    Mr. Elnahal. Well, the first thing I will say, General, is 
that we concurred strongly I would say with GAO's insights on 
our need to better track what mobile medical units are doing. 
The outcome that we track should be quite simple. It should be 
access to care. It should be wait times for care. If we are not 
making access more convenient for veterans with mobile medical 
units, then we are not sending them to the right places.
    We have what we call our North Star metrics for access, 
which is simply the wait time for direct care, the time it 
takes to schedule community care, and what veterans are telling 
us through surveys on access. Mobile medical units have to be 
improving all three of those for us to know that it is working.
    Mr. Bergman. The reason I ask is not necessarily to be 
answered now but again, in our neck of the woods, literally, 
not all of our folks who live there are going to be veterans 
and be eligible for the mobile units. If there is something 
going on outside of veterans health care with other entities, I 
would very much like to hear where there is a sharing of 
information because care is care in the rural and remote areas.
    I have 45 seconds left. Ms. Hundrup, you have been sitting 
there very quiet for a very, very, very long time. Any thoughts 
that you would like to share with the committee here on GAO's 
perspective?
    Ms. Hundrup. Thank you.
    I will try to make this quick. I could say a lot but let me 
be brief with regard to mobile medical units. I think we found 
in our work that they absolutely do have the potential to fill 
a lot of gaps but the information that is out there now, it 
suggests they are underperforming. I think just to underscore 
Dr. Elnahal, we really need better information so that we have 
a complete picture which will give us a better sense of where 
they can be more strategically used and fill a critical gap in 
care. I think just to very briefly say, I think really focusing 
on the information by rurality to understand what is happening 
and then take action to develop guidance to really just look 
at, we have talked a lot about women-specific issues, the needs 
of rural areas, tailoring that to the guidance to get that out 
to the field so that they can then take action.
    I could go on but I am going to stop there. Thank you.
    Mr. Bergman. No, thank you.
    Thank you, Mr. Chairman, for giving me an extra 30 seconds.
    The Chairman. All right. Before I dismiss the panel I have 
two really quick questions for Dr. Elnahal.
    Doctor, it is the committee's priority to ensure that VA 
provides the care our veterans deserve. Do you think the work 
environment at Loma Linda Veterans Affairs Medical Center 
(VAMC) is conducive to our veterans receiving the care that 
they deserve?
    Mr. Elnahal. Well, I heard concerns, Chairman, about the 
work environment at Loma Linda, which is why I visited myself. 
It was eye opening to hear directly from employees, labor 
leaders and, you know, the difficult experience that many of 
the employees had there and the behavior that we have seen from 
certain leaders in the past was not excusable. I will say that 
I think things, the culture there is beginning to improve. I 
intend to get an update soon from the director at Loma Linda 
but what I want to make sure that the whistleblowers know at 
Loma Linda and at every corner of our system is that we are 
here to listen to you and we take those concerns very 
seriously. I going to be personally tracking progress at Loma 
Linda. I was there with Representative Takano as well.
    The Chairman. Thank you.
    Also, in November 2023, the Secretary committed to 
providing the committee with a list of possible health 
conditions that could quality for VA's health exceptions for 
abortions. It has been 69 days since this commitment was given 
to me to get this communication. Will you give me the 
commitment? Will you provide that information as promised by 
January 19?
    Mr. Elnahal. Mr. Chairman, my commitment is to make sure 
you get that as soon as we possibly can. We took the questions 
very seriously in your latest letter and we want to make sure 
we provide the most precise and accurate response as possible 
for the record.
    The Chairman. All right. Well, thank you for being here, 
Doctor, and also Mr. Jacobs, Mr. Boerstler, and Ms. Handrup for 
testifying today. You are now excused. Thank you for being 
here.
    We want to try to get the second panel up and seated as 
quickly as possible. The second panel is seated. Welcome.
    I would like to welcome Ms. Marisa Schultz and Dr. Buu 
Nygren and Mr. John Lovald. Finally, Mark Holmes. Thank you for 
being here. We had another witnessed scheduled, Mr. Mikelson, 
John Mikelson, but in a vivid reminder of the challenges rural 
veterans face, his appearance here was stopped by a snowstorm.
    I would like to recognize myself if I may to introduce our 
first witness who I am proud to say is from my home district, 
Illinois 12. Ms. Marisa Schultz is a veteran who understands 
the issues on how to navigate the VA and is a tireless advocate 
for veterans. Marisa served in the Illinois National Guard and 
deployed to Iraq in 2005. When she got home she enrolled in 
classes at Eastern Illinois University and eventually took a 
job with the Salvation Army Supportive Services Veterans 
Families program where she is a healthcare navigator. It is my 
pleasure to have Marisa here today to bring her vitally 
important perspective to the table.
    Ms. Schultz, you are recognized for 5 minutes for your 
opening statement.

                  STATEMENT OF MARISA SCHULTZ

    Ms. Schultz. Thank you, Chairman Bost, Ranking Member 
Takano, and members of the House Committee on Veterans' Affairs 
for this opportunity.
    My name is Marisa Schultz. I am a disabled combat veteran 
and a healthcare advocate. I commend your dedication to our 
veterans and I am honored to represent the rural veteran 
community.
    I served in the Illinois National Guard, being deployed in 
2004 through 2005. I have personal and professional experience 
utilizing health care in rural areas through the VA. 
Professionally, I serve veterans in rural communities 
identifying their needs and helping them access healthcare 
systems, community care, and other outside providers.
    As we convene today, I implore you to consider a group of 
heroes who often face an unnoticed battle, the veterans 
residing in rural America. As stewards of their well-being, it 
is imperative that we acknowledge the stark disparities between 
urban and rural healthcare access for our veterans. We owe it 
to them to level the playing field.
    Imagine being a veteran eagerly awaiting a VA arranged ride 
to a medical appointment, excited to get help dealing with 
chronic pain from a helicopter crash during employment. For one 
such veteran I served, lengthy wait times and repeated failures 
in VA transportation options led to desperation ending in a 
call to 988. This veteran suffered from emotional and physical 
distress and feeling like the system had failed him.
    This is not an isolated scenario. It is the reality for 
many of our rural veterans. Transportation, or rather lack 
thereof, emerges as a top barrier for our healthcare access. 
Financial constraints and employment vulnerabilities further 
compound this dilemma, forcing veterans to make agonizing 
choices between their health and their livelihoods.
    Moving on, to provide model health care to our veterans, we 
must acknowledge and address another critical issue, a need for 
gender-specific health care within the VA. Rural female 
veterans who served our country with equal valor encounter 
unique challenges in accessing specialized health care tailored 
to their needs. In my case, securing a female provider for a 
compensation and benefits examination necessitated a 2-hour 
commute. This challenge of meeting this basic, yet serious 
request reflects limited availability of practitioners in rural 
locations.
    A third critical issue is the advancement of telehealth 
which has a potential to break geographical barriers and 
provide unparalleled health care for our veterans. Telehealth 
offers a lifeline to veterans residing in remote areas often 
struggling with limited access to traditional healthcare 
facilities. It presents the opportunity to help ensure timely 
care reaches these underserved communities.
    While the flexibility of telehealth has significantly 
expanded accessibility, it has also brought some notable 
challenges. Elderly and aging populations encounter challenges 
with digital literacy hindering the seamless use of telehealth 
system. Limited phone minutes and need for internet access also 
present hurdles. Overall, significant progress has occurred in 
the past few years and we hope to see further improvements to 
telehealth options.
    We have explored some challenges our rural veterans face in 
accessing health care such as transportation options, access to 
gender-specific providers, and digital literacy for telehealth. 
One way to help rural veterans access care and meet them where 
they are can be done through the strategic deployment of mobile 
medical units which can be designed to provide primary care and 
other essential services. These could be deployed to areas 
lacking traditional healthcare access, effectively addressing 
the insufficient healthcare access for rural veterans. 
Additionally, emphasizing the pivotal role of technology, 
specifically telehealth, by expanding or creating digital 
education can help bridge this gap.
    To conclude, I urge this committee to consider critical 
issues faced by rural veterans, specifically transportation 
options, access to gender-specific providers, and digital 
literacy for telehealth. Let us work together to ensure that 
health care for our veterans it not determined by their 
geographical location.
    Thank you for your attention, and I look forward to 
positive outcomes that benefit our rural veterans.

    [The Prepared Statement Of Marisa Schultz Appears In The 
Appendix]

    The Chairman. Thank you very much for your testimony.
    For our next witness I yield to Mr. Crane to introduce the 
witness.
    Mr. Crane. Thank you, Mr. Chairman, for holding today's 
hearing on an important topic and for your concern for rural 
and tribal veterans. I am glad your staff was able to 
experience firsthand the incredible Navajo veteran community in 
Tuba City this past August.
    I want to take a minute to welcome President Buu Nygren to 
the committee today. I visited President Nygren in Window Rock 
following his inauguration last year shortly after I kicked off 
my time here in Congress and appreciated learning more from him 
about the unique challenges Navajo veterans face in obtaining 
health care and other critical services.
    We met with former Navajo Nation chairman and code talker 
Peter MacDonald and I was grateful to hear his experience. I 
also joined President Nygren in welcoming VA Secretary 
McDonough to Tuba City last July. We appreciate the Secretary 
coming out to my district and meeting with our veterans.
    For those of you who do not know, I am proud to represent 
over half the tribes in Arizona including the Navajo Nation. My 
district spans 20,200 square miles of Arizona land. That is 
larger than nine U.S. states, and the rural and tribal areas I 
represent do not have reliable access to VA services.
    Native Americans historically have the highest record of 
military service per capital and Navajo veterans specifically 
have a rich history of service to our Nation. Navajo patriots 
serving as code talkers during World War II used traditional 
tribal languages to send secret messages in battle, a 
contribution that along with their warrior mentality was 
essential to our victory.
    Unfortunately, despite their remarkable impact on our 
military history and culture, Navajo veterans face many 
barriers to VA service and care. The VA hospitals in Phoenix 
and Albuquerque are the only full-service medical centers 
within driving distance to the Navajo Nation and veterans still 
face a 3-to 5-hour drive to get to those locations.
    I, myself, have made the drive from Tuba City to Phoenix, 
almost 4 hours of driving and that is just not feasible for a 
veteran needing frequent and reliable access to medical care.
    While several VA outpatient clinics have been established 
within Navajo Nation lands, these clinics often focus on 
primary care or less severe mental health issues. This means 
that many do not have the resources to address severe PTSD and 
they may also lack the ability to provide specialty care for 
chronic pain or diabetes. Two of the most common diagnoses 
among Navajo veterans. If they cannot reach a VA facility that 
is capable of providing the type of care they need, Navajo 
veterans suffer. This is unacceptable, and I hope that in this 
hearing today we can discuss ways to address this to ensure our 
tribal veterans can receive the care they need and deserve.
    I am looking forward to hearing President Nygren's 
perspective as he represents the voice of our Navajo veterans 
who have played an integral role in our military victories and 
continue to serve honorably today.
    Thank you, Mr. Chairman. I yield back.
    The Chairman. Thank you, Mr. Crane.
    Dr. Nygren, you are recognized for 5 minutes.

                    STATEMENT OF BUU NYGREN

    Mr. Nygren. Yaateeh, Chairman Bost, Ranking Member Takano, 
and members of the committee, and our representative Eli Crane, 
thank you so much.
    My name is Dr. Buu Nygren. I serve as the president of the 
Navajo Nation. I come before you today to discuss critical and 
ongoing issues of access to care and benefits for our veterans 
all across the Navajo Nation, who have a proud history of 
military service. As many of you know, Native Americans have a 
profound and honored legacy with the United States military. 
Our warriors have served with distinction in every major 
conflict since World War I. During World War II, the Navajo 
Code Talkers created an unbreakable code from our Dine language 
that was instrumental in securing the victory for the Allies in 
the Pacific theater. Their valor and courage exemplify a 
patriotism and sacrifices that is a hallmark of our Navajo 
people.
    Despite this rich history, Navajo veterans face significant 
barriers in accessing the care and benefits they have earned. 
The closest VA Medical Center as mentioned earlier is in 
Phoenix, Arizona; Albuquerque, New Mexico; and Salt Lake City, 
Utah. The distances present a formidable obstacle often 
requiring veterans to travel many, many hours at great personal 
expense across remote areas just to receive basic services. 
This burden is compounded by social determinants of health that 
disproportionately affects our community such as high rates of 
poverty, unemployment, and limited access to transportation. 
Telehealth services, which is beneficial, are not a cure all 
for our veterans. The digital divide is a stark reality on the 
Navajo Nation where many of our veterans lack adequate internet 
access or the technology needed to utilize telehealth 
effectively. The limitation is not just a matter of convenience 
but a barrier to essential health care, mental health services, 
and benefit assistance.
    The VA's Beneficiary Travel program is critical, yet it 
does not fully offset the high costs of the logistical 
challenges associated with traveling many, many hours to the VA 
facilities. Furthermore, grant and per diem rates for 
homelessness of veterans do not reflect the higher cost of 
living in remote areas which further disadvantage our veterans 
in need.
    Access to healthcare providers is another significant 
challenge. There is a scarcity of medical professionals in our 
region and their shortage means that even basic care can be 
very hard to come by. Compensation and pension exams which are 
crucial for veterans seeking disabilities and benefits are 
often delayed or inaccessible due to this lack.
    The issues I have outlined today represent a larger 
problem. The lack of adequate VA care on the Navajo Nation is 
not reflective of the continuous contributions the Navajo 
people have provided this country. Our veterans have earned the 
right to accessible, quality care, and benefits through their 
service and sacrifice. It is for these reasons I ask Congress 
to work with my administration to bring a full-service VA 
Medical Center into the Navajo Nation. This center would 
provide quality care not only for our Navajo veterans but most 
of the rural southwestern part of the United States.
    I am also asking Congress to appropriate funds to build a 
VA benefit center on the in New Mexico side of the Nation to 
help educate our veterans on the benefits that they have earned 
together through their service.
    In closing, I urge the committee and Congress to take a 
decisive action to address these critical issues facing our 
Navajo veterans. We need increased funding aimed specifically 
at improving infrastructure and services in rural areas 
tailored to the unique challenges of our Nation and the region. 
We must bridge the digital divide to ensure telehealth is a 
viable option for our veterans. It is essential to address 
grant and per diem rates that reflect the true cost of living 
in remote areas and to expand the beneficial travel program to 
alleviate the significant financial burdens our veterans 
undertake. Our Navajo veterans have honored their commitments 
to our Nation. We must continue to honor them by bringing 
services closer to them.
    Thank you for your time and consideration. Thank you.

    [The Prepared Statement Of Buu Nygren Appears In The 
Appendix]

    The Chairman. Thank you, Doctor.
    Next we have Mr. Jon Lovald, Chief Operations Officer for 
the Minnesota Assistant Council for Veterans.
    Mr. Lovald, you are recognized for 5 minutes.

                    STATEMENT OF JON LOVALD

    Mr. Lovald. Thank you, Chairman Bost, Ranking Member 
Takano, committee members.
    My name is Jon Lovald and I am the Chief Operating Officer 
for the Minnesota Assistance Council for Veterans. I grew up in 
rural Minnesota, and before joining MACV I served for 25 years 
in the Army retiring as a lieutenant colonel.
    MACV is a 501(c)(3) statewide nonprofit with the mission to 
end veteran homelessness in Minnesota. MACV served more than 
2,000 veterans and their families last year with roughly half 
of those veterans residing in rural and other nonurban areas 
across Minnesota.
    I thank you for this opportunity to share the observations 
and experiences our organization has gleaned from decades spent 
serving thousands of veterans in greater Minnesota.
    The challenges and opportunities facing rural veterans can 
vary considerably depending on where they reside. Combined with 
their individual backgrounds and needs, the most effective way 
to serve these veterans might look different than what is 
available to the urban veteran.
    Some of rural veterans' most consistent barriers include 
lack of affordable housing, few jobs which pay a living wage, 
transportation limitations, scarcity of support of services, 
and many rural communities simply have no emergency shelter. 
MACV's team regularly encounters these challenges while serving 
rural veterans as finding housing, employment, transportation, 
and short-term shelter are all interconnected and determine 
their stability.
    For example, we have Ryan, a 66-year-old Coast Guard 
veteran from Winona, Minnesota, with an honorable discharge. 
Served 4 years on the Coast Guard cutter Steadfast. Last year's 
housing stability was challenged after he lost his wife and he 
was struggling to care for himself while he was grieving. He 
was hospitalized with a life-threatening infection that needed 
a partial amputation of his foot. During those months he was in 
the hospital he fell several months behind on rent, and 
additionally during that time a family member who was staying 
in his house was arrested triggering the landlord to evict Ryan 
leaving him homeless upon his discharge from the hospital.
    Luckily, the small town of Winona has a shelter and staff 
there realized Ryan was a veteran and they connected him with 
MACV services. Due to his medical situation, it was untenable 
for him to stay in the shelter, but MACV was able to place him 
into a hotel room using a state-funded emergency shelter 
program.
    MACV was able to then help him search for his sustainable 
housing solution to fit his needs. Through our landlord 
partnerships, we were able to find Ryan accessible housing 
designed for veterans. Thankfully, this location has an 
accessible transportation program as well since he does not 
drive. This all sounds like a great assist.
    However, all these resources required him to move miles 
away from his hometown of Winona to Rochester. While he is 
currently housed, he would prefer to live where he still has 
family and a support system but there are no options for a 
veteran with his limitations in a smaller town.
    Jerome, a 27-year-old Army veteran living in Olivia, 
Minnesota, was staying with family after his discharge from the 
military. He had a fallout with family forcing him to leave. 
Due to the fact that there is not emergency shelter in his 
community, he started living out of his car in a campground. He 
could afford to pay for the camp fees because he was employed 
and he stayed there to be able to take showers and maintain his 
outward appearance to ensure he could keep his job. However, 
with winter looming, the campground would be closed for the 
season. Thankfully, in Minnesota, every county in the state is 
required to have either a county veteran service officer (CVSO) 
or a tribal veteran service officer. His CVSO connected Jerome 
to MACV and we were able to supply him a cell phone through the 
VA's Homeless Smartphone Initiative. That helped us stay in 
contact with him even though he was homeless and miles from our 
closest office. Through that connection we were able to work 
with him to find housing near his job in Redwood Falls, then 
using Supportive Services for Veterans Families (SSVF) funds to 
help him with his deposit and first month's rent.
    I mentioned that the VA's Smartphone Initiative ended in 
2023. This was a program that greatly helped rural veterans 
with limited access to the internet. In every case where we end 
a veteran's homelessness is done through a network of 
collaborative efforts involving Federal VA, state, local, and 
nonprofit agencies working together to find the best outcome 
possible. There are many resources for veterans but most of 
them tend to be in larger towns or metropolitan areas with 
limited affordable housing options due to their desired 
locations. Rural housing, while it can be affordable, rarely 
has access to homeless resources, jobs with livable wages, and 
no access to public transportation for rural veterans to reach 
critical resources.
    I am pleased to report to you today that Minnesota has 
achieved a functional end to veteran homelessness in 8 of our 
10 continuums of care, including all of our COCs in rural 
Minnesota through our partnerships.
    Thank you for the chance today to speak on serving rural 
veterans.

    [The Prepared Statement Of Jon Lovald Appears In The 
Appendix]

    The Chairman. Thank you for your testimony.
    Next we have Dr. Mark Holmes. He is a director of the Cecil 
G. Sheps Center for Health Science Research and North Carolina 
Rural Health Research Center at the University of North 
Carolina at Chapel Hill.
    Dr. Holmes, you are recognized for 5 minutes.

