[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
ISSUES FACING WOMEN AND MINORITY VETERANS
=======================================================================
JOINT HEARING
before the
SUBCOMMITTEE ON HEALTH
and the
SUBCOMMITTEE ON DISABILITY ASSISTANCE
AND MEMORIAL AFFAIRS
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
JULY 12, 2007
__________
Serial No. 110-33
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South RICHARD H. BAKER, Louisiana
Dakota HENRY E. BROWN, Jr., South
HARRY E. MITCHELL, Arizona Carolina
JOHN J. HALL, New York JEFF MILLER, Florida
PHIL HARE, Illinois JOHN BOOZMAN, Arkansas
MICHAEL F. DOYLE, Pennsylvania GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
Malcom A. Shorter, Staff Director
______
SUBCOMMITTEE ON HEALTH
MICHAEL H. MICHAUD, Maine, Chairman
CORRINE BROWN, Florida JEFF MILLER, Florida, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
PHIL HARE, Illinois JERRY MORAN, Kansas
MICHAEL F. DOYLE, Pennsylvania RICHARD H. BAKER, Louisiana
SHELLEY BERKLEY, Nevada HENRY E. BROWN, Jr., South
JOHN T. SALAZAR, Colorado Carolina
______
SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS
JOHN J. HALL, New York, Chairman
CIRO D. RODRIGUEZ, Texas DOUG LAMBORN, Colorado, Ranking
PHIL HARE, Illinois MICHAEL R. TURNER, Ohio
SHELLEY BERKLEY, Nevada GUS M. BILIRAKIS, Florida
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
__________
July 12, 2007
Page
Issues Facing Women and Minority Veterans........................ 1
OPENING STATEMENTS
Hon. Michael Michaud, Chairman, Subcommittee on Health........... 1
Prepared statement of Chairman Michaud....................... 31
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs................................ 3
Prepared statement of Chairman Hall.......................... 31
Hon. Doug Lamborn, Ranking Republican Member, Subcommittee on
Disability Assistance and Memorial Affairs..................... 2
Prepared statement of Congressman Lamborn.................... 32
Hon. Michael R. Turner........................................... 4
Hon. Gus M. Bilirakis, prepared statement of..................... 32
WITNESSES
U.S. Department of Veterans Affairs:
Shirley A. Quarles, R.N., Ed.D., Chair, Advisory Committee on
Women Veterans............................................. 12
Prepared statement of Dr. Quarles........................ 33
Colonel Reginald Malebranche, USA (Ret.), Member, Advisory
Committee on Minority Veterans............................. 14
Prepared statement of Col. Malebranche................... 35
Betty Moseley Brown, Ed.D., Associate Director, Center for
Women Veterans............................................. 27
Prepared statement of Dr. Brown.......................... 47
Lucretia M. McClenney, Director, Center for Minority Veterans 29
Prepared statement of Ms. McClenney...................... 51
______
Disabled American Veterans, Joy J. Ilem, Assistant National
Legislative Director........................................... 21
Prepared statement of Ms. Ilem............................... 41
Murdoch, Maureen, M.D., MPH, Center for Chronic Disease Outcomes
Research, Minneapolis Veterans Affairs Medical Center,
Minneapolis, MN, Veterans Health Administration, U.S.
Department of Veterans Affairs................................. 17
Prepared statement of Dr. Murdoch............................ 40
Rosenberg, Saul, Ph.D., Associate Clinical Professor of Medical
Psychology, University of California, San Francisco, CA........ 15
Prepared statement of Dr. Rosenberg.......................... 37
Wilson, Hon. Heather, a Representative in Congress from the State
of New Mexico.................................................. 4
SUBMISSIONS FOR THE RECORD
American Legion, Shannon L. Middleton, Deputy Director for
Health, Veterans Affairs and Rehabilitation Commission,
statement...................................................... 54
Brown, Hon. Corrine, a Representative in Congress from the State
of Florida, statement.......................................... 56
Miller, Hon. Jeff, Ranking Republican Member, Subcommittee on
Health, and a Representative in Congress from the State of
Florida, statement............................................. 56
Veterans of Foreign Wars of the United States, Dennis Cullinan,
Director, National Legislative Service, statement.............. 56
Vietnam Veterans of America, Marsha Four, Chair, Women Veterans'
Committee, and John J. Rowan, National President, joint
statement...................................................... 58
Women's Research and Education Institute, Susan Scanlan,
President, statement........................................... 62
MATERIAL SUBMITTED FOR THE RECORD
Post Hearing Questions and Responses for the Record:
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Hon. R. James Nicholson, Secretary, U.S.
Department of Veterans Affairs, letter dated July 26, 2007. 64
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Shirley A. Quarles,
R.N., Ed.D., Chair, Advisory Committee on Women Veterans,
U.S. Department of Veterans Affairs, letter dated August 2,
2007....................................................... 81
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Colonel Reginald
Malebranche, USA (Ret.), Member, Advisory Committee on
Minority Veterans, U.S. Department of Veterans Affairs,
letter dated August 2, 2007................................ 83
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Saul Rosenberg, Ph.D.,
Associate Clinical Professor of Medical Psychology,
University of California, San Francisco, CA, letter dated
August 2, 2007 [NO RESPONSES WERE RECEIVED FROM DR.
ROSENBERG]................................................. 85
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Joy J. Ilem, Assistant
National Legislative Director, Disabled American Veterans,
letter dated August 2, 2007................................ 86
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Betty Moseley Brown,
Ed.D., Associate Director, Center for Women Veterans, U.S.
Department of Veterans Affairs, letter dated August 2, 2007 87
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Lucretia M. McClenney,
Director, Center for Minority Veterans, U.S. Department of
Veterans Affairs, letter dated August 2, 2007.............. 90
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Shannon L. Middleton,
Deputy Director for Health, Veterans Affairs and
Rehabilitation Commission, American Legion, letter dated
August, 2, 2007............................................ 91
ISSUES FACING WOMEN AND
MINORITY VETERANS
----------
THURSDAY, JULY 12, 2007
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Subcommittee on Disability Assistance
and Memorial Affairs,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:00 a.m., in
Room 334, Cannon House Office Building, Hon. Michael H. Michaud
[Chairman of the Subcommittee on Health] presiding.
Present from the Subcommittee on Health: Representatives
Michaud and Hare.
Present from the Subcommittee on Disability Assistance and
Memorial Affairs: Representatives Hall, Hare, Lamborn, Turner,
and Bilirakis.
OPENING STATEMENT OF CHAIRMAN MICHAUD,
SUBCOMMITTEE ON HEALTH
Mr. Michaud. The Subcommittee on Health will come to order.
I'd like to thank everyone for coming today. This is a joint
hearing with the Subcommittee on Disability Assistance and
Memorial Affairs as well.
Today we will examine the U.S. Department of Veterans
Affairs (VA) programs regarding women and minority veterans.
The face of the military is changing and so is the face of the
veterans' population. According to the 2000 census, minorities
make up over 14 percent of the existing veterans' population.
The population of women veterans is projected to continue to
rise from 6 percent in 2000 to 8 percent in 2010 and to 10
percent in 2020.
VA needs to consistently evaluate existing programs to
address the needs of special groups and make changes when
needed. I further believe that VA should implement new and
innovative programs to help close the many gaps that exist
today in delivering high-quality, safe health care and other
benefits and services VA provides.
Service in Operating Enduring Freedom (OEF) and Operation
Iraqi Freedom (OIF) has created growing challenges for the VA
in meeting the needs of women and minority veterans as they
separate from service. We know that an unprecedented number of
female servicemembers have been routinely exposed to combat or
combat-like conditions. VA reports that the prevalence of
potential post traumatic stress disorder (PTSD) among new OEF/
OIF women veterans treated at VA has grown from 1 percent in
2002 to nearly 19 percent in 2006. Issues such as cultural
differences, effective outreach, education, research and
delivery of care should be carefully examined in an effort to
provide the best possible service to these veterans.
I hope that we will learn how the VA is meeting the needs
of these populations, what challenges are on the horizon, and
what we can do to provide veterans the best possible care
available.
At this time, I would yield to Mr. Lamborn who is the
Ranking Member of the Disability Assistance and Memorial
Affairs Subcommittee for an opening statement.
[The prepared statement of Chairman Michaud appears on
p. 31.]
OPENING STATEMENT OF HON. DOUG LAMBORN,
RANKING REPUBLICAN MEMBER, SUBCOMMITTEE ON
DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS
Mr. Lamborn. Thank you, Mr. Chairman, for recognizing me
and I look forward to this hearing with you, with Mr. Hall from
New York, with Mr. Turner and everyone else who can join us as
we go through this hearing.
I'm glad that we are having this hearing on the challenges
facing minority and women veterans. I welcome our witnesses
including my colleague from New Mexico Representative Heather
Wilson. And I thank you all for your contributions to the
Veterans' Affairs system.
America's minorities and women of our great Nation are
integral to the quality of our national security. Women make up
nearly 10 percent of our Nation's 24 million living veterans.
Women on active duty represent more than 15 percent of our
armed forces. According to a 2005 Heritage Foundation study,
about 25 percent of military recruits identify themselves as
other than Caucasian. Further, military women are more likely
to identify themselves as members of a racial or ethnic group
than men.
Our military has a higher percentage of some minorities
such as African Americans, American Indians, Native Alaskans
and Hawaiians and Pacific Islanders than the percentage of
these minorities in the general population. These men and women
are patriots. In more than 2 centuries of service to our
country, women and minority servicemembers have created a rich
legacy. This legacy has only been enriched by the intrepid and
resolute accomplishments of their decedents in the global war
on terror.
Our challenge is to ensure that women and minority veterans
indeed all veterans receive equal treatment for their
qualifying service to our Nation. The VA Centers for Women and
Minority Veterans and the Department's associated Advisory
Committees are charged with increasing awareness of VA
programs, with identifying barriers and inadequacies in VA
programs, and with influencing improvement.
We do not look to these VA programs to merely identify and
report, we want them to influence policy and accept a measure
of accountability for departmental results. In that regard, I
will, of course, be very interested in hearing today about
challenges facing women and minority veterans such as gender
specific health care.
I want to learn about disabilities more likely to effect
minority veterans. I want to hear about the challenges facing
veterans who wish to take advantage of economic opportunities
in the public and private sectors. I will, however, especially
want to learn today how the VA and it's component organizations
are effectively rising to meet these challenges.
Mr. Chairman, I yield back.
[The prepared statement of Congressman Lamborn appears on
p. 32.]
Mr. Michaud. Thank you very much, Mr. Lamborn. And now I
would like to yield to a gentleman who feels strongly about
veterans' issues as well, Mr. Hall who is the Chairman for the
Subcommittee on Disability Assistance and Memorial Affairs for
an opening statement.
Mr. Hall.
OPENING STATEMENT OF CHAIRMAN HALL, SUBCOMMITTEE
ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS
Mr. Hall. Thank you, Chairman Michaud and Mr. Lamborn. I
always enjoy serving with you on our Disability Assistance
Subcommittee. Good morning, all.
I would first like to say that I am honored to join Mr.
Michaud in cochairing this hearing and I applaud the leadership
he exercises on behalf of our veterans, especially on veterans
health care issues. I would also like to thank the witnesses
for joining the 2 Subcommittees this morning for a hearing to
examine issues facing women and minority veterans.
This rare joint hearing speaks volumes about how important
these issues are to the Committee as a whole. I look forward to
hearing from all of today's witnesses. I also want to apologize
in advance for the fact that I am double booked in another
Committee meeting and will have to leave and then come back in
a little while so that I can hear as much testimony as
possible. I will read the written testimony that I may miss in
person.
Women veterans are the fastest growing segment of the
veteran population comprising 7 percent of the total veteran
population and 5 percent of those using VA services. Over 14
percent of veterans are from a racial or ethnic minority group
with African Americans comprising the bulk at 9.7 percent
according to 2000 U.S. Census figures. I am certain that the VA
does its best to ensure that all veterans encounter no barriers
to access and the receipt of veterans' benefits, treatment and
services. However, the fact remains that the barriers in
society at large that women and minorities often face might
very likely translate into barriers in the smaller VA system.
As such, Congress, in its wisdom, developed both the Center
for Minority Veterans and the Center for Women Veterans in 1994
to ensure that these veterans are fully integrated into the VA
system. I look forward to hearing from both Centers as well as
their separate Advisory Committees, which developed detailed
reports to help inform the policies of the VA for women and
minority veterans. I especially would like to learn the VA's
and the Advisory Committee on Minority Veterans' views on the
sunsetting provisions that would end the Advisory Committee in
2009 and what, if any, plans it has to replace this vital
organization.
I know that Representative Gutierrez has introduced a bill,
H.R. 674, that would prevent this from occurring. Getting rid
of the Minority Veterans Advisory Committee would be a
seriously troubling result in light of the recent findings by
VA researchers that health disparities appear to exist in all
clinical arenas and have a direct impact on the health outcomes
for minority veterans.
And last, but certainly not least, I welcome my colleague
Congresswoman Heather Wilson, the only woman veteran in
Congress. I am sure that all of our witnesses, including our
experts and the veterans service organizations will provide
critical insight on issues facing women and minority veterans,
especially in light of returning OIF and OEF veterans.
Thank you very much and I yield back, Mr. Chairman.
[The prepared statement of Chairman Hall appears on p. 31.]
Mr. Michaud. Thank you very much, Chairman Hall. Mr.
Turner, do you have an opening statement?
OPENING STATEMENT OF HON. MICHAEL R. TURNER
Mr. Turner. Mr. Chairman, I want to thank both of the
Chairmen for our proceeding with this hearing. This is very
important and I want to congratulate and thank Heather Wilson
for all of her efforts in Congress, not only to be a strong
advocate for veterans in our military, but also to bring her
experience to assist us so that we can also better serve. Thank
you.
Mr. Michaud. Thank you. Mr. Bilirakis, do you have an
opening statement?
Mr. Bilirakis. I'll submit my opening statement for the
record, but I wanted to thank you for having this hearing. I
also want to thank Congresswoman Heather Wilson for her great
insight. And it is just a great subject and we need to
concentrate more on minority veterans and women veterans. Thank
you very much. I appreciate it.
[The prepared statement of Congressman Bilirakis appears on
p. 32.]
Mr. Michaud. Thank you very much. It is my pleasure now to
introduce our first panelist, Congresswoman Heather Wilson of
New Mexico. I want to thank you very much for your willingness
to come here and give us your expertise and your insight on
these very important issues. Thank you for your leadership as
well on these issues.
So without further ado, Congresswoman Wilson.
STATEMENT OF HON. HEATHER WILSON, A REPRESENTATIVE IN CONGRESS
FROM THE STATE OF NEW MEXICO
Ms. Wilson. Mr. Chairman, thank you. And thank you very
much for having this hearing today and bringing some focus on
an issue very important to me.
Now all of us are concerned about whether the VA health
care system is meeting the needs of our current generation of
veterans, but there is a special subcategory that sometimes I
think gets overlooked. And the fact that you are having this
hearing today says that the Congress and this Committee in
particular cares about women veterans and whether they are
getting the services that they need.
In 1978, I got a one way ticket to Colorado Springs,
Colorado, to attend the United States Air Force Academy in the
third class with women. They opened the Air Force Academy to
women when I was a junior in high school. And I got on the bus
and went to the base of that big ramp at the front edge of the
ramp part range in Colorado and walked up a ramp with huge
letters over the top of it that said, ``Bring me men.''
It took over 25 years to get that sign taken down. It is
gone now, but some of us as women veterans think that maybe the
VA health care system is now only experiencing the kind of
integration that the military saw 20 years ago because my
classmates and the women who went into the military in the
seventies are now starting to retire. And, we also have women
returning from combat zones with health care needs that we
haven't seen in previous generations. So it creates a new
challenge for the VA and I appreciate your willingness to look
at this.
Currently deployed in Iraq, 1 in 7 Americans deployed in
Iraq and Afghanistan are women. They are doing jobs that in
previous generations no women undertook in the military. And we
need to orient our health care system toward the needs of both
women and men. Women, frankly, face different obstacles when
trying to get care from the VA, their needs are often
different. Whether it is long term, whether the VA is going to
be able to deal with the problems, whether it is osteoporosis
or obstetrics/gynecology (OB/GYN) care or cancer screening and
treatment or mental health issues and how they manifest
themselves, they are often different needs. And we need to make
sure that the VA is responsive to those needs.
For example, if you are a veteran and you go to one of the
clinics for a problem with PTSD at the VA hospital and they
have a support group that is a bunch of guys, is that really
where a woman feels particularly comfortable talking about her
experiences? I am not sure I would. And I am not sure I would
turn to the VA for the kind of care. Likewise, many women
veterans do not even call themselves veterans. It is an
interesting phenomena. But it is only now that women who have
served in the military even use that term to describe
themselves. And it is very different from men who have served.
Someone, a fellow woman veteran gave me a tee shirt which I
still have and wear from time to time around the house that
says on the back of it, ``I am a veteran too.''
Getting women to that point where they feel like they are
veterans and they feel comfortable calling on the VA health
care system, that the door is open to them, is a hurdle that we
have to get over and the VA has to reach out to women veterans,
I believe. In addition to those kinds of social or psycho-
social issues, there is a question of appropriate care. And
while I haven't seen too many specifics incidences of problems
in the VA health care system, I certainly had my share of them
going through the U.S. Department of Defense (DoD) health care
system and I can't imagine that the VA has magically addressed
all of these problems without having to kind of go through
their own learning curve.
You know, for example, when I was on active duty and they
had opened up flight school to women, you had to have a flight
physical. Well a flight physical for women included an OB/GYN
exam. The rules said that a flight physical had to be done by a
flight surgeon, but the flight surgeons often times had only
done their, you know, their last OB/GYN exam was in medical
school and they didn't like it much when they did it the first
time. So there were rules about how health care was to be
provided for active duty women that weren't--there wasn't a
most appropriate way to provide care. And I believe that those
kinds of things probably exist in the VA health care system,
but were only on the upward curve now with respect to the women
that are getting care from the VA because their numbers have
been so small, particularly the numbers of women veterans who
are also combat veterans.
In the 110th Congress, I have introduced a piece of
legislation. It is a bipartisan commission on wounded women
warriors. We focused a lot in the last year about the VA health
care system and it's responsiveness to veterans overall. And
all of us are keenly aware of the problems at Walter Reed and
elsewhere on the care of our returning soldiers and veterans,
but I think there is a subgroup we also need to look at. And I
introduced this legislation to establish a 12 member bipartisan
commission to bring some focus and expertise on this issue, to
identify major problems and surface them at senior levels. The
military did this in the seventies and eighties and it was very
effective at identifying policies that needed to be changed,
capabilities and services that needed to be expanded and
provided and to better support our women in the military. And
now I need to--I think we need to do a similar kind of thing
for women veterans.
Last month during debate on the military construction and
VA Appropriations bill for fiscal year 2008, I offered an
amendment that was accepted by voice that would devote $2
million from the Administration's general operations expenses
account to the Advisory Committee on Women Veterans. The intent
of that amendment was to provide the funding for a bipartisan
commission on wounded women warriors to look at these issues
and identify problems and plans to make sure health care for
women veterans is what it needs to be so that we can adequately
meet their needs.
We can't address the needs of women veterans unless we
fully understand the problems. And I don't think we are yet
fully at the point of fully understanding the problems within
the VA health care system. And I think this Congress needs to
make sure that we put ourselves on a path to do so.
I thank you very much for holding this hearing today. And
to the extent I can, I would be very happy to answer any
questions you may have of me.
Mr. Michaud. Thank you very much, Congresswoman Wilson.
Just a quick question, do you get a lot of communication
between women veterans that might not go to a male Member of
Congress that know your experience? And what has been some of
their concerns, if there is anything different than what you
have already given in your testimony?
Ms. Wilson. Sure. I think women sometimes feel more
comfortable coming to me and it is I am sure it is--all of us
come here with our own stories. And sometimes people will come
where they feel more comfortable or feel somebody will get it.
And so, yes, women veterans do come to me, both New Mexicans
and some of the groups nationally or leaders nationally both
veterans and active-duty servicemembers.
Some of the kinds of issues is women's health care clinics
at VA hospitals. We have had a problem in some VA hospitals
including our hospital in New Mexico where several years ago
they wanted to close the women's health care clinic. For some
women being able to walk in and they are, you know, that they
have a women's clinic is kind of important. Now there are a lot
of ways and different models to provide that, but that was an
issue. And it wasn't just an issue on the appropriateness of
health care, it was the VA sending a message as to whether we
are welcome here, or not, or do they want us to go somewhere
else?
And so that is an issue. I dealt with academy issues with
respect to sexual assault, discrimination, those kinds of
things come up. I was very active with Mr. Langevin of Rhode
Island when women in Saudi Arabia were being asked to wear the
abaya with the Muslim cloak while they were fighting to free
the Afghan women from having to wear the burka. And they were
required to wear by DoD policy, and we were able to change that
by law. So, yes, women do come to me.
Mr. Michaud. My last question, since there is not a large
number of women veterans using VA facilities, trying to look on
the fiscal side of the issue, do you think that VA should hire
more women staff, or would it be more fiscally responsible to
contract out the type of services a woman might need to help
women veterans?
Ms. Wilson. I think it is going to depend on the population
served and, you know, we have clinics in all over New Mexico
that are really quite small. And it so that a veteran can get
primary care and in Truth or Consequences, New Mexico, without
having to come all the way to Albuquerque. At the same time,
the availability of services, particularly OB/GYN services in
our major VA hospitals, I think is probably an issue. And the
appropriateness of that care, whether it is by a contract
doctor or an agreement with one of the universities or direct
on-staff hire, and as you all know, the VA has had difficulty
filling positions for a variety of reasons over time, but it is
an issue of the appropriateness of care. And frankly, some
women prefer to have a women doctor as an OB/GYN. And even the
policy that says for most hospitals now you are a primary
provider. If your health care is from a health maintenance
organization, I can go to my primary care doctor. I can also
get direct access to my OB/GYN. I believe that is currently VA
policy, but making clear that you can go. You don't have to go
through another gatekeeper. You can go directly. Those kinds of
things I think are important to women.
Mr. Michaud. Great. Thank you very much. Mr. Lamborn?
Mr. Lamborn. I thank you, Mr. Chairman. In counting back
the years, I think you were leaving Colorado Springs just as I
was arriving there, because I moved there in 1987.
Ms. Wilson. I graduated in 1982.
Mr. Lamborn. Okay. How prevalent is the problem of women
veterans being unaware that their military service qualifies
them for VA health care? We are finding that male veterans are
many times unaware of the benefits that they are entitled to.
Ms. Wilson. I think you were right, Mr. Lamborn, that there
is a problem of awareness of what benefits you are eligible for
across the board. When I left the service, I didn't retire from
the service, I left after 7 years as an officer. I had no clue,
you know, that I left without any disability or any problems or
anything. But I think most folks are pretty clueless. They, you
know, we sign off on the forms and go on with our lives and
things.
So I think there does need to be outreach, but there really
is a difference and it is starting to change, but women do not
think of themselves. In my generation of women, we don't call
ourselves veterans. I mean it doesn't, it didn't feel
comfortable. It is starting to more, but if you don't even
think of yourself as a veteran, it is unlikely that you are
going to walk into the VA and say, ``I am a veteran and I want
to see if I can get help.''
Mr. Lamborn. Representative Wilson, you have made reference
to that a couple of times now. Why do you think that is the
case?
Ms. Wilson. Because guys are veterans. You know, it is. And
I don't, I think, probably for younger women, that is not the
case. I think for our generation of women there is also an
association that you are only a veteran if you were in combat.
It is the veterans of foreign wars kind of standard. I even
remember I had an uncle, a World War II veteran, and I was
serving in the military. He is a loveable person and I thought
the world of him. And he arranged for me to be a member of the
American Legion Auxiliary, because I thought I should.
Mr. Lamborn. Okay.
Ms. Wilson. And I was on active duty in the military. And I
thanked him so much and I was a member. But we didn't think of
ourselves as being necessarily part of the group.
Mr. Lamborn. Okay. Thank you. Now, the VA has brought
authority to contract for care of women's veterans to contract
out these services for care. Do you think non-VA professionals
understand the unique needs of women who have served in the
military, or are they subject to the same possible issues that
the VA is?
Ms. Wilson. The difficulty in the VA is that you are still
dealing with a fairly small percentage of the clientele who are
women. So they are not dealing with these issues in large
numbers. I think that one of the areas we do need to look at is
combat disabled veterans, and particularly some of the mental
health issues that can manifest themselves differently among
men and women. How do women approach mental health issues? How
do they present themselves? What kinds of therapies are
effective? And I having worked with children, mentally ill
children, there are some differences among teens and young
adults, men and women and what is affective? And I think we're
going to need to take a look at that issue.
And we know that there are large numbers of veterans
returning with PTSD, acute PTSD as opposed to chronic PTSD,
which we saw in the Vietnam cohort or we had been used to
dealing with it in the Vietnam cohort. Do these 2 populations
of women and men respond different, present differently, and
what does that mean for the best kind of treatment, whether
that is contract or whether that is within the actual VA
system.
Mr. Lamborn. Thank you. And my last question, to accomplish
these goals that we are talking about today, should the VA have
women's clinics? Should it better integrate women's health care
into existing VA clinics or should it enhance the contracting
out of care in community settings?
Ms. Wilson. I like the idea of at least some point of
presence. A women's clinic is a way of reaching out to women in
a place particularly for OB/GYN care, cancer screenings, those
kind of things, preventative health care. But this was one of
the reasons why I think we need a high level commission to
focus on things for a while to identify major issues and give
us advice as legislators as opposed to all of us taking a wag
based on personal experience or what we are seeing in our
communities. Lets get some smart people together to really
focus on this. Call in a lot of women veterans. It is amazing
what they will tell when you turn off the microphones and close
the doors and say, ``What is really happening? What works? What
doesn't work? What regulations are you facing that are barriers
to you?''
And when we did that with women in the Defense Department,
it was amazing. Some of the stupid rules and regulations that
were barriers to women getting care.
Mr. Lamborn. Well thank you for your answers. Thank you for
your testimony today. And thank you for all the work that you
are doing in this area. And most of all, thank you for your
service to our country.
Ms. Wilson. Thank you very much.
Mr. Michaud. Mr. Hare.
Mr. Hare. Thank you, Mr. Chairman. And thank you so much
for coming this morning, Representative Wilson. I just had a
comment, maybe a question. Well, actually, I was just thinking
about what you said about a new generation of women veterans
and perhaps that is because we see currently in Iraq, when
causalities come, we are seeing a lot of women who are injured
and who are losing their lives. I think it is very unfair to
your generation, to our generation of veterans that preceded
them that they are somehow forgotten. In other words, if they
haven't served recently are they really veterans? I think that
is sad.
I guess what I would like to know from your perspective is
what can we, and the VA do, to really bring the attention back
to the people like yourself who have served honorably? We have
a responsibility, I think, to and I have said this many times
to this Committee to all of our veterans irregardless of what
branch, irregardless of what their gender is. What can we do,
do you think, to get the VA and to promote the type of benefits
for veterans so that they--you know you just said you get women
behind a door and you shut off the microphones and they will
talk a lot. What could we do to enhance that and to be able to
get more women to be able to understand that there are benefits
available, and how to get them? Because I think it is terribly
important that we do this.
Ms. Wilson. A couple of things. First of all, I think it is
important for the Congress as a Congress to establish a
commission and say, ``Let's get some smart people and get some
recommendations on what legislation and programs we need to
support. I think that is important and it allows us to provide
some leadership.
One of the things that is important, and I heard someone
slip recently in a position of public prominence, I don't want
to identify them in a speech talking about our men in military.
Our men overseas.
Mr. Hare. Uh huh.
Ms. Wilson. It was the first Persian gulf war when the
lexicon of American public life changed for the first time.
When you heard at that time, General Colin Powell, Brent
Scowcroft, the first President Bush, the Members of Congress,
for the first time they talked about our men and women in the
Persian Gulf. The military had gone co-ed. And that was the
first Cable News Network (CNN) war really where, you know,
America was surprised that we had women helicopter pilots
flying into harms way in front of the infantry forces. It was a
major social change. But we can't go back, as I and that was
just a slip, but I heard it. And when someone said, ``Our men
in the military. Our men in Iraq and Afghanistan.'' Language
matters, and people like me will hear that if you say it.
I would also encourage, you there are now, there is at
least in New Mexico and I think it is growing national
movement. I look at all the flags behind you and all of us have
the Jewish War veterans and the Purple Heart veterans and the
American Legion and the VFW that all come to see us and see all
of you annually. There is now a group starting and I think it
is nationwide, but a chapter has started in New Mexico of a
national Association of Women Veterans. We have to stand up
first for ourselves. And I would encourage you to reach out to
women veterans and ask them to come in and talk to you about
what is going on with the VA in your community.
And I am a member of some of those organizations of women
veterans and there is an Association of Women Aviators that I
am an honorary--well I am an associate member of I guess. I am
not an aviator by profession. But those kinds of things I think
help women to bring our issues to the floor just like the
Reserve Officers Association does and make people aware of
problems.
So a commission, meet with people, and as leaders be
careful to include us.
Mr. Hare. Absolutely. I am sorry I came in late and I don't
know if you mentioned this in your testimony or not, but do you
have any idea of how many women veterans we are talking about
think are being underserved or not being served?
Ms. Wilson. In Afghanistan and Iraq, 1 in 7 Americans
serving there is a woman. There have been over 2 million
American women who have served this country in uniform in our
history. Over 2 million and every single one of them was a
volunteer.
Mr. Hare. That is amazing. Thank you very much.
Mr. Michaud. Thank you, Mr. Hare. Mr. Bilirakis?
Mr. Bilirakis. Thank you, Mr. Chairman. I have one
question. First of all, thank you for your testimony and
enlightening us on this issue. Do you think it would be helpful
if we had a program within the VA where women veterans can talk
to women veterans and identify with them whether it is
outreach, any kind of an issue. Would you think that would be
helpful?
Ms. Wilson. The VA does have an office for women's veterans
that does outreach and so forth, but I actually think it is
helpful to facilitate women coming together. At one time in my
deep dark past, I served on the Defense Advisory Committee on
Women in the Service after I had left the military but came
back. And one of the great things about those conferences and
meetings that we had was women in the military got together and
there was cross talk.
If you are in any group and you were talking about there is
what 6 percent now? Between 6 and 8 percent of our veterans are
women. That means in any room with 100 people there are only 6
women. You are feeling a little isolated in any group. If you
make the effort to pull women together so that you can get
cross talk about what is going on in my State, in your State,
and the health care system and so on, you get good ideas that
come out of that and you help to identify problems.
The VA does have an office for women veterans. I am not
sure how much they really bring together in a working group
kind of way, those kinds of colloquy to pull together women
veterans in a circumstance where they are not out numbered. And
to be able to take our shoes off and say, ``So what is going on
in your State, because this one is a mess,'' or whatever it is.
I think it would be helpful.
Mr. Bilirakis. And maybe making sure that we mandate that
there is one, at least one person at an out-patient clinic or
the VA where the veteran can go to that individual, making sure
that that is a women so they feel comfortable talking to them.
Ms. Wilson. There are up sides and down sides to that,
which is why I get back to lets pull some people together and
make sure the system of care is responsible. If you created it
at one VA hospital the women's office or the women's advocate
in some ways that says to the rest of the system, ``Well, I
don't have to deal with that. Go down to the women's office.
Now that is not my job,'' as opposed to if you are a cancer
specialist or the oncology department has to be taking into
account possible screenings for breast cancer and cervical
cancer, so integrating into the way the VA does it's business.
But I do think that there is advantage, particularly in OB/
GYN, care to having systems set up so that women feel as though
they are welcome here. There is a place for----
Mr. Bilirakis. Sure.
Ms. Wilson [continuing]. And they are not separate but
equal or pushed out somewhere else.
Mr. Bilirakis. Make sure that there is a women's counselor
there available for them. Would you agree with that?
Ms. Wilson. Yeah, I would. But I don't want to say, ``All
right, we are going to create a space within the VA for women
and this is the women's office and that is where we deal with
that problem because we are the VA, and you know just stay over
there. We have got a little office for you in the closet.''
Mr. Bilirakis. Okay. Thank you very much. I appreciate it
Mr. Chairman. Thank you.
Mr. Michaud. Thank you very much. And once again, thank you
very much, Congresswoman Wilson. We really appreciate you
enlightening us on this particular area. And thank you for your
service not only to your constituents back in your district,
but also to your country. So thank you very much.
Ms. Wilson. Thank you, Mr. Chairman. I appreciate it.
Mr. Michaud. We will now move to our second panel. And I
would ask that the members of the second panel to please come
forward.
I would like to thank the second panel. We have for the
second panel Shirley Ann Quarles who is Chairwomen of the
Advisory Committee on Women Veterans; Colonel Reginald
Malebranche who is a member of the Advisory Committee on
Minority Veterans; Saul Rosenberg, who is Clinical Psychologist
at the University of California, San Francisco; and Maureen
Murdoch who is a VA Medical Center doctor in Minneapolis.
So I want to thank the panelists for coming today. I look
forward to hearing your testimony. Why don't we start with Dr.
Quarles and work our way down?
Thank you once again for coming here this morning. Dr.
Quarles?
STATEMENT OF SHIRLEY A. QUARLES, R.N., ED.D., CHAIR, ADVISORY
COMMITTEE ON WOMEN VETERANS, U.S. DEPARTMENT OF VETERANS;
COLONEL REGINALD MALEBRANCHE, USA (RET.), MEMBER, ADVISORY
COMMITTEE ON MINORITY VETERANS, U.S. DEPARTMENT OF VETERANS
AFFAIRS; SAUL ROSENBERG, PH.D., ASSOCIATE CLINICAL PROFESSOR OF
MEDICAL PSYCHOLOGY, UNIVERSITY OF CALIFORNIA, SAN FRANCISCO,
CA; AND MAUREEN MURDOCH, M.D., MPH, CENTER FOR CHRONIC DISEASE
OUTCOMES RESEARCH, MINNEAPOLIS VETERANS AFFAIRS MEDICAL CENTER,
MINNEAPOLIS, MN, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS (ON BEHALF OF HERSELF AND NOT
VA)
STATEMENT OF SHIRLEY A. QUARLES, R.N., ED.D.
Dr. Quarles. Thank you. Chairman Michaud, Chairman Hall and
Members of the Subcommittees. I am Chair of the Department of
Veterans Affairs Advisory Committee on Women Veterans and also
a Colonel in the United States Army Reserve. I am pleased to
testify today on behalf of the Department of Veterans Affairs
Advisory Committee on Women Veterans regarding our views on:
The Department of Veterans Affairs and how they serve women
veterans through it's current programs; the present and future
needs of women veterans, which is a growing population; VA
strategies to meet those needs; and outreach efforts that are
being conducted on women veterans.
The Advisory Committee was established in 1983 by Public
Law 98-160 and charged with advising the Secretary of Veterans
Affairs on VA benefits and services for women veterans. The
Committee submits a biennial report to the Secretary about
findings and recommendations.
The Advisory Committee on Women Veterans consists of 14
members, men and women who are mostly veterans. As a means to
obtain information regarding women veterans' services, and
programs provided by the VA, the Committee conducts site visits
to VA facilities throughout the U.S. During the site visits,
the Committee tours the facilities, meets with senior leaders,
and hosts an open forum for the local women veterans community.
The forum provides an opportunity for open dialog to learn more
about women veterans' experiences within the VA, to discuss
issues, and for women veterans to raise questions regarding
gender specific VA benefits and services.
Another means for the Advisory Committee on Women Veterans
to obtain information regarding services provided by the VA is
by meeting twice a year at VA Central Office in Washington, DC.
During these meetings the Committee has briefs from various
program leaders. The Committee also submitted recommendations
to the Secretary in their 2006 Report. The Committee made 23
recommendations that addressed mental health, outreach,
research, strategic planning, training, women veterans health
program, and women veterans health program managers and
coordinators and homeless women veterans.
One recommendation that has already been implemented is the
organizational realignment of the Women Veterans Health Program
Office to Strategic Healthcare Group. This recent realignment
elevated the Women's Health Program Office and provided it an
opportunity to gain more expertise in the area of women's
health.
