Legislature(2015 - 2016)ANCHORAGE
07/28/2015 09:30 AM MILITARY & VETERANS' AFFAIRS
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|Presentation: North Star Behavior Health System,|
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ALASKA STATE LEGISLATURE HOUSE SPECIAL COMMITTEE ON MILITARY AND VETERANS' AFFAIRS July 28, 2015 9:37 a.m. MEMBERS PRESENT Representative Bob Herron, Chair Representative Gabrielle LeDoux, Vice Chair Representative Jim Colver Representative Shelley Hughes Representative Chris Tuck MEMBERS ABSENT Representative Bob Lynn Representative Max Gruenberg Representative Chris Tuck COMMITTEE CALENDAR PRESENTATION: NORTH STAR BEHAVIOR HEALTH SYSTEM - COUNSELING FOR PTSD, SUBSTANCE ABUSE, AND DEPENDENCE TREATMENT FOR VETERANS - HEARD PREVIOUS COMMITTEE ACTION No previous action to record WITNESS REGISTER DEBORAH GURIS, M.D. Staff Psychiatrist North Star Behavioral Health Anchorage, Alaska POSITION STATEMENT: Discussed PTSD and substance abuse. MICHAEL ALCORN, M.D., Psychiatrist North Star Behavioral Health Anchorage, Alaska POSITION STATEMENT: Discussed PTSD and substance abuse. ANDY LANNING Chief Master Sergeant, Air Force, (Ret) Division Director of Military Programs Universal Health Services Patriot Support Program Kansas City, Missouri POSITION STATEMENT: Discussed program facilities across the country. WILLIAM J. MCDANIELS, M.D. Rear Admiral, U.S. Navy, (Ret) Universal Health Services Patriot Support Program Board Member Kansas City, Missouri POSITION STATEMENT: Discussed treatment and recovery. LAURA MACKINZIE Alaska Veterans Administration Healthcare System Anchorage, Alaska POSITION STATEMENT: Discussed veteran homelessness and alcohol abuse. ANN HUTCHINSON, PsyD. Interim Chief of Psychology Alaska Veterans Administration Healthcare System Anchorage, Alaska POSITION STATEMENT: Discussed PTSD and substance abuse. VERDIE BOWEN, Director Office of Veterans' Affairs Alaska Department of Military and Veterans' Affairs (VA) Anchorage, Alaska POSITION STATEMENT: Discussed the Alaska Veterans Administration Healthcare System payment procedure. ACTION NARRATIVE 9:37:57 AM CHAIR BOB HERRON called the House Special Committee on Military and Veterans' Affairs meeting to order at 9:37 a.m. Representatives LeDoux, Hughes, Tuck, Colver, and Herron were present at the call to order. 9:38:29 AM ^PRESENTATION: NORTH STAR BEHAVIOR HEALTH SYSTEM, COUNSELING FOR PTSD, SUBSTANCE ABUSE, AND DEPENDENCE TREATMENT FOR VETERANS PRESENTATION: NORTH STAR BEHAVIOR HEALTH SYSTEM, COUNSELING FOR PTSD, SUBSTANCE ABUSE, AND DEPENDENCE TREATMENT FOR VETERANS 9:39:29 AM DEBORAH GURIS, M.D., Staff Psychiatrist, North Star Behavioral Health, advised that substance abuse disorder involves 10 separate classes of drugs, including alcohol, stimulants, opioids, [indisc.] are issues in the State of Alaska. [Indisc.] activating and repeated activation of the [indisc.] system and when they are in excess behavior associated with these in assessing, many of which are not adaptive, and lead to intense [indisc.] experienced by the individual [indisc.] abuse [indisc.]. She explained they diagnose substance abuse disorder based on the amount [indisc.] associated with an individual's abuse. Behaviors can be classified into three major categories: (1) Impaired control as patients use larger amounts and over a greater period of time they originally intended and report repeated attempts to cut down or [indisc.] and spend more time either trying to [indisc.] or recover [indisc.]. The usual experience is then [indisc.] when exposed to the environmental substance abuser and that could lead to relapsing; (2) social impairment as when individuals suffer from substance abuse disorder over time they fail to provide major goal obligations, their families, work, and community, and continue to use despite negative consequences in those areas and ignore [indisc.] family obligations [indisc.]. They repeatedly go into high risk situations in order for [indisc.] substance infraction and continue using despite the fact they have experienced some type of physiological impairment from the drugs such as, mood disorder, repeated intoxication withdrawal, liver ailment, [indisc.]. With most drugs, people build up tolerance and increase their use of drugs if they have been using it for a long time. She pointed out that with alcohol, for example, withdrawal syndrome precipitated by discontinuing use can be dangerous or life threatening. There is a very high problem of substance abuse disorder and it can affect anyone in any walk of life. [Indisc.] and for alcohol [indisc.] substance abuse disorder [indisc.]