[Senate Hearing 111-205]
[From the U.S. Government Publishing Office]
S. Hrg. 111-205
VA HEALTH CARE SERVICES FOR WOMEN VETERANS: BRIDGING THE GAPS IN CARE
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
__________
JULY 14, 2009
__________
Printed for the use of the Committee on Veterans' Affairs
Available via the World Wide Web: http://www.access.gpo.gov/congress/
senate
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COMMITTEE ON VETERANS' AFFAIRS
Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West Richard Burr, North Carolina,
Virginia Ranking Member
Patty Murray, Washington Lindsey O. Graham, South Carolina
Bernard Sanders, (I) Vermont Johnny Isakson, Georgia
Sherrod Brown, Ohio Roger F. Wicker, Mississippi
Jim Webb, Virginia Mike Johanns, Nebraska
Jon Tester, Montana
Mark Begich, Alaska
Roland W. Burris, Illinois
Arlen Specter, Pennsylvania
William E. Brew, Staff Director
Lupe Wissel, Republican Staff Director
C O N T E N T S
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July 14, 2009
SENATORS
Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........ 1
Burr, Hon. Richard, Ranking Member, U.S. Senator from North
Carolina....................................................... 2
Burris, Hon. Roland W., U.S. Senator from Illinois............... 3
Murray, Hon. Patty, U.S. Senator from Washington................. 4
Brown, Hon. Sherrod, U.S. Senator from Ohio...................... 5
Begich, Hon. Mark, U.S. Senator from Alaska...................... 53
WITNESSES
Hayes, Patricia M., Ph.D., Chief Consultant, Women Veterans
Health Strategic Health Care Group, U.S. Department of Veterans
Affairs; accompanied by Irene Trowell-Harris, M.Ed, Ed.D,
Director, Center for Women Veterans, U.S. Department of
Veterans Affairs............................................... 6
Prepared statement........................................... 7
Response to requests arising during the hearing by:
Hon. Daniel K. Akaka..................................... 44
Hon. Patty Murray........................................ 51
Hon. Mark Begich.....................................54, 58, 64
Response to post-hearing questions submitted by:
Hon. Daniel K. Akaka..................................... 65
Hon. Richard Burr........................................ 68
Williamson, Randall B., Director, Health Care Issues, Government
Accountability Office.......................................... 12
Prepared statement........................................... 14
Ilem, Joy, Deputy National Legislative Director, Disabled
American Veterans.............................................. 70
Prepared statement........................................... 71
Christopher, Tia, U.S. Navy Veteran; Women Veterans Coordinator,
Iraq Veteran, Project Associate, Swords to Plowshares.......... 78
Prepared statement........................................... 79
Chase, Genevieve, U.S. Army Reserve Veteran, Operation Enduring
Freedom, Afghanistan; Founder and Executive Director, American
Women Veterans................................................. 82
Prepared statement........................................... 84
Williams, Kayla M., U.S. Army Veteran; Board of Directors, Grace
After Fire; Senior Adviser, VoteVets.org....................... 85
Prepared statement........................................... 87
Olds, Jennifer, U.S. Army Veteran on behalf of Veterans of
Foreign Wars................................................... 89
Prepared statement........................................... 91
APPENDIX
Veterans Health Administration, U.S. Department of Veterans
Affairs, Patient Satisfaction Scores by Gender Using CAHPS;
report......................................................... 103
Four, Marsha (Tansey), RN, Chair, Woman Veterans Committee,
Vietnam Veterans of America; prepared statement................ 109
Bhagwati, Anuradha K., MPP, Executive Director, Service Women's
Action Network (SWAN); prepared statement...................... 113
VA HEALTH CARE SERVICES FOR WOMEN VETERANS: BRIDGING THE GAPS IN CARE
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TUESDAY, JULY 14, 2009
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 9:33 A.M., in
room 418, Russell Senate Office Building, Hon. Daniel K. Akaka,
Chairman of the Committee, presiding.
Present: Senators Akaka, Murray, Brown, Begich, Burris, and
Burr.
OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN,
U.S. SENATOR FROM HAWAII
Chairman Akaka. This hearing of the Senate Veterans'
Affairs Committee will come to order.
Aloha and good morning to all of you. Welcome to this
important hearing on VA's Health Care Services for Women
Veterans. We will be looking at programs already in the works
to improve access to and the quality of care and other unique
issues facing women veterans.
Women veterans are the fastest-growing segment of veterans.
In 1988, when VA first began providing care to women, they were
only 4 percent of the veteran population. Today, the percentage
of women veterans is nearing 8 percent and expected to rise
substantially over the next two decades. So, it is appropriate
that we ask now, ``Is VA meeting the needs of women veterans?''
Many women veterans in need of services fall through the
cracks because VA does not have a thoroughly gender-focused
range of care set up to catch them. There are many obstacles
that veterans face. Access to health care and homelessness are
two, and many veterans--women veterans in particular--are
struggling to get the services they deserve. For too long, the
approach to helping veterans avoid obstacles through veteran
benefits and services has been predominantly focused on men.
Today, the Committee will review these issues and how they
affect women veterans.
While I applaud VA for the progress it has made in recent
years to ramp up services for the rapidly growing number of
women veterans, there is much still to be done to bridge the
gaps in access to care that women veterans face compared to
their male counterparts.
I am pleased that the Committee, with the leadership of
Senator Murray, recently approved legislation designed to
enhance the understanding of women veterans' need for health
care and to improve the delivery of that care. I hope to bring
this legislation before the full Senate during this work
period.
Today's hearing gives us a chance to better understand the
current situation with an eye toward fixing what is not working
and expanding what is.
And now I'd like to call on our Ranking Member for his
opening statement.
STATEMENT OF HON. RICHARD BURR, RANKING MEMBER,
U.S. SENATOR FROM NORTH CAROLINA
Senator Burr. Mr. Chairman, thank you. I hope you're doing
well this morning. Aloha.
Chairman Akaka. Aloha.
Senator Burr. Welcome to our witnesses.
We're here to look at the advocacy of health care services
VA provides to a growing number of individuals who have proudly
worn the Nation's uniform: women veterans. The statistics do
not lie. In 1990, there were 1.2 million women veterans. Today,
there are 1.8 million, a number that continues to grow. In
1990, women represented 4 percent of the veterans' population.
Today, they represent 8 percent.
North Carolina is no stranger to this growth. My State
ranks sixth in the total number of women veterans, with just
over 67,000 residing there. Fourteen percent of the active duty
force is comprised of women, many of whom have served in combat
or war zones. They fly combat aircraft, man missile placements,
serve on ships in dangerous waters, drive convoys in areas at
risk of ambush.
In short, our military and our country are heavily
dependent on the service of women. We must honor their service
by ensuring VA health care systems meet their unique needs.
As we move forward to do that, there is one more statistic
that I would like to call to the attention of everyone--one
that suggests we have some work to do. According to the VA
budget submissions, in 2007, just over 146,000 women veterans
used gender-specific health care services at the Veterans
Administration.
In 2008, despite the growing number of women veterans that
I talked about, there were over 141,000 users of the system, a
decline of 3 percent from just 1 year ago.
The question this Committee must ask is why? Why do women
veterans feel uncomfortable coming to a hospital system largely
comprised of male patients, or do they? Does the VA provide the
unique services required by women veterans? Does it provide
these services in enough locations to make travel convenient?
When VA cannot provide quality care, does it use services
that already exist in the community that are specific to the
needs of women? These are all questions that I am hopeful our
panelists will help us find the answers to.
Mr. Chairman, just across the Potomac River stands the
Women in Military Service for America Memorial. The memorial
serves as the ceremonial entrance of Arlington National
Cemetery. I think its placement at the front gate of American's
most hallowed military cemetery is symbolic.
For many years, the service of military women often went
overlooked and unheralded. We now know better. As Former
Senator Bob Dole said at its dedication 12 years ago, the
memorial serves as ``a lens through which we can better see and
appreciate the dedication and sacrifice of American service
women.''
I look forward to hearing from our witnesses today, and I
hope that this will serve as a lens through which this
Committee can see where improvements need to be made for women
who have served their country and their military.
I thank you, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Burr.
Now I'd like to call on Senator Burris for his opening
statement.
STATEMENT OF HON. ROLAND W. BURRIS,
U.S. SENATOR FROM ILLINOIS
Senator Burris. Thank you very much, Mr. Chairman, Ranking
Member Burr.
Unfortunately, Members, I am scheduled to preside over the
Senate in just a few moments. But, before I go, I would like to
recognize the importance of this hearing.
As someone who has fought for the quality and diversity
throughout my career, I believe this hearing is long overdue.
Too often the role of women in military has been misunderstood;
their accomplishments and needs overlooked.
In the VA health system, women's status as a minority has
lead to disjointed, gender-specific care that can be difficult
to access and hard to navigate. There is no reason why a woman
seeking basic, primary care should have to go to two or three
different providers in order to meet their needs.
Women make up the largest-growing segment of the veterans'
population, which is all the more reason for us to move forward
toward integrated services, including mental health providers
that recognize the unique needs of women, such as military
sexual trauma.
I commend the work of the VA thus far at addressing these
issues. Tremendous progress has been made, but I am concerned
that only one-third of the Veterans' health facilities provide
for the one-stop shop approach, an approach which shows the
highest level of patient satisfaction. All of our female
veterans deserve the highest quality of care, and we must work
toward that day when every VA facility is fully equipped to
address these needs.
Mr. Chairman, I recall a presentation on the floor by
Senator Kay Bailey Hutchison from Texas about these women who
were in the Air Force in World War II--and there are a few of
them still around--and what the trauma was from Senator
Hutchison's presentation, which she was trying to get
resolution.
I became a cosponsor, so I really want to know just where
that is because women flew those missions while the men were
fighting the wars. They flew the supply missions on those
airplanes, and they paid their way to Texas. Then, when they
were discharged--unbelievably, as Senator Hutchison said--they
had to pay their way back home. Some of these women are still
alive. And after hearing that speech, I told her to put me on
that bill as a cosponsor, because we have to recognize those
women, the same way we recognize the Tuskegee Airmen for their
dedicated service to this country.
So, I am going to still try to follow-up on that, Mr.
Chairman, find out what is really happening to that resolution
that Senator Hutchison presented to the Senate because we need
to recognize those women that are still alive and give respect
to those who passed on for their service to this country.
Thank you, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Burris.
And now we'll hear from Senator Murray with an opening
statement.
STATEMENT OF HON. PATTY MURRAY,
U.S. SENATOR FROM WASHINGTON
Senator Murray. Thank you very much, Chairman Akaka and
Senator Burr for holding today's hearing to have a chance to
really examine the status of the VA's health care services to
women veterans. I want to thank today's witnesses for all of
their hard work to both improve the level of care provided to
women veterans and to increase the public awareness of this
important issue, as well.
As has been said very well by my colleagues here, since the
founding of our Nation, women have always played a role in our
military, and that role, of course, has changed over time. In
today's conflicts, women are playing a far different and far
greater role. And, while they have historically remained as a
very small portion of the veteran population and a small
minority at the VA, women veterans now total about 1.8 million,
and they make up nearly 8 percent of the total veteran
population in the United States.
That percentage, we all know, is expected to increase more
than 14 percent by 2033, and the number of women veterans
enrolled in the VA System is expected to double in the next 2
to 4 years. That makes female veterans one of the fastest
growing demographics of the veterans today, and I think it is
really important at this hearing and always that we remember
that behind those statistics are real women. These are women
who sacrificed for their country, they have borne the burden of
battle, and they now deserve the respect and the benefits that
their service has earned.
Earlier this year, as has been referenced, the Committee
passed my bill, the Women Veterans Health Care Improvements Act
of 2009. More recently, the full House has passed similar
legislation. I think this is very important progress. I hope we
can pass this out of the Senate soon because that bill will
encourage women to access the VA, increase the VA's
understanding of the needs of women veterans and, really, the
practices that helped them get the best kind of care.
But we cannot stop there and we are not stopping there. I
know that the VA is recognizing the need to improve services to
women veterans and are taking steps to ensure equal access to
benefits and health care for them.
So, I look forward to today's hearing for the steps the VA
is taking and what else we need to be doing to achieve that
goal.
I would say to Senator Burris, I believe that the bill that
Senator Hutchison was talking about was a Congressional Gold
Medal that has been sent to committee. I appreciate you
bringing that up and hope that it can move forward.
Senator Burris. Mr. Chairman, my staff said the resolution
was approved, but we need to get the Gold Medal part for the
women. So, that is what is pending. That is correct, for the
record.
Thank you very much, Senator Murray. We must do that.
Chairman Akaka. Thank you very much, Senator Murray.
I want to welcome our principal witness from VA, Dr.
Patricia Hayes, Chief Consultant of the Women Veterans Health
Strategic Health Care Group. She is accompanied by Dr. Irene
Trowell-Harris, Director of the VA Center for Woman Veterans.
Following Dr. Hayes, we have GAO's Director of Health Care
Issues, Mr. Randall Williamson.
Thank you, all, for being here this morning. Both VA and
GAO's full testimony will appear in the record.
Before I call on Dr. Hayes for her testimony, I call on
Senator Brown for an opening statement.
STATEMENT OF HON. SHERROD BROWN,
U.S. SENATOR FROM OHIO
Senator Brown. Yes. Thank you, Mr. Chairman. I appreciate
that. I appreciate the work that Senator Murray has done in the
Women Veterans Health Care Improvement Act of 2009; and thank
you, Mr. Chairman, for holding this meeting.
I wanted to mentioned briefly, we know what the issue is,
we know how important it is that there be more parity--if that
is the right word--more equality in everything from the big VA
Centers to the CBOCs to veterans' health care generally, but I
wanted to tell a real quick story.
A woman by the name of Loretta Schimmoler of Crawford
County, Ohio--a rural county halfway between Columbus and
Cleveland--was one of the first woman to be inducted in the
Ohio Veterans Hall of Fame, helped to lead the way in what was
to become the Flight Nurses Corps. Her story mirrors in many
ways what women have faced in the military dealing with VA
care.
She was a dedicated patriot, intent on making our Nation
and our military better. Despite the hurdles she faced, she was
able to change the way our military did business to the
betterment of all those who served. She began flying in 1932
for her service. At that time, nurses, of course, were almost
exclusively women, and would serve on planes and helicopters
that provided care and evacuation to wounded servicemembers. It
was not until World War II that the program became a reality,
due in large part to her persistence and her vision.
The VA of her day, of Loretta Schimmoler's day, looked a
lot different from the Department of Veterans Affairs today in
meeting the needs of our women veterans, but much more needs to
be done.
This hearing is a major step in doing that.
I thank the Chairman and thank Senator Murray for her work.
Chairman Akaka. Thank you very much, Senator Brown.
Again, let me call on Dr. Hayes and ask for your testimony.
STATEMENT OF PATRICIA HAYES, PH.D., CHIEF CONSULTANT, WOMEN
VETERANS HEALTH STRATEGIC HEALTH CARE GROUP; ACCOMPANIED BY
IRENE TROWELL-HARRIS, M.ED, ED.D, DIRECTOR, CENTER FOR WOMEN
VETERANS, U.S. DEPARTMENT OF VETERANS AFFAIRS
Ms. Hayes. Good morning, Mr. Chairman and Ranking Member.
Thank you very much for the opportunity to discuss how VA has
provided and will continue to improve the health care for women
veterans.
As you mentioned, I am accompanied by Dr. Irene Trowell-
Harris, the Director of the Center for Women Veterans. Thank
you for submitting my written testimony into the record.
I also want to thank you, Chairman Akaka and Senator Murray
specifically, again for your interest in working with VA to
ensure that the quality of care for women veterans is improved
and that they do get what they deserve for service to their
country.
Secretary Shinseki recently testified before this Committee
that enhancing the primary care for women veterans is one of
VA's top priorities. Women who were deployed and served in the
recent conflicts in Afghanistan and Iraq are enrolling in VA at
record numbers.
Of all the women veterans who are deployed and served in
Afghanistan or Iraq, VA knows that 44 percent have enrolled in
VA health care, which suggests that many of these newly-
enrolled women veterans really rely on VA for their health care
needs.
Women veterans are entering VA's health care system
younger, and they have health care needs distinct from their
male counterparts. The average age of women veterans is 48-
years-old compared to 61-years-old among men. Nearly all newly-
enrolled women veterans are under age 40 and they are of
childbearing age. This obviously means a trend that will create
a shift in how we provide their care.
This shift will move primary care and gender-specific care
needs of women veterans from the multi-visit, multi-provider
model that has been mentioned here--which does not achieve the
continuity of care that we desire--to a more comprehensive,
primary care delivery model. VA recognizes many current
challenges and has initiated new programs, including the
implementation of comprehensive primary care, enhancing the
health care environment for women veterans, creating a mini
residency education program among women's health, staffing
every VA Medical Center with a Women Veterans Program Manager,
and improving communication and outreach to women veterans.
Most importantly, VA is implementing an innovative approach
to women's health care that will address the concerns about
fragmented care, quality disparities, and lack of provider
proficiency in women's health by fundamentally changing the
experience for women veterans in VA.
To achieve the goal of providing comprehensive primary
care, we have designed three models to promote the delivery of
optimal primary care, and we recognize that more than one model
might be needed even within various facilities in order to meet
the needs to deliver comprehensive care to women veterans.