To address a strategy as it relates to VA meeting the
present and future needs of women veterans, the Committee was
able to witness first hand the need to provide mental health
care during a site visit at Palo Alto VA Women's Center for
Mental Health. Another strategy that the Committee recommends
for future needs is through research studies. Research studies
were recommended in both the 2004 and 2006 Advisory Committee
on Women Veterans Reports.
Also there is a current national survey that is being
conducted to address the knowledge gap we have regarding women
veterans. The final findings for this national survey will be
submitted December of 2008. As it relates to outreach, the
Advisory Committee on Women Veterans 2004 Report recommended
that materials such as brochures, pamphlets, booklets, and fact
sheets be published in both English and Spanish languages.
The Committee also encourages increased partnership with
the Federal, State, county agencies, and national veterans
service organizations. Additionally, the Committee plans to
participate in the upcoming 2008 National Summit for Women
Veterans.
The Advisory Committee on Women Veterans is grateful to the
VA and to the Center for Women Veterans for taking care of our
women veterans of yesterday, today, and the future.
This concludes my formal testimony. I will be pleased to
answer any questions.
[The prepared statement of Dr. Quarles appears on p. 33.]
Mr. Michaud. Thank you very much. Colonel.
Dr. Quarles. Thank you.
STATEMENT OF COLONEL REGINALD MALEBRANCHE, USA (RET.)
Colonel Malebranche. Chairman Michaud, Chairman Hall, and
Members of the Subcommittee, I am indeed honored to represent
the Chairman of the Advisory Committee on Minority Veterans and
give you our views on the services provided by the Department
of Veteran Affairs.
Pursuant to Public Law 103-146, the Committee is tasked
with assessing the needs of the minority veteran population and
reporting back to the Secretary on the effectiveness of the
programs and services at meeting those needs. The Committee
works in close coordination and collaboration with the Center
for Minority Veterans and relies on the expertise of the Center
for current information about VA programs, policies, and
services.
In it's 2006 report on the Greater Los Angeles Healthcare
System, the Committee made 11 recommendations with the key
issues being outreach, research, staff diversity, and seamless
transition. During its visit to the Los Angeles Ambulatory Care
Center, the Committee was dismayed by the staggering number of
homeless veterans. Twenty-three percent of the 90,000 homeless
population in Los Angeles were reported to be veterans. The
Committee was encouraged though by the range of programs
identified by VA for homeless veterans, yet the Committee was
concerned that these programs may not reach the targeted
audience.
Outreach is a major challenge for the VA. At the townhall
meeting, the Committee learned that the major issue was that
minority veterans were unaware of their VA benefits and other
VA services available. Transportation to VA Centers in major
metropolitan, rural and isolated areas is an impediment for
minority veterans. Accessibility, affordability, and distances
to VA Centers are major problems affecting minority veterans.
Much remained to be accomplished in the area of outreach.
The Committee recognize that is not simply a VA issue. Several
of its members have taken the mantle to assist the VA in its
quest to reach out to minority veterans.
Access to care is another challenge for VA. The plight of
Alaskan natives and other minority veterans living in rural and
isolated areas cannot be ignored. The challenge for VA is to
develop and implement innovative programs which target those
minority veteran populations. Rural and remote areas in Alaska
and the Navajo Nation may be good targets to test rural health
initiatives. VA could enter into a reimbursable agreement with
Alaska natives organizations, Health and Human Services, and
the Indian Health Service to reach out to minority veterans and
provide all the services which fall within the realm of VA.
The Committee applauds the strides made by VA in expanding
its telehealth and telemedicine programs and its ability to
reach a significant number of the minority veteran population.
Mental health is and will become a major challenge. The
Committee recognizes the efforts and the programs put forth by
VA to support, identify, and care for service personnel who
serve and are serving in OEF and OIF. The early identification
of post traumatic stress disorder will certainly help in the
observation and treatment of veterans who served in those
areas. Yet, the Committee is concerned that the same level of
services might not be readily available to minority veterans
who have served in prior conflicts.
Electronic health records are another part that we need to
develop and embrace all services personnel with VA. The
processing and adjudication of benefits seem to affect all
veterans and to make them aware of their entitlements. The
Veterans Claim Assistant Act of 2000 puts the onus on VA to
maximize its assistance to all veterans.
Senior staff diversity remains an issue at VA. The absence
of minorities at the senior staff level has been, and continues
to be, noticeable during site visits. Data presented and
subscribed by VA suggest that VA's problems is limited to
recruiting white females and Hispanic females, yet all the data
maintained at VA suggested that minorities were not well
represented at senior staff levels.
The professionalism, the expertise shown by VA personnel
was striking. There was a perception that most staff would
endeavor to do anything or everything for a veteran. The
challenge is to include minority veterans in that equation and
that philosophy.
Sir, I thank you for this opportunity to address the
Subcommittee. And I would be happy to answer any questions.
Thank you very much.
[The prepared statement of Colonel Malebranche appears on
p. 35.]
Mr. Michaud. Thank you very much, Colonel. Dr. Rosenberg.
STATEMENT OF SAUL ROSENBERG, PH.D.
Dr. Rosenberg. Thank you both Chairmen and the Committee
for inviting me this morning. I am Dr. Saul Rosenberg. I am a
clinical psychologist. I did my very first clinical training at
the Ann Arbor VA and it has stuck with me ever since. I
currently teach and supervise interns in residence at the San
Francisco VA, which is associated with University of
California, San Francisco (UCSF) where I am on the faculty. I
am not currently on the faculty or receive salary from the VA.
So I am, I would say, independent of the VA and a friend of the
VA.
My interest is in mental health and what the needs are for
screening returning troops, when troops screen positive what
kind of diagnostic assessments are conducted, and what kinds of
treatment recommendations are made, and how can we follow up
treatments to make sure that the veterans are getting the most
affective treatments.
So we can start with screening. The DoD, and with the VA
and the Deployment Center, have started the use of pre- and
post-deployment questionnaires, which is a wonderful
innovation. Soldiers coming back are filling out brief
questionnaires regarding exposure to combat, regarding symptoms
of PTSD, regarding possible exposure to roadside bombs and
improvised explosive devices (IEDs). The returning soldier then
has an interview with a primary care physician who goes over
the form, and from that interview a determination is made
whether they need to go on to more intensive evaluation and
treatment.
My colleagues at UCSF and the San Francisco VA recently
completed a nationwide epidemiological study of veterans
returning from Iraq. They studied over 100,000 veterans in VA
health care facilities all across the country. They found a
high prevalence of mental disorders. Mental disorders that fit
the criteria of the diagnostic and statistical manual of the
American Psychiatric Association were about 25 percent and
about 5 percent had psycho-social and social relational
problems.
So almost a third of this sample had diagnosed mental
disorders. Now these disorders were not based on just the
screening form, they were based on the actual diagnosis. There
have been reports about the prevalence of PTSD based on the
screening form and so it is important to note the difference.
This was an actual diagnosis.
The sample, I think, was pretty representative of women and
racial groups. And one of the positive things about the study
is that they did break their results down by racial groups. A
simple recommendation that I would make that would help us
understand better the needs and the treatment outcomes of women
and minorities is to ask researchers to include gender and a
description of race, education, and marital status, all of
those variables, when they are doing research so that we have
an opportunity to look and see if in fact there are
differences. Oftentimes you will see reports in the literature
in which there is no comment at all about race or gender as if
everyone is the same. Researchers should be aware of that.
A related point is that the assessment of mental disorders
requires a clinician to do an interview and often benefits from
psychological test, which is my area of expertise. Now
psychological tests have often been developed on a white
middle-class population. And so psychologist know, and the
American Psychological Association has put out papers on this
topic, that there needs to be more what is called culturally
sensitive and culturally competent assessment. Having an
individual of this same race interview and test a veteran is a
proxy in a way for that cultural sensitivity. What we care
about is does the interviewer or the doctor, the evaluator is
that person capable of empathizing with the experience of the
person that they are evaluating? And more particularly, do they
know anything about the values and preferences of that person?
Particularly if that person comes from another culture. So
there has been a move within the American Psychological
Association to do culturally sensitive training and the result
has been more satisfaction of individuals of a different race
than the treating doctor when the treating doctor has gone
through a training program that helped him be more culturally
sensitive.
In this sample of 100,000, women comprised 13 percent; 69
percent were white; 18 percent were black; 11 percent Hispanic;
and 2 percent came from other racial groups. The most striking
finding in the study wasn't about race or gender, it was about
the different risk of developing PTSD and mental disorders in
our youngest veterans. Veterans between the ages of 18 and 24
had dramatically higher risk of developing PTSD or mental
disorder than veterans 40 years and over, irrespective of race.
That is an important finding. And we have to think about,
well how can we use this information? I have, like many of my
academic colleagues, written papers and they get published in
peer review journals and they are mostly read by other doctors
and psychologists and clinical investigators. The serving the
needs of the veterans returning from Iraq requires a different
kind of research. At UCSF, we call it clinical and
translational research, which means we need research on real
patients, clinical research, but we have to translate that
research into actual services that benefit patients and then
study whether the treatments we are doing actually work.
We can't expect providers to be going into the academic
literature to find information they need about treating an
individual. So, for example, this fact that young veterans are
at much higher risk, that information belongs in a clinical
practice guideline that comes up on the doctor's screen
automatically as the doctor is seeing the patient in that age
group. You are about to interview a patient between the ages of
18 and 24 and a little alert or reminder comes up. A little
pop-up comes up on the screen, ``This group, younger veterans,
may be at more risk. Consider asking a few additional
questions.''
Mr. Michaud. Doctor, I was wondering, since your time has
expired, could you please summarize? I am sorry to interrupt
you.
Dr. Rosenberg. The main point I want to make is the VA has
conducted wonderful research and National Institute of Mental
Health (NIMH) has conducted wonderful research. We need to
bring that research into the clinical situation. The VA is an
ideal place to do that because of its excellent electronic
health record, VistA. What I am talking about is taking the
next step, which is developing clinical practice guidelines
within VistA and then the next step beyond that is developing
clinical decision support systems. These are systems that can
integrate biomedical and psycho-social data and suggest
diagnosis or treatment plans and offer ways to evaluate how
effective a treatment is.
Clinical decision support has been used in medicine for
decades. It has been relatively rare in mental health. And
there is a possibility of a great contribution that could be
made in mental health from clinical decision support systems.
[The prepared statement of Dr. Rosenberg appears on p. 37.]
Mr. Michaud. Thank you, Doctor. Dr. Murdoch.
STATEMENT OF MAUREEN MURDOCH, M.D., MPH
Dr. Murdoch. Thank you. Mr. Chairman and Members of the
Subcommittees, thank you for the opportunity to appear before
you today. Today I will present some findings from my team's
research on possible disparities in PTSD disability awards
among race and gender groups. I must note that the views
presented here today are mine and do not necessarily represent
the views of the Department of Veterans' Affairs. And they
reflect the results of my studies and not necessarily the
findings of others. And I also need to point out that
unfortunately after this panel is done I am on service at
Minneapolis and so I have to leave and catch a plane and go
back to the hospital. So, I apologize for that.
PTSD as you may know is the most common psychiatric
condition for which veterans seek VA disability benefits. And
long-term health studies indicate that women have a higher
prevalence of PTSD than men and may be more susceptible to
PTSD. Conversely, African American or black persons appear to
have similar risk for PTSD compared to persons of other race or
ethnic groups.
In 2000, my colleagues and I began investigating if there
were race and gender disparities in VA disability awards for
PTSD. We assembled a representative sample of almost 5,000 men
and women veterans who applied for disability benefits on the
basis of PTSD between 1994 and 1998. We tested 4 hypotheses
examining the relationships between PTSD symptoms severity, the
level of disability, combat experience, and a race or gender
differences as they impact the determination about service
connection.
Overall, the 3,337 respondents were highly symptomatic.
About 80 percent met our definition for PTSD and 62 percent
were service connected for PTSD. Concerning the relationship
between PTSD and gender: PTSD service connection and gender,
once we controlled for combat exposure, the effect of gender
and service connection for PTSD became insignificant. However,
because men had notably greater combat exposure they likewise
had a higher rate of service connection.
In our investigation of racial disparities we found that in
our sample African Americans were just as likely to be service
connected for disorders other than PTSD as the rest of the
respondents. However, they were substantially and significantly
less likely to be service connected for PTSD compared to the
other respondents.
The negative association between African American race and
service connection for PTSD was not found for any other racial
or ethnic group. Now among the veterans who actually got
service connection PTSD the service connected rating or the
degree of service connection awarded was similar regardless of
race. So African American respondents had an average service
connected rating of 43 percent--if they were service
connected--and other veterans had an average service connected
rating of 45 percent, if they were service connected.
However, after fully adjusting for everything that we could
think of, the estimated probability of being service connected
for PTSD was 43 percent for African American veterans compared
to 56 percent for other respondents; a 13 percent difference.
Examining clinicians were about seven-tenths as likely to
diagnose PTSD in African Americans as they were to diagnose
PTSD in other veterans.
When thinking about these results, there are several issues
that need to be considered. First, the pool of respondents was
selected based on their submitted claims for PTSD service
connection. But our questions focused on their current health
and adjustment status. It is distinctly possible that those
with the greatest need at the time of their application have
been receiving treatment and now may actually report better
health outcomes then their peers.
Second, the study relied on veterans' self-reports of their
PTSD symptoms severity, the degree of disability and trauma
history, which may not have been clinically accurate or
universally consistent.
So, I have a few recommendations. In order to strengthen
and expand this research, I would suggest that future studies
identify and evaluate veterans shortly after applying for PTSD
disability benefits, instead of 2 years later as we did. And in
addition, we need to collect and assemble more data from the
claims file to supplement survey data. And finally, I would
recommend that future studies investigate for possible
disparities in disorders other than PTSD, when we think about
service connection awards.
Mr. Chairman and Committee Members, this concludes my
statement. And I am pleased to respond to any questions that
you may have. Thank you.
[The prepared statement of Dr. Murdoch appears on p. 40.]
Mr. Hare. Thank you, Doctor. And let me thank all the
panelist for being here. I have a number of questions and I
know, Doctor, you have to leave fairly soon. We will try to
brief on this. I don't want you to be late getting back to work
and getting in trouble on my account.
So Ms. Quarles, I was pleased to see that the National
Survey of Women Veterans is being implemented with results
expected in December of 2008. In your estimation, what do you
think are the 3 most prevalent or urgent issues facing women
veterans today?
Dr. Quarles. I think that, or the Committee feels that,
issues that are facing women veterans today certainly access to
care. And these are women veterans who live in the rural areas.
Another concern that we feel the Advisory Committee has
observed through briefings and visits is that primary care in
the Community Based Outpatient Centers (CBOCs), in the clinics
is the same as the services provided at the facilities.
And also another concern that we are hearing through our
open dialog from women veterans is that women veterans want to
know that they can receive the same equal health care as their
male veteran counterparts.
Mr. Hare. To my knowledge, the VA has not yet held any type
of summit or conference on OEF or OIF female veterans and the
unique needs that are arising with women being in combat. Has
the Advisory Committee looked into this and if so what have you
found, if anything?
Dr. Quarles. Well the Advisory Committee is learning
through our briefs and through our visits that mental health
care is certainly continuing to be an issue and that there is a
need for mental health care to be enhanced throughout. One of
the concerns we have is the training. Training for personnel
with the VA as well as training for affiliated professionals
who come to the VA to understand the women veterans population
regarding unique needs they will have. And it is very important
that we look at the continue monitoring of training for our
professionals and the VA.
Mr. Hare. Thank you. Colonel, I was just wondering in your
testimony you stressed the absence of diversity at the senior
staff level. When the Committee presented their concerns to the
VA about this issue, how did they respond to you?
Colonel Malebranche. They will look at it, sir, and then,
however, though when we look at the data, the data that VA
utilizes seems to suggest that their major problems is in the
recruitment of white females and Hispanic females. However, all
the data at VA suggests otherwise. So it appears to be an
aspect of using the data that is available in terms of what it
shows and then presenting that to--if you tell me that I can
only recruit white female and Hispanic female that is all I am
going to try to recruit.
Mr. Hare. A big concern regarding the provisions of care to
the minority veteran population is sensitivity to the cultural
differences of minority veterans. For example, the differences
in how to approach an Alaskan Native veteran community as
opposed to Hispanic veteran community. Does the VA provide
education to many of it's employees on cultural competencies
and sensitivities, particularly to the frontline medical
personnel, to your knowledge?
Colonel Malebranche. Sir, I think there is an attempt at
doing that for the staff. Alaska is a particular issue because,
one, the location of really the population at risk and the
ability to get to that population. The diverse dialects that
they are spoken in Alaska. So it presents some different
challenges. I think the challenge is basically to find means to
use the Alaskan Native organization that already exist possibly
even the U.S. Department of Health and Human Services or the
Indian Health Service and enter into an agreement, reimbursable
agreement or cooperative agreement that is going to target
those population.
Recently, Alaska probably had the largest deployment of
Alaskan Natives to OEF and OIF. And those units are slowly
coming back.
Mr. Hare. Thank you. I guess this is both for Dr. Rosenberg
and Dr. Murdoch or whoever would like to take a stab at this.
You mentioned, and I know my time is running out, but I was
interested in the testimony and your comments on the fact that
African American veterans were about half as likely as other
veterans to receive service-connected disability for post
traumatic stress disorder. I am wondering from your perspective
why this is happening. Do you have any thoughts on, why it is
happening and what we can do to improve this? Because it seems
to me to be grossly unfair here.
Dr. Murdoch. That is an excellent question. I think that,
first of all, keeping in mind the limitations of the study it
would be extremely helpful to replicate it collecting better
data. And second of all, to expand upon it to try and
understand why those differences exist.
Mr. Hare. Dr. Rosenberg.
Dr. Rosenberg. That would cover it for me, but I would like
the opportunity to add something of that----
Mr. Hare. Sure.
Dr. Rosenberg [continuing]. Unique needs of women veterans.
The Institute of Medicine was asked to do a report on PTSD
disability in veterans. It is an excellent report. And they
expressed a concern that women are victims of sexual assault
called military sexual assault. That those women victims are
not getting sufficient treatment, identification, or disability
determination. It is a lot harder to prove sexual assault than
you were in combat. And the Institute of Medicine recommended
much more attention be paid to understanding this phenomena of
military sexual assault, doing everything we can to prevent it.
And making sure that those individuals who are injured in that
way do receive treatment, rehabilitation, and disability.
Mr. Hare. Thank you, Doctor. Mr. Lamborn.
Mr. Lamborn. Thank you Representative Hare. Dr. Murdoch,
just to clarify something, I think you eluded to this, but I
just wanted to make sure I understand. Did you document and
verify the combat history disability status or PTSD diagnosis
of the individuals in your study or did they self report those
factors?
Dr. Murdoch. We got the disability status from VBA records.
They self-reported their PTSD, their combat exposure, and I
forget the last one that you asked about.
Mr. Lamborn. Combat history, disability status, and PTSD
diagnosis.
Dr. Murdoch. Yeah. So PTSD diagnosis and their disability
status in terms of how disabled they reported themselves to be,
those were self-report.
And then we did take a small sample, 11 percent, where we
also audited their claims file and tried to verify what they
reported in the survey. And it seems that the--that their
reports of PTSD matched up with the clinical diagnosis that
they were being given in the claims file.
Mr. Lamborn. And, Doctor, what was that percentage again?
Dr. Murdoch. About 80 percent.
Mr. Lamborn. That you audited their----
Dr. Murdoch. Right. So about 80 percent met survey criteria
for PTSD and then when we did the claims audit and looked for a
clinical diagnosis by a qualified examiner in their claims
file, 80 percent of them had a diagnosis of PTSD.
Mr. Lamborn. Okay. Thank you. And I yield back to the
Chairman.
Mr. Hall. Mr. Bilirakis.
Mr. Bilirakis. I don't have any questions.
Mr. Hall. Okay. Thanks so much. Let me thank the panel and
wish you a safe trip back to all of you. Thank you for taking
the time to be here for this morning. Thanks so much.
Dr. Murdoch. Thank you.
Dr. Quarles. Thank you.
Mr. Hall. Our next panelist is Joy Ilem who is the
Assistant National Legislative Director for the Disabled
American Veterans.
Thank you, Ms. Ilem. Sorry for disappearing and then
reappearing. You are now recognized for 5 minutes. Your written
remarks will be submitted for the record.
STATEMENT OF JOY J. ILEM, ASSISTANT NATIONAL LEGISLATIVE
DIRECTOR, DISABLED AMERICAN VETERANS
Ms. Ilem. Thank you very much. Mr. Chairman and Members of
the Subcommittees, thank you for inviting DAV to provide
testimony on the present and future needs of women and minority
veterans seeking services from the Department of Veterans
Affairs.
In June 2007 the VA Health Services Research and
Development Service completed a systematic review of racial and
ethnic disparities in the VA health care system. Researchers
concluded that disparities appear to exist in all clinical
arenas. According to the researchers, one key finding was
especially troubling since it may indicate that disparities in
health care delivery are contributing to real disparities in
health outcomes.
It is clear from the findings of this recent study that
much more needs to be done in this area, therefore, we urge VA
to continue it's research, to adjust policies, and to provide
appropriate resources to eliminate racial disparities in VA
health care.
In preparing for this hearing, we also reviewed the most
recent annual report available from the VA Advisory Committee
on Minority Veterans. The Committee made a number of
recommendations, but of special concern was the issue of
outreach to minority veteran populations. We agree with the
Advisory Committee that the VA should clarify it's policy with
regard to outreach to ensure minority veterans are aware about
their VA benefits.
We support the recommendations made by the Advisory
Committee and applaud it's continued efforts to increase
awareness about minority veteran issues and advance the quality
of services minority veterans currently receive.
With increasing numbers of women serving in the military
and with more women veterans seeking VA health care following
military service, it is essential that VA be responsive to the
unique demographics of this population. In addition, VA must
ensure that it's special disability programs are tailored to
meet the unique health care concerns of women who have served
in combat theaters and those who have suffered catastrophic
disabilities as a result of military service.
Researchers report that VA care for women veterans is
fragmented. Researchers also found a number of barriers to
delivering high quality health care to women veterans.
Specifically, field reports of insufficient funding for women's
health programs, competing local or network priorities, limited
resources for outreach, inability to recruit specialists and an
insufficient number of clinicians skilled in women's health. We
urge VA to implement recommendations by researchers to address
these barriers.
Several years ago VA established women's health as a
research priority to develop new knowledge about how to best
provide for the health and care of women veterans. We strongly
encourage VA as it takes steps to advance this agenda to focus
on research and programs that enhance VA's understanding of
women veteran health issues and discover new ways to optimize
health care delivery and improve health outcomes for this
patient population.
The challenge of addressing the unique health care needs of
the newest generation of women veterans returning from combat
theaters in Iraq and Afghanistan is daunting. In reviewing VA's
health care utilization data we see increasing numbers of women
veterans accessing VA health care and increasing rates of PTSD
and other medical conditions among women who served in combat
theaters.
DoD and VA need to coordinate and improve sharing of data
and women's health information. We also need to learn more
about what barriers exist for women veterans trying to access
VA care following deployments.
In closing, VA needs to ensure priority is given to women
veterans programs so quality health care and specialized
services are available equally for women and men. VA must
continue to work to provide an appropriate clinical environment
for treatment even where there is a disparity in numbers. Given
the changing in roles of women in the military, VA must also be
prepared to anticipate the specialized needs of women who were
sexually assaulted in the military or catastrophically wounded
in combat theaters.
Although it is anticipated that many of the medical
problems of male and female veterans returning from combat
operations will be the same, VA must address the health issues
that pose special challenges for women.
DAV has recommended that VA focus its women health research
on finding the health care delivery model that demonstrates the
best clinical outcomes for women veterans. Likewise, VA should
develop a strategic plan along with DoD to collect critical
information about the health status and care needs of women
veterans, with a focus on evidence based practices to identify
other strategic priorities for its women health research
agenda.
Mr. Chairman, that concludes my testimony and I will be
happy to answer any questions that you or Members of the
Subcommittees may have. Thank you.
[The prepared statement of Ms. Ilem appears on p. 41.]
Mr. Hall. I thank you Director Ilem and thank all DAV
members for their work and to their service.
I first of all wanted to ask regarding your statement that
it is unlikely that the past experiences of women veterans in
the VA will serve as an accurate guide because of the unique
experiences of women who served in OIF/OEF, particularly
because of this ongoing exposure to combat conditions. Could
you elaborate further, please, on why this is true and offer
your opinion on a few things that the VA can do to prepare for
the impending influx of women veterans of OIF/OEF?
Ms. Ilem. Sure. Thank you for the question. I think that,
you know, and this is--that came about as from talking to
different mental health providers within the VA. And I think,
you know, the equal access to health care for specialized
programs for men and women is extremely important. And this
newest generation of veterans returning are looking like there
is some unique health concerns and mental health, perhaps
mental health issues as well that need special attention.
One of the things that I think would be important is to
really talk to these women in terms of looking at the barriers
for care that they perceive or have had and exist, you know,
trying to access VA care. So just by doing the patient
satisfaction report, I don't think you are going to see that
within VA. Those are people that are using the VA system, but
what about those that have met up with a barrier and aren't
feeling that they, you know, can use VA health care or have had
some problem getting that care.
So I think it would be important to talk to them directly,
for VA to hold focus groups with these women veterans. And
people that have expressed a barrier to getting care for those
services.
Mr. Hall. You mentioned in your testimony that one of the
Advisory Committee's recommendations was to expand outreach to
all veterans, including minorities. Can you elaborate on what
you believe would be useful and adequate measure to improve
those outreach programs?
Ms. Ilem. I think that, you know, just outreach in general
is extremely important I mean to all veterans, obviously. And
then with special attention, I think, as has been mentioned by
the previous panel to looking at unique concerns of either
minority populations or women veteran population. Things that
you need to do specifically to outreach to them that they have
found, you know, seems where there is a barrier. And make sure
that things are culturally sensitive to some, you know, to
their needs.
And I think you know VA I think is trying to do a very good
job in terms of the transitioning veterans that are coming out
of the military, but I don't know how much focus in terms of
outreach has been put on specifically minority veterans and
women veterans. I think that, you know, we would like to see
more being done in that area as well in terms of working with
DoD to get on those bases to make sure the people as they are
transitioning out are aware of their benefits.
And then I know that VA is providing doing a letter to all
veterans coming back from OEF/OIF, but you know probably
continued follow up needs to be done. There are reports from
the Women Veterans Advisory Committee that often these veterans
go back to their communities and then just disappear or their
work, you know, they have children, they have other things that
they are trying to accomplish in their lives and they just
don't get that message that there is great benefits out there
in terms of VA health care and services that could help them.
Mr. Hall. Thank you. You also mentioned that some women
will suffer from severe PTSD, which will require more intensive
evidence-based treatment. I am curious if you have noticed any
difference between PTSD issues that women face compared to men?
It is the old Mars and Venus thing. I have known that in the
educational and psychological communities there is quite a lot
awareness about the difference in how women perceive the world
and react to it and how men do.
Also with regard to women with children, the stress that
they feel because of fear for their children or the stress that
the children are feeling, that the women and mothers feed off
of in some instances. In particular, is child care at VA
facilities something that we should focus on more so that we
remove that barrier to mothers who have no other option to seek
treatment themselves when they have children at home?
Ms. Ilem. Right. Right. Thank you for that question, those
series of questions. I just spoke with a former VA mental
health provider that for many years, that I really look to,
that has been involved in this issue and participating on the
Dole Shalala Commission as well. And you know, in talking to
him about these evidence based treatments and how important
they are and how case intensive they are. I asked him, you
know, that very question, ``What are you seeing? What are women
reporting or what are the doctors reporting that are seeing
them, you know, that have had combat PTSD related and males?
Are you putting males and females together? What are, you know,
what is happening out there?''
And it was interesting he noted that women are reporting
and he is hearing from clinicians that they are--when women
have combat related PTSD that they prefer to be with their
fellow soldiers, so male and female. That seems to be
appropriate. They feel that connection. They have been through
the same thing, they have had similar experiences. And although
there is some evidence-based treatment, I understand in current
research of evidence-based treatment and that is specific to
women, you know, that it is still the clinical move for putting
them together in that environment appears to work best for them
so far from what they are seeing.
The difference is if it is the dual burden of sexual trauma
and combat related, certainly women veteran may not feel
comfortable being in an environment, you know, with male
colleagues talking about something as personal as sexual
assault. I am sure either a male or a female probably would
have similar feelings.
So you know that is more of a unique consideration in terms
of being able to have the number of providers that are needed
for this very intensive resource-based evidence-based
treatments for PTSD. And making sure that clinicians not only
are trained in it, but then have the time to work with these
patients where it is, you know, on an outpatient basis but it
may be very over a number of days a week, many hours a day.
On the child care issue thinking long and hard on that. I
mean certainly women often are the primary caretaker of women
either if they are married or single parent. And attending the
Evolving Paradigms seminar that VA put on conference out in Las
Vegas, there was a panel on women veterans talking about their
experiences. They were all from OEF or OIF. And I mean that was
a real eye opener, but listening to women talk about sometimes
having trouble re-connecting with their children because of the
emotional distress that they are going through based on their
experience in the military and exposure to combat.
And if they are the primary caretaker that is obviously,
you know, a real concern in the family to be able to have that
re-connection and get them the help that they need in terms of
re-connecting with their family and their children, but also if
there are these evidence based treatments available, if they
have child care as a responsibility and they can't afford child
care then, you know, what is the option for them?
So I am hoping that VA will their Women Veterans Program
managers are excellent group of people that, you know, are very
innovative and can think of ways to maybe connect with the
community or to see what the need is out there. What they are
hearing and seeing from women veterans and if that is something
that they can do to either work with the community or a
voucher. Do something to make sure they can also participate in
those programs.
Mr. Hall. Thank you very much for your generous and
detailed response. My time has expired. I will now recognize
Mr. Bilirakis.
Mr. Bilirakis. Thank you Mr. Chairman, I appreciate it.
Thank you Ms. Ilem. You did an outstanding job. Thanks for your
testimony.
In your written testimony you state that, ``Although the VA
has improved health care services for women veterans . . .
privacy issues for women veterans still exist at some VA
facilities.'' That really concerns me. Are these deficiencies
concentrated in a particular region of the country or are the
spread out throughout the health care system? That is my first
question.
Ms. Ilem. I think in general, I mean, I would say first of
all that VA has done a really good job in the last several
years really trying to deal with this, especially the Center
for Women Veterans and the Women's Health Program, to make sure
that those deficiencies don't exist. However, from being a
member of that Advisory Committee and traveling around the
country and just as my position now I had the opportunity to
visit many VA facilities and that is something that I am always
on the look out for.
And I think it is more of an issue that, you know, women's
clinics where they have, you know, had to make room for them
and they try to make a very nice area in most places, but
sometimes it is a space issue in the VA health care system in
general of where those clinics are located and what space they
were provided.
And occasionally we see that there is an issue when you
come in with regard to privacy one thing comes to mind is just
being a user of the VA health care system myself and being in
the clinic, coming in. Great people. Everybody is very
friendly, wants to make my visit go well and I hear the person
speaking on the phone to a veteran with being very, very nice
to them, but in the conversation they have named their name.
They have talked about a particular medical issue that they
have had. And that was information that, you know, that clinic
is very small, it is very confined space. And everyone in that
clinic can overhear that information. And to me that is a
privacy issue, you know, that gives me concern.
And I know that sometimes there is just not, you know,
there needs to be more, maybe more awareness. If the space is
not available where that receptionist can have a private
conversation with a person on the phone they need to be made
aware then about the, you know, what they are saying and
knowing that other people in the waiting room can hear that.
Mr. Bilirakis. Thank you very much. What role do the
Advisory Committees on Minority and Women Veterans and the
Center for Women and Minority Veterans planning and influencing
VA policy.
Ms. Ilem. What role do they play? I----
Mr. Bilirakis. Yeah. No. Are they effective?
Ms. Ilem. Yes. I think they are. It is really a committed
group of veterans that have been willing to serve on those
Committees. They are very active. They are usually in their
other roles outside of the VA, active in women's issues. People
take it upon themselves to do extra visits, to really, I think,
they really take on these issues. And I think that they try
very hard in their reports to report that information to the
Secretary and to Congress. And I think it was great that there
was an opportunity for them to testify today.
And I just hope that, you know, people pay attention to
those reports and that, you know, their energies are not
wasted. That those recommendations are taken to heart and
things are made better for these populations.
Mr. Bilirakis. Okay. Thank you very much. Thank you, Mr.
Chairman, appreciate it.
Mr. Hall. Thank you, Mr. Bilirakis. And Ms. Ilem, thank you
for your testimony and your answers to our questions. You are
now excused. Give us a minute for our changing of the guard.
Welcome to our panel 4 witnesses, Betty Moseley Brown,
Associate Director of the Center for Women Veterans of the U.S.
Department of Veterans Affairs; and Lucretia McClenney,
Director of the Center for Minority Veterans of the U.S.
Department of Veterans Affairs. Welcome.
It is my understanding that we are going to have a vote
called soon on the House floor, but we will begin and hope we
can get through your testimony before they do that.
Dr. Moseley Brown, you are recognized for 5 minutes. And
your written statement is in the record.
STATEMENT OF BETTY MOSELEY BROWN, ED.D., ASSOCIATE DIRECTOR,
CENTER FOR WOMEN VETERANS, U.S. DEPARTMENT OF VETERANS AFFAIRS;
AND LUCRETIA McCLENNEY, DIRECTOR, CENTER FOR MINORITY VETERANS,
U.S. DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF BETTY MOSELEY BROWN, ED.D.
Dr. Moseley Brown. Chairman Hall and Members of the
Subcommittees, I am pleased to testify today on behalf of the
Department of Veterans Affairs and the Center for Women
Veterans. The Center was established by Public Law 103-446 in
November 1994 to oversee VA programs for women veterans. The
Center's mission is to ensure that women veterans receive
benefits and services on par with male veterans; and that VA
programs are responsive to gender specific needs of women
veterans; and that outreach is performed to improve women
veterans awareness of services, benefits, and eligibility
criteria. And, finally, that women veterans are treated with
dignity and respect.
The Center monitors these changes in services through
briefings by the 3 VA administrations and assesses the impact
these changes have on the delivery of care of our 1.75 million
women veterans. As stated earlier, there are women veterans
that still don't believe that they are women veterans, so part
of our charge is to make sure that every woman who served knows
that she too is a veteran.
Regarding health care, in fiscal year 2006, the Veterans
Health Administration served over 235,000 women veterans in our
health system. This is a 5-year relative increase of 37.8
percent. At each VA Medical Center there is a women veterans
program manager and each regional office a women veterans
coordinator to help our women to maneuver through the system of
VA. We know that it can be difficult and those employees are
there to help our women veterans coordinate for their benefits
and services.
Of the total number of women who have been discharged from
active duty after deployment of Operation Iraqi Freedom and
Operation Enduring Freedom, 37.5 percent have been to a VHA
health care facility at least once.
I would like to also state that there is a 2006 study
cosponsored by Dr. Yano from Los Angeles that actually
clarified which model of care women prefer. There was earlier
discussion regarding if women wanted to go to a primary care
facility or a gender specific type environment and VA is
currently looking at that to see what women really want, what
their needs are, and then to make changes regarding that.
In the area of mental health, there are specialized women's
mental health services. There are in-patient and residential
programs for women veterans where the length of stay ranges
from 28 days to 18 months. At every VA facility there is a
designated military sexual trauma coordinator who serves as a
point of contact for military sexual trauma issues.
In fiscal year 2007, VA's Office of Mental Health Services
established a military sexual trauma support team that is
designed to help ensure that VA is in compliance with legally
mandated monitoring of military sexual trauma screening and
treatment.
Currently, the VHA Office of Research and Development is
supporting a broad portfolio focused on women's health issues.
In 2001, this Office created a Center of Excellence for
Research aimed at identifying factors which cause disparities
in health outcomes across racial, ethnic, and gender lines, as
well as promoting equity in health and health care.
These Centers are co-located in 2 sites in Pittsburgh and
Philadelphia; has 29 core investigators and have contributed
over 128 peer reviewed scientific articles over the past 2
years.
We have been talking about health care, but I do want to
add some things about benefits, because our women veterans are
also concerned about benefits. In fiscal year 2006, Vocational
Rehabilitation and Employment Program received 57,856
applications of which almost 10,000 were female veterans. Also
during fiscal year 2006, there was an increase in the percent
of guaranteed home loans for our women veterans. The average
loan amount was $173,923 and it went to over 17,000 women
veterans.