                    STATEMENT OF MARK HOLMES

    Mr. Holmes. Thank you, Mr. Chairman.
    Good afternoon. My name is Mark Holmes. I am the director 
of the Cecil G. Sheps Center for Health Services Research and 
the North Carolina Rural Health Research Center at the 
University of North Carolina at Chapel Hill. I am an economist 
whose expertise is in rural health policy. For today's hearing, 
I will provide context on challenges facing the non-VHA rural 
healthcare system.
    Rural veterans may receive some or much of their health 
care from community providers, so it is important to recognize 
the fragility of the overall rural healthcare system as part of 
their healthcare portfolio. I am unable to cover all the 
salient topics in rural health today so I will focus my 
comments on three main points relevant to today's topic.
    The first is that rural healthcare infrastructures continue 
to erode and this threatens the health and well-being of the 
60,000,000 Americans, including the 5,000,000 veterans who live 
in rural areas.
    Two, Congress should consider some effective rural health 
workforce policies.
    Third is that many rural communities have also shown 
remarkable ability to innovate and use their strength and local 
assets to overcome challenge.
    Since 2005, nearly 200 rural communities have seen their 
hospital close or close its inpatient service. Those hospitals 
that do survive have steadily gotten smaller. Rural hospitals 
have cut services like maternity care and home health services 
and inpatient care in rural hospitals has fallen by 13 to 20 
percent in the last decade alone with most of the decreases 
driven by rural residents being increasingly likely to receive 
inpatient care at urban hospitals.
    Access to specialty care is also affected. Approximately 20 
percent of Americans live more than 60 minutes from oncology 
services and rural residents who have to drive an hour each way 
for 5 weeks in a row to get their radiation treatment are 
facing fatigue of long car travel while fighting cancer.
    Meanwhile, many specialty services including maternity, 
surgical, and other key specialties are eroding in rural areas. 
Given evidence that female veterans may be more dependent on 
non-VHA providers to receive certain gender specific services 
like obstetric and gynecologic care, the erosion of these 
services in rural communities is especially worrisome for this 
population.
    Rural places have long faced workforce shortages. Many 
proposed policy solutions to address these workforce challenges 
focus on one profession at one stage in their career and it is 
critical that we look at solutions that are not siloed in this 
fashion and support healthcare workers across their entire 
career trajectory. Decades of research have taught us that one 
of the most effective ways to boost health workforce in rural 
and underserved areas is to train them in rural and underserved 
areas. By growing the number of rural training opportunities 
and ensuring that resources are available to retain that 
workforce across their careers, we can ensure that the 
workforce needed to support rural areas is there for decades to 
come.
    Efforts to expand physician training have paid great 
dividends. For example, Rural Residency Planning and 
Development program has helped lead to more rural residency 
slots in the last 5 years than were established during the 
previous decade. By supporting residency program development, 
Congress can increase the number of slots in underserved 
communities which improves access to health care.
    As you all know, the Choice Act directed and funded the VHA 
to increase the number of residency slots by 1,500 with many 
rural VHA facilities receiving priority for additional slots.
    Additionally, the VA's GME pilot program on Graduate 
Medical Education residency will allow the VA to fund startup 
costs for new programs that train VA residents at non-VHA 
facilities. This is a new approach for the VHA and will help 
bolster their ability to train residents at facilities where 
many veterans seek care. Congress could consider whether to 
expand this model to train additional types of health 
professions beyond physicians. Veterans would benefit from 
health professionals who are trained and practice on 
interprofessional teams both in VHA and non-VHA facilities.
    Behavioral health is a particularly salient healthcare 
service for veterans. Veterans experience certain conditions 
like Traumatic Brain Injury (TBI) and substance use disorders 
more often than their civilian counterparts. Although access to 
behavioral health care remains a crisis throughout the country, 
compared to urban residents rural residents receive less care 
from providers with less specialized training, and the care 
they receive is less likely to be innovative. This creates a 
particularly acute challenge for rural veterans. There are 
fewer healthcare providers to treat and manage their more 
prevalent behavioral health needs.
    Perhaps because of the more limited resources in rural 
communities there are many examples where rural healthcare 
innovations led the way. It is important to continue to 
recognize that rural healthcare systems are different and not 
simply small versions of urban and can yield similar outcomes 
when given the opportunity.
    One word of caution as we talked a lot about telehealth 
today and we have heard about one-quarter of rural veterans not 
having internet in their home, and we cannot have systems that 
are built on veterans connecting with their providers in the 
parking lot of a library.
    Although rural residents and those who visit rural 
communities face real barriers to achieving their full health 
potential, history has shown that thoughtful legislation 
designed to address rural-specific challenges and leverage the 
assets of rural American has been successful in improving the 
lives of those who live in our rural communities. Thank you.

    [The Prepared Statement Of Mark Holmes Appears In The 
Appendix]

    The Chairman. Thank you.
    Now we are going to go to questions. I will recognize 
myself for 5 minutes.
    Ms. Schultz, how is it different for a homeless veteran in 
rural Illinois than it is in Chicago or other major cities?
    Ms. Schultz. Thank you for your question.
    In rural communities for homelessness veterans you lack no 
public transportation. I mean, there is no public 
transportation. The access to everything is impossible, really. 
If you do not live in a community where you have access to more 
jobs, apartments, all the things, even healthcare access, VA 
care, it is just very different. It is night and day really.
    The Chairman. As far as the actual homeless veterans, there 
are a lot more urban programs than for rural homeless veterans 
to try to find anything?
    Ms. Schultz. I believe for urban homeless veterans you have 
more resources. You have clothing banks. You have food 
pantries. We have those things in rural areas. They are just 
more widespread and harder to get to.
    The Chairman. In your opinion, what can VA do to help make 
sure rural homeless veterans are treated equally to those ones 
in the urban areas?
    Ms. Schultz. Just expanding healthcare access programs to 
support them. I mean, things need to be more readily available.
    The Chairman. Okay. Mr. Lovald, H.R. 3848 and the Housing 
Oversight and Mitigating Exploration (HOME) Act that passed the 
House late last year would include authority for VA to provide 
similar assistance with rides of appointments for homeless 
veterans. Would this additional authority alleviate some of the 
strain on the MACV and the other providers seeking to help the 
homeless veterans?
    Mr. Lovald. Chairman Bost, thank you for that question.
    That absolutely could assist in the process of us 
connecting with those veterans. I think that one thing I would 
highlight, in the state of Minnesota, the Disabled American 
Veterans (DAV), in partnership with the VA, provides numerous 
rides. Currently those rides very specifically have to be 
related to VA health care. If there was an expansion on where 
those vehicles could be used for or another way to access 
transportation that did not require the veterans to have a 
vehicle, many of them cannot, many of them are not driving 
anymore, anything that addresses exactly what was just 
discussed about getting said veteran to that resource is going 
to be helpful.
    The Chairman. Well, first off, I want to say thank you to 
each one of the panelists because I am going to turn it over to 
Mr. Takano for his questions. Let me say this. When you come 
from areas that are rural like I do--I know many of the people 
on this committee do--any unique ways that you can see to help 
us help VA to make sure that they can provide those services. 
You know, when we started talking about telehealth everybody 
thought how great it is. It is true for the rural area. It 
handles great for the rural area if you have a connection. 
Quite often we have watched in the rural areas getting a 
connection might even be easier than getting potable water, 
too, but that is a whole different story for the rural areas. 
It is unique, and I appreciate you being here. I will now turn 
it over to Ranking Member Takano for questions.
    Mr. Takano. Thank you, Mr. Chairman.
    Mr. Nygren, thank you. Dr. Nygren, thank you so much for 
being here. I had the pleasure of visiting Window Rock in 2022.
    In your testimony you advocate for Congress to appropriate 
funds to build a full-service VA Medical Center in the Navajo 
Nation. Who do you envision this facility serving? Just 
veterans or all Navajo Nation citizens?
    Mr. Nygren. Thank you, Honorable Takano, for coming out 
last year. I just missed you just by a few months. Hopefully 
you come back out.
    Mr. Takano. I would love to. It is a beautiful country. I 
would love to be the guest of Representative Crane.
    Mr. Nygren. All right. Well, thank you to both of you.
    The first thing I think about is I think it is going to 
serve all veterans in the area. I think that not only it would 
benefit Navajo veterans. It would benefit Hopi veterans, Ute 
veterans and non-Native American veterans just because it would 
be a lot closer to the Four Corners area because we are in such 
a unique, beautiful area that if that facility was actually 
built in Chinle, Arizona it would actually bring a lot more 
people closer to where their travel distances are not as far. I 
do know that most of our Navajo citizens do use Indian Health 
Services to the best of their abilities but I do know if this 
facility is built it would really benefit the 10,000 plus 
Navajo veterans and probably a lot more that have not really 
realized some of their benefits that are available.
    Mr. Takano. Well, have we given thought to a possible joint 
facility with VA and the IHS so that your people could benefit 
from the economy of scale to bring out specialists, to make it 
a real, a much fuller array of services. We could justify that 
by opening it up to both the IHS beneficiaries as well as VA 
beneficiaries. Is that an idea you are open to?
    Mr. Nygren. I think, Mr. Takano, I think that would be a 
great idea. I know that one of the things that currently we are 
going to reopen a small contract agreement with the Chinle IHS, 
but most of the concerns of the veterans is they want to be 
treated more tailored as if they showed up at a VA center 
instead of being just treated like a normal Native American 
going to that facility. That was one of the things that I have 
been told is let us make sure they treat us like veterans 
instead of them not even asking us if we are a veteran or not.
    Mr. Takano. I think that is a very valid concern. I think 
just knowing that it is primarily a VA facility but there has 
historically been this connection between the IHS and VA. I 
hope to talk to Representative Crane more about this idea 
because I believe as far as directing resources to a major 
facility, this is one way to maybe get it done.
    I was impressed by the fact that you have your own college 
and that you have a nursing program is what I recall. Of 
course, as Dr. Holmes has mentioned, one of the best ways to 
get health practitioners into rural areas is to get medical 
residencies and training opportunities into these areas. I have 
Sherman Indian Institute, which many of your young people come 
to in Riverside, California.
    Do you think there might be ways for us to work together to 
create pipelines of training opportunities for students to come 
to Sherman, students that go to your own schools and to your 
own college to train for these medical professions?
    Mr. Nygren. Honorable Takano, I think that is a great idea. 
I think that one of the things that we really need within that 
area is trying to develop that pipeline of nurses that are 
local so that people are not crisscrossing across the country 
to take on contracts for a few weeks at a time because what 
will happen is you will have people that come out for short 
stints of time but they do not truly understand the culture. 
They do not understand the people. If we can train up our own 
people, whether they go to the program at Sherman Indian 
School--just so you know, my grandma went to Sherman a long 
time ago. One time I was there and she showed me a picture of 
where they would pick up dates and stuff and things like that. 
I know it is a long way from Navajo but it is one of those site 
topics to where I think that I cannot believe people traveled 
that far back in the 1940's and the 1950's so far away from 
home. I am definitely open to what we can do with the Sherman 
Institute and our own school. I know that Northern Arizona 
University is working on developing a medical school, and I 
think that is something that Representative Crane and myself 
and you, we can talk with Northern Arizona University to figure 
out is there a program that can be geared toward Navajo nurses 
and doctors and be a lot closer to Navajo.
    Mr. Takano. Thank you.
    Mr. Chairman, if you might permit me to ask just ask one 
question of Dr. Holmes. Thank you for being here, Dr. Holmes.
    You know, you talk about other ways that VA and healthcare 
systems could attract and retain mid-and later-career 
professionals in rural areas. Can you point to any success 
stories about how that has already happened or could happen?
    Mr. Holmes. Thank you for the question.
    I think one of the themes that I have heard all day and at 
this panel as well is the notion that rural communities need to 
design programs that are tailored to the assets that are there. 
If some communities have really strong broadband then that 
might be a solution there. Others may have a scope of practice 
that enables. I am getting to your answer, I promise.
    All that is to say that healthcare systems are often really 
innovative at this and they recognize what it is that they need 
in order to keep their mid-and late-career professionals. Part 
of that is a career ladder. Particularly in rural areas, you 
need to be able to see I have progress in my career and I can 
move forward. Investments in those kinds of models have proven 
highly effective where a medical assistant can become a nurse 
and expand their career over time.
    Mr. Takano. Thank you. We have a tremendous brain trust 
here and I hope that we can make some movement on rural 
healthcare.
    I yield back.
    The Chairman. Representative Radewagen.
    Ms. Radewagen. Ms. Schultz, can you describe the specific 
challenges you face in accessing healthcare services in your 
rural area such as transportation or distance to the nearest VA 
facilities? How have these challenges affected your ability to 
receive timely and adequate health care, especially for any 
ongoing or specialized medical needs?
    Ms. Schultz. Okay. Thank you for the question.
    My closest VA hospital is 2 hours from me but I do have the 
privilege of having a Community Based Outpatient Clinic (CBOC) 
in my town. If I cannot go to the 2 hours then I can get care 
locally. When we dive into Community Care, because not 
everything is available at a CBOC, I still have to travel. I 
have one Community Care. I still have to travel an hour and 15 
minutes to get to a Community Care provider because it is so 
hard to get into the Community Care system and it is a rural 
area so not as many providers are available for Community Care.
    I have had personal difficulty getting referrals to 
specialists so I use my private insurance to do those things 
which, again, I am blessed to be able to do. I work with 
veterans who do not have those same privileges and they miss 
appointments because of VA options for transportation or there 
is no options for transportation or they are working. A lot of 
veterans who I work with have to choose between going to work, 
and they do not have the kinds of jobs that allow them time off 
for medical appointments. They do not have Paid Time Off (PTO) 
so they do not have that access to care readily available. As 
far as female providers, again, for specialized female care I 
would have to travel 2 hours to get to the facility for that 
care.
    Ms. Radewagen. In your testimony you mentioned mobile 
medical units. What has your experience been like in regards to 
receiving health care at mobile medical units? Have they 
provided you with adequate care and met all your needs?
    Ms. Schultz. I do not have any personal experience with 
mobile medical units. I just do not want to bring problems 
without solutions and I feel like mobile medical units coming 
into rural areas would be beneficial for our veterans who do 
not have transportation, or if they have transportation it is 
only getting them locally, right, to their basic needs, to 
their job. I did a little research with the mobile medical 
units that were deployed starting in August 2023 and it 
appeared to me that they were really in urban areas. Refocusing 
some of those units or getting additional units into rural 
areas could really be a gamechanger.
    Ms. Radewagen. Thank you.
    Mr. Chairman, I yield back the balance of my time.
    Ms. Schultz. Thank you.
    The Chairman. General Bergman.
    Mr. Bergman. Thank you, Mr. Chairman. Thank you all for 
being here.
    Mr. Lovald, I am sure you are familiar with Scott County. 
My dad, a World War II vet's last community service was driving 
veterans from around Scott County into the VA Medical Center 
over by the airport. It was one of the proudest moments of his 
life, especially it was not about so much getting them to the 
appointment, which was essential but the interaction that he 
had with them as some old guys who have been around a long time 
sharing stories toward the end of life, if you will. I thank 
you for all you do across the state of Minnesota.
    Dr. Nygren, I greatly appreciate you being here and 
providing the testimony. Michigan's 1st District which I 
represent is home to seven federally recognized tribes. All are 
in rural and remote areas and all with a long history of 
service to our country in uniform. Some of my most 
heartwarming, fulfilling interactions over these last 7 years 
in Congress is to attend the different tribal ceremonies at 
different times of the year to dance and participate in the 
ceremonies because we are all thankful for everybody's service 
over time.
    One of the recommendations in your testimony is to foster 
collaboration between Congress, the VA, tribal leaders, and 
tribal health authorities. I am going to ask one question and 
just say any steps that you think you would like to take, next 
steps you would like to take to accomplish this. Is part of 
this the potential for utilization of excess space in tribal 
health clinics that are rural and remote that here you have the 
existing tribal health clinic and you have space, is there an 
opportunity for us to deliver some of that rural and remote 
care? Veterans are not driving by the tribal health clinic 
because they are not a member of the tribe. I would just like 
to hear your thoughts on that.
    Mr. Nygren. Thank you, Congressman Bergman. I thank you for 
the tribes that you represent, the seven tribes, and I am very 
happy that you are open to being a part of their traditions and 
cultures as my representative is, too, as well. Thank you so 
much. I think this question also kind of comes back to Mr. 
Takano's question as well, too, is what can we do to better 
utilize? All of us know that any healthcare facility in rural 
America, if we can find a way to collaborate and bring them 
together to work with the VA is good for all of us because it 
is already tough enough to get water, electricity, and sewer. 
If there is a tribal health facility that is there, my 
recommendation would be to continue that collaboration so that 
veterans feel like when they walk in--not only when they walk 
into that tribal facility, but if a part of it is dedicated to 
them so that they understand that a veteran is going to be 
talking to me. They know the challenges that they have gone 
through and things like that. I believe that if we can continue 
to foster that spirit of collaboration to figure out how can we 
combine the VA and the tribal facilities to work together so 
the veteran does show up, I think that will definitely work a 
lot easier. It actually would make it a lot more feasible 
because I know there are times when it is a tremendous task to 
bring a facility out to any remote rural areas but if you can 
already tap into the existing infrastructures that are there to 
kind of build off of I think that will be a great way to start 
those discussions as well.
    Mr. Bergman. Well, when you think about it certain things 
that are done, procedures performed, pharmacies potentially, 
whatever it happens to be, the idea of shared services, you 
already have a physical facility. How do we get maximum 
utilization out of that for all concerned?
    I just want to thank you all for being here and I will 
yield back 30 seconds here for the good of the order. Thank you 
all.
    The Chairman. Representative Crane, you are recognized.
    Mr. Crane. Thank you, Mr. Chairman.
    President Nygren, thank you again for being here today, 
sir. Thank you for everything you do for the Navajo Nation. It 
is definitely critical for us to hear your perspective on these 
issues.
    As we previously discussed, Navajo veterans face extremely 
lengthy trips to VA health centers, often driving multiple 
hours just for one health visit. At some clinical locations 
they may not even be able to get that type of specialty care.
    In your opinion, what is the greatest barrier to care for 
Navajo veterans?
    Mr. Nygren. Thank you, Representative Crane.
    The greatest one that I think about is the distances that 
they travel. If you have ever been to Navajo country it is 
very--as we are speaking now, there is big weather that is 
coming through and elders are stuck in communities to where 
even it is hard to get a grader or a backhoe in some of those 
communities. It is one of those things where I think about 
where if we can bring the services a lot closer to them and 
more accessible that would actually make it a lot easier on 
them because for them to travel down to Phoenix, they have told 
us that the mileage reimbursement is enough to just cover the 
gas but it does not account for the vehicles that they drive 
because a lot of the vehicles that they drive are 4-by-4 
vehicles because of the rural areas that 9 miles a gallon is 
only going to get you so far when you go down to Phoenix.
    Those are some of the challenges. The other challenge is 
that a lot of these veterans are elderly. They are either 
Vietnam veterans or they are in that age where it is very 
difficult for them to travel. They are going to have to have 
people to actually take them down there. To me one of the 
greatest challenges would be to bring it a lot closer to them.
    Mr. Crane. Absolutely.
    Now, we talked about a possible VA hospital, improving 
telehealth reliability, adjusting per diem rates to relieve 
costly financial burdens. Is there anything else on that list 
that we can do to help veterans on the Navajo Nation?
    Mr. Nygren. Honorable Representative Crane, when it comes 
to telehealth, as everyone mentioned here, when we talk 
telehealth for rural communities it all depends on the services 
that we can actually get to actually get videoconferencing. Our 
veterans on Navajo, they actually really prefer people to deal 
with because a lot of them only speak Navajo. They do not quite 
understand a lot of the challenges that a lot of people can use 
a telephone. A lot of them do not prefer that. They really 
prefer in-person discussions, one-on-one discussions and to be 
able to relate to someone. I think that might be another 
obstacle really to think about when it comes to telehealth is 
just there is that generation that would really prefer in-
person meetings instead of telehealth.
    Mr. Crane. Absolutely. If you had to rank those three 
priorities--the hospital, telehealth, and then adjusting per 
diem rates, would it go in that order, one, two, and three, 
just like that?
    Mr. Nygren. Yep. They would be very close to one another.
    Mr. Crane. Okay. Thank you, President Nygren, for being 
here today.
    One question for Mr. Lavold real quick. Sir, I know your 
big issue is veteran homelessness. I know there are several 
reasons that our veterans end up homeless. What is the biggest 
reason that you tend to see our veterans becoming homeless?
    Mr. Lovald. Representative Crane, thank you for that 
question.
    As it relates to rural veterans specifically or just 
veterans in general, veterans who are finding their selves 
homeless have essentially run out of resources. They have maybe 
burned bridges. They have run out of family. They have run out 
of places that they can actually go before they are actually 
homeless. There rarely is somebody waking up and the next day 
they are homeless.
    We have seen and witnessed that a lot of mental health 
issues are what are contributing to decision-making that then 
lends into difficult situations with their family or friends. 
Maybe creating incarceration situations as well. The mental 
health component I think is a very big piece of why an 
individual becomes homeless and honestly, why some veterans 
choose to be homeless is because they are not connected to the 
mental health services that they might need to help them see a 
solution in front of them that is viable.
    Mr. Crane. Yes. That is something a lot of people do not 
understand that some veterans actually do choose that lifestyle 
at least for a period of time; is that correct?
    Mr. Lovald. That absolutely is correct. We continue to 
reach out to these individuals with different solutions hoping 
that the next opportunity, maybe we built that relationship to 
offer something new.
    Mr. Crane. Thank you, Mr. Lavold.
    I yield back.
    The Chairman. Thank you.
    Ranking member, do you have any--first of all, I want to 
say thank you to the panel here, but do you have any closing 
remarks?
    Mr. Takano. No. We have got to go vote. I appreciate the 
courtesy in letting me ask Dr. Holmes more questions.
    The Chairman. I want to say thank you to the ranking 
member. I want to thank all the witnesses for joining us here 
today, especially the second panel who traveled from all over 
from rural America to try to get here today and provided access 
to the best healthcare benefits and veterans. As I asked 
earlier, if you come up with ideas, please bring them to us, 
any suggestions you may have. We want to make sure that we do 
this and we want to make sure that our veterans are provided 
for no matter where they live and where they choose to live.
    I appreciate Ranking Member Takano and the members of the 
Committee for standing shoulder to shoulder with me in a 
bipartisan manner to do that.
    I ask unanimous consent that all members shall have 5 
legislative days in which to revise and extend their remarks 
and include extraneous material.
    Hearing no objection, so ordered. This hearing is now 
adjourned.
    [Whereupon, at 1:54 p.m., the committee was adjourned.]   
      