All three models ensure that every women veteran, wherever
she comes to VA, has access to a VA primary care provider who
is capable of meeting all of her primary care needs in the one-
stop shop model that we have described. A site-level evaluation
will also begin so that we can be certain that this program is
effective. We are going to start that in fiscal year 2010.
All women veterans need to feel welcomed in their VA
setting. The health care environment directly and indirectly
affects the quality of the care that is provided to women
veterans, and a part of redefining our comprehensive care to be
delivered means that we have to have improvements in the health
care environment which are being made in order to support
dignity, privacy, and sense of security.
VA recognizes many primary care providers need to update
their women-specific clinical experience. VA is offering many
residencies in women's health across the country. Early results
from this program indicate success in increasing competencies
in 12 areas of women's health care.
As of June 2009, 216 participants from 90 VA medical
centers and 28 community-based outpatient clinics have
completed the program. In order to ensure improved advocacy at
the facility level, VA has mandated that all medical centers
appoint a full-time Women Veterans Program Manager. These
managers support increased outreach to women veterans, improve
the quality of care, and develop best practices in the
organizational delivery of women's health care.
Effective internal and external communication is also
important in terms of outreach and our success of implementing
comprehensive care. VA Center for Women Veterans will continue
to expand its ongoing outreach and communications plan to
ensure not only public awareness of women veterans' service to
our country, but making sure that women veterans are aware of
their eligibilities and access to VA health care.
Mr. Chairman, VA's commitment to women veterans is
unwavering, and while significant efforts are underway, we know
that we have to do a lot more to improve the care. A lot more
needs to be done. We stand at a really unique moment in time
where our actions and plans today will build this system that
will provide equal care for all of American veterans regardless
of gender.
Thank you once again for this opportunity to testify, and
we now are very prepared to answer any addition questions that
you may have of us.
[The prepared statement of Ms. Hayes follows:]
Prepared Statement of Patricia Hayes, Ph.D., Chief Consultant, Women
Veterans Health Strategic Health Care Group, Veterans Health
Administration, Department of Veterans Affairs
Good morning, Mr. Chairman and Ranking Member. Thank you for the
opportunity to discuss how the Department of Veterans Affairs (VA) has
provided, and will continue to improve, health care availability for
women Veterans. I would like to thank the Chair, this Committee and
Senator Murray specifically for your interest in working with VA to
ensure women Veterans receive the care they have earned through service
to their country.
The Secretary has recently testified before this Committee that
enhancing primary care for women Veterans is one of VA's top
priorities. VA recognizes that the number of women Veterans is growing
with women becoming increasingly dependent on VA for their health care.
Of the 1.8 million women Veterans in the United States more than
450,000 have enrolled for care. This number is expected to grow by 30
percent in the next 5 years. Women currently comprise approximately 14
percent of the active duty military, 17.6 percent of Guard and Reserves
and 5.9 percent of VA health care users.
Women who were deployed and served in the recent conflicts in
Afghanistan and Iraq are enrolling in VA at historical rates. Of all
women who were deployed and served in Afghanistan or Iraq, 44 percent
have enrolled and 43 percent have used VA between 2 and 11 times. This
suggests that many of our newer women Veterans rely more heavily on VA
to meet their health care needs.
My testimony will describe how VA plans to continue to enhance the
delivery of high quality health care to this fastest growing cohort of
Veterans and ensure today's heroes and tomorrow's Veterans receive the
care they need. Women Veterans served; they deserve the best care
anywhere.
current challenges
Women Veterans entering VA's system are younger and have health
care needs distinct from their male counterparts. The average age of
women Veterans is 48 years old, compared to 61 years old among men.
Nearly all newly enrolled women Veterans accessing VA care are under 40
and of childbearing age. This trend creates a need to shift how we
provide health care.
General primary care and gender-specific care needs of women
Veterans are currently provided through a multi-visit, multi-provider
model that may not achieve the continuity of care desired.
Additionally, some VA facilities rely on outside providers for gender-
specific primary care and specialty gynecological care through the use
of fee-basis care. This approach to women's health delivery can provide
challenges in providing continuity of care.
Moving to a more comprehensive primary care delivery model could
challenge VA clinicians, who may have dealt predominately with male
Veterans and sometimes have little or no exposure to female patients.
VA facilities may also need to increase both focus and resources on
women's health (e.g., space, staffing, appropriately equipped exam
rooms) to ensure adequate privacy for women during examinations.
Initiatives are underway and under development to address these and
other changes brought on by the increasing number of women Veterans
seeking care from VA.
The quality of health care VA provides to women Veteran's exceeds
the care many would receive in other settings (including commercially
managed care systems, Medicare and Medicaid). For example, VA's system
of quality management and preventive patient care, supported by
technology like our electronic health record and clinical reminders,
ensures women are screened for unique health concerns like cervical
cancer or breast cancer at higher rates than non-VA health care
programs. On the other hand, VA is aware of existing disparities
between male and female Veterans in our system. The Department is
particularly concerned with performance measures related to
cardiovascular disease, the leading cause of death in women.
Performance scores for several quality measures, including high blood
pressure, high cholesterol and diabetes, all of which contribute to
cardiovascular disease risk, show a consistent difference between men
and women Veterans. Gender-neutral prevention measures such as colon
cancer screening, depression screening and immunizations show a
disparity between men and women Veterans as well. For example, although
VA significantly outperforms Medicare on colorectal cancer screening,
only 75 percent of women Veterans are screened compared with 83 percent
of male Veterans. These issues and other quality issues are being
addressed.
Some women report that lack of newborn care and child care forces
them to seek care elsewhere. VA recently supported section 309 of
S. 252, which would authorize VA to furnish health care services up to
7 days after birth to a newborn child of a female Veteran who is
receiving maternity care furnished by VA if the Veteran delivered the
child in a VA health care facility or in another facility pursuant to a
contract for service related to such delivery. We similarly supported a
companion measure in the House. We believe benefits such as these will
help improve women Veterans' perception that VA welcomes them and will
provide complete, effective and compassionate care.
current initiatives
VA recognizes the need to continually improve our services to women
Veterans, and has initiated new programs including the implementation
of comprehensive primary care throughout the Nation, enhancing mental
health for women Veterans, staffing every VA medical center with a
women Veterans program manager, creating a mini-residency education
program on women's health for primary care physicians, supporting a
multifaceted research program on women's health, improving
communication and outreach to women Veterans, and continuing the
operation of organizations like the Center for Women Veterans and the
Women Veterans Health Strategic Healthcare Group.
Comprehensive Primary Care for Women Veterans
VA is implementing an innovative approach to women's health care
that seeks to reduce the possibilities of fragmented care, quality
disparities, and lack of provider proficiency in women's health by
fundamentally changing the experience of women Veterans in VA.
In March 2008, the former Under Secretary for Health charged a
workgroup to define necessary actions for ensuring every woman Veteran
has access to a VA primary care provider capable of meeting all her
primary care needs, including gender-specific and mental health care,
in the context of a continuous patient-clinician relationship. This new
definition places a strong emphasis on improved coordination of care
for women Veterans, continuity, and patient-centeredness. In November
2008, the workgroup released its final report identifying
recommendations for delivering comprehensive primary care. These
recommendations included: (1) delivering coordinated, comprehensive
primary women's health care at every VA health care facility by
recognizing best practices and developing systems and structure for
care delivery appropriate to women Veterans; (2) integrating women's
mental health care as part of primary care, including co-locating
mental health providers; (3) promoting and incentivizing innovation in
care delivery by supporting local best practices; (4) cultivating and
enhancing capabilities of all VA staff to meet the comprehensive health
care needs of women Veterans; and (5) achieving gender equity in the
provision of clinical care.
To implement these goals and recommendations, the Women Veterans
Health Strategic Health Care Group developed a women's comprehensive
health implementation planning (WCHIP) tool to assist facilities in
analyzing its own current health care delivery for women Veterans and
plans for primary care delivery enhancement. Every VA health care
facility was requested to convene a multidisciplinary planning and
implementation team to address comprehensive primary care for women
Veterans. The WCHIP tool outlines an analysis of current services and
projected use, a market analysis and a needs assessment, which
facilitated the development of a business plan. This plan includes
resource needs, goals, timelines, budgets, training needs and program
evaluation metrics to deliver comprehensive health care to women
Veterans. No later than August 1, 2009, facilities will finalize their
analyses and action plans based on the WCHIP tool. These plans will be
instrumental in decisions for directing resources for fiscal 2010 and
2011.
To achieve the goal of providing comprehensive primary care for
women Veterans, VA has designed three models to promote the delivery of
optimal primary care. Under the first model, women Veterans are seen
within a gender neutral primary care clinic. Under the second model,
women Veterans are seen in a separate but shared space that may be
located within or adjacent to a primary care clinic. Under the third
model, women Veterans are seen in an exclusive separate space with a
separate entrance into the clinical area and a distinct waiting room.
In this scenario, gynecological, mental health and social work services
are co-located in this space. Each of these models can be tailored to
local needs and conditions to systemize the coordination, continuity,
and integration of women Veterans' care. One-third of VA facilities
have already adopted the third model of comprehensive primary care
delivery and found it to be very effective. Access and wait times are
better at sites where gender-specific services are available in an
integrated women's primary care setting, regardless of whether the care
was delivered in a separate space (such as a women's clinic) or
incorporated within general primary care clinics. VA facilities that
have established a ``one-stop'' approach to primary care delivery have
already reported higher patient satisfaction on care coordination for
contraception, sexually transmitted disease screening, and menopausal
management.
In addition to improving the primary care infrastructure for women
Veterans, VA is committed to advancing the entire range of emergency,
acute, and chronic health care services needed by women Veterans to
develop an optimal continuum of health care. Such a continuum of health
care includes: enhancing and integrating mental health care, medical
and surgical specialty care, health promotion and disease prevention,
diagnostic services and rehabilitation for catastrophic injuries.
Enhancing Mental Health
VA has identified that 37 percent of women Veterans who use VA
health care have a mental health diagnosis; these rates are higher than
those of male Veterans. Women Veterans also present with complex mental
health needs, including depression, post- traumatic stress disorder
(PTSD), military sexual trauma (MST), and parenting and family issues.
In response, VA has instituted policy requirements, such as that
outlined in its Handbook on Uniform Mental Health Services in VA
medical centers and Clinics, to emphasize the importance of being aware
of gender-specific issues when providing mental health care. In
particular, the Handbook identifies services every health care facility
must have available for women Veterans to ensure integrated mental
health services as a part of comprehensive primary care for women
Veterans. For example, the services provided optimally involve a
designated, co-located, collaborative provider (psychologist, social
worker, or psychiatrist) and care management with an emphasis on the
need for safety, privacy, dignity, and respect to characterize all
gender-specific services provided. Facilities are strongly encouraged
to give patients treated for other mental health conditions the option
of a consultation from a same-sex provider regarding gender-specific
issues. All inpatient and residential care facilities must provide
separate and secured sleeping accommodations for women. Every VA
facility has a designated MST coordinator who serves as a contact
person for related issues. VA is ensuring a concerted effort to provide
quality mental health care appropriate to the needs of women Veterans.
Women Veterans Program Managers
In order to ensure improved advocacy for women Veterans at the
facility level, VA has mandated all VA medical centers appoint a full-
time Women Veterans Program Manager. These Women Veterans Program
Managers support increased outreach to women Veterans, improve quality
of care provision, and develop best practices in organizational
delivery of women's health care. They serve as advisors to facility
directors in identifying and expanding the availability and access of
inpatient and outpatient services for women Veterans and provide
counseling on a range of gender- specific care issues. Women Veterans
Program Managers also coordinate and provide appropriate local outreach
initiatives to women Veterans. As of June 2009, each of VA's 144 health
care systems has appointed a full-time Women Veterans Program Manager.
Mini-Residency Training in Women's Health
As the number of women Veterans continues to grow, particularly
women of childbearing age, VA recognizes many primary care providers
need to update their women-specific clinical experience. VA is offering
waves of mini-residencies in women's health across the country in
strategic geographic locations. Each mini- residency lasts two and a
half days and is taught by national women's health experts. Clinical
staff receive presentations on contraception, cervical cancer screening
and sexually transmitted infections, abnormal uterine bleeding, chronic
abdominal and pelvic pain, post-deployment readjustment issues for
women Veterans, and other womens' health topics. Early results from
this program indicate its success in increasing competencies in 12
areas of women's health care. As of June 2009, 216 participants (119
physicians, 77 nurse practitioners, 10 physician assistants, 9
registered nurses and 1 therapist) from 90 VA medical centers and 28
community-based outpatient clinics have either scheduled or completed
this program.
Research on Women Veteran's Health Issues
VA has clearly established women's health as a research priority
and intensified its efforts in the last decade. Currently, VA's Office
of Research and Development supports a broad research portfolio focused
on women's health issues, including studies on diseases prevalent
solely or predominantly in women, hormonal effects on diseases in post-
menopausal women, and health needs and health care of women Veterans.
VA's Office of Health Services Research and Development is funding 27
research projects in this area. VA is also conducting a study that will
survey 3,500 women Veterans (both those who use VA health care and
those who do not) to identify the changing health care needs of women
Veterans and to understand the barriers they face in using VA health
care. We anticipate receiving the results of this study within the next
several months, and we will share these findings with the Committee. VA
is also conducting risk assessments to track the effects of deployments
on women Veterans and improve our epidemiological data on Operation
Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) women Veterans
through the National Health Study for a New Generation of U.S. Veterans
(an OEF/OIF cohort study). We are enrolling 60,000 Veterans for this
study--of these 12,000 are women.
Outreach Initiatives
Effective internal and external communication and outreach to women
Veterans is critical to the success of implementing comprehensive care.
Surveys and research show that women Veterans are often not aware of
the services and benefits available to them. VA is engaging in multiple
efforts to correct this. For example, VA's Center for Women Veterans
and the Women Veterans Health Strategic Health Care Group will continue
to expand its ongoing outreach and communications plan to ensure
increased public awareness of women Veterans and their service to our
country and increased awareness by women Veterans of VA health care.
Center for Women Veterans
The Center's mission is to ensure that women Veterans have access
to VA benefits and services on par with male Veterans; that VA programs
are responsive to the gender- specific needs of women Veterans; that
joint outreach is performed to improve women Veterans' awareness of VA
services, benefits, and eligibility criteria; and that women Veterans
are treated with dignity and respect. The Center coordinates and
collaborates with Federal, State and local agencies, Veterans service
organizations and community- based organizations.
Women Veterans Health Strategic Healthcare Group
VA has developed a women Veterans health care ``brand'' within VA
and among women Veterans. VA has made available upgraded communication
resources, processes, and tools to Veterans Integrated Service Networks
(VISN) and facilities. VA is building on the OEF/OIF call center to
reach out to women Veterans. New scripts, new outreach materials and
training are being developed to ensure women Veterans are aware of VA's
services and benefits. While these efforts have created an important
foundation upon which to build, it will take sustained and coordinated
planning to successfully reach out to women Veterans.
future plans
While significant efforts are underway, we recognize that more must
be done. VA must provide recurring funds to build adequate
infrastructure for primary care and expand services to provide a full
continuum of care for women Veterans at its secondary and tertiary care
facilities. This investment of resources will contribute to the
continuing goal of delivering quality health care focused on privacy,
safety, sensitivity, dignity and continuity.
Expanding Access to Gynecology
Gynecologists are indispensable in providing care for women with
abnormal findings on pelvic exams, such as abnormal pap smears,
complicated cases of pelvic pain and abnormal vaginal bleeding in
addition to specialized services in urology-gynecology, gynecology-
oncology and obstetrics care. As VA primary care physicians increase
their proficiency in women's health care to meet the needs of the
growing numbers of women Veterans, primary care physicians will need to
have on-site gynecologists available to act as experts, consultants and
teachers. VA plans to have a gynecologist available at each of VA's 144
health care systems by 2012.
Expanding Innovative Technology
In the area of innovative technologies, VA is expanding its efforts
to dramatically transform and improve care for women Veterans by
enhancing its electronic health records system to provide more
functionality related to women's health, including clinical reminders,
pharmacy alerts for teratogenic drugs, improved decision support,
gender-specific health history and screening questionnaires, e-videos
and other tools for shared decisionmaking, particularly with regard to
preference-sensitive health care choices (e.g., breast cancer surgery
and treatments).
conclusion
Mr. Chairman, VA's commitment to women Veterans is unwavering. We
stand now at a unique moment in time where our actions and plans today
will build the system that will provide care equal to the health care
needs of all of America's Veterans, regardless of gender. Thank you
once again for the opportunity to testify. My colleagues and I are
prepared to address any additional questions you might have.
Chairman Akaka. Thank you very much, Dr. Hayes.
Mr. Williamson, we will now begin with your testimony.
STATEMENT OF RANDALL B. WILLIAMSON, DIRECTOR OF HEALTH CARE
ISSUES, GOVERNMENT ACCOUNTABILITY OFFICE
Mr. Williamson. Good morning, Mr. Chairman and Members of
the Committee. I am pleased to be here today as the Committee
considers issues related to VA's health delivery of service to
women veterans.
VA provided health services to over 281,000 women veterans
in fiscal year 2008, an increase of 12 percent in just 2 years.
Looking ahead, VA estimates that, while a total number of
veterans will decline by 37 percent by the year 2033, the
number of women veterans will increase by more than 17 percent
over that period; thereby putting greater demands on VA's
health care system to meet the physical and mental health care
needs of women veterans.