Also in fiscal year 2006, 8,442 women veterans used their
education benefits under the Montgomery GI Bill. Part of our
mission in the Center for Women Veterans is to attend some of
the transition assistance program briefings that are held
nationally. And we listen to what is stated and last year 8,541
VA benefit briefings were given to both male and female
servicemembers, including Guard and Reserve who were
transitioning.
I also wanted to state that to promote accuracy and
consistency in the claims review process, VBA has taken a
number of actions. For example, in the last 4 years, VBA has
published guidance and conducted training for employees on a
full range of issues related to PTSD claims adjudication--from
development of the claim to proper application of the rating
schedule. VBA and VHA are also working very closely regarding
PTSD in modifying the examination request worksheet and
template when a veteran applies for PTSD.
In closing, I would like to say that the Center has
developed a 25 most frequently asked questions booklet that I
believe you have received. We created this booklet from
thousands of inquiries from women veterans. It has been
published in both English and Spanish and is on our website as
well as VA's website.
Next year, June 20 through the 22nd, we are going to hold a
national Women Veterans Summit here in Washington, DC. We are
planning to outreach to our military services, particularly our
Reserves and National Guard. We are going to have workshops
including ``Readjustment Counseling Service: Outreach and
Transition Services for Veterans Families,'' ``Gender
Differences: What the Data Shows,'' and workshops on mental
health issues.
Our Nation is proud of our women veterans and I am proud to
be a women veteran and to serve our women veterans. This
concludes my formal testimony, but I am pleased to take any
questions.
[The prepared statement of Dr. Moseley Brown appears on p.
47.]
Mr. Hall. Thank you very much for your testimony and for
your service to our veterans and to our country. Ms. McClenney,
I will now recognize you for a 5-minute statement. There is a
vote that has just been called, but we are going to stay here
and listen to you and then we may ask you to answer our
questions in writing so that you don't have to sit here and
wait for an hour or more while we are across the street voting.
Ms. McClenney, your statement is in the record and you are
recognized for 5 minutes.
STATEMENT OF LUCRETIA McCLENNEY
Ms. McClenney. Thank you Chairman Hall and Members of the
Subcommittee. I appreciate the opportunity to come before you
today to discuss the mission of the Center for Minority
Veterans and address your specific questions on the Department
of Veterans Affairs service to minority veterans through its
current programs, present and future strategies addressing the
needs of this growing population, and out reach efforts being
conducted by VA to minority veterans.
Like the Center for Women Veterans, the Center was created
by Public Law 103-446 in November 1994. The Director of the
Center serves as primary advisor to the Secretary and Deputy
Secretary of Veterans Affairs on all matters related to
minority veterans.
The role of the Center is primarily one of advocacy for
minority veterans. Pursuant to Public Law, the Center's primary
emphasis is on veterans who are African Americans, Asian
Americans, Pacific Islanders, Hispanics and Native Americans
including American Indians, Alaska Natives, and Native
Hawaiians.
To establish a national presence and to ensure issues are
addressed at the local level, the Secretary directed the
appointment of Minority Veterans Program Coordinators (MVPCs)
at each VA health care facility, Regional Benefits Office, and
National Cemetery. There are approximately 300 MVPCs serving
across the Nation.
The Center provides training to the MVPCs in cultural
competency and outreach strategies. These coordinators educate
their facility personnel to the needs of the minority veterans
in their local communities and promote the use of VA benefits
and services by minority veterans. In addition, the 3
administrations each have a designated central office MVPC
Liaison. The Center's staff meets monthly with these liaisons
and quarterly with the senior leadership of each administration
to discuss outreach activities and to benchmark best practices.
The Advisory Committee on Minority Veterans advises the
Secretary and Congress on VA's administration of benefits and
services and makes recommendations in an annual report to
address unmet needs of the minority veteran population. The
Center facilitates the Committee's outreach to minority
veterans by ensuring they are kept abreast of VA's policies and
programs that may impact minority veterans and coordinates the
logistics and travel for all site visits and business meetings
for the Committee. In addition, the Center tracks the
Department's action taken on the Committee's recommendations.
The needs of our Nation's 4.7 million minority veterans are
not unlike the needs of minorities throughout our Nation. Some
of these may include access to medical facilities, especially
for veterans living in rural, remote, or urban areas.
Disparities in health care centered on diseases that
disproportionately affect minorities, homelessness,
unemployment, limited medical research and limited statistical
data related to minority veterans. VAs strategies to meet the
needs of minority veterans include but are not limited to the
following: VA is improving access to care as evidenced by the
significant increase in outpatient clinics. For example, in
1995, VA had only 102 community based outpatient clinics and by
2007, 872 ambulatory care and outpatient clinics were in
operation.
VA is addressing homelessness in the minority population by
partnering with community stakeholders and expanding VA's grant
and per diem program. The Center is working with VHA's Office
of Health Services Research and Development Service to target
minority groups and encourage minority veterans participation
in research programs.
The Center has staff who serves as veteran liaisons for
each of the 5 minority groups that we are mandated to oversee.
They establish active partnerships with veterans service
organizations as well as internal and other external
stakeholders to increase awareness of minority veterans issues
and develop collaborative strategies to address unmet needs.
Mr. Chairman, this concludes my prepared statement.
[The prepared statement of Ms. McClenney appears on p. 51.]
Mr. Hall. Thank you, Ms. McClenney.
Ms. McClenney. I would be happy to answer any questions.
Mr. Hall. Thank you so much for your work, for your
statement, for the service that you give to our veterans and to
our country. If Mr. Bilirakis would agree, which I think he
does, neither of us have the power to control the schedule on
the floor of the House. But some day, maybe we will.
We appreciate your patience and we are sorry we can't ask
you questions now. We do have a number of them, but we will
submit them to you in writing. If you would be so kind as to
respond in writing, we would appreciate that.
Ms. McClenney. It will be an honor, sir.
Dr. Moseley Brown. Yes.
Mr. Hall. Once again, thank you very much. This hearing is
adjourned.
[Whereupon, at 11:45 a.m., the Subcommittee was adjourned.]
A P P E N D I X
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Prepared Statement of Hon. Michael H. Michaud,
Chairman, Subcommittee on Health
The Subcommittee on Health will come to order. I would like to
thank everyone for coming today.
This is a joint hearing with the Subcommittee on Disability
Assistance and Memorial Affairs.
Today, we will examine the Department of Veterans Affairs programs
regarding women and minority veterans.
The face of the military is changing and so is the face of the
veteran population. According to the 2000 Census minorities make up
over 14 percent of the existing veteran population. The population of
women veterans is projected to continue to rise, from 6 percent in
2000, to 8 percent in 2010 and to 10 percent by 2020.
VA needs to constantly evaluate existing programs to address the
needs of these special groups, and make changes when needed.
I further believe that VA should implement new and innovative
programs to help close the many gaps that exist today in delivering
high quality, safe health care and the other benefits and services VA
provides.
Service in Operations Enduring Freedom and Iraqi Freedom has
created growing challenges for VA in meeting the needs of the women and
minority veterans as they separate from service.
We know that an unprecedented number of female servicemembers have
been routinely exposed to combat or combat like conditions.
VA reports that the prevalence of potential PTSD among new OEF/OIF
women veterans treated at VA has grown from 1 percent in 2002 to nearly
19 percent in 2006. This represents a considerable and disturbing
increase.
Issues such as cultural differences, effective outreach, education,
research and delivery of care should be carefully examined in an effort
to provide the best possible service to these veterans.
I hope that we will learn how VA is meeting the needs of these
populations, what challenges are on the horizon and what we can do to
provide these veterans with the best possible care available.
Prepared Statement of Hon. John J. Hall,
Chairman, Subcommittee on Disability Assistance and Memorial Affairs
Good morning.
I would first like to say that I am honored to join Mr. Michaud in
cochairing this hearing and I applaud the leadership he exercises on
behalf of our veterans, particularly on veteran health care issues.
I would also like to thank the witnesses for joining the 2
Subcommittees this morning for a hearing to examine issues facing women
and minority veterans. I think this rare joint hearing speaks volumes
about how important these issues are to the Committee as whole and I
look forward to hearing from all of today's witnesses.
Women veterans are the fastest growing segment of the veteran
population, comprising 7% of the total veteran population and 5% of
those using VA health services.
Over 14% of veterans are from a racial or ethnic minority group
with Blacks comprising the bulk at 9.7% (2000 U.S. Census figures).
I am certain that the VA does its best to ensure that all veterans
encounter no barriers to access in the receipt of VA benefits,
treatment and services.
However, the fact remains that the barriers in the society at large
that women and minorities often face, might very likely translate into
barriers in the smaller VA system.
As such, Congress in its wisdom developed both the Center for
Minority Veterans and the Center for Women Veterans in 1994 to ensure
that these veterans are fully integrated in the VA system.
I look forward to hearing from both Centers, as well as their
separate Advisory Committees, which develop detailed reports which help
to inform the policies of the VA for women and Minority veterans.
I especially would like to learn the VA's and the Advisory
Committee on Minority Veterans' views on the sunsetting provisions that
would end the Advisory Committee in 2009 and what if any plans it has
to replace this vital organization. I know representative Gutierrez has
introduced a bill, H.R. 674 that would prevent this from occurring.
Getting rid of the Minority veterans' Advisory Committee would be a
seriously troubling result in light of recent findings by VA
researchers that health disparities appear to exist in all clinical
arenas and have a direct impact on the health outcomes for minority
veterans.
Last, but certainly not least, I welcome my colleague Congresswoman
Heather Wilson, the only woman veteran in Congress.
I am sure all of our witnesses, including our experts and the VSOs,
will provide critical insight on issues facing women and Minority
veterans, especially in light of returning OIF/OEF veterans.
Thank you.
Prepared Statement of Hon. Doug Lamborn, Ranking Republican Member,
Subcommittee on Disability Assistance and Memorial Affairs
Thank you Mr. Chairman for recognizing me. I thank you for holding
this hearing on the Challenges Facing Minority and Women Veterans.
I welcome our witnesses, and thank you all for your contributions
to the veterans' affairs system.
America's minorities and the women of our great Nation are integral
to the quality of our National security. Women make up nearly 10
percent of our Nation's 24 million living veterans. Women on active
duty represent more than 15 percent of our armed forces.
According to a 2005 Heritage Foundation study, about 25 percent of
military recruits identify themselves as other than Caucasian; further,
military women are more likely to identify themselves as members of a
racial or ethnic group than men.
Our military has a higher percentage of some minorities--such as
African Americans, American Indians, Native Alaskans and Hawaiians, and
Pacific Islanders--than the percentage of these minorities in the
general population. These men and women are patriots.
In more than 2 centuries of service to country, women and minority
servicemembers have formed a glorious legacy. That legacy has only been
enriched by the intrepid and resolute accomplishments of their
descendents in the global war on terror.
Our challenge is to ensure that women and minority veterans--indeed
all veterans--receive equal treatment for their qualifying service to
our Nation.
The VA centers for women and minority veterans and the department's
associated advisory Committees are charged with increasing awareness of
VA programs, identifying barriers and inadequacies in VA programs, and
influencing improvement.
We do not look to these VA programs to merely identify and report.
We want them to influence policy and accept a measure of accountability
for departmental results.
In that regard, I will of course be very interested in hearing
today about the challenges facing women and minority veterans, such as
gender-specific health care.
I want to learn about disabilities more likely to affect minority
veterans. I want to hear about the challenges facing veterans who wish
to take advantage of economic opportunities in the public and private
sectors.
I will also, however, especially want to learn today how VA and its
component organizations are effectively rising to meet those
challenges.
Mr. Chairman, I yield back.
Prepared Statement of Hon. Gus M. Bilirakis,
a Representative in Congress from the State of Florida
I want to thank Chairman Hall and Chairman Michaud for scheduling
today's joint hearing on the issues facing women and minority veterans.
As a new Member of the Veterans' Affairs Committee, I am glad that we
will be examining how women and minority veterans are being treated
within the Department of Veterans' Affairs.
The numbers of women and minorities serving in our military
continues to grow, and consequently, their ranks among our Nation's
veterans' population is also rising. As a result of the changing
demographics of our military personnel, I believe it is important for
our Committee to examine the challenges that face women and minority
veterans as they transition back into civilian life.
We must also ensure that they have access to the services and
benefits that they have earned through their service to our country. I
am anxious to hear from our witnesses to learn more about how we
improve the services provided to women and minority veterans.
Thank you, Mr. Chairman. I look forward to working with you and our
colleagues on the VA Committee on these important issues.
Prepared Statement of Shirley A. Quarles, R.N., Ed.D., Chair,
Advisory Committee on Women Veterans,
U.S. Department of Veterans Affairs
Chairman Hall, Chairman Michaud, and Members of the Subcommittees,
I am pleased to testify today on behalf of the Department of Veterans
Affairs Advisory Committee for Women Veterans regarding our views on:
how the Department of Veterans Affairs (VA) serves women veterans
through its current programs; the present and future needs of a growing
women veterans population; the strategies VA has for meeting these
needs; and outreach efforts that are being conducted by VA for women
veterans.
The Advisory Committee on Women Veterans (ACWV) was established by
Public Law 98-160 in 1983. The Advisory Committee is charged with
advising the Secretary of Veterans Affairs on VA benefits and services
for women veterans, assessing the needs of women veterans, reviewing VA
programs and activities designed to meet the needs of women veterans,
and developing recommendations that address unmet needs of women
veterans. The Advisory Committee submits a biennial report to the
Secretary of Veterans Affairs that delineates the Committee's findings
and recommendations.
The Advisory Committee on Women Veterans consist of 14 members
(women and men) most are veterans; who have served across all services
of the Armed Forces. This Committee is supported by the Center for
Women Veterans with advisors and ex-officio members from the Department
of Defense (DoD), Veterans Benefits Administration (VBA), Veterans
Health Administration (VHA), National Cemetery Administration (NCA),
Department of Labor (DoL), and the Department of Health and Human
Services (HHS).
How is the Department of Veterans Affairs (VA) serving women through
its current programs?
As a means to obtain information regarding women veterans' services
and programs provided by VA on health care and benefits, the Advisory
Committee on Women Veterans (ACWV) conducts site visits to VA
facilities throughout the U.S. Additionally, the ACWV tours the
facilities and meets with senior leaders to discuss services and
programs available to women veterans. During the site visits, the ACWV
also hosts open forums with the local women veterans' community to
encourage open dialog from women veterans to share their experiences
within VA, to discuss issues, and to raise questions related to gender
specific VA benefits and services.
As another means to obtain information regarding women veterans'
services and programs provided by VA, the ACWV meets twice a year at VA
Central Office (VACO) and receives briefings from the Veterans Health
Administration (VHA), Veterans Benefits Administration, (VBA), National
Cemetery Administration (NCA), Office of Research and Development
(ORD), and other staff offices. These briefings update the Committee on
the status of VA programs and how these programs address the needs of
women veterans. During these meetings, members have the opportunity to
question presenters about services in their area of concentration and
share their observations and concerns from site visits. The Advisory
Committee uses information gathered from the site visits and briefings
to formulate recommendations to the Secretary of Veterans Affairs in
the biennial reports. The Center for Women Veterans provides support to
the ACWV during their site visits and meetings at VACO.
In the 2006 Report of the Advisory Committee on Women Veterans, the
Committee made 23 recommendations that addressed behavioral and mental
health care, health care, military sexual trauma (MST), outreach,
research studies, strategic planning, training, women veterans health
program, women veterans program managers and women veterans
coordinators, and homeless women veterans.
One recommendation that has already been implemented was to
organizationally realign the Women Veterans Health Program Office to
the status of a Strategic Healthcare Group. With the recent elevation
of the Women Veterans Health Program to the Women Veterans Health
Strategic Healthcare Group, it has positioned the office to gain
expertise in the population of women veterans, strategically plan for
health care delivery and provide leadership in clinical knowledge of
this unique group of women and to catalyze optimal integration of women
veterans health issues across all VHA programs and offices. VA strives
to be the lifetime provider of health care services to women veterans
and exceed their expectations for care during each phase of their
lifecycle. Additionally, VA aims to be a world leader in innovative and
high quality for women veterans.
In the area of women veterans health program, the Advisory
Committee on Women Veterans 2006 Report recommended that VA ensure that
the Center for Women Veterans is provided an annual update on the
effectiveness of the responsibilities of the VHA Women Veterans Program
Managers. VHA leaders and the Acting Chief Consultant, Women Veterans
Health Strategic Healthcare Group (formerly known as Women Veterans
Health Program), briefed the Committee on this issue at the February-
March 2007 Advisory Committee for Women Veterans meeting. Additionally,
the Acting Chief Consultant and the Women Veterans Health Strategic
Healthcare Group work closely with the Center for Women Veterans on
issues that are frequently referred to Women Veterans Program Managers
in field facilities.
The submission of the 2006 Report to Congress was at the discretion
of the Secretary for Veterans Affairs; a strong supporter of the
Advisory Committee on Women Veterans. As a courtesy to this Committee,
the Secretary agreed to forward the report to Congress during May 2007.
What are the present and future needs of these growing populations and
what strategies does VA have for meeting them?
One area the Advisory Committee for Women Veterans was able to
witness first hand the present needs of women veterans' mental health
care was at our site visit in June 2007 to the Women's Mental Health
Center in Palo Alto, CA. The Women's Trauma Recovery Program (WTRP) is
a 60-day residential post-traumatic stress disorder (PTSD) and military
sexual trauma (MST) treatment program.
The future needs can be met through research and studies
specifically on women veterans. In the 2004 and 2006 Advisory Committee
on Women Veterans Reports, research and studies have been recommended.
The last national survey of female veterans was conducted in 1985,
leaving VHA policy makers and managers with limited information with
which to adequately plan for future health care services for women
veterans. To address this knowledge gap, the WVHSHG commissioned Donna
Washington, MD, MPH, VA Greater Los Angeles HSR&D Center of Excellence,
to conduct a national Survey of Women Veterans. The objectives of the
National Survey of Women Veterans are: (1) identify the current
demographics, health care needs, and VA experiences of women veterans;
(2) determine how health care needs and barriers to VA health care use
differ among women veterans of different periods of military service,
e.g., OEF/OIF versus earlier periods; and (3) assess women veterans
preference for and perceived value of different types of VA
interventions to improve access and quality. The survey will enroll
from 2,500 to 3,200 women veterans across the Nation, including equal
numbers of VA users and nonusers. The final report will be submitted by
December 31, 2008. The initial funding award was for $870,400.
What outreach efforts are being conducted by VA to women veterans?
We continue to outreach to the women veterans' community with
increased emphasis with our partnerships with federal, state, and
country agencies, national veterans service organizations and community
organizations. To enhance collaboration and better serve our women
veterans, appointed advisors and ex-officio representatives from HHS,
DoL, DoD, and VA Administrations (VHA, VBA and NCA) serve on the
Advisory Committee on Women Veterans. The Center's Director, Dr. Irene
Trowell-Harris serves as an ex-officio member of the Defense Advisory
Committee on Women in the Services (DACOWITS). In this role, she
ensures that DoD and VA, as a team, address military and women
veterans' health and benefits issues.
The 2004 Advisory for Women Veterans Report recommended that
brochures and outreach materials that are currently only available in
English be translated in Spanish. VA has distributed brochures,
pamphlets, fact sheets, and booklets in Spanish from VHA, VBA and NCA.
Numerous benefit fact sheets and other informational materials, printed
in Spanish, are available on VA's Internet web site at www.va.gov.
The Advisory Committee on Women Veterans plans to participate in
the 2008 National Summit on Women Veterans Issues to be held in
Washington, DC during June 2008 and to facilitate a townhall meeting to
better serve our women veterans.
The Advisory Committee on Women Veterans is grateful to the VA and
the Center for Women Veterans on their vision and professional efforts
to take care of our women veterans of yesterday, today, and the future.
This concludes my formal testimony. I will be pleased to answer any
questions.
Prepared Statement of Colonel Reginald Malebranche, USA (Ret.),
Member, Advisory Committee on Minority Veterans,
U.S. Department of Veterans Affairs
Chairman Michaud, Chairman Hall, and Members of the Subcommittees,
I am indeed pleased to represent the Chairman of the Advisory Committee
on Minority Veterans, give you our views on the services provided by
the Department of Veterans Affairs (VA) to Minority Veterans; on VA's
present and future strategies addressing the needs of this growing
population; and VA's outreach efforts toward Minority Veterans.
The Advisory Committee on Minority Veterans (Committee) was
established in November 1994, pursuant to Public Law 103-146. The
Committee is tasked with assessing the needs of minority veteran
populations, and reporting back to the Secretary on the effectiveness
of VA programs and services at meeting those needs. The Committee works
in close coordination and collaboration with the Center for Minority
Veterans (Center) and relies on the expertise of Center staff for
current information about VA programs, policies and services.
The Advisory Committee on Minority Veterans members are appointed
by the Secretary, and serve at his/her discretion. The majority of the
Committee members are veterans and are representative of the 5 minority
groups--African American, Asian American, Hispanic, Pacific Islander,
Native American (including Alaskan Native, American Indian, and Native
Hawaiian).
As a means of obtaining information regarding the delivery of
health care and services to minority veterans, the Committee conducts
an annual site visit to a selected VA facility with a high density of
minority veterans. During these visits, the Committee tours the
facilities and meets with senior VA officials to discuss services and
programs available to minority veterans. The Committee also hosts open
forums with Veteran Services Organizations with the local veterans, to
encourage them to discuss issues, problem areas, and seek information
related to VA benefits and services.
The Committee meets once a year at VA Central Office and receives
briefings from the VA Senior leadership, the Center for Minority
Veterans, Veterans Health Administration (VHA), Veterans Benefits
Administration (VBA), National Cemetery Administration (NCA) and other
staff offices. These briefings update the Advisory Committee on the
status of VA programs and address issues and concerns raised during the
site visits.
In its 2006 Report on the Greater Los Angeles Health Care System,
April 3-7, 2006, the Advisory Committee made eleven recommendations,
with the key issues being Outreach, Research, Staff Diversity, Seamless
Transition, and the Native American Veteran Housing Loan Program.
During its visit to the Los Angeles Ambulatory Care Center, The
Committee was dismayed by the staggering number of homeless veterans.
Twenty-three percent (23% or 21,424) of the 90,000 homeless populations
in Los Angeles were reported to be veterans. The Committee was
encouraged by the range of programs identified by VA for homeless
veterans. Yet, the Committee was concerned that those programs may not
reach the targeted audience. There was insufficient evidence that
outreach programs had been designed and publicized to a level to ensure
that homeless minority veterans were aware of their existence. The
Committee believed that similar situations may affect the homeless
veteran population throughout the Continental United States and its
Territories.
What outreach efforts are being conducted by VA to minority veterans?
Outreach is a major challenge for the VA. During its sessions with
Veteran Services Organizations, and with minority veterans, at its
townhall meeting, the Committee learned that the major issue was that
minority veterans were unaware of their VA benefits, and other VA
services available. The Committee recognized that VA made strides to
reach out to minority veterans and inform them of their benefits and
the services available. The Committee noted that VA had developed and
distributed comprehensive and illustrative pamphlets. However, the
Committee believes that additional resources such as publishing and
distributing a veterans' magazine similar to the VA employee magazine
Vanguard, could be utilized to inform veterans of their entitlements.
Transportation to VA centers, in major metropolitan, rural and
isolated areas, is a major impediment for minority veterans.
Accessibility, affordability, and distances to VA centers are major
problems affecting minority veterans. Although Veterans Services
organizations and many non-profit organizations provide some forms of
relief, the Committee noted that a major segment of the minority
veterans were not within easy or affordable reach to VA centers.
Much remained to be accomplished in the area of outreach. The
Committee recognized that it is not simply a VA challenge. Several of
its members have taken the mantle to assist VA in its quest to reach
out to minority veterans. Committee members head Veterans Services
Organizations and insure that the VA's efforts are well publicized and
supported. Others visit medical centers and hold informal meetings with
minority veterans to ensure that those veterans, and/or their family
members/friends/acquaintances are aware of their entitlements and
benefits.
The challenge to reach all minority veterans will require a
concerted effort of VA, other Federal and state agencies, Veterans
Services Organizations, Members of the Committee, and the public to
make sure that all veterans are keenly aware of their entitlements.
What are the present and future needs of those growing populations and
what strategies does VA have for meeting them?
Access to Care
Minority veterans' access to care is a major challenge for VA,
particularly for minority veterans in large metropolitan areas, in
rural and isolated areas. For example the plight of Alaska Natives,
living in rural and isolated areas of the state, cannot be ignored; and
neither can the plight of minority veterans living in rural and
isolated areas within the Continental United States. The challenge for
VA is to continue to develop and implement innovative programs which
target those minority veteran populations.
Rural and remote areas such as Alaska and the Navajo Nation may be
good areas to test rural health initiatives. VA could enter in a
reimbursable agreement with all Alaska Natives' organizations, the
Health and Human Services and Indian Health Service to reach out to all
minority veterans and provide all the services, which fall within the
realm of the VA.
The Committee applauds the strides made by VA in expanding its
telehealth and telemedicine programs, and its ability to reach a
significant number of the minority veteran population. Yet, those
programs are not stand alone, and will require significant investment
and training.
Mental Health
Mental health is and will become a major challenge. The Committee
recognizes the efforts and the programs put forth by VA to support,
identify, and care for soldiers, sailors and airmen, who have served in
Operation Enduring Freedom and Operation Iraqi Freedom theaters of
operations. The early identification of Post Traumatic Stress Disorder
will certainly help in the observation and treatment of all veterans
who served in those areas. Yet, the Advisory Committee is concerned
that the same level of services might not be readily available to
minority veterans who have served in prior conflicts.
The Committee is also concerned that an interoperable electronic
health record has not been developed to embrace all Uniformed Services
personnel.
Benefits
The processing and adjudication of benefits seem to affect all
veterans. The Committee recognized the initiatives approved by the
Congress to improve the processing and adjudication of benefits by VA.
The Veterans Claims Assistance Act of 2000--Public Law 106-475--puts
the onus on VA to maximize its assistance to all veterans and to make
them aware of their entitlements.
Staff Diversity
Senior staff diversity remains an issue at VA. The absence of
minorities at the senior staff level has been and continues to be
noticeable during site visits. Data presented and subscribed by VA
suggests that VA's problem is limited to recruiting white females, and
Hispanics. Yet, other data maintained at VA suggested that minorities
were not well represented at senior staff levels. The Committee was
concerned at the inconsistency of the data, and its implications for
minority veterans and the minority population at VA.
How is the U.S. Department of Veterans Affairs (VA) serving minorities
through its current programs?
The professionalism, the expertise shown by VA personnel was
striking. The Committee noted in several instances that VA's efforts in
most areas were only limited by personnel and time. There was a
perception that most staff would endeavor to do all possible for a
veteran. The challenge is to include minority veterans in that equation
and philosophy.
VA's strides in supporting veterans are especially noteworthy.
Thank you for this opportunity to address the Subcommittees. I would be
happy to address any questions you may have.
Prepared Statement of Saul Rosenberg, Ph.D.,
Associate Clinical Professor of Medical Psychology,
University of California, San Francisco, CA
Mr. Chairman, thank you for inviting me to this joint hearing of
the Subcommittees on Health and Disability Assistance and Memorial
Affairs to discuss the needs of women and minority veterans. My name is
Dr. Saul Rosenberg. I have been engaged in assessing and treating
veterans and civilians with Posttraumatic Stress Disorder (PTSD) for
many years. As a clinical psychology intern at the Ann Arbor VAMC I
learned that to be an effective therapist I had to understand the
cultural experiences, preferences and values of the individual I was
trying to help. The lessons I learned as a trainee I have taught to
interns and psychiatry residents at the San Francisco VAMC. I am not
employed by the VA nor do I represent the VA.
With my colleagues in the Dept. of Psychiatry at the University of
California, San Francisco and the San Francisco VAMC I have
participated in the development of diagnostic interviews and
psychological tests to help counselors and therapists better understand
the psychological problems that contribute to social isolation. Social
support from families, friends, Vet Centers and veterans' service
organizations play a huge role in healing the body, mind and spirit.
My current professional interest is in the development of public-
private partnerships, between University of California campuses,
affiliated military hospitals and VAs, governmental agencies,
foundations and the private sector to improve access to evidence-based,
cost-effective mental health diagnostic and treatment services. I
believe that public-private partnerships are essential to reduce the
disparities in access to mental health services for racial and ethnic
minorities, native Americans, rural populations, women, children, the
elderly and all underserved and vulnerable populations.
My colleagues at UCSF and the SFVAMC recently published the first
detailed report on the prevalence of mental health and psychosocial
problems, with a breakdown by gender and race, for over 100,000
veterans first seen at VA health care facilities. The prevalence of
mental disorders was high: over 30% had a diagnosed mental disorder or
psychosocial problem. Posttraumatic Stress Disorder (PTSD) was the most
common diagnosis, and more than half of those diagnosed with a mental
disorder had 2 or more mental health diagnoses.
Women comprised 13% of the sample; 69% were White, 18% were Black,
11% were Hispanic and 2% came from other racial groups. The likelihood
of receiving a diagnosis for PTSD or another mental disorder was the
same for women and men and across all racial groups. The most striking
finding in the study had to do with age and not with race or gender.
The youngest veterans, between 18 and 24 years of age, had a
significantly higher likelihood of being diagnosed with PTSD or another
mental disorder, compared to veterans 40 years and older. The youngest
men and women, Whites, Blacks and Hispanics, were more vulnerable to
stress than those who were over 40 years of age. The results of this
study point to the importance of funding programs that target the early
identification and treatment of PTSD in the youngest servicemen and
women.\1\
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\1\ Karen H. Seal, MD, MPH; Daniel Bertenthal, MPH; Christian R.
Miner, PhD; Saunak Sen, PhD; Charles Marmar, MD, ``Bringing the Ware
Back Home: Mental Health Disorders Among 103 788 U.S. Veterans
Returning from Iraq and Afghanistan Seen at Department of Veterans
Affairs Facilities'' Arch Intern Med. 1007, 167, 476-482.
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In this study, most mental disorders were identified in primary
care and non-mental health settings within a few days of the first
visit to a VA clinic. The detection of PTSD, depression and substance
abuse in primary care settings is crucial in order to initiate
treatment which can prevent chronic mental disorders and disability.
This study shows that the emphasis the VA is placing on the early
detection of mental disorders in primary care settings has been
effective.
Clinical research on the screening and psychological assessment of
mental and substance abuse disorders and suicide risk in primary care
deserves continued funding. Evidence-based clinical guidelines for the
detection of PTSD, substance abuse and suicide risk should be
continuously evaluated. The most effective protocols should be
disseminated to all settings where veterans receive care, including the
private sector.
For many years, The VA, DoD, National Institute of Health (NIH) and
the National Institute of Mental Health (NIMH) have supported research
on evidence-based diagnostic tools and treatments for PTSD, depression
and substance abuse. I have been grateful to the NIMH for supporting my
own research. Like most academics, I have published my research in peer
reviewed journals. However I now believe that research that benefits
patients needs to be delivered to health care providers when they need
it--at the point of care.
The VA--more than any other public or private institution--is in
the best position to implement computer-aided decision support for
mental disorders at the point of care. The VA is the largest integrated
delivery system that provides mental and behavioral health care. In
addition, the VA has VistA, the oldest and most robust Electronic
Health Record (EHR). The delivery of clinical practice guidelines
matched to a patient's diagnosis and delivered directly into to a
patient's EHR at the point of care deserves the highest priority. In
addition, efforts now underway to develop portable longitudinal
Personal Health Records that injured veterans can take with them
wherever they seek care deserve continued support.
Too much excellent research that could benefit veterans is buried
in professional journals; we need one place to accumulate all the data
from all the studies so that health care providers can learn from past
experience and share knowledge about the best ways to treat and
rehabilitate injured veterans. All researchers and contractors who
receive Federal funding for health related projects should be
encouraged to deposit their data in a secure, private and confidential
data base. Investigators and contractors should be encouraged to report
results by gender and race to insure that treatments are available that
are attuned to the experiences, culture, values and preferences of
injured veterans and their families.
Many servicemen and women returning from Iraq have been exposed to
roadside bombs and improvised explosive devices. Never before have so
many soldiers received simultaneous injuries to their brain and mind.
There is much that we have to learn about the diagnosis and cognitive
rehabilitation of Traumatic Brain Injuries (TBI) from powerful bombs.
These blast injuries are not the same as concussions resulting from a
car accident or a sports injury. Thorough screening and comprehensive
neurological and neuropsychological assessment is essential to
characterize these injuries and to maximize the prospects for recovery,
a good quality of life and the ability to work, contribute and
participate in a community.
Most veterans receive their health care outside the VA system. I am
especially concerned about the lack of coverage provided by private
health insurance plans for neuropsychological assessment. Many private
insurance companies will pay over $1,000 for neuroimaging studies but
refuse to pay for the costs of comprehensive neuropsychological
testing. Proper neuroimaging studies are essential but they cannot
measure cognitive functioning, like the ability to sustain and focus
attention or short-term memory--only neuropsychological tests can do
that. Congressional hearings that investigate the treatment of veterans
with TBI should invite neuropsychologists and representatives of
professional neuropsychological associations to provide testimony on
this issue. Before the DoD and VA outsource the treatment of military
personnel and veterans with brain injuries to private facilities they
should have the assurance that unwarranted restrictions on
neuropsychological assessment are the exception rather than the rule.
The VBA has acknowledged a backlog of over 400,000 disability
claims awaiting disability determination. The VBA has acknowledged that
the waiting time to complete disability examinations is unacceptably
long.
According to a 2007 Institute of Medicine (IOM) report regarding
disability determination for veterans, the methodology the VBA uses for
determining disability is outmoded and does not reflect current
knowledge about the assessment of functional impairments. The IOM
recommended development of pilot programs to immediately award partial
disability to veterans who meet presumptive criteria for a disabling
mental disorder. Implementing the IOM's recommendations would assure
that injured veterans received immediate help and financial support
while waiting--sometimes for years--for their claims to be adjudicated.
The IOM also recommended funding demonstration projects to
implement the International Classification of Functioning, Health and
Disability published by the World Health Organization. The IOM pointed
out that we need better description and quantification of functional
capacities that promote involvement. Projects should be encouraged that
map the full range of impairments and also the full range of functional
capacities. A major goal of rehabilitation is to reengage the disabled
veteran and promote social connections. Injured veterans need to be
engaged in their communities, working, volunteering and connecting with
friends and veterans.
Wide variability exists between military and VA disability ratings
and across different regions of the U.S. I am especially concerned
about the possibility of racial disparities in disability ratings for
PTSD. In a presentation to the Institute of Medicine, Dr. Charles
Engel, the Director of the Deployment Health Clinical Center, reported
that African American veterans were about half as likely as other
veterans to receive service connected disability for PTSD (Medical Care
2003;41(4):536-549). This issue deserves urgent attention. Culturally
sensitive assessment tools need to be developed to insure that
consistent and equitable procedures are implemented and that any racial
disparities that exist are eliminated.
A 2007 Institute of Medicine (IOM) report, PTSD Compensation and
Military Service, recommended that new methods should be developed to
identify women who are victims of military sexual assault. Because PTSD
from sexual assault is more difficult to prove than PTSD resulting from
combat, the IOM recommended that more attention should be focused on
the prompt identification and treatment of women who are victims of
sexual assault and that better procedures be established for awarding
disability compensation.
A 2007 report form the DoD Task Force on Mental Health has called
for more attention to the prevention of mental disorders and the
building of resilience and coping strategies to deal with the stress of
deployment. The report stated:
``The mission of caring for the psychological health of the
military has fundamentally changed--new programs are needed--to
meet current and future demands for a full spectrum of services
including: resilience-building, assessment, prevention, early
intervention, and provision of an easily accessible continuum
of treatment for psychological health of service members and
their families in both the Active and Reserve Components. There
are not sufficient mechanisms in place to assure the use of
evidence-based treatments or the monitoring of treatment
effectiveness'' \2\
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\2\ Defense Health Board Task Force on Mental Health (2007). An
achievable vision: Report of the Department of Defense Task Force on
Mental Health. Falls Church, VA; Defense Health Board; ES 2-3
Currently, health information technology contracts and clinical
research are conducted along parallel separate tracks. I recommend that
contracts and research be funded for joint projects that integrate
health services research and health information technology. Programs
like the VA Special Fellowship Program in Medical Informatics provide a
bridge for connecting patients, providers and researchers to health
information technologies. The next generation of providers will be
increasingly sophisticated in utilizing cutting edge technologies for
telemedicine such as those being developed by the Telemedicine and
Advanced Technology Research Center (TATRC).