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                         A  P  P  E  N  D  I  X

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                    Prepared Statement of Witnesses

                              ----------                              


                 Prepared Statement of Shereef Elnahal

    Chairman Bost, Ranking Member Takano, and Members of the Committee, 
thank you for the opportunity to appear before you today to discuss the 
ways VA provides health care and benefits to Veterans in rural or 
highly rural areas.\1\
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    \1\ Veterans Health Administration uses the Rural-Urban Commuting 
Areas system to define rurality. The Rural-Urban Commuting Areas system 
considers population density as well as how closely a community is 
linked socio-economically to larger urban centers. We use the term 
rural to include rural, highly rural, and insular island areas.
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    Almost a quarter of all Veterans, more than 4.4 million reside in 
rural communities. Many of these Veterans face unique challenges and 
obstacles that differ widely from their urban counterparts. Veterans 
often reside in rural communities to be close to family, friends, and 
community; to have open spaces for recreation; more privacy; lower cost 
of living; and less crowded towns and schools. However, the 
geographical isolation of rural areas can create challenges for rural 
Veterans in accessing VA resources, including medical care, educational 
benefits, and employment assistance.
    Rural Veterans often face unreliable internet access, long travel 
distances, and less awareness about the benefits and care available to 
them through VA. Unreliable internet access restricts their ability to 
connect with online platforms and information, limiting access to 
essential resources like telehealth services and online application 
processes. Long travel distances can also pose financial and logistical 
challenges for rural Veterans, who must travel considerable distances 
to receive medical care, appointments, or other essential services. 
Furthermore, historically limited outreach efforts in rural communities 
may prevent many Veterans from fully utilizing the resources to which 
they are entitled.
    VA is committed to working across Government, including with 
Congress, the White House, and Executive branch, and with Veterans, and 
external stakeholders to overcome these challenges and provide rural 
Veterans with the care and benefits they have earned and deserve. The 
Department is doing so through new efforts under the Biden-Harris 
Administration and through ongoing efforts across the agency.

President Biden's Policies Benefit Rural Veterans

    The Biden-Harris Administration's general policy framework has 
provided more care and benefits to Veterans, including rural Veterans. 
The Administration emphasizes expanding access to quality health care 
services, including mental health and substance use disorder resources, 
through initiatives like telehealth and mobile clinics. The framework 
aims to address long travel distances and limited access to medical 
facilities experienced by rural Veterans and to increase awareness of 
benefits and care available to these Veterans through outreach efforts 
and improved communication channels. By prioritizing rural Veterans' 
needs and improving their access to care, the President, and VA, aim to 
improve their quality of life and overall well-being.

The Sergeant First Class Heath Robinson Honoring our Promise to Address 
    Comprehensive Toxics (PACT) Act \2\
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    \2\ Pub. L. No. 117-168, 136 Stat. 1759 (2022).

The PACT Act marked the largest expansion of Veteran benefits in a 
    generation. From August 2022 to mid-December 2023, VA enrolled more 
    than 500,000 new Veterans, over 100,000 of which were eligible to 
    enroll based on specific new authorities in of the Act itself, and 
    included 25,000 rural Veterans. To date, VA has also screened over 
    five million Veterans enrolled in VA health care for toxic 
    exposures, of which 1.7 million live in rural areas. This marks 
    significant progress toward our goal of screening all Veterans 
    enrolled in VA health care for toxic exposures at least once every 
    five years.
    Rural Recruitment and Hiring Efforts. Department recruitment 
efforts for physicians and health care providers in rural regions have 
been a longstanding challenge. In fiscal year (FY) 2022, turnover rates 
within the Veterans Health Administration (VHA) hit their highest 
levels in over 20 years, reaching 11 percent for VHA overall and 12.1 
percent in rural facilities. In FY 2023, the PACT Act provided VA with 
unprecedented authority and flexibility to better recruit and retain 
staff. Leveraging these and other authorities, VHA saw a 7.4 percent 
overall growth rate and 7.7 percent in rural facilities for health care 
providers, the highest rate in over 15 years. Despite the fact that 
rural hiring outpaced the enterprise's overall growth, physicians 
remain more difficult to recruit in rural areas in particular. In FY 
2023, rural areas saw a 2.1 percent growth rate in physicians, compared 
to 3.6 percent for VHA overall. VA continues to work with Congress to 
strengthen VA's ability to recruit and retain providers in high-need 
areas and specialties.
    As part of PACT Act implementation, VA has also developed the FY 
2023 Rural Recruitment and Hiring Plan \3\ to ensure VA has the 
workforce it needs to meet our obligation to rural Veterans. The plan 
outlined goals to improve staffing levels at all rural facilities, 
engage stakeholders to improve recruitment and onboarding, empower 
leadership across rural facilities to implement comprehensive 
strategies, increase satisfaction with the recruitment, hiring, and 
onboarding process, and provide the soonest and best care to Veterans 
living in rural communities.
---------------------------------------------------------------------------
    \3\ Veterans Health Administration. (2023). Rural Recruitment and 
Hiring Plan. Workforce Management & Consulting, in partnership with the 
Office of Rural Health.
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    Beyond efforts under the PACT Act, the Integrated Clinical Staffing 
Project contract, announced last year, is designed to address staffing 
shortages and improve care for Veterans.\4\ It covers various clinical 
and non-clinical positions, including physicians, nurses, pharmacists, 
therapists, technicians, social workers, and administrative staff. The 
contract will support VA's transformation initiatives, including the 
expansion of telehealth services and the enhancement of community care 
partnerships.
---------------------------------------------------------------------------
    \4\ Note: The tentative award date for acquisition is January 9, 
2024. No awardees have been named to date.
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    Largest Outreach Campaign in VA's History. With the passage of the 
PACT Act, VA launched its largest outreach campaign to ensure every 
Veteran impacted by toxic exposures receives the benefits and care they 
deserve. This required collaboration with community and national 
partners to reach Veterans across the country, especially rural 
Veterans, like never before. To this end, VA pushed an agency-wide 
enterprise initiative called ``Summer Vet Fest,'' intended to inform 
Veterans, their families, caregivers, and survivors about the PACT Act 
and encourage them to apply for due benefits and care. Additionally, in 
the last calendar year, VA led at least two community-level events in 
every state and Puerto Rico and participated in 14,036 PACT Act-focused 
events, reaching 1,129,916 people. Of these PACT Act briefings, 5,883 
included Congressional representation, and 32,248 included the media. 
VA also held 436 claims clinics across the country, reaching more than 
18,000 attendees and resulting in 13,172 claims filed.
    Veterans Exposure Team-Health Outcomes Military Exposures (VET-
HOME). The VET-HOME program \5\ is a vital initiative aimed at 
addressing the health concerns of Veterans, with an emphasis on 
military exposures, such as hazardous chemicals or environmental 
toxins, to identify and mitigate potential health risks. Launching over 
the past year, the program offers clinical evaluations on a national 
scale through a geographically distributed team of providers trained in 
military environmental exposures. This initiative is particularly 
important for rural Veterans who may have limited access to health care 
resources and face challenges in receiving timely and specialized care.
---------------------------------------------------------------------------
    \5\  For more information, see https://www.publichealth.va.gov/VET-
HOME/index.asp.

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Caregiver Support

    Caregivers can play a crucial role in the well-being and quality of 
life of rural Veterans, especially those with physical or mental health 
challenges. In rural areas with limited health care and support 
resources, caregivers play a vital role in filling gaps and providing 
necessary support. They assist with medication management, 
transportation to appointments, and ensuring treatment plan adherence, 
leading to better health outcomes. Caregivers also positively impact 
the mental and emotional well-being of rural Veterans,\6\ providing 
emotional support, a listening ear, and a safe space for them to 
express their feelings. They also help alleviate social isolation, 
providing companionship, engagement in social activities, and 
connecting Veterans with support networks.
---------------------------------------------------------------------------
    \6\ L'Heureux T, Parmar J, Dobbs B, Charles L, Tian PGJ, Sacrey LA, 
Anderson S. Rural Family Caregiving: A Closer Look at the Impacts of 
Health, Care Work, Financial Distress, and Social Loneliness on 
Anxiety. Healthcare (Basel). 2022 Jun 21;10(7):1155. doi: 10.3390/
healthcare10071155. PMID: 35885682; PMCID: PMC9318565. See also Talley 
R., Crews J., Caring for the Most Vulnerable: Framing the Public Health 
of Caregiving. Am J Public Health. 2007;97:224-228.
---------------------------------------------------------------------------
    In April 2023, President Biden signed an executive order to 
increase access to high-quality care and supporting caregivers,\7\ 
enabling families, including Veteran families, to have access to 
affordable, high-quality care and to have support and resources as 
caregivers themselves. As of December 19, 2023, 19,200 active 
caregivers in rural areas are enrolled in the Program of Comprehensive 
Assistance for Family Caregivers, offering services and benefits. This 
Executive Order called for the expansion of the Veteran Directed Care 
program to all VA Medical Centers by the end of 2024. VA's Veteran 
Directed Care Program (VDC) provided personal care services to over 
7,200 Veterans in FY 2023, with over 50 percent living in rural areas. 
VDC is crucial due to limited home health aide agencies and labor 
market shortages.
---------------------------------------------------------------------------
    \7\  See generally https://www.whitehouse.gov/briefing-room/
Presidential-actions/2023/04/18/executive-order-on-increasing-access-
to-high-quality-care-and-supporting-caregivers/.

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Food Security

    Another significant health concern for rural Veterans, especially 
those who are younger, unmarried, unemployed, and have children is food 
security.\8\ Veterans who are food insecure are more likely to 
experience physical and mental health problems and have a fourfold 
higher risk of suicidal ideation. In 2022, VA established the VHA Food 
Security Office to address food insecurity among Veterans through 
partnerships, data management, and research. The office provides 
clinical nutrition care to many rural Veterans through tele-nutrition 
visits and VA Video Connect.
---------------------------------------------------------------------------
    \8\ See Widome R, Jensen A, Bangerter A, Fu SS. Food insecurity 
among Veterans of the US wars in Iraq and Afghanistan. Public Health 
Nutrition. 2015;18(5):844-849. doi:10.1017/S136898001400072X. See also 
Cohen AJ, Dosa DM, Rudolph JL, Halladay CW, Heisler M, Thomas KS. Risk 
factors for Veteran food insecurity: findings from a National US 
Department of Veterans Affairs Food Insecurity Screener. Public Health 
Nutrition. 2022;25(4):819-828. doi:10.1017/S1368980021004584, and Wang 
EA, McGinnis KA, Goulet J, et al. Food Insecurity and Health: Data from 
the Veterans Aging Cohort Study. Public Health Reports. 
2015;130(3):261- 268. doi:10.1177/003335491513000313.

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American Indian and Alaska Native Veteran Initiatives

    Meeting the needs of rural Veterans also means ensuring American 
Indian and Alaska Native (AI/AN) Veterans receive the care and benefits 
they deserve. These Veterans serve in the military at one of the 
highest rates of all racial and ethnic groups and are the most likely 
to live in rural communities. These veterans' already significant 
health care disparities are aggravated by barriers related to access to 
care, coordination, and care navigation. Thus, VA has worked with its 
partners to develop programming to address these challenges.
    Copayment Exemption for American Indian/Alaska Native Veterans. In 
April 2023, VA implemented the Johnny Isakson and David P. Roe, M.D. 
Veterans Health Care and Benefits Improvement Act of 2020 \9\, 
exempting eligible Native Veterans from copayments for VA health care. 
The copayment exemption honors our treaties with sovereign Nations, 
addresses health care access and disparities, provides more health care 
options, and continues to build trust in VA. As of December 8, 2023, VA 
has canceled over 118,000 copayments for over 3,400 eligible AI/AN 
Veterans, amounting to $2.1 million in canceled and reimbursed 
copayments. VA continues to receive, review, and process applications 
for exemption and conduct outreach to ensure qualified Veterans get 
this exemption.
---------------------------------------------------------------------------
    \9\ Pub. L. No. 116-315, 134 Stat. 4932
---------------------------------------------------------------------------
    Tribal-VHA Collaboration on Suicide Prevention. In 2021, the 
highest suicide rate within minority populations was found amongst AI/
AN Veterans. VA is focusing on increasing access to care, delivering 
culturally meaningful treatments, and growing support networks to 
reduce suicide risk among these Veteran groups through a suicide 
prevention strategy that is guided by the National Strategy for 
Preventing Veteran Suicide 2018-2028 and aligns with the President's 
2021 National Strategy for Reducing Military and Veteran Suicide. To 
this end, VA continues to collaborate with Federal, tribal, state, and 
local governments to advance a public health approach to suicide 
prevention. These efforts include:

      Advancing suicide prevention for Rural Native Veterans 
through Tribal-VHA partnerships;

      Implementing Mental Health and Suicide Prevention 
Outreach to Minority Veterans and American Indian and Alaska Native 
Veterans (P.L. 117-328 Sec.  101);

      Awarding $52.5 million to 80 community-based 
organizations through the Staff Sergeant Parker Gordon Fox Suicide 
Prevention Grant Program; and

      Expanding collaborative suicide prevention efforts with 
AI/AN tribal communities in FY 2024 as part of VA and the Substance 
Abuse and Mental Health Services Administration's (SAMHSA) Governor's 
Challenge to Prevent Suicide Among Service Members, Veterans, and their 
Families.

COMPACT Act

    The Biden-Harris Administration recognizes that reducing suicide 
cannot be accomplished singularly through reactive policy change; 
rather, it requires a long-term strategic vision and commitment to 
implement systemic changes in how we support Service members, Veterans, 
and their families across the full continuum of risk and wellness. In 
addition to continuing to build on VA's public health approach to 
suicide prevention, this year, VA implemented section 201 of the 
Veterans Comprehensive, Access to Care and Treatment Act of 2020 
(COMPACT) \10\ Act. This law enables VA to provide, pay for, or 
reimburse emergent suicide care for eligible Veterans, determine 
eligibility for other VA programs and benefits, and make appropriate 
referrals for care. The ability to be seen at any medical facility for 
this care without prior authorization can be critical for rural 
Veterans who may have to travel long distances to their nearest 
facility. In addition, rural Veterans in crisis now have simpler access 
to the Veterans Crisis Line. The National Suicide & Crisis Lifeline's 
new number--988 (then Press 1 for Veterans)--helps make it easier to 
remember and share the number to access help in times of need, 
regardless of location.
---------------------------------------------------------------------------
    \10\ Pub. L. No. 116-214, 134 Stat. 1026.

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Ongoing Efforts to Serve Rural Veterans

    VA's longstanding efforts continue to help bridge the gap between 
rural Veterans and the resources available to them. Through outreach 
efforts, telehealth services, mobile clinics, and partnerships with 
local community organizations, VA is working diligently to address the 
specific needs of rural Veterans and improve their overall well-being.

Outreach Initiatives

    VA is committed to reaching rural Veterans where they are, ensuring 
they can access healthcare services and information about benefits, 
mental health support, and other available resources. This outreach 
involves partnering with various agencies, including Veteran Service 
Organizations (VSO), State Departments of Veterans Affairs, Federal 
agencies, and non-governmental organizations. VA.gov offers an online 
platform for Veterans to learn about, apply for, and manage their VA 
benefits and health care. In rural communities, VA collaborates with 
Rural Outreach Coordinators, VHA's Office of Rural Health (ORH), Mobile 
Vet Centers, County Veterans Service Officers, Transition Assistance 
Advisors, disability and aging network organizations, and community 
faith-based organizations to coordinate outreach support for events.
    VA's success in providing updated benefits and service information 
to rural Veterans is largely due to its collaboration with local VSO 
Officers. The Rural Veteran Special Emphasis outreach program 
identifies gaps in benefits delivery to remote locations, ensuring 
equal access to and knowledge of all benefits. In FY 2023, VA completed 
over 1,100 Rural Veteran outreach events, connecting with over 300,000 
Veterans, Service members, and beneficiaries. Additionally, Regional 
Offices across the U.S. have outreach plans based on their state's 
Veteran demographic and population data. For instance, the Winston-
Salem Regional Office uses this data to determine the best methods for 
rural and untethered Veterans. They also collaborate with VA, VSOs, and 
other Veteran stakeholders to ensure effective outreach. Further, the 
Homeless Veterans Outreach Program focuses on assisting homeless or at-
risk Veterans through outreach events and partnerships with 
stakeholders.
    Rural Partners Network to Empower Rural Communities to Access 
Federal Resources. The Office of Rural Engagement (ORE) is a key 
partner in the Rural Partners Network (RPN), a whole-of-government 
initiative led by the U.S. Department of Agriculture. ORE collaborates 
with various stakeholders, including the RPN, government agencies, and 
community organizations, to understand and address the unique needs of 
rural Veterans. The ORE's mission is to leverage the strengths of the 
Federal Government, the Department of Veteran Affairs, and Veterans 
themselves to build resilient rural communities and improve the health 
and well-being of rural Veterans. ORE connects VA programs and policies 
to the unique needs of rural Veterans, employing a whole-of-government 
approach to support and engage both Veterans and their communities. It 
serves as the front door for rural Veterans, improving accessibility to 
resources specific to their needs. ORE also assesses VA policy 
implications for rural Veterans, providing relevant information to 
Congress, the White House, the Interagency, and VA senior leadership. 
VA conducts outreach to engage rural Veterans and their advocates, 
aiming to increase participation in earned benefits and develop 
effective strategies for reaching rural communities.