Women veterans seeking care at VA medical facilities need
access to a full range of physical health care services
including: basic gender-specific services, such as cervical
cancer screening and clinical breast examinations; specialized
gender-specific services such as obstetric care and treatment
of reproductive cancers; and mental health care services, such
as care for depression and anxiety.
In addition, women veterans from conflicts in Iraq and
Afghanistan present new challenges for VA's health care system.
These women have experienced a greater exposure to combat than
women participating in previous conflicts. VA data showed that
as many as 20 percent of women veterans of Iraq and Afghanistan
have been diagnosed with Post Traumatic Stress Disorder. An
alarming number have also experienced sexual trauma while in
the military. As a result, many have complex physical and
mental health care needs.
In my testimony today, which is based on ongoing work for
the Committee, I will discuss three aspects based largely on
the work we did at 19 VA medical facilities.
First, the onsite availability of health care services for
women veterans at VA facilities. Second, the extent to which VA
facilities are following VA policies for delivering health care
service for women veterans. And, third, some key challenges
that VA facilities face in providing women's health care.
Dr. Hayes has outlined a number of steps VA is undertaking
to fulfill its commitment to provide high-quality health care
services for women veterans. VA has taken some bold steps in
this regard. However, much remains to be done in some areas to
fully implement the new initiatives.
Regarding the availability of services, we found that basic
gender-specific services, including pelvic and clinic breast
examinations, were available onsite at all 9 VAMCs and 8 of the
10 CBOCs we visited. All of the VAMCs that we visited offered
at least some other specialized gender-specific services, such
as treatment for abnormal cervical screening test and breast
cancer.
Among the CBOCs, the two largest facilities we visited
offered an array of specialized, gender-specific care onsite.
The other eight referred women to other VA and non-VA
facilities for most of these services. Outpatient mental health
care services for women varied widely among the VAMCs and the
eight Vet Centers we visits, but were more limited at some of
the CBOCs.
Four CBOCs offered women-only counseling groups, and only
the two larger CBOCs offered specific programs for women who
had experienced sexual trauma in the military. Also, only two
VAMCs offered residential treatment programs for women who
experienced sexual trauma. None had dedicated inpatient
psychiatric units for women.
Regarding the extent to which VA facilities are following
VA policies for delivering health care services for women
veterans, we found that none of the VAMCs and CBOCs we visited
was fully compliant with VA policy requirements related to
privacy for women veterans in all clinical settings where those
requirements applied.
For example, many of the outpatient clinics we visited did
not have adequate visual and auditory privacy in their check-in
areas. Further, the facilities we visited were in various
stages of implementing VA's new initiative to provide
comprehensive primary care for women veterans.
Finally, officials at facilities that we visited identified
challenges they face in providing health care services to the
increasing numbers of women seeking VA health care. One
challenge involves space constraints.
For example, the number, size, and configuration of exam
rooms, as well as limited space for women's bathrooms,
sometimes made it difficult for facilities to comply with VA's
privacy requirements.
Officials also reported challenges in hiring providers with
specific training and experience in women's health care issues,
including treatment for women veterans with Post Traumatic
Stress Disorder and those who had experienced military sexual
trauma.
So, overall, Mr. Chairman, while VA has taken important
steps in many areas to improve health care services for women
veterans, some areas still require attention.
Mr. Chairman, that concludes my remarks.
[The prepared statement of Mr. Williamson follows:]
Chairman Akaka. Thank you very much, Mr. Williamson.
Dr. Hayes, thank you for your testimony.
VA is poised to make some important changes to how care is
delivered to women, but, in fairness, we seem to have a bit of
a disconnect between mandates and what is actually happening. I
am going to ask you a series of questions about this.
First, VA has mandated that all VA medical centers appoint
a full-time Women Veterans Program Manager.
Does every VA medical center have one in place?
Ms. Hayes. VA has reported, as you know, that there are 144
out of the 144 sites that have a full-time Women Veterans
Program Manager. I am actively now in the process of verifying
that.
What we do know is that my office, over the last 3 months,
has held three different trainings. We trained 142 Women
Veterans Program Managers over the last 3 months. We think it
is very important to train folks--to take these brand-new folks
and make sure that they know what they are doing--in terms of
this plan to develop health care for women.
Chairman Akaka. Dr. Hayes, hopefully, you have read the
testimony of the second panel.
Jennifer Olds details her battle with PTSD and specifically
makes a case for cognitive therapy. Congress passed a law last
year requiring that these state-of-the-art therapies be
available to all veterans.
I suppose this is something you need to take for the
record, but are all veterans with PTSD able to receive this
kind of treatment?
Ms. Hayes. You're right, Mr. Chairman, I will have to take
that specifically for the record in terms of the issues about
access to PTSD treatment. But I think that one of the things
that was pointed out in the GAO report about where there is
access, it is very important that we first ask veterans what
they need, and that is why it is important to hear from
veterans about what their struggles are and, I think, to make
sure that we are addressing what that veteran needs in terms of
her care.
So, for example, there has been a lot of question about
residential treatment. I think when we look at women veterans,
we have to be aware that, for example, women with children are
not necessarily interested in going off, leaving their
children, and going to a residential site. So that every time
we look at what we have available, we have to make sure we have
available for each veteran what she might need, whether it is
intensive outpatient, residential, or telehealth-telemedicine.
Some of our veterans have rated that as very highly successful
for them to be in that type of treatment.
So, we will take the question for the record in terms of
the exact issue of where PTSD treatment is available, but I
think that it needs to be a constant issue of asking the
veteran what they need, and that particular issue for Ms. Olds,
I think, is very important.
Chairman Akaka. Thank you.
[The response to additional information requested during
the hearing follows:]
Response to Request Arising During the Hearing by Hon. Daniel K. Akaka
to Patricia Hayes, Ph.D., Chief Consultant, Women Veterans Health
Strategic Health Care Group, U.S. Department of Veterans Affairs
The Department of Veterans Affairs (VA) is strongly committed to
making evidence-based psychotherapies for Post Traumatic Stress
Disorder (PTSD) widely available to Veterans. VA is in the process of
actively disseminating Cognitive Processing Therapy (CPT) and Prolonged
Exposure Therapy (PE), two specialized forms of Cognitive-Behavioral
Therapy for PTSD. CPT and PE are recommended in the VA/Department of
Defense (DOD) Clinical Practice Guidelines for PTSD stating that the
intervention is always indicated and acceptable. Moreover, in 2008, the
Institute of Medicine conducted a review of the literature of
pharmacological and psychological treatments for PTSD and concluded in
its report, Treatment of Post Traumatic Stress Disorder: An Assessment
of the Evidence, that the evidence was greater for these treatments
than for all other currently available treatments for PTSD.
To date, 1,908 Veterans Health Administration staff have received
training in CPT. The majority of these clinicians were trained as part
of the national CPT rollout, with some staff also receiving training
through similar, locally arranged training. In addition, 722 DOD
clinicians have received CPT training through the national rollout or
locally arranged VA training. Seven hundred and twenty-eight VHA
providers have received training in PE, with the majority of staff
being trained as part of the national PE rollout. One hundred and
twenty-nine DOD clinicians have received PE training through the
national rollout or other similar VA training. Additionally, VA is
planning training in CPT and PE for the remainder of this Fiscal Year
and beyond. Currently, 94 percent of VA medical centers provide CPT or
PE; remaining sites are implementing plans to provide at least one of
these therapies. Moreover, to promote the implementation and ongoing
delivery of evidence-based psychotherapies for PTSD and other mental
disorders, VA has designated a Local Evidence-Based Psychotherapy
Coordinator at each medical center.
Chairman Akaka. Mr. Williamson, your testimony lays out
that none of the facilities reviewed fully implemented VA's
policies for women's health care.
Could you determine the reasons behind this noncompliance?
Was it funding, lack of training, or anything else?
Mr. Williamson. Thank you, Mr. Chairman.
It is very difficult sometimes to understand the reason.
The area you referred, for example, in assuring privacy of
women veterans, part of it is due to facilities in terms of the
layout that currently exists and is trying to convert and
modify that. But, also, I think part of it comes down to
commitment at the local level.
There is no doubt that the Secretary, Dr. Hayes, and others
at the top are very committed to implementing VA policies and
improving overall health care for women. Yet, as we visited the
facilities, simple things that are easy to do like placing exam
tables so the foot is away from the door, putting sanitary
products in bathrooms for women--those things are easy--and if
they're not being done, part of that reason may come back to is
there a commitment at the local level to make sure these
policies are done?
Chairman Akaka. Several witnesses on the second panel are
quite critical of VA care for women. Let us take these one by
one.
DAV is most concerned that some service-connected women
veterans are without access to VA health care.
Ms. Williams detailed a lack of understanding on the part
of VA providers.
Ms. Christopher found that community care is easier to
access than VA care.
And Ms. Chase finds that, generally, VA is playing catch-up
to meet the needs of women veterans.
Dr. Hayes, what is at the root of all these issues, and how
can we rectify them?
Ms. Hayes. I think that what is at the root of these issues
really is a system that has not been responsive to the needs of
women veterans.
I came a year ago and launched an initiative specifically
to make VA more inclusive of women veterans: to establish
primary care that meets their needs so they do not have to come
for multiple visits; and to make sure that we reach out to
those who do not have health care.
One of the things that research has shown us over and over
again is that women do not know that they have VA services
available. And it is not good enough if we reach them yet we do
not have the right care when they get in our front door.
And, so, we have a very intensive effort going on, which
started, as you saw last year, but is rolling up August 1 with
every facility giving us an implementation plan for: how to fix
primary care for women veterans; how to make the facilities
respond to the environment of care issues; and to develop
services going forward that will meet women veterans' needs. I
think that until we do that--until we make sure that it is
right--then we should begin to reach out to our women veterans
and welcome them back. We will have a specific initiative which
we identified the need for service-connected women veterans to
get their health care, and that is the first on our list. When
we can be assured that there is primary care available for them
when they walk in the door.
Chairman Akaka. Thank you.
Senator Burr, your questions?
Senator Burr. Thank you, Mr. Chairman.
Dr. Hayes, I want to give you an opportunity to clarify
something for me from a statement.
In your testimony on page 7, you state, ``As of June 2009,
each of the VA's 144 health care systems has appointed a full-
time Women Veterans Program Manager,'' but I thought I heard
you say in the response to Senator Akaka that you were in the
process of confirming if you had 144 Women Veterans Program
Managers. Which one is accurate? Do we have them or are you in
the process of verifying that we----
Ms. Hayes. I am personally in the process of verifying, and
because I want to make sure that I can tell you that is
accurate when we say that we have 144 in place.
Senator Burr. How long does that take?
Ms. Hayes. We have a list out now. It is really a question
sometimes of are they in place or not. The 144 was----
Senator Burr. But your testimony says, ``As of June 2009,
each of the VA's 144 health care systems has appointed a full-
time Women Veterans Program Manager.''
Is that a correct statement or an incorrect statement?
Ms. Hayes. That is a correct statement in terms of a person
appointed to be in that job. We want to make sure that person
is full-time, they are able to do the job, they have been
trained, and they are the person in place to do the work that
we need them to do to advance this program.
Senator Burr. But what----
Ms. Hayes. Some of them had just been hired----
Senator Burr. This is under an architecture put out by VA
leadership that you are going to have 144 individuals in 144
facilities, and I would take for granted that listed in the
dictate is permanent and full-time. It spells out exactly what
these program managers are going to do.
Ms. Hayes. That is correct.
Senator Burr. So, I guess what I am having difficulty
clarifying is if you say they are ``in place,'' but you have to
verify they are in place because you want to make sure that
they are full-time folks, et cetera. Does that mean that you
have had individual facility managers who have hired somebody
different than what the leaderships dictate was?
Ms. Hayes. No, sir. I do not want to indicate that.
For example, we had sites where a Women Veteran Program
Manager was half-time, and----
Senator Burr. But is that allowable under----
Ms. Hayes. No, excuse me. I do not mean new, I meant that
she was doing it half-time. She was performing duties serving
women veterans in a clinic setting, and she has been appointed
as a full-time person. We want to make sure that veterans have
been transferred appropriately to other people so that her
full-time can be devoted to the Women Veteran Program Manager
job.
We are still in a transition phase. I'm making sure that we
are fulfilling what we said we're fulfilling, which is making
sure those folks are available to do this work for us.
Senator Burr. OK. You said on page 9, ``The VA plans to
have gynecologists available at each of the VA's 144 health
care systems by 2012.''
Why is it 2012 and not 2009?
Ms. Hayes. Maybe I should explain. We have gynecologists
onsite in approximately 70 locations. And, again, I do not have
an exact number for the record on that. At the other sites, we
have gynecology services available largely by fee-basis.
As we develop and the number of women veterans increases,
we anticipate that we will need to bring those services in-
house; and we want to move toward that by fiscal year 2012.
Senator Burr. Well, do you agree with the statement that I
made that we've actually had a decrease in the number of women
seeking gender-specific health care services at the VA from
last year to this year?
Ms. Hayes. I do not actually think that we have had a
decrease. I think that the way that we were accounting for the
numbers for gender-specific health care has changed, and that,
in fact, masked some of the gender-specific care. We've changed
from having women go just to pap clinics to having women go to
comprehensive primary care clinics, and the costs of that were
all rolled in together so that we actually, on paper, look like
we decreased our gender-specific care, when, in fact, we
believe that it has increased.
Senator Burr. What percentage of gender-specific care does
the VA purchase in the community? Has it increased or
decreased?
Ms. Hayes. I do not know the answer to that.
Senator Burr. OK. In your testimony, you mentioned the
disparity in quality between male and female veterans in the VA
System. You specifically noted the disparity in prevention
measures such as colon cancer screening, depression screening,
and the immunizations.
What are you doing to address these issues?
Ms. Hayes. We are quite aware that there have been quality
differences for women. The quality for performance measures for
women has been significantly lower than that for men, and we
have data now consistently showing that trend from 2006
forward.
We have launched, with the Office of Quality and
Performance, efforts which are identifying the quality measures
at each site. That data was not available to facility directors
until very recently, so, we knew there was a national problem,
but we did not know exactly how people were doing. So, we have
asked the facilities now--as we rolled out this data just this
last week--to address specific areas at their facility where
the gender performance scores are lower for women than men; and
we are helping them as we develop mechanisms to look at patient
factors, provider factors, and system factors.
And, again, it goes back to the issues about are we
providing care that women can access in a way that once we say,
for example, come back for your fasting lipid test, that that
is even possible for a woman to conveniently do. So, we need to
look at all of it. We need to look at it from a facility-
specific level, and we need to address these gender disparities
very actively, and we are doing that.
Senator Burr. You noted the recently-released report
``Provisions of Primary Care to Women Veterans,'' and you point
to it as a roadmap for improving service to women veterans. The
report's recommendations, I think, have been well-received
throughout the veterans' community.
Let me ask you, does the VA have a timetable for
implementing the report's recommendations?
Ms. Hayes. We have a timetable for implementing
comprehensive primary care to women veterans. The first part--
the comprehensive plans--are due by the facilities in August,
and that is a 5-year plan. Not to say they have 5 years to get
it done, but they must take immediate actions, interim actions,
and mid-term actions.
Senator Burr. Does that plan encompass all of the
recommendations in that report?
Ms. Hayes. That plan does not encompass all the
recommendations in the report. There are many recommendations
that are still being developed in terms of a timeline.
Senator Burr. Whose responsibility will it be for
implementing the recommendations in the report?
Ms. Hayes. It is ultimately the responsibility of the Under
Secretary for Health. The workgroup was set up by the Under
Secretary for Health, but I consider the responsibility largely
on my shoulders and my office.
Senator Burr. Great. I thank you and thank you, Mr.
Chairman.
Chairman Akaka. Thank you, Senator Burr.
Senator Murray?
Senator Murray. Thank you, Mr. Chairman.
Let me follow-up on Senator Burr's question on the report
called ``Provision of Primary Care for Women Veterans.''
I thought it was a good report, and it did a good job of
detailing some of the most pressing challenges, but it was sent
out as not mandatory. It was just sent out to the VA
facilities.
If it did not include any mandatory requirements or any
accountability, how do we expect it to be implemented?
Ms. Hayes. There are two factors that actually help us move
forward immediately with the recommendations of the report. As
I mentioned, there were these mandatory implementation plans
which started in January; and there was a gap analysis that was
mandatory and required in March; and a resource request that
was submitted in May, which was also required.
The other part of the policy, though, is that we have the
policy for Women Veterans Program Health Services Handbook,
formally known as handbook 1330.01, which has been revised and
is now in the concurrence process. It details mandated policy
changes, including the one-stop type model for Provision of
Women's Health Care and Primary Care. It also continues to
mandate the privacy standards and the other environment issues
that are required.
Senator Murray. OK. Well, sometimes when things are sent
out, it is informational; they're not implemented. So, I am
concerned that there is not any mandatory requirements, but we
will continue to follow that.
Dr. Hayes, as you know, the military currently bars women
from serving in combat. We all know, however, in today's wars
that there is no frontline on the battlefield. We know that
women are serving right alongside their male colleagues and
they are engaging in combat with the enemy. Unfortunately, the
new reality of this modern warfare is not well understood here
at home, including by some in the VA. This knowledge gap
obviously impacts the ability of women veterans to receive
health care and disability benefits from the VA.
