Challenges in Rural America: VA Access and Mental Health Care











On behalf of the men and women of the Veterans of Foreign Wars of the United States (VFW), our Auxiliaries, and specifically the 10,000 VFW members living in New Mexico today,  I would like to thank you for the opportunity to submit testimony for the record regarding access to mental health care in rural America.

Access to quality health care is a persistent challenge for rural America.  While 20 percent of Americans live in rural areas, only 10 percent of all doctors choose to practice in those locations.  Specialty care providers, including mental health professionals, are in particularly short supply in these areas, and patients must often travel great distances to their appointments.  Veterans are even more likely to live in rural areas than most Americans.  Approximately 36 percent of all Department of Veterans Affairs (VA) enrollees live in rural locations, making delivery of care much harder.  Still, rural veterans are equally entitled to VA health care as their urban counterparts, and Congress must continue to do everything it can to ensure that they are guaranteed access to quality care in a timely manner.

The VFW would like to thank the members of this committee and all members of Congress who voted “yes” for the Veterans Access, Choice and Accountability Act last week.  This landmark legislation contains multiple new authorities that will allow VA to improve services for rural veterans in New Mexico and elsewhere. Allowing veterans who live more than 40 miles from a Department facility to choose to receive non-VA care is perhaps the most significant provision for rural veterans, who often have to travel great distances to get the care they deserve.  We are also hopeful that the additional resources and improved hiring authorities provided by the bill will help rural VA facilities attract quality health care professionals to historically underserved areas. 

Still, more must be done.  Many statements have been made that H.R. 3230 is only the beginning of the improvements needed to fully reform VA health care.  The VFW agrees, and believes this is especially true for rural veterans.  We appreciate that the bill will allow VA to reimburse outside providers at increased rates in rural areas, but we believe that VA will also need additional tools to recruit and retain its own rural providers.  H.R. 3230 rightly raised the cap on the VA Health Professionals Education Assistance Program, but did not create extra incentives that would attract providers to rural areas.  The VFW believes that this is still needed, and could be accomplished either by increasing debt repayment caps or by offering direct financial incentives to those providers who agree to long-term employment in underserved rural areas.

Another opportunity for improvement is telehealth.  The VFW believes that telehealth is an important component of 21st century medicine, and has great potential for breaking down distance barriers for rural veterans, particularly in the area of mental health.  Today, most veterans must still travel to a community based outpatient clinic or other Department facility to receive telemental health services.  We believe that VA should be given the resources it needs to expand services by providing more veterans with telehealth access in their homes through the use of secure internet connections.  Additionally, the VFW believes that VA doctors should be authorized to provide telehealth services across state lines, an authority that DOD doctors already have, allowing rural veterans to be treated by out-of-state providers.

While mental health care and specialty care are in especially short supply, access to primary care is also an issue for rural veterans.  The choice provision of the Veterans Access, Choice and Accountability Act will allow veterans to receive care closer to home, but VA facilities do not typically have local contracts in place for primary care.  The VFW is concerned that rural veterans may be scheduled for primary care appointments on a fee basis which lacks the necessary care coordination that is built in to most contract care.  For this reason, we strongly urge Congress to exercise proper oversight to ensure that VA creates a national contract for non-VA primary care which requires record sharing and contains quality and timeliness standards, similar to the requirements under PC3, the national contract for specialty care.

 In order for any non-VA care option to benefit veterans, it is necessary for VAMCs to provide referrals when appropriate.  In the past, manipulation of appointment wait time data at many facilities obscured the demand for care.  As a result, VAMCs underutilized their non-VA care authorities.  Instead, they kept veterans on unofficial waiting lists or dropping them from the lists completely, rather than offering them well-coordinated care in their communities.  Going forward, the VFW believes it will be important to monitor each VAMC to ensure that non-VA care is being used appropriately, and that veterans are not being denied appropriate outside care due to any lingering institutional resistance or disincentives. 

Given that this hearing is being held in New Mexico, the VFW took this opportunity to gather information on PC3 utilization at the Albuquerque VAMC.  We were shocked to learn that until last week, Albuquerque had issued zero authorizations for non-VA mental health care.  Although they have issued approximately 400 authorizations for other types of specialty care since PC3 was implemented in May, it should be noted that this is the lowest number of authorizations of any VAMC in VISN 18.  The Phoenix VAMC, for example, has issued over 5,000 authorizations during the same time period. 

Although there are many legitimate factors that could explain the low utilization rate, the VFW doubts that the Albuquerque VAMC is not issuing referrals because they are fully meeting demand.  In fact, the Albuquerque VAMC had the ninth longest appointment wait times of all VAMCs nationwide as of July 15th, with 17.08 percent of appointments scheduled over 30 days out.  Although the VFW cannot say for certain why the Albuquerque VAMC appears to be underutilizing PC3, we would encourage the committee to use its investigative authority to ensure that veterans in New Mexico are not being made to suffer long wait times unnecessarily.

Mr. Chairman, this concludes my testimony. I would be happy to take any questions you or the members of this Committee may have.