A recent study by Dr. Charles Marmar at the San Francisco VAMC and
UCSF and his colleagues across the country, found predictors of PTSD
for police and other first responders following a disaster or critical
incident.\3\ This study measured personal characteristics
prospectively--prior to exposure to a stressful event. Factors that
predicted chronic and severe PTSD symptoms and greater functional
impairments included the use of maladaptive coping strategies,
especially self-medication with alcohol. In contrast, police officers
who had a strong social support network after exposure to a critical
stressful incident, exhibited less symptoms and impairments in
functioning and were more likely to return to duty. The National
Institute of Mental Health has generously funded research on
vulnerabilities and protective factors related to the development of
PTSD; congress should continue to support these promising initiatives.
---------------------------------------------------------------------------
\3\ Charles R. Marmar; Shannon E. McCaslin; Thomas J. Metzler;
Suzanne Best; Daniel S. Weiss; Jeffery Fagan; Akiva Liberman; Nnamdi
Pole; Christian Otte; Rachel Yehuda; David Mohr; and Thomas Neylan,
``Predictors of Posttraumatic Stress in Police and Other First
Responders'' Ann. N.Y. Acad. Sci. 1071: 1-18 (2006).
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The Mental Illness Research, Education and Clinical Centers
(MIRECC) were established by Congress to translate clinical research
and best practices in mental health care into tangible benefits for
patients of the VA. The MIRECCs are conducting research on post-
deployment mental disorders, PTSD, substance abuse and suicide
prevention. In addition, the MIRECCs produce clinical educational
programs. These excellent programs deserve continued support and new
programs should be funded, such as centers of excellence for the study
of resilience--an idea promoted by the DoD Task Force on Mental Health.
The Telemedicine and Advanced Technology Research Center (TATRC)
was established by congress to implement innovative telemedicine and
technology projects to deliver medical expertise anywhere it is needed.
Technologies developed by TATRC to help injured servicemen and women on
the battlefield, and in remote rural communities, can be transferred to
the private sector. Like many technology projects sponsored by the VA,
the benefits accrue not only to veterans and their families but to the
whole community. VistA, the VA's EHR is being installed around the
world; countries that cannot afford to spend millions of dollars to
develop an EHR can install VistA for a tiny fraction of the cost of
commercial EHR.
Thank you for your support for research and for the education and
training of the clinicians who provide health care to injured veterans.
I will be happy to answer any questions.
Prepared Statement of Maureen Murdoch, M.D., MPH,
Center for Chronic Disease Outcomes Research,
Minneapolis Veterans Affairs Medical Center, Minneapolis, MN
Veterans Health Administration, U.S. Department of Veterans Affairs
(on behalf of herself)
Mr. Chairman and Members of the Subcommittees, thank you for the
opportunity to appear before you today to present findings from my
team's research on possible disparities in PTSD disability awards among
race and gender groups. I must note the views presented today are mine
and do not necessarily represent the views of the Department of
Veterans Affairs (VA) and reflect the results of my studies and not
necessarily the findings of other research.
Background
PTSD is the most common psychiatric condition for which veterans
seek VA disability benefits. Long-term health studies indicate women
have a higher prevalence of PTSD than men, and may be more susceptible
to PTSD. Conversely, African American or blacks appear to have similar
risks for PTSD compared to whites.
In 2000, my colleagues and I began investigating if there were race
and gender disparities in VA disability awards for post-traumatic
stress disorder (PTSD). We assembled a representative sample of almost
5,000 men and women veterans who applied for PTSD disability benefits
between 1994 and 1998.
We developed and tested 4 hypotheses:
1. Veterans reporting more severe PTSD symptoms would be more
likely to be Service-Connected for PTSD than veterans reporting less
severe PTSD symptoms.
2. Veterans reporting more severe disablement would be more likely
to be Service-Connected for PTSD than veterans reporting less
disablement.
3. Veterans with combat experience would be more likely to be
rated Service-Connected for PTSD than veterans not in combat.
4. These 3 covariates (PTSD symptom severity, degree of
disability, and combat exposure) would explain any race or gender
differences in VA PTSD disability awards.
Results of the Studies
Overall, the 3,337 respondents were highly symptomatic. About 80
percent met our definition for PTSD and 62 percent were service
connected for PTSD. Our results yielded several interesting findings.
Concerning the relationship between PTSD service connection and gender,
despite fewer major medical complications and superior physical
functioning, women's overall role functioning was similar to men's.
Almost 94 percent of men and 29 percent of women reported at least some
combat exposure. Most importantly, once combat exposure was controlled,
the effect of gender on service connection for PTSD became
insignificant. Specifically, more than 90 percent of combat-injured
veterans, regardless of gender, became service-connected for PTSD.
Those with higher levels of combat exposure were substantially more
likely than those with lower levels to be service connected for PTSD.
Since men had notably greater exposure to combat, they likewise had
higher rates of service connection. In sum, instead of a gender bias in
awards for PTSD service connection, we found evidence of a combat
advantage that disproportionately favored men and adversely affected
women.
We also compared PTSD symptom severity and Social Adjustment scores
of veterans reporting sexual assault and combat exposure. We found, on
average, veterans reporting combat alone had marginally less severe
PTSD symptoms than those reporting sexual assault. Veterans reporting
only combat exposure also reported significantly better Social
Adjustment Scores than those reporting sexual assault. Men and women
who reported sexual assault were equally unlikely to be service
connected for PTSD.
In our investigation of racial disparities, we found that the
African Americans in our sample were just as likely to be service
connected for other disorders, but were substantially and significantly
less likely than other respondents to be service connected for PTSD.
The negative association between African Americans and service
connection for PTSD was not found for any other racial or ethnic group.
Among veterans receiving service connection for PTSD, the service-
connected rating was almost identical, regardless of race--an average
rating of 43 percent for African Americans versus 45 percent for all
other veterans. Controlling for gender, African Americans' modified
combat exposure scores were similar to other veterans, but African
Americans were significantly less likely to have a documented combat
injury. With full adjustment, the estimated probability of being
awarded service connection for PTSD was 43 percent for African American
veterans compared with 56 percent for other respondents. Examining
clinicians were about seven-tenths as likely to diagnose PTSD in
African Americans as they were for other veterans, although this
difference was not statistically significant.
Discussion About the Studies
There are several issues warranting consideration when evaluating
this research. First, the pool of respondents was selected based upon
their submitted claims for PTSD service connection, while our questions
focused on their current health and adjustment status. It is distinctly
possible that those with the greatest need at the time of their
application have been receiving treatment and may now actually report
better health outcomes than their peers. Second, the study relied on
veterans' self-reports of their PTSD symptom severity, degree of
disability, and trauma history, which may not have been clinically
accurate or universally consistent.
Recommendations
In order to strengthen and expand this research, future studies
should identify and evaluate veterans shortly after applying for PTSD
disability benefits. In addition, we need to collect and assemble more
data from the claims files. Finally, future studies should investigate
claims for disorders other than PTSD.
Mr. Chairman, this concludes my statement. I am pleased to respond
to any questions you or the Subcommittee members may have. Thank you.
Prepared Statement of Joy J. Ilem,
Assistant National Legislative Director, Disabled American Veterans
Messrs. Chairmen and Members of the Subcommittees:
Thank you for inviting the Disabled American Veterans (DAV) to
provide testimony at this joint hearing on the present and future needs
of women and minority veterans seeking services from the Department of
Veterans Affairs (VA). You have called a hearing on important topics
that demand attention by the Committee, the VA, and the Department of
Defense (DoD).
MINORITY VETERANS
In June 2007 the VA Health Services Research & Development Service
(HSR&D) released a new report, Racial and Ethnic Disparities in the VA
Healthcare System: A Systematic Review.
For many years, the VA has expressed its commitment to eliminating
ethnic disparities in health care to ensure equal access and quality
health care for all veterans using VA services. Researchers
systematically reviewed the existing evidence on disparities to
determine which clinical areas racial and ethnic disparities are
prevalent within VA, described what is known about the sources of those
disparities and qualitatively synthesized that knowledge to determine
the most promising avenues for future research aimed at improving
equity in VA health care.
Researchers looked at a number of clinical areas including:
arthritis and pain management; cancer; cardiovascular diseases;
diabetes; HIV and Hepatitis C; mental health and substance abuse;
preventative and ambulatory care; and rehabilitative and palliative
care. The findings of the study concluded that disparities appear to
exist in all clinical arenas and a number of reasons were offered as to
why disparities exist. More notably, researchers commented in nearly
each case that the underlying causes of these disparities were not
explored or remain unclear. One key finding was that in studies
examining quality indicators representing immediate health outcomes--
such as control of blood sugar, blood pressure, or cholesterol--non-
white veterans generally fared worse than whites. The researchers noted
that this finding was especially troubling since it may indicate that
disparities in health care delivery are contributing to real
disparities in health outcomes. It was also noted that fewer studies
examined Hispanics, American Indians, and Asians and that in general,
disparities in the VA appear to affect African American and Hispanic
veterans most significantly.
The study relates specific sources of disparities and offers a
number of future research recommendations to further elucidate and
reduce/eliminate racial disparities in VA health care including:
Designing decision aids and information tools for
minority veterans with a focus on literacy, language and cultural
issues.
Interventions to make patients more active participants
in their health care decisions.
Improved communication strategies for patients and
clinicians to help strengthen patient-provider relationships.
Additional studies to determine sources of variation in
clinical judgment by patient race.
Interventions to promote evidence-based decisionmaking by
providers.
Interventions to provide support to veterans to improve
adherence to medication and treatment plans.
It is clear from the findings of this recent study that much more
needs to done in this area. We urge VA to continue its research and
provide appropriate resources and policies to eliminate racial
disparities in VA health care.
In preparing for this hearing we also reviewed the most recent
annual report (July 1, 2006) available from the VA Advisory Committee
on Minority Veterans. The Advisory Committee made a number of
recommendations including: improved outreach to all veterans including
minority veterans; expansion of Internet based access to VA benefits
and health care with particular attention given to cultural and
linguistic diversity; continued research to help eliminate barriers for
minority veterans to access health care and other benefits; increased
attention to minority veterans living in rural areas, increase staff
diversity; hire minority veterans from Operation's Enduring and Iraqi
Freedom (OEF/OIF) to ensure sensitivity to a new generation of minority
veterans seeking benefits and health care services from VA; improve
coordination between VA and DoD to ensure basic information about VA
benefits and services is made available to newly returning minority
veterans from OEF/OIF. Of special concern to the Advisory Committee was
the issue of outreach versus marketing. The Committee reported that
field facilities may be under the impression that they are prohibited
from marketing including conducting outreach to minority veteran
populations. We agree with the Advisory Committee that this
interpretation of policy is a serious impediment to minority veterans'
knowledge of their VA benefits.
We support and applaud the Advisory Committee for its continued
efforts to increase awareness about minority veteran issues and advance
the quality of the services minority veterans currently receive.
WOMEN VETERANS
With increasing numbers of women serving in the military, and with
more women veterans seeking VA health care following military service,
it is essential that the VA be responsive to the unique demographics of
this veteran population cohort. In addition, VA must ensure that its
special disability programs are tailored to meet the unique health
concerns of women who have served in combat theaters and those who have
suffered catastrophic disabilities as a result of military service.
Although VA has markedly improved health care services for women
veterans over the past 10 years, privacy issues at some facilities and
other deficiencies still exist. VA needs to monitor and enforce, at the
network and local levels, the legislation, regulations, and policies
specific to health care services for women veterans. Only then will
women veterans receive high quality primary and gender-specific care,
continuity of care, and the privacy they expect and need at all VA
facilities.
Messrs. Chairmen, there has been a trend in the Veterans Health
Administration (VHA) to move away from comprehensive or full-service
women's health clinics for the purpose of providing both primary and
gender-specific health care to women veterans. According to VA, less
than half of its facilities surveyed provide care to women through
mixed gender primary care teams and refer women to specialized women's
health clinics for gender-specific care. As you are aware, in the mid-
nineties VA reorganized from a predominantly hospital-based delivery
care model to an outpatient health care delivery model focused on
preventative and health maintenance care. While we supported that
shift, we are concerned about the incidental impact of the primary care
model on the quality of health care delivered to women. VA's 2000
conference report ``The Health Status of Women Veterans Using
Department of Veterans Affairs Ambulatory Care Services'' noted that
with the advent of primary care in VA, many women's clinics were being
dismantled and that women veterans were assigned to primary care teams
on a rotating basis, essentially without regard to gender. Findings
from the report indicated that this practice further reduced the ratio
of women to men in any one practitioner's caseload, making it even more
unlikely that the clinician would gain the clinical exposure necessary
to develop and maintain expertise in women veterans' health. We
understand that a follow on study is currently being conducted and we
look forward to those findings.
VA acknowledges that full-service women's primary care clinics that
provide comprehensive care, including basic gender-specific care, are
the optimal milieu for providing care to women veterans. Or, in cases
where there are relatively low numbers of women being treated at a
given facility it is preferable to assign all women to one primary care
team in order to facilitate the development and maintenance of provider
clinical skills in women's health. VA also notes that the health care
environment directly affects the quality of care provided to women
veterans and has a significant impact on the patient's comfort,
privacy, feeling of safety, and sense of welcome.
According to VA researchers, although women veterans surveyed
reported that they prefer receiving primary and gender-specific health
care from the same provider or clinic, in actuality, their care is
fragmented, with different components of care being provided by
different clinicians with variable degrees of coordination and
expertise of caring for women. Additionally, researchers found a number
of barriers to delivering high quality health care to women veterans.
Specifically, insufficient funding for women's health programs,
competing local or network priorities, limited resources for outreach,
inability to recruit specialists, lower numbers of women veterans'
caseloads, limited availability of afterhours emergency health
services, and an insufficient number of clinicians skilled in women's
health.
VA Researchers made several recommendations to address these
barriers, including concentrating women's primary care delivery to
designated providers with women's health expertise within primary care
or women's health clinics; enhancing provider skills in women's health;
providing telemedicine access to experts to aid in emergency health
care decisionmaking; and, increasing communication and coordination of
care for women veterans using fee-basis or contract care services. We
are pleased that funding has been approved for VA researchers to study
the impact of the practice structure on the quality of care for women
veterans and fragmentation of care for women veterans including unmet
health care needs for women with chronic physical and mental health
conditions.
Messrs. Chairmen, VA previously established women's health as a
research priority to develop new knowledge about how to best provide
for the health and care of women veterans. In 2004, VHA's Office of
Research and Development held a groundbreaking conference, ``Toward a
VA's Women's Health Research Agenda: Setting Evidence-Based Research
Priorities for Improving the Health and Care of Women Veterans.'' The
participants of the conference were tasked with identifying gaps in
understanding women veterans' health and health care and with
identifying the research priorities and infrastructure required to fill
these gaps. In April 2005, a special solicitation was issued for
research proposals to assess health care needs of women veterans and
demands on the VA health care system in targeted areas, such as mental
health and combat stress, military sexual trauma (MST), post-traumatic
stress disorder (PTSD), homeless women veterans, and differences in era
of service (e.g., Iraq vs. Gulf war). An entire issue of the Journal of
General Internal Medicine was dedicated to VA research and women's
health in March 2006. Published findings included articles on why women
veterans choose VA health care; barriers to VA health care for women
veterans; health status of women veterans; PTSD and increased use in
certain VA medical care services; and, MST.
We have strongly encouraged VA, as it takes steps to advance this
agenda, to focus on research and programs that enhance VA's
understanding of women veterans' health issues and discover new ways to
optimize health care delivery and improve health outcomes for this
patient population.
Addressing the Needs of Women Veterans Who Served in Operations
Enduring and Iraqi Freedom (OEF/OIF)
According to the VA Women Veterans Health Program Office, as of
August 31, 2006, approximately 70,000 women have served and separated
from military service in OEF/OIF. Among this group nearly 37.2 percent,
or 25,960, have sought and received health care from VA since
separation from military service (up from 32.9 percent, or 15,903, in
the previous year). According to VAthe prevalence of potential PTSD
among new OEF/OIF women veterans treated at VA from fiscal year 2002-
2006 has grown dramatically from approximately 1 percent in 2002 to
nearly 19 percent in 2006.
The challenge of addressing the health care needs of the growing
number of women veterans exposed to combat with and without obvious
injury is daunting. In the future, the needs will likely be
significantly greater with more women seeking access to care, increased
health care utilization, and a more diverse range of medical
conditions. It is unlikely the past experience of women veterans in the
VA will serve as an accurate guide because of the unique experiences of
women who have served in OEF/OIF.
Equal access to quality mental health services is critical for
women veterans, especially women veterans who have readjustment
problems associated with serving in a combat theater or those who have
suffered sexual or other trauma during military service. The VA Women's
Health Project, a study designed to assess the health status of women
veterans who use VA ambulatory services, found that active duty
military personnel reported rates of sexual assault higher than
comparable civilian samples, and there is a high prevalence of sexual
assault and harassment reported among women veterans accessing VA
services. The study noted and we agree, that it is ``essential that VA
staff recognizes the importance of the environment in which care is
delivered to women veterans, and that VA clinicians possess the
knowledge, skill, and sensitivity that allows them to assess the
spectrum of physical and mental conditions that can be seen even years
after assault.''
According to VA, approximately 19 percent of the women screened
between fiscal years 2002 and 2006 responded ``yes'' to experiencing
MST, compared to 1 percent of men screened. In response to these
reports, VA established a Committee to explore ways to address the
mental health needs of women veterans and to improve mental health
services to women who have experienced MST. In 2006, VA developed an
MST support team under its mental health service to specifically work
with MST coordinators in the field to better monitor tracking,
screening, treatment, and training programs for MST. VA is yet to
implement earlier recommendations made by the Mental Health Strategic
Health Care Group Subcommittee on Women's Mental Health, including
development of an MST provider certification program, providing
separate sub-units for inpatient psychiatry and other residential
services, and improved coordination with DoD on transition of women
veterans. We encourage VA revisit these recommendations.
Given the increasing role of women in combat deployments and with
more than 70,000 women now having served in OEF/OIF combat theaters, we
are pleased that VA's Women's Health Science Division of VA's National
Center for PTSD is evaluating the health impact of combat service on
women veterans, including the dual burden of exposure to traumatic
events in the war zone and MST. According to the center, although there
is no current empirical data to verify MST is occurring in Iraq there
have been numerous reports in the popular press citing cases of sexual
misconduct. In the center's Women's Stress Disorder Treatment Team, of
49 returning female veterans, 20 (41 percent) reported MST.
The Center notes that anecdotal reports from OEF/OIF veterans
suggest a number of unique concerns that have a more direct impact on
women than their male counterparts returning from combat theaters,
including lack of privacy in living, sleeping, and shower areas; lack
of gynecological health care; health care impact of women choosing to
stop their menstrual cycle; health consequences of dehydration and
chronic urinary tract infection. There are also reported findings that
suggest distinct differences in homecoming, including that women may be
less likely to have their military service recognized or appreciated;
possible differential access to treatment services; and possible
increased parenting and financial stress. Additionally, women may be
more likely to seek help for psychological difficulties.
We are pleased the Center is looking at gender differences in
mental health, MST in the war zone, and gender differences in other
stressors associated with OEF/OIF service and homecoming. We understand
a number of research initiatives/projects are focused on treatment of
PTSD in women, enhancing sensitivity toward and knowledge of women
veterans and their health care needs among VA staff, and MST among
Reserve components of the armed forces.
Some women will suffer from severe PTSD which will require more
intensive evidence based treatment. VA has conducted ground breaking
research on evidence based treatment for PTSD, including a recent study
that established the efficacy for women. The most effective approaches
often require intensive outpatient or residential care. Lack of
adequate child care is a significant problem for women requiring such
care, as is transportation to treatments which require frequent, even
daily attendance. Furthermore, while the establishment of the efficacy
of these approaches is an important first step, they will only have an
impact on the thousands of women veteran affected when they are fully
deployed throughout the VA system and easily accessible to patients.
This is not currently the case, as acknowledged by the National Center
representative in recent testimony before the President's Wounded
Warriors Commission.
We recognize that VA is attempting to address the needs of women
veterans returning from combat theaters in a variety of ways and has
provided guidance for medical facilities to evaluate the adequacy of
programs and services for returning OEF/OIF women veterans in
anticipation of gender-specific health issues. We understand that the
Women Veterans Health Program Office and the local women veterans'
program managers (WVPMs) have partnered with the VA Seamless Transition
Office to provide information during National Guard, Reserves, and
family member demobilization briefings on VA services and programs for
women veterans. VA should continue to strengthen its partnership with
the DoD to ensure a seamless transition for women from military service
to veteran status. An improvement in sharing data and health
information between the Departments is essential to understanding and
best addressing the health concerns of women veterans. Unlike female
veterans from previous conflicts, this new cohort of female veterans
has been routinely exposed to combat in Iraq. It is imperative to
acknowledge that we do not fully understand the barriers that may
prevent OEF/OIF women from accessing VA care. We do know from recent
studies of OEF/OIF active duty and reserve component personnel that
stigma is a major in accessing mental health services; with over 40%
reporting that stigma would impact their access. Furthermore, we must
acknowledge that we will never adequately understand the barriers to
seeking VA care by only studying the minority of female veterans who
actually receive care, as is the case with VA patient satisfaction
surveys.
Therefore, DAV makes the following recommendations to better serve
women veterans returning from combat theaters.
VA and DoD should collaborate to conduct surveys of
recently discharged active duty women and recently demobilized female
reserve component members that fully assess the barriers that they
perceive or have experienced to seeking health care through VA. These
surveys should include assessments of the effect of sigma, driving
distance, absence of child care, understanding of VA eligibility and
services, user friendliness of VA services for those who have attempted
to access care, cultural sensitivities that differentially affect
women, and other key potential barriers.
VA should quickly disseminate and deploy resources to
make evidence based PTSD treatment easy accessible for women veterans
across the country, and explore options for providing child care for
those needing it to attend treatment.
DoD should fund a prospective, population-based health
study of women who served in OEF/OIF. An epidemiologic study with at
least a 10 year follow-up is needed. This study should be carried out
by DoD, VA and University researchers collaboratively.
VA should conduct a comprehensive assessment of its Women
Veterans' Health Programs, including specialized programs for women who
are homeless or have substance-use and/or mental health issues, and
develop an action plan to improve services for this population and
projected future needs of OEF/OIF women veterans.
VA's sexual trauma programs should be enhanced.
Family counseling programs should be expanded and
enhanced to meet the needs of the spouses and children of veterans who
have served in combat theaters. These mental health programs are
critical to veterans and their families after military deployments.
Each VA Medical Center should establish a consumer
council that includes veterans' service organizations, family members,
and veterans including OEF/OIF veterans to ensure that care is veteran
centered.
VA's Women Veterans and Minority Advisory Committees
should include representative(s) who served in Iraq and Afghanistan.
At a recent VA National Conference: Evolving Paradigms--Providing
Health Care to Transitioning Combat Veterans--one track focused on
women veterans who served in Iraq. A panel discussion by those women
was very revealing about their unique experiences in the military and
the impact of that service on their physical and mental health, as well
as their existing impressions of access to VA services post-deployment.
The women who participated in this panel, as well as other women who
have served in combat theaters, could offer valuable insight on the
impact of military experience on this new generation of women veterans.
We understand that VA had planned to convene a focus group of
approximately 50 women veterans of the wars in Iraq and Afghanistan to
examine gaps in service and how VA could better meet the needs of this
group. It is not clear whether VA still plans to convene such a group,
but DAV believes this could stimulate an effective policy debate within
VA and greatly benefit this new generation of women veterans.
Finally, some women serving in the military may suffer the dual
burden of combat exposure and MST. While the DoD has established an
office to deal with the incidence of sexual trauma, the conditions of a
combat theater, quartering and lack of personal security offer special
threats to women. VA and DoD need to better coordinate policies and
treatment for transitioning women veterans who suffer readjustment
issues related to combat exposure and/or have suffered MST. With
increasing pressure to address MST, DoD established a Sexual Assault
Prevention & Response Office (SAPRO). Veterans now have the option to
file either a ``restricted'' or ``unrestricted'' report of sexual
assault in the military. In the case of a ``restricted'' report there
is no investigation or legal action sought on behalf of the veteran but
he or she will have access to medical treatment, counseling and
advocacy support. Records detailing the assault and medical findings
are kept for 1 year following the incident. It is our understanding
that after the 1 year period if the veteran has not filed an
unrestricted report any evidence collected including records of the
incident will be destroyed. It is our hope that VA will collaborate
with the SAPRO to ensure these records are either provided to the
veteran or put in safe keeping. If a veteran is diagnosed with a mental
health or physical disorder related to the assault during military
service the records at the time of the assault would be essential in
supporting the veterans claim for service-connection.
As we see growth in the number of women veterans using VA health
care services, we also expect to see increased VA health care
expenditures for women's health programs. Unfortunately, VA medical
center administrators are under continued pressure to streamline
programs and impose every efficiency practicable. Often, smaller
programs, such as programs for women veterans, are at risk of
discontinuation. The loss of a key staff member responsible for
delivering specialized health care services or developing outreach
strategies and programs to serve the needs of women veterans, can
threaten the overall success of a program.
Women veterans program managers (WVPM) and benefits coordinators
are another key component to addressing the specialized needs of women
veterans. These program directors and benefits coordinators are
instrumental to the development, management, and coordination of
women's health and benefits services at all VA facilities. Given the
importance of this position, DAV is concerned about the actual amount
of time WVPMs are able to dedicate to women veterans issues and if they
have appropriate administrative support to carry out their duties.
According to VA, 71 percent of all WVPMs serve in a collateral role.
Only 20 percent reported they were allocated more than 20
administrative hours per week to fulfill their program responsibilities
during the fiscal year. With increasing numbers of women veterans, VA
WVPMs must have appropriate support staff and adequate time allocated
to successfully perform their program duties and to conduct outreach to
women veterans in their communities. Increased focus on outreach to
these veterans is especially important because they tend to be less
aware of their veteran status and eligibility for benefits than male
veterans.
In closing, VA needs to ensure priority is given to women veterans'
programs so quality health care and specialized services are available
equally for women and men. VA must continue to work to provide an
appropriate clinical environment for treatment, even where there is a
disparity in numbers. Given the changing roles of women in the
military, VA must also be prepared to anticipate the specialized needs
of women veterans who were sexually assaulted in military service or
catastrophically wounded in combat theaters, suffering amputations,
blindness, spinal cord injury, or traumatic brain injury. Although it
is anticipated that many of the medical problems of male and female
veterans returning from combat operations will be the same, VA
facilities must address the health issues that pose special challenges
for women. DAV has recommended that VA focus its women's health
research on finding the health care delivery model that demonstrates
the best clinical outcomes for women veterans. Likewise, VA should
develop a strategic plan along with DoD to collect critical information
about the health status and care needs of women veterans with a focus
on evidence-based practices to identify other strategic priorities for
women's health research agenda.
Messrs. Chairman, this concludes my testimony and I will be happy
to address questions from you or other Members of the Subcommittees.
Prepared Statement of Betty Moseley Brown, Ed.D., Associate Director,
Center for Women Veterans, U.S. Department of Veterans Affairs
Chairman Hall, Chairman Michaud, and Members of the Subcommittees,
I am pleased to testify today on behalf of the Department of Veterans
Affairs (VA) about services in VA for women veterans. Particularly, I
will address how VA serves women veterans through its current programs,
how present and future strategies will address the needs of this
growing population, and what outreach efforts are being conducted by VA
to women veterans. The Center for Women Veterans was established by
Public Law No. 103-446 in November 1994 to oversee VA programs for
women veterans. The Center's mission is to ensure that women veterans
receive benefits and services on par with male veterans; that VA
programs are responsive to gender-specific needs of women veterans;
that outreach is performed to improve women veterans' awareness of
services, benefits and eligibility criteria; and that women veterans
are treated with dignity and respect. The Director, Center for Women
Veterans, acts as the primary advisor to the Secretary and Deputy
Secretary on all matters related to policies, legislation, programs,
issues, and initiatives affecting women veterans.
How is the Department of Veterans Affairs (VA) serving women through
its current programs?
The Center for Women Veterans monitors changes in services through
briefings by the 3 VA administrations and assesses the impact these
changes may have on the delivery of services for the Nation's 1.75
million women veterans--from programs for homeless women veterans with
children, elderly women veterans, women veterans living in rural areas,
and for those women still unaware they, too, are veterans, since many
do not identify themselves as such. The Center regularly monitors VA
briefings during Transition Assistance Programs to ensure that active
duty women are provided access to information on the benefits and
services available to them as veterans prior to their release from
active duty.
The Advisory Committee on Women Veterans was established by Public
Law 98-160 in 1983. The Advisory Committee is charged with advising the
Secretary of Veterans Affairs on VA benefits and services for women
veterans, assessing the needs of women veterans, reviewing VA programs
and activities designed to meet those needs, and developing
recommendations addressing unmet needs. The Advisory Committee submits
a biennial report to the Secretary incorporating the Committee's
findings and recommendations.
As a means of obtaining information regarding the delivery of
health care and services to women veterans, the Advisory Committee
conducts site visits to VA facilities throughout the country. In
addition, the Advisory Committee tours the facilities and meets with
senior officials to discuss services and programs available to women
veterans. During site visits, the Advisory Committee also hosts open
forums with the women veterans' community, encouraging women veterans
to discuss issues and ask questions related to VA benefits and
services. The Advisory Committee meets twice a year at VA Central
Office (VACO) and receives briefings from the Veterans Health
Administration (VHA), Veterans Benefits Administration (VBA), National
Cemetery Administration (NCA) and other staff offices. These briefings
update the Committee on the status of VA programs and respond to
concerns raised during the site visits. The Advisory Committee uses
information from these site visits and briefings in its biennial
reports to the Secretary.
In the 2006 Report of the Advisory Committee on Women Veterans, the
Advisory Committee made 23 recommendations. Some of the key report
issues included outreach, behavioral and mental health care, military
sexual trauma, health care, research and studies, strategic planning,
training, and women veterans who are homeless. The 2006 Report has been
provided to Congress.
Regarding women veterans health program, the Advisory Committee, in
its 2006 Report, recommended VA ensure the Center is provided an annual
update on the effectiveness of the VHA Women Veterans Program Managers
Program. VHA officials, including the Women Veterans Health Strategic
Healthcare Group (formerly known as Women Veterans Health Program),
briefed the Center and Advisory Committee members on this issue at the
February- March 2007 meeting of the Advisory Committee. In addition,
the Women Veterans Health Strategic Healthcare Group works closely with
the Center on issues that are frequently referred to Women Veterans
Program Managers in field facilities.
In FY 2006, the VHA served 235,901 women veterans in our
health system. By comparison, in FY 2001 VHA served 171,161 women
veterans. This is a 5 year relative increase of 37.8 percent.
In FY 2006, 14 percent of the census-projected number of
all women veterans utilized VHA services. This compares to 22 percent
of all male veterans utilization.
Of the total number of women who have been discharged
from active duty after deployment in Operation Iraqi Freedom and
Operation Enduring Freedom (OIF/OEF), 37.5 percent, or 25,960 women
veterans, have been to a VHA health care facility at least once. This
compares to a male utilization rate of 32 percent for OIF/OEF veterans.
There are 22 VA health care facilities that have
dedicated, comprehensive women's center space.
VHA's Women Veterans Health Strategic Healthcare Group (WVHSHG)
studies the continuum of care available to women veterans through an
annual Plan of Care-Clinical Inventory Report. This Report surveys
availability of all related types of physical and mental health
services for women at each medical facility. Every facility has a
designated Women Veterans Program Manager to serve as program
administrator, veteran advocate and referral source to appropriate
care; this report also tracks their time allotment.
In addition, in 2006 WVHSHG cosponsored Elizabeth Yano, PhD, MSPH,
Deputy Director VA Greater Los Angeles HSR&D Center of Excellence and
Associate Professor at UCLA, to survey VISN Leadership, facility and
program directors regarding provision of care models in women's health
in VHA. We expect delivery of this report in late 2007, informing VHA
of the provision of primary care to women veterans through models of
specialized women's health clinics and in models of mixed-gender
primary care sites, including community based outpatient sites. This
study will clarify which models of care for women provide the best
performance outcomes and higher patient ratings of care.
Realizing the current influx of returning women veterans will
increase the number of women seen by VHA in the next several years, VHA
has initiated programs to identify interested primary care providers
and provide them with intensive training in women's health. The needs
assessment for this program will be implemented in September 2007
through VA's Employee Education Service efforts. This program will be
especially important in addressing the health care needs of rural
women. We also recognize that the majority of women veterans new to VHA
are of childbearing age and could be at risk for birth defects from
some prescription medications. This presents new challenges which we
are addressing through initiatives in pharmacy management and provider
education.
VHA is committed to expanding the focus of women veterans' health
care beyond the issues of gender specific screening for breast and
cervical cancer. In the United States, heart disease is the number one
cause of death in women, and WVHSHG has proposed initiatives in
improved management and prevention for heart disease risk including
cholesterol, weight management and smoking cessation. On June 22, 2007,
VHA's Office of Public Health and Environmental Hazards awarded 2
clinical demonstration grants specific to smoking cessation programs
for women veterans.
Another focus area for women veterans' health is prevention and
detection of cancers, particularly colorectal cancers, through improved
screening of women veterans. We are evaluating factors related to the
fact that fewer women than men receive colorectal cancer screening,
both within VA and in community samples.
Mental Health
There are specialized women's mental health services in VHA:
Specialized inpatient and residential programs for women
veterans--these programs are for women who need more intensive
treatment and support. While in these programs, women live either in
the hospital or in a residence with other women. Length of stay for
these programs ranges from 28 days to 18 months.
Inpatient and residential programs with cohort treatment
for women or separate women's wings--these are programs for women who
need more intensive treatment and support, like the specialized
inpatient and residential programs discussed above. However, these
programs accept both men and women and accept women in groups at
specific start dates or have separate space for women.
Women's Stress Disorder Treatment Teams (WSDTTs)--these
are specialized outpatient mental health programs that focus on the
treatment of Post Traumatic Stress Disorder and other problems related
to trauma.
Women's Homelessness Programs--although many VA
homelessness programs serve women, there are also programs specific for
women veterans that provide services for those who are homeless or at
risk of becoming homeless.
Military Sexual Trauma (MST) Coordinators--every VA
facility has a designated MST Coordinator who serves as a point of
contact for MST-related issues. Vet Centers also have specially trained
sexual trauma counselors.
Sexual Trauma Treatment Provided in Residential or
Inpatient Settings--there are programs that offer sexual trauma-
specific treatment in a residential or inpatient setting. Programs
range from those solely dedicated to the treatment of sexual trauma; to
those with a special track emphasizing the treatment of sexual trauma;
to those with 2 or more staff members with expertise in sexual trauma
who, in the context of a larger program not focused on sexual trauma,
provide treatment targeting this issue.
MST Support Team--In FY07, VA's Office of Mental Health
Services (OMHS) established a Military Sexual Trauma (MST) Support Team
that is designed to help ensure that VA is in compliance with legally
mandated monitoring of MST screening and treatment. The team also helps
to coordinate and expand legally mandated education and training
efforts related to MST, and to promote best practices in the field.
National Training Initiatives in Evidence-Based Practices
for PTSD--there are currently 2 national initiatives to train
therapists in evidence-based practice for PTSD being funded by VA's
Office of Mental Health. The first one is to train and support
therapists to conduct cognitive processing therapy (CPT), a highly
effective treatment for PTSD and related symptoms. The second therapy
is an exposure therapy for PTSD called prolonged exposure. There have
been a number of studies supporting the use of exposure treatment for
PTSD.
In addition, there is a wide range of services for women
available through VA's Readjustment Counseling Services and Vet Center
Programs. Female veterans who served in combat theaters are eligible
for the full range of readjustment services as provided by VA's Vet
Center Program. Since the onset of the Vet Center program, women
veterans have been provided outreach services to promote early
intervention and access to VA care, preventive educational services,
counseling for substantive readjustment problems (including war-related
PTSD services), family counseling and employment related services.