. [Indisc.] which increases [indisc.] for inherent and [indisc.] substantive function. She advised they found that substantive [indisc.] caused the disorder and prolonged use can lead to nerve impairment. When a patient first arrives, she explained, a thorough assessment is performed to identify the nature of the substance abuse disorder, nature of substances used, the degree of inherent and substance abuse disorder, and identify any [indisc.] disorder or preexisting disorder [indisc.] if necessary perform neuropsychological testing. [Indisc.] they carefully use medication when appropriate to address any [indisc.] mood disorder and offer medication that may assist with the patient moving to sobriety. Within group psychotherapy, the focus is on education as the patients learn about substance abuse disorder, but they suffer from [indisc.] and understand there are triggers in developing coping skills [indisc.]. [Indisc.] suffering. 9:46:58 AM CHAIR HERRON asked whether combat victims of PTSD are at a higher risk versus post-traumatic events happening in lives not related to combat. 9:47:10 AM DR. GURIS responded that the percentage of [indisc.] combat victims but certainly [indisc.] in the risk factor in general [indisc.]. 9:47:42 AM REPRESENTATIVE LEDOUX surmised that Dr. Guris could not speak to the percentage of PTSD soldiers with substance abuse problems versus the general population. 9:48:12 AM DR. GURIS responded that she cannot answer that question. 9:48:17 AM REPRESENTATIVE TUCK noted that substance abuse disorders could lead to mood disorders and asked whether mood disorders could lead to substance abuse disorders. 9:48:34 AM DR. GURIS replied that often those events co-occur and when talking about substance abuse disorder it is known that depression [indisc.] alcohol, sedatives, and [indisc.] over time can lead to [indisc.] usually for four to six weeks. It is not known that [indisc.] lead [indisc.] but it is known they are highly [indisc.]. 9:49:23 AM REPRESENTATIVE HUGHES asked whether suicide risk and substance abuse is higher in Alaska as opposed to other places in the nation. DR. GURIS [indisc.] military but in general substance abuse is a high risk factor [indisc.] assessments improve their ability to assess. 9:50:05 AM MICHAEL ALCORN, M.D., Psychiatrist, North Star Behavioral Health, said he was recently discharged from the military where he had been working with the active duty military population. He noted that during the first part of his practice as a psychiatrist trained in a Veteran's Administration Hospital regarding PTSD and substance abuse issues. He pointed out that PTSD and traumatic brain injury have been the cardinal injuries of the Iraq and Afghanistan wars, and statistics reveal that 2004-2012 the rate of PTSD in military retirees rose from 4 percent to 20 percent. During the period 2003-2013 the number of service connected disability cases for PTSD rose from 109,000 to over 653,000, and overall PTSD is the third most common disability amongst military retirees involving hearing loss and ringing in the ears. The increase overall for PTSD cases, and PTSD hospitalizations from 2006-2012 increased by 192 percent and he noted that PTSD is at the point of condition that requires a lot of treatment. During his practice of working PTSD patients, and also training medical students and psychiatry residents he pointed out that it is a very diverse condition as there are no stereotypical PTSD patients. He said there are typically 20 symptoms when evaluating a diagnosis and among 4 different categories in that an individual must have a combination of 6 of the 20 symptoms. He calculated there are clinically over 636,000 combinations of symptoms that can make up the diagnosis for a different patient. Due to that, he trains people that PTSD can only be on the differential diagnosis partly because trauma in general is high even for the general population. Not everyone that is traumatized develops PTSD as possibly one-third of people exposed to trauma will develop PTSD. He remarked that the rates are so high he teaches people that any mental health guidelines [indisc.] really anyone who is in and out of [indisc.] screen for exposure to trauma for PTSD. A person diagnosed with PTSD can look like they are very depressed, anxious, preoccupied with [indisc.] concentration problems, ADHD, and often before they come to the clinic develop substance abuse issues, and no matter what they come in with, PTSD is something the doctors are always looking for to determine whether this is a case. 9:54:37 AM DR. ALCORN continued that the symptoms they are going with are very diverse, every patient with PTSD can take their own [indisc.] or patients will develop the first symptoms flare shortly after they are exposed to the trauma, but other times a patient can go years or decades without their first symptoms flare. Likewise, he related, that some patients are very sensitive and anything psychologically stressful can cause symptoms that flare whereas other patients need a specific reminder that reminds them of the trauma, such as smell, sound, or place. When it comes to aligning a treatment plan the doctors consider out-patient treatment, in-patient, what do they need, and must evaluate the patient where they are at. Out- patient therapy has a good chance of succeeding when patients are ready to get their experience off their