What are you doing, Dr. Hayes, to ensure that all VA
staff--both in the VHA and in the VBA--are aware that women are
serving in combat and that they are getting the health care and
benefits that they have earned?
Ms. Hayes. We have initiated a number of efforts. In
addition to training providers--we know that it is not enough
just to train the providers in terms of women's health--we need
to train all of the staff. We have a staff module--a
sensitivity module, which is under development--in order to get
across and make sure that everyone who comes into contact with
women veterans appreciates the extensiveness of her service and
some of the complex issues that she may face.
As you know and are well aware that many of our women
veterans have the effects of combat and are serving--there is
not, I do not think, anyone who is serving today who is not
under significant stress.
Senator Murray. Right. But we have people who say well, you
were not in combat. You are a woman.
Ms. Hayes. I am distressed that those reports have come
forward, and we are educating our mental health people and our
other staff about the significance of women's service.
Senator Murray. Are you working with the Defense Department
to make sure that the experience of women veterans is properly
documented in their DD-214s?
Ms. Hayes. Dr. Trowell-Harris?
Ms. Trowell-Harris. I serve as an ex-officio on the Defense
Advisory Committee on Women in the Services, and the director
for that committee also is an ex-officio on the VA Advisory
Committee on Women Veterans.
This issue does come up frequently, and we are attempting
to educate everybody within DOD and VA; and currently we are
exploring an option of working with DOD and VA through the
White House Project called the Interagency Council on Women and
Girls. But, in this case, we are looking at women veterans and
servicemembers.
We are interested in an outreach communications model for
exploring that and which could help educate because the
education is not just to women veterans, the women
servicemembers----
Senator Murray. But you are talking about outreach in
general. I am talking about the problem which women are finding
on their DD-214s. It's not that nobody wrote ``combat'' because
nobody wanted to say they are in combat, but they come home and
then they cannot get service.
And Mr. Chairman and Members of the Committee should know
that we do have the Defense Bill on the floor right now. I am
going to be offering an amendment to make sure that the Defense
Department properly notes the combat experience on the DD-214s
so that when women come home, they are not fighting somebody
when saying ``but I was in combat.'' And they reply, ``Well,
you can't be.''
Ms. Trowell-Harris. Right.
Senator Murray. So, I hope that I get the support of this
Committee to do that.
Ms. Trowell-Harris. And that issue was raised in a
roundtable we had recently, which we were told during that
session that the military documents the location and they do
not use the word of combat. So, we did take that back to the
DACOWITS Committee, and they had somebody who is going to be
looking at that.
But this is probably an area where you all could really
help us with that, because the documentation needs to be there.
That would make it really easy for VA to deal with those
particular cases.
Senator Murray. OK. Well, I plan on offering that. I will
have more on the second round, but, for this round, I hear so
often from women veterans that you can provide all the service
you want, but I have got to take care of my kids. There is no
childcare available.
Are we looking at the issue of making sure women have
childcare so that is not the obstacle to them getting the
treatment they need?
Ms. Hayes. As you mentioned, we are very much aware that
women and men with children and grandparents with children need
childcare in order to access VA services. The Secretary has us
actively examining the issues, and we also are looking at the
opinion of General Counsel.
We may need Congress's support on this in terms of
authority to provide childcare, but we are actively exploring
it with the task force. We do have some pilots----
Senator Murray. You need authority from Congress to be able
to provide childcare? Did I hear----
Ms. Hayes. General Counsel may advise us. We will have to
get back with you for the record because there is concern about
the authority to provide childcare by VA.
Senator Murray. Well, do you expect to have that soon?
Ms. Hayes. Yes. Yes, ma'am, we do.
[The response to additional information requested during
the hearing follows:]
Response to Question Arising During the Hearing by Hon. Patty Murray to
Patricia M. Hayes, Ph.D., Chief Consultant, Women Veterans Health
Strategic Health Care Group, U.S. Department of Veterans Affairs
Senator Murray. OK.
Thank you, Mr. Chairman.
Chairman Akaka. Thank you, Senator Murray.
Senator Begich?
STATEMENT OF HON. MARK BEGICH,
U.S. SENATOR FROM ALASKA
Senator Begich. Thank you, Mr. Chairman. Thank you very
much for your testimony.
I apologize I was not here when you gave your verbal
testimony, but I have a few questions. I do want to follow-up
on several of the questions by the Chairman and the Ranking
Member in regards to the Women Veterans Program Managers.
I have a friend in Alaska, Joelle Hall, who's a female
veteran with two kids and a husband in the Guard. She has given
me kind of a shopping list the minute I told her that you all
were coming in front of me. She quickly gave me a list of
questions to ask and this is one of them.
I know there is a lot of discussion of what the 144 is or
is not, and I am going to ask you this question, then ask for a
timeline.
Can you provide the list of the positions that will be
occupied and by whome full-time, part-time, and when they will
actually be working full-time?
Ms. Hayes. We can provide that for the record.
Senator Begich. And your timetable to do that?
Ms. Hayes. We can provide that very soon for the record.
[The response to additional information requested during
the hearing follows:]
Senator Begich. OK, I think that will specifically answer
the questions that we are all asking around this topic and, in
that process, make sure that we know where they are going to be
assigned, which would help us understand the 144, and what they
mean, and what they are going to be doing.
Also, in regards to the Women Veterans Program Manager, is
there discussion of expanding this requirement to the CBOCs?
Ms. Hayes. We currently require that there be a liaison
named at each CBOC--a VA employee who is the liaison to the
Women Veterans Program Manager. We are not requiring that at
the CBOCs. They are facilities that we are looking at,
particularly at the very large CBOCs, as to whether that would
be an appropriate placement. But, no, we do not have a
requirement for that at the CBOCs.
Senator Begich. Let me ask you personally. Do you think
that is something that we should strive to do? I mean, it is
easy to have a task force and a group, but what do you think?
You are running the program.
Ms. Hayes. I think that if the person is full-time at the
facility and they are doing their job to involve everyone in
taking care of women veterans, then we do not necessarily need
one at a CBOC. I think the person has the ability to go out to
that CBOC, to make sure what is going there, and to provide
active coordination through other means--telephone and other
means--with that site.
So, I think if we make it so they are able to do their job,
then the CBOCs do not necessarily have to have one onsite.
Senator Begich. OK. Let me ask, and I do not know who would
answer this--Dr. Hayes or Dr. Harris. In regards to the design
of the facilities, we know--based on some of the other
facilities--the design is not there really to take into account
women veterans.
What is the process now to expand the facilities for that
purpose? And then I have a couple of additional questions.
Ms. Hayes. In part of the implementation plan, which, as I
said, could expand as far as 5 years, we have asked facilities
to name where they need space, where they need construction
monies to be able to fix the situation in terms of women
veterans. And, so, they are able to submit those longer-term
requests right now.
Also, my office is working with the Office of Construction
and Design so that new construction appropriately has designs
for women veterans' exam rooms, appropriately has requirements
for bathrooms, et cetera, in the new design process.
Senator Begich. In the Office of Construction Design, other
than your office, do they actually have clients that sit down
with them on a regular basis reviewing the designs? Do people
actually use the facilities?
Ms. Hayes. I do not know. We would have to get back with
you on that.
[The response to additional information requested during
the hearing follows:]
Women Veterans Facility Design Guidance
VA's Office of Construction & Facilities Management's (CFM) guiding
principles for the development of design and construction standards for
state-of-the-art 21st century VA facilities include a variety of
approaches to ensure they address the needs of Veterans, their
families, and VA health care providers in the most efficient and cost-
effective manner.
Advocating evidence-based design, with involvement and
awareness of latest issues in healing environment forums including
Planetree, Greenhouse, AIA Academy of Architecture for Health, American
Society of Healthcare Engineers, Center for Health Environments
Research, and others. Example: VAMC Martinsburg '07 Patient Single
Rooms Mock-up Study with results published in Health Environments
Research and Design (HERD) Journal, a leading peer reviewed evidence-
based design publication.
Basing Space Planning Criteria and Design Guide programs
on applicable evidence-based design research, active participation of
VA healthcare providers, administrators, and staff. Surveying best-
practice in private sector and other agencies, with Veterans' input.
All CFM efforts are focused on providing Veteran- and family-centric
healing environments supporting world class health care. Design Guides
depict functional relationships and design considerations in addition
to space planning criteria for heath care functions. They include
comprehensive information including an overview of design principles
and concepts, narrative text descriptions, and guide plates for
reference.
Extensively involving state-of-the-art experienced
national health care consultants together with field input in regular
VA Design and Construction Standards upgrades. CFM also follows the
principles in 2010 Guidelines for the Design and Construction of
Healthcare Facilities used by HHS, most state and local Authorities
Having Jurisdiction, and the Joint Commission for Accreditation of
Health Care Facilities as codes, regulations, or guidelines for design
and inspection. This process provides the experience of a wide range of
technical consultants and users.
Coordinating with over 70 VA advisory groups who
collaborate in the development and updating of VA Design Guides, Space
Planning Criteria, and Construction Standards and Specifications for
life-cycle operations. Examples: VA Community Living Centers; VA Mental
Health Facilities; Polytrauma Rehabilitation Centers; etc.
Many of the Veteran- and family-centric environments included in
our updated criteria reflect women's needs; these include the privacy
afforded by single bedrooms with bathrooms in hospitals and VA's
patient-centered design for Community Living Centers, replacing older
design concepts of traditional nursing home care facilities, again with
single bedrooms with bathrooms, organized in small community family-
like living units.
The Space Planning Criteria and Design Guides, completed in the
recent past, have addressed numerous specific changes reflecting
women's issues. These include Design Guides for Ambulatory Care,
Outpatient Clinic, and Leased-Based Clinic Design Guide, MRI,
Radiology, Nuclear Medicine, Radiation Therapy, etc. Changes include
increased importance of Mammography spaces, adjustment of workload
criteria to ensure the appropriate generation of women's health spaces,
larger more private dressing rooms areas, women's specialty exam/
procedure rooms larger than standard spaces, more bathrooms in targeted
treatment and diagnostic areas, separate male and female bathrooms in
small pubic areas and waiting rooms where one unisex bathroom would
technically suffice. On going recent efforts include:
February 5, 2010 finalization of interim space criteria
for Women's clinic, working with CFM staff and the Chief, Consultant
Women's Health Office. This interim space criteria will be utilized
either as part of a larger ambulatory care clinic or a stand alone
women's clinic.
Chief, Consultant Women's Health Office and members of her
staff have been regular members of advisory committee reviewing CFM
Standard updates.
00CFM has been meeting regularly with Women's Health
Office since early 2009 to review standards and discuss comments
Ongoing updates of Mental Health Design Guide, Community
Living Center Design Guide, Inpatient Units--Medical, Surgical Patient
Care Units Design Guide, and Procedure Suites Design Guides will
include updated criteria specifically addressing women's issues,
related to waiting rooms, privacy, check in areas, bathroom facilities
etc. These will be completed later this year.
Current IDQA/E task order is complete and soon to be
contracted for the updating or development of 6 priority Design Guides,
one of which is the Women's Clinic Design Guide which will include the
interim space criteria for women's clinic noted above and additional
guidance, to be completed later this year.
Project Examples:
VAMC Las Vegas New Hospital--Under Construction:
Women's Ambulatory Care Clinic located at the 3rd floor level
of the tower. The clinic area is 5600 sq. ft. and includes 9
exams rooms, 2 procedure rooms, a reception/waiting area, a
nurse station, utility rooms (clean and soiled), patient
toilet, staff lounge, staff toilet and offices.
VAMC Walla Walla OPC:
Women's Exam Rooms and physician offices grouped in a ``mini''
pod type arrangement (800 sq. ft.) along a dedicated clinic
corridor affording privacy, two dedicated exam rooms with
dedicated women's toilet provided between the exam rooms,
private dressing cubicle within the room and exam table out of
the line-of-sight from the door, and separate family waiting
and toilet rooms room to accommodate women and families.
08 February 2010
Senator Begich. I would suggest, as a former mayor who
dealt with many designs of buildings, that the users need to be
part of the equation. If they are not involved, they should be,
to be very frank with you, because--no offense to your office
and anyone else--but I know construction people; I used to be
in the business. They build to facilitate, they work off of
budget, and then they are done. I highly recommend that you
establish your work with the Office of Construction including
an advisory of actual clients who utilize those facilities
currently or have utilized their facilities to give advice on
how those should be constructed.
Some of the issues that you brought up, Mr. Williamson, are
small, yet they are significant. And design is part of it
because I can tell you if you do not design the bathroom the
right size, those extra items that you want in there are not
going to fit. Just if you would take that under at least some
advisement, I would appreciate that.
Mr. Williamson. If I may add also----
Senator Begich. Sure.
Mr. Williamson. We have heard the same thing in terms of
needing to have good communication between Dr. Hayes' office
and others with the construction people because, again, we are
dealing with a cultural change here. And it is really important
that the design people and the people who do specifications
have incorporated the needs of women veterans in terms of the
facilities.
Senator Begich. Well, thank you very much for echoing that.
Again, if you could report back to the Committee what your
plans are. I cannot stress enough, I have seen projects turn
from good projects to excellent projects because of the client
involvement. It does not matter if it is health care facilities
or anything, but, in this case, health care.
I will just end on this one question.
To follow-up on Senator Murray's comments in regards to how
women veterans understand what care is available, you had
mentioned there were veterans that are not necessarily aware of
the benefits.
How big would you say that universe is if you could measure
it in volume of people? Is it a few thousand? Is it tens of
thousands?
Ms. Hayes. I think it might be on the level of about 1
million women veterans.
Senator Begich. One million women.
Ms. Hayes. We have an active plan now to utilize the VA
call centers to reach out to women veterans and advise women
veterans about the benefits and the access. Again, that is
going to be phased in. We will start with the service-connected
women veterans, but we want to make sure that that does not
start until at least this fall because we want to make sure the
clinics are available.
Senator Begich. OK.
Ms. Hayes. And we have been told that there may be in the
neighborhood of 1.5 million women veterans altogether,
including those who use us.
There are about 450,000 enrolled women veterans right now.
So, there are about 1 million women veterans who have not
enrolled in VA. To the extent that they do not know about us,
we can only hope that we can reach out and tell them.
Senator Begich. And where do you think they get health care
coverage now?
Ms. Hayes. We don't know that.
Senator Begich. Or do they?
Ms. Hayes. We do have a study underway by Dr. Donna
Washington, and the results of that study will be available
approximately September. She has done research on this for us--
a stratified random sample of women--women who use VA, women
who do not use VA who are veterans, and those who use this and
don't come back. That study is going to help us understand how
women veterans who do not use VA access health care.
Senator Begich. Great. If you could share that with us,
that would be great.
[Note: This study was not completed in the anticipated
timeframe and the target for completion and release is spring
of 2010.]
Senator Begich. Mr. Chairman, I apologize for going over,
and thank you very much.
Chairman Akaka. Thank you very much, Senator Begich.
I have one remaining question for you, Dr. Hayes.
As part of my oversight responsibility, I learned that some
veterans at the Austin, Texas, clinic were inappropriately
being charged for services related to military sexual trauma.
As you well know, such care is provided at no charge. It is
quite difficult for women to seek such care to begin with, let
alone to be presented with a bill for it. One woman told me she
found this emotionally draining and an insult to all women who
served.
Is it your belief that this situation at Austin is an
isolated incident or are veterans nationwide being charged for
care for military sexual trauma?
Ms. Hayes. I can only let you know that personally having
been in the field for 25 years, I was actually involved in the
initial attempts to roll out the eligibility for military
sexual trauma for free counseling. It should not be ``free;''
it is without-charge counseling for veterans who have undergone
such trauma. So, it is personally distressing when I see all
these years later that there are veterans who have, I think,
inadvertently been charged, but, nevertheless, been charged for
their counseling services.
After the incident in Austin, a mental health group that
oversees the Military Sexual Trauma Program not only educated
the persons there at Austin regarding eligibility, but have
done a nationwide search and should have a report very soon
about any other cases that were uncovered. But we believe it is
an isolated type of occurrence.
They made an effort to retrain the eligibility clerks
through some online information that has gone out, and they
will have a report as to whether they discovered any other
sites where veterans were being charged for these services.
Chairman Akaka. Thank you very much.
Let me call on Senator Murray for any second round
questions.
Senator Murray. Thank you, Senator Akaka. I just have two
additional questions.
One is about homeless female veterans. The number of women
veterans who are ending up homeless has nearly doubled over the
last decade. One out of every 10 homeless veterans under the
age of 45 is now a woman. Many of these homeless female
veterans have kids.
According to Pete Dougherty, who is the Director of VA's
Homeless Veteran Programs, he said, ``While the overall numbers
of homeless vets have been going down, the number of women
veterans who are homeless is going up.''
I have introduced legislation to expand and improve the
services and care for homeless female veterans and their
children through the VA Grant and Per Diem Program in the Labor
Department's Homeless Veteran's Reintegration Program.
Dr. Hayes, tell me what else you think we should be doing
currently; and are you aware of this challenge that we have?
Ms. Hayes. Yes, I am very aware of the challenge. And I
think it is in part an unfortunate side effect of what is going
on in terms of the number of new women veterans, but it is a
particular challenge in a system that we have not done what I
think we need to do with screening for the things that underlie
the problems of homelessness.