Since 1993, female veterans of any era have also been able to access
military related sexual trauma counseling at Vet Centers. Vet Centers
promote the hiring of female veteran service providers at equal to or
higher than the representation of women in the military. Access to care
for women veterans is also promoted through the Vet Center program's
working group. The working group is composed of female staff members
who assist management by educating their fellow Vet Center staff on the
contributions made by women in the military and exploring gender-
related issues to promote gender-sensitive services to women veterans.
Research
Currently, the VHA Office of Research and Development (ORD) is
supporting a broad portfolio focused on women's health issues,
including studies on diseases prevalent solely or predominantly in
women [e.g., certain types of cancer (breast, cervical, ovarian),
lupus, human papillomavirus (HPV) and hormonal effects on diseases in
post-menopausal women], research focusing on women subjects (e.g., PTSD
in women, osteoporosis in women, multiple sclerosis in women) and
research on the health care of women veterans.
ORD's efforts to support research that will improve the health care
of the growing number of women veterans can be categorized in 3 areas:
Research assessing VA's organization of care for women
veterans and the implications for improved quality of care.
Research on the unique experiences of women veterans
regarding risks, treatment and health care outcomes related to sexual
and other military traumas.
Research examining the general health care needs and
service utilization of women veterans.
In 2001, VA's Office of Research and Development created
a Center of Excellence for Research aimed at identifying factors which
cause disparities in health outcomes across racial, ethnic, and gender
lines, as well as ways for promoting equity in health and health care.
This center, co-located at 2 sites (Pittsburgh and Philadelphia), has
29 core investigators who have contributed over 128 peer-reviewed
scientific articles over the past 2 years.
Veterans Benefits Administration
In fiscal year 2006, Vocational Rehabilitation and
Employment Program (VR&E) received 57,856 applications of which 9,895
were female veterans. During the entire fiscal year, VR&E had 52,982
active participants of which 12,627 were female veterans.
In fiscal year 2006, 193,112 female veterans received
compensation for a service-connected disability.
In fiscal year 2006, the percent of guaranteed loans was
increased for women veterans with 12.2 percent in FY06 with 17,355
loans to women veterans at an average loan amount of $173,923.
In fiscal year 2006, 8,442 women separating from service
used their education benefits under the Montgomery GI Bill (MGIB).
Since the inception of the MGIB, 214,369 female veterans have used
their benefits under Chapter 30 of the program. This represents a 72.7-
percent rate of usage.
There are 58,086 female veterans covered under the
Veterans Group Life Insurance (VGLI) program. The total amount of
coverage in force for female veterans is $17.6 billion for an average
coverage of $123,300.
Presented and participated in 8,541 VA benefits briefings
attended by 393,345 active duty military service members including
Guard and Reserve members.
To promote accuracy and consistency in the claims review
process, VBA has taken a number of actions. For example, in the past 4
years, VBA has published guidance and conducted training for employees
on the full range of issues related to PTSD claims adjudication--from
development of the claim to proper application of the rating schedule.
VBA and VHA have worked collaboratively to modifying the
examination request worksheets and the examination templates related to
PTSD. This ensures that the information gathered during the exam is
uniform and sufficient to make the determinations concerning
entitlement and degree of impairment.
What are the present and future needs of these growing populations and
what strategies does VA have for meeting them?
The last national survey of female veterans was conducted in 1985,
leaving VHA policy makers and managers with limited information with
which to adequately plan for future health care services for women
veterans. To address this knowledge gap, the WVHSHG commissioned Donna
Washington, MD, MPH, VA Greater Los Angeles HSR&D Center of Excellence,
to conduct a national Survey of Women Veterans. The objectives of the
National Survey of Women Veterans are: (1) identify the current
demographics, health care needs, and VA experiences of women veterans;
(2) determine how health care needs and barriers to VA health care use
differ among women veterans of different periods of military service,
e.g., OEF/OIF versus earlier periods; and (3) assess women veterans
preference for and perceived value of different types of VA
interventions to improve access and quality. VA will survey between
2,500 and 3,200 women veterans across the Nation, including equal
numbers of VA users and nonusers. The survey began in April of 2007 and
the final report will be submitted by December 31, 2008.
The recent elevation of the Women Veterans Health Program to the
Women Veterans Health Strategic Healthcare Group has positioned the
office to gain expertise in the population of women veterans,
strategically plan for health care delivery and provide leadership in
clinical knowledge of this unique group of women and to catalyze
optimal integration of women veterans health issues across all VHA
programs and offices. We aim to be a world leader in innovative and
high quality care to women veterans.
What outreach efforts are being conducted by VA to women veterans?
We continue to outreach to the women veterans' community with
increased emphasis on our partnerships with Federal, state, and county
agencies, national Veterans Service Organizations and community
organizations. To enhance collaboration and better serve our women
veterans, representatives from the Department of Health and Human
Services (HHS), the Department of Labor (DoL), the Department of
Defense (DoD), and VA Administrations (VHA, VBA and NCA) serve on the
Advisory Committee on Women Veterans as appointed ex officio members.
The Center's Director serves as an ex officio member on the Defense
Advisory Committee on Women in the Services (DACOWITS). In this role,
she ensures that DoD and VA collaboratively address military and women
veterans' health and benefits issues.
The Center published the 25 most Frequently Asked Questions from
women veterans in English and Spanish based on thousands of inquiries
from women veterans. These questions are posted on the Center's website
and the VA website.
The next National Summit on Women Veterans Issues will be June 20-
22, 2008. We are planning to outreach to the military services,
particularly the Reserves and National Guard. We are planning various
workshops, including ``Readjustment Counseling Service: Outreach and
Transition Services for Veterans Families,'' ``Gender Differences: What
the Data Shows,'' and ``Mental Health Issues.'' Our previous summit was
attended by over 300 women veterans, Federal, state and veteran
advocates and developed recommendations for how to better serve women
veterans.
Since October 2001, the Center staff has completed nearly 100media
interviews and hundreds of keynote speeches, participated in veterans
forums, and monitored Transition Assistance (TAP) sessions and veterans
briefings. To ensure veterans' issues are addressed quickly during
forums, VA has assigned local women veterans program managers from VA
Medical Centers and women veteran coordinators from Regional Offices to
accompany Center staff to answer general questions and see that health
care and benefit issues raised regarding individual cases receive
immediate attention. In addition, Center staff works closely with
numerous other VA advisory Committees and councils, DoD, DoL, HHS,
Women's Policy, Inc., state and local agencies, and VSO's to address
and resolve women veterans issues.
VA is grateful for the work of the Advisory Committee because its
activities and reports play a vital role in helping VA assess and
address the needs of women veterans.
This concludes my formal testimony. I will be pleased to answer any
questions.
Prepared Statement of Lucretia M. McClenney, Director,
Center for Minority Veterans, U.S. Department of Veterans Affairs
Chairman Hall, Chairman Michaud, and Members of the Subcommittees,
I appreciate the opportunity to come before you today to discuss the
mission of the Center for Minority Veterans and address your specific
questions on the Department of Veterans Affairs (VA) service to
minority veterans through its current programs; present and future
strategies addressing the needs of this growing population; and
outreach efforts being conducted by VA to minority veterans.
Center for Minority Veterans
The Center for Minority Veterans was created by Public Law 103-446,
in November 1994. The Director of the Center serves as primary advisor
to the Secretary and Deputy Secretary of Veterans Affairs on all issues
related to minority veterans.
Our Mission
The mission of the Center for Minority Veterans includes serving in
an advisory role to the Secretary and Deputy Secretary on the adoption
and implementation of policies and programs affecting veterans who are
minorities; making recommendations to senior VA officials for the
establishment or improvement of programs; promoting minority veterans'
use of benefits; analyzing and evaluating complaints made by or on
behalf of minority veterans; and consulting with, and providing
assistance and information to external local, state and Federal
stakeholders.
Who We Serve
The Center serves all veterans regardless of race or ethnicity, but
pursuant to Public Law 103-446, the Center's primary emphasis is on
minority veterans. Specifically, veterans who are: African Americans,
Asian Americans, Pacific Islanders, Hispanics, or Native Americans,
including American Indians, Alaska Natives, and Native Hawaiians.
How is the Department of Veterans Affairs (VA) serving minority
veterans through its current programs?
Minority Veterans Program Coordinators (MVPC)
To establish a national presence and to ensure issues are addressed
at the local level, the Secretary of Veterans Affairs in 1995 directed
the appointment of Minority Veterans Program Coordinators (MVPCs) at
each VA Health Care Facility, Regional Benefits Office and National
Cemetery. There are approximately 300 MVPCs across the Nation. The
Center provides training to MVPCs in cultural competency and outreach
strategies. These coordinators educate and sensitize facility personnel
to the needs of minority veterans in the community and promote the use
of VA benefits, programs and services by minority veterans. In
addition, the Veterans Health Administration (VHA), Veterans Benefits
Administration (VBA) and National Cemeteries Administration (NCA) each
have designated a Central Office MVPC Liaison. The Center staff meets
monthly with these liaisons and quarterly with the senior leadership of
each Administration to discuss outreach activities, issues and concerns
that impact minority veterans.
The Center has converted the coordinators' annual written report to
a quarterly web based report to provide greater visibility on their
outreach efforts, identify opportunities for improvement, benchmark
best practices and recognize the Minority Veterans Program Coordinator
of the Quarter and Year for each Administration.
Advisory Committee on Minority Veterans (ACMV)
The Advisory Committee on Minority Veterans (ACMV) was also
established under Public Law 103-446. The Committee is composed of
veterans of all ranks and services appointed by the Secretary. Members
represent the 5 minority groups the Center is mandated to oversee. The
Committee advises the Secretary and Congress on VA's administration of
benefits and provision of health care to minority veterans; assessing
the needs of minority veterans, reviewing VA programs and activities
designed to meet those needs and developing recommendations to address
unmet needs.
The Committee submits an annual report to the Secretary
incorporating its findings and recommendations. In order to assess the
delivery of health care services and benefits, the Committee conducts 2
meetings annually (one site visit and 1 business meeting). During the
site visits the Committee tours VA facilities (of all 3
Administrations), meets with senior officials to discuss services and
programs available for minority veterans, and conducts Town Hall
meetings for local veterans and the community to hear firsthand their
concerns and/or issues. The Committee meets once annually at VA Central
Office (VACO) and receives briefings from VHA, VBA and NCA and other
staff offices. These briefings provide the Advisory Committee an update
on current VA policies and programs and afford them the opportunity to
discuss their findings and concerns impacting minority veterans.
What are the present and future needs of this growing population and
what strategies does VA have for meeting them?
Needs of Minority Veterans:
In many instances, any challenges that minority veterans encounter
as they seek services from VA are magnified by the adverse conditions
in their local communities. These challenges may include access to VA
medical facilities (especially for American Indians, Alaska Natives,
and Pacific Islanders, and other veterans residing in rural, remote or
urban areas), disparities in health care centered on diseases and
illnesses that disproportionately effect minorities, homelessness,
unemployment, lack of clear understanding of VA claims processing and
benefit programs, limited medical research and limited statistical data
related to minority veterans.
Cultural competency and diversity training assist VA employees when
serving our very diverse minority veteran population.
VA Strategies to Meet the Needs of Minority Veterans include but are
not limited to the following:
Access to VA medical care has been addressed by
dramatically increasing the number of Community Based Outpatient
Clinics (CBOC). In 1995, VA had 102 Community Based Outpatient Clinics
and by 2000, VA had 600 Community Based Outpatient Clinics. In the
second quarter of 2007, 872 Ambulatory Care and Outpatient Clinics were
in operation. One hundred Operation Enduring Freedom and Operation
Iraqi Freedom Patient Advocates have recently been assigned to assist
our newest veterans as they seek care from VA.
VA is addressing homelessness in the minority veteran
population by partnering with community stakeholders; enhancing
outreach activities; and expanding VA's Grant and Per Diem Program.
In 2001, VA's Office of Research and Development created
a Center of Excellence for Research aimed at identifying factors which
cause disparities in health outcomes across racial, ethnic, and gender
lines, as well as ways for promoting equity in health and health care.
This center, co-located at 2 sites (Pittsburgh and Philadelphia), has
29 core investigators who have contributed over 128 peer-reviewed
scientific articles over the past 2 years.
The Center is working with VHA's Office of Health
Services Research and Development and the Center for Health Equity
Research Program to target minority groups such as the Tuskegee Airmen,
Buffalo Soldiers, Montford Point Marines, and National Congress for
American Indians by actively encouraging minority veteran's
participation in research programs.
Since 2003, VHA has encouraged minority veterans to
voluntarily self identify by racial and ethnic groups to assist in data
retrieval of minority veteran demographics and utilization of VA
services and benefits.
VA's Office of Patient Care Services is developing a 3
year phased educational cultural competency curriculum for clinicians
and administrative leadership.
Native American traditional healing has been recognized
as an additional avenue to pursue to enhance clinical outcomes. Several
VA medical centers have sweat lodges, and some VA facilities utilize
the fee basis program to secure the services of Native American
healers.
To promote accuracy and consistency in the claims review
process, VBA has taken a number of actions. For example, in the past 4
years, VBA has published guidance and conducted training for employees
on the full range of issues related to PTSD claims adjudication--from
development of the claim to proper application of the rating schedule.
VBA and VHA have worked collaboratively to modifying the
examination request worksheets and the examination templates related to
PTSD. This ensures that the information gathered during the exam is
uniform and sufficient to make the determinations concerning
entitlement and degree of impairment.
VBA's Native American Veteran Direct Loan Program (NADL)
enables a Native American veteran or a veteran who is married to a
Native American veteran to use their VA home loan guaranty benefit on
Federal trust land. The program began as a pilot in 1992 and was made
permanent by Public Law 109-233, The Veterans Housing Opportunity and
Benefits Act of 2006. Nearly 550 loans have been made to eligible
veterans in 14 states and 3 U.S. territories. 71 tribal governments and
3 territorial governments have participated in the program.
With enactment of Public Law 109-461, The Veterans
Benefits, Health Care, and Technology Information Act of 2006, on
December 22, 2006, the National Cemetery Administration (NCA) may now
award grants to Tribal Organizations for the establishment, expansion
and improvement of veteran cemeteries on trust lands.
NCA strives to accommodate the special needs of Native
American veterans. This includes active participation in meetings with
tribal nations, the encouragement of participation in new VA national
cemetery dedications, and accommodating the religious customs during
committal services at VA national cemeteries.
What outreach efforts are being conducted by VA to minorities?
The Center for Minority Veterans has staff who serve as veteran
liaisons for each of the 5 minority groups: African Americans, Asian
Americans, Pacific Islanders, Hispanics and American Indians and serve
as consultants to the Minority Veterans Program Coordinators. They
establish partnerships with Veterans Service Organizations as well as
internal and external stakeholders to increase awareness of minority
veteran issues and develop collaborative strategies to address unmet
needs. The Center has active partnerships with VA's Center for Veterans
Enterprise, National Veterans Employment Program, Women Veterans Health
Program, and Health and Human Services' Center for Medicare and
Medicaid Services who are active participants in our community outreach
efforts and presenters in our biennial training conferences.
Other active partnerships with minority organizations include, but are
not limited to:
African Americans--Congressional Black Caucus, NAACP and The
National Urban League
Hispanics/Latinos--American GI Forum and League of United Latin
American Citizens (LULAC)
Native American--National Congress of American Indians, United
South and Eastern Tribes, Navajo Nation Washington Office, and the
White House Indian Affairs Working Group
Asian/Pacific Islanders--Japanese American Veterans Association and
Federal Asian Pacific Americans Council
VA is most appreciative of the outstanding accomplishments of the
Advisory Committee on Minority Veterans and the Minority Veterans
Program Coordinators because their outreach activities and reports are
critical in helping VA assess and address the needs of minority
veterans.
This concludes my prepared statement. I would be happy to answer
any questions you may have.
Statement of Shannon L. Middleton, Deputy Director for Health,
Veterans Affairs and Rehabilitation Division, American Legion
Mr. Chairman and Members of the Subcommittee:
Thank you for this opportunity to submit The American Legion's
views on VA's programs addressing women and minority veterans. The
American Legion commends the Subcommittees for holding a hearing to
discuss these very important issues.
Programs Serving Women and Minority Veterans
The Center for Women Veterans and the Center for Minority Veterans
were established by Congressional mandates to ensure that the needs of
the growing populations of women and minority veterans are reflected in
policies implemented and services and benefits provided by the
Department of Veterans Affairs (VA). Through these offices, VA has
improved access to benefits and services for women and minority
veterans and shaped policy addressing the provision of health care for
female veterans.
The Center for Women Veterans' activities include monitoring
changes in VA policy to ascertain the impact of the changes on the
delivery of services to homeless women with children, rural and elderly
women veterans, and minority women veterans; ensuring that active duty
women are provided access to information on VA benefits and services
available to them, prior to their release from active duty; conducting
outreach to allow women veterans to express their needs and concerns;
ensuring that VA research initiatives include adequate consideration
for the effects of the military experience on women veterans; and
working with Veteran Service Organizations (VSO) to disseminate
information. The Center for Women Veterans also serves as a conduit
through which the Advisory Committee on Women Veterans makes
recommendations to the Secretary of VA.
The Center for Minority Veterans' activities include ensuring that
minority veterans are aware of VA programs, benefits, and services;
conducting outreach initiatives to allow minority veterans to voice
concerns; making VA benefits and health care services more accessible
to minority veterans; and making recommendations on how VA can better
serve minority veterans. The Center for Minority Veterans also supports
an advisory Committee and works with the Center for Women Veterans to
address concerns faced by minority women veterans.
The VA offers a full continuum of comprehensive medical services to
include disease prevention, primary care, women's gender-specific
health care, acute medical/surgical, substance abuse and mental health
treatment, domiciliary, rehabilitation and long-term care options.
Present and Future Needs
The current Global War on Terror illustrates a few deficiencies in
services provided for women veterans. Never before have women service
members been engaged in constant combative environments. Participation
in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF)
has forced them to expand their military roles to ensure their own
survival, as well as the survival of their units. They sustain the same
types of injuries that their male counterparts endure. Any future women
veterans' research conducted by VA will need to take into consideration
the physical effects of combat on women veterans, not just mental
effects of combat and military sexual trauma (MST).
Since women veterans are sometimes the family's sole care givers,
services and benefits designed to promote independent living for
combat-injured veterans will need to consider other needs--like child
care during rehabilitation. This dynamic should also be considered more
when designing domiciliary and homeless women veteran programs. Not
making provisions that would accommodate the children of homeless women
veterans would bring more devastation to an already unstable home life
and may actually be a deterrent for seeking assistance from the VA.
Providing quality health care in a rural setting has proven to be
very challenging, given factors such as limited availability of skilled
care providers and inadequate access to care. Even more challenging
will be VA's ability to provide treatment and rehabilitation to rural
veterans, to include women veterans, who suffer from the signature
ailments of the on-going Global War on Terror--traumatic blast injuries
and combat-related mental health conditions. VA's efforts need to be
especially focused on these issues.
Gaining access to the nearest facility providing gender-specific
services can prove even more of an obstacle, since the nearest facility
may be a Community Based Outpatient Clinic (CBOC) which may not offer
these services.
The American Legion believes veterans should not be penalized or
forced to travel long distances to access quality health care because
of where they choose to live. Women veteran who reside in rural areas
need to have improved timely, access to gender-specific care. We urge
VA to improve access to quality primary and specialty health care
services--to include gender-specific services--using all available
means at VA's disposal, for veterans living in rural and highly rural
areas.
Some minority veterans, especially those who suffer from combat-
related injuries, have to rely on family and friends as care givers. In
this situation, communication can literally be a matter of life, or
death. Some of these care givers may not speak English as their first
language. When there is a language barrier, there is a great chance
that the veteran may not be informed of benefits and services to which
he/she may be entitled and coordinating rehabilitation or care becomes
daunting.
VA has made the effort to have several of its brochures printed in
Spanish and is attempting to make staff and health care providers more
knowledgeable about cultural diversity. However, given the diverse
make-up of the veteran population, materials and outreach have to
address more than Spanish-speaking populations. The American Legion
believes that VA needs to remove any hindrance that prevents veterans
from obtaining the care they have earned through their military
service.
VA Outreach Efforts
The Center for Women Veterans outreach activities include: a
national Summit on Women Veterans Issues to address emerging needs
facing female veterans and provide information about VA benefits and
services that female veterans have earned through their military
service; creation of the Women Veterans Frequently Asked Questions
pocket guide; and conducting townhall meetings and community forums.
The Center for Minority Veterans provides veteran outreach through
minority veteran program coordinators, who inform minority veterans of
VA benefits and services on the local level; collaboration with VA's
Office of Small and Disadvantage Business Utilization (OSDBU) to
cosponsor business outreach activities to sponsor business and
entrepreneurial outreach conferences for minority and disabled
veterans; and through the Advisory Committee for Minority Veterans,
conducts site visits and townhall meetings.
The VA utilizes opportunities to address veteran service
organizations (VSO) to disseminate information. These opportunities or
information exchanges include: participating in VSOs annual conventions
and training conferences; collaborating in writing informative articles
for membership magazines and newsletters; and inviting VSOs to
participate in focus groups/work groups and planning for outreach
activities. By participating in activities sponsored by the various
VSOs, VA provides information to advocates who directly work with and
for veterans to ensure that they receive the quality of care and
benefits to which they are entitled.
The Center for Women Veterans, the Center for Minority Veterans and
the Office of Research and Development eagerly participate in The
American Legion's annual Convention and training conferences. They
provide speakers to address specific topics affecting women and
minority veterans.
Again, thank you for allowing the American Legion this opportunity
to present its views on women and minority veterans. We look forward to
working with the subcommittees and VA to improve access to quality
health care for all veterans.
Statement of Hon. Corrine Brown,
a Representative in Congress from the State of Florida
Thank you, Mr. Chairman for holding this hearing.
I am pleased to hear the testimony from the many interested parties
today.
As we are all aware, the face of the military has changed
dramatically over the last 10 years. With the all-volunteer force the
military is made up of now, more minorities and women are choosing this
career.
I am sure you have noticed, I am both a woman and a minority. This
issue is very important to me.
The total veteran population in the United States and Puerto Rico,
is about 24 million. The population of women veterans approaches 2
million. Florida is the third largest state with the women veterans.
Almost 20 percent of the veterans in this country, in the 2000
census, are of a minority.
Is the VA addressing the needs of this changing military? Are they
adequately addressing the needs of the increasing number of women and
minorities coming out of the minorities?
I look forward to the answers of these and other questions as the
hearing moves forward.
Thank you again, Mr. Chairman.
Statement of Hon. Jeff Miller,
Ranking Republican Member, Subcommittee on Health,
and a Representative in Congress from the State of Florida
Thank you, Chairman Michaud.
I ask unanimous consent that my statement be included in the
record, and that I may have 5 legislative days to revise and extend my
remarks.
It is good to be here with our colleagues from the Subcommittee on
Disability Assistance and Memorial Affairs, and I would like to welcome
Chairman Hall and Ranking Member Lamborn.
We have seen both women and minorities answer the call of duty in
growing numbers and it is vitally important that we make sure that
there are not any barriers for these veterans to access VA benefits and
services, and that VA provides specialized services to meet their
unique needs.
Seven percent of our Nation's veterans or roughly 1.7 million are
women. My home state of Florida is 1 of the 5 States with the largest
number of women veterans, with over 132,000. As the number of women
serving in the active duty, guard and reserve continue to increase, so
must our over oversight to monitor the activities of VA to serve this
population.
I am pleased to see our colleague, Representative Heather Wilson
from New Mexico before the Subcommittees. She holds the distinct honor
of being the only woman veteran of the United States Congress.
Previously, she testified before the Health Subcommittee in the 107th
Congress. I look forward to her testimony and to learn how VA's
performance in meeting the specialized needs of women veterans has
evolved over the past 5 years.
Similarly, there are over 3.8 million minority veterans, accounting
for roughly 15 percent of the veteran population according to the 2000
Census. We need to be aware of the actions VA is taking to support the
use of VA benefits, programs, and services by minority veterans; to
target outreach efforts through community networks and to initiate
activities that educate and sensitize staff to the unique needs of
minority veterans.
I thank all of our witnesses for joining us today. Your testimony
will provide us insight into how well VA is attending to the specific
needs of women and minority veterans and help us to identify gaps in
services and necessary improvements with respect to both benefit and
health care programs including outreach and mental health treatment.
Thank you and I yield back the balance of my time.
Statement of Dennis Cullinan,
Director, National Legislative Service,
Veterans of Foreign Wars of the United States
MESSRS. CHAIRMEN AND MEMBERS OF THE SUBCOMMITTEES:
On behalf of the 2.4 million members of the Veterans of Foreign
Wars of the U.S. (VFW) and our Auxiliaries, I would like to thank you
for allowing us to express our views on this very important and timely
subject.
According to recent Department of Veterans Affairs and Military
Services data 10% of all veterans are women and 15% of today's active
duty military are women. VA has made vast improvements in care and
services provided to female veterans in the last 10 years, but with
increasing numbers of females deployed to Iraq and Afghanistan a
system-wide change may be in order. VA must be prepared to meet the
needs of the increasing number of women veterans who will be seeking
health care services, including mental health care and ensure that its
special disability programs are tailored to meet their unique health
concerns, especially those who have served in combat.
VFW is concerned that although VA has markedly improved the way
health care is provided to women veterans, deficiencies still arise in
the area of privacy and delivery of services across the Veterans
Integrated Service Networks (VISN). The Independent Budget, of which
VFW is a co-author, found that the model used for delivery of primary
health care to women veterans using VA health care services is
variable. The trend has been to move away from full-service women's
health clinics dedicated to both primary and gender-specific health
care to providing mixed gender primary care teams and contracting out
other more specific gender care.
VA's 2000 conference report ``The Health Status of Women Veterans
Using Department of Veterans Affairs Ambulatory Care Services'' noted
that with the advent of primary care in VA, many women's clinics were
dismantled and female veterans were assigned to primary care providers
on a rotating basis. The report also found that this further reduced
the ratio of women to men using VA, making it more unlikely that a
clinician will gain clinical knowledge to develop and maintain
expertise in women's health.
VFW believes that VA needs to increase the priority given to women
veterans and take the necessary steps to focus on research and programs
that enhance their understanding of women veterans' health issues. This
will enable them to evaluate which health care delivery model
demonstrates the best clinical outcomes for women. VA must ensure that
clinicians caring for women veterans are knowledgeable about women's
health and that they participate in ongoing education about the health
care needs of women and be competent to provide gender-specific care to
women. They must also ensure that its specialized programs for post-
traumatic stress disorder, spinal cord injury, prosthetics and
homelessness are equally available to women veterans as to male
veterans. Most importantly VA needs to increase its outreach efforts
toward this population as women veterans tend to be less aware of their
veteran status and eligibility for benefits than their male
counterparts.
VFW believes that the future needs of women veterans can only be
met through continued research and studies specifically tailored toward
women veterans. VA should collaborate with DOD to collect critical
information about the health care needs of women veterans to identify
current priorities of returning female servicemembers. An improved
environment of sharing data and health information between Departments
is essential to ensuring a truly seamless transition from military
service to veteran status.
We are pleased to hear that a national survey currently being
conducted by the Women Veterans Health Strategic Healthcare Group
(WVSHCG) will survey 2,500 to 3,200 women veterans across the Nation,
including VA users and non-users. The objectives of the survey include
identifying the current demographics, health care needs and VA
experiences of women veterans. It will also address how health care
needs and barriers to VA health care differ among periods of service
including OEF/OIF veterans and earlier periods and last assess women
veterans' preference for and perceived value of types of VA services
and how to improve access to care. We look forward to reading the
findings of the report due out in December 2008.
The challenges facing minority veterans are both similar and
different to those facing women veterans. Barriers to service and
health care access among minority veterans remain prevalent within the
VA system. VA's Health Services Research and Development Service
released a report in June 2007 entitled Racial and Ethnic Disparities
in the VA Healthcare System: a Systematic Review. The findings of the
study concluded that disparities appear to exist in all clinical areas
of VA. Most troubling was the fact that researchers commented in nearly
each case that the underlying cause of these disparities were not
explored or remained unclear.
The study did offer a number of future research ideas to help
reduce racial disparities within VA--the VFW acknowledges that
increased outreach and marketing geared toward literacy, language and
cultural issues is a start. Studies centered on diseases and illness
that disproportionately affect minorities, along with creating an
environment where patients are more active participants in their health
care decisions are also keys to change. Materials (federal benefit
handbooks, brochures and other materials) printed and made available in
Spanish are also critical.
We would also like to recognize recommendations made in the July 1,
2006 report of the (VA) Advisory Committee on Minority Veterans (ACMV).
The ACMV conducts site visits and meets with VA officials in
preparation for their annual report of recommendations to better
service minority veterans. Their input as to what improvements need to
be made is invaluable. Some of the current recommendations include:
Coordination with local, Federal and state veterans
services organizations in VA outreach activities.
Periodic Town Hall meetings to discuss minority veteran
issues/concerns.
Expanding and improving Internet-based access to VA
benefits/health care with particular attention given to cultural and
linguistic diversity.
Full-time Minority Outreach Coordinators.
More staff diversity in VA facilities.
Research that focuses on minority veterans issues to help
understand potential barriers to access and find ways to eliminate the
barriers.
More funding for minority veterans programs.
We applaud the efforts VA has made to reach out to identify and
care for the current generation of returning veterans but much remains
to be done to improve care and services provided all veterans, in
particular women and minority veterans. VA must continue to work to
provide an appropriate environment so that all veterans can access the
health care, benefits and services they have so deservedly earned.
Mr. Chairman and Members of the Subcommittees, this concludes the
VFW testimony. We again thank you for including us in this important
discussion.
Statement of Marsha Four, Chair, Women Veterans' Committee, and
John Rowan, National President, Vietnam Veterans of America
Good morning Chairman Michaud, Chairman Hall, and Ranking Member
Miller, Ranking Member Lamborn and distinguish Members of these
Subcommittees. Thank you for giving Vietnam Veterans of America (VVA)
the opportunity to offer our comments for the record on the issues
facing Women Veterans.
WOMEN'S HEALTH ISSUES
According to figures supplied by the Department of Defense (DoD),
20% of new recruits are women, almost 15 percent of America's active
duty military is women, and nearly half of them have been deployed to
Iraq and Afghanistan (i.e., 1 in 7 Americans deployed to Iraq is a
woman). This has particularly serious implications for the VA health
care system because the VA itself projects that by 2010, over 14
percent of all veterans will be women, compared with 2 percent in 1997.
The VA has made vast improvements in treating women veterans since
1992. However, this increase in potential health care system ``users''
coupled with returning female OIF and OEF veterans, who, in particular,
face a variety of co-occurring ailments and traumas heretofore unseen
in the VA health care system, we believe that the VA is in need of
ramping up its efforts to bring into modern times, the delivery of its
medical and mental health care to women veterans. Even today, some
women continue to report a less than ``accepting'', ``friendly'', or
``knowledgeable'' attitude or environment both within the VA and/or by
its third party vendors. This may, in part, be the result of a system
that has evolved principally on the medical needs of the male veteran.
Reports also indicate that in mixed gender residential programs women
remain fearful and unsafe.
Compounding the emotional turmoil for women are wounds and injuries
that range from life-changing--the loss of limbs and brain injuries--to
temporary, such as infections and rashes. Although some of the short-
term health problems are likely tied to the harsh realities of war,
where women can go weeks without a shower and spend months hauling gear
and lifting heavy weapons in triple-digit heat, the VA has found 29
percent of the women veterans it evaluated returned with genital or
urinary system problems, 33 percent had digestive illnesses and 42
percent had back troubles, arthritis and other muscular ailments.
This obviously points up the need for a well-conceived and well-
implemented long-range plan for health care services and delivery for
our women veterans. To VVA's knowledge there is no such plan that
exists today. As we have already noted, the VA has taken great strides
in the past 15 years toward improvement of the quality of care for
female veterans, but there is always room for improvement. While it is
fair to say that the quality of care at most VA facilities is equal to
that of any other medical system in the world, it does not help women
veterans who cannot access that fine care because it's not available.
DELIVERY OF SERVICES
Providing care and treatment to women veterans by professional
staff that have a proven level of expertise is vital in delivering
appropriate and competent gender-specific care. It is not sufficient to
simply have training in internal medicine. Women's health care is a
specialty recognized by medical schools throughout the country.
Providers who have both a knowledge base and training in women's health
are able to keep current on health care and its delivery as it relates
to gender. In order to maintain proficiency in delivering care and
performing procedures, these providers must meet experience standards
and maintain an appropriate panel size. This cannot occur if women
veterans are lost in the general primary care setting. It is critical
that women receive care from a professional who is experienced in
women's health. If attention is not given to defining qualified
providers, it will be a detriment to the quality of care provided to
women veterans.
VVA does, however, feel comprehensive women's health care clinics
are most desirable where the medical center populations indicate
because comprehensive consolidated delivery systems present increased
advantage to the patients they serve.
Vietnam Veterans of America (VVA) believes women's health care is
not evenly distributed or available throughout the VA system. Although
women veterans are the fastest growing population within the VA, there
seems to remain a need for increased focus on women health and its
delivery. It seems clear that although VACO may interpret women's
health as preventative, primary and gender specific care, this
comprehensive concept remains ambiguous and splintered in its delivery
throughout all the VA medical centers. Many view women's health as only
a GYN clinic. As you are aware, throughout medical schools across the
country and in the current health care environment, women's health is
viewed as a specialty onto itself and involves more that gender
specific GYN care. VVA is hopeful that the revision of VHA Services for
Women Veterans, Handbook 1330.1, and its recommendations for an
integrated primary care/mental health model of service delivery will
pass concurrence. Additionally, that after concurrence it will be
strongly supported and recommended to all medical centers in the VHA
system.
VVA supported VHA's past creation of ``Centers of Excellence'' for
women veterans' health. We believe these should be evaluated for
standard compliance and re-established. These Centers of Excellence are
an investment in innovative health care delivery specifically
addressing the unique needs of women, serving as a model in prevention,
education, outreach, and research programs. This emphasis could lead to
the creation of VA training fellowships in women's health care. These
centers could also assist in the recruitment and retention of women
health care specialists.
There are increasing numbers of women veterans of childbearing age.
More than 62 percent of all women veterans are under 45, and of women
veterans seeking health care from the VA, 56 percent are under 45.
Providing for the cost of maternity services but not providing newborn
care for a reasonable post-delivery period presents an unfair financial
burden to the woman veteran. It could additionally compromise adequate
health care for her newborn. VVA seeks legislation to provide contract
care, for up to 14 days post-delivery, for infants born to women
veterans who receive delivery benefits through the VA and are in need
of this extended care.
WOMEN VETERAN PROGRAM MANAGERS
The duties, responsibilities, advocacy, oversight and reporting of
the VA Women Veteran Program Managers, as defined in their handbook
(1330.2), are substantial. As such, it is not difficult to understand
why VVA stands with a firm resolve to call for the VA to provide the
Women Veteran Program Managers with a minimum of 20 hours per week to
accomplish the responsibilities of the position. VVA believes that
these significant duties and responsibilities are essential and should
not be minimized in light of the collateral duties they usually must
perform. `Further, we believe that while each VISN must designate,
support, and utilize one of its Medical Center Woman Veteran Program
Managers as the VISN Women Veteran Program Manager, we believe
additional time must be allocated for these increased duties and
responsibilities.
PTSD AND SUBSTANCE ABUSE
The VA counts PTSD as the most prevalent mental health malady (and
one of the top illnesses overall) to emerge from the wars in Iraq and
Afghanistan, but the VA is facing a wave of returning veterans who are
struggling with memories of a war where it's hard to distinguish
innocent civilians from enemy fighters and where the threat of suicide
attacks and roadside bombs hovers over the most routine mission.
Moreover, the return of so many veterans from Afghanistan and Iraq is
squeezing the VA's ability to treat yesterday's soldiers from Vietnam,
Korea, the Cold war, and World War II. Top VA officials have said that
the agency is well-equipped to handle any onslaught of mental health
issues and that it plans to continue beefing up mental health care and
access under the administration's budget proposal released in mid-
February.
