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Patricia Vandenberg, M.H.A., B.S.N.

Patricia Vandenberg, M.H.A., B.S.N., and Acting Director, Office of Rural Health, Assistant Deputy Under Secretary for Health for Policy and Planning, Veterans Health Administration, U.S. Department of Veterans Affairs

Good Morning, Mr. Chairman and Members of the Committee.  Thank you for inviting me here today to discuss the progress the Department of Veterans Affairs (VA) has made in implementing section 403 of Public Law (PL) 110-387.  Joining me today is a member of my staff, Ms. Gita Uppal, Director of Policy Analysis for the Veterans Health Administration (VHA).

Section 403 requires VA to conduct a pilot program to provide non-VA health care services through contractual arrangements to eligible Veterans.  This is an issue of significance to both Congress and the Department, and we look forward to continuing to work together to ensure Veterans in geographically remote areas receive the care they have earned through service to our country.  My testimony will provide background information on the provision, discuss VA’s efforts to implement this provision and the challenges it has encountered, document the Department’s accomplishments to date, and report on its continuing plan for full implementation of the program.


Public Law 110-387, the Veterans’ Mental Health and Other Care Improvements Act of 2008, was signed by President Bush on October 10, 2008.  Section 403 of this law requires VA to conduct pilot programs during a 3 year period to provide non-VA health care services through contractual arrangements to eligible Veterans.  The pilot program must be conducted in at least five Veterans Integrated Service Networks (VISN), which were to be selected using specific criteria defined in the law.  In determining which VISNs would meet Congress’ requirements, VA reviewed the number of highly rural counties (using the VA definition of highly rural, which is fewer than seven civilians per square mile) in every VISN.  Additionally, VA analyzed the number of states within each VISN and excluded those participating in the Project Healthcare Effectiveness through Resource Optimization (Project HERO) pilot program.  VA determined the following VISNs met the statute’s requirements:  VISN 1: VA New England Healthcare System; VISN 6: VA Mid-Atlantic Health Care Network; VISN 15: VA Heartland Network; VISN 18: VA Southwest Health Care Network; and VISN 19: Rocky Mountain Network.

Veterans who are enrolled in VA as of the commencement of the pilot or are eligible under section 1710(e)(3)(C) of title 38, United States Code, reside in any of the five VISNs meeting the statute’s criteria (VISNs 1, 6, 15, 18, 19), and meeting the statute’s definition of “highly rural” are eligible to participate in the pilot program.  Veterans eligible to enroll under section 1710(e)(3)(C) of title 38, United States Code, essentially includes Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans and Veterans who served on active duty in a theater of combat operations during a period of war after the Persian Gulf War or in combat against a hostile force during a period of hostilities after November 11, 1998.  Veterans who meet the driving distance and hardship criteria for eligibility but are not enrolled in VA as of the commencement of the pilot  or eligible to enroll under 1710(e)(3)(C) of title 38 are not eligible to participate in the pilot program.

The statute defines a Veteran to be highly rural based on driving distances to the nearest VA health care facility.  Under the statute, a Veteran is considered highly rural if the Veteran resides in a location that is:

  1. More than 60 miles driving distance from the nearest VA health care facility providing primary care services, if the Veteran is seeking such services; or
  2. More than 120 miles driving distance from the nearest VA health care facility providing acute hospital care, if the Veteran is seeking such care; or
  3. More than 240 miles driving distance from the nearest VA health care facility providing tertiary care, if the Veteran is seeking such care.

Veterans also are considered highly rural and thus eligible if they experience “hardship or other difficulties in travel to the nearest appropriate [VA] health care facility that such travel is not in the best interest of the Veteran.”  Details of what constitutes “hardship” are not specified in the law.  VA is formulating regulations to define this term with sufficient clarity to provide practical standards, while still maintaining a proper breadth to accommodate Veterans with special circumstances.  As noted below, however, the requirement for this regulation may be eliminated, and the criteria for highly rural may be changed slightly, by legislation passed recently by the House of Representatives and the Senate.

