Veterans Health Care

Floor Speech

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Ms. MURKOWSKI. Madam President, there are 2 days every year when this Nation focuses special attention on those who served--Memorial Day and Veterans Day. I plan to approach this Memorial Day by expressing gratitude to those who have served and honoring the memory of those who sacrificed their lives for our freedom.

When you serve in the military, supporting your buddy is everything. So as we honor the memory of those lost in action, we know they would want us also to care for their buddies who came home. Advances in military medicine since the Vietnam war have made it possible for many to survive the wounds of war that they would not have otherwise been able to do in earlier conflicts. But these veterans still do not return as they left, and many more return to the scourge of post-traumatic stress disorders.

I will see a lot of veterans this Memorial Day weekend. I would like to be able to tell the veterans of Alaska that their Federal Government is doing right by them, but when it comes to the matter of health care, and particularly the failings we see with the Choice Program, I can't in good conscience tell them things are better in Alaska.

It has been a while since I have been to the floor to speak in relatively bleak terms about the care our veterans receive in Alaska because for some while things had been improving. They had been improving for much of the last 8 years, but now it seems as if this pendulum is swinging the other way.

When I came to the Senate 13 years ago, Alaska veterans who lived someplace other than the metropolitan area of Anchorage or Fairbanks or the Kenai Peninsula really didn't think about the VA health care. Those who lived in those three communities were able to gain their care at the local VA clinic, and it worked for them. But if they didn't live in a community where the VA was located and if they weren't eligible for beneficiary travel, the VA just didn't mean much to them. That was the status quo, and it really didn't show much sign of changing.

Alaskans really began to challenge the status quo during the second gulf war. Operation Iraqi Freedom resulted in a large-scale deployment of Alaska National Guard members from throughout the State. At one point, 89 different Alaska communities were represented in the Middle East, and it was fully apparent that when these heroes returned home and were released from Active Duty, the VA was not prepared to meet their needs.

When then-VA Secretary Nicholson visited Anchorage in 2006, he heard the message loud and clear from Alaska's veterans service organization, and that created a groundswell to turn the Alaska VA in a more veteran- centric direction. It wasn't easy.

The familiar slogan that ``it doesn't matter who wins an election; the bureaucracy always wins'' was a way of life in the Alaska VA health care system, but we developed a pretty strong ally when Secretary Shinseki came on board. During his tenure as Secretary, we saw three significant changes from the status quo.

The first thing that happened was that the VA began contracting with Alaska's tribal health care providers to care for both our Native and non-Native veterans who lived outside the reach of any VA facilities. If you are a veteran living in Bethel, it didn't make any difference if you were Native or non-Native--you could receive care through the tribal health care provider, and they were compensated by the VA at the same encounter rate the Indian Health Service paid them.

The second thing we saw with Secretary Shinseki--I had commissioned an inspector general's inquiry into allegations that the VA was sending our Alaska vets to Seattle and other points even farther than Seattle for care that could be purchased from community providers in Alaska. There were situations where a veteran dealing with cancer and needing radiation or chemotherapy treatment would be sent to Seattle for a series of treatments when that same treatment could be provided in Anchorage or Fairbanks. Secretary Shinseki brought an end to that practice.

Third, the VA hired a creative executive with deep experience in the Alaska health care market to lead the Alaska VA health care system. Even better, the VA senior leadership actually empowered her to do the right things for Alaskan veterans. So when that director began to see waiting lists forming for primary care and behavioral health services in Anchorage, she took the initiative and she enlisted non-VA providers to come in and work with them to solve the problems. We were in a pretty unique situation. We didn't suffer the wait list that veterans in the lower 48 saw because we had somebody who was at the helm, saw the problem, and said: We can be creative; we just need a little bit of flexibility so we can address our veterans' needs.

The model was pretty simple. If a veteran needed to see someone outside the VA, they were placed with that outside provider by VA staff. And those VA staffers who matched the veteran with a local provider actually lived in Alaska. They knew Alaska's geography. They knew it wasn't possible to drive from Bethel to Anchorage. They knew the breadth and limitations on services available within our State.