Compensation and Pension (C&P) Examinations and VA's Over-Development 
Reduction Task Force

    VA strives to improve service delivery to the rural Veteran 
population. VA's Medical Disability Examination (MDE) vendors 
understand the need to expedite C&P examinations in remote geographical 
locations with limited medical resources. VA uses several methods to 
ensure rural Veterans are receiving C&P examinations in a timely 
manner.
    VA began using the Acceptable Clinical Evidence (ACE) process to 
streamline and enhance the disability claims evaluation. The ACE 
process provides C&P examination services for Veterans that reside in 
rural areas, and those who are elderly and may have difficulty 
traveling distances, utilizing C&P examiners who assess Veterans using 
Disability Benefits Questionnaires (DBQs) and existing medical 
evidence, supplemented by interviews conducted telephonically or via 
video when deemed appropriate. From FY 2021 to FY 2023, MDE vendors 
have increased their ACE modality usage by 123.8 percent. Tele-C&P 
(that is, telehealth) examinations expanded in 2020. The use of 
telehealth in the C&P disability examination program provides services 
for Veterans who reside in rural areas, those who are elderly and may 
have difficulty traveling distances, and those requiring specialty 
examinations. This allows for flexible exam scheduling and reduces the 
likelihood a Veteran will miss their examination. Tele-C&P examinations 
use video technologies for accurate face-to-face assessments, ensuring 
safety and efficiency. From FY 2021 to FY 2023, MDE vendors have 
increased their Tele-C&P modality usage by 74.6 percent.
    VA has also utilized vendors to deploy mobile units throughout the 
country to augment existing provider networks and provide a full range 
of exam services which allow Veterans to undergo exams where they live. 
These units allow providers to conduct examinations in rural areas of 
every state within the lower 48 states. Mobile units are equipped to 
complete general medical and most specialty exams, as well as 
diagnostic testing. The units are handicap accessible, with wheelchair 
lifts and ramps, and are fully self-contained with power supply and 
internet connectivity, allowing for secure evidence transmission to VA 
systems. VA Medical Disability Examinations (MDE) Contract Vendors 
continue to expand their mobile unit fleets and collectively have 31 
operational individual units.
    VA collaborates internally with other VA benefits and services 
offices committed to reaching our rural Veterans, such as VA's Office 
of Outreach, Transition, and Economic Development, Office of Field 
Operations, Office of Tribal Government Relations, local VHA Outreach 
Coordinators, as well as VSOs, to support claims clinic events by 
providing onsite C&P examinations utilizing MDE vendor Mobile Units. 
MDE vendors have supported events for C&P examinations with the Crow 
Agency, Cheyenne, Arapahoe, Saginaw-Chippewa, and Apsaalooke Tribes.
    MDE vendors are beginning to use newly approved innovative measures 
to complete C&P examinations such as boothless technology for audio 
exams, newly approved portable visual field-testing units for optometry 
exams, and wearable home sleep monitoring devices for in-home sleep 
studies. These technologies reduce the need for Veterans to travel in 
some geographical areas.
    In addition to increased examination modalities, MDE vendors use 
traveling providers and per-diem or rented locations, such as a 
temporary medical office space in Fulton, Illinois, to assist rural 
Veteran populations. License portability is utilized by MDE vendors, 
allowing covered examiners to travel across state lines to supplement 
the provider network in areas with limited medical provider options.

Supporting Rural Veterans' Health

    ORH also works to improve the health and well-being of rural 
Veterans by increasing access to care and services. Nine specific 
programs include:

        (1) Telemedicine: ORH supports various telemedicine programs, 
        including Clinical Resource Hubs for primary care, mental 
        health and substance use disorder treatment, and specialty care 
        in 18 VISNs, Tele-Critical Care for remote critical care 
        expertise in rural intensive care units, and over a dozen 
        specific telemedicine programs in various specialties.

        (2) Transportation: ORH collaborates with the Veterans 
        Transportation Program to support two programs that provide 
        transportation options to rural Veterans. The Highly Rural 
        Transportation Grant Program grants to local and tribal 
        programs, while the Veteran Transportation Service offers 
        services like VetRide and ambulances, partnering with VSOs.

        (3) Broadband: ORH, in collaboration with the Office of 
        Connected Care, is providing VA Video Connect Patient Tablet 
        program equipment, training, and broadband to Veterans without 
        access.

        (4) Workforce: Rural health care can be disproportionately 
        impacted by both chronic and sudden shortages. ORH is working 
        to leverage the full VA workforce through telemedicine, 
        clinical education and training to rural sites, and 
        disseminating best practices for recruiting and retaining 
        providers in rural areas.
        (5) Other Specific Rural Clinical Initiatives: ORH has 
        developed a pipeline of innovation and research to enhance care 
        models for rural Veterans, including 36 enterprise-wide 
        initiatives, 9 Rural Promising Practices, and hundreds of 
        small-scale pilots in various fields like primary care, 
        emergency medicine, geriatrics, and more.

Caring for Veterans Where They Are

    Telehealth, mobile clinics, and innovative technologies are also 
helping bridge health care barriers. Telehealth reduces wait times and 
travel costs, mobile clinics bring health care directly to rural 
communities, and wearable devices enable effective home health 
management. These approaches promote preventive care, early 
intervention, and reduce emergency treatment costs, improving the 
quality of life for rural Veterans.
    Telehealth. In FY 2023, the VA delivered more telehealth services 
than in any previous fiscal year, while achieving increased Veteran 
trust and satisfaction. Over 11.6 million telehealth episodes were 
delivered to over 2.4 million unique Veterans, with over 2.9 million 
delivered to over 770,000 rural Veterans. Further, 48.6 percent of 
rural Veterans identified telehealth as their preferred mode of care.
    Telehealth also allows VA to expand clinical capacity and address 
health care disparities in rural areas by sharing clinical services 
across its health care system. The Clinical Resource Hub program 
delivered over 340,000 telehealth encounters to over 144,000 rural 
Veterans in FY 2023, a 21 percent increase in the number of encounters 
delivered to rural Veterans. Additionally, VA Health Connect offers 24/
7 access to dedicated clinical triage registered nurses, urgent care 
providers, clinical pharmacy, and pharmacy support. It provides four 
essential core services: scheduling and administrative services, 
clinical triage, virtual clinic, and pharmacy. In the last fiscal year 
alone, VA Health Connect saw an increase of 3 million calls from rural 
Veterans and a nearly 70 percent increase in Virtual Clinic visits by 
rural Veterans.
    Community Care. VA provides care to Veterans through community 
providers when VA cannot provide the care needed. The department does 
so through Third-Party Administrators (TPA), who maintain and 
strengthen the provider network, particularly in rural areas with fewer 
providers. The reliance on community care in rural areas continues to 
grow; it remains critical that we maintain a network of providers to 
ensure Veterans receive needed care. In cases where there are not 
enough providers in certain areas, VA works with TPAs to adjust 
reimbursement rates. The rate waiver process allows TPAs to request 
higher rates to attract providers to the network. The relationship with 
TPAs is a two-way dialog, with ongoing monthly meetings to address 
standing and emerging needs. If TPAs are not meeting designated 
metrics, they must develop a corrective action plan and report 
regularly on measures they are taking to improve access to care.

Beneficiary Travel

    The beneficiary travel program addresses the financial and 
logistical challenges of traveling long distances for specialized 
medical care for rural Veterans. This program reimburses eligible 
Veterans for travel expenses, such as mileage, lodging, and meals, 
ensuring they receive the care they need. It not only improves access 
to necessary medical appointments but also alleviates financial stress, 
allowing rural Veterans to prioritize their health without worrying 
about associated costs. VA's commitment to beneficiary travel is an 
important part of providing comprehensive and inclusive health care 
services to rural Veterans.

Homelessness

    VA is committed to ending homelessness among Veterans because it is 
our Nation's duty to ensure all Veterans have a safe place to call 
home, including Veterans living in rural areas. One of the programs 
making that possible is the VA Grant-Per-Diem (GPD) program, which 
provides 365 transitional housing grants, including to rural 
organizations. These grants provide 10,500 total GPD beds nationwide. 
The program operates in all 50 states, Washington, DC, and Puerto Rico. 
GPD grantees establish programs to meet their communities' unique 
needs. They collaborate with VAMCs to identify resource gaps and 
determine how their proposed grants may fill them. Grant funding 
decisions consider factors like geographic dispersion, equity, and 
responsiveness to community needs. GPD continues to support rural 
communities and end homelessness among Veterans by providing 
transitional housing resources.
    Chairman Bost, Ranking Member Takano, thank you for the opportunity 
to discuss VA's efforts to best serve Veterans living in rural 
communities. Through our collaborative efforts, we are proud to have 
expanded our reach and provided more benefits and more care to more 
Veterans than ever before. Rural Veterans, and all Veterans, benefit 
from the strong working relationship between VA and Congress. We 
appreciate your continued partnership as we embrace our collective 
responsibility to serve those who have served.
                                 ______
                                 

                  Prepared Statement of Alyssa Hundrup
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                  Prepared Statement of Marisa Schultz

Introduction

    I want to begin by thanking Chairman Bost, Ranking Member Takano 
and Members of the House Committee on Veterans' Affairs for this 
opportunity to speak as a representative of the rural veteran 
community. I greatly appreciate the Committee's dedication to our 
Veterans and their families.
    My name is Marisa Schultz; I am a disabled combat veteran and 
veteran advocate. I served in the Illinois National Guard, having 
deployed to Iraq in 2004. I have personal and professional experience 
utilizing the Department of Veterans Affairs healthcare system in a 
rural area. I serve professionally, helping veterans in my community 
identify their needs and helping them access VA healthcare systems, 
community care, and other outside providers. Today, I come to you as a 
veteran looking to help my fellow veterans get the best access and care 
possible at the VA. To make the most substantial difference for rural 
veterans, the Committee can direct its attention toward enhancing the 
programs and services below.

Telehealth

    Telehealth has emerged as an invaluable asset in healthcare, 
notably benefiting me personally. I have been able to secure mental 
health services through community care with a telehealth provider who 
resides in another state. This kind of healthcare connection would only 
exist with telehealth. It's crucial, however, to highlight my access to 
stable internet and ability to navigate technology and how this 
supports my positive experience with telehealth. Along with my own 
experiences, I can also attest to the experiences of veterans 
challenged by rural geography, low incomes, and homelessness.
    The flexibility of telehealth has significantly expanded 
accessibility yet brings some notable challenges. The elderly/aging 
population encounters challenging barriers due to inexperience with 
technology, hindering the seamless use of the telehealth system. 
Furthermore, rural low-income and homeless veterans face complex 
limitations. Limited phone minutes, a glaring issue among this 
demographic, challenge the full utilization of telehealth services. 
Additionally, the dire need for internet access among rural low-income 
veterans poses an additional financial burden. Despite the availability 
of iPads equipped for telehealth within the VA system, I have seen that 
the procurement process proves complex and presents hurdles, thus 
delaying timely access to care.
    The CARES Act improved communication between providers and 
veterans; however, rural areas still lack adequate access. Implementing 
tailored training programs for our aging and digitally illiterate 
veterans and enhancing digital literacy can help bridge the gap. 
Reestablishing the VA Homeless program: The disposable smartphone 
initiative would be another way to reduce communication barriers and 
provide better access to telehealth for our rural veterans. Also, those 
accessing the VA Homeless Disposable Smartphone Initiative can now 
answer calls regarding VA appointments and have the ability to receive 
calls about potential jobs. Additionally, staff education on services 
that could help our rural veterans is necessary. Addressing these 
challenges and implementing robust solutions, the VA can provide access 
to quality healthcare regardless of veterans' location or digital 
literacy.

Beneficiary Travel

    VA beneficiary travel poses considerable challenges for rural 
veterans. Criteria for VA transportation include individuals who must 
be at least 30 percent service-connected or have low income. 
Additionally, specialized transportation is a prerequisite, making 
accessibility a hurdle. While mileage reimbursement supports those with 
personal vehicles, reaching a VA facility in rural areas often demands 
one or two hours of travel. We are speaking of a population whose 
vehicles cannot be correctly maintained due to low income. Traveling 
hours at a time, risking the vehicle that gets them to basic needs and 
work, is challenging for rural veterans. In my own experience, I have 
witnessed rural veterans struggle with meeting the criteria for VA-
provided transportation to appointments.
    I have observed numerous veterans missing appointments due to a 
lack of transportation and availability. One specific veteran who has 
chronic pain from a helicopter crash, while deployed, requested 
transportation to VA appointments. This particular veteran was 
authorized travel assistance, but when it came time for them to be 
picked up, transportation did not show. After being assured this would 
not happen again, this happened three more times, leading this veteran 
to call 988 (suicide hotline) due to the stress and frustration of a 
system they felt failed them. This is often aggravated by appointment 
cards arriving only days before or after scheduled appointments, 
leaving inadequate time for transportation arrangements.
    Seeking reimbursement for beneficiary travel also presents 
challenges for our aging and digitally illiterate rural veterans. 
Several veterans I work with require assistance submitting mileage 
reimbursement claims due to difficulties navigating va.gov and the 
Beneficiary Travel Self Service System (BTSSS).
    Improvements for beneficiary travel could involve enhanced VA 
transportation by expanding coverage and ensuring reliability. This can 
involve better scheduling systems for more time to arrange 
transportation. When making appointments, an option to sign up for 
travel reimbursement as part of the scheduling process could 
significantly reduce veteran frustration. Rural areas often lack local 
transportation services or community organizations to provide reliable 
transportation options for veterans residing in rural areas; forming 
partnerships with service organizations for ease of use would be 
beneficial. Increasing the availability and promotion of telehealth 
with education and access could reduce the need for physical visits. 
Simplifying the reimbursement process for beneficiary travel, creating 
a user-friendly system, or providing assistance programs to aid 
veterans, especially those aging and with digital illiteracy, can 
assist rural veterans in claiming reimbursements for their travel 
expenses. Policy changes are needed to address limitations in VA 
beneficiary travel criteria. This will make it more inclusive for rural 
veterans who face challenges in meeting the current requirements.
    As a more significant consideration for rural veterans, the 
deployment of Mobile Medical Units (MMU), especially in rural areas, 
could provide essential medical services directly to veterans, reducing 
the need for extensive travel. In August 2023, the Department of 
Veterans Affairs announced they were deploying 25 Mobile Medical Units 
nationwide, with 23 presently active. Although the current MMUs focus 
on large homeless populations, utilizing MMUs in rural areas could be a 
game changer. With the ability to ``meet veterans where they are,'' 
providing sign-up services, primary care, mental health clinics, access 
to social workers, women's health, audiology, laboratory, and education 
on telehealth for those who do not have access to VA medical centers 
due to transportation limitations could significantly increase 
healthcare access to our rural veterans.

Inadequate grant and per diem rates for homeless veterans

    The VA Grant and Per Diem program aims to assist organizations in 
offering homeless veterans transitional housing, care, and other 
supportive services. During the COVID-19 pandemic, several adjustments 
were made to support homeless veterans in GPD programs. Rates have 
since decreased and significantly affected the ability to assist 
effectively in rural areas. If rates were returned to the previous 
years' rates, rural grant per diem programs could offer competitive 
wages to retain employees for consistency of care. GPD sites could hire 
additional staffing for housing navigation and landlord recruitment to 
facilitate low-barrier entry into housing and better facilitate same-
day access/enrollment in GPD programs. For those unable to be housed 
immediately, there would be funds for emergency hotel stays. Rural GPD 
programs would also be able to contract transportation for veterans, 
making access to care more manageable for those in the GPD programs 
through the VA.
    Insufficient funding can limit the quality and range of services 
available to our rural homeless veterans. Emergency funding provided a 
short-term solution but did not address the long-term financial needs 
of GPD programming. The need for sustained and adequate support for 
homeless veterans remains a critical issue. In supporting this 
vulnerable population, regular assessments and adjustments of grant and 
per diem rates that align with the actual costs of providing housing 
and supportive services are a must.

Adequate access to healthcare providers

    Shifting the focus to access to healthcare providers, I find myself 
fortunate to be a part of a community that houses a Community-Based 
Outpatient Clinic (CBOC). With the privilege of owning a vehicle and a 
job that supports flexibility for medical visits, coupled with the 
convenience of digital communication through va.gov and myhealthyvet 
portal, my access to healthcare stands at a level that eludes many in 
our rural areas.
    Recognizing this privilege fuels my passion for aiding rural 
veterans, especially those grappling with low income or homelessness, 
to secure equitable access to healthcare. I encounter veterans who lack 
transportation means, making it nearly impossible for them to reach 
healthcare providers. It's evident that meeting veterans where they 
are, particularly in rural areas, is pivotal for their well-being.
    I've witnessed veterans neglecting their health needs due to 
financial constraints or employment vulnerabilities. I have worked with 
a veteran working hard to get out of homelessness, putting their mental 
health on hold because they want to do better for themselves and their 
family, and the risk of losing their job prevented them from getting 
proper care. For many, the fear of losing their jobs due to taking time 
off for medical appointments further complicates matters. I have seen 
dental care for our rural veterans be impossible to get, affecting 
their overall health. A veteran who was injured on deployment has 
needed extensive dental work, bone grafts, and posts. It has taken 
three years to get an appointment for an assessment, causing extreme 
emotional distress to the family and veteran. I have seen veterans who 
request mental health appointments have to wait months to be seen.
    One potential solution is expanding health care services such as 
Mobile Medical Units (MMU) for primary care. These units, strategically 
deployed to areas where traditional healthcare access is limited, have 
the potential to bridge that gap. Extending VA hours, including weekend 
appointments and introducing MMUs, can significantly enhance healthcare 
accessibility for rural veterans. The Department of Veterans Affairs 
initiative in 2023 to deploy mobile medical units nationwide is 
promising. However, I have noticed a concentration of these units in 
major metropolitan areas, often neglecting rural regions where the need 
for accessible healthcare is equally critical. For real transformation 
for rural veterans, healthcare access with MMUs must extend its reach 
beyond urban areas. It's essential to devise a more coordinated 
approach that considers the geographical disparities and prioritizes 
areas with limited access to traditional VA medical centers. In 
addition to the MMUs, enhancing telehealth services, making them more 
accessible and user-friendly for veterans and rural regions, and 
providing transportation solutions are all ways to combat limited 
access to healthcare for our rural veterans. I urge you today to 
consider ``meeting our veterans where they are.''