chest and form a therapeutic relationship and talk. Whereas other patients have tried to avoid thinking about or talking about their experience and for those individuals out-patient wouldn't work because they cannot get comfortable when seeing their therapist once a week and a level of trust can't be developed in order to raise themselves to reveal the things they've experienced. He opined that sometimes with PTSD there is a lot of shame and guilt that goes along with it, and the doctors determine whether a residential treatment program would be better where they can see their therapist every day, break through and build a trust relationship, and progress with their treatment. Dr. Alcorn commented that the program is structured in a manner that is consistent with the evidence as the first phase of the program is working with the patient developing their coping skills, making sure they are comfortable, and build a level of trust before they are pushed into the next phase in starting to address their trauma and work through those issues. Over the last five-seven years, he noted, there is a benefit to offering a program in Alaska and working with the military. He advised they have sent a large number of patients from the clinic to the lower-48 for residential treatment either for PTSD, substance abuse, or both. It has been successful for some of the patients but, he described, definite challenges in that it is difficult to provide family therapy and services to the family that will need to work with the patient when they return to their home. He offered there are programs tied to teleconferencing, but it is not the same and frequently sees that patients come back from the lower-48 and look improved during their first visit. Unfortunately, rapidly thereafter they change to how they were before they went to treatment and it triggered an increase in symptoms. Within out-patient treatment, he said, he initiates the family therapy component and provides psycho-education for the individual's trusted figure so at least they have an elementary understanding of PTSD, and understand why the patient experiences symptoms. He noted that he includes discussing changes the family can make at home or work so it is a little more tolerable for the patient. He conveyed that having local programs available is also beneficial cost-wise as patients sent to the lower-48 requires an escort. [Indisc.] Anchorage or in Alaska for the soldier [indisc.] and how [indisc.] with the program here. The ability to treat both substance abuse and PTSD under the same roof is vital as many patients with PTSD look for any way possible to make their symptoms more tolerable, he pointed out. Treating a person with a substance abuse problem to fully engage in PTSD treatment therapy must be treated at the same time otherwise facing their trauma becomes that much more difficult when treatment is sequentially, he opined. 10:01:22 AM REPRESENTATIVE LEDOUX surmised there has been a huge increase in the number of diagnosed PTSD cases. She asked whether there are more PTSD cases in those increased numbers or whether it has something to do with the focus put on PTSD and the diagnoses of PTSD. She pointed out that the cases that might be diagnosed now with PTSD may not have been diagnosed previously. 10:01:56 AM DR. ALCORN responded there are a combination of things that play into the increase in PTSD. He pointed out the previously it was called "shell shock," and currently people would be diagnosed with PTSD, including schizophrenia. He described a greater awareness of PTSD with regard to the Iraq and Afghanistan wars including advances in battle field medicine and technology which allows a lot of soldiers to survive wounds they previously would not have. While that is a good thing, obviously psychological trauma becomes more prominent, especially later in life. He noted that the military must determine whether PTSD is a legitimate diagnoses, whether they are they trying to mimic what their buddy just said, or trying to gain their symptoms. When diagnosing PTSD, there are different psychological tests and the more information the patient can offer the more helpful it is, he remarked. 10:03:26 AM REPRESENTATIVE LEDOUX asked whether a physical injury must be involved or another person's injury observed. 