Also, the bills for services were sent to the VA; they were not sent to the veteran. If for some reason a provider wasn't paid on time, the veterans were insulated. They were protected from collection agency calls.

It wasn't a perfect system and it wasn't without complaints, but on balance this was the best Alaskan veterans were ever treated.

Then came the Phoenix scandal. We hoped that what had happened there--the spotlight that was shown on the VA as a result of a horrible scandal--would not affect the good things we were doing in Alaska.

Two years later, I can tell you that things have changed profoundly and unfortunately, not for the better. The Choice Act seems to have been the catalyst for unraveling the VA reforms in our little corner of the world. Let me explain why.

When we were presented with the Choice Act, I looked at it as having another tool that the VA could use to help expedite care to veterans who couldn't get their care in a timely fashion. If this is another tool in the toolbox, this is going to be good for our vets. But the VA didn't view the Choice Act simply as another tool; they viewed the Choice Act as the single right answer to care outside the VA. To this day, the VA seems to almost resent the fact that a variety of other purchase care programs coexist with the Choice Act, and they worked to undermine them through a hierarchy of care policies that make it impossible for our local VA officials to use community providers with whom they have built these relationships.

That whole unraveling was enough to send our creative, innovative Alaska VA director into retirement, and unfortunately that position has been vacant ever since.

By the way, when veterans asked ``What happened here? We had a good system. It was working. What has happened?'' the VA talking points said ``Blame the Congress. They gave us the Choice Act, and there is nothing we can do about it.'' That is an entirely disingenuous response given that all of the purchased care authorities that were on the books before the Choice Act remained on the books after the Choice Act became law. The VA had the flexibility before the Choice Act to craft local solutions, and they had the same flexibility to do so after the Choice Act. The decision not to support local flexibility was a deliberate choice, and it was a choice of the bureaucracy, not a choice that was mandated by the Congress.

How has the Choice Act been working out in the State of Alaska? I spend a lot of time back home. I spend a lot of time visiting with our veterans, and I am listening hard. Every now and again, I do hear a veteran say: Yeah, I think things are OK. I think I am getting the care I want. But more often than not, what I am hearing from our vets is that instead of calling it the Choice Act, it is called the ``bad Choice Act'' or ``no choice at all.''

For a while, it seemed that the Native partnerships would be subsumed in Choice, and we pushed back on that and we won. But for the veterans who needed specialty care, the Choice Act has been a tough road to hoe, and I have a couple of examples.

There was an elderly Tlingit Indian gentleman from southeast Alaska. He was sent to Seattle for a form of cancer therapy that was not available in Alaska. In the middle of his episode of care, he was told: You will have to return to Alaska. It was only after days on the phone with the VA and the Choice contractor--each whom was pointing the finger at the other--and then my office that the problem was resolved. Meanwhile, this veteran was telling his family to prepare for a funeral. It was that dire.

Then there was the veteran who was scheduled for neurosurgery. This veteran was told that her referral from the Anchorage VA was rescinded and she would need to go to the Choice Program for another one. She called the Choice contractor's hotline and was referred not to neurosurgeons but to behavioral health providers. Evidently, the individual on the other end of the line didn't know what neurosurgery was. When the particular problem was resolved, the neurosurgeon was no longer available and the veteran was stuck on painkillers until her surgery could be rescheduled. That is not a good outcome.

Another example is when a veteran living in Juneau, our capital city, was under the ongoing care of an ophthalmologist, but that doctor didn't take Choice. The veteran called the 800 number for Choice to get another referral. He was told that he could drive to Sitka and see someone there. If you lived in Alaska, you would be laughing because you would know there is no road from Juneau to Sitka. They are both islands. Another reason you might raise an eyebrow is because not only can you not drive there, but the Choice participant was an optometrist. Think about how this veteran feels after calling the 800 number and then being told to just drive down to the next town. You can't drive there, and oh, by the way, that specialist doesn't exist there.

The VA and the Choice contractor claim to have fixed these problems, but for every problem that is fixed, there is still a veteran with a new one, a veteran who has lost faith with the Choice Program or a provider who no longer wants the hassle of taking Choice.

One provider told me that the amount of time his staff has to spend on the phone with the Choice Program is disruptive to his practice. He said it is unfair to the other patients who aren't getting the attention they need from the office staff.