Compensation and pension exams

    Accessing compensation and pension examinations has been a 
significant challenge, particularly considering the logistical hurdles 
and emotional strain involved. Drawing from my personal encounters, 
these examinations are critical for veterans' well-being; however, they 
are often presented with formidable obstacles. In my case, securing a 
female provider, a basic yet serious request, necessitated a two-hour 
commute, reflecting a limited availability of specific practitioners in 
my rural location. My first-hand experience took me through four 
different towns for these examinations, each site requiring a 
considerable travel distance, none closer than an hour away. This 
exhausting journey was compounded by the emotional toll often 
accompanying such assessments.
    Witnessing veterans struggling with transportation barriers has 
compelled me to assist them in reaching their appointments. One 
incident stands out vividly: I supported a veteran on a two-hour drive 
only to face an abrupt cancellation 15 minutes before the scheduled 
examination. This unforeseen disruption added distress to an already 
trying experience underlying the emotional preparation veterans invest 
in these evaluations. Working closely with another veteran, I 
encountered a stark reality that there would be a three f1/2-hour 
commute for their compensation and pension exam. This individual 
struggling with homelessness and lacking personal transportation faced 
an audacious journey to attend that appointment. Through collaborative 
efforts with the local veteran support organization, we managed to 
arrange transportation, be it with the inherent discomfort of relying 
on an unfamiliar volunteer, adding to the distress and an already 
emotionally charged examination.
    While the VA system has made strides in enhancing these 
examinations utilizing outside organizations, there remains a clear 
need for further improvements addressing transportation challenges, 
enhancing proximity to examination facilities, and considering the 
emotional strain endured by veterans during this process are essential 
areas for refinement within the system. Improving access to 
compensation and pension examinations can be addressed by establishing 
more examination centers in rural or underserved areas to consider 
reduced travel distances for veterans. These centers could offer a wide 
range of examinations to minimize the need for extensive travel. 
Expanding transportation assistance programs specifically tailored for 
veterans attending examinations can alleviate the burden of long 
commutes. Recognizing the emotional impact of these examinations and 
providing support services or counseling to veterans before and after 
examinations could help alleviate the stress and anxiety associated 
with the process. The central focus is meeting veterans where they 
are--in rural communities, so they have the ability to access the 
healthcare they have earned.

Conclusion

    As you deliberate on these strategies to improve rural access to 
healthcare for rural veterans, keep these stories in mind. Each 
narrative underscores the imperative need for actionable solutions.
    Thank you again for the opportunity to participate in today's 
hearing on rural healthcare access and how VA can better meet veterans 
where they live. I and other veterans like me sincerely appreciate your 
continued support of veterans.
                                 ______
                                 

                    Prepared Statement of Buu Nygren

    My name is Dr. Buu Nygren, and I serve as the President of the 
Navajo Nation. I come before you today to discuss the critical and 
ongoing issue of access to care and benefits for our Navajo veterans, 
who have a proud and storied history of military service.

Background

    The Navajo People hold a special place in American military 
history, having made extraordinary and unparalleled contributions. 
During the harrowing years of World War II, a select group of Navajo 
patriots, known as the Navajo Code Talkers, were pivotal to securing 
the Allied victory in the Pacific Theater. Harnessing the complexity 
and beauty of the Dine language, these heroes crafted an unbreakable 
code that confounded the Japanese military intelligence.
    In the blood-soaked sands of Iwo Jima, Navajo Code Talkers operated 
with relentless precision, flawlessly transmitting over 800 messages in 
the span of the first 48 hours of combat. Their efforts were 
impeccable, their dedication unwavering, and their impact on the war, 
immeasurable. Astoundingly, the participation of the Navajo people in 
World War II was not a mere footnote; over one in ten Navajos answered 
the call to serve--a testament to their indelible spirit and enduring 
patriotism.
    For more than two decades, the Code Talker program was shrouded in 
secrecy, their vital role in the Allied victory hidden from public 
accolades. Unbeknownst to many, the threads of Navajo valor continued 
to be woven through the fabric of American military engagements, from 
the bitter cold of Korea to the arid landscapes of the Middle East.
    The legacy of military service within the Navajo Nation is not just 
a chapter in history; it is a venerated tradition, a badge of honor 
that reflects the unyielding courage, resourcefulness, and sacrifice 
that define the Navajo people.
    The commitment of Native Americans to the United States military 
tapestry is not limited to the Navajo Nation. Native Americans have 
enlisted to serve at the highest rate of any ethnic group, 
demonstrating a profound dedication to the country. This tradition of 
service stretches back to the earliest days of the nation, from the 
Oneida warriors who fought alongside the Continental Army to the 
Cherokee and Choctaw Code Talkers of World War I, who used their 
languages to secure communications.
    Remarkably, this level of service was provided at a time when 
Native Americans were not yet fully recognized as American citizens. 
Despite this, an estimated 15,000 Native Americans served in World War 
I, accounting for nearly a quarter of the Native American adult male 
population of the time. Their valor was undeniable, yet it took until 
2008 for the United States to officially acknowledge and honor the 
contributions of the Native Code Talkers from both World Wars.
    In a profound expression of reverence for those who have served, 
the Navajo Nation took a significant step in 2016. The 23rd Navajo 
Nation Council, in a unanimous decision, enacted Legislation No. 0006-
16, establishing the Navajo Nation Veterans Administration (``NNVA'') 
as an entity dedicated to the welfare of Navajo veterans. This historic 
move, spearheaded by President Russell Begaye, was not simply 
administrative; it was a declaration of the inherent value and dignity 
of Navajo servicemen and women.
    This commitment bore fruit on May 2, 2022, when the NNVA was 
acknowledged by the United States Department of Veterans Affairs as the 
first tribal organization to be entrusted with assisting Native 
American veterans in navigating their benefits. This recognition is not 
just an administrative success; it is a beacon of respect and 
acknowledgment for the sacrifices and service of all Native American 
veterans, who have shown time and again that their bravery and . . . 
who have shown time and again that their bravery and loyalty know no 
bounds.
    The story of the Navajo warriors and Native American servicemen and 
women is one of unheralded sacrifice, of silent valor that echoes 
through the generations. It is a narrative that deserves its rightful 
place in the forefront of our nation's consciousness, a narrative that 
should be taught to our children as an integral piece of the American 
tapestry. These warriors, from the deserts of Arizona to the forests of 
the Northeast, have not only defended the United States but have also 
enriched its character, strengthened its resolve, and honored the very 
principles upon which it was founded.
    The Navajo Nation, along with the greater Native American 
community, has exemplified a commitment to service that transcends the 
call of duty. Their contributions have been etched into the stone of 
our nation's history, a permanent reminder of the price of freedom and 
the enduring strength of the human spirit.
    As we pay tribute to the Navajo Code Talkers and all Native 
American veterans, let us not simply remember their deeds as acts of 
the past. Instead, let them inspire us and guide us toward a future 
where their dedication to community, country, and valor are the 
standards to which we all aspire. The legacy of the Navajo Nation's 
contribution to military service is not just a chapter in history; it 
is a continuing journey of honor, resilience, and an unwavering 
commitment to the ideals of liberty and justice for all.

Healthcare

    Through programs like pensions for Revolutionary War veterans and 
institutions like the Naval Asylum (1811) and the Soldiers' Home 
(1851), America has always sought to reward veterans for their service 
and sacrifice. From the first consolidation into the Veterans Bureau in 
1921 to the Department of Veterans Affairs today, the VA has striven to 
continue this mission of caring for those who have sacrificed for 
America. Today, the VA operates over 1,600 healthcare facilities across 
the Nation, and nearly 75 percent of service-connected American Indian/
Alaskan Native (''AI/AN'') veterans utilize VA healthcare.
    Despite the rich history of service, Navajo veterans face 
significant barriers in accessing the care and benefits afforded them 
through their patriotism and sacrifices. The closest VA medical centers 
are hundreds of miles away from the Navajo Nation, in Phoenix, Arizona, 
Albuquerque, New Mexico, and Salt Lake City, Utah. Distance presents a 
formidable obstacle, and our veterans are often forced to travel long 
hours, at great personal expense, across remote areas and countless 
miles to receive basic services such as routine exams. This burden is 
compounded by social determinants that disproportionately affect our 
community, such as high rates of poverty, unemployment, and limited 
access to transportation, internet, and other necessities.
    To put the distance into perspective, a Navajo veteran living in 
Shiprock, NM, our largest community with over 8,000 residents, would 
need to drive 214 miles, roughly 4 hours, one-way to reach the closest 
full-service VA medical center, in Albuquerque, NM. A Navajo veteran 
living in Kayenta, AZ with over 5,000 residents located in the 
northwestern part of the Nation, would need to drive 291 miles, roughly 
5 hours one-way, to reach the closest full-service VA medical center in 
Phoenix, AZ. A Navajo veteran living in Montezuma Creek, our 
northernmost community in Utah would have to drive a staggering 351 
miles, roughly 6 hours without breaks to reach the VA Medical Center in 
Salt Lake City. These are rural roads that can be unpassable in winter.
    The distance between AI/AN veterans and centers is a significant 
factor in their likelihood to delay care, as well as not getting 
through the phone and not getting timely appointments. Additionally, 
AI/AN veterans tend to be less likely to get dental care, prescription 
medications, medical care and glasses than white veterans, despite 
being more likely to need these services due to the difficulty for them 
to get full services from the VA. The challenges of not having a full-
service VA medical center are exacerbated when veterans need specialty 
care.
    There are only three VA clinics on the Navajo Nation (Chinle, Tuba 
City, and Kayenta) and their focus is on primary care, laboratories, 
and less severe mental health issues. Considering that AI/AN veterans 
who use VA mental health services tend to experience Post Traumatic 
Stress Disorder (PTSD) at a greater rate than all other veteran groups, 
the fact that the three VA clinics on the Nation focus on less severe 
mental health issues is a present concern. Another present concern is 
that AI/AN veterans are diagnosed with chronic pain and diabetes at a 
higher rate than any other veteran group, and that AI/AN veteran women 
are two times more likely to experience pregnancy difficulties due to 
hypertension or diabetes than white veteran women. None of the clinics 
can provide specialty care such as cardiology, oncology, or osteology. 
A veteran should not have to travel several hours each way to see a 
specialist, especially when those medical conditions may have been the 
price for their service to the United States.
    Furthermore, in addition to the difficulty AI/AN veterans have 
accessing vital health resources to get treatment for medical 
conditions that might have stemmed from their time in the military, 
they also share the same negative social determinants of health that 
other AI/AN citizens have. For the Navajo, whether they are a veteran 
or not, the average life expectancy is that of 72.3 years, 4.2 years 
lower than the average U.S. life expectancy, and Navajo have a 31 
percent higher mortality rate than the U.S. average. The leading cause 
of death for the Navajo is unintentional injury, and the second one is 
heart disease.
    Another challenge is the cost of travel to the full-service 
facilities. According to the Department of Veteran Affairs, AI/AN 
veterans have the lowest personal incomes among veterans of other 
races/ethnicities. The median income of an AI/AN veteran is $29,920, 
over $10,000 less annually than white veterans. The median income of 
Navajo veterans is in line with these disproportionate numbers at 
$30,682. Considering that a Navajo veteran would likely need to stay at 
a hotel given the 8-hour or more roundtrip drive to receive specialized 
care and the high cost of gas, the commute to VA medical centers has a 
disproportionate economic effect on Navajo veterans.
    The current mileage reimbursement by the VA is $0.415 per mile 
approved. The same veteran traveling from Shiprock, NM would travel 428 
miles roundtrip and be reimbursed $177.62. With a current national 
average gas price of $3.088 as of January 05, 2023, it would cost a 
Navajo veteran $74.11 to fill up a 24-gallon tank, not to mention wear 
and tear on their vehicle. Given the heavily agricultural economy of 
the Nation along with the severe winter storms we experience, most 
Navajo citizens drive larger vehicles which are not fuel efficient. 
Lower income levels also translate into older vehicles and therefore 
are even less fuel efficient and subject to more costly/frequent 
maintenance. The cost of transportation in gas and maintenance can 
easily exceed the mileage reimbursement.
    Telehealth services, while beneficial, are not a cure-all for our 
veterans. The digital divide is a stark reality for the Navajo Nation, 
where many veterans lack adequate internet access, or the technology 
needed to utilize telehealth effectively. This limitation is not just a 
matter of convenience, but a barrier to essential healthcare, mental 
health services, and benefits assistance.
    According to the FCC, about 23 percent of households in the Nation 
do not have access to download/upload internet speeds of at least 25/3 
mega-bits per second (mbps). This is the minimum speed a single device 
needs to have an adequate video call assuming no other devices are 
connected at the same time. Only 3.54 percent of households in the 
Navajo Nation have download/upload speeds of at least 100/200 mbps, 
which is typical of a single to small household.
    The VA's beneficiary travel program is critical, yet it does not 
fully offset the high costs and logistical challenges associated with 
long-distance travel to VA facilities. Furthermore, grant and per diem 
rates for homeless veterans do not reflect the higher costs of living 
in remote areas, which further disadvantages our veterans in need.
    I am respectfully requesting Congress to consider appropriating 
funds to build a full-service VA medical center ion the NavajoNation. 
Having this center on the Nation would contribute greatly to providing 
the quality of care our veterans deserve. It would also have a 
tremendous and positive economic impact for the Nation. The medical 
center would not just serve Navajo veterans, but much of rural Arizona, 
New Mexico, and Utah. The tax dollars generated from gas, food, and 
other items purchased within the Nation would be contributed to 
providing more services to our Dine people. It would also help keep our 
limited Navajo tax dollars in the Nation instead of going to our 
surrounding states.
    My recommendation on how to meet veterans where they are and 
provide competent and quality care breaks down into five parts:

    First, Congress should work with the Department of Veterans Affairs 
to conduct a comprehensive needs analysis, incorporating key factors 
such as population demographics, healthcare consumption trends, and the 
incidence of specific health conditions among Navajo veterans. This 
data-driven approach will provide an accurate understanding of 
healthcare needs of Navajo veterans and pave the way for targeted 
interventions.

    Second, we should foster collaboration between Congress, the VA, 
Navajo Nation leaders, and tribal health authorities. This will be 
instrumental in gaining a nuanced understanding of the existing 
healthcare infrastructure, identifying synergistic partnership 
opportunities, and ensuring the proposed VA medical center aligns with 
the cultural values and healthcare expectations of Navajo veterans.

    Third, we should commit resources for infrastructure development by 
allocating sufficient funds and resources for constructing and 
operationalizing the VA medical center. It is imperative to ensure that 
the center is appropriately staffed with healthcare professionals who 
are adept at managing the unique healthcare needs of Navajo veterans.

    Fourth, we should integrate telehealth services by incorporating 
and expanding telehealth services to provide remote healthcare access, 
especially for those veterans residing in distant areas where travel to 
a VA medical center is difficult. This digital platform can enhance 
healthcare accessibility while reducing travel-related barriers.

    Fifth and finally, we should adopt a culturally competent care 
model. The healthcare services at the VA medical center should be 
culturally competent, integrating traditional healing practices and 
respecting the cultural and linguistic diversity of the Navajo Nation. 
Such an approach will foster a sense of belonging and trust among 
Navajo veterans, thereby encouraging them to seek and adhere to 
necessary healthcare services.

Other Services

    Another challenge our Navajo veterans face is inadequate access to 
information regarding their benefits and entitlements. In 2017, less 
than half of AI/AN veterans used at least one VA benefit or service.
    The Navajo Nation Veterans Administration is proposing the 
construction of a regional Veterans Administration Center / Veterans 
Benefits Administration Center, a one-of-a-kind community-based 
outreach center of sorts, that is available to all veterans but focuses 
services on Native American veterans. The purpose of this facility is 
to provide much needed services in a geographical area that are not 
currently being delivered by the Department of Veterans Affairs.
    This facility would serve as a hub for a variety of services that 
include non-emergency / non-urgent care services typically found 
outside of a Veteran Affairs Medical Center (``VAMC''), such as 
physical or occupational therapy, mental health services, vocational 
training and education, temporary / transitional housing, and 
transportation services, as well as serving as an administrative 
facility for Navajo Nation, state, and federal VA staff to administer 
program services.
    The Navajo Nation has already chosen a location for this facility 
and taken the legal step of ``withdrawing'' the land so that it is 
preserved for this facility. It is situated on New Mexico's Highway 
264, less than two miles from the Arizona state line, and adjacent to 
the Navajo Nation capital in Window Rock, Arizona. It is located 
adjacent to the future Navajo Code Talkers Museum site. This site has 
easy access to public roads with heavy traffic, as well as existing 
power, water, and sewage. It has been determined through surveys that 
the site is appropriate for the construction of a project of this 
magnitude. This facility is also consistent with the master plan for 
this area's development, which will boost the Navajo Nation's economic 
development efforts. Congress must provide adequate funding for 
facility construction.
    The Navajo Nation also has a very high portion of senior citizen 
veterans. Over 46 percent of veterans living on the Nation are aged 65 
or older. Many of these veterans need quality nursing home care and are 
severely underserved. There are no VA recognized nursing homes on the 
Nation, or within a reasonable commute. Our veterans living in the Utah 
portion of the Nation again have the longest distance with the closest 
VA contracted nursing home being 327 miles away from Montezuma Creek. 
The distance makes it difficult for families to visit their loved ones 
in their retirement and final years. I respectfully ask Congress to 
work with both the Navajo Veterans Affairs Administration and the US 
Department of Veteran Affairs to get our nursing homes VA contracted.

Conclusion

    The lack of adequate VA care on the Navajo Nation dishonors the 
contributions the Navajo people have made to the defense of this 
country. Our veterans have earned the right to accessible, quality care 
and benefits through their service and sacrifice.
    I urge this Committee and Congress to take decisive action to 
address these critical issues faced by Navajo veterans. We need 
increased funding aimed specifically at improving infrastructure and 
services in rural and highly rural areas, tailored to the unique 
challenges of these regions. We must bridge the digital divide to 
ensure telehealth is a viable option for all veterans. It is essential 
to adjust grant and per diem rates to reflect the true cost of living 
in remote areas, and to expand the beneficiary travel program to 
alleviate the significant financial burden on our veterans.
    Our Navajo veterans have honored their commitments to our country. 
It is time that we honor our commitments to them. Thank you for your 
time and consideration.
    Ahehee' (Thank you).
                                 ______
                                 

                    Prepared Statement of Jon Lovald

    Chairman Bost, Ranking Member Takano, and Committee Members, my 
name is Jon Lovald and I'm the Chief Operations Officer for the 
Minnesota Assistance Council for Veterans--MACV. We are a 501c3 
statewide nonprofit with the mission to end veteran homelessness in 
Minnesota. I began with MACV in May 2017. Before my time at MACV, I 
served in the Army and Minnesota National Guard for 25 years, retiring 
as a Lieutenant Colonel. I am beyond honored to be a part of MACV and 
our mission, working to incorporate housing for all Minnesota veterans 
with wrap-around services for stability.
    MACV has served veterans and families experiencing or facing 
homelessness since 1990. We do so with a wide-reaching, comprehensive 
network of over 100 staff, as well as community partners throughout the 
state. The experience, professionalism and compassion our team shows 
the veterans we serve speaks to a devotion to mission. MACV's services 
include housing stability case management, landlord engagement, 
employment, healthcare navigation, legal services, permanent and 
transitional housing, financial management and representative payee 
services launched through the VA's Money Management Intervention pilot. 
MACV operates statewide through offices in the Twin Cities, Duluth, 
Saint Cloud, Moorhead, Mankato, Bemidji, and Rochester. The key to 
success in all our programs is the combination of individualized 
services each client receives with MACV's singular goal for all 
veterans to achieve or maintain housing stability.
    MACV is proud to receive more than $7 million in federal grants 
each year. Our awards include grants through the U.S. Veterans 
Administration (Supportive Services for Veteran Families--SSVF, Grant & 
Per Deim transitional and case management grants - GPD, and Legal 
Services for Veterans - LSV), the U.S. Department of Labor (Urban and 
Non-Urban Homeless Veteran Reintegration Program - HVRP), and the U.S. 
Department of Housing and Urban Development (four rural Continuum of 
Care grants). These federal grants make up the single largest source of 
funding for MACV and our mission.
    MACV operates 225 beds of transitional and permanent supportive 
housing scattered across the state. These units, including 52 in 
Greater Minnesota, have gradually come online through a combination of 
federal, state, and philanthropic partnerships. This year, we plan to 
open at least 11 new housing units in the Twin Cities metro, and an 
additional 8 in Greater Minnesota. We are excited to offer supportive 
housing in the Rochester area for the first time in the coming months, 
providing much-needed options in one of Minnesota's hardest-hit regions 
for lack of affordable housing.
    Our staff has witnessed a significant uptick in veterans needing 
assistance since the end of the COVID-19 pandemic. In many rural 
communities, the scarcity of local support makes MACV's outreach and 
engagement activities even more crucial. Strategic outreach provides 
rural communities with a wide array of resources that empower veterans 
to stay ahead of crises and remain in their communities. We leverage a 
variety of federal, state, and philanthropic resources to address the 
needs of veterans affected by homelessness.
    We are proud to count our partners within the VA, DOL, and HUD 
among our strongest allies in the fight to end veteran homelessness in 
Minnesota, including our rural communities. The funds appropriated to 
MACV by the U.S. Department of Veterans Affairs are especially 
important to our mission's success. In 2023, MACV enrolled 937 veterans 
in comprehensive services in Greater Minnesota to end or prevent an 
episode of homelessness. This figure represents a 22 percent increase 
in the number of rural veterans served in 2021. Of those 937 
individuals:

      66 percent have a documented disability, including 52 
percent with a service-related disability.