I think--again, women veterans are largely invisible, so we
need to do more to screen for risks of homelessness in our
primary care setting. We need to do a better job of screening
women for substance use, asking women about whether they have
enough to get by, and having earlier interventions to avoid the
final decline into homelessness.
So, that is what I think we need to do in our system; and,
again, when we organize the primary care better to
comprehensively serve women and not just say, well, we will
take care of your pap smear and we will take care of your
mammogram, but to say instead, we will take care of you as a
whole person. Part of our goal is to make sure that we have
adequate mental health and social work in our primary care
setting for women.
I applaud and thank you for your efforts to put more into
the Grant and Per Diem Program. As you know, there have been
barriers because of the issues of children, and women with
children have been the most difficult group to place--whether
they are veterans or non-veterans--and, so, I certainly applaud
that effort because that is clearly what we need in expanding
the services that are available to women.
And I think it is another area where we have to continue to
provide education to our homeless outreach workers and our
homeless placement folks in areas where we may underserve the
women homeless so that they clearly ask a homeless person
whether they are a veteran and ask a homeless women whether she
is a veteran to make sure she gets in the VA services.
Senator Murray. Which goes to my last question. When a man
tells you they are a veteran, folks immediately say yes. Women
do not perceive themselves to be veterans. The general public
does not perceive women to be veterans, even if the woman says
she served in the military.
How are we going to overcome that sentiment and make the VA
and the general public really respect the service of women and
for women to perceive themselves as veterans? I mean, may we
should not call them ``veterans.'' I do not know. It is just a
real problem.
Have you thought about that? Do you have any advice for us?
What can we do to change that?
Ms. Hayes. I may turn to Dr. Trowell-Harris. A major effort
of her office is to tackle this problem.
I, myself, believe that the kind of effort that you are
putting in to raise the awareness goes very far in helping to
identify that women proudly served, and women have always
served as volunteers. I think we have to continue to get that
message out in the media, in the Internet, any way that we can,
and turn to our partners who are here--the veterans who are
here--to help us with that message.
But Dr. Trowell-Harris' office is dedicated also to this
outreach effort.
Ms. Trowell-Harris. We participate in all of the major
women's policy groups, the Veteran Service Organizations
Convention, minority groups, roundtable groups, hearings, and
we work with DOD. So, we try to get the education out there.
But my opinion is it is a matter of changing the culture,
getting everybody to understand that women are veterans.
So, you may recall that, years ago, the census used to ask
women are you a veteran? They would say, ``no.'' But the census
question changed to ask, ``Have they ever served in the Armed
Forces?'' Then women would say, ``yes.''
But, still, the education is needed for everybody, as Dr.
Hayes, said: the media, the women veterans, VA staff, and
Congressional members. It takes all of us. And, again, this is
one way that you can help us.
We are doing extensive outreach with the State Departments
of Veterans Affairs. Each State Department of Veterans Affairs
has a designated female assigned to work with women veterans,
and we do have conferences and send them tons of educational
material. Again, we work with various committees, such as the
Homeless Committee, the Minorities Affairs Committee, and the
Research Committee.
I have a report which some of you have seen. I had 20
recommendations for women veterans, and, as part of that, the
program managers who were part of that committee got Dr. Hayes'
office raised on the VA organizational chart, which was one of
the recommendations, and that has been done.
So, all of these things we are trying to do to improve
outreach. We are also working with the Honorable Tammy
Duckworth, who was just employed with VA. She heads a major
outreach effort, so we are meeting with her staff, looking at
some creative ways of getting the message out--not just to the
women veterans, but to everybody.
Senator Murray. I appreciate that. I think we really have
to focus on that as communities, as the media, as everybody so
that we, as a country, recognize that women who serve in the
military are veterans, deserve the benefits that they have
earned, and the respect of this country.
Ms. Trowell-Harris. Thank you.
Chairman Akaka. Thank you very much, Senator Murray.
Senator Begich?
Senator Begich. Mr. Chairman, if I can just ask a couple
more quick questions. I know I went over time last time.
Can you give me a sense of--making people aware as women
who are getting into the military--what kind of relationship
does the VA have with the DOD in ensuring that knowledge of
what is available specifically for women is available once they
become a veteran?
Who could answer that? Just what kind of relationship is
there?
Ms. Trowell-Harris. Our Secretary works with the Secretary
of Defense, and, also, there is a designated person at DOD that
works on benefit issues and also on health care issues. And I
did mention before about being on the DACOWITS Committee.
We do have some printed material that we use at all major
conventions and forums for women veterans. We have open forums.
Women do site visits to the field with our Advisory Committee.
So, we're trying multiple ways of getting the word out.
We have numerous media interviews, also; and we really
appreciate those because they help us get the word out to the
veterans nationally.
Senator Begich. And recruitment centers? Is there
information available at the recruitment centers?
Ms. Trowell-Harris. You mean military?
Senator Begich. Yes.
Ms. Trowell-Harris. I am not sure about that. We can get
back to you on that.
Senator Begich. I mean, the recruitment centers are the
first opportunity to educate on what the benefits are on the
back-end. So, if you could let me know how the recruitment
centers are operating and people are doing the recruitment,
what is there also? Is there any special effort, especially for
women on what is available and what could be available to them?
So, whichever of you could answer that, that would be
great.
Ms. Trowell-Harris. Sure, we will get back to you on that.
Senator Begich. And please, whoever would be the right
person to answer this, please do so.
From a funding level, is there enough resources for what
you need in some of the leasing of the space that is occurring
as well as future construction, and what will be necessary to
expand these facilities to meet the women veterans' needs? And,
if not, is that part of the 5-year plan, and tell me how that
all works.
Ms. Hayes. We have been working very closely with the
Office of Budget and with the Secretary's office to help define
the resource needs for this infusion of infrastructure, and we
understand that with the support of the Secretary, VA will have
the resources needed to enhance the care to women veterans.
Senator Begich. That is good. Very good.
At what point will you have kind of the strategic plan of
expansion of facilities that this Committee could at least see?
In other words, a plan that would kind of say, here is our game
plan for the next five or so years and here are the highest
priorities based on demand, based on facility structure, and so
forth.
Ms. Hayes. OK, that will not be my office specifically,
although, the plans are coming back through the VISN level
office and the Offices of Construction, but we can get back to
you regarding the Secretary's response on how the Secretary's
office would see these priorities.
[The response to additional information requested during
the hearing follows:]
Responses to Questions Arising During the Hearing by Hon. Mark Begich
to the Department of Veterans Affairs
Question. Please provide a priority list of VA's plans to have the
facilities identified in the GAO's preliminary findings on VA's
Provision of Health Care Services to Women Veterans.
Response. VHA has identified the following as top privacy and
security priorities based on the preliminary findings of the GAO's
Report on VA's Provision of Health Care Services to Women Veterans:
Adequate visual and auditory privacy at check-in;
Adequate visual and auditory privacy in the interview
area;
Exam rooms located so they do not open into a public
waiting room or a high-traffic public corridor;
Privacy curtains present in exam rooms;
Exam tables placed with the foot facing away from the door
(if not possible, placed so they are fully shielded by privacy
curtains);
Changing area provided behind privacy curtain;
Toilet facilities immediately adjacent to examination
rooms where gynecological exams and procedures are performed;
Sanitary napkin and/or tampon dispensers and disposal bins
in at least one women's public restroom;
Privacy curtains in inpatient rooms (with exception of
psychiatry and/or mental health units);
Access to a private bathroom facility (with toilet and
shower) in close proximity to the patient's room (inpatient and
residential units).
Senator Begich. That would be great. And that is just so I
can get a sense of where and what in preparation priorities.
You see, when I sat on the Armed Services Committee we
sometimes focused just on the year. The problem with that is
one year will have ramifications for the next and following
years. So, it just kind of helps.
Ms. Hayes. Yes.
Senator Begich. I know there is a big commitment from the
president in regards to dollars for the Veterans
Administration, which is great. I just want to make sure we are
in the right tow here.
Ms. Hayes. I also want to clarify, a lot of the issues, as
Mr. Williamson said, are really issues of being able to put
some renovation costs and would be on the priority list for
construction, but rather needing the ability to plan and put
together a space that would really involve renovation costs and
local costs.
Senator Begich. If I can ask, so, will the renovation costs
then not be in the long-term capital improvement?
Ms. Hayes. Oh, no, I did not mean to confuse that.
Senator Begich. Oh, OK.
Ms. Hayes. I am just telling you that the process is one in
which we are looking at both short-terms in terms of some
renovation where places are putting in new projects. That is
already part of other processes that you would be aware of.
Senator Begich. OK. Very good.
Mr. Chairman, I am going to end there. I do have some
additional questions, but I know I exceeded my time the last
time and I have a feeling with about 30 seconds left, I'll burn
that up very quickly. So, let me end here.
Thank you.
Chairman Akaka. Thank you very much, Senator Begich.
I want to thank the first panel for your testimony and your
responses.
As we know, we are facing a huge surge of an issue here
that has been important to our country, and some of the
problems have been noted. We want to work together as closely
as we can to move it and provide the health care services that
our women veterans expect and will have.
So, we look forward to working with you. Thank you very
much.
Ms. Trowell-Harris. Thank you.
Ms. Hayes. Thank you.
Response to Post-Hearing Questions Submitted by Hon. Daniel K. Akaka to
Patricia Hayes, Ph.D., Chief Consultant, Women Veterans Health
Strategic Health Care Group, U.S. Department of Veterans Affairs
Question 1. VA's written testimony discusses how the ``women's
comprehensive health implementation planning (WCHIP) tool'' is used to
``assist facilities in analyzing its own current health care deliver
for women veterans.'' After the initial analysis is completed by each
facility, is there a process to repeat the analysis periodically to
account for the expected growth in the women veteran population and how
that may affect the model a facility uses to provide care for its women
veterans?
Response. The Veterans Health Administration (VHA) continues to
incorporate WCHIP to assess the current status of primary care delivery
to women Veterans across VHA, and recommend enhancements as required.
For every VA health care facility, VHA will create a benchmarking
tool to evaluate WCHIP. The tool will help define and develop
recommendations regarding the essential components and critical
capabilities of comprehensive primary care delivery models. In
addition, metrics will be developed that evaluate the implementation of
comprehensive care for women Veterans. The tool is currently being
developed with an expected completion of February 2010. A plan to pilot
the tool is expected in March 2010, and validation is expected May-
August 2010. Once the tool has been validated, an annual reporting
process will be established for ongoing evaluation and resource
monitoring and tracking so that facilities can plan for the expected
growth in the women Veteran population in their areas.
Question 2. During the hearing, there was discussion regarding VA's
plans for expanding and remodeling clinical areas that provide women's
health care and the need to maintain close coordination with VA's
Office of Construction and Facilities Management when implementing
these plans. In addition to evaluating the space used to provide
women's health care, is VA evaluating the equipment, such as exam
tables, used in these spaces to ensure it is appropriate for all women
veterans, particularly those with catastrophic disabilities?
Response. VA's design criteria moved aggressively to improve space
and logistics issues related to women's health this past year. The
design criteria incorporated many women-specific requirements, such as
ensuring adequate space for women specific equipment, ensuring 100%
private patient rooms and ensuring adequate space for dependents
accompanying the women Veterans. These design criteria have been
incorporated into both, our existing facilities, as well as new Women's
Centers.
More specifically for high-tech/high-cost equipment, equipment
needs are assessed and evaluated for performance continually. Prior to
a new acquisition, an intensive review occurs to optimize the selection
to best suit VA's needs. This new equipment then becomes the basis for
designing the room to ensure adequate space and
privacy.
Regarding the space designs for women's areas in general, VA's
standards development efforts have increased addressing the physical
and mental health care needs of the growing number of women Veterans.
Most efforts related to updating VA's Space Planning Criteria and
Design Guides for specific functional areas. Space Planning Criteria
provides space requirements and guidance for development of space
programs for specific VA Facility Project development and leasing
agreements. It contains functional relationships and design
considerations in addition to space planning criteria for heath care
functions. Design Guides provide comprehensive information, including
an overview of design principles and concepts, narrative text
descriptions, and guide plates for reference.
These Space Planning Criteria and Design Guides, particularly over
the recent past, have addressed numerous specific changes reflecting
women's issues. In the most recent Design Guides for Ambulatory Care,
Outpatient Clinic, MRI, Radiology, Nuclear Medicine, Radiation Therapy,
etc., changes include increased importance of Mammography spaces,
adjustment of workload criteria to ensure the appropriate generation of
women's health spaces, larger more private dressing room areas, women's
specialty exam/procedure rooms (10% larger than standard spaces), more
bathrooms in targeted treatment and diagnostic areas, separate male and
female bathrooms in small public areas, and waiting rooms where one
unisex bathroom would technically suffice.
The Office of Construction and Facility Management (CFM) is
partnering with and including the Chief Consultant Women's Health
Office, on the Advisory Teams established to update Space Planning
Criteria and Design Guides along with consultants and other VHA health
care providers. Design Guide and Space Planning Criteria recently
completed or major updates are underway: Mental Health; Inpatient
Units--Medical, Surgical, and Neurological Patient Care Units;
Intensive Care Units; Procedure Suites; and Leased-Based Clinic Design
Guide.
Question 3. Much attention is given to providing gender-specific
care to women Veterans from OIF/OEF. Besides the research mentioned in
written testimony regarding hormonal effects on diseases in post-
menopausal women, what is VA doing to ensure there are adequate gender-
specific services for our older generations of women veterans?
Response. The gender-specific services VA provides takes into
account the changing needs of women at each stage of their lives. VA's
comprehensive health services for older women Veterans include:
Continued access to gender-specific screening for breast
and cervical cancer to detect early malignancies and improve survival.
VA also notes that postmenopausal women are at increased risk of having
cardiovascular disease, the number one killer of women. Thus our
comprehensive primary care initiatives take into account the needs of
our aging women Veterans and focus on breast health and heart health,
diabetes and weight management, and smoking and lung cancer.
Education initiatives for women's health providers include
modules on prevention and management of osteoporosis in addition to
evaluation and basic assessment of reproductive issues in older women.
In addition to hormonal replacement therapy, these issues include
urinary incontinence, pelvic floor disorders, and reproductive cancers.
Women Veterans with are appropriately and expeditiously referred to
subspecialty care services as needed.
Question 4. VA's testimony referred to the mini-residency training
in women's health which is taught by national women's health experts.
During the hearing it was suggested numerous times that it would be
beneficial for someone to learn about women veterans' experiences in
the military from actual women veterans. What is your view about having
women veterans provide education and insight to VA health care
providers in order to help them understand their patients better?
Response. VA understands and agrees that it is essential to have
women Veterans participate in providing insight to VA health care
providers. In September 2009, VA held a conference entitled, ``OEF/OIF
Evolving Paradigms II: The Journey Home,'' that was aimed at preparing
approximately 3,000 VA providers of care to Veterans returning from the
current conflicts. This conference included several plenary sessions
featuring men and women Veteran patients sharing their stories.
VHA also created a staff training CD-Rom which includes numerous
images of women Veterans, aimed at increasing awareness and sensitivity
about women Veterans. This presentation also includes a video of a
woman Veteran describing her military experiences, and her perspectives
on care in a VA primary care women's clinic. VA will include women
Veterans in person and videos when possible in future educational
events. In addition, future educational programs will include
techniques and tools for providers such as the military service history
pocket card (http://vaww.va.gov/oaa/pocketcard/default.asp) to help
providers discuss a better military history and to begin to engage
their own patients in the dialog to better understand the experiences
of their patients.
All of these things are essential as VA moves toward providing
health care that is more patient-centered.
Question 5. What can this Committee do to assist the CWV in its
efforts to increase awareness about the women veterans' programs?
Response. The Center for Women Veterans continues to encounter
women Veterans who do not self-identify as Veterans, or who are unsure
of their entitlement to VA benefits and services. The Senate Committee
on Veterans' Affairs could complement the Center's efforts to educate
women Veterans about VA's programs for women Veterans as it interacts
with constituents, especially those who are women Veterans. Examples of
actions the Committee and its members can consider include:
Including information about women Veterans programs in
outreach literature targeting Veterans in general.
Noting the contributions of women in the military and
women Veterans in remarks and speeches, as appropriate.
Establishing forums for women Veterans in their respective
states that would provide opportunities to learn about these programs
and how to access them.
Sharing initiatives and ideas with non-Committee lawmakers
regarding VA's programs and efforts for women Veterans in order to
expand opportunities for
outreach.
Question 6. What happens if a female veteran asks for a female
provider and one is not available?
Response. It is VHA's goal that women Veterans be given the option
to designate their preference for a female provider. Overall, 62% of
VHA providers are female. More than 80% of all nurse practitioners are
women and up to one third of all VA physicians are women. Facilities
are strongly encouraged to make the necessary accommodations for a
female provider (if one is requested) so that services are provided in-
house to the greatest extent possible. If a female provider is not
available in-house, services are to be provided through fee-basis
arrangements or sharing contracts to the extent the Veteran is
eligible.
Question 7. When will the new handbook for VHA services for women
veterans be issued?
Response. The revised handbook for VHA services for women Veterans
incorporates the new standard requirements and delineates the essential
components necessary to ensure that all enrolled women Veterans have
access to appropriate services, regardless of their VHA site of care.