10:03:37 AM DR. ALCORN replied it can be witnessed or even repeatedly listen to an event in stories. He related that if the soldier's response at the time of observing or witnessing it indicates they're significantly affected, a soldier can be diagnosed with PTSD. He said it is fairly rare that he has diagnosed PTSD involving [indisc.] in some way experienced it directed toward themselves. He offered that possibly the soldier does not have the actual physical injury, although [indisc.] five feet away from them and didn't explode but assumed they were going to be killed. He opined that it is rare someone watching a program on television or hears something is diagnosed with PTSD. 10:05:02 AM ANDY LANNING, Chief Master Sergeant, Air Force, (Ret), Division Director of Military Programs, Universal Health Services Patriot Support Program, [Indisc.] said there are over 27 medical surgery facilities across the country, including Puerto Rico, Virgin Islands, and England, with continued care. He said that within that piece is the Patriot Support Program and almost eight percent of the facilities are affiliated with [indisc.] and people are seen from [indisc.] down to 4-years old. He explained that the Patriots Support Program is focused on veteran and active duty service members and noted that 14 facilities have dedicated programs similar to the Chris Kyle Program in Anchorage with a dedicated treatment program for active duty members and veterans. He explained that at the height of the wars it was determined that veterans react to treatment better when in groups as they go through some of the trauma cases, combat trauma and stresses of military life, and felt better corresponding with their brothers and sisters. He advised that was the prelude to opening facilities in treating substance abuse, combat trauma, [indisc.] and military sexual trauma for females and men. In addition to that, last year they have 13 other basic core service centers with programs [indisc.] established, all are best practices and repeated visits to facilities to ensure that the core executive programs are [indisc.] hit or miss with the civilian population. Some of the installations are uncomfortable with that, they may be [Indisc.] out in [indisc.] integration in with the civilian population is actually beneficial to them to learn social skills to reintegrate back into civilian life after living solely with military members. He referred to the Military Advisory Board which includes seven officers, military consultants, [indisc.] medical integrity programs [indisc.]. He advised he spent a lot of time at facilities regarding communication, understanding military culture, and providing training for doctors and staff that have not been in the military as to the culture of the military and when men and women come in, staff has a better understanding of military life. 10:09:35 AM WILLIAM J. MCDANIELS, M.D., Rear Admiral, U.S. Navy, (Ret), Universal Health Services Patriot Support Program Board Member, [Indisc.] advised an effective way to treat recovery is to get groups together and talk it out, and is involved in the 28-day program [indisc.] that turns out to be phenomenally effective. [Indisc.] when veterans came home from World War II they spent three weeks on a cruise ship with 5,000 buddies all in unknown pain and trauma with nothing to do on the ship except talk. In this manner, he explained, the returning soldiers provided their own therapy extremely well [indisc.] but in fact it was believed one of the reasons it continued [indisc.] than what occurs now is [indisc.] blown up [indisc.] back with their family with no chance to decompress and no chance to compare events with military friends, and no chance to talk it out. He said that's hard [indisc.] tracking inefficacies, rapid diagnosis, and patient [indisc.]. The history of this disease [indisc.]. [Indisc.] three two-star and three three-star adjutant generals from the Army, Navy, and Air Force, two two-star and one one- star [indisc.]. These individuals have all been to combat and dealt with this condition [indisc.] all of their professional lives and all continue to have the desire to still give the best treatment possible to the people who were once under their care and in their memories. He pointed out that these individuals have many opportunities, as [indisc.] officers to serve on various committees and everyone wants to just because [indisc.]. Previously they very carefully looked around at systems trying to [indisc.] and when they were approached by Universal Health Services (UHS) as to whether they would be interested in an endeavor with them they looked very carefully [indisc.] and realized that what UHS was doing follows very closely to what they aspired to do which is to give the best help possible to the young men and women who put their lives on the line for the nation. [Indisc.] and that is what they do. [Indisc.], he advised he is an orthopedic surgeon [indisc.] and usually [indisc.] giving a talk in that very profession but [indisc.]. 10:13:17 AM CHAIR HERRON asked what is the Universal Health Services (UHS) and why did Admiral McDaniel affiliate himself with it. 10:13:35 AM REPRESENTATIVE LEDOUX questioned whether Dr. McDaniel has seen an increase in PTSD because people go from a battle zone to the states in a brief period of time instead of being on a carrier for 18 days having a chance to decompress with their buddies. She suggested going back to a carrier system to bring the soldiers back to the states or some sort of camp or something for them to decompress. DOCTOR MCDANIEL responded that they have [indisc.] with that but the answer is political as these people have been gone 6-12 months, they get [indisc.] if they know that in the event they show symptoms of PTSD and will be held someplace for three weeks for treatment, he guarantees there will be no signs or symptoms. Then [Indisc.] political windstorm that no one would survive and that is [indisc.] war zones and can't see their family for another three weeks as they will be held just in case, would never work. He offered that the idea had been discussed at length and disregarded as it absolutely politically impossible [indisc.]