      47 percent are 55 years of age or older

      19 percent have minor children

      18 percent identify as Veterans of Color

      12 percent were female veterans

      62 percent had household income below 50 percent Area 
Median Income

      43 percent were below 30 percent Area Median Income

      107 veterans were placed into employment

    Minnesota is determined to become the fourth state in the union to 
achieve Functional Zero for veteran homelessness statewide by the end 
of 2025. The United States Interagency Council on Homelessness (USICH) 
has already qualified MACV and our network of statewide partners as 
functionally ending veteran homelessness in eight of Minnesota's 10 
homeless Continuums of Care (CoC) regions, including its seven rural 
CoCs. While this declaration does not mean there are no veterans 
experiencing homelessness within these geographies, it does mean that 
each region has the systems and partnerships in place to ensure that 
veteran homelessness is rare, brief, and non-recurring.
    MACV utilizes numerous tools in pursuit of achieving our mission. 
Resources including Minnesota's Homeless Veteran Registry (HVR) provide 
a real-time snapshot of veterans experiencing homelessness anywhere in 
the state. The HVR allows us to keep count of those experiencing 
homelessness, their most recent location, the amount of time spent in 
homelessness, as well as other key pieces of information. As of January 
5, 2024, there are 262 veterans on the HVR, including 46 veterans in 
rural CoCs. Program staff for the HVR partner agencies of MACV, the 
Minnesota Department of Veterans Affairs, and the VA homeless program 
teams throughout the state, discuss each veteran on the list at bi-
weekly meetings. Regular case conferencing allows for the organizations 
best situated to serve homeless veterans to identify their needs and 
barriers, as well as ensure that plans for housing stability are in 
place and being followed. The need for this service coordination is 
especially high in rural areas, where resources are geographically 
spread out.
    While each veteran experiencing homelessness has their own unique 
set of challenges and goals on the path to housing stability, there are 
also noted barriers that the rural veteran consistently faces. Some of 
the barriers include:

      Lack of affordable rental housing.

      Struggling to find jobs that pay a livable wage.

      Limited to no public transportation options.

      Scarcity of supportive services.

      Many communities with no emergency shelter.

    The lack of affordable rental housing in rural areas has become 
increasingly acute as climbing rents consistently outpace income in 
recent years. Once-affordable housing has become much more competitive, 
while the criteria for selecting rental tenants have grown narrower. In 
addition to having low income, many veterans on the by-name list have 
other barriers such as poor credit, a history of prior evictions, a 
need for handicapped-accessible units, or past justice involvement. 
These barriers lead to many veterans unable to access housing in their 
communities even if they can locate an affordable unit. In larger rural 
population hubs, such as Duluth, Rochester, and Mankato, significant 
student populations and specialized workforces such as professional 
staff for the Mayo Clinic in Rochester further reduce the number of 
affordable housing units available to MACV-served veterans.
    The challenge experienced by veterans in finding living wage 
employment closely ties to a lack of public transportation in rural 
communities. One MACV-served veteran walked 30 miles per day to make it 
to work until the season changed and that was no longer an option. 
Veterans without reliable transportation are relegated to finding jobs 
within walking distance from where they are staying or moving to larger 
population hubs to find work or job training. As nearly half of the 
veterans MACV serves in rural communities are over 55, finding living 
wage employment that is not physically demanding is an even greater 
challenge in rural areas without diverse industries. To have 
transportation, many veterans take on the added expense of a vehicle. 
These vehicles are often unreliable based on what the veteran can 
afford. This creates additional burdens of repairs, insurance, and fuel 
that veterans in urban centers can avoid by relying on public 
transportation. High vehicle costs make it even more challenging to 
afford housing, leading to difficult choices of paying for housing or 
for their vehicle to maintain work. Far too often, the vehicles become 
housing themselves.
    Many nonprofits, healthcare, chemical health, and mental health 
services are located in urban centers. The inequity in service 
availability to obtain and then sustain housing stability is a 
challenge for rural veterans experiencing homelessness. These services 
help to navigate a complex web of benefits and resources and require a 
hands-on approach. With many veterans experiencing housing instability 
in rural areas having inconsistent access or proficiency with 
technology, make person-to-person connections more critical, and the 
shortage of providers more destabilizing.
    In addition to the challenges of obtaining support for long-term 
stability, most of rural Minnesota does not have emergency shelters 
available for homeless community members. As a result, veterans without 
a place to stay must either leave their home communities to find a warm 
place to sleep, or survive in the Minnesota winters by sleeping in 
tents, in trailers with no heat or water, in vehicles, or fish houses. 
With a lack of shelter in the winter, if a friend or family member of a 
veteran lets them stay, the veteran may then lose eligibility for 
homeless designated housing programs and services, putting them back at 
square one once they are no longer able to temporarily double up.
    Federal programs that benefit veterans experiencing homelessness 
are an incredible resource. However, many are not available to veteran 
households in rural areas. HUD-VASH, which provides a Section 8 voucher 
coupled with VA clinical case management, does not provide vouchers to 
many Minnesota rural geographies based on distance to VA supportive 
services. Where HUD-VASH can provide services, vouchers are scarcer 
than in urban centers. Local VA Medical Centers in Minnesota have done 
great work in expanding their geography to cover more communities 
outside of metropolitan hubs, there remains significant geography 
outside of the catchment for this resource. Of the 276 rural veterans 
on the Homeless Veteran Registry throughout 2023, over 80 percent were 
eligible for HUD-VASH, while only 11 percent received a voucher. In 
addition, VA Community Based Outreach Clinics (CBOCs) and DOL funded 
veteran services at American Job Centers, which are often in rural 
population centers, are miles from many of our most rural Minnesota 
veterans.
    While not all federal resources are available in each rural 
community, as the only VA Supportive Services for Veteran Families 
grantee in our state, MACV is pleased with the efforts of the VA to 
ensure that each county in the nation is served by SSVF. Telehealth has 
also become a great resource for many veterans that we serve by 
assisting eligible individuals with access to key healthcare resources. 
While this has been a fantastic expansion of federal support, it is a 
challenge for the rural veteran experiencing homelessness to use. Many 
veterans with low incomes have limited or no access to reliable 
technology like cell phones, or access to laptops. Many veterans simply 
do not feel comfortable or knowledgeable enough to utilize telehealth, 
another perennial challenge to an otherwise helpful initiative on the 
part of the VA.
    Specific initiatives undertaken by individual VA facilities have 
also improved client outcomes across Minnesota in recent years. MACV 
supports Fargo VA's process of opening a Community Resource and 
Referral Center. This center focuses on serving homeless veterans, 
particularly rural veterans in the Fargo/Moorhead community, and is an 
asset to the State. The Minneapolis VAHCS has recognized the dearth of 
VA presence in many of Minnesota's rural regions and expanded its HUD-
VASH catchment to serve more veterans than the standard 30-mile radius 
around the VA campus. The Minneapolis VA has elected to include 10 
public housing authorities in rural Minnesota and Wisconsin, in 
addition to its standard HUD-VASH catchment area. We are lucky to have 
such amazing partnerships with our local VA partners on the ground 
throughout the State. We hold these partnerships up to anyone in the 
country.
    Minnesota is fortunate to have a State Department of Veterans 
Affairs with a shared mission of ending veteran homelessness through 
innovative practices and initiatives. Addressing the lack of affordable 
housing in Minnesota, the State has granted funds for housing 
development for veterans on the Homeless Veteran Registry with the most 
significant barriers to accessing housing. MACV has used this 
investment to strategically develop housing in Greater Minnesota. The 
State has also granted funds to MACV to develop a statewide housing 
subsidy program with clinical case management, similar to HUD-VASH, 
specifically targeting veterans who cannot enroll in HUD-VASH. One of 
the largest beneficiary groups for the subsidy, titled MNVEST, is the 
veteran population in rural communities that simply do not offer HUD-
VASH as a subsidy program. The State has also worked to fill the gap in 
rural emergency shelters through the administration of a reimbursable 
hotel shelter program. The State also funds County and Tribal Veteran 
Service Officers for each county and tribal nation. We know how lucky 
we are that the State has stepped up to help fill gaps for resources 
that are not available federally.
    MACV regularly reaches beyond Minnesota's traditional veteran 
service agencies in the course of our work. Some of our strongest local 
allies include County or Tribal Veteran Service Officers, who are 
county employees working to connect veterans to the benefits and groups 
which can change the trajectory of their lives. County and Tribal VSOs 
can assist with the MACV intake process and gather documents and 
signatures to speed up the time from initial contact to housing 
solutions. MACV has forged relationships with local American Legion and 
VFW posts throughout the State. Local chapters of Disabled American 
Veterans provided more than 7,500 free rides covering 373,000 miles to 
rural veterans who lack transportation options for important medical 
appointments in 2023. Leveraging local groups who know the veterans in 
their community is a key component of our rural outreach strategy that 
has allowed us to achieve the benchmarks of functional zero in 85 of 87 
Minnesota counties. MACV has partnered with thousands of veterans and 
their families in accessing the resources these individuals earned 
through service to our country. We understand the many strengths that 
rural communities have when it comes to taking care of local veterans. 
While MACV has offices in rural population centers, we intentionally 
build strong partnerships with those closest to the veterans living 
everywhere in Minnesota.
    Federal resources, when implemented locally by the people who best 
know their community, are key components of Minnesota's progress in 
ending veteran homelessness. When we equip veterans with tools and 
support for their success, the resilience of this group is proven to be 
remarkable. The VA and their federal USICH partners have taken the 
initiative to lead this effort using proven methods that lift veterans 
and their loved ones out of homelessness and into the safety and 
dignity of housing suited to every veteran's needs. Expanding the 
availability of HUD-VASH, responsively addressing rural transportation 
barriers for veterans, providing access to technology, and other 
supportive services targeting rural veterans are simply essential to 
preserve the progress Minnesota has made in our smaller communities. 
The VA's temporary expansions for addressing the need for rideshares 
and cell phone provision made remarkable impacts on the well-being of 
rural veterans across our state. We hope to see these initiatives 
reimplemented in the future because they simply work.
    Thousands of veterans MACV and our VA partners serve each year have 
unique stories. One veteran, whom we'll call Ryan, served our country 
for four years in the U.S. Coast Guard before receiving an honorable 
discharge. He contacted MACV after he lost his wife. Struggling to care 
for himself while grieving, Ryan was hospitalized and had a partial 
amputation of his foot. When he was discharged, Ryan was several months 
behind on rent and about to lose his housing. MACV provided emergency 
financial assistance to get Ryan back in the black. After a family 
member living with Ryan was arrested, Ryan was evicted from his home. 
The lack of reliable transportation and communication put him out of 
contact with his care team for significant amounts of time. This stint 
of homelessness ended with Ryan being hospitalized for three months 
with a life-threatening infection. Following discharge from the 
hospital, Ryan was placed in a hotel room for emergency shelter while 
securing more sustainable supportive housing. Today, Ryan resides in a 
supportive housing unit secured by his MACV team and focuses his time 
and energy on applying for the benefits and programs that will improve 
his long-term stability. The story is one with challenges, but the 
outcome of Ryan living in his own apartment and having his life back as 
a member of the community is the result that MACV strives to give every 
single veteran affected by homelessness in Minnesota.
    MACV has a vision for every veteran we serve to have a way to 
afford housing, access housing, and have the services and support 
needed to sustain long-term stability. We could not do this critical 
work without the support of our federal partners, VA, HUD, DOL, USICH, 
and Congress. Thank you for your past support of the key federal 
programs targeting veterans of the U.S. military, and consideration of 
future initiatives toward achieving our mission to end veteran 
homelessness in Minnesota and in the United States.
                                 ______
                                 

                   Prepared Statement of Mark Holmes

    Chairman Bost, Ranking Member Takano, and Members of the Committee:
    My name is Mark Holmes. I am the Director of The Cecil G. Sheps 
Center for Health Services Research and North Carolina Rural Health 
Research Center at the University of North Carolina at Chapel Hill. I 
am also a professor in the UNC Gillings School of Global Public Health. 
I have been a rural health researcher for 25 years; my expertise is in 
hospital finance and health policy, especially federal public insurance 
payment policy. Growing up in Michigan's rural Thumb, I witnessed 
firsthand some of the health challenges facing our rural communities.
    The Cecil G. Sheps Center for Health Services Research is one of 
the nation's leading institutions for health services research. Our 
interdisciplinary researchers undertake innovative research and program 
evaluation to understand health care access, costs, delivery, outcomes, 
equity, and value. The Sheps Center has a long-standing reputation for 
conducting high-quality, objective research that informs science, 
practice, and policy. The Center's Program on Rural Health Research is 
one of many Sheps Center programs generating the evidence to inform 
policy makers about the challenges and opportunities in ensuring access 
to health care services. For today's hearing, I will speak primarily 
about challenges facing the non-VHA rural health care system. Rural 
veterans may qualify to access community (``non-VHA'') providers, so 
it's important to recognize the fragility of the rural health care 
system as part of their care. I am unable to cover all the salient 
issues in rural health today, so I will focus my comments on three main 
points relevant to today's topic:

        1. Rural health care infrastructure continues to erode, and 
        this threatens the health and well-being of the 60 million 
        Americans - including the 4 million veterans--who live in rural 
        areas.

        2. Congress can improve the health of rural communities by 
        addressing some specific policy issues in rural health 
        workforce.

        3. The common narrative of rural places having sicker, poorer, 
        and older populations is mostly accurate, but is too 
        fatalistic--many rural communities have also shown remarkable 
        ability to use their strength to overcome challenge.

Threats to a Robust Rural Health Care System

    Since 2005, nearly 200 rural communities have seen their hospital 
close, or close its inpatient service.\1\ Although roughly half of 
these hospitals have continued to provide some kind of health care to 
their community, the remainder have not; they've become condominiums, a 
car wash, or more often completely abandoned. In addition to providing 
health care, we also know how important hospitals are to rural 
economies. Recent research has shown that hospital closures can lead to 
decreases in the size of the labor force and the population living in 
the community.\2\ Those hospitals that do survive have steadily gotten 
smaller. Rural hospitals have cut services like maternity care and home 
health services,\3\ and inpatient care in rural hospitals has fallen by 
13 to 20 percent in the last decade,\4\ with most of this decrease 
driven by rural residents being increasingly likely to receive 
inpatient care at urban hospitals (bypassing local care).\5\ Access to 
specialty care is also affected. Approximately 20 percent of Americans 
live more than 60 minutes from a medical oncologist,\6\ and the 
financial burden of increased travel time reduces the use of life-
saving treatments and, paradoxically, increases the cost of care; 
geographic barriers to care actually lead to higher costs in the long 
run.\7\ Rural residents who drive an hour a day - each way - for five 
weeks in a row to get their radiation treatment are facing fatigue of 
long car travel while fighting cancer.
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    \1\ Rural Hospital Closures. The Cecil G. Sheps Center for Health 
Services Research, University of North Carolina at Chapel Hill. https:/
/www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-
closures/
    \2\ Malone, TL, Planey, AM, Bozovich, LB, Thompson, KW, Holmes, GM. 
The economic effects of rural hospital closures. Health Serv Res. 2022; 
57( 3): 614-623. https://doi.org/10.1111/1475-6773.13965
    \3\ Knocke K, Pink G, Thompson K, Randolph R, Holmes M. Changes in 
Provision of Selected Services by Rural and Urban Hospitals between 
2009 and 2017. NC Rural Health Research Program, UNC Sheps Center. 
April 2021. FB 174.
    \4\ Malone, T.L., Pink, G.H. and Holmes, G.M. (2021), Decline in 
Inpatient Volume at Rural Hospitals. The Journal of Rural Health, 37: 
347-352. https://doi.org/10.1111/jrh.12553
    \5\ Fiedman HR, Holmes GM. Rural Medicare beneficiaries are 
increasingly likely to be admitted to urban hospitals. Health Serv Res. 
2022 Oct;57(5):1029-1034. https://doi.org/10.1111/1475-6773.14017.
    \6\ Levit LA, Byatt L, Lyss AP, Paskett ED, Levit K, Kirkwood K, 
Schenkel C, Schilsky RL. Closing the Rural Cancer Care Gap: Three 
Institutional Approaches. JCO Oncol Pract. 2020 Jul;16(7):422-430. 
https://doi.org/10.1200/OP.20.00174.
    \7\ Rocque GB, Williams CP, Miller HD, Azuero A, Wheeler SB, Pisu 
M, Hull O, Rocconi RP, Kenzik KM. Impact of Travel Time on Health Care 
Costs and Resource Use by Phase of Care for Older Patients With Cancer. 
J Clin Oncol. 2019 Aug 1;37(22):1935-1945. https://doi.org/10.1200/
JCO.19.00175.
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    This diminishing access has led to increasing rural-urban 
disparities in health outcomes. In 1999, the death rate in the most 
rural counties was 6 percent higher than it was in large urban 
counties; in 2019, it was 28 percent higher.\8\ Meanwhile, research led 
by experts at the Centers for Disease Control and Prevention (CDC) 
found that communities where a rural hospital closed saw an increase in 
preventable admissions.\9\
---------------------------------------------------------------------------
    \8\ Analysis of United States Department of Health and Human 
Services (US DHHS), Centers for Disease Control and Prevention (CDC), 
National Center for Health Statistics (NCHS), Multiple Cause of Death 
1999-2020 on CDC WONDER Online Data base, released 2021. Data are 
compiled from data provided by the 57 vital statistics jurisdictions 
through the Vital Statistics Cooperative Program.
    \9\ Khushalani JS, Holmes M, Song S, Arifhanova A, Randolph R, 
Thomas S, Hall DM. Impact of rural hospital closures on 
hospitalizations and associated outcomes for ambulatory and emergency 
care sensitive conditions. J Rural Health. 2022 May 5. https://doi.org/
10.1111/jrh.12671.
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    Hospitals have had weak and declining finances for years. In 2018, 
roughly half of rural hospitals were unprofitable, and financial 
distress is one of the leading causes of rural hospital closure. As 
hospitals close, residents face a decrease in access to health care. 
Facing this decline in access, Congress, the Medicare Payment Advisory 
Commission and others have often proposed new models of care that focus 
on a hospital's emergency department services. The Consolidated 
Appropriations Act of 2021 created a new type of health care provider--
the Rural Emergency Hospital (REH). This model has some appealing 
elements, and at this time 18 rural hospitals have officially converted 
to REHs, but interest has been more modest due to some program design 
elements that can only be addressed legislatively. I applaud Congress 
for acting innovatively to address rural health needs. Continued 
monitoring of this provider type will be necessary to ensure it is 
meeting the needs Congress intended.
    While REHs try to take root, the growth of hospital systems and 
consolidation continues to raise questions. Increasingly, rural 
hospitals are becoming part of a larger health care systems, and this 
can lead to further service erosion. Work by researchers out of the 
Agency for Healthcare Research and Quality has found that rural 
hospitals that merge are more likely to close their obstetric and 
surgical units.\10\ Given that one study concluded female veterans may 
be more dependent on non-VHA providers to receive certain gender-
specific services, like obstetric and gynecologic care,\11\ the erosion 
of these services in rural communities is especially notable.
---------------------------------------------------------------------------
    \10\ Henke RM, Fingar KR, Jiang J, Liang L. and Gibson TB. Access 
To Obstetric, Behavioral Health, And Surgical Inpatient Services Ager 
Hospital Mergers In Rural Areas. Health Affairs 2021 40:10, 1627-1636
    \11\ Marshall V, Stryczek KC, Haverhals L, Young J, Au DH, Ho PM, 
Kaboli PJ, Kirsh S, Sayre G, The Focus They Deserve: Improving Women 
Veterans' Health Care Access, Women's Health Issues 2021, 31(4): 399-
407. https://doi.org/10.1016/j.whi.2020.12.011