The handbook has recently been revised to reflect comments made in the
review process and is going back through internal concurrence. The
handbook is expected to be issued during the second quarter of FY 2010.
______
Response to Post-Hearing Questions Submitted by Senator Burr to
Patricia Hayes, Ph.D., Chief Consultant, Women Veterans Health
Strategic Health Care Group, U.S. Department of Veterans Affairs
Question 1.a. As we discussed at the hearing, on page 7 of your
written testimony there is a statement that ``As of June 2009, each of
VA's 144 health care systems has appointed a full-time Women Veterans
Program Manager.'' On page 9 of GAO's testimony there is a statement
that ``In July 2008, VA required VAMCs to establish the WVPM as a full-
time position (no longer a collateral duty) no later than December 1,
2008. So, it appears that according to both VA's internal directives
and your own testimony that each health care system should have
appointed a full-time WVPM long ago.
In response to questions from the Chairman, however, you stated
that you were ``actively in the process of verifying'' whether that is,
in fact, the case. In response to my questions you stated, in essence,
that just because each system has appointed a full time WVPM that it
doesn't necessarily mean that it's happening, and that you wanted to
make sure it was because VA was in a ``transition phase'' on this
matter. For the record:
Please clarify these statements. Is there a distinction between the
``appointment'' of a WVPM and the actual placement of an individual to
fill that job?
Response. Occasionally during the hiring process, when bringing on
board a new person to fill a vacant slot, there may be a lag from
appointment to actual on-site placement. In those cases, the Department
of Veterans Affairs (VA) names an acting women Veterans program manager
(WVPM) until the appointed individual is officially on board.
Additionally, many of the WVPMs who held the position prior to its
becoming a full-time position have had to greatly reduce their clinical
time to fill the role of a full-time WVPM. For some, the transition
from clinical duties had taken longer than expected. This process is
still underway. VA currently employs 137 full-time WVPMs; 7 sites have
individuals acting in these roles with recruitment for full-time
employees underway.
Question 1.b. Is it typical for VA to appoint someone to a position
who is unable to perform the job to which they are appointed?
Response. VA does not appoint anyone to a position who is unable to
perform that position. Mandatory training of new hires does not suggest
they are unqualified or unable to perform the job to which they are
appointed. The role of the WVPM is quite complex with regard to
understanding the population of women Veteran and their unique needs.
Therefore, significant training of new WVPMs and ongoing training for
all existing WVPMs is required.
Every new WVPM is required to complete a Web-based, 40-hour
certificate training course, which is monitored through the employee
education system. In addition, VA women Veterans health strategic
health care group (SHG) has provided training for all WVPMs. The
eastern region 1 training was held in Baltimore, MD, in April 2009; the
mid-western/south region 2 in Chicago, IL, in May 2009l and the western
region 3 in San Francisco, CA, in June 2009. Through the course of
these three sessions, VA trained all existing, acting and new WVPMs in
additional program-specific skills areas. A follow-on training meeting
for all current WVPMs was held on September 20, 2009. This training
focused on a variety of relevant topics including:
Follow-up on the Women's Comprehensive Health Care
Implementation Plan (WCHIP)
Issues related to the newly developing Veteran-centered
patient care model
Building a successful women's health center with full
backing of leadership
Writing successful request for proposal responses
Issues associated with military sexual trauma
Question 1.c. How long before you have verified that each of the
144 WVPMs is in place, trained, and performing the duties for which
they were appointed? Please report that to me as soon as possible.
Response. Attached is a comprehensive list of the 144 WVPMs, where
they are posted and when they began working full time in that position;
2 WVPMs are currently part-time, and 3 sites have acting WVPMs, while
recruitment for the 5 permanent positions are being advertised. All
have received the WVPM training referred to in response to question 1b.
Question 2.a. At the hearing I noted that VA budget submissions
show a decline, from 2007 to 2008, in the number of unique users
seeking gender-specific care at VA. In response you stated that ``on
paper it looks like we've decreased our gender specific care when, in
fact, we believe that it's increased.'' Please clarify this for me If
from one year to the next the number of unique users seeking gender-
specific care has declined, doesn't that indicate that those who were
once users of the system for gender-specific purposes are seeking that
care elsewhere?
Response. In the fiscal year (FY) 2010 President's Budget
submission the reported number of the female Veterans being treated for
gender specific conditions (FY 2008 actual) was lower than the number
that was reported in the FY 2009 President's Budget (FY 2007 actual).
The reason the FY 2007 (actual) number was higher is because non-
Veteran women were mistakenly counted in the FY 2007 number; that
cohort should have been deleted from the equation before the budget
submission was finalized.
In addition to identifying the non-Veteran inconsistency, the VA
review process produced insight on what is identified as gender-
specific care for women. In that review, 172 additional diagnosis codes
that represent gender specific were added to the former list of 441
codes to more accurately identify care that is gender-specific. These
additional codes were applied to historical data for use in the FY 2011
budget process.
Question 2.b. If you believe that the number of women seeking
gender-specific care has actually gone up instead of down, then, what
are the true numbers? What do the numbers look like for 2009 and do
they track what was estimated for 2009?
Response. The table below shows the revised historical data for
female Veterans who come to VA for gender-specific care using the
expanded list of diagnosis and clinics.
In FY 2008, actual data through mid-year reflected 61 percent of
the annual total unique female Veteran patients in FY 2008 had already
received care and 43 percent of the annual total costs had been
expended by mid-year FY 2008. At mid-year FY 2009, actual unique
patients are 68 percent of the estimated annual total and actual costs
are 50 percent of the estimated annual total, so actual experience thus
far indicates that the estimate may have been low if second half
expenditures occur at the same pace as happened in FY 2008. As compared
to mid-year FY 2008, FY 2009 actual data shows a 14 percent increase in
female Veteran patients and a 26 percent increase in cost.
The following table shows historical data for female Veterans who
come to VA for gender-specific care using the expanded list of
diagnosis and clinics. The response to question 2a discusses the
expansion of the scope of gender-specific care.
----------------------------------------------------------------------------------------------------------------
FY 2008 FY 2009 FY 2008 Mid- FY 2009 Mid-
Actual Budget Year Year
----------------------------------------------------------------------------------------------------------------
Female Veteran Patients................................. 141,698 145,647 87,128 99,500
Obligations (000s)...................................... $153,315 $167,330 $65,758 $82,860
----------------------------------------------------------------------------------------------------------------
Question 3. What percentage of the gender-specific care (as a
percentage of obligations) VA provides was purchased from a non-VA
provider? Has this number increased or decreased in the last decade?
Response. The data below shows the percentage spent in VA and the
percentage spent on non-VA providers. Data are not available prior to
FY 2005. Since FY 2005 the percent spent on gender-specific care
increased between 12.18 percent in FY 2005 to 14.2 percent in FY 2009.
The data over this short period is narrow in variance and does not
allow for reliable trending.
----------------------------------------------------------------------------------------------------------------
Fiscal Year VA Non-VA
----------------------------------------------------------------------------------------------------------------
2009, 2nd quarter.................................. 85.80 percent 14.20 percent
2008............................................... 86.90 percent 13.10 percent
2007............................................... 87.92 percent 12.08 percent
2006............................................... 88.49 percent 11.51 percent
2005............................................... 87.82 percent 12.18 percent
----------------------------------------------------------------------------------------------------------------
Chairman Akaka. I welcome now a second panel this morning.
Members of this panel are five women veterans, each working in
the field of advocacy in its various forms.
First, I welcome Joy Ilem, Deputy National Legislative
Director for Disabled American Veterans.
Next, we have Tia Christopher, who is an Iraq Veteran and
Project Associate and Women Veteran Coordinator for Swords to
Plowshares.
Next, welcome to Genevieve Chase, Executive Director for
American Women Veterans.
We will hear testimony also from Kayla Williams, a veteran
of the U.S. Army.
And, finally, we have Jennifer Olds, also a U.S. Army
veteran. I am grateful to VFW for making it possible for Ms.
Olds to join us today.
Ms. Ilem, we will begin with you and then move down the
table in order.
Ms. Ilem?
STATEMENT OF JOY ILEM, DEPUTY NATIONAL LEGISLATIVE DIRECTOR,
DISABLED AMERICAN VETERANS
Ms. Ilem. Thank you, Mr. Chairman and Ranking Member Burr.
Thank you for inviting the Disabled American Veterans to
participate in this timely hearing on women veterans.
The changing roles of women in the military, increasing
numbers of women coming to VA for care, and the impact of war
on women's health present a number of new challenges for VA in
meeting the unique needs of women veterans today.
Ensuring equal access to benefits and high-quality health
care services for women veterans is a top priority for DAV. We
have a longstanding resolution that calls for review of VA's
health program for women to ensure they have access to the same
high-quality health care and specialized services that male
veterans receive.
It is apparent from the recently-released Report of the
Under Secretary for Health Workgroup on Women Veterans that VA
is aware of the shortcomings in its women's health program and
is making a concerted effort to systematically address the
significant challenges it faces to bring care provided to women
veterans on par with male veterans.
The report outlines the most critical challenges VA faces
in caring for women veterans, and, more importantly, provides a
roadmap for change. Some of the most critical issues identified
in the report include: significantly increasing utilization
rates of younger women accessing VA care; the systemic
fragmentation of primary care delivery for women; too few
proficient, knowledgeable providers with expertise in women's
health; and a number of identified outpatient quality
disparities for women veterans.
Additionally, VA researchers report a number of access
barriers for women veterans, including lack of childcare
services, privacy, safety, and comfort concerns, and unique
post-deployment mental health reintegration issues for newly-
discharged women veterans who have served in Operations Iraqi
and Enduring Freedom.
The workgroup states its primary objective is to ensure
every woman veteran has access to a qualified health care
provider who can deliver coordinated, comprehensive, primary,
women's health care inclusive of gender-specific care,
preventive, and mental health services.
It plans to achieve these goals through a number of key
policy recommendations to reform and enhance women's health
delivery in VA. These recommendations thoroughly address
quality, efficiency, access, and equity of care for women who
use VA services.
And we congratulate the Women Veterans Health Strategic
Health Care Group for an extraordinarily forthcoming report in
a highly-detailed series of goal-orientated recommendations and
action items. These recommendations are fully consistent with a
series of recommendations that have been made in recent years
by VA researchers, experts in women health, VA's Advisory
Committee on Women Veterans, and the Independent Budget.
If implemented, these reforms will change the face of
health care delivery for women veterans in the VA health care
system, and, in turn, improve the health of women veterans.
Without question, VA has a lot of hard work ahead to
achieve these goals it has set out for itself, but we are
hopeful with the attention, oversight, and collaboration of
this Committee, that an implementation plan can be
expeditiously carried out.
A number of events focused on women veterans have been held
in recent months and all are essential to process of change.
However, nothing is more important than taking action. For
these reasons, DAV urges the Committee to carefully consider
the recommendations outlined in the report on women's health
and to support VA's efforts for change.
Although this groundbreaking report represents progress, we
question if the women's health program directors have the
resources to build adequate infrastructure and program capacity
and the internal support necessary at the very highest levels
to make the reforms it says are necessary.
One final concern we bring to the Committee's attention,
although it appears VA has been making a good faith effort to
move forward on its plans for improving women's health care
services and implement the principles outlined in the report,
it does not appear VA has issued a formal policy or directive
to the field to address the gaps identified in the report.
Therefore, we seek assurance from VA that its implementation
will be, in fact, faithfully executed.
Mr. Chairman, again, we thank you and other Members of the
Committee for your leadership and continued support on women
veteran's issues, and we appreciate the opportunity to
participate in this important hearing.
Thank you.
[The prepared statement of Ms. Ilem follows:]
Prepared Statement of Joy J. Ilem, Deputy National Legislative
Director, Disabled American Veterans
Mr. Chairman and Members of the Committee: Thank you for inviting
the Disabled American Veterans (DAV) to testify at this hearing that is
focused on women veterans, entitled ``Bridging the Gaps in Care.'' This
hearing is extremely timely given the changing roles of women serving
in our Armed Forces today, the 1.7 million women veterans who served
previously, and the dramatically growing number of women seeking health
care and other benefits from the Department of Veterans Affairs (VA).
Ensuring equal access to benefits and high quality health care
services for women veterans is a top priority for DAV. We have a long-
standing resolution from our membership of 1.2 million disabled war
veterans that seeks to ensure VA health care services for women
veterans, including gender-specific care, are provided to the same
degree and extent that services are provided to male veterans. Also,
given the undoubted greater exposure of servicewomen to combat, we
believe they should have equal access to supportive counseling and
psychological services incident to combat exposure. Military sexual
trauma, while not exclusively a women's issue, is also of special
concern to DAV. Additionally, we urge VA to strictly adhere to their
stated policies regarding privacy and safety issues related to the
treatment of women veterans and to proactively conduct research and
health studies as appropriate, periodically review its women's health
programs, and seek innovative methods to address women's barriers to VA
health care and services, thereby better ensuring women veterans
receive the treatment and specialized services they rightly earned
through military service to America.
Likewise, for many years, the organizations that make up the
Independent Budget (IB)--AMVETS, DAV, Paralyzed Veterans of America
(PVA) and Veterans of Foreign Wars of the United States (VFW)--have
included a special section in the IB emphasizing women veterans, in an
effort to call attention to the need to address many of the challenges
VA faces in providing high quality health services to women veterans in
a predominantly male-oriented health care system. We are pleased to see
that many of the recommendations made in this section of the fiscal
year 2010 IB have been addressed by VA in a recent ground-breaking
publication--Report of the Under Secretary for Health Workgroup:
Provision of Primary Care to Women Veterans (Report), published in
November 2008 but released only very recently. Additionally, DAV
included a special focus on women veterans as part of our ongoing Stand
Up For Veterans campaign--focusing public attention on the unique needs
of women veterans--with a special emphasis on women who became disabled
during their wartime service.
VA's 2008 Report \1\ reflects the most pressing challenges VA
faces: specifically, developing the appropriate health care model for
women in a system that is disproportionately male focused, the
increasing numbers of women coming to VA for care, the impact of
changing demographics in the women veteran population, and impact on VA
health care delivery as well as the already-identified gender
disparities in quality of care for women veterans.
---------------------------------------------------------------------------
\1\ U.S. Dept of Veterans Affairs, Office of Public Health and
Environmental Hazards, Women Veterans Health Strategic Health Care
Group; Report of the Under Secretary for Health Workgroup: Provision of
Primary Care to Women Veterans. Washington, DC: November 2008.
---------------------------------------------------------------------------
Women veterans are the fastest growing segment of the veteran
population--and according to the Veterans Health Administration (VHA),
women are projected to account for one in every seven enrollees within
the next fifteen years, compared to the one in every sixteen enrollees
today. Because of the large and growing number of women serving in the
military today, the percentage of women veterans is projected to rise
proportionately from 7.7 percent of the total veteran population in
2008, to 10 percent in 2018. Additionally, VA notes that women who
served in Operations Iraqi and Enduring Freedom (OIF/OEF) utilize VA
services at a higher rate than other veterans, including other women
veterans and male OIF/OEF veterans--with 42.5 percent of the 102,000
OIF/OEF women veterans having enrolled in VA, and nearly 43.8 percent
who are consuming between two and ten VHA visits per year on average.
Earlier generations of women veterans enrolled in VA health care at a
15 percent average rate.\2\
---------------------------------------------------------------------------
\2\ Patty Hayes, Ph.D., Chief Consultant, Women Veterans Health,
Strategic Health Care Group, Department of Veterans Affairs; Women
Veterans Health Care, Evolution of Women's Health Care in the Veterans
Administration, Page 1. June 2009. www.amsus.org/sm/presentations/
Jun09-B.ppt
---------------------------------------------------------------------------
As reported by VA, historically, women have underutilized VA health
in comparison to male veterans. In the past five years, on average, 22
percent of men versus 15 percent of women have accessed VA health care.
Women veterans using VA health care are also younger--with an average
age of 48 compared to male veterans' average age of 61. Among women
users from OIF/OEF, more than 85 percent are under age 40 and of child-
bearing age, and nearly 60 percent are between the ages of 20-29.\3\ In
addition, women veterans have been shown to have unique and more
complex health needs with a higher rate of comorbid physical health and
mental health conditions, i.e., 31 percent of women have such
comorbidities versus 24 percent of men. Even with this high rate of
comorbidity, women veterans receive their primary and mental health
care in a fragmented model of VA health care delivery that complicates
continuity of care. In fact, according to the VHA Plan of Care Survey
for fiscal year 2007, 67 percent of sites provide primary care in a
multi-site/multi-provider model (i.e., with primary care at one visit
and gender-specific primary care at another visit), with only 33
percent of facilities offering care to women in a one-visit model. The
Under Secretary's workgroup concluded given these facts that there are
now sufficient numbers of women veterans to support coordinated models
of service delivery to meet their needs, and that while women will
always comprise a minority of veterans in the VA system, they represent
a critical mass as a group and should therefore be factored into plans
for focused service delivery and improved quality of care.
---------------------------------------------------------------------------
\3\ Ibid.