. [Indisc.] using blood tests and behavioral tests before they go [indisc.] and before they come back [indisc.] but people will hide if they think there is any chance that [indisc.] their family and friends. [Indisc.] there are a number of groups around the country that approached the Patriot Support Advisory Board [indisc.] who want to be involved [indisc.]. A program must have a majority [indisc.] or military associated programs [indisc.] and must understand military culture. He remarked that some of the psychiatric groups don't [indisc.] they think any [indisc.] facts will do. The Patriot Support Advisory Board believes the culture of having a military [indisc.] and need to have a program set up so there are three choices in the military and [indisc.] what you do here [indisc.] you have [indisc.] program and get up every morning and go to physical therapy, which many veterans have twice a day. He pointed out that there must be a regiment very akin to what they underwent in the military and that is what UHS does and if a program is set up as closely as possible to what veterans are accustomed to in their military lives, the results will be better. He said that UHS offers those programs which is why the Patriot Support Advisory Board chose to associate with it. 10:17:19 AM REPRESENTATIVE LEDOUX asked whether Universal Health Services is a governmental agency or non-profit. 10:17:44 AM DOCTOR MCDANIELS answered that [indisc.]. The founding gentleman of Universal Health Services is in Anchorage and will make the dedication this morning. He [indisc.] very patriotic and believes in it totally which is one of the reason for the dedication today. [Indisc.]. 10:18:05 AM REPRESENTATIVE HUGHES referred to previous discussion regarding increases in veterans [indisc.] active duty [indisc.]. [Indisc.] Viet Nam [indisc.] so they are managing it on [indisc.] and help them [indisc.]. [Indisc.] mission but does a person once identified [indisc.] do they ever recover or will always require services throughout their lifetime [indisc.]. 10:19:11 AM DOCTOR MCDANIELS responded [indisc.] there are varieties of grief issues [indisc.] function throughout their lives, they don't have episodes. He offered that within his experience when they get stressed they may [indisc.]. [Indisc.]. The vast resources are in that [indisc.]. [Indisc.] a very small amount of [indisc.] just since [indisc.]. [Indisc.]. He advised that he spoke long ago on this condition and hired professionals to work together in Seattle, and thought [indisc.] on the other side of the bar there are [indisc.]. He said the Viet Nam era [veterans] have learned to treat themselves. Successfully he couldn't say but in fact they get along in the [indisc.]. 10:20:52 AM LAURA MACKINZIE, Alaska Veterans Administration Healthcare System, [Indisc.] active duty service members and veterans. [Indisc.] located at the [indisc.] facility which provides residential treatment for both homeless veterans and [indisc.]. She said [indisc.] provides comprehensive residential treatment which is greatly needed for this population. Substance abuse and mental health services [indisc.] there are an estimated 23.4 million veterans in the United States and approximately 2.2 million will [indisc.]. Within Alaska there are approximately 77,000 veterans and 25,000 active service members. She noted Alaska has the highest per capita numbers of veterans in the country. The demanding environment of military life and experiences of combat during which they may experience psychological distress can be further complicated by substance abuse and related disorders, she remarked. Many service members face critical issues, such as trauma, suicide, homelessness, and toward [indisc.] emotions, and approximately [indisc.] percent of service members returning from Iraq and Afghanistan have Post Traumatic Stress Disorder (PTSD) or depression. In [indisc.], experienced in traumatic brain [indisc.]. Between 2005-2006 approximately 20 percent [indisc.] substance abuse disorder, 70 percent of the total [indisc.] substance abuse disorder. [Indisc.] PTSD, substance abuse in the military population for men and women. More than [indisc.] PTSD. [Indisc.] combat does [indisc.] PTSD and alcohol [indisc.]. [Indisc.]. [Indisc.] soldiers in the VA have a problem with alcohol or drugs. [Indisc.] more women are serving in the military than at any point in the history of this country. She pointed out that the gender shift creates new challenges of [indisc.] returning veterans [indisc.] disorder. [Indisc.] military women are doing. Included in this need are service [indisc.] issues arise [indisc.] dominantly males. [Indisc.]