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Rural Areas are Facing Acute Health Workforce Shortages

    Rural places have faced persistent workforce shortages. Over the 
past 20 years, it has become even more difficult to recruit, retain, 
and sustain rural health care workers ranging from doctors to nurses to 
emergency medical service (EMS) personnel in rural areas.\12\ Without 
an adequate health workforce, it is becoming more difficult for 
individuals in rural areas to access health care.\13\ Many proposed 
policy solutions to address these workforce challenges focus on one 
profession, for example nurses, or one stage of the career, such as 
graduate medical education. To shore up and grow the rural health 
workforce, it is critical that we look to solutions that aren't siloed 
in this fashion and support health care workers across their entire 
career trajectory.\14\
---------------------------------------------------------------------------
    \12\ Rural Health Research Gateway. Trends in Health Workforce 
Supply in the Rural. U.S. https://www.ruralhealthresearch.org/projects/
926
    \13\ Strengthening the Rural Health Workforce to Improve Health 
Outcomes in Rural Communities Council on Graduate Medical Education 
24th Report. 2022. https://www.hrsa.gov/sites/default/files/hrsa/
advisory-committees/graduate-medical-edu/reports/cogme-april-2022-
report.pdf
    \14\ Fraher E, Brandt B. Toward a system where workforce planning 
and interprofessional practice and education are designed around 
patients and populations not professions. J Interprof Care. 2019 Jul-
Aug;33(4):389-397. https://doi.org/10.1080/13561820.2018.1564252.
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    Evidence-based investments that increase the number of health 
professionals training in rural areas, increase the number of 
preceptors and faculty, provide support to early career health care 
workers, and focus on retaining mid to late career health care 
professionals can be further scaled. Health professionals that train in 
rural areas are five times as likely to remain in practice in rural 
areas.\15\ By growing the number of rural training opportunities and 
then ensuring that resources are available to retain that workforce 
across their careers, we can ensure that the workforce needed to 
support rural areas is there for decades to come.\16\
---------------------------------------------------------------------------
    \15\ Russell DJ, Wilkinson E, Petterson S, Chen C, Bazemore A. 
Family Medicine Residencies: How Rural Training Exposure in GME Is 
Associated With Subsequent Rural Practice. J Grad Med Educ 1 August 
2022; 14 (4): 441-450. https://doi.org/10.4300/JGME-D-21-01143.1
    \16\ Kumar S, Clancy B. Retention of physicians and surgeons in 
rural areas--what works?, Journal of Public Health December 2021, 
43(4), 689-700, https://doi.org/10.1093/pubmed/fdaa031
---------------------------------------------------------------------------
    Decades of research have taught us that one of the most effective 
ways to boost health workforce in rural and underserved areas is to 
train them in rural and underserved areas.\17\ Efforts to expand 
physician training have paid great dividends; for example, during the 
five-years of the Rural Residency Planning and Development program, 
there have been more new rural residency slots (463) than were 
established during the prior decade (418). Meanwhile, the VHA has 
increased the number of residency slots by 1,500, with many rural VHA 
facilities receiving priority for additional slots.\18\
---------------------------------------------------------------------------
    \17\ E.g. Holmes G.M. Increasing physician supply in medically 
underserved areas. Labour Economics. Volume 12, Issue 5, 2005, Pages 
697-725, ISSN 0927-5371, https://doi.org/10.1016/j.labeco.2004.02.003.
    \18\ Klink KA, Albanese AP, Bope ET, Sanders KM. Veterans Affairs 
Graduate Medical Education Expansion Addresses U.S. Physician Workforce 
Needs. Acad Med. 2022 Aug 1;97(8):1144-1150. https://doi.org/10.1097/
ACM.0000000000004545.
---------------------------------------------------------------------------
    Congress has enacted legislation to address rural physician 
shortages via training. The Consolidated Appropriations Act of 2021 
included provisions that expand rural resident training opportunities. 
Section 126, for example, increased the number of physician residency 
slots, to be phased in over several years. To qualify, training 
programs must meet one of four criteria, including being located - or 
being treated as being located - in a rural area. Legal decisions have 
led to a rapid increase in the number of urban hospitals that 
reclassify as rural; this means that, under current legislation, they 
are treated as rural hospitals in all respects, including eligibility 
for residency slots. Despite a ten-percent floor on the number of 
expanded residency slots allocated to rural hospitals, only five 
percent of slots were allocated to hospitals located in rural areas; 
another 42 percent were allocated to urban hospitals that have been 
reclassified as rural.\19\ This may not have been Congress's intention.
---------------------------------------------------------------------------
    \19\ Rains J, Holmes GM, Pathak S, Hawes EM. The Distribution of 
Additional Residency Slots to Rural and Underserved Areas. JAMA. 
2023;330(10):968-969. https://doi.org/10.1001/jama.2023.14452
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    Behavioral health is a particularly important health care service 
for our veterans. Veterans experience certain conditions - notably, 
traumatic brain injury and substance use disorders - more often than 
their civilian counterparts.\20\ Although behavioral health remains a 
crisis across the country, compared to urban residents, residents 
living in rural areas receive less care, from providers with less 
specialized training, and the care they received is less likely to be 
innovative.\21\ This creates a particularly acute challenge for rural 
veterans - there are fewer health care providers to treat and manage 
their more prevalent behavioral health needs.
---------------------------------------------------------------------------
    \20\ Olenick M, Flowers M, Diaz VJ. US veterans and their unique 
issues: enhancing health care professional awareness. Adv Med Educ 
Pract. 2015 Dec 1;6:635-9. https://doi.org/10.2147/AMEP.S89479.
    \21\ Morales DA, Barksdale CL, Beckel-Mitchener AC. A call to 
action to address rural mental health disparities. J Clin Transl Sci. 
2020 May 4;4(5):463-467. https://doi.org/10.1017/cts.2020.42.

Rural Can Innovate and Lead When Policies Are Rural-Appropriate and 
---------------------------------------------------------------------------
Supportive

    We commonly hear about rural America being sicker, poorer, and 
older. It is also relatively well-known rural residents are less likely 
to have health insurance,\22\ more likely to travel farther for health 
care,\23\ and more likely to have chronic diseases. The CDC found that 
rural residents are more likely to die of the five leading preventable 
causes of death.\24\ These are accurate descriptions of a population 
that provides much of America's food, fun, and fuel. Although accurate, 
I often worry that it suggests government is powerless to improve rural 
health. Historically, when Congress and policymakers have developed 
policy to address rural needs, it has led to dramatic improvements in 
conditions for relatively small expenditures. In the early 1990's, 
rural hospitals were closing at a dramatic pace, and Congress 
introduced the Critical Access Hospital program in 1996. That program 
has stabilized the rural health care system for over 1,300 rural 
communities. Although roughly one quarter of acute care hospitals are 
CAHs, the program only accounts for five percent of total hospital 
outlays by Medicare.\25\
---------------------------------------------------------------------------
    \22\ Turrini G, Branham DK, Chen L, Conmy AB, Chappel AR, and De 
Lew N. Access to Affordable Care in Rural America: Current Trends and 
Key Challenges (Research Report No. HP-2021-16). Office of the 
Assistant Secretary for Planning and Evaluation, U.S. Department of 
Health and Human Services. July 2021.
    \23\ Ostmo P Rosencrans J. Travel Burden to Receive Health Care. 
Rural Health Research Gateway. 2022. https://
www.ruralhealthresearch.org/assets/4993-22421/travel-burden-recap.pdf.
    \24\ National Center for Chronic Disease Prevention and Health 
Promotion. Rural Health: Preventing Chronic Diseases and Promoting 
Health in Rural Communities. https://www.cdc.gov/chronicdisease/
resources/publications/factsheets/rural-health.htm
    \25\ Medicare Payment Advisory Commission. Critical Access 
Hospitals Payment System. https://www.medpac.gov/wp-content/uploads/
2021/11/medpac_payment_basics_21_cah_final_sec.pdf
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    Perhaps because of the more limited resources in rural communities, 
there are many examples where rural health care innovation has led the 
way. Telehealth, community health workers, expanded scope of practice 
and task shifting, drones, new payment models, and leveraging strong 
trust in community leaders (faith leaders, agriculture, other community 
organizations) are all examples where lessons from rural innovation has 
helped fuel transformation throughout the health care system. One word 
of caution, however; the pandemic saw dramatic increases in the use of 
telehealth, which seems particularly well-suited to the challenges 
described today. Telehealth-based solutions may be one promising 
strategy, but will not be effective for all veterans; roughly one 
quarter of rural veterans do not have internet in their home.

Conclusion and Future Directions

    Although rural residents - and those who visit rural communities - 
face real barriers to achieving their full health potential, there are 
policy strategies that Congress can consider to mitigate some of the 
barriers. History has shown that thoughtful legislation designed to 
address rural-specific challenges and leverage the assets of rural 
America has been successful in improving the lives of the 60 million 
who live in our rural communities. It is important to continue to 
recognize that rural health care systems are different, and not simply 
``small versions of urban'' and can yield similar outcomes, when given 
the opportunity.\26\
---------------------------------------------------------------------------
    \26\ Centers for Medicare & Medicaid Services. Rural-Urban 
Disparities in Health Care in Medicare. November 2020. https://
www.cms.gov/files/document/omh-rural-urban-report-2020.pdf

                       Statements for the Record

                              ----------                              


   Prepared Statement of American Association of Nurse Anesthesiology
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

           Prepared Statement of American Nurses Association

    The American Nurses Association (ANA) applauds the House Veterans' 
Affairs Committee for holding this oversight hearing on ``Rural Access: 
Is VA Meeting All Veterans Where They Live.'' As a leading voice of the 
nursing profession, ANA is committed to working with the U.S. House 
Committee on Veterans' Affairs and the U.S. Department of Veterans' 
Affairs (VA) to ensure that our nation's veterans and their families 
have timely access to highly qualified healthcare professionals, 
especially in rural and underserved communities. With this mission in 
mind and given how nurses provide care for VA patients on a national 
basis, ANA would like to respectfully share its perspective on how the 
VA can better serve our veterans through the issuance of national 
standards of practice (NSPs) for certified registered nurse 
anesthetists (CRNAs).

Development of National Standards of Practice

    The VA has been developing NSPs for various non-physician health 
care professionals employed at VA facilities nationwide. These 
standards aim to improve patients' access to care by ensuring that the 
delivery of healthcare by medical professionals covered by these 
standards are uniform throughout the VA system, regardless of what is 
permitted by state licensure laws. According to the VA, the development 
of these standards would allow the VA to ``Ensure safe, high-quality 
care for the Nation's Veterans. Standardize the practice of each health 
care occupation irrespective of State requirements. More Efficiently 
Allocate resources to support organizational missions to include 
national disasters and pandemics. (...) Leverage a modernized, mobile 
workforce to support rural areas and crisis response.'' \1\
---------------------------------------------------------------------------
    \1\ ``VA National Standards of Practice,'' The Department of 
Veterans Affairs, 2023. http://www.va.gov/STANDARDSOFPRACTICE/index.asp
---------------------------------------------------------------------------
    The VA announced their NSPs for advanced practice registered nurses 
(APRNs) in December 2016 and extended full practice authority (FPA) to 
three of four APRN roles. While we are pleased that nurse practitioners 
(NPs), clinical nurse specialists (CNSs), and certified nurse midwives 
(CNMs) were granted FPA, this rule excluded CRNAs.\2\ This decision was 
made despite a body of evidence in support of granting FPA to CRNAs 
that was incorporated into the rule and its supporting documents. In 
fact, the VA's own Supplementary Information provided with the Rule 
rebuffed arguments against FPA for CRNAs and agreed with comments 
supporting CRNA full practice. CRNAs were not granted full FPA due to 
vocal opposition from the physician community, which sent 100,000 
comments opposing FPA to the VA. The VA, in the final rule, 
acknowledged that these comments were not substantive and agreed that 
granting FPA to CRNAs in the VA system would not eliminate the team-
based care approach to the delivery of health care.
---------------------------------------------------------------------------
    \2\ ``Advanced Practice Registered Nurses, Final Rule'' The 
Department of Veterans Affairs, 2016. https://www.federalregister.gov/
documents/2016/12/14/2016-29950/advanced-practice-registered-nurses

---------------------------------------------------------------------------
Anesthesiologist Shortage

    Anesthesiologists, and their allies, oppose FPA for CRNAs on the 
ground that there is no shortage of anesthesiologists practicing at the 
VA, which contradicts existing evidence. The American Medical 
Association has stated that there is a general physician shortage that 
is expected to worsen.\3\ While this shortage is for physicians in 
general, there is a shortage of anesthesiologists as well. In fact, a 
March 2018 report on the critical deficiencies at the Washington, DC. 
VA Medical Center showed that procedures are being delayed or canceled 
due to a lack of anesthesia staff.\4\ Furthermore, there have been 
reports that the VA is having trouble recruiting anesthesiologists. 
Specifically, 25 percent of VA facility chiefs of staff are having 
issues recruiting or hiring anesthesiologists. These are some examples 
of how our Nation's veterans are not receiving timely access to trained 
medical professionals. By allowing CRNAs to practice to the top of 
their education and training at VA facilities, the department can 
alleviate the healthcare professional shortage and greatly improve the 
care that our veterans and their families are receiving.
---------------------------------------------------------------------------
    \3\ ``The physician shortage crisis is here - and so are bipartisan 
fixes'' American Medical Association http://www.ama-assn.org/practice-
management/sustainability/physician-shortage-crisis-here-and-so-are-
bipartisan-fixes, November 6, 2023
    \4\ ``Critical Deficiencies at the Washington DC VA Medical 
Center,'' (Department of Veterans Affairs, Office of the Inspector 
General, 2018 http://www.oversight.gov/sites/default/files/oig-reports/
VAOIG-17-02644-130.pdf
---------------------------------------------------------------------------
    Additionally, the VA commissioned a study published by the Temple 
University Beasley School of Law in 2022 that concluded that policy 
decisions on CRNA standards should be guided by currently available 
data. The data provided in the study shows that removing restrictions 
on CRNAs would have no negative impact on patients and may also be a 
cost-effective solution to physician shortages and increasing access to 
care.\5\
---------------------------------------------------------------------------
    \5\  ``Certified Registered Nurse Anesthetist Scope of Practice 
Laws,'' (DeAnna Baumle, JD, MSW,2022).  http://www.va.gov/
STANDARDSOFPRACTICE/docs/CRNA_PolicyBrief_Temple.pdf

---------------------------------------------------------------------------
Meeting Patients Where They Live

    The title of the hearing asks whether the VA is meeting patients 
where they live. Unfortunately, the answer to this question is no. 
There are dire physician shortages in rural areas and APRNs are used 
extensively in these areas to meet the required demand of the patients. 
The previously referenced Temple study stated that APRNs, ``including 
CRNAs, are typically more accessible to historically underserved 
populations and geographic areas. For instance, rural facilities are 
more heavily reliant on CRNAs for anesthesia and surgical practices.'' 
Granting FPA to CRNAs at rural VA facilities would promote the VA's 
goal of ensuring that our veterans have access to safe, high-quality 
care.
    The VA is also trying to create a mobile workforce that can respond 
to emergencies and be available in areas where there are shortages. 
Given the lack of a national standard for CRNAs, those CRNAs employed 
by the VA in states that allow FPA will likely choose to stay in these 
states, thereby undermining efforts to expand the heath care workforce 
in other states. Adopting NSPs for CRNAs will allow the VA to shift 
these highly qualified professionals to facilities in states where they 
are needed without worrying about whether they will be able to practice 
to the top of their education and training.

Conclusion

    In closing, our veterans and their families deserve access to the 
highest quality healthcare regardless of where they live. To bring this 
aspiration to fruition, the VA must bring an end to the current 
supervisory model of care for CRNAs and move toward a model where both 
physicians and CRNAs work independently to provide direct patient care. 
ANA appreciates this opportunity to share the nursing community's 
perspective and stands ready to partner with this committee and the VA 
to improve healthcare for veterans and their families in rural and 
underserved communities. Should you have any questions, please reach 
out to Tim Nanof, Vice President of Policy and Government Affairs, at 
(301) 628-5081 or Tim.Nanof@ana.org.
                                 ______
                                 

 Prepared Statement of Center for Healthcare Quality and Payment Reform
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                    Prepared Statement of NeuroFlow
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

      Prepared Statement of QTC Health Services, a LEIDOS Company
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                Prepared Statement of U.S. VETS Prescott