---------------------------------------------------------------------------
As indicated above, we have read with great interest a recently
released VA publication titled: Report of the Under Secretary for
Health Workgroup: Provision of Primary Care to Women Veterans, dated
November 2008. We are impressed with the thoroughness of the review of
women's care in VHA, and also with the optimism of its recommendations
to improve women's health. If implemented nationally its
recommendations could assure that women veterans receive coordinated,
comprehensive, primary care at every VA facility from clinical
providers who are trained to meet their needs; an integration of
women's mental health with primary care in each clinic treating women
veterans; the promotion of innovation in women's health delivery;
enhanced capabilities of all staff interacting with women veterans in
VA health care facilities; and an achievement of gender equity in the
provision of clinical care within VA facilities.
As directed by the VA Under Secretary for Health, the workgroup was
charged with defining the actions necessary to ensure that every woman
veteran has access to a VA primary care provider who can meet all her
primary care needs. The workgroup reviewed the current organizational
structure of VHA's women's health care delivery system, addressed
impediments to delivering their care in VHA, identified current and
projected future needs, and proposed a series of recommendations and
actions for the most appropriate organizational initiatives to achieve
the Under Secretary's goals.
current challenges
VA noted in its Report that only recently had it begun to address
development of the most appropriate health care services for women
veterans at each VA facility. The workgroup identified seven challenges
that VA must overcome in order to deliver quality, comprehensive
primary care to women veterans.
Challenge 1: VA recognizes that women have been under-served in the
veterans health care system. Utilization rates for men have held at
approximately 22 percent for many years--while utilization rates for
women range between 11-19 percent. Research shows that women veterans
do not self-identify as bona fide veterans, and are more unlikely to be
unaware of their enrollment eligibility. Of special note to DAV--and
greatest concern is that among women veterans in this study who had not
had access to health care in the past 12 months, 18.7 percent of this
group is service-connected for disability incurred in the line of
duty.\4\ This finding--that service-connected women veterans are
without access to health care, are not enrolled in nor using VHA
services--is especially distressing to DAV.
---------------------------------------------------------------------------
\4\ Patty Hayes, Ph.D., Chief Consultant, Women Veterans Health,
Strategic Health Care Group, Department of Veterans Affairs; Women
Veterans Health Care, Evolution of Women's Health Care in the Veterans
Administration, Page 15. June 2009. www.amsus.org/sm/presentations/
Jun09-B.ppt
---------------------------------------------------------------------------
Challenge 2: VA acknowledged there is a clear and growing need for
improved service delivery to women veterans in VHA. Given the
significantly higher VA utilization rates among women returning from
OIF/OEF as indicated above, VA expects the number of women veterans
coming to VA for care will likely double within the next four years.
The workgroup noted there are now sufficient numbers of women to
justify a VA effort to produce coordinated models of service delivery
to meet their needs--and that as a group women veterans should be
factored in as a special population cohort in any new strategic plans
for service delivery.\5\
---------------------------------------------------------------------------
\5\ Ibid.
---------------------------------------------------------------------------
Challenge 3: In recent years, VA reports have shown a significant
demographic shift related to women VA-users and notes the impact of
age-related health concerns. Given the fact that almost all new users
of the system are under age 40--and of child-bearing age--there is a
need for a focused shift in the provision of health care services. The
Under Secretary's workgroup also noted VA must continue to be sensitive
to the needs of older women veterans as well, since women over 55 years
of age face high risks for cardiac disease, cancers and the
consequences of obesity (such as Type 2 diabetes).
Challenge 4: The workgroup identified and acknowledged gender
disparities in quality of care in VHA. Despite positive results on
gender-specific measures such as screening for cervical and breast
cancer, significant differences are recorded in VHA performance scores
between men and women on certain outpatient quality measures that are
common to both men and women. Specifically, depression and PTSD
screening, colorectal cancer screening and vaccinations were reported
as less favorable for women.
Challenge 5: The workgroup identified routine fragmentation of
health care delivery to women veterans that poses possible negative
health outcomes. According to the report, to a large extent, health
care services offered to women veterans have evolved in a patchwork
fashion. Some facilities have strong champions with expertise in
women's health and offer comprehensive services in one location; other
facilities, however, require women to see several providers for basic
primary care services, and some VA facilities rely heavily on fee-basis
providers to care for enrolled women veterans.
Challenge 6: One of the most significant challenges VHA faces
according to this workgroup report is an insufficient number of
clinicians with specific training and experience in women's health. The
report acknowledges that the historical predominance of male veterans
in the VA setting has resulted in many providers lacking or having
limited exposure to women patients.\6\ According to the workgroup,
women veterans' numerical minority in VHA has created logistical
challenges in creating and sustaining delivery systems that assure VA's
goal of equitable access to high quality comprehensive services that
include gender-specific care.
---------------------------------------------------------------------------
\6\ Patty Hayes, Ph.D., Chief Consultant, Women Veterans Health,
Strategic Health Care Group, Department of Veterans Affairs; Women
Veterans Health Care, Evolution of Women's Health Care in the Veterans
Administration, Page 16. June 2009. www.amsus.org/sm/presentations/
Jun09-B.ppt
---------------------------------------------------------------------------
Challenge 7: Finally, the workgroup identified that there is
inconsistent policy in place for women's health in VHA. The group noted
that, in previous directives issued by VA Central Office, VA clinical
staff were required to provide gender-specific care on-site in VA
facilities, but, that more recent versions of the directives shifted
the emphasis to ``preferred'' rather than ``required.'' As a result, a
decline in on-site gynecological services occurred with an increase in
fee-basis referral for those key women's health care services. The
workgroup noted that in contrast, gender-related care always has been
recognized as an integral part of primary care delivery for men in VA
health care.
To aid in the implementation of comprehensive health care for women
veterans at every VA facility, the Women Veterans Health Strategic
Health Care Group developed a Women's Comprehensive Health
Implementation Planning (WCHIP) tool. The tool, which outlines a care
gap analysis, market analysis and needs assessment, was designed to
help VA facilities and VISNs assess and make decisions about which
services need to be developed and what resources were necessary to
carry out those plans. The stated goal was to then have Women Veterans
Program Managers (WVPM) work directly with strategic planners at their
VA facilities to incorporate the results of the WCHIP into the health
care planning model for those facilities. We are pleased the WVPM
position was made full time in July 2008, since these managers are
clearly integral to providing increased outreach to women veterans,
improving quality of care and developing best practices in the delivery
of care to women veterans throughout the VA health care system.
workgroup report recommendations
The workgroup made a series of key recommendations with
accompanying action items, as follows:
Recommendation 1 focuses on the delivery of coordinated,
comprehensive primary women's health care at all VA facilities,
including the development of systems and structures for care
delivery that ensure every woman veteran has access to a
qualified primary care physician who can provide care for acute
and chronic illnesses, gender specific care, and preventative
and mental health services.
Actions items necessary to achieve this goal include using
the WCHIP tool to provide an assessment of the current status
of care delivery and resources at each facility; identify steps
needed to achieve coordinated comprehensive primary women's
health care and implement a practice plan for each facility and
women's population in a particular catchment area; provide
appropriate funding to build adequate infrastructure and
program capacity; increase utilization rates for women and
provide staff and resources to conduct outreach and education
to women veterans; collect, analyze and report on data related
to access, staffing flexibility, and cost to carry out plan;
and, coordinate with VA academic affiliates for delivery of
comprehensive primary care services to women.
The workgroup noted that current research evidence, clinical
data and the adoption of models of patient-centered care
support the advancement of comprehensive primary women's health
care and are further supported by existing policies in VHA
Handbook 1330.1 and Standards of Primary Care Directive 2006-
031. These directives state that primary care includes gender-
specific care services.
Recommendation 2 seeks to ensure integration of women's
mental health care as a part of primary care. The workgroup
identified that women veterans using the VA health care system
carry a heavy burden of mental illness diagnosis--with
depression being the most frequent condition in women seeking
care in 2007. PTSD was the fourth most frequent diagnosis
reported, above diabetes and hypertension. (page 52 Rec. 2) The
workgroup concluded the adoption of the combined provision of
primary and mental health care services would help women
veterans overcome barriers to access needed mental health care.
Action items for Recommendation 2 include: assignment of
mental health providers in primary care clinics who can provide
assessment and psychosocial treatment for a variety of mental
health problems, including depression and problem drinking with
associated sexual behavior risk factors; facilitating
collaboration of behavioral health with primary care to provide
ancillary services such as pain management, weight management,
and smoking cessation programs designed to meet the needs of
women veterans.
Recommendation 3 focuses on promoting new ways of providing
care delivery for women through support of best practices
fitted to a particular facility or VISN configuration and the
women veteran population in that location or region. The
workgroup opined that individual VA facilities are best
positioned to develop innovative programs to meet the needs of
women veterans, especially sub-populations of minority groups
and women veterans from rural areas. We concur with VA that
best practices can help address variation in geographic and
demographic challenges across the system, and that innovative
technologies should be utilized to enhance delivery of care for
this population.
Action items to achieve this goal include: sharing best
practice models for comprehensive women's health care through
an improved web portal, conferences and other appropriate
information transfer methods; developing requests for proposals
from VA field facilities for pilot project initiatives using
new technology; collaboration between the Offices of Care
Coordination and Information to explore new opportunities in
telehealth, inclusive of women veterans; recognize and promote
local achievements in creating environments of care that
support privacy, safety and comfort for women veterans who seek
VA care.
Recognizing that VHA has a longstanding history and focus on
male patients, Recommendation 4 addresses the need to cultivate
and enhance the capabilities of all VHA staff--including
medical providers, clinical support, non-clinical, and
administrative staff, to meet the comprehensive health care
needs of women veterans. The workgroup acknowledged that
despite increasing numbers of women enrolling for VA care,
women users of the system continue to be relatively
``invisible.'' We fully concur that a paradigm shift is
necessary and that a coordinated training and cultural
sensitivity program will be essential to creating an atmosphere
of equity and welcome for women veterans in VA health care
facilities.
According to the workgroup, many VA clinical providers have
acquired skills during health professions internships or
residencies but have subsequently lost those proficiencies in
their intervening years working in VA facilities therefore, a
concerted effort must be made to cultivate and enhance the
capabilities of all VA staff to meet the needs of women
veterans. Action items to achieve this goal include:
recruitment and training of practitioners to be proficient,
knowledgeable, and engaged providers in women's health; funding
mini-residency programs in women's primary care programs for
current VA providers; continue to strengthen VA-based women's
health fellowships; develop recruitment and retention
strategies to increase the number of trained staff in women's
health; train and sensitize all VA staff on issues specific to
women's health care.
Recommendation 5 seeks to achieve parity in clinical
performance measures and gender equity in clinical quality of
care issues by addressing the systemic reasons for the
identified disparities in outcomes for women using VA in order
to effect change in clinical practice.
Although overall quality of care is high compared to the
private sector and despite positive results on gender-specific
measures such as screening for cervical and breast cancer, VA
acknowledges that clinical quality performance disparities
exist in the provision of care to women for certain prevention
measures. We are pleased the workgroup states its goal is to be
a ``national model for women's health care'' and challenges VA
to stand by its principles of providing the highest quality of
care--the best care anywhere--and to ensure gender parity in
the delivery of VA health care.
Actions necessary to achieve this goal include: assuring
continual measurement of women veterans' health outcomes for
gender-specific and gender-neutral care; continuing research
that addresses best practice models for delivery of care to
women veterans; working closely with the VA Office of Research
and Development to better understand the unique health concerns
of post-deployed women veterans; developing and implementing a
validated tool for routine clinical assessment of sexual
activity, risk behaviors, and anticipation of pregnancy.
These recommendations thoroughly address quality, efficiency,
access and equity of VA care for women who use VA services. The
workgroup found the need to improve all these areas in today's VA
health care programs for women veterans, and to better prepare these
programs for tomorrow's women veterans. We commend the members of the
workgroup who contributed so much to what appears to us to be a
comprehensive roadmap that could lead VA to make great strides in
improving health programs and services for women veterans.
research
Research plays an integral role in developing the most appropriate
health care delivery model for women veterans and providing access to
high quality health care services.
Over the years, VA researchers have brought to light a number of
important facts that, if acted upon, would greatly improve the care
that women veterans receive at VA health care facilities. Among these
facts, it was shown that access and waiting time scores were better at
sites where primary care and gender-specific services were available in
a one-stop setting. VA facilities that have established this type of
primary care delivery, whether in women's clinics or in general primary
care, have better patient satisfaction scores on care coordination for
contraception, sexually transmitted disease screening and menopausal
management than facilities that separate these services across multiple
clinics.
DAV is pleased that VA's Office of Research and Development (ORD)
supports a comprehensive women's health research agenda, and VA has
intensified its research on women's health in the last decade. The
first comprehensive VA women's health research agenda, which covered
biomedical, clinical, rehabilitative and health services research, was
directed by ORD in 2004 with the goal of positioning VA as a national
leader in women's health research. ORD successfully mapped research
priorities based on the needs of women veterans and capitalized on VA's
significant and productive research enterprise while using evidence-
based data on the health status and health care needs of women veterans
to include a systemic literature review on health care research related
to women veterans and women in the military. Within ORD, VA's Health
Services Research and Development Service (HSR&D) is at the forefront
of research focused on understanding and improving the health and
health care of women veterans.
ORD currently supports a broad research portfolio that includes:
studies on diseases prevalent solely or primarily in women; hormonal
effects on diseases in post-menopausal women; PTSD and other post-
deployment mental health concerns among women; and, osteoporosis and
multiple sclerosis in women. Gender disparities have also been analyzed
and highlighted in addition to the disparities in some types of
preventative care among spinal cord injured women veterans that include
the need of special equipment and body adjustments required to perform
care. HSR&D is also currently funding 27 research projects that examine
the health and health care of women veterans; the consequences of
military sexual trauma and other military traumas; PTSD treatment in
women; screening and utilization as well as post-deployment access and
reintegration issues; utilization; outcomes and quality of care for
women veterans related to ambulatory care; chronic mental and physical
illness, alcohol misuse, breast cancer and pregnancy outcomes. HSR&D is
also in Phase II of a study examining VA's approaches for delivering
care to women veterans while another is assessing the implementation
and sustainability of VA women's mental health clinics. These studies
include OIF/OEF populations.
We look forward to the results of these 27 research projects, and
applaud VA for standing in the forefront and leading the way in
assuring our women veterans that they will secure the same access to
and quality of care that their male counterparts receive in the VA
health care system.
summary
We congratulate the Women Veterans Health Strategic Health Care
Group for an extraordinarily forthcoming report and highly relevant
series of goal-oriented recommendations and action items. These
recommendations are fully consistent with a series of recommendations
that have been made in recent years by VA researchers, experts in
women's health, VA's Advisory Committee on Women Veterans, the
Independent Budget, and DAV. DAV Resolution 238 seeks to ensure high
quality comprehensive VA health services for all women veterans, with a
special focus on the unique post-deployment needs of women veterans
returning from OIF/OEF. DAV's resolution notes that VA needs to
undertake a comprehensive review of its women's health programs, and to
seek innovative methods to address barriers to care for women veterans
to ensure they receive the treatment and specialized services they need
and deserve. Therefore, we fully support the recommendations made in
the Report and urge their speedy implementation.
We are pleased that VA Secretary Shinseki has testified previously
that the delivery of enhanced primary care for women veterans is one of
VA's top priorities. Likewise, the Women Veterans Health Strategic
Health Care Group's commitment to assuring all eligible women veterans
will receive gender-specific primary care by proficient and interested
primary care providers; privacy, dignity, and sensitivity to gender-
specific needs; state-of-the-art health equipment and technology;
gender parity in performance measures; and, the right care in the right
place and time are all laudable goals. We fully concur with the
workgroup's conclusion that ``the debt owed to all our veterans and to
women in particular demands nothing less than our full attention.''
However, making these goals a reality will require VA's building
the proper resources and adequate infrastructure and program capacity
and developing the internal support necessary at the highest levels to
make the changes it says are needed. Without question, this is a
significant undertaking by VA and there is a lot of hard work ahead to
achieve the goals it has set out for itself, but we are hopeful with
the attention, oversight and collaboration of this Committee that VA
can achieve implementation of the recommendations in this report.
Mr. Chairman, a number of public events focused on women veterans
have been held in recent months. All are essential to the process of
change; however, nothing is more important than taking action. For
these reasons DAV urges the Committee to carefully consider the
recommendations outlined in the Provision of Primary Care to Women
Veterans Report and to support VA's efforts to achieve these reforms.
We would like to point out, Mr. Chairman, that as of March 11,
2009, this landmark report on women veterans was distributed to VA
field facilities and to regional network management offices within VHA.
However, its transmittal to the field by VA Central Office did not take
the form of a VHA directive; nor did it convey any mandatory
implementation requirements or accountability on the part of local or
regional officials. It was simply transmitted to VA field elements as
an informational device, apparently for their discretionary use in
planning. We recognize that VA has been making a good faith effort to
move forward on its plans for improving women veterans' health
services, and it is clear from VA correspondence included at the end of
the workgroup report that at multiple levels work is underway to assess
and implement principles outlined in the report. However, we note there
is no formal expression of policy or directive to fill the gaps that
this report identified.
For these reasons we ask the Committee to oversee and seek VA's
commitment to issue instructions to all VA health care personnel who
will be held accountable for implementation of this comprehensive
policy. The implementation phase should include establishing
performance measures for facility and network executive staffs,
submission of appropriate reports and provision of other oversight to
ensure these reforms are implemented and sustained at every VA facility
caring for women veterans. Additionally, we ask that Congress ensure VA
is provided sufficient resources to accomplish these essential reforms.