VA’s Efforts and Challenges

Immediately after Public Law 110-387 was enacted, VA focused its efforts on plans to implement this pilot program at several sites.  Since it is an ambitious and complex undertaking, VA established a cross-functional workgroup (the Workgroup) with a wide variety of representatives from various offices, as well as VISN representatives.  The Workgroup began identifying issues and developing an implementation plan.  VA soon realized that the pilot program could not be responsibly commenced within 120 days of the law’s enactment, as called for in the law.  In March 2009, VA officials briefed Subcommittee staff on these implementation issues.

The first challenge VA shared with Congress was that the statute’s definition of “highly rural” was one not being used by VA:  the statute uses driving distances to define a highly rural Veteran, whereas VA defines a highly rural Veteran as a Veteran who resides in a county with fewer than seven civilians per square mile.  VA has well-developed data systems based on its definition and uses these systems to identify highly rural Veterans.  To implement the law, VA needed to re-configure its data systems to determine which Veterans would be eligible to participate in the pilot program.  These changes required VA to identify travel distances for each enrollee for multiple VA facilities, conduct analyses to identify eligibility according to the statute’s definition, and develop enrollment and utilization projections for the pilot program using the definitions in the law.  VA completed this reconfiguration in October 2009. 

The second challenge involved the term “hardship,” which would need to be defined through regulations.  The Federal regulations process involves many steps, including public review and comment.  That may be a lengthy process, depending on the number and complexity of regulations.  VA is now drafting the regulation defining “hardship”, which represents the lengthiest task necessary prior to implementing the pilot.

Our staff had subsequent discussions with the Health Subcommittee staff, continuing to report on the status of the project and also identifying possible changes that could speed implementation.  Section 308 of S. 1963, which recently passed the House of Representatives and the Senate , would remove the requirement regarding the hardship exception as well as slightly modify the definition of ‘highly rural.”  We believe those changes could speed implementation of the pilot program.


VA has made notable strides in implementing section 403 of PL 110-387, with the goal of having the pilot program operating late in 2010 or early in 2011.  Specifically, VA has:

  • Developed an Implementation Plan, which contains the Workgroup’s recommendations on implementing the pilot program;
  • Analyzed driving distances for each enrollee to identify eligible Veterans (using the drive distance criteria) and re-configured its data systems;
  • Provided eligible enrollee distribution maps to each participating VISN to aid in planning for potential pilot sites;
  • Developed an internal Request for Proposals that was disseminated to the five VISNs asking for proposals on potential pilot sites;
  • Developed an application form that will be used for Veterans participating in the pilot program;
  • Formulated a definition for “hardship,” and began drafting regulations; and
  • Taken action to leverage lessons learned from Project HERO and adapt it for purposes of this pilot program.

Next Steps

VA continues to address the ongoing issues associated with implementing this pilot program.  VA will assemble an evaluation team of subject matter experts to review the proposals from the five VISNs regarding potential pilot sites.  This team will then recommend specific locations for approval by the Under Secretary for Health.  We anticipate this process will be complete in summer 2010.  After sites have been selected, VA will begin the acquisitions process.  Because this process depends to some degree on the willingness of non-VA providers to participate, VA is unable to provide a definitive timeline for completion, but it is making every effort to have these contracts in place by fall 2010.  This would allow VA to begin the pilot program in winter 2010 or early 2011.  These estimates are also dependent upon the approval process for VA’s regulations.  Delays in final publication of the regulations could further postpone the start date for the program.

VA is developing information materials for Veterans participating in the pilot program, for non-VA providers, for VA employees, and for other affected populations so that, when the pilot is implemented, all parties will have the information they need to fully utilize these services.  VA is committed to implementing in full, the program directed by Congress and to maintaining the quality of care Veterans receive.  Other issues, such as securing the exchange of medical information, verifying Veterans’ eligibility for this pilot program, coordinating care, and evaluating the success of the pilot program, are also important priorities.  


Thank you again for the opportunity to discuss the status of the pilot program required by section 403 of PL 110-387.  This program will explore opportunities for collaboration with non-VA providers to examine innovative ways to provide health care for Veterans in remote areas.  VA continues to work diligently to implement the program and will continue to keep Congress apprised on the status of these efforts.  VA is prepared to do whatever it takes to serve the needs of all Veterans, including those in rural and highly rural areas.  My staff and I look forward to answering your questions.