Yet according to a GAO report issued in November 2006, the VA did
not spend all of the extra $300 million budgeted to increase mental
health services and failed to keep track of how some of the money was
used. The VA launched a plan in 2004 to improve its mental health
services for veterans with PTSD and substance-abuse problems. To fill
gaps in services, the department added $100 million for mental health
initiatives in 2005 and another $200 million in 2006. That money was to
be distributed to its regional networks of hospitals, medical centers,
and clinics for new services. But the VA fell short of the spending by
$12 million in 2005 and about $42 million in fiscal 2006, said the GAO
report. It distributed $35 million in 2005 to its 21 health care
networks but didn't inform the networks the money was supposed to be
used for mental health initiatives. VA medical centers returned $46
million to headquarters because they couldn't spend the money in FY'06.
More troubling, however, is the fact that the VA cannot determine
to what extent about $112 million was spent on mental health services
improvements, or new services in 2006. In September 2006, the VA said
that it had increased funding for mental health services, hired 100
more counselors for the Vet Center program, and was not overwhelmed by
the rising demand. That money is only a portion of what VA spends on
mental health. The VA planned to spend about $2 billion on mental
health services in FY'06. But the additional spending from existing
funds on what the VA dubbed its Mental Health Care Strategic Plan was
trumpeted by VA officials as a way to eliminate gaps in mental health
services now and services that would be needed in the future.
Furthermore, an investigation by McClatchy Newspapers in early
February of this year found that even by its own measures, the VA isn't
prepared to give returning veterans the care that could best help them
overcome destructive, and sometimes fatal, mental health ailments. For
example, the McClatchy report found that VA mental health care is
extremely inconsistent and highly variable from state to state and from
facility to facility. In some places, there is no mental health care,
while at others, veterans may get individual psychotherapy sessions, or
in others, they meet mostly for group therapy.
Some veterans are cared for by psychiatrists; others see social
workers. Some veterans get in quickly. Others wait. Once they're in the
door, some veterans get visits of 75 to 80 minutes, while others get 20
to 30-minute appointments. In other words, the VA's mental health
system is nonexistent for many of the veterans it is supposed to be
serving.
Last, the nature of the combat in Iraq and Afghanistan is putting
service members at an increased risk for PTSD. In Iraq, close-quarters
urban combat is unpredictable, with a constant risk of roadside bombs.
Troops end up feeling out of control of their surroundings, a major
risk factor for PTSD. Service members are serving multiple tours, and
the intensity of the conflict is constant.
In these wars without fronts, ``combat support troops'' are just as
likely to be affected by the same traumas as infantry personnel. This
has particularly important implications for our female soldiers, who
now constitute about 16 percent of our active-duty fighting force.
Returning female OIF and OEF troops face ailments and traumas of other
sorts. For example, studies conducted at the Durham, North Carolina
Comprehensive Women's Health Center by VA researchers have demonstrated
higher rates of suicidal tendencies among women veterans suffering
depression with co-morbid PTSD. And according to a Pentagon study
released in March 2006, more female soldiers report mental health
concerns than their male comrades: 24 percent compared with 19 percent.
In addition, roughly 40 percent of these women warriors have
musculoskeletal problems that doctors say likely are linked to carrying
too-heavy and ill-fitted equipment. A considerable number--28 percent--
return with genital and urinary system infections. In addition, there
are gender-related societal issues that make transitioning tough.
For example, women are more likely to worry about body image
issues, especially if they have visible scars or amputations, and their
traditional roles as care givers in civilian life can set them back
when they return. They are the ones who have traditionally had the more
nurturing role within our society, not the ones who need nurturing.
Although the VA has, after much prodding by Congress, finally come to
implement services to women to treat PTSD and other after-effects of
military sexual trauma at VA medical centers, there are very few
clinicians within the VA who are prepared to treat combat situation-
induced PTSD as opposed to MST-induced PTSD. Additionally, there are
already cases where returning women service personnel have a
combination of the 2 etiologies, making it extremely difficult for the
average clinician to treat, no matter how skilled in treating either
combat-incurred PTSD in men, or MST-induced PTSD in women. Because of
the number of women who are now de facto combat veterans and because of
the nature of the conflicts in both Afghanistan and particularly Iraq,
VVA believes that we have entered a whole new world of mental health
needs for our veterans.
Furthermore, VVA believes there is a need for increased VA research
specifically focused on women veterans' health care issues. For
example, as of August 2006 VA data showed that 25,960 of the 69,861
women separated from the military during fiscal years 2002-06 sought VA
services. Of this number approximately 35.8 percent requested
assistance for ``mental disorders'' (i.e., based on VA ICD-9
categories) of which 21 percent was for post traumatic stress disorder
or PTSD, with older female vets showing higher PTSD rates. Also, as of
early May 2007, 14.5 percent of female OEF/OIF veterans reported having
endured military sexual trauma (MST). Although all VA medical centers
are to have MST clinicians, very few clinicians within the VA are
prepared to treat co-occurring combat-induced PTSD and MST. These
issues singly are ones that need address, but concomitantly create a
unique set of circumstances that demonstrates another of the challenges
facing the VA. The VA will need to directly identify its ability and
capacity to address these issues along with providing oversight and
accountability to the delivery of services in this regard. VVA believes
that the VA has twelve programs that address PTSD in women veteran, but
they are not exclusively for MST (some are general PTSD programs), and
not all are gender specific programs.
As previously mentioned, studies conducted at the Durham, North
Carolina Comprehensive Women's Health Center by VA researchers have
demonstrated higher rates of suicidality among women veterans suffering
depression, substance abuse and co-occurring PTSD. But at the present
time there are only 3 VA women's residential treatment centers for PTSD
and substance abuse in the country (i.e., a fourth with 8 beds is
scheduled to open later this summer in the Boston area).
VVA calls upon this Committee to appoint a task force within the VA
to begin work to produce a reasonable and practical plan of how VA can
best reach this ever increasing veteran cohort in the coming years,
providing them a delivery model of inclusive comprehensive and
integrated care.
Few of us can know the dark places in which those who have suffered
as the result of rape and physical violence must live every day for the
rest of their lives. It is a very long road to find the path that leads
them to some semblance of ``normalcy'' in order to feel the free,
outside of the secluded, lonely, fearful, angry corner into which they
have been hiding. A concern for the environment of the delivery of
services also exists in the residential programs of the VA. Most, if
not all residential programs, are designed for treatment of mental
health problems. The veterans of these programs are a very vulnerable
population. This was particularly brought to our attention in regard to
women veterans, who, in light of the high incidence of past sexual
trauma, rape, MST, and domestic violence find it difficult, if not
impossible, to share residential programs with male veterans. They
openly discuss their concern for a safe treatment setting, especially
on units where the treatment unit layout does not provide them with a
physically segregated, secured area. They also discuss the need for
gender specific group sessions, in light of the nature of some of their
personal and trauma issues. VVA asks that all residential treatment
areas be evaluated for the ability to provide and facilitate this
environment and that medical center facilities develop cost plans to
address this accommodation.
This submission points to the need for a well-conceived and well-
implemented long-range plan for medical and mental health care services
and delivery for our women veterans. VVA has not been made aware that
any such inclusive comprehensive plan exists today. As we have already
noted, the VA has taken great strides in the past 15 years toward
improvement of the quality of care for female veterans, but there
exists a need for increased attention, followed by enhancement of
programs and services, in a concerted effort to meet the increasing
demand and complexity of women's health. This enhancement will
certainly put a demand on the ever-present budget. VVA respectfully
requests that women's health care be evaluated for budgetary
consequences and that Congress considers this when determining the
dollars required to meet these needs. VVA also respectfully requests
that continued oversight be requested of the VA in regard to the issues
of this submission and those of others during this hearing. While it is
fair to say that the quality of care at most VA facilities is equal to
that of any other medical system in the world, it does not help women
veterans who cannot access that fine care because it's not available.
Vietnam Veterans of America thanks the Committee for this
opportunity to provide submitted testimony.
Statement of Susan Scanlan,
President, Women's Research and Education Institute
Military Women and Women Veterans and Stress Urinary Incontinence
On behalf of the Women's Research and Education Institute (WREI), I
appreciate the opportunity to submit this written testimony to the
Committee. I am Susan Scanlan, President of the Women's Research &
Education Institute. For thirty years, WREI has provided timely
information and expert issue analysis about women and their families to
policymakers and the public.
For nearly that long, WREI has been one of the few, if not the only
progressive organization with a nonpartisan focus on the rights and
responsibilities of women in uniform. The Women in the Military project
was established in 1983, and is now headed by Captain Lory Manning, a
veteran of 26 years of service in the U.S. Navy. This project provides
research and analysis of issues of importance to military women and
female veterans to legislators, the media, scholars, and the general
public. WREI publishes Women in the Military: Where they Stand, now in
its 5th edition, and we also hold a Women in the Military Conference
every other spring.
Women veterans are the second fastest growing segment of the
veteran population. By 2040, it is estimated that women will exceed 11%
of the veteran population. Women veterans today are younger, more
ethnically diverse, and have fewer socioeconomic resources than
previous generations of military women. In addition, the changing
nature of war and its porous battlefields means servicewomen--and men--
are faced with new health risks.
I want to bring to the Committee's attention a health condition
that affects up to 30% of military women--namely, stress urinary
incontinence (SUI). At our May 2007 Women in the Military Conference,
Lieutenant Colonel Irene Rosen, M.D., Assistant Chief of Family
Medicine at Madigan Army Medical Center in Fort Lewis, Washington,
reported that genitourinary problems are the fifth most common disease
and non-battle injury (DNBI), and accounted for 5% of hospital
admissions during Desert Shield/Storm. The VA Health Services Workgroup
also identified urinary incontinence among women veterans as a high-
priority issue for research.
Stress urinary incontinence is the involuntary leakage of urine
associated with laughing, coughing, sneezing, sexual, and recreational
activities. The condition is caused by a variety of factors, most
commonly childbirth, and often restricts the social, professional, and
personal lives of an estimated 15 million women in the U.S. alone.
Physical fitness requirements and the demands of military life put both
men and women, but particularly women, at risk for SUI during and after
their military service. Environmental barriers in the field often limit
access to hygienic measures and can lead to urinary tract infections
that can lead to incontinence.
According to Dr. Rosen's research, 30% of female soldiers reported
urinary incontinence in the field. Similarly, Dr. Roger Dmochowski, a
professor of urology and researcher at Vanderbilt University, cited
studies that found that 30% of female parachutists reported
experiencing urinary incontinence when they hit the ground. An April
2001 article entitled ``Urinary Incontinence in Vulnerable Populations:
Female Soldiers'' published in Urologic Nursing (attached) reported the
following additional statistics:
Nearly one-third of 450 female soldiers in field-oriented
environments at Fort Lewis had significant problems with exercise-
induced urinary incontinence.
At Fort Benning, 100% of active duty women airborne
trainees (n=10) who had no incontinence before airborne training
demonstrated SUI after training.
In a study involving 563 female soldiers from several
units at Fort Lewis, Fort Benning, and Fitzsimons Army Medical Center,
33% reported UT during physical training.
24% reported urine loss during recreational activities
such as exercise and walking and 30% reported urine loss during the
annual 2-mile physical fitness run.
Field exercises, which involve long road marches with
heavy field backpacks, precipitated urinary incontinence.
Alarmingly, 30% of active duty military women with SUI
reported restricting fluid intake in order to control symptoms.
Women veterans of the Persian Gulf War have a higher
proportion of genitourinary problems than other populations.
Given that approximately 20% of the total U.S. military active duty
force in the future will be women, it is important for the military--
both the Department of Defense and the Veterans Health Administration--
to address this growing problem.
As Dr. Rosen's research found, lack of awareness or embarrassment
or reluctance concerning SUI may preclude optimal prevention and
treatment of this common problem. This research reinforces the results
of a June 2007 Lewin Group report, Prevalence and Treatment Patterns of
Pelvic Health Disorders Among U.S. Women, which found that
approximately 50 to 75 percent of women who likely have SUI fail to
tell their health care providers about their symptoms and, therefore,
are never properly diagnosed and treated.
Non-treatment of SUI can put women at increased risk for numerous
physical, social, and psychological conditions. Avoidance of exercise
and an active life, depression, loss of self-esteem, loss of a sense of
control over one's life, social withdrawal, and sexual dysfunction
related to embarrassment, are just a few of the potential physical,
psychological, and social impacts associated with non-treatment of SUI.
Withdrawal from physical and social activities can lead to a reduction
in physical well-being, which may in turn lead to obesity, diabetes,
heart disease, and other medical complications.
In order to properly diagnose and treat SUI, Dr. Rosen recommends
educating and screening military women and veterans for the condition,
and providing appropriate treatment. Walter Reed Army Medical Center's
Internet fact sheet on stress incontinence (which was last updated in
September 2004) recommends the following treatments:
Practicing good hygiene.
Learning and practicing Kegel pelvic floor muscle
exercises.
Weight loss, smoking cessation, and cough suppression.
Biofeedback, electrical stimulation, or special weights
to strengthen pelvic muscles.
Wearing absorbent underpants or incontinence pads.
A pessary (support device) made of rubber or other
materials to fit inside the vagina for support.
Surgery.
With regard to medications, alpha-adrenergic drugs or estrogen
therapy may be prescribed.
Walter Reed's list of treatments fails to include Renessa, an FDA-
cleared non-surgical treatment for SUI that would be particularly
beneficial in the military and VA health care settings. This procedure
is a non-surgical approach that can be performed in the convenience of
a physician's office or other outpatient setting. It takes less than 30
minutes and involves the use of radiofrequency energy to treat tissue
targets within the lower urinary tract. Most importantly, the procedure
allows women to return to their duties quickly. Most patients return to
normal activities within 24 hours, and heavy lifting within days, not
weeks.
It is my understanding that this procedure has already been
performed at several military facilities, including Dr. Rosen's
institution--Madigan Army Medical Center, Evans U.S. Army Community
Hospital (Fort Carson, CO), and Travis Air Force Base in California. A
non-surgical option for the treatment of SUI would also be an
attractive option for female dependents of military men.
As Members of Congress know, FDA approval does not automatically
lead to the adoption of new medical technologies. The Veterans Health
Administration and the Department of Defense should do more to ensure
that women veterans and active duty women are educated about stress
urinary incontinence, screened, and provided with access to the full
range of FDA-approved treatments--including non-surgical procedures--to
address this debilitating condition.
Thank you for the opportunity to submit this testimony and bring
this important women's health issue to the attention of the Veterans'
Affairs Committee.
POST-HEARING QUESTIONS AND RESPONSES FOR THE RECORD
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC
July 26, 2007
Honorable R. James Nicholson
Secretary
Department of Veterans Affairs
Washington, DC 20420
Dear Mr. Secretary:
In reference to our Subcommittee hearing on Issues Facing Women and
Minority Veterans on July 12, 2007, I would appreciate it if you could
answer the enclosed hearing questions.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all Full
Committee and subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Please provide your response to Orfa Torres and fax your responses
to Orfa at 202-225-2034. If you have any questions, please call 202-
225-9756.
Sincerely,
JOHN J. HALL
Chairman
______
Questions for the Record
The Honorable John J. Hall Chairman
Subcommittee on Disability Assistance and Memorial Affairs,
House Committee on Veterans' Affairs
July 12, 2007
Issues Facing Women and Minority Veterans
Questions for Center for Minority Veterans
Question 1: Please explain in detail what the VA is doing to
address the findings in the report entitled Racial and Ethnic
Disparities in the VA Health System, dated June 2007, which found that
health disparities exist throughout all of the VA and that these
disparities in treatment yielded poorer health outcomes for minority
veterans.
Response: The Department of Veterans Affairs' (VA) Office of
Research and Development (ORD) within the Veterans Health
Administration (VHA) is continuing to support a broad portfolio of
research into health care disparities. While earlier ORD-funded
research focused on identifying disparities, more recently funded
studies have highlighted important determinants explaining ethnic
minority health care disparities, such as patient-physician
communication, patient attitudes and health literacy; suggesting that
patients, providers, health care facilities and health care systems may
all contribute to these disparities. Accordingly, ORD has issued a
priority solicitation for research proposals to develop and evaluate
interventions to reduce racial and ethnic disparities in health care.
ORD understands that interventional studies aimed at these sources, as
well as other identified sources, may playa significant role in
promoting equitable health care services among all veterans.
ORD strives to obtain adequate representation of minorities in its
funded clinical trials. ORD requires potential investigators to
acknowledge its policy to include women and minorities in clinical
research.
Questions for Center for Women Veterans
Question 1: The Committee is aware that the Director of the Center
reports to the Secretary.
Question 1(a): Does the Center provide any type of annual updates
to the Secretary?
Response: The Center for Women Veterans (CWV) provides quarterly
reports on its outreach activities, performance measures and financial
obligations to the Secretary. The CWV director presents updates on key
issues related to women veterans at the Secretary's senior staff
meetings; and provides a monthly update on its key activities to the
Deputy Secretary.
Question 1(b): Please describe the Center's annual performance
goals?
Response: CWV's annual performance goals are linked to VA's
Strategic Goal 2 and its Enabling Goal.
Strategic Goal 2 is to ensure a smooth transition for veterans from
active military service to civilian life. In order to achieve this goal
VA's operational objective is to increase awareness of, access to, and
use of VA health care, benefits and services. CWV's goal (in support of
VA's goal) is to attend transition assistance program (TAP) briefings
and assess the quality of the briefing materials and its focus on women
veteran-specific issues.
VA's Enabling Goal is to apply sound business principles, and one
of the objectives to meet this goal is to improve communications with
veterans, employees and stakeholders about VA's mission, goals and
current performance as well as benefits and services that VA provides.
CWV's goal linked to this is to facilitate, sponsor, or attend
collaborative meetings with agencies representatives and stakeholders;
and community-based forums for women veterans. CWV also has as its
goals to provide prompt responses to inquiries and resolve complaints
timely.
Question 1(c): How does the Secretary measure the Center's
effectiveness in meeting its performance goals?
Response: The Secretary measures CWV's effectiveness in meeting its
performance goals by reviewing its quarterly and annual reports.
Question 2: The Center provides administrative support to the
Advisory Committee and the Advisory Committee through its site visits
prepares reports which are transmitted to the Secretary and then to
Congress.
Question 2(a): Please explain what if any interface occurs between
the Center and the Advisory Committee.
Response: There is extensive interface that occurs between CWV and
the Advisory Committee on Women Veterans (ACWV). CWV collects data,
provides written materials on key issues, and obtains subject matter
experts to address ACWV at its bi-annual meetings and annual site
visits to a medical center. CWV and ACWV collaborate on developing
legislative proposals affecting women veterans; and annual
Congressional meetings. CWV hosts ACWV meetings, arranges lodging,
transportation and conference room space. CWV introduces new ACWV
members to VA, and arranges ethics briefings.
Question 2(b): For the recommendations made by the Advisory
Committee, and for which the VA concurs, who is responsible for
ensuring implementation of the recommendations?
Response: VHA, Veterans Benefits Administration (VBA), and National
Cemetery Administration (NCA), along with various staff offices are
responsible for implementing the recommendations of ACWV. CWV tracks
the status of recommendations to ensure implementation; and requests
briefings on unresolved recommendations at ACWV bi-annual meetings.
Question 2(c): How are these missives sent down throughout all of
the VA?
Response: CWV assigns each recommendation to the appropriate
administration or staff office, and then monitors and follows up as
needed.
Questions for VA
MINORITY VETERANS
Question 1: It seems as if both Directors of the Centers and the
Advisory Committees report directly to the Secretary.
Question 1 (a): Please explain the working relationship, if any,
between the Centers and the Advisory Committees and the VA (Secretary's
office) and the Advisory Committees?
Response: Both the Center for Minority Veterans (CMV) and CWV fall
under the Office of the Secretary. The directors of CMV and CWV serve
as the primary advisors to the Secretary and Deputy Secretary on all
issues related to minority and women veterans and serve as the
designated Federal officials to the Advisory Committee on Minority
Veterans (ACMV) and ACWV. CMV and CWV facilitate ACMV's and ACWV's
outreach to minority and women veterans by ensuring they are kept
abreast of VA's policies, programs, and services that may impact
minority and women veterans, and coordinating the logistics and travel
for all site visits and business meetings. In addition, CMV and CWV
track VA's action taken on ACMV and ACWV recommendations.
Question 1(b): Whose role is to ensure that there are no
disparities in the receipt of benefits and services for these veterans?
Response: CMV, CWV, ACMV, and ACWV identify needs of minority and
women veterans and make recommendations to address unmet needs. The
administrations and staff offices are responsible for ensuring that the
areas highlighted as in need of improvement are addressed in a timely
manner. It is every VA employee's responsibility to ensure all veterans
are treated equally without regard to sex, race, or ethnicity.
The Secretary directed the appointment of the minority veterans'
program coordinators (MVPC) to be located at each VA health care
facility, regional office and national cemetery, thus ensuring that
issues regarding benefits and services for minority and women veterans
are addressed at the local level. CMV provides oversight, and training
to the MVPCs in cultural competency and outreach strategies. MVPCs
educate facility personnel to the needs of minority veterans in the
community. MVPCs promote the use of VA benefits, programs and services
by minority veterans. In addition, each administration has a designated
MVPC liaison at VA central office. CMV staff meets monthly with these
liaisons and quarterly with the senior leadership of each
administration to discuss outreach activities, issues and concerns that
impact minority veterans.
VHA medical facilities have specially designated outreach
coordinators who conduct outreach to various populations (i.e.,
minority veterans, women veterans, homeless veterans, former prisoners
of war, recently separated veterans) to provide these individuals
information about VA health care issues. VHA central office provides
guidance and support to these coordinators.
VHA has implemented various programs within the networks to ensure
that the issues and needs of minority veterans are adequately
addressed. Some examples of this in action are:
Veteran Integrated Service Network (VISN) 15's Diversity
Implementation Plan a 3 pronged approach to implementing diversity
within the Heartland Network.
Fargo VA Medical Center's (VAMC) Comprehensive Diversity
Management Program dedicated to promoting diversity awareness through
training with special emphasis on outreach programs, and clinical
guidelines to promote the concept of culturally competent care and
quality improvement in various community partnerships. In collaboration
with the Dakotas VA Regional Office, veterans service organizations,
and the Social Security Administration, the Fargo VAMC sustained
outreach efforts on 7 of the 8 Native American Nations and cosponsored
with Indian Health Services (IHS) the first Annual/Tribal Open House.
Southern Arizona VA Healthcare System (VAHCS) is
recognized for its sustaining leadership, governance, and incorporation
of diversity management into strategic business plans. The Southern
Arizona VAHCS sponsored the first Annual Diversity Day that
incorporated educational information on special emphasis groups and
MVPCs.
In addition, VHA's Office of Research and Development (ORD)
continues to support a broad portfolio in health disparities research.
While earlier ORD-funded research focused on identifying disparities,
more recently funded studies have highlighted important determinants
explaining ethnic minority health care disparities, such as patient-
physician communication, patient attitudes and health literacy,
suggesting that patients, providers, health care facilities and health
care systems may all contribute to these disparities. Accordingly, ORD
has issued a priority solicitation for research proposals to develop
and evaluate interventions to reduce ethnic minority health care
disparities. ORD understands that interventional studies aimed at these
sources, as well as other identified sources, may play a significant
role in promoting equitable health care services among all veterans.
VBA regional offices have also specially designated outreach
coordinators who conduct outreach to various populations (i.e.,
minority veterans, women veterans, homeless veterans, former prisoners
of war, recently separated veterans) to provide these individuals
information about VA benefits and services. VBA central office provides
guidance and support to these coordinators to ensure that they provide
all needed services and benefits. VBA coordinators work closely with
their counterparts in VHA, NCA, veterans service organizations, and
other Federal and State agencies to provide complete assistance to all
veterans.
In addition to its outreach coordinators, VBA uses the systematic
technical accuracy review (STAR) to assess accuracy of claims
processing decisions made at all regional offices. VBA also regularly
conducts site visits to regional offices to ensure that policies and
procedures pertaining to compensation and pension are consistent
nationwide. During these site visits outreach practices are reviewed to
ensure activities are reaching targeted groups.
NCA conducts local and national initiatives in an effort to
identify minority veterans. The outreach practices to these veterans
include all national cemetery directors having the responsibility to
identify groups of veterans within the service area of their cemetery
and providing information about VA memorial benefits to these
individuals. NCA regularly attends 10 to 12 national conferences each
year to increase awareness of memorial benefits among minority groups.
NCA memorializes every deceased veteran who has served honorably in
the Armed Forces, regardless of their race, sex, religion, or national
origin. Every day the 1,500 employees of NCA commemorate the service of
America's veterans at 125 national cemeteries, where more than 2.7
million gravesites are maintained. NCA provides headstones and markers
for placement on the graves of eligible veterans, provides Presidential
Memorial Certificates to veterans' loved ones, and assists States and
tribal governments in the construction of veterans' cemeteries.
Question 2: In the Minority Advisory Committee's last Report dated
July 2006, it recommended that the VA clarify and disseminate its
policies pertaining to the issue of marketing, as it had observed
during its field visits to VA facilities that the confusion served as a
``serious impediment'' to minority veterans' knowledge of their VA
benefits and VA health care entitlements. What has the VA done to
educate staff at VA facilities of the rescission of this 2002 rule
regarding marketing? Please explain.
Response: VA supports an extensive array of outreach efforts to
inform and educate veterans about their eligibility for health care,
benefits, and other services. In fact, VA strongly encourages its
leadership and staff to participate in community activities as a forum
for outreach. Every separating service member receives a letter from
the Secretary to advise them on how they might receive VA benefits
(including health care). Additionally, VA is working closely with the
Department of Defense (DoD) to ensure that returning Global War on
Terror (GWOT) veterans are aware of the services VA offers. One example
is the post deployment health reassessment activity (PDHRA) which
provides outreach, education, screening for deployment-related health
conditions and readjustment issues, outreach and referrals to military
treatment facilities (MTFs), VA health care facilities, TRICARE
providers and others for additional evaluation and/or treatment.
Question 3: The IOM in its report Separate and Unequal regarding
Healthcare and Health Disparities found that Minorities receive
disparate health care treatment regardless of income or insurance
status and that as a direct result, they suffer higher mortality and
morbidity rates. Has the VA performed any research to determine whether
there are parallels in the VA health care and benefits system? Are you
aware of any parallels that translate in poorer health and benefits
outcomes for minority veterans?
Response: Because of its structure, VA's health care system
provides unique opportunities for researchers to distinguish racial and
ethnic differences from economic differences in health care. Minorities
are well represented in ORD's cooperative studies program clinical
trials and currently comprise 20 percent of participants in trials that
have ongoing recruitment.
ORD funds a research center of excellence for health equity
research and promotion. Its mission is to reduce disparities and
promote equity in health and health care among vulnerable groups of
veterans and other populations. The center's research agenda is based
on the natural progression of research projects from detecting
unrecognized disparities, to identifying and understanding reasons for
these disparities, to designing interventions to promote equity in
health care among vulnerable populations.
ORD also funds a targeted research enhancement program to
understand racial and ethnic variations in health outcomes for chronic
diseases. The goals of this program are to advance knowledge on racial
and ethnic variations in care by focusing on patient trust and patient
preferences for care, and to evaluate the incremental effect of these
patient level factors on racial and ethnic disparities in health
outcomes for chronic medical conditions such as diabetes and
hypertension.
Examples of recently completed ORD-sponsored health disparities
research include:
While demographics and health experiences vary by race
among women veterans, race was not significantly associated with any
primary care domain (i.e., patient preference for provider,
interpersonal communication, accumulated knowledge and coordination) or
satisfaction among women receiving care at VA (Journal of General
Internal Medicine, Vol. 21, October 2006, 1105)
There are no significant racial differences in general
innovativeness between Black and White veterans, but White veterans had
higher medical technology innovativeness scores
Medical technology innovativeness scores correlated
with a greater likelihood that veterans would be favorably
oriented to new medical devices and prescription drugs
Both Black and White veterans with low innovativeness
scores were hesitant to accept a new medical device, but White
veterans were more likely to adopt a new prescription than
Black veterans
More Black than White veterans expressed discomfort
with taking risks (Journal of General Internal Medicine, June
2006)
Black veterans had less severe coronary artery disease
than White veterans, and treating physicians' estimates of the
probability of coronary disease were similar for Black and White
veterans
Findings suggest that despite less frequent use of
coronary angiography, Black veterans who undergo the procedure
are at lower risk for having coronary obstructive disease than
White veterans who undergo the procedure (Journal of the
American College of Cardiology, May 2006)
Black patients appear to have lower trust in physicians
regarding lung cancer treatment because of poorer physician-patient
communication
Physician communication was perceived as less
supportive, less partnering and less informative, accounting
for Black patients' lower trust in physicians (Journal of
Clinical Oncology, Vol. 24, 2006 Feb 20. 904)
End of life wishes vary among racial and ethnic groups,
as a result of divergent views regarding health care, spirituality,
family and dying (Journal of the American Geriatrics Society, Vol. 54,
No.1, January 2006)
There are ethnic variations in the use of nicotine
replacement therapy (NRT) among smokers receiving care from VA, with
Black and Hispanic smokers about half as likely as White smokers to use
NRT to quit smoking
These disparities were not explained by social,
physiologic or psychological factors or by facility differences
in prescribing policy of tobacco dependence medications
(American Journal of Health Promotion, Nov/Dec 2005, 20
(12):108)
Black and White patients in VA displayed similar
knowledge about coronary heart disease (CHD) risk factors. However,
Black patients had
Less specific knowledge, such as the difference
between ``good'' and ``bad'' cholesterol
More fear related to physical activity after a CHD
diagnosis
Belief that racism contributed to stress as a risk
factor (Patient Educ. Couns. 2005 May;57(2):225-31)
Hispanic and Black VA patients had a higher frequency of
severe diabetic retinopathy
This was not accounted for by traditional risk
factors (Diabetes Care 28: 19541958, 2005)
In the year following prostate specific antigen (PSA)
testing, Black patients strictly under VA care were more likely to
Know about their PSA test
Have higher rates of urology referrals and prostate
biopsies
However, for Black patients under partial VA care,
these differences did not occur (Am J Public Health. 2004
Dec;94(12):2076-8)
Black veterans in VA had poorer outpatient access to
mental health services than White veterans during 1995-2001
On some measures their access to care improved
relative to White veterans (Adm. Policy Mental Health. 2003
Sep;31(1):31-43)
In VA stroke patients referred to inpatient
rehabilitation
No racial differences in proportion of patients
referred or in the intensity of rehabilitation
However, there was less recovery of function in Black
patients (Stroke. 2003 Apr;34(4): 1027-31)
No significant systematic differences in post traumatic
stress disorder (PTSD) treatment or outcome between White, Black and
Hispanic VA patients overall (Med Care. 2002 Jan;40(1 Suppl):I52-61)
In a VA administrative database (28,934 White and 7,575
Black), Black patients had lower mortality rates than White patients at
30 days and 6 months in
Pneumonia
Angina pectoris
Congestive heart failure
Chronic obstructive pulmonary disease
Diabetes
Chronic renal failure (JAMA. 2001 Jan 17;285(3):297-
303)
It is important to note that ORD-sponsored studies focus on health
and health care related research and not on the services provided by
VBA or NCA.
ORD did, however, recently fund a study examining racial
disparities in PTSD disability awards. The study reported a significant
difference in Black veterans odds of being service connected for PTSD
compared to other veterans' odds, and this could not be explained by
variation in PTSD symptom severity, degree of disablement or race
differences in combat exposure. Among veterans who were awarded PTSD
disability benefits, the service-connected rating (``degree of service
connection'') did not vary by race (Medical Care. 2003;41(4):536-549).
Past ACMV reports findings/recommendations have addressed minority
veterans' perceptions of disparities in the VA claims process. VBA
presently does not collect racial or ethnics data that can be used to
make a comparative analysis. VBA has responded that it will give
consideration to collecting this data as it modifies its business
practices.
Question 4: The Advisory Committee also recommended that the DVA
design, develop and fund research agendas focusing on minority veteran
issues in order to inform minority veterans and those entities serving
the minority community of potential barriers to access. Please update
the Committee on efforts to promote this recommendation and eliminate
this barrier.
Response: ORD strives to disseminate its research results to all
applicable parties. While this is accomplished primarily through
publication of research results in scientific journals and
presentations at scientific meetings, ORD also publishes a variety of
publications highlighting recent research advances, such as its monthly
Research Currents newsletter. A diverse audience, including VA staff,
Congressional staff and veterans service organizations (VSO) receives
Research Currents newsletter. ORD also supports speakers and
information booths about its research programs and projects at numerous
VSO meetings and conventions, including organizations such as the
Montford Point Marine Association that was established to perpetuate
the legacy of the first African Americans who entered the United States
Marine Corps from 1942 to 1949, at Montford Point Camp, New River, NC.
Finally, ORD maintains a Web site containing information on research
programs and recent findings (http://www.research.va.gov). and so do
many of its centers of excellence (http://
www.cherp.research.med.va.gov).
In addition, ORD has been working with CMV to develop other
mechanisms for disseminating research results to veterans. Currently,
CMV's Web site has a link to the ORD Web site for research related to
minority veterans.
Question 5: Has the VA performed research to identify barriers that
prevent minority veterans from accessing and using their benefits? Has
the VA identified any culturally appropriate practices that would
support greater participation in VA benefits and services by minority
veterans as advocated by the Committee? (p.21).
Response: ORD has funded extensive research examining barriers to
health care for minority veterans and, in recent years, considerable
attention has been focused on cultural factors that affect the use of
VA health care services, and potentially the health care status and
outcomes of veterans. Those areas where potential barriers, cultural
factors and other contributors to racial disparities in VA health care
have been identified in ORD-sponsored research are summarized below.
Veteran medical knowledge and information sources.
Minority and nonminority veterans differ in their degree of familiarity
with and knowledge about medical interventions. This difference stems
from different levels of experience with those interventions among
minority vs. non-minority veterans and their families, friends, and
communities; from different amounts of information conveyed by health
care providers; and from different levels of health literacy and
understanding among veterans. Different knowledge and information may
affect patients' perceptions of, or degree of uncertainty about, the
necessity and benefits of medical interventions in relation to their
risks. Uncertainty about the necessity of interventions may in turn
reduce patients' willingness to accept and adhere to them. Several
studies indicate that minority veterans are less informed about their
care, compared to non-minority veterans, and that this difference
affects decisionmaking.
Veteran trust and skepticism. Minority veterans tend to
harbor less trust and more skepticism about the benefits of medical
interventions, relative to their risks. These perceptions appear to be
influenced by lack of familiarity with medical interventions, by
historical or personally experienced discrimination, and for some Black
veterans in particular, by a reliance on religious and spiritual
avenues for coping with illness as opposed to medical therapies.
Studies in our review suggest that minority veterans are more skeptical
of information provided by health care professionals, as compared to
non-minority veterans. It is important, however, not to misconstrue
this skepticism as unwarranted. Nonminority veterans' general lack of
skepticism may be more problematic if it leads to acceptance of
unnecessary or undesired care.
Racial/cultural milieu. Some have suggested that a more
racially and culturally congruent health care environment (including
racially concordant health care providers) for minority veterans may
elevate trust, reduce skepticism, and enhance the acceptability of
care. Two studies directly examined this issue and found that Black
veterans experienced better interactions and fared somewhat better
clinically, when cared for by Black vs. White providers. Another study
suggested that Black patients in group therapy might fare better when
grouped with other Black patients.
Patient participation. Several studies suggest that
minority veterans are less active participants in their care as
compared to non-minority veterans. Minority veterans tend to ask fewer
questions of their providers, who in turn provide less information.
Less information may lead to lower acceptance of and adherence to
medical interventions. In addition, lower patient participation
diminishes the strength of the patient-provider partnership, which may
in turn lead to less investment by both parties in following
recommended care plans, and to lower trust and greater skepticism among
minority veterans.
Clinician judgment. Studies suggest that clinicians'
diagnostic and therapeutic decisionmaking varies by veteran race. The
degree to which this differential decisionmaking is based on clinical
factors vs. non-clinical factors, including racial stereotypes, is
unclear. For instance, in one study clinicians judged Black veterans to
be less appropriate candidates for coronary interventions, even after
accounting for chart-documented variables. The degree to which this
judgment reflected undocumented clinical factors vs. non-clinical
influences was not clear. Similarly, clinicians prescribe opioid
medications less frequently to Black vs. White veterans and are more
likely to diagnose Black veterans presenting with mental illness as
having psychotic vs. affective disorders. The degree to which these
phenomena are driven by racial differences in co-existing substance
abuse disorders, by cross-cultural misunderstanding of symptom
presentations, or by racial bias, remains unclear.