. [Indisc.] more than quadrupled the numbers [indisc.]. Recent reports in the last [indisc.]. [Indisc.] hospital discharge [indisc.] nearly doubled [indisc.]. She related that the current availability of treatment provided for Alaskans is inadequate because [indisc.] communities. [Indisc.] over [indisc.]. The top 10 percent per capita in alcohol related [indisc.]. [Indisc.] active duty [indisc.]. The VA provides services on an out- patient and residential basis for [indisc.]. Industry programs [indisc.] utilize [indisc.]. [Indisc.]. Substance abuse treatment provides [indisc.]. [Indisc.]. She conveyed that the VA is working on [indisc.] grateful launching [indisc.]. [Indisc.] welcome partnership in providing care for veterans [indisc.]. Additional treatment [indisc.] potential providers [indisc.] substance abuse treatment [indisc.]. Welcome [indisc.] and support Safe Harbor in Anchorage. [Indisc.]. 10:27:41 AM ANN HUTCHINSON, PsyD, Interim Chief of Psychology, Alaska Veterans Administration Healthcare System, [Indisc.] This position was created to better serve the needs of veterans, she explained. [Indisc.] 70 percent of those suffering from PTSD also have an alcohol use disorder problem over the course of their life. [Indisc.] veterans population that also parallels the Viet Nam veterans hospital. She expressed that is one of the main reason she developed this position for better analysis and treatment [indisc.]. The evidence of psychotherapy [indisc.]. [Indisc.] preferred treatment of the veteran [indisc.] treatment of PTSD and training process [indisc.]. [Indisc.] get that training and get back to [indisc.] prevention. [Indisc.] treated by VA physicians and as Dr. Alcorn mentioned, he can see as often [indisc.] treated. [Indisc.] primary care, social workers [indisc.] She advised that shows her they are doing a great job identifying PTSD and able to treat the condition early for a brief behavioral care intervention. A veteran seen in outpatient care [indisc.] her role [indisc.]. [Indisc.] offer a one-time [indisc.] may be asked to go on and take some symptom management classes [indisc.] identify different symptoms and offer practical skills. [Indisc.] PTSD is often recommended [indisc.]. [Indisc.] gold standards of treatment [indisc.] provided good feedback as it has been a hopeful group and the VA also has a [indisc.] treatment called [indisc.] which is another great therapy [indisc.]. [Indisc.] group and individual therapy [indisc.] the second is the [indisc.] version which are also gold standards [indisc.] The VA has the ability to send veterans to the lower-48 to American Lake or Wyoming for residential treatment. [Indisc.] 10:32:08 AM CHAIR HERRON asked whether the Veterans Administration (VA) embraces this private sector effort. MS. MACKENZIE responded that the VA welcomes additional resources for veterans and recognizes that the need is greater than what the VA can meet at this time and is good for veterans. 10:32:44 AM REPRESENTATIVE LEDOUX questioned the payments for the services, and whether Tri-Care pays for services or whether the Veterans Administration refers people to the private health sectors and the VA pays for it. MR. LANNING explained that the VA's column of money is separate from Tri-Care money as the veteran's treatment is paid through the VA or charged to [indisc.]. [Indisc.] would pick up that cost. REPRESENTATIVE LEDOUX surmised that the VA refers veterans to UHS or a similar entity when the VA does not believe it has the services in-house. 10:34:17 AM VERDIE BOWEN, Director, Office of Veterans' Affairs, Alaska Department of Military and Veterans' Affairs (DMVA), explained that the VA refers patients to out-patient care and the service can be paid in three different processes: the VA can offer direct payment to the facility providing care to the veteran; or [indisc.] they have a network of care [indisc.], or they use the [indisc.] which is available for the next three years and veterans [indisc.] as well. REPRESENTATIVE LEDOUX inquired as to the veteran's choice per family [indisc.]. MR. BOWEN advised that recently President Barack Obama signed the Veterans Access, Choice and Accountability Act of 2014 (Choice Act) allowing veterans to choose health care in two ways: [indisc.] choice 30/40 program or the Veteran's First Program which is a referral process within the VA system and is utilized for non-critical care, urgent care is provided under a different vehicle which is [indisc.]. The PT3 contract is nationwide and is outside contracts, Tri-Care, United Health Care, the State of Alaska, and the VA system, have other PT3 contracts [indic.] which is a third-party administrator for that program as well. 10:36:26 AM ADJOURNMENT There being no further business before the committee, the House Special Committee on Military and Veterans' Affairs meeting was adjourned at 10:36 a.m.