I don't want to stand here and complain without offering solutions. There is a solution to Choice's problems in the State of Alaska, and that solution is to go back to the way we had it, with the local VA partnering local providers with local patients.

The Senate Appropriations Committee has urged the VA to reinstate this model in Alaska through language that is included in the fiscal year 2017 report, but I am really not sure where it is going, given the current VA leadership. The rapport, unfortunately, is just not there.

Toward the end of Secretary Shinseki's tenure, members of the Veterans' Affairs Committee in the other body berated the VA for its poor congressional relations.

I will say that when I needed to talk to the Assistant Secretary for Congressional and Legislative Affairs or, for that matter, Secretary Shinseki, they were right there. And even if the results didn't come as quickly as I would have liked them to, that team was clearly delivering for our folks in Alaska, but I cannot say the same for the current team.

Through the fiscal year 2016 VA appropriations bill, I demanded a report on how the VA would serve Alaskan vets under the consolidated Choice Program that told the VA to formulate last summer, and we still haven't seen that report.

During the recent appropriations hearings, I raised concerns about how personnel vacancies and management issues in the Alaska VA were affecting performance, and Dr. Shulkin took issue with that characterization. He offered to show me some metrics. We are still waiting.

Last week he sent a young doctor from Philadelphia, whom he has charged with running purchased care, up to Alaska. The report back is that he was tone-deaf to criticisms of Choice lodged by our veterans and providers, and he suggested that the rate being paid to the Native health system to do work that the VA should be doing themselves was unjustifiably high. This is very troubling.

So we learn that VA is hiring a bunch of new executives to help this individual manage a nationwide community care program out of the VA central office. I remain very concerned. Long before the Phoenix scandal, the VA was purchasing community care using a decentralized model. Now it seems to be moving abruptly to a centralized model. I don't know how well centralized models work in other parts of the West or rural communities in other regions, but I can state that they just do not work in a place such as Alaska. One-size-fits-all is not the model that best serves our veterans, but this seems to be the direction we are moving toward.

To make matters worse, we are not even debating what we want community care in the VA to look like. We have 100 Members who have a stake in the outcome, but only a few seem to be involved in that discussion. The votes always seem to be pretty much straight up or down, with no opportunity for amendments. We have done that now twice-- in the first instance with the Choice Act itself and then again last year when we had to bail the VA out because its health care programs would have gone insolvent during the August break if we hadn't done so.

We need to address this. We can't keep writing a blank check to the VA. We have to have reform, and that reform needs to work.

Last week the Senator from Arizona proposed a 3-year extension of the Choice Program, but the amendment included some changes in the way the VA pays providers in the purchased care arena. There was some problematic language, so I wasn't able to support his amendment at that time. Since then, he has worked with us, which I greatly appreciate, and the leaders of the Senate Veterans Affairs Committee worked with us to resolve those problems. So I can now support the 3-year extension in the Choice Program that he proposes which I expect will include the language changes we discussed.

But even if we approve that 3 year extension that's not the end of our interest in the Choice program or VA purchased care. I think it is important to take the time; let's get this right. I think we need to come to terms with what we want care outside of the VA to look like. I think there are still some huge problems in the implementation of the Choice Program that we need to address, and, unfortunately, these problems are profound in the smaller and harder to get places like Alaska.

I think it is high time that we give the VA clear direction about the value we place on access to veterans' health care in those smaller and hard to get places. In many cases we know the dynamics of the local health care markets better than the folks in a central VA office. Fixing purchased care begins with directing the VA to collaborate with Members of this body to get it right--not allowing the VA to play members off one another so that, once again, the bureaucracy wins. We can't sit quietly by while the VA blames us for failings that they need to own--failures that might have been avoided through collaboration with those who know their localities best.

I appreciate the opportunity to spend a few minutes on the floor this evening talking about how we make things right for who have served us. Memorial Day is but once a year. Veterans Day is but once a year. But every day--every day we need to be honoring and thanking those who serve us, and when we say thank you for their service, let's show them that we mean it. Holding the VA's feet to the fire on results is one way to do that.

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