Veteran social support and resources. Minority veterans
may have fewer social support and other external resources to help with
both illness management and decisionmaking. This is particularly
relevant in that minority veterans may rely more heavily on external
resources than on health care professionals for information and
support. This may particularly affect adherence and decisionmaking
around high-risk procedures.
Health care facility characteristics. Some disparities
are at least partly explained by the fact that minority and non-
minority veterans tend to receive care at different VA medical centers
(VAMCs). In some cases, VAMCs that disproportionately serve minority
veterans have fewer available services or deliver lower quality care
overall than VAMCs serving predominantly non-minority veterans. This
potential source of disparities, however, remains under-explored. It
should be noted that many studies have demonstrated disparities within
single VAMCs, suggesting that system-level factors are unlikely to
explain all observed disparities.
CMV and ORD have collaborated to provide a link from the CMV Web
site to the ORD Web site to provide veterans information related to VA
research initiatives. Minority veterans program coordinators (MVPC)
were provided cultural competency training during their biennial
training conference in June of 2007.
At CMV's request, ORD has provided briefings to our MVPCs during
the biennial MVPC training conferences and to minority groups such as:
Tuskegee Airmen, Buffalo Soldiers, Montford Point Marines, and the
National Association of Black Veterans.
Question 6: Please advise what the VA is doing with regard to its
land use policies that allow greater flexibility to make business
decisions that would result in more funds for ancillary programs such
as those that address outreach to minority veterans and homeless
veteran populations.
Response: VA has been using its enhanced use (EU) leasing program
to turn underused land and buildings into transitional housing for
homeless veterans. This has been successful in 12 instances providing
housing to more than 550 homeless veterans; and will be used more in
the future as properties are identified via the Capital Asset
Realignment for Enhanced Services (CARES) reuse studies, VA's own
internal site review initiative, and individual initiatives presented
by homeless providers through a sponsoring VAMC.
In addition VA has numerous sharing agreements and sort term leases
that are allowing more than 2 dozen nonprofit organizations to provide
transitional housing to more than 1,300 homeless veterans. The more
than half of all veterans seen in VA's homeless providers grant and per
diem program are identified as minority. The largest single program for
women veterans in the country is operated on the grounds of the VAMC at
Coatesville, Pennsylvania.
Question 7: The Advisory Committee observed that staff diversity
during its Los Angeles VA facilities was not representative of the
Minority Veteran population, especially with regard to the higher pay
grades and for African Americans, Hispanics, and Americans Indians. The
ACMV noted that this appears to be a systemic problem throughout VA.
Please advise what the VA is doing to ensure staff diversity in these
subsets of veterans.
Response: The Los Angeles Regional Office (RO) has 221 employees
serving approximately 737,000 veterans. Of the 221 employees, 40.7
percent are veterans. Within that number, minorities comprise the
following: 15.4 percent Black, 8.6 percent Hispanic, 1.4 percent Native
American, and 2.7 percent Asian American and Pacific Islander American.
Of the veteran employees at the higher grade levels, GS-12 and above,
53 percent are minority veterans.
VA work force is comprised of 74 percent women and minorities;
24.43 percent of the work force is Black, 7 percent Hispanic, 1 percent
Native American, and 6.24 percent Asian American. Veterans make up 33
percent of VA's work force. Of employees at a GS-13 and above, 38
percent are minorities.
VHA work force is comprised of 75 percent women and minorities; 24
percent of the work force is Black, 7 percent Hispanic, 1 percent
Native American and 7 percent Asian American. Veterans make up 31
percent of VHA's work force. Of employees at a GS-13 and above, 30
percent are minorities.
VHA has consistently provided career development training
opportunities designed to prepare all VA employees with knowledge and
skills necessary to perform in higher grades. These programs include
the technical career field program (TCF)-GS-5-9; the leadership,
effectiveness, accountability, development program (LEAD)-GS-11-13; the
executive career field candidate development program (ECFCDP)-GS-1314/
nurse IV/physician tier 2), and Leadership VA (LVA)-G8-13 and higher.
The percentages of minority participation for these programs in FY 2006
were: LEAD, 27.12 percent; TCF, 29.90 percent; ECFCDP, 20 percent; and
LVA, 24.29 percent.
VBA's work force of over 13,000 employees is comprised of 69
percent women and minorities; 27 percent of the work force is Black, 6
percent Hispanic, 2 percent Native American, and 3 percent Asian
American. Veterans make up 48 percent of VBA's work force. Of employees
at a G8-13 and above, 51 percent are minorities.
The Under Secretary for Benefits aggressively supports hiring
veterans as reflected in the high percentage of veterans in the
workforce. Within the next 18 months, VBA plans to hire more than 2,000
employees. Recruitment of veterans and any underrepresented minority
groups will be a focus of this hiring effort.
NCA's work force is comprised of 49 percent women and minorities;
20 percent of the work force is Black, 9 percent Hispanic, 1.55 percent
Native American and 3.58 percent Asian American. Veterans make up 72
percent of NCA's work force. Of employees at a GS-13 and above, 64
percent are minorities.
NCA strives to increase the percentage of women and minorities in
the ranks of leadership by providing career development training. In
2006, 40 percent of the participants in the training program for
cemetery directors were women and 30 percent were Black. In this year's
class, 33 percent are women, 22 percent are Black, and 11 percent are
Hispanic.
Staff offices' work force is comprised of 59 percent women and
minorities; 22 percent of the work force is Black, 6 percent Hispanic,
1 percent Native American, and 5 percent Asian American. Veterans make
up 40 percent of staff offices' work force. Of employees at a G8-13 and
above, 44 percent are minorities.
Question 8: The ACMV also recommended that the VA should hire OIF/
OEF Minority veterans into the agency to ensure departmental
sensitivity to a new generation of minority veterans seeking services.
Question 8(a): What processes has the VA put into place to advance
this recommendation?
Response: VA remains committed to hiring veterans, particularly
disabled veterans and those transitioning from active service in OEF/
OIF. VA's National Veterans Employment Program (NVEP) continues to
advance efforts by the Department to employ veterans VA-wide, promoting
or participating in targeted outreach and recruiting events nationally.
VA is a regular participant of the DoD Hiring Heroes Career Fairs, the
Annual Road to Recovery Conference hosted by the Coalition to Salute
America's Heroes and other events targeting seriously injured and
wounded OEF/OIF servicemembers transitioning to the civilian work
force. NVEP has also helped establish veteran employment coordinators
(VEC) at human resource facilities throughout the department to lead
local efforts to attract, recruit, and retain veterans in VA.
VHA's fiscal year (FY) 2007 equal employment opportunity
Initiatives were to increase the representation of individuals with
targeted disabilities, particularly increasing the veterans and
disabled veterans, and the number of minorities and women in the
qualified applicant pool. To enhance the employment of OEF/OIF minority
veterans and people with disabilities, VHA will continue to network
with military installations, State vocational rehabilitation services,
the Work force Recruitment Program, and community organizations (i.e.
job accommodation networks and computer electronic accommodation
program). VHA has an overall plan to increase the number of people with
targeted disabilities. Each VISN director was asked to increase the
employment of individuals with targeted disabilities to 1.5 percent in
FY 2007, and incremental increases to 2.2 percent by FY 2011. It is
anticipated that this effort will also increase the number of disabled
veterans in the Department's work force.
VHA has appointed 98 transition patient advocates (TPA) since March
2007 when the Secretary authorized 100 new positions in VA's continuing
commitment to help severely injured OEF/OIF veterans and their families
navigate VA's system for health care. The TPAs serve as the point of
contact for these veterans transitioning to VA from military treatment
facilities. As in other recruitment activities, selecting officials
were instructed to make every effort to ensure a representative number
of women and minority candidates were selected. VHAs commitment of
hiring OEF/OIF veterans was demonstrated during this recruitment effort
by including qualification requirements that targeted these veterans.
VHA continues to aggressively use the special veteran appointing
authorities, including the veterans' recruitment appointment, the
veterans' preference program for disabled veterans, and the Veterans
Employment Opportunities Act 1998.
Currently, no means exists to identify employees who are OEF/OIF
veterans, minority or otherwise. VA has addressed this issue with the
Office of Personnel Management (OPM). So, until OPM establishes a code
for OEF/OIF veterans, much in the same way Vietnam Era veterans were
coded, their numbers in VA and the rest of the Federal work force will
remain unknown. Certain programs (i.e. Coming Home to Work) can
possibly provide raw numbers of OEF/OIF veterans hired, but when it
comes to sorting them demographically, that presents a greater
challenge.
Question 8(b): For instance has the VA established processes at the
Cabinet level to ensure that all applicable agencies are engaged?
Response: VA participates with the Department of Labor (DoL),
Department of Transportation and DoD in the transitional assistance
program (TAP) to provide servicemembers who are within 6 months of
discharge or 2 years of retirement with information and assistance they
need to transition to civilian life.
Question 8(c): Can the VA seamlessly help these veterans
transition?
Response: In January 2005, VA established a permanent Office of
Seamless Transition which reports through VA/DoD coordination officers
to the Principal Deputy Under Secretary for Health and is composed of
representatives from VHA and VBA, as well as an active duty Marine
Corps officer and an Army officer. Since its inception, the seamless
transition program has achieved numerous accomplishments that result in
great strides toward the seamless transition of OEF/OIF servicemembers
into civilian life, including minority and women veterans. The ability
to register for VA health care and file for benefits prior to
separation from active duty is the result of the seamless transition.
VA/DoD social work liaisons and VBA benefit counselors are now
located at 10 military treatment facilities (MTFs) to assist active
duty servicemembers as they transfer from MTFs to VAMCs. In addition,
our VHA liaisons help newly wounded servicemembers and their families
plan a future course of treatment for their injuries after they return
home. VA nurses, social workers, benefits counselors, and outreach
coordinators advise and explain the full array of VA services and
benefits. VHA staff has coordinated over 7,900 transfers of OEF/OIF
servicemembers and veterans from a MTF to a VA medical facility. Active
duty Army liaison officers are assigned to each of the 4 VA polytrauma
rehabilitation centers to assist servicemembers and their families from
all branches of service on issues such as pay, lodging, travel,
movement of household goods, and non-medical attendant care orders.
The Office of Seamless Transition established an OEF/OIF Polytrauma
Call Center to assist our most seriously injured veterans and their
families with clinical, administrative, and benefit inquiries. The Call
Center which opened February 2006, is operational 24 hours a day, 7
days a week to answer clinical, administrative, and benefit inquiries
from polytrauma patients and their families. In addition, the Call
Center has contacted 950 veterans since February 2007. Through these
outreach phone calls, we have been able to provide these veterans
additional assistance with health or benefits concerns.
VA has implemented an automated tracking system to track
servicemembers and veterans transitioning from MTFs to VA facilities.
As part of this system, VHA implemented a 2007 performance measure to
ensure VHA assigns a case manager to seriously injured servicemembers
being referred from a MTF to a VA treatment facility in a timely
fashion. This performance measure monitors the percent of severely ill/
injured servicemembers and veterans who are contacted by their assigned
VA case manager within 7 days of notification of transfer to the VA
system.
In April 2007, VA integrated the tracking system with DoD's joint
patient tracking application (JPTA) which tracks servicemembers from
the battlefield through Landstuhl, Germany, to MTFs in the States. The
new application, known as the veterans tracking application (VTA), is a
modified version of DoD's JPTA--a web-based patient tracking and
management tool that collects, manages, and reports on patients
arriving at MTFs from forward-deployed locations. VTA is compatible
with JPTA and allows the electronic transfer of DoD medical data JPTA
on medically evacuated patients to VA on a daily basis.
VA is participating in DoD's post deployment health reassessment
(PDHRA) program for returning deployed servicemembers at Reserve and
Guard locations by providing information on VA care and benefits,
enrolling interested Reservists and Guardsmen in the VA health care
system, and arranging appointments for referred servicemembers. Since
its inception, over 121,721 Reserve and Guard members have completed
the PDHRA on-site screen resulting in over 27,755 referrals to VA
facilities and 13,848 referrals to vet centers.
In order to ensure that OEF/OIF combat veterans receive high
quality health care and coordinated transition services and benefits as
they transition from the DoD system to the VA, VA developed a robust
outreach, education and awareness program. The signing of a memorandum
of agreement (MOA) between the National Guard and VA, in May 2005, and
the formation of VA/National Guard State coalitions in each of the 54
States and territories now provides the opportunity for VA to gain
access to returning troops and families as well as join with community
resources and organizations to enhance the integration of the delivery
of VA services to new veterans and families. This is a major step in
closer collaboration with the National Guard soldiers and airmen. A
similar MOA is being developed with the U.S. Army Reserve Command and
the U.S. Marine Corps at the national level. VA and the National Guard
Bureau teamed up to train 54 National Guard transition assistance
advisors who assist VA in advising Guard members and their families
about VA benefits and services.
VA participates in TAP workshops to provide servicemembers who are
within 6 months of discharge or 2 years of retirement with information
and assistance as they transition to civilian life. Part of the
briefing conducted by DoL includes reviewing servicemembers' job
seeking skills and allowing them to use DoL services to obtain
employment following separation from service. At this time DoD does not
make attendance at TAP briefings mandatory for servicemembers. The
Marine Corps is the only branch of service that requires all
discharging and retiring Marines to attend TAP. Currently just over 50
percent of all eligible servicemembers attend TAP. Following TAP
briefings VA military service coordinators are available on most
military bases to meet with interested servicemembers to discuss VA
services and benefits.
The Secretary of Veterans Affairs sends a personal ``thank you''
letter together with information brochures to each returning OEF/OIF
veteran based on lists routinely provided by the DoD. These letters
provide information on health care and other VA benefits, toll-free
information numbers, and appropriate VA Web sites for accessing
additional information. In addition, VA and DoD are collaborating to
ensure VA is notified of severely ill or injured servicemembers
transitioning to civilian life. Under this initiative, DoD is
transmitting the names of servicemembers entering Do D's physical
evaluation board (PEB) process. This list enables VA to contact active
duty servicemembers to inform them of VA benefits and health care
services available to them and to assist them in accessing these
services.
Question 8(d): Has the VA pursued the collection of DoD data
identifying the upcoming release/discharge of minority servicemembers
within 90 days of their release to assist the VA with outreach to the
service member?
Response: VA and DoD are collaborating to ensure VA is notified of
severely ill or injured servicemembers transitioning to civilian life.
Under this initiative, DoD is transmitting the names of servicemembers
entering DoD's physical evaluation board (PEB) process. This list
enables VA to contact active duty servicemembers to inform them of VA
benefits and health care services available to them and to assist them
in accessing these services. In addition the Secretary of Veterans
Affairs sends a personal ``thank you'' letter together with information
brochures to each returning OEF/OIF veteran based on lists routinely
provided by the DoD. These letters provide information on health care
and other VA benefits, toll-free information numbers, and appropriate
VA Web sites for accessing additional information.
Question 9(a): How does the Center/VA identify Minority Vets?
Response: CMV uses the U.S. Census data to identify minority
veterans. In order to identify minority veterans using VA health care
services, veterans applying for enrollment in the VA health care
system, or for nursing home, domiciliary or dental benefits, veterans
(or their legal proxies) must complete the 1010 EZ form. The form
includes 2 questions, similar to those used in the 2000 Census, asking
the applicant to self-identify Spanish, Hispanic or Latino ethnicity
(yes or no) and to self-identify race (one or more). This information
is self-reported, is strictly voluntary, and a disclaimer is offered
that any information collected is used for statistical purposes only.
Enrollment and benefit eligibility decisions are not influenced by the
answer to one or both of these questions, including a non-response.
Once a veteran is enrolled, information on ethnicity and race is not
routinely collected, although it may be referenced in the enrollee's
confidential electronic health record.
Since 1999, VHA has conducted comprehensive nationwide surveys
designed to provide input into estimates of enrollees' demand for
health care services. Surveys consist of telephone interviews with
random stratified samples of enrolled veterans. Recognizing that good
administrative data on race and ethnicity are lacking, the 2005 survey,
for the first time, asked respondents their race and ethnicity.
Question 9(b): What are your outreach practices to these subsets of
veterans for VA facilities to ensure equitable access to benefits?
Response: CMV has program analysts who serve as veterans liaisons
for each of the 5 minority groups: Asian Americans, Blacks, Hispanics,
Native Americans, and Pacific Islander Americans. They establish
partnerships with VSOs as well as internal and other external
stakeholders to increase awareness of minority veterans' issues and
develop collaborative strategies to address unmet needs.
VHA has developed a wide range of outreach programs in response to
the health care and other benefits needs of veterans and their
families, which focus on minority, women, newly separated and younger
veterans, as well as on their health care providers. Many of these
represent ``lessons learned'' from VA's experiences responding to the
outreach, education, health care and other benefits needs of minority
and women veterans returning from the 1991 gulf war, and from the
Vietnam War.
These include:
Since 2005, VA has published and distributed over 250,000
brochures titled VA Reaching Out to Women Veterans.
VA's Secretary sends a letter to all newly separated OEF/
OIF veterans, based on records provided by DoD, thanking them for their
service, welcoming them home, and providing basic information about VA
health care and other benefits.
Expanded VA provider education on combat health care
including:
Preparing for the Return of Women Veterans from
Combat Theater, USH IL 10-2003-011, on special care needs for
women OEF and OIF combat veterans;
A Guide to gulf war Veterans Health originally for
1991 gulf war combat veterans, remains relevant for OEF/OIF
combat veterans;
Endemic Infectious Diseases of Southwest Asia, on
infectious disease risks not typically seen in North America;
Military Sexual Trauma on recognition and treatment
of health problems related to military sexual trauma;
Post-Traumatic Stress Disorder (PTSD): Implications
for Primary Care on PTSD diagnosis, treatment, referrals,
support and education;
Traumatic Amputation and Prosthetics for patients
with traumatic amputations, their rehabilitation, primary and
long-term care, prosthetic, clinical and administrative issues.
Publish the quarterly OIF and OEF Review newsletter
mailed to all separated OEF/OIF veterans (nearly 700,000 as of May
2007) and their families, on VA health care and assistance programs for
these newest combat veterans.
Published and distributed more than 1 million copies of
brochure A Summary of VA Benefits for National Guard and Reservists
Personnel, which summarizes health care and other benefits available to
this special population of combat veterans upon their return to
civilian life.
Published Health Care and Assistance for U.S. Veterans of
Operation Iraqi Freedom, a brochure on basic health issues for that
deployment.
Developed and distributed the VA Health Care and Benefits
Information for Veterans, wallet card concisely summarizing all VA
health and other benefits for veterans, along with contact information,
in a single, wallet-sized card for easy reference.
Promoted eligibility rules providing reservists and
active duty personnel who served in a designated combat zone such as
Afghanistan or Iraq with 2 years of free VA health care, in posters,
information letters and news letters for veterans.
Developed a clinical reminder (part of VA's computerized
reminder system) to assist VA primary care clinicians in providing
timely and appropriate care to new combat veterans.
Sponsored a 3-day National Conference on Providing Health
Care for a New Generation of Combat Veterans Returning From OEF/OIF,
April 10-12, 2007, in Las Vegas, Nevada to sharpen VA's response to new
and transitioning combat veterans coming to VA, and to the new physical
and behavioral health care challenges they bring with them. The
national conference attracted 1,400 primary care providers from around
the country, including social workers, psychologists and mental health
professionals, physicians, physician assistants, nurses and others who
provide direct care to new combat veterans returning from Afghanistan
and Iraq.
VBA's outreach efforts are designed to reach a broad spectrum of
veterans, generally irrespective of race. However, each regional office
has specially designated outreach coordinators who conduct outreach to
various populations, including minority veterans, to provide these
individuals information about VA benefits and services. MVPCs are also
available to respond to requests concerning VA benefits and services.
NCA conducts local and national initiatives in an effort to
identify minority veterans. The outreach practices to these veterans
include all national cemetery directors having the responsibility to
identify groups of veterans within the service area of their cemetery
and providing information about VA memorial benefits to these
individuals. NCA regularly attends 10 to 12 national conferences each
year to increase awareness among minority groups of memorial benefits.
Question 9(c): How do they differ for non-minority vets?
Response: Minority veterans experience many of the same challenges
that all veterans experience. However, minority veterans have
experienced and often experience racial/ethnic discrimination or lack
of cultural sensitivity more often than non-minority veterans. Minority
veterans are more likely to be effected by chronic diseases,
disparities in health care, homelessness, and unemployment.
Question 10: During its last site visit to the Los Angeles
Ambulatory Center, the ACMV was overwhelmed by the staggering number of
homeless veterans. In Los Angeles, it was reported that the veterans'
homeless population comprised 23 percent of the total 90,000 total
population in Los Angeles. Despite the fact that Los Angeles has the
highest homeless population in the country, the Committee believed that
these numbers might be similar throughout the country. While it wasn't
clear what percent of these veterans were minority veterans.
Question 10(a): Please update the Committee on what the VA is doing
to stem the rising tide of homeless amongst our veterans?
Response: Since 1987, VA has developed the largest integrated
network of services and programs designed to address the treatment,
rehabilitation, and residential needs of homeless veterans. VA
specialized homeless programs include domiciliary care for homeless
veterans (DCHV); compensated work therapy/transitional residence (CWT/
TR); health care for homeless veterans (HCHV), homeless providers grant
and per diem [GPD], and supported housing [SH]. VA in partnership with
Housing and Urban Development (HUD) provides HUD-VA supported housing
program [HUD-VASH]).
VA homeless programs are designed to provide a continuum of care
for homeless veterans. Key elements of this continuum are:
outreach to identify veterans among homeless persons
encountered in communities
clinical assessment to determine the needs of those
veterans;
rehabilitation in VA domiciliary, in community-based
contracted residential treatment facilities, or in transitional
residences;
supportive transitional housing to facilitate community
re-entry (such as those supported by the VA grant and per diem
program);
supportive case management to maintain independent jiving
in the community (such as the supportive housing program provided by
HUD-VA).
For the past several years, VA specialized homeless programs have
treated 70,000 to 75,000 homeless veterans. In fiscal year (FY) 2006,
VA homeless programs provided services to approximately 72,000 homeless
veterans. Approximately 4 percent of VA homeless program clients are
female; about 46 percent are White; about 46 percent are Black; about 5
percent are Hispanic; about 1 percent are Native American; and 1
percent are Asian American and Pacific Islander American. Consistent
with the missions of the programs, the vast majority of clients have
serious psychiatric, substance abuse or medical problems.
About two-thirds of clients in these programs are seen on an
outpatient basis, receiving direct services and referral to other
treatment as needed. About one-third are seen more intensively in the
residential programs. A recent longitudinal study of clients discharged
from VA residential treatment programs indicated that approximately 80
percent are stably housed 1 year later. Similarly favorable housing
outcomes have been observed in studies of VA's longer term supportive
case management programs.
Question 10(b): What is it doing for homeless Minority vets with
dependents?
Response: VA homeless programs provide outreach and assessment
services to minority veterans with dependents. The programs provide
referral to community resources for dependents of homeless patients
requiring shelter, residential services, medical and psychiatric care,
or other social services.
Question 11: The ACMV was concerned that the early identification
of PTSD and the accompanying services might not be readily available to
minority veterans who have served in the Vietnam Conflict. What is the
VA doing to ensure access to treatment and benefits, when warranted,
are made available to this particular subset of veterans?
Response: VA is successful in providing mental health services to
minority veterans of the Vietnam era and other service eras. VA has had
clinical practice guidelines (CPG) that include PTSD since the mid
eighties with the current PTSD CPG released in 2004. Following the
release of the 2004 PTSD CPG, all veterans have been screened for PTSD
(as well as for depression and alcohol abuse) on an annual basis.
Beginning in FY 2007, PTSD screen is completed once every 5 years for
Vietnam era veterans.
Data from the National Vietnam Veterans Readjustment Study, that
sampled Black and Hispanic veterans, and the subsequent Matsunaga study
that specifically targeted Native American and Pacific Islander
American veterans, showed increased incidence of PTSD among minority
veterans. As a result, in the 1990s, training videos were created by
VA's National Center for PTSD directed at providers and veterans and
their families on PTSD in these minority groups.
Data on use of VA mental health services by minority Vietnam era
veterans indicates that overall, minorities are no less likely than
non-minorities to use VA services (Rosenheck & Fontana, Journal of
Nervous & Mental Disease, 1994).
VA's ongoing program evaluation of PTSD care, entitled the Long
Journey Home, is produced annually by VHA's Northeast Program
Evaluation Center (NEPEC). NEPEC data for FY 2000 indicated that 33
percent of veterans using special outpatient PTSD services were members
of minority groups. For FY 2006, the percentage was 35 percent. A
special survey of the 10,131 new Vietnam era veterans, who received
intake assessments for the specialized outpatient PTSD program in FY
2006, showed that 37.5 percent were members of minority groups. This is
about double the proportion of minorities in the general population of
Vietnam era veterans.
While VBA does not conduct specific outreach to veterans who may
suffer from PTSD, all outreach coordinators and telephone
representatives are knowledgeable about the condition. They can inform
an inquirer what is needed to file a claim and how to request
treatment. They are also trained in how to deal with callers with
extreme mental conditions, including PTSD, who are threatening suicide.
Additionally, VA's Web site has a wealth of information on PTSD for the
veteran and his or her family.
Question 12(a): Please provide a demographic breakdown of the
number of Minority Veterans, African American, Hispanic, Samoan, Native
American, and so forth.
Response: The U.S. Census Bureau, Census Bureau 2006 American
Community Survey data show the following veteran demographics:
------------------------------------------------------------------------
Race Number
------------------------------------------------------------------------
Blacks 42,436,205
------------------------------------------------------------------------
Hispanic 1,100,977
------------------------------------------------------------------------
American Indian/Alaskan Native 163,975
------------------------------------------------------------------------
Asian American 281,100
------------------------------------------------------------------------
Native Hawaiian/Other Pacific Islander 23,425
------------------------------------------------------------------------
Question 12(b): How does the VA gather this information and make
determinations for resources accordingly, please explain? For instance
the Advisory Committee was very concerned about how the VA collects its
data on ethnicity, especially as it seemed to disadvantage Native
American veterans.
Response: The VA Office of the Actuary within the Office of Policy
and Planning develop estimates of veterans by race and ethnicity based
on assumptions derived from analysis of U.S. Census Bureau data. Since
1999, VHA has conducted comprehensive nationwide surveys designed to
provide input into estimates of enrollees' demand for health care
services. Surveys consist of telephone interviews with random
stratified samples of enrolled veterans. Recognizing that good
administrative data on race and ethnicity are lacking, the 2005 survey,
for the first time, asked respondents their race and ethnicity.
National estimates of enrollee demographics derived from responses
to the 2005 Annual Survey of Veteran Enrollees, a telephone survey
random stratified sample of approximately 42,000 enrollees. The
estimated distributions from each source are as follows:
----------------------------------------------------------------------------------------------------------------
American Native
Indian Black/ Hawaiian More
Hispanic or Asian African or Other White than one
Alaska American Pacific race
Native Islander
----------------------------------------------------------------------------------------------------------------
Office of the Actuary (2007) 5.6% 0.8% 1.2% 10.9% 0.1% 79.9% 1.4%
----------------------------------------------------------------------------------------------------------------
Survey of Veteran Enrollees (2005)* 4.5% 4.6% 0.7% 10.0% 0.5% 84.1% 2.8%
----------------------------------------------------------------------------------------------------------------
*Does not add to 100% because of non-responses
In addition, to apply for enrollment in the VA health care system,
or for nursing home, domiciliary or dental benefits, veterans (or their
legal proxies) must complete the 1010 EZ form. The form includes 2
questions, similar to those used in the 2000 Census, asking the
applicant to self-identify Spanish, Hispanic or Latino ethnicity (yes
or no) and to self-identify race (one or more). This information is
self-reported, is strictly voluntary, and a disclaimer is offered that
any information collected is used for statistical purposes only.
Enrollment and benefit eligibility decisions are not influenced by the
answer to one or both of these questions, including a non-response.
Once a veteran is enrolled, information on ethnicity and race is not
routinely collected, although it may be referenced in the enrollee's
confidential electronic health record.
Each administration is responsible for making resource
determinations in order to serve this minority population. At the
Department level the Secretary established minority veterans' program
coordinators (MVPC) at each VA health care facility, regional office
and national cemetery. The directors of the health care facility,
regional office and national cemetery are responsible to ensure that
MVPCs have the necessary resources to be effective and efficient to
perform the functions needed (e.g., numbers of hours allocated to
perform the duties, computer access/email, and funding for projects
and/or special programs as required).
Question 13(a): For the recommendations made by the Advisory
Committee, and for those in which the VA concurs, who is responsible
for ensuring implementation of the recommendations made by the Advisory
Committee?
Response: The administrations along with various staff offices are
responsible for implementing the recommendations of ACMV. CMV tracks
the status of recommendations to ensure implementation; and requests
briefings on unresolved recommendations at ACMV bi-annual meetings.
Question 13(b): How are these missives sent down throughout all of
the VA?
Response: CMV assigns each recommendation to the appropriate
administration or staff office, and then monitors and follows up as
needed.
Questions on the Backlog
Question 1: During its visit, the Committee also noted that the LA
VARD had a significant backlog in its appellate reviews. In fact, it
was reported to the Advisory Committee that 4,000 appeals were pending
but that only 8 percent of the VARO staffing was designated to work on
those appeals. How does the VA determine the allocation of resources
for these backlogged areas?
Response: Under the claim process improvement (CPI) model, a
regional office has established claims processing teams performing the
functions of triage, pre-determination, rating, post-determination,
appeals, and public contact.
The claims processing taskforce recommends the following
distribution of staffing:
------------------------------------------------------------------------
------------------------------------------------------------------------
Triage: 20-25 percent
------------------------------------------------------------------------
Pre-determination: 15-20 percent
------------------------------------------------------------------------
Rating: 20-25 percent
------------------------------------------------------------------------
Post-determination: 10-15 percent
------------------------------------------------------------------------
Appeals: 5-10 percent
------------------------------------------------------------------------
Public contact: 15-18 percent
------------------------------------------------------------------------
The Los Angeles RO allocates 12.4 percent of its Veterans Service
Center decisionmakers, to the appeals process. Because of the
complexity of the appeals process, these decisionmakers are highly
skilled and more experienced.
Since October 2006, the Los Angeles Regional Office has reduced its
appeals workload by 15 percent, and improved the timeliness of the
notice of disagreement process by 24 percent. There are currently 3,673
appeals pending.
Question 2: Has been omitted.
Question 3: What percentage of the VA population is Native
American?
Response: Public Law 103-446 denotes that Native Americans include
American Indians, Alaskan Natives, and Native Hawaiians. The U.S.
Census 2006 reflects that there are 163,975 American Indian veterans
and 23,425 Native Hawaiians and Pacific Islanders. U.S. Census data
doesn't provide a separate breakdown for Native Hawaiians and Pacific
Islanders.
Question 4: What is being done in terms of outreach for this
special set of Minority Veterans?
Response: The Department of Health and Human Services (HHS) and the
VA signed a memorandum of understanding (MOU) in February 2003 to
encourage cooperation and resource sharing between the Indian Health
Service (IHS) and VHA to deliver quality health care services and
enhance the health status of American Indian and Alaska Native (AI/AN)
veterans.
Outreach. Most networks are engaged in a variety of outreach
activities, including meetings and conferences with IHS program and
tribal representatives, VA membership in the Native American Healthcare
Network, VA participation in traditional Native American ceremonies,
transportation support to AI/AN, and so forth.
Education. VHA Employee Education Service (EES) provides training
programs to IHS staff and the tribal community. In FY 2007, VHA has
delivered 123 training programs to IHS staff and the tribal community
of which 68 were made available using satellite technology and 55 using
web based technology. These educational programs will be continued in
2008, and VHA will also provide selected IHS staff an opportunity to
attend regional EES workshops.
Behavioral Health. The Behavioral Health workgroup developed a
framework for AI/AN communities to assist returning OEF/OIF AI/AN
servicemembers and veterans reintegrate with their families and
communities and readjust to civilian life. The objective is to promote
a community health model with tools that is provided to Tribal
communities and families to help returning veterans address emerging
adjustment reactions, traumatic stress, and PTSD, emphasizing recovery
as the goal. The Joint Committee has developed a slide presentation to
be used by outreach teams. There have been briefings using the slide
presentation in Montana, with approximately 30 veterans now receiving
services from VA.
Expanded Health Care Services. At the local level, 10 VHA networks
are engaged in targeted initiatives aimed at providing a full continuum
of health care services, such as; health fairs, VA/IHS advisories, use
of Health Buddy, and education and/or shared services in substance
abuse, domestic violence programs, cardiac rehabilitation, dietetics,
behavioral medicine, and so forth.
Care Coordination. The VHA-IHS Shared Health Care workgroup is
working on developing an Inter-Departmental coordinated care policy.
The goals are to optimize the quality, appropriateness and efficacy of
the health care services provided to eligible AI/AN veterans receiving
care from both VHA and IHS or Tribes and to improve the patients'
satisfaction with the coordination of care between the 2 Departments. A
separate memorandum of understanding to facilitate electronic record
sharing was signed in August 2007.
Tribal Veteran Representatives. In July 2007 9 Tribal veteran
representatives (TVRs) and a drum group participated in a Wounded
Warriors program in Park City, Utah for returning OEF/OIF veterans. A
similar program is being considered for women and then another for men.
American Vet video filmed and will have a new film come out soon. TVRs
are working on an outreach program to urban veterans in October 2007.
Training to add TVRs continues.
Telemedicine. Telemedicine has proven to be an extremely effective
in the treatment of PTSD in Alaskan Native villages. VA and IHS are
working to spread the use of telemedicine services by AI/AN veterans,
which will allow VA to bring physical and mental health care to the
tribes, especially those in remote areas of the country.
Traditional Healing. Some VHA facilities and Vet Centers have
incorporated traditional healing ceremonies along with modern methods
of treatment and counseling. As a national initiative, VA has sent over
500 letters to tribal leaders to ask them to provide information on
appropriate providers of traditional practices so that they may be
called upon for religious/spiritual care of AI/AN veterans.
The majority of VBA's outreach to this group is in those States
where there are concentrations of Native American veterans. Several
regional offices have been very successful in establishing
relationships with tribal councils to allow VBA to meet with Native
American veterans in familiar settings. Currently, VBA works closely
with TVRs a liaison between the Tribes and VBA in processing of claims.
NCA has recently added a Native American member to its Advisory
Committee on Cemeteries and Memorials. In addition to his regular
duties as a Committee member he will assist in identifying and
conducting outreach to Native American populations unaware of VA
memorial benefits.
Public Law 109-461, Veterans Benefits, Health Care, and Information
Technology Act of 2006 amended section 2408 of title 38, United States
Code, to allow the Secretary to make cemetery grants to tribal
organizations in the same manner, and under the same conditions, as
grants to States are made under the State cemetery grants program.
Inclusion of tribal organizations into the State cemetery grants
program will assist NCA in identifying groups of veterans interested in
learning about VA memorial benefits when they initiate the grant
process.
Question 5: What metrics does the VA use to measure success in its
outreach programs to Minority veterans?
Response: The purpose of outreach is to make individuals aware of
the benefits available from VA. Of course, awareness does not always
translate into applying for benefits. Under section 805 of Public Law
108-454, VA is charged with conducting a national survey to ascertain
servicemembers' and veterans' and their family members' and survivors'
levels of awareness of VA benefits and services. When this survey is
completed we will have a better understanding of the effectiveness of
the outreach initiatives.
Question 6: What has the VA done to implement the establishment of
full-time Minority Outreach Coordinators where warranted?
Response: The Secretary's memorandum dated April 25, 1995,
established MVPCs at each VA medical center, regional office, and
national cemetery. VA Directive 0801, Minority Veterans Program
Coordinator signed by the Secretary of Veterans Affairs on April 15,
2007 States that each administration shall support facility MVPCs and
ensure they are provided the necessary resources to be effective and
efficient to perform the functions needed (e.g., numbers of hours
allocated to perform the duties, computer access/email, and funding for
projects and/or special programs as required).
VHA has designated MVPCs at each medical center. The MVPC assist
the medical center director and CMV with identifying the needs of
minority veterans through outreach activity. The primary goal of this
outreach initiative is to increase local awareness of minority veteran
related issues and develop strategies for increasing their
participation in existing VA benefit programs for eligible veterans.