    My name is Carole Benedict, National Director of Executive 
Leadership for U.S. VETS, formerly serving as the Executive Director at 
the U.S.VETS Prescott, Arizona location. U.S. VETS, the leading 
nonprofit organization committed to the welfare of at-risk veterans and 
their families experiencing homelessness, is the largest provider in 
this sector. Our mission is to ensure a smooth transition for military 
veterans and their families back into civilian life, offering an array 
of supportive services including housing, counseling, career 
development, and comprehensive support. Since inception in 1993, 
U.S.VETS has engaged with over 179,000 veterans, provided homes for 
more than 57,000, and placed nearly 15,000 veterans into employment.
    I am privileged to present this statement on behalf of U.S.VETS in 
Prescott, Arizona, and the veterans in rural communities they serve at 
the oversight hearing of the Committee on Veterans' Affairs on January 
11, 2024.
    Since opening in 2003, U.S.VETS--Prescott has been a critical 
resource in Arizona, providing housing and comprehensive services to 
over 8,500 veterans in the past 21 years. In Arizona, particularly 
within Yavapai County where Prescott is located, challenges are 
pronounced due to the rural setting. The county, with a population 
density of only twenty-six people per square mile and 11 percent of 
whom are veterans, faces unique challenges. The cost of housing here is 
significantly high, 42 percent above the national average. Furthermore, 
the Northern Arizona VA Healthcare System, covering a vast area of 
65,000 square miles, includes regions with some of the highest rates of 
veteran suicides in Arizona from 2015 to 2022. During the 2021 point-
in-time count, over 15 percent of individuals in Arizona's homeless 
shelters were identified as veterans.
    At U.S.VETS--Prescott, the team confronts these challenges daily. 
Despite the Veterans Affairs' (VA) advancements in providing care and 
benefits, significant obstacles remain. These include difficulties in 
travel, inadequate funding for homeless veterans, and a lack of 
affordable housing. The VA's Community Based Outreach Clinics (CBOCs), 
although beneficial, do not fully address the vast distances and 
transportation challenges inherent to rural environments, nor do they 
comprehensively address the complex health issues faced by many 
veterans. The existing grant and per diem rates for homeless veterans 
are insufficient, failing to reflect the actual costs of service 
provision in these areas.
    One of the major barriers for rural veterans in Prescott is 
transportation, as there is no public transportation system. U.S.VETS--
Prescott offers three scheduled van trips daily to the VA and 
healthcare providers over one hundred miles away in Phoenix and other 
outlying areas. This service is crucial for veterans who would 
otherwise be unable to access necessary care due to distance and 
transportation challenges.
    U.S.VETS--Prescott's onsite services are comprehensive. They 
provide three meals daily along with snacks, case management, 
employment assistance, transportation, career development, individual 
and group counseling, and housing navigation. The organization offers 
six different housing interventions, including emergency shelter, 
transitional housing, long-term supportive housing, housing for frail 
elderly, transition in place, rapid rehousing, and specialized housing 
for veterans who are victims of military sexual assault.
    In addition to these services, U.S.VETS--Prescott contracts with 
local community providers to offer unique therapies often inaccessible 
to veterans, such as equine therapy, acupuncture, biofeedback, and CNA 
care for elderly veterans. These therapies are vital for veterans who 
lack financial and transportation resources to access specialized care.
    In September 2023, U.S.VETS--Prescott opened the Veteran Connection 
Hub in Prescott, focusing on suicide prevention among veterans. The Hub 
offers a range of support services, including counseling, support 
groups, access to mental health professionals, and benefits counseling. 
Their approach is proactive and preventative, focusing on early 
intervention and resilience-building strategies.
    Moreover, U.S.VETS--Prescott annually hosts a 2-day Stand Down 
event, bringing together over thirty-five providers from various 
sectors, including the local health department, motor vehicle services, 
VA, Department of Economic Security, and other community service 
organizations. 185 veterans were assisted at this event in 2023. This 
event serves as a one-stop resource for veterans, offering a range of 
services in one location. Notably, the Stand Down event also includes a 
full-day veteran court, which has proven highly effective, with over 
forty veterans having their cases resolved in a single day.
    U.S.VETS--Prescott's collaboration with the Northern Arizona VA 
Healthcare System is multifaceted and enhances their service delivery. 
This partnership provides the flexibility to tailor programs to fill 
gaps in services that the VA may not cover, including specialized 
programs and support services designed to address the specific 
challenges faced by the veteran community. Additionally, their 
collaboration with the VA ensures a smooth transition for veterans 
requiring services through the VA, reducing bureaucratic hurdles and 
delays, and providing veterans with timely and efficient access to a 
wide range of resources and support.
    U.S.VETS--Prescott is more than just a service provider; it is a 
community dedicated to supporting veterans in every aspect of their 
lives. However, the sustainability of their work is challenged by the 
low per diem rates, which are incongruent with the escalating costs due 
to inflation and the growing complexity of the needs of the veterans 
they assist. U.S.VETS has been a strong advocate of H.R. 3848, the HOME 
Act, and requests your strong advocacy with the Senate to pass this 
bill which will bring per diem rates in line with actual expenditures, 
particularly in rural areas, that will help them better serve veterans 
in rural areas.
    U.S.VETS--Prescott believes in a collaborative approach with 
federal, state, and local entities, along with veteran service 
organizations, to develop effective solutions. Their goal is to ensure 
that every veteran has equitable access to the care and benefits they 
deserve. U.S.VETS--Prescott looks forward to working with the Committee 
on Veterans' Affairs and other stakeholders to enhance support and 
access for rural veterans.

    References:

    https://dvs.az.gov/sites/default/files/2022-07/2022-07-14-
AVSAC%20Strategic%20Policy%20Objectives%20-%20APPROVED_.pdf
    https://cvpcs.asu.edu/sites/default/files/2023-11/
vetsuicide2023_july_v2_003.pdf
    https://population.us/county/az/yavapai-county/
    https://www.bestplaces.net/cost_of_living/county/arizona/yavapai

                    Prepared Statement of ATA Action
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

          Prepared Statement of Western Governors' Association
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

 Prepared Statement of Alzheimer's Association and Alzheimer's Impact 
                                Movement

    The Alzheimer's Association and Alzheimer's Impact Movement (AIM) 
appreciate the opportunity to submit this statement for the record for 
the United States House Committee on Veterans' Affairs hearing on 
``Rural Access: Is VA Meeting All Veterans Where They Live?''. The 
Association and AIM thank the Committee for its continued leadership on 
issues, such as rural health care access, that are important to our 
nation's veterans living with Alzheimer's and other dementia and their 
caregivers. This statement highlights the importance of dementia care 
and support programs at the Department of Veterans Affairs (VA) and 
discusses how our nation's veterans living with dementia are benefiting 
from such programs.
    Founded in 1980, the Alzheimer's Association is the world's leading 
voluntary health organization in Alzheimer's care, support, and 
research. Our mission is to eliminate Alzheimer's and other dementia 
through the advancement of research; to provide and enhance care and 
support for all affected, and to reduce the risk of dementia through 
the promotion of brain health. AIM is the Association's advocacy 
affiliate, working in a strategic partnership to make Alzheimer's a 
national priority. Together, the Alzheimer's Association and AIM 
advocate for policies to fight Alzheimer's disease, including increased 
investment in research, improved care and support, and the development 
of approaches to reduce the risk of developing dementia.
    Nearly half a million American veterans have Alzheimer's--and as 
the population ages, that number is expected to grow. In 2015, an 
estimated 486,000 veterans were living with Alzheimer's. The annual 
number of veterans newly diagnosed with dementia has increased by more 
than 22 percent since 2008. For veterans, the prevalence may grow even 
faster in future years because they have a higher risk of developing 
dementia. The significant increase in the number of veterans with 
Alzheimer's and other dementias will place a heavy burden on the VA 
health care system, and in particular, rural health practices.
    Rural communities often face higher prevalence rates of dementia 
due to risk factors such as an aging population, limited access to 
healthcare services, and socioeconomic challenges. And, while the 
Committee develops policy proposals in this space, we ask that you take 
into consideration that the rate of Alzheimer's and dementia among 
veterans continues to increase, and so does the need for well-trained 
physicians in dementia and cognitive care. The United States will have 
to nearly triple the number of geriatricians to effectively care for 
the number of people projected to have Alzheimer's in 2050, while 
efforts to increase recruitment and retention remain slow. From 2016 to 
2026, the demand for direct care workers is projected to grow by more 
than 40 percent, while their availability is expected to decline. 
Meanwhile, veterans with dementia are 2.6 times more likely to be 
hospitalized than other veterans--and hospital stays are, on average, 
2.4 times longer. Not only do longer hospital stays add to the great 
financial toll dementia has on families, but this can also prove 
burdensome for rural hospitals with limited bed space and providers. 
While we are deeply grateful for the VA's comprehensive approach to 
dementia and the people it affects, more can always be done to ensure 
veterans are better able to receive high-quality care in rural areas.

VA's Continued Role in Addressing Alzheimer's Disease in Rural Areas

    We are grateful for the VA's participation in the Department of 
Health and Human Services (HHS) Advisory Council on Alzheimer's 
Research, Care, and Services, which plays a key role in developing and 
annually updating the National Plan to Address Alzheimer's Disease - as 
set forth by the National Alzheimer's Project Act (P.L. 111-375). The 
National Plan is a roadmap of strategies and actions of how HHS and its 
partners can accelerate research, expand treatments, improve care, 
support people living with dementia and their caregivers, and encourage 
action to reduce risk factors The most recent update to the Plan was 
released in December 2023, and includes a number of highlights on VA's 
continued work to better serve our nation's veterans living with 
dementia.
    VA continues to collaborate with federal agencies on a number of 
the key goals of the National Plan detailing rural health care, 
including Action 2.A.1 to educate health care providers on Alzheimer's 
disease. The VA's Geriatric Scholars Program is a workforce development 
program to infuse geriatrics into VA primary care settings by 
conducting intensive training in geriatrics, including rural 
interdisciplinary team training. The program includes an intensive 
workshop in quality improvement and each participating Scholar 
initiates a local quality improvement project to demonstrate learning 
and improve care or clinic efficiency. The program also includes a wide 
variety of training activities focused on dementia, including training 
sessions on dementia caregiver coordinator education and rural 
caregiver education. Finally, the program provides participants with 
hands-on experience and practical skills in geriatric care necessary 
for adequately treating the aging population.
    We also ask that the Committee continue to support the Veterans 
Health Administration's 20 Geriatric Research, Education, and Clinical 
Centers (GRECCs), which are geriatric centers of excellence focused on 
aging. GRECCs reported in the 2023 National Plan Update that their work 
included 78 research grants in dementia covering basic science to 
clinical care and health services research and 25 clinical innovation 
projects that directly served veterans with dementia and their 
families. GRECC faculty have developed numerous clinical programs to 
aid family members and care providers including e-Consults for 
Behaviors in Dementia, Health Care Directives for Veterans with 
Dementia, Reaching Out to Rural Caregivers and Veterans with Dementia 
Utilizing Clinical Video-Telehealth and Virtual Dementia Caregiver 
Support Programs. The GRECC Program produced 56 educational programs 
for staff and trainees on best practices in dementia care, including 
the use of simulation technology to demonstrate techniques for 
communication and facilitating ADLs for veterans with dementia. 
Finally, GRECC authors published 259 manuscripts in peer-reviewed 
journals in Fiscal Year 2022 on their research and clinical work in 
dementia. VA must continue supporting the GRECCs in disseminating 
findings from this research to integrate scientifically proven dementia 
interventions into local and rural communities.
    The VA also continues to collaborate with the Indian Health Service 
(IHS) and Centers for Disease Control and Prevention on the National 
Plan Action 2.A.6 to strengthen the ability of primary care teams in 
Indian country to meet the needs of people with Alzheimer's and related 
dementias and their caregivers. For example, in 2022 the IHS launched 
the Indian Health GeriScholars Pilot, developed with the support and 
collaboration of the VA Office of Rural Health. Modeled after the VA 
Geriatric Scholars Program, the Indian Health GeriScholars pilot is 
providing primary care clinicians at IHS, Tribal, and Urban Indian 
Organization health programs with an individual intensive learning 
track for professional continuing education.
    These are only a few examples of ways in which the VA remains 
involved in working to ensure a high-quality, well-trained dementia 
care workforce, and continue bridging the gap in cognitive services in 
rural areas. The National Alzheimer's Project Act as a whole has led to 
great achievements in the treatment and research of Alzheimer's 
disease; however, this important law expires soon. The bipartisan NAPA 
Reauthorization Act (H.R. 619/S. 133) and Alzheimer's Accountability 
and Investment Act (H.R. 620/S. 134) would extend the National Plan, 
and ensure researchers at NIH continue to receive the funding necessary 
to sustain vital Alzheimer's and dementia research. These bills will 
ensure the nation continues addressing Alzheimer's as a national 
priority, providing continuity for the community.

Program for Advancing Cognitive Disorders Education for Rural Staff 
    (PACERS)

    The VA Employee Education System and South Central Mental Illness 
Research Education and Clinical Center administer the Program for 
Advancing Cognitive Disorders Education for Rural Staff, also known as 
PACERS. The PACERS program at the VA is designed to enhance dementia 
care through a specialized training program for clinicians who care for 
veterans with cognitive disorders. It aims to improve outcomes for 
veterans and their caregivers, especially those living in rural 
communities. The program includes six e-learning courses and five 
videos that focus on normal cognitive aging and dementia caregiving, 
addressing decision-making and safety in dementia, and reviewing case 
studies in treating dementia. In rural settings with limited resources, 
the PACERS program is a crucial tool for healthcare professionals to 
better provide dementia patients with high-quality care within the 
constraints of rural healthcare infrastructure. The VA may consider 
adopting similar online programs to further enhance dementia care 
training for rural physicians at the Veterans Health Administration.

Conclusion

    The Alzheimer's Association and AIM appreciate the Committee's 
steadfast support for veterans and their caregivers and the continued 
commitment to advancing issues important to the millions of military 
families affected by Alzheimer's and other dementia. We look forward to 
working with the Committee and other Members of Congress in a 
bipartisan way to advance policies that will ensure access to high-
quality dementia care and support in rural areas, especially as the 
population of veterans living with dementia continues to grow.

      Prepared Statement of American Society of Anesthesiologists
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                  Prepared Statement of John Mikelson

    Chairman Bost , Ranking Member Takano, and distinguished members of 
the House Committee on Veterans' Affairs - thank you for inviting me to 
submit this written statement for the record of today's hearing on 
rural health care provided by the Veterans Health Administration (VHA) 
within the U.S. Department of Veterans Affairs (VA). I have looked at 
the VA's data and there are 4.4 million rural and highly rural Veterans 
with 2.7 million enrolled in VA. 61 percent of rural Veterans are 
enrolled in the VA health care system; a significantly higher rate than 
the 41 percent enrollment rate of urban Veterans. I appreciate your 
attention to this topic and am pleased to share my perspective.
    I love the Iowa City VA Health Care System. I get all my care there 
since 2004 and have a great relationship with their leadership and 
staff. However there are a few rough spots.

Appointment Travel

    The Beneficiary Travel Self Service System (BTSS) is difficult to 
operate especially for non computer literate elderly. In my experience, 
BTSS assumes that all veterans are computer savvy, and have access, to 
computers. 27 percent of rural veterans do not access the internet at 
home according to the VA's own Rural Health page.
    Often times veterans give up applying for a benefit that is 
rightfully theirs because the VA removed the most accurate and 
available resources, which was the convenient Kiosks located in the VA 
Hospitals main corridor to be used to check in for appointments and 
file for travel the veterans were attending their appointments. I don't 
why they were removed.

Recreational Therapy

    Iowa City VA HCS only has 1 Recreational Therapist, and she is only 
associated with the inpatient mental health unit. She is not associated 
with the VA's National Disabled Veterans Golf Clinic held locally each 
September; the Golf For Injured Veterans Everywhere (GIVE); nor does 
she have time to assist with other National VA therapy programs like 
coordinating local entries for the VA's National Creative Arts 
Festival. How can we best connect rural Veterans with others to 
maintain a healthy lifestyle. Other VA Hospitals in more urban 
locations offer more activities for socialization through sports 
recreation or creative expression.

Telehealth

    I truly believe in the importance of telehealth and asks that you 
continue to leverage its benefits for the veteran community. I live in 
Louisa County. We do not have a single Red/Amber/Green Stoplight in the 
entire county. No paid firefighters or EMTs. We depend on surrounding 
areas for support. The Iowa City VA is a good 40 minute drive. Rural 
Veterans enrolled in VA's health care system are also significantly 
older: 55 percent are over the age of 65. Telehealth and telemedicine 
services should be expanded to improve access to care, especially for 
veterans in remote areas. Telehealth enables virtual consultations, 
remote monitoring, and the delivery of healthcare services, reducing 
the need for veterans to travel long distances for appointments.
    While telehealth has been critical to expanding access to health 
care services; telehealth cannot simply replace in-person service 
delivery. Patients, in consultation with their providers, must be able 
to choose whether telehealth or in-person services are most appropriate 
for their needs. Outside of VA, some health plans have implemented 
strategies to limit consumers' options by offering ``telehealth only'' 
or ``telehealth first'' coverage, which bars or limits access to in-
person care. For individuals who need a higher level of outpatient 
care, residential care, or inpatient care to treat their MH/SUD 
condition(s), a ``telehealth only'' option can negatively impact 
treatment options, further delay an appropriate level of care, and can 
be a significant financial barrier if individuals find they must pay 
out-of-pocket for additional services.
    Even when telehealth is available, however, the 3-4G network is 
spotty across Iowa and 5G is only available in major Metro areas. 
Public resources can help, but there is a lack of public video access 
points including the Iowa Workforce Development terminals in libraries 
and National Guard Readiness Centers. While these are State owned 
systems for employment but they could be cross purposed for telehealth. 
I understand that is a state issue but can Congress empower the VHA to 
coordinate resources in joint State/Federal buildings? Not all veterans 
have a computer, my self included, or an adequate Wi-Fi connection to 
VA. VA software is not always compatible with off the shelf platforms. 
My physical therapist had to go to Zoom because my phone could not 
handle the VA platform.
    I ask your support of the telehealth provisions in S. 1315, the 
Veterans Health Empowerment, Access, Leadership, and Transparency for 
our Heroes Act of 2023, and H.R. 3520, the Veteran Care Improvement Act 
of 2023. Both bills include measures that would require VA to discuss 
telehealth options for care, both at VA and in the community, if 
telehealth is available, appropriate, and acceptable to the veteran. 
Congress should continue to work with VA and other stakeholders to 
ensure that the necessary balance is found between the efficiencies of 
telehealth and veteran preference.

Women Veterans

    OB care is still lacking. The Veterans Affairs Medical Centers are 
understaffed in the OB/Gyn field, so are the rural communities. Seeking 
Care in the Community is often hard find. Due in part to Mercy Hospital 
going under and being purchased by University Of Iowa Hospital and 
Clinics, high malpractice cost and restrictions on women's health care, 
some of those OB/Gyn resources have left the area. This is certainly 
not the VA's fault but many young veterans do their initial tour of 
Duty and get out to go to college or start a family. Those 22-30 year 
olds are in their prime child bearing years. I ask that this 
subcommittee continue expanding resources for our female veterans and 
support the recommendations of the Woman's Veterans Task Force.

Mental Health

    Mental health bed space is in short supply across the Midwest. Not 
just in the VHA system but across the board. Iowa has been short since 
the facility in Knoxville closed years ago and has not been able to 
replace them. Wait times for admission persist. We need to incentivize 
careers in Mental Health fields to ensure veterans can get timely 
access to the help they need when they need it rather than when it's 
available.
    To be clear, there is no shortage of VA programs nationally to 
support veterans and their families, but not enough mental heath beds. 
However, in that abundance, many in this population remain confused by 
the number and types of VA services, employee roles in their delivery, 
and eligibility criteria. Veterans and the general public cannot 
discern between what is a County or State issue versus VHA or VBA 
territory much less a concern for Big VA. For having no Active Duty 
installations in Iowa, we do a pretty fair job differentiating the 
Marines from the Air Force from the Army National Guard or Navy 
Reserves. We need to do a better job of promoting VHA services and 
eligibility. More than 301,000 rural Veterans served in Iraq and 
Afghanistan. When I retired in 2004 from Active Duty (Title 32 AGR) and 
was granted a 60 percent VA Disability Rating I went to a county 
veteran services office and was told they could not assist me since I 
was National Guard and ineligible for VA Health Care. He just didn't 
know any better. That County has since hired a much more knowledgeable 
CVSO and the State now requires each County to have a VA Certified 
Service Officer. But, the misconceptions persist in the community and 
among service members past or present.
    On a positive note there exist a Recovery in Action group at the 
Iowa City HCS the includes Mental Health Inpatient staff, Outpatient 
staff, Suicide Prevention Team, the Vets Center, VR&E, Iowa Workforce, 
University of Iowa Veterans staff, the local NAMI Chapter and other 
community resources to ensure there is no wrong door for care. The 
Cedar Rapids Vet Center has a Mobile Office (A converted camper) that 
travels to surrounding counties and veterans events and does have 
telehealth capabilities. I would love to see more of these community 
integration efforts to bring the VHA to the rural communities as the VA 
does not exist in a vacuum.

CLOSING

    I would like to thank the House Committee on Veteran Affairs its 
distinguished members for inviting me to submit this statement. I am 
grateful for your attention and efforts to ensure that veterans receive 
the best possible care and outcomes through the Veterans Health 
Administration, particularly through well-coordinated care. I am 
greatly appreciative of this opportunity to share my experience and 
perspective with you all today. I look forward to continuing to work 
with you on these issues and am standing by to assist in any way I can 
toward our shared goal of serving those that have served this country.

                                 [all]