MVPC's are responsible for:
Promoting the use of VA benefits, programs, and services
by minority veterans.
Supporting and initiating activities that educate and
sensitize internal staff to the unique needs of minority veterans.
Targeting outreach efforts to minority veterans through
community networks.
Advocating on behalf of minority veterans by identifying
gaps in services and make recommendations to improve service delivery
within their facilities.
VBA has designated outreach coordinators at every regional office
for several specific audiences of servicemembers and veterans including
minority, OEF/OIF, women, the elderly, Native American, former
prisoners of war, and homeless. Because of the overlap of groups, a few
regional offices have consolidated their outreach activities with one
coordinator. In 20 States, the homeless coordinator is a full-time
position because of the size of the homeless veteran population in
those States. In only a few other cases is there a substantial specific
population to justify assigning a full-time coordinator to any specific
targeted group.
NCA now has an outreach coordinator staff position at the national
level within the Communications Management Service. The position
includes responsibilities for minority outreach as well as other
program outreach on the national level.
Questions for Women Veterans
Question 1: In its 2004 Report, the VA Advisory Committee on Women
Veterans indicate that the VA perform a study to determine the
prevalence of Military Sexual trauma among homeless women veterans and
the psychosocial consequences of Military Sexual Trauma (MST) and
whether a correlation exists between MST and homelessness. The VA
concurred. Please update the Committee on the results of any follow-up
studies that may have been conducted. (p. 36).
Response: North East Program Evaluation Center (NEPEC) has
conducted a follow-up study of homeless female veterans in the course
of which we have collected data on military sexual trauma (MST). These
data show that among female veterans being served at 1 of the 11
specialized homeless women veterans programs throughout the country, 43
percent reported being raped while in the military. This rate of MST
can be compared to rates reported among VA ambulatory female
outpatients of 23 percent (Skinner, 2000) and rates noted through
mandatory VA screening procedures of 21 percent (external peer review
package data). Skinner, Katherine M; Kressin, Nancy; Frayne, Susan;
Tripp, Tara J; Hankin, Cheryl S; Miller, Donald R; Sullivan, Lisa M.
The prevalence of military sexual assault among female Veterans'
Administration outpatients. Journal of Interpersonal Violence. Vol.
15(3) Mar 2000, 291-310.
Question 2: Are there any correlations between MST and
Homelessness?
Response: NEPEC collected data on homeless female veterans. These
data show that among female veterans being served at specialized
homeless women veterans programs throughout the country, 43 percent
reported being raped while in the military. This rate of MST can be
compared to rates reported among VA ambulatory female outpatients of 23
percent (Skinner, 2000) and rates noted through mandatory VA screening
procedures of 21 percent (external peer review package data). This
difference suggests that homeless female veterans under VA care may be
more likely to have suffered MST than non-homeless female VA clients.
However, without longitudinal data it is not possible to conclude that
experiencing MST significantly increases the risk of homelessness among
all female veterans. Skinner, Katherine M; Kressin, Nancy; Frayne,
Susan; Tripp, Tara J; Hankin, Cheryl S; Miller, Donald R; Sullivan,
Lisa M. The prevalence of military sexual assault among female
Veterans' Administration outpatients. Journal of Interpersonal
Violence. Vol. 15(3) Mar 2000, 291-310.
Question 3(a): As women are increasingly prevalent on the
frontlines of combat, what is the VA doing to prepare for and address
the needs of the growing number of veterans who are minority?
Response: VA is aware that the number of women serving on active
duty and in combat area deployments has dramatically increased. Because
of the numbers of new OEF/OIF veterans, VA is preparing for the
population of women veterans to double in the next 2 to 5 years. To
address the needs of these women veterans, including minority women, VA
plans to:
Enhance the skills of primary care providers treating
women through primary care education initiatives;
Increase the focus on comprehensive care, including those
conditions that have high mortality for women, such as heart disease
and obesity; and,
Help new OEF/OIF women veterans stay fit and healthy for
life, since we expect them to be receiving care from VA throughout
their adult years. Special attention to issues for minority veterans,
and veterans' perception of health care are being addressed in this
program.
Question 3(b): Please inform the Committee what percentage of OIF/
OEF women veterans are minority?
Response: As of August 31, 2006, of the 69,861 women veterans who
had served in OEF/OIF 42 percent are minorities. Of this 42 percent, 26
percent are Black, 9 percent are Hispanic, and 7 percent are members of
other minority groups or multiple races.
Question 4: Based on a recommendation by the Women's Advisory
Committee, what has the VA done specifically to ensure that Veterans
Benefits advisors at the Transition Assistance Program (TAP) briefings
specifically address MST (military sexual trauma) information, Le.
placing in packets?
Response: The VA TAP benefits briefing presentation used by
military services coordinators includes 5 slides on Military Sexual and
Other Personal Trauma. These slides are mandatory at all VA benefits
briefing presentations conducted for separating and retiring
servicemembers. When VBA conducts site visits to evaluate TAP VA
benefits presentations, this requirement is on our checklist to confirm
it is included in the briefings.
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
August 2, 2007
Shirley Ann Quarles, R.N., Ed.D
Chairwoman, Advisory Committee on Women Veterans
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Shirley:
In reference to our joint Subcommittee hearing on ``Issues Facing
Women and Minority Veterans'' held on July 12, 2007, I would appreciate
it if you could answer the enclosed hearing questions by the close of
business on October 2, 2007.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full and
Subcommittee hearings. Therefore, we would appreciate it if you would
provide your answers consecutively and single-spaced. In addition,
please restate the question in its entirety before the answer.
Please provide your response to Cathy Wiblemo. If you have any
questions, please call 202-225-9154.
Sincerely,
MICHAEL H. MICHAUD
Chairman
______
Dr. Shirley Quarles, R.N., Ed.D.
Response to Follow-Up Questions for the Record
From Joint Subcommittee Hearing
U. S. House of Representatives Committee on Veterans' Affairs
Subcommittees on Health and the
Subcommittee on Disability Assistance and Memorial Affair
Question 1--
I was pleased to see that there is a national Survey of Women
Veterans being implemented with the results expected in December 2008.
In your estimation, what are the 3 most prevalent and
urgent issues facing women veterans today?
As stated in earlier testimony in July 2007, 1) access to care for
women veterans in rural areas, 2) primary care in community-based
outpatient clinics that offer the same services that are provided at VA
medical centers, and 3) that women veterans receive health care on par
as male veterans.
Question 2--
To my knowledge, VA has not yet held any type of summit or
conference on OEF/OIF female veterans and the unique needs that are
arising as a result of women in combat.
Has the Advisory Committee looked at this, and if so,
what have you found?
In April 2007, VA held a national conference in Las Vegas, Nevada
called ``Evolving Paradigms: Providing Health Care to Transitioning
Combat Veterans''. The main attendees to the conference were VA and DoD
primary care givers and related health care professionals from all
disciplines who work with new combat veterans returning from Iraq and
Afghanistan to include: physicians, nurses, pharmacists, psychologists,
social workers, rehabilitation and mental health staff. The primary
purpose of the conference was to disseminate information to VA and DoD
health care providers on unique and challenging health care needs for
transitioning veterans with war wounds. Veterans transition to VA with
multiple and complex war wounds and the environment of care is critical
to the healing process. VA health care providers need to understand all
of these complex health care needs in a variety of settings, as these
new veterans transition from DoD to VA for their immediate and long-
term health care needs. Sessions focused toward women included: Health
Issues of Female Soldiers in Garrison, Combat and VA; Sexual Trauma;
and Gender Differences: What the Data Shows.
More recently, on February 19, 2008, the Department of Veterans
Affairs held a 1-day conference entitled Update on Health Care:
Responding to the Needs of VA's Newest Generation of Combat Veterans,
in the Sonny Montgomery Conference Center. Speakers from VA and the
Department of Defense covered such topics as traumatic brain injury and
polytrauma; mental health, post-traumatic stress disorder, and
readjustment issues; DoD/VA data sharing, changes in VA and DoD
disability evaluation; an individual veteran's experience, case
management: role of the Federal recovery coordinators, transition
patient advocates, and VA social workers; pay and compensation; and
special issues for national guard and reserve.
Veterans Health Administration is scheduled to participate in the
6th Annual Battlefield Healthcare Combat Casualty Care from the Front
Line to CONUS on March 31-April 2, 2008 at Georgetown University
Conference Center (and Hotel), Washington, DC. The conference will
discuss the continued operations in Iraq and Afghanistan and addressing
new challenges in care for combat veterans who serve in theater.
Also, The Department of Veterans Affairs, Center for Women Veterans
is planning the 2008 National Summit on Women Veterans Issues scheduled
for June 20-22, 2008 in Washington, DC. This is the 4th such Summit,
the prior Summits having been held in 1996, 2000, and 2004. Summit 2008
will look at the issues and recommendations from the 2004 Summit,
review VA's progress on these issues, provide information on current
issues, and develop recommendations and a plan for continuous progress
on women veterans' issues. A special focus of this Summit is on updates
for the Reserve and Guard. Breakout sessions have been designed for our
returning OEF/OIF service members and veterans, however, there will be
breakout sessions that are relevant for women veterans of all eras as
well. A townhall meeting and health expo are also planned.
Question 3--
Could you tell me what the biggest barriers to care for women
veterans are?
Access to care continues to be a barrier for women veterans. We
continue to outreach to the women veterans' community with increased
emphasis, working with our partnerships with Federal, state, and county
agencies, national veterans service organizations and community
organizations. HVAC, Subcommittees on Health and DAMA, 7-12-07,
Questions for the Record, Malebranche
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
August 2, 2007
Colonel Reginald Malebranche, USA (Ret.)
4919 Donovan Dr.
Alexandria, VA 22304
Dear Reginald:
In reference to our joint Subcommittee hearing on ``Issues Facing
Women and Minority Veterans'' held on July 12, 2007, I would appreciate
it if you could answer the enclosed hearing questions by the close of
business on October 2, 2007.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full and
Subcommittee hearings. Therefore, we would appreciate it if you would
provide your answers consecutively and single-spaced. In addition,
please restate the question in its entirety before the answer.
Please provide your response to Cathy Wiblemo. If you have any
questions, please call 202-225-9154.
Sincerely,
MICHAEL H. MICHAUD
Chairman
______
Follow-Up Questions for
Col. Reginald Malebranche, USA (Ret.)
Question:
In your testimony you stress the absence of diversity at the senior
staff level.
When the Committee presented their concern to the VA
about this issue, how did they respond?
Answer:
VA's answer has been to ``concur in principle.'' The Committee did
note that VHA planned on adding a 2007 work force performance measure
for diversity management for all Senior Managers that includes the
following:
``a. VISNs will take action to remove any barriers to full
participation of the local work force.
``b. Based on the analysis of the results from the Diversity
Acceptance factors from the 2006 All Employee Survey (AES),
VISNs will develop goals for improvement and implement the
resulting action plan.''
The absence of diversity at the senior staff level is a systemic
issue, which has been addressed and discussed in the majority of ACMV
reports. Yet, diversity at the senior staff level continues to be a
major problem at and within VA.
VA perceives its problem to be the lack of white and Hispanic
females at its senior staff level, even though the supportive data is
inconclusive. It stands to reason that VA's targets will be white and
Hispanic females, although analysis of VA data would suggest that
minorities, excluding white and Hispanic females, were significantly
absent from senior staff level positions at and in VA settings.
The Committee has been on record to recommend that VA exercise all
leverage available, including performance bonuses to bring required
changes, including the establishment of goals or floors, and hold all
leaders and managers personally accountable to meet established or
required goals, for the hiring of minority staff. The Committee
believes that these actions would result in a work force population
which would be more representative of the veteran population being
served.
Question:
To your knowledge, has the VA put forth a strategic plan
that would target recruitment and retention of minority veterans among
the senior staff level?
Answer:
I am unaware of a specific strategic plan, which would remedy the
issue. During the Committee's meeting in Washington, DC, April 16-19,
2007, the Office of Diversity Management and EEO Administration, VA,
presented data in the Executive Summary, EEOC Form 715-01 Part E, for
Fiscal Year 2007, which may be construed as VA's strategic plan. The
Executive Summary, EEOC Form 715-01, offered the following:
``WORKFORCE PROFILE: VA has a workforce of approximately 238,580
employees. During Fiscal Year (FY) 2006, total VA staffing increased by
more than 4,700 employees, including about 600 temporary appointments.
White women are 35.7% of the permanent positions, significantly below
their 47.5% in the Relevant Civilian Labor Force (RCLF) for VA
occupations, and declining slightly. Hispanic women are 3.6% of the
permanent positions, well below their 4.4% in the RCLF, and not making
meaningful progress toward RCLF parity. Hispanic men and American
Indian women are slightly underrepresented, but at the current rate of
gains should reach parity within 2 years. No other groups are
underrepresented in national total. Black men are represented at almost
3 times the RCLF and Black women are represented at almost double the
RCLF.''
This would suggest that VA's strategic plan is to focus on the
recruitment, hiring, and training of white and Hispanic females, only.
This would also suggest that VA does not consider having problem with
minorities hiring, promotion, and so forth., except for White and
Hispanic females. Data available at VA does not support this
conclusion.
There have been indications that VA had developed strategic
initiatives targeting the recruitment and retention of minority
veterans at the senior staff level. The plan and/or programs have not,
to my knowledge, been presented to the Committee, which will ask for a
comprehensive brief during its fall 2007 meeting in Washington, DC.
Question 2:
A big concern regarding the provision of care to the minority
veteran population is sensitivity to the cultural differences of
minority veterans--for instance, the differences in how to approach the
Alaska Native veteran community as opposed to the Hispanic veteran
community.
Does VA provide education to its many employees on
cultural competencies and sensitivity, particularly to the frontline
medical personnel?
Answer:
Indications are that the Veterans Health Administration (VHA) is
developing a 3-year phased cultural competency plan, targeting Alaska
Natives, Native Americans and Hispanic Americans veterans. The
Committee will endeavor to seek a comprehensive brief on the plan,
during its fall 2007 meeting in Washington, DC.
The Center for Minority Veterans does conduct a biennial training
conference for its Minority Veterans Program Coordinators (MPVC).
Included in that format is a cultural and sensitivity competency
module.
Question 3:
Outreach is a major challenge for the VA. In your testimony you
mention transportation to VA centers, in major metropolitan, rural, and
isolated areas, is a major impediment for minority veterans.
What kinds of recommendations concerning outreach has the
committee made to VA to be more effective?
Answer:
In its July 1, 2006 report, the Committee recommended:
Outreach Program
``The Secretary mandates that an outreach program be
established by all Veterans Affairs Administrations and
appropriate staff offices to reach out and support all
veterans. As a minimum, the program must incorporate the
following goals/activities:
a. ``Inclusion of and coordination with local,
Federal and state veteran serving organizations in VA
facilities' outreach activities. These entities should
include, as a minimum, state and county Veterans
Affairs Agencies, Veteran Service Organizations (VSOs),
veteran serving organizations (i.e. minority veterans'
organizations that have not been granted VSO status),
agencies and organizations that serve the minority
community in the local area, faith-based organizations
that serve veterans, etc.;
b. ``Establishment of periodic Veteran Town Hall
meetings with veterans and their families to determine
needs and issues; meetings/processes must ensure that
minority veterans and communities are targeted in
culturally appropriate venues;
c. ``Allow facilities to advertise veteran benefits
and health care services and consult Marketing experts
to help VA facilities conduct effective communication
of VA offerings with particular attention to marketing
to minority communities;
d. ``Expand and improve the use of Internet based
access to VA benefits and health care, with particular
attention given to cultural and linguistic diversity;
e. ``Establish Minority Outreach Coordinators that
are full time, where warranted. Further recommend that
these be additional billets that are fully resourced
for those facilities, rather than requiring facility
directors to give up other billets to fill those
positions;
f. ``Mandate enhanced outreach communication and
coordination between VHA, VBA, NCA and appropriate
staff offices;
g. ``Identify Federal grants for states to conduct
grassroots outreach programs.''
The Committee also recommended that That VA's Outreach program is
extended and/or modified to include all means and processes to advise
minority veterans of their entitlements.
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
August 2, 2007
Saul Rosenberg, Ph.D.
Associate Clinical Professor of Medical Psychology
University of California, San Francisco
401 Parnassus Avenue
San Francisco, CA 94143
Dear Dr. Rosenberg:
In reference to our joint Subcommittee hearing on ``Issues Facing
Women and Minority Veterans'' held on July 12, 2007, I would appreciate
it if you could answer the enclosed hearing questions by the close of
business on October 2, 2007.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full and
Subcommittee hearings. Therefore, we would appreciate it if you would
provide your answers consecutively and single-spaced. In addition,
please restate the question in its entirety before the answer.
Please provide your response to Cathy Wiblemo. If you have any
questions, please call 202-225-9154.
Sincerely,
MICHAEL H. MICHAUD
Chairman
______
Questions for the Record
Joint Subcommittee Hearing
``Issues Facing Women and Minority Veterans''
held on July 12, 2007, 10:00 a.m.
Room 334, Cannon House Office Building
Follow-Up Questions for Saul Rosenberg, Ph.D.
I was particularly interested in the part of your testimony that
comments on the fact that African American veterans were about half as
likely as other veterans to receive service connected disability for
PTSD.
Was there an explanation as to why this was so?
You also mention in your testimony an idea promoted by the DoD Task
Force on Mental Health regarding Centers of Excellence for the Study of
Resilience.
Would you elaborate on that for the Subcommittee?
[DR. ROSENBERG DID NOT RESPOND TO THESE QUESTIONS SUBMITTED BY THE
SUBCOMMITTEE.]
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
August 2, 2007
Joy J. Ilem
Assistant National Legislative Director
Disabled American Veterans
807 Maine Ave. SW
Washington, DC 20024
Dear Joy:
In reference to our joint Subcommittee hearing on ``Issues Facing
Women and Minority Veterans'' held on July 12, 2007, I would appreciate
it if you could answer the enclosed hearing questions by the close of
business on October 2, 2007.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full and
Subcommittee hearings. Therefore, we would appreciate it if you would
provide your answers consecutively and single-spaced. In addition,
please restate the question in its entirety before the answer.
Please provide your response to Cathy Wiblemo. If you have any
questions, please call 202-225-9154.
Sincerely,
MICHAEL H. MICHAUD
Chairman
______
POST-HEARING QUESTIONS FOR
JOY J. ILEM
OF THE
DISABLED AMERICAN VETERAN
Question 1:
In testimony provided, DAV gives 8 recommendations to better serve
women veterans from combat theaters. The first recommendation concerns
barriers to seeking health care through VA.
In your estimation, what are the 3 biggest barriers
female veteran encounter when trying to access health care through VA?
Response: DAV believes women veterans face many barriers, some very
tangible and others that are seemingly invisible. As for the top 3 I
offer the following remarks.
Women's programs are small. When a new VA initiative or program is
created, for mental health, homeless veterans, or residential care, for
example, women typically constitute the smallest fraction of veterans
to be served. Sometimes this causes VA planners and managers
significant difficulty in program design and management. Additionally,
women's care is often complicated by a history of military sexual
assault, or they have minor children. Program planners typically design
these programs for the majority of patients who will use them, and the
majority of VA's patients are males. Fitting in women with their
special needs is often problematic, or women are required to accept the
program designed ``as is,'' without special consideration for their
circumstances. This is a barrier to care.
Second, there are no ``best models'' of care for women in VA. VA is
becoming recognized as a system that bases its services on evidence and
efficacy. We believe evidence-based care is the best care because VA
has tested its methods and has measured its outcomes for certain health
issues versus other health care techniques and practices that have not
been subjected to rigorous review. DAV supports this policy because it
produces higher quality of care for veterans. In respect to women,
however, until 2006 VA had no systematic research agenda for women's
health. While now underway, the results of this research agenda will
not be known or implemented for some time. In the interim, VA
clinicians are treating women without best-practices guidance. This is
a barrier to care.
Third, privacy and security for women remains a problem in VA
facilities. DAV continues to hear from women veterans that their
personal security and privacy are regularly compromised in VA
facilities that lack adequate space, secured rooms, private restrooms,
dressing rooms and sufficient privacy curtains in some VA clinics.
Women are frequently integrated into VA primary care teams, often
without regard to these gender and privacy issues. DAV and the
Independent Budget veterans service organizations have raised these
issues in the past, but progress in improving privacy and security for
women patients has been slow. This is a barrier to care.
Today's military will soon be comprised of 20 percent women.
Additionally women veterans are the fastest growing segment of the VA-
enrolled population. VA Central Office has established an Office of
Women's Health and a Center for Women Veterans, and VA has a Women's
Advisory Committee. Field facilities of the VA have designated women's
coordinators to help women move more smoothly through VA's various
processes. We hope that some of these developments and efforts will
help VA better address the needs of women who need VA health care as
urgently as their male counterparts who do not face these barriers to
care.
Question 2:
Women and minority OEF/OIF veterans returning from theater face,
what I believe, are additional challenges than their returning peers,
due, in part, to the lack of cultural education, lack of adequate
research on meeting their unmet needs and other issues.
What has your organization done to help in the outreach
effort?
Response: While outreach is a statutory responsibility of the
Department of Veterans Affairs, to ensure veterans are fully aware of
the benefits and services for which they may be eligible, DAV has a
fully trained corps of 260 National Service Officers (NSOs) who work in
both VA regional offices and VA medical centers, to ensure veterans
have full access to their rights and benefits. Also, DAV has stationed
NSOs and special Transition Service Officers (TSOs) in or near major
military treatment facilities to aid active duty members and veterans
who are under care in those facilities. The primary purpose of our out-
stationing the NSOs and TSOs in military facilities is to ensure that
claims for benefits are filed early and that we at DAV are able to help
get those claims processed in an expedited fashion. The TSO corps of
over 30 specially trained individuals plays an additional key role, of
providing VA benefits presentations, reviewing service medical records,
and assisting transitioning servicemembers with filing original VA
claims for benefits at nearly 100 military separation sites in the U.S.
These TSOs also participate in Department of Labor programs in
transition assistance.
Question 3:
Does your organization have any recommendations as to how to
address the growing need for specialized services for both women and
minority veterans?
Response: DAV believes that these matters are improved when they
are not concealed within VA but are properly brought out and to the
attention of the veterans service organization community and to
Congress. The more oversight the Committee is able to provide helps
keep these important issues surfaced. If the Department sees that the
Committee places a high priority on them, they will draw necessary
resources (in whatever form) so that progress can be made.
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
August 2, 2007
Betty Moseley Brown, Ed.D.
Associate Director, Center for Women Veterans
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Betty:
In reference to our joint Subcommittee hearing on ``Issues Facing
Women and Minority Veterans'' held on July 12, 2007, I would appreciate
it if you could answer the enclosed hearing questions by the close of
business on October 2, 2007.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full and
Subcommittee hearings. Therefore, we would appreciate it if you would
provide your answers consecutively and single-spaced. In addition,
please restate the question in its entirety before the answer.
Please provide your response to Cathy Wiblemo. If you have any
questions, please call 202-225-9154.
Sincerely,
MICHAEL H. MICHAUD
Chairman
______
Questions for the Record
Hon. Michael H. Michaud, Chairman
Subcommittee on Health, House Committee on Veterans' Affairs
July 12, 2007
``Issues Facing Women and Minority Veterans''
Question 1: Your testimony indicates that there are 22 VA health
care facilities that have dedicated comprehensive women's center space.
I have 3 questions on that:
Are you saying that 22 of the 154 VA Medical Centers have space for
women? That isn't a very good percentage if that is what you are
saying. Why don't all of the V AMC's have dedicated space for women? Is
the space proportionate to the number of female veterans provided
services at those locations?
Response: The Veterans Health Administration (VHA) provides high
quality primary and specialty health care to women veterans at its
facilities and clinics throughout the country. At 22 of these
facilities, VHA has comprehensive women's primary care clinics that
provide coordinated care such as mental health treatment, and
gynecological and breast services at the same visit and within the same
physical space.
Any specialty care that is needed but not available at a specific
facility can be provided by another Department of Veterans Affairs (VA)
facility in the same geographic area, or fee-for-service arrangements
with a community provider.
The women veterans' strategic health care group monitors services
provided to women veterans through an annual, Web-based survey, Plan of
Care/Clinical Inventory (POC/CI). The fiscal year (FY) 2006 Annual
Report of 153 VA medical facilities found that 41 percent of VA medical
facilities have designated women's primary care clinics and teams. An
additional 43 percent of VA medical facilities provide separate gender-
specific care in a women's health clinic, with the woman veteran
receiving her primary care in a mixed gender primary care clinic. Only
16 percent of VA facilities have no separate women's health clinic to
provide care to women veterans. The Under Secretary for Health has
asked for program proposals to address gender gaps during FY 2008.
Decisions on those proposals will occur in the next 60 days.
With regard to space, the women's comprehensive health clinic
spaces are designed locally to meet the needs of the women veterans in
that geographic area. Most commonly the development has been in
response to the increasing numbers of women presenting for care and
using the medical facility. In addition, VA research has shown that
having strong physician leadership in women's health has been a key
factor in development of comprehensive women's clinics.
Question 2: Are the Military Sexual Trauma (MST) Coordinators that
are designated in every VA facility full time?
Response: Every VA facility is required to appoint an MST
coordinator to serve as a point person for staff and veterans regarding
MST issues. This position is currently a collateral one, such that
coordinators are usually performing their MST coordinator duties along
with other clinical and/or administrative duties related to their
primary position. Many MST coordinators provide clinical care to
veterans with experiences of MST as part of their primary position.
However, clinical care is not a required component of the MST
coordinator position itself.
Question 3: The MST Support Team that was established in FY 2007 in
VA's Office of Mental Health Services help to ensure that VA is in
compliance with mandated monitoring of MST screening and treatment.
When in FY 2007 was this team established? How are they monitoring
compliance of MST screening and treatment? What have been the findings
so far?
Response: The MST support team was established in October, 2006.
The MST support team uses data from VHA electronic medical records to
monitor MST screening and treatment. The team submits annual screening
reports that describe the proportion of all veteran patients who have
been screened for MST in the past fiscal year. A screening rate is
provided for VHA nationally and for each VHA facility. The information
is also aggregated by gender, as is mandated by public law.
The team also submits annual treatment reports, which contain the
proportion of all veterans with positive MST screens that have received
free MST-related treatment, and the amount of treatment provided. These
reports also provide both national treatment rates and treatment rates
for each VHA facility, and provide data aggregated by gender.
During FY 2007 the MST support team accomplished the following:
Produced and distributed MST screening reports for FY
2005 and FY 2006. These reports improved upon existing MST monitoring
by aggregating data by VA facility, and for the first time enabled VA
facilities to monitor the proportion of all patients screened for MST.
Prior to this time, only national MST Screening rates were reported.
Created benchmarks for MST screening performance and
identified facilities functioning below the benchmark. VA's Office of
Mental Health Services (OMHS) set the target MST screening rate at 90
percent and above. The target was met by 96 out of 127 VA facilities.
There were 13 facilities with rates below 90 percent but greater than
or equal to 80 percent and 18 facilities with rates below 80 percent.
Provided consultation to sites regarding issues of
monitoring and performance benchmarking, with special attention to
sites not meeting the 90 percent criterion.
Identified that MST-related treatment is provided at all
VA facilities. These data also provide key feedback to VA clinicians
regarding the proportion of MST patients they are able to engage in
treatment.
Identified facility-based information resources
management (IRM) errors in clinical reminder implementation and
provided technical assistance for these facilities to correct
implementation and effectively screen for MST.
Identified the need to develop a more refined screening
tool that provides more specific data about the range of MST.
Question 4: What do you believe is the biggest challenge facing
women veterans today?
Response: The biggest challenge facing women veterans today is
gaining awareness of the benefits and services for which they are
entitled. According to a VA study, titled Women Veterans' Perceptions
and Decision-Making about Veterans Affairs Health Care (Washington et
al 2007), in spite of efforts to make women veterans knowledgeable
about available gender-specific services, there is an information gap
regarding women veterans' VA eligibility and advances in care. A second
article, titled To Use or Not to Use: What Influences Why Women
Veterans Choose VA Health Care (Washington et al 2006), cited that'' .
. . non-VA users had substantial knowledge deficits of VA benefits,
eligibility, and availability of women's health care service.'' The
study notes that 48.5 percent of non-VA users cite lack of knowledge of
VA eligibility and benefits as the reason for not using them.
VA is tenaciously addressing this information deficit. Not only are
we aggressively informing women veterans of their benefits, we have
women veterans program managers at each VA medical center and women
veteran coordinators at each VA regional office to assist women
veterans.
The number of women using VA health care continues to rise, and is
projected to be 8.11 percent of all veteran users by FY 2011. VA is
committed to meeting the needs of returning deployed women veterans as
well as those of our aging women's population, and to create an
environment that serves the woman veteran by providing excellent
comprehensive health care services.
In order to increase focus on quality of care issues and
comprehensive longitudinal care for women veterans, additional
initiatives in FY 2008 are focused on comprehensive care of women,
including those conditions which have high mortality for women, such as
heart disease, obesity, and cancers such as lung cancer and colorectal
cancer. HVAC, Subcommittees on Health and DAMA, 7-12-07, Questions for
the Record, McClenney
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
August 2, 2007
Lucretia McClenney
Director, Center for Minority Veterans
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Lucretia:
In reference to our joint Subcommittee hearing on ``Issues Facing
Women and Minority Veterans'' held on July 12, 2007, I would appreciate
it if you could answer the enclosed hearing questions by the close of
business on October 2, 2007.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full and
Subcommittee hearings. Therefore, we would appreciate it if you would
provide your answers consecutively and single-spaced. In addition,
please restate the question in its entirety before the answer.
Please provide your response to Cathy Wiblemo. If you have any
questions, please call 202-225-9154.
Sincerely,
MICHAEL H. MICHAUD
Chairman
______
Questions for the Record
Hon. Michael H. Michaud, Chairman
Subcommittee on Health, House Committee on Veterans' Affairs
July 12, 2007
``Issues Facing Women and Minority Veterans''
Question 1: In your testimony you indicate that the Minority
Veterans Program Coordinators' annual report has been converted to a
quarterly web based report.
Question 1(a): Could you elaborate on what measures are taken once
your Center identifies opportunities for improvement?
Response: The Center for Minority Veterans (CMV) meets on a monthly
basis with senior Department of Veterans Affairs (VA) officials and
program offices to identify opportunities for improvement, to develop
strategies, and to track progress. The Director of CMV meets monthly
with the Deputy Secretary and provides updates on the status of these
opportunities.
Question 1(b): What type of support do the coordinators get at the
local level from the director's of the facilities?
Response: The directors of the health care facility, regional
office and national cemetery are responsible to ensure that MVPCs have
the necessary resources to be effective and efficient to perform the
functions needed (e.g., numbers of hours allocated to perform the
duties, computer access/email, and funding for projects and/or special
programs as required). In addition, each administration has a
designated MVPC liaison at VA central office. CMV staff meets monthly
with these liaisons and quarterly with the senior leadership of each
administration to discuss outreach activities, issues and concerns that
impact minority veterans.
Question 1(c): Are these full time positions?
Response: As of September 2007, 5 minority veterans program
coordinators are full time positions. The majority are part time or
collateral duties.
Question 2: You mention that the Center provides cultural
competency training to the field.
Question 2(a): How comprehensive is the training and is it hands on
or remote training as in web based?
Response: CMV provides training to the minority veterans program
coordinators by 2 primary means:
Biennial Training Conference--Every 2 years, CMV sponsors
a minority veterans program coordinator training conference. During
these conferences attendees are provided instruction on various topics
of interest to support their local programs. Cultural competencies are
one of the subject areas covered. After the recent 2007 conference,
slides from the cultural competencies presentation were posted on the
VA Employee Education Service (EES) website for use by minority veteran
program coordinators who were not able to attend the conference.
Monthly Conference Calls--Cultural competencies have been
a training topic during monthly conference calls with minority veterans
program coordinators.
Question 3: Outreach to minority veterans can be particularly
challenging given the differences in cultures. There are many ways to
conduct outreach, but to conduct effective outreach is critical. How
does the center measure its success in reaching minority veterans
through the various partnerships and programs that you have?
Response: CMV measures its success in reaching minority veterans by
tracking the number of veterans calling or writing directly for
assistance, participation at outreach activities, and partnerships that
have been established with external stakeholders.
Question 4: What do you believe is the biggest challenge facing
minority veterans today?
Response: Minority veterans experience many of the same challenges
that all veterans experience. However, minority veterans have
experienced and often experience racial/ethnic discrimination or lack
of cultural sensitivity more often than non-minority veterans. Minority
veterans are more likely to be effected by chronic diseases,
disparities in health care, homelessness, and unemployment. HVAC,
Subcommittees on Health and DAMA, 7-12-07, Questions for the Record,
Middleton
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
August 2, 2007
Shannon L. Middleton
Deputy Director, Veterans Affairs and Rehabilitation Division
The American Legion
1608 K Street, NW
Washington, DC 20006
Dear Shannon:
In reference to our Subcommittee on Health hearing on ``Vet
Centers'' held on July 19, 2007, and our joint Subcommittee hearing on
``Issues Facing Women and Minority Veterans'' held on July 12, 2007, I
would appreciate it if you could answer the enclosed hearing questions
by the close of business on October 2, 2007.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full and
Subcommittee hearings. Therefore, we would appreciate it if you would
provide your answers consecutively and single-spaced. In addition,
please restate the question in its entirety before the answer.
Please provide your response to Cathy Wiblemo. If you have any
questions, please call 202-225-9154.
Sincerely,
MICHAEL H. MICHAUD
Chairman
______
Questions for the Record
Joint Subcommittee Hearing
Issues Facing Women and Minority Veterans
Held on
July 12, 2007, 10:00 a. m.
Follow-Up Questions for Shannon L. Middleton
1. In testimony provided, DAV gives 8 recommendations to better
serve women veterans from combat theaters. The first recommendation
concerns barriers to seeking health care through VA.
In your estimation, what are the 3 biggest barriers
female veterans encounter when trying to access health care through VA?
The 3 biggest barriers female veterans encounter when trying to
access health care through VA are: lack of knowledge about VHA
services, not knowing that they may be eligible for health care
benefits, and the perception that VA only caters to male veterans.
2. Women and minority OEF/OIF veterans returning from theater face,
what I believe, are additional challenges than their returning peers,
due, in part, to the lack of cultural education, lack of adequate
research on meeting their unmet needs and other issues.
What has your organization done to help in the outreach
efforts?
The American Legion publishes a booklet entitled Guide for Women
Veterans that provides information about VA health care, services
provided by The American Legion, information about health issues (like
breast cancer, PTSD, sexual trauma, heart disease, drug and alcohol
addiction) and a list of resources to enable them to find information
about various issues. We disseminate them through our department
service officers, outreach events, on our website and make them
available upon request to the public.
In the past, The American Legion has participated in a homeless
female veteran workgroup for the Southeast Veterans Service Center and
served on Subcommittees for the 2004 Women Veterans Summit hosted by
the Department of Veterans Affairs.
The American Legion is currently planning to collaborate with the
Center for Women Veterans to organize a Women Veterans' Forum to be
held in conjunction with the organization's mid-winter conference. The
American Legion is also participating in the 2008 Women Veteran's
Summit.
We are constantly seeking new ways to bring information to
veterans, all veterans.
Does your organization have any recommendations as to how
to address the growing need for specialized services for both women and
minority veterans?
One effective way to ascertain the need for specialized services is
to find various ways to ask women and minority veterans what needs they
have that are not being met by current services. This can be patient
survey, or an outreach initiative that includes a survey that VA
disseminates by mail or via web. The information gathered would be
useful in determining system-wide need for specific programs or
services and may be useful in depicting geographical or population
trends for needed services.
Once these needs are identified, The American Legion recommends
that VA develop and implement policy to address these deficiencies in a
timely manner and conduct an extensive outreach campaign to make these
special populations--and those who serve them--aware of the
enhancements. The organization also recommends that Congress
appropriate adequate funding to maintain these enhancements, once they
are in place.
Finally, DAV's recommendations that VA and DoD collaborate to
conduct surveys of recently discharged active duty women and recently
demobilized female Reserve component members to assess the barriers
that they perceive or have experienced in seeking health care through
VA and that VA Medical Centers establish a consumer council that
includes veterans' service organizations, family members, and
veterans--especially OEF/OIF veterans--would be excellent approaches as
well.