As you know, women are a growing population within the ranks of the
active, Guard and Reserve forces of our Armed Services, and women
veterans are streaming into VA health care by the thousands. Soon women
veterans will share ranks nearly two million strong and will constitute
one of every seven veterans enrolled in VA health care. Expectations
for VA to step up to this challenge are high, and this report by VHA's
own workgroup clearly reveals the necessity for VA to make significant
changes in the short term to begin better addressing women's needs in
the long term. This workgroup report is an excellent beacon to show
them the way, but we must have, and seek assurance that its
implementation will be faithfully executed.
Mr. Chairman, again we thank you for the opportunity to share our
views at this important hearing focused on women veterans--and bridging
the gaps in their care. We will appreciate your consideration of our
views on this pressing and important matter to America's women
veterans. I would be pleased to address your questions, or those of
other Committee Members.
Chairman Akaka. Thank you very much for your testimony. I
want you to know that your prepared remarks will be, of course,
made part of the hearing record.
So, now, let me call on Ms. Christopher.
STATEMENT OF TIA CHRISTOPHER, U.S. NAVY VETERAN; IRAQ VETERAN
PROJECT PROGRAM ASSOCIATE, WOMEN VETERAN COORDINATOR FOR SWORDS
TO PLOWSHARES
Ms. Christopher. Thank you, Mr. Chairman and Members of the
Committee for allowing me to speak.
My name is Tia Christopher. I'm a U.S. Navy veteran, and
Woman Veterans Coordinator for the veteran non-profit Swords to
Plowshares. I speak before you today both in my professional
capacity and from my personal experience as a woman veteran.
I am 70 percent VA-rated disabled veteran for PTSD and
military sexual trauma. My experiences have given me the
passion and perseverance to do advocacy work on behalf of
Swords to Plowshares. I mention this to illustrate that I am a
VA consumer, as well as a community avenue for my peers to seek
and access care.
The VA has made notable strides in the care of our Nation's
women veterans. I would not be the person I am today without
the young woman veteran PTSD groups established at some VA
medical centers.
Even as we acknowledge the amazing strides that have been
made, it must be noted that services and support for women
remain insufficient both in quality and accessibility. More
women are serving in the military than ever before.
No one entity should be expected to provide the breadth of
services and support needed for female veterans. There needs to
be a coordination and collaboration between the DOD, VA, and
community providers in order to delivery adequate care.
Community providers, such as Swords to Plowshares, are on
the frontlines everyday serving veterans from all our Nation's
conflicts. Because of the historical lack of gender-appropriate
services, it is critical that no door be the wrong door to
accessing care.
Resources are stretched--we all know that--both for the
government and non-profits. Women veterans may seek assistance
in the community, which do not address their underlying health
issues, but address their pragmatic needs in the moment.
For example, I had a young woman Air Force veteran come in
initially asking for help finding a job, but, at the end of our
conversation, it became evident she was homeless. This young
women who honorably served her country divulged that she was
now selling her body just to get by. It broke my heart that
this sister veteran of mine had been reduced to this.
Because of the specific employment and training services
that Swords provides and the fact that she was able to speak
with a fellow female veteran, she felt comfortable asking for
help. In this case, she needed mental health attention, as
well. Services need to reflect the myriad, co-occurring issues
surrounding our female veterans and care providers need to be
versed in how to appropriately and comprehensively address
these issues.
This veteran is not unique in her experience. Female
veterans frequently access community care rather than VA care,
which is often times less of a hurdle to navigate, as well as
less intimidating. Swords to Plowshares conducted focus groups
of female veterans in San Francisco, during which many
participants noted barriers to VA services.
One stated, ``If you do have benefits available through the
VA, you have to be very persistent, you have to want to get
your benefits, and you have to fight for them. If the benefits
are there, you're entitled to them, and you just have to find
the right person in the office that's going to help you fight
for them.''
Women need not only more gender-specific care, but also
care that is appropriate for their needs. The gender of a
mental health provider does not necessarily qualify them to
treat that woman veteran. It is essential that women who do
need inpatient treatment for PTSD, whether combat or sexual
assault-related, receive care in a safe treatment space. A coed
environment can truly be the worst thing for a woman suffering
from military sexual trauma and PTSD. We need more woman-
veteran-only inpatient VA programs.
Just having the resources is not enough. Again, the
quality, quantity, and accessibility of that care is vital. For
those who are uncomfortable receiving treatment at a VA
facility for whatever reason, funding needs to be allotted for
culturally-competent care within the community.
Both government and community entities need to be educated
on the specific needs of women veterans. I regularly speak
during the community panel portion of the National Center for
PTSD's Clinical Training Program. Sharing my story and
experience navigating the VA system and receiving treatment has
helped these clinicians better understand their patients.
The Iraq Veteran Project of Swords to Plowshares is
primarily composed of staff who are veterans. We provide
foundation-funded free panel representations for VA clinicians
and community behavioral health providers on issues such as
prevalence of PTSD, TBI, MST, military terminology
clarification, triggers, cultural obstacles to care, and
effective outreach approaches. This has led to greater dialog
and collaboration among community and government entities
treating veterans, as well as help the veterans themselves feel
that they are understood by their caregivers.
Thank you very much for your time.
[The prepared statement of Ms. Christopher follows:]
Prepared Statement of Tia Christopher, U.S. Navy Veteran and Women
Veteran Coordinator--Iraq Veteran Project, Swords to Plowshares
Good morning. Thank you, Senators, for allowing me to speak. My
name is Tia Christopher. I am a U.S. Navy veteran and Women Veterans
Coordinator for the veteran nonprofit Swords to Plowshares. Our
organization has been helping veterans since 1974.
In response to the wars in Iraq and Afghanistan, we established the
Iraq Veteran Project to specifically address the needs of the newest
generation of veterans. Following the formation of the Iraq Veteran
Project, Swords created my position to respond to the specific needs of
the fastest growing cohort of the U.S. veteran population: Women. I
speak before you today both in my professional capacity and from my
personal experience as a woman veteran. I am a 70% VA-rated, disabled
veteran for PTSD and Military Sexual Trauma. My experiences have given
me the passion and perseverance to do advocacy work on behalf of Swords
to Plowshares. I mention this to illustrate that I am a VA consumer as
well as a community avenue for my peers to seek and access care.
The Department of Defense has made considerable progress in the
eight years since I served. Significant steps have been made in the
area of sexual assault prevention; (i.e.: the establishment of the SAPR
program). In the same spirit, the VA has made notable strides in the
care of our Nation's women veterans. I would not be the person I am
today without the young women veteran PTSD groups established at some
VA medical centers. Even as we acknowledge the amazing strides that
have been made, it must be acknowledged that services and support for
women remain insufficient both in quality and accessibility. More women
are serving in the military than ever before. No one entity should be
expected to provide the breadth of services and support needed for
female veterans. There needs to be coordination and collaboration
between the DOD, VA, and community providers in order to deliver
adequate care.
Community providers such as Swords to Plowshares are on the front
lines every day serving veterans from all our Nation's conflicts.
Because of the historical lack of gender appropriate services it is
critical that no door be the wrong door to accessing care. Resources
are stretched; we all know that, both for the government and
nonprofits. I am scrambling every day to find resources for the women
veterans who come through our door.
Whether it is housing, inpatient programs, or resources for their
families, services are insufficient for women veterans. Women veterans
may seek out services in the community which don't address their
underlying health needs but address their pragmatic needs in the
moment. For example, I had a young woman Air Force veteran come in
initially asking for help finding a job, but at the end of our
conversation it became evident she was homeless. This young woman who
honorably served her country divulged that she was now selling her body
just to get by. It broke my heart that this sister veteran of mine had
been reduced to this.
Because of the specific employment and training services that
Swords provides, and the fact that she was able to speak with a fellow
woman veteran, she felt comfortable asking for help. In this case, she
needed mental health attention as well. Services need to reflect the
myriad co-occurring issues surrounding our female veterans; and care
providers need to be versed in how to appropriately and comprehensively
address these issues.
This veteran is not unique in her experience; female veterans
frequently access community care rather than VA care, which is
oftentimes less of a hurdle to navigate, as well as less intimidating.
Swords to Plowshares conducted focus groups with female veterans in San
Francisco, during which many participants noted barriers to VA
services. One participant stated, ``If you do have benefits available
through the VA, you have to be very persistent. You have to want to get
your benefits, and you have to fight them for it. The benefits are
there, you're entitled to them, and you just have to find the right
person in the office that's going to help you fight for them.''
Women need not only more gender specific care, but also care that
is appropriate for their needs. It is essential that women who do need
inpatient treatment for PTSD, whether combat or sexual assault related,
receive care in a safe treatment space. A coed environment can truly be
the worst thing for a woman suffering from Military Sexual Trauma (MST)
and PTSD. Just having the resources is not enough, again, the quality,
quantity, and accessibility of that care is vital. For those who are
uncomfortable receiving treatment at a VA facility, for whatever
reason, funding needs to be allotted for culturally competent care
within the community.
Both government and community entities need to be educated on the
specific needs of women veterans. I regularly speak during the
community panel portion of the National Center for PTSD's clinical
training program. Sharing my story and experience navigating the VA
system and receiving treatment has helped these clinicians better
understand their patients. The Iraq Veteran Project is primarily
composed of staff who are veterans. We provide free panel presentations
for clinicians and community behavioral health providers on issues such
as prevalence of PTSD, TBI and MST, military terminology clarification,
triggers, language, cultural obstacles to care, and effective outreach
and treatment approaches. Sessions such as these are a foundation-
funded free service provided by our nonprofit to government and
community entities. This has led to greater dialog and collaboration
among the various entities treating veterans, as well as helping the
veterans themselves feel that they are understood by their caregivers.
Another area of great concern is an understanding of the resources
available to them, and an understanding of what to expect during
transition. I encountered dry, outdated materials that were difficult
to digest and did not speak to me as a young veteran. As a result,
Swords to Plowshares published our OIF/OEF transition manual written in
familiar language from one veteran to another. The concept behind this
manual is not profound- however- it is unique in its approach and has
been met with extremely positive feedback from DOD, VA, and community
entities, as well as from the veterans themselves. Materials such as
this could considerably augment and aid accessibility to VA services on
a nationwide scale. This is one example of how the community and the VA
can work together. Based on the success of this manual written for both
genders, it is my dream to write one specifically for women veterans,
working in partnership with the DOD and VA.
Finally, women veterans have expressed their need for resources
strictly for them. During the focus groups with Swords to Plowshares
many expressed the need for peer-based emotional support. One
participant stated, ``Getting support from other military veterans
definitely helps. We have something in common.'' One answer to this has
been weekend retreats. In October 2008 several veteran nonprofits came
together with the support of several VAs, Vet Centers, and active duty
bases. This retreat was attended by OIF/OEF women veterans, reservists,
and active duty. The overwhelming response from the 25 participants was
how important it was for them to have a space to call their own. Being
surrounded by their peers was integral for their healing; they heard
and saw that they were not alone. This experience not only aided in
their healing and transition process into the civilian world, but also
functioned as a successful augmentation to the post-deployment process.
In the words of one participant, ``Thank you for recognizing this
aching need for women veterans to meet and bond with other women
veterans. Military service as a female . . . has been a very lonely and
isolated experience, and I wish that I had been able to attend a
workshop/retreat like this much earlier in my military career. Perhaps
if such a support group/network had been established for me early on, I
would not have struggled so much (or at least, not alone) through the
dark valleys of depression and self-doubt that I traversed as a young
female in the military.''
The following are a list of recommendations for greater access to
care for women veterans:
Mandatory and routine training for VA clinicians on the
specific issues facing women veterans.
Resources available for VA providers to include: issues
facing female combat veterans; military era specific information (i.e.,
OIF/OEF versus the Vietnam era); military terminology; the differences
between Military Sexual Trauma and sexual trauma in a civilian setting;
co-occurring combat and sexual trauma based PTSD, sometimes referred to
as ``The Double Whammy;'' etc.
Escorts at VA facilities for women veterans not
comfortable going alone. This ``battle buddy'' system could be
implemented at no cost to the VA through use of volunteers, the
Chaplain Service, and veteran peers. This simple gesture could
eliminate a huge barrier to care.
Development of permanent women-only clinics at VA
facilities, and improved signage at all VA facilities designating where
the women's clinic is.
Separate entrances or waiting areas that are safe and
monitored.
Childcare and extended clinic hours, at least for mental
health. Some VA facilities do have extended hours, however this option
needs to be universal regardless which community women veterans return
to.
More female only inpatient PTSD and MST programs. For
veteran nonprofits providing these programs, greater collaboration
between the VA and these entities needs to occur.
Greater outreach concerning the eligibility for veterans
with MST.
Utilization of peer based approaches and the retreat model
to supplement care received at the VA.
More collaboration with community entities and the DOD to
truly make transition seamless.
VA to track rates of MST and subsequent early discharge
from military service to provide evidence that rates of MST are a
retention issue for the DOD.
about swords to plowshares
War causes wounds and suffering that last beyond the battlefield.
Swords to Plowshares mission is to heal the wounds, to restore dignity,
hope and self-sufficiency to all veterans in need, and to significantly
reduce homelessness and poverty among veterans.
Founded in 1974, Swords to Plowshares is a community-based not-for-
profit organization that provides counseling and case management,
employment and training, housing and legal assistance to homeless and
low-income veterans in the San Francisco Bay Area.
We promote and protect the rights of veterans through advocacy,
public education, and partnerships with local, state and national
entities. Over the years the name Swords to Plowshares has become
synonymous with excellence in serving veterans in need, a highly
visible yet dramatically underserved population. We developed a model
of coordinated care based on the philosophy that the many obstacles
veterans face-including homelessness, unemployment and disability-are
interrelated and require an integrated network of support.
Frontline Drop-In Center
Provides mental health services, including counseling for drug and
alcohol problems and PTSD, as well as case management, income advocacy
and referrals.
Supportive Housing
We offer permanent supportive housing combined with options for
counseling, academic instruction and vocational training for 102
formerly homeless disabled veterans. Additionally, we provide
transitional housing for 75 veterans at a time for intensive
individual, group and peer counseling and a variety of recreational,
cultural and community-building activities. Both housing programs
provide daily hot meals to residents.
Employment Support
Swords to Plowshares helps veterans make the transition to gainful
employment by offering vocational counseling, life-skills training,
resume preparation and job referrals.
Legal Services
Many of our country's veterans never apply for or receive the
benefits they deserve. Swords to Plowshares is one of the few
organizations in the country that provides free attorney
representation, case management and advocacy to indigent veterans
seeking benefits.
The Iraq Veteran Project
Launched in 2005 to make sure systems of care are appropriate,
sufficient and accessible to meet the needs of veterans returning from
the wars in Iraq and Afghanistan, and the needs of their families as
well.
Chairman Akaka. Thank you, Ms. Christopher.
Now Ms. Chase.
STATEMENT OF GENEVIEVE CHASE, U.S. ARMY RESERVE VETERAN;
EXECUTIVE DIRECTOR, AMERICAN WOMEN VETERANS
Ms. Chase. Mr. Chairman and Members of the Subcommittee,
thank you for inviting us to testify today.
My name is Genevieve Chase, and I am a Founder and
Executive Director of American Women Veterans. On behalf of my
peers, I would like to thank you for your commitment and
dedication to serving the growing number of women veterans.
I am a veteran of combat operations in Afghanistan. While
serving in the Army Reserve, I volunteered for a 32-month
active-duty tour, which included deployment in support of
Operation Enduring Freedom.
On April 7, 2006, our vehicle was attacked by a suicide
vehicle-borne, improvised explosive device. The car that hit
our truck nearly disintegrated. Although I suffered minor
external injuries, the impact of that explosion has continued
to this day, and I now know that we were not adequately
informed of the services available to us after our service.
The Reserve soldiers I served with were discharged from
active service with a 5-minute out-briefing. A single sheet of
paper listing Web sites to access for VA health care and
services. What I recall from that time was that being focused
on overwhelming issues, like finding a job and figuring out how
I was going to make it in a civilian world that had become
somewhat foreign to me, not on service-related health issues I
would face in the months to come or how I would seek care for
those issues. I was not and am not alone in this.
Weeks after returning home, I began to experience
additional symptoms that I now know to be characteristic of
Post Traumatic Stress and mild Traumatic Brain Injury, such as
extreme guilt, anxiety, panic attacks, memory loss,
hyperactivity, and bouts of deep depression, in addition to
periods of consecutive days where I suffered exhaustion from
insomnia and lacked the energy to leave my apartment or speak
to anyone.
During the past 2 years, I have gone to the VA Web site
repeatedly and called the VA to pursue an assessment and
screening for TBI and other related issues. After attempting to
navigate through the bureaucracy, I gave up, frustrated by an
unclear Web site and unfriendly service on the other end of the
phone.
I looked to the VA for help when I most needed it, but
never succeeded in completing my enrollment, let alone actually
receiving the care that I needed. In communicating with other
veterans, I have found that I am hardly alone in this, as well.
While the VA struggles to catch up and provide adequate,
gender-specific care to previous generations of women veterans,
the total number of women veterans is projected to double in
the next 10 years. It is vital that this Nation proactively and
immediately address the broad spectrum of treatment needs for
this significant increase in the women veteran population.
VA resources for women must expand to meet the growing
number of combat-experienced women; and women dealing with PTS,
military sexual trauma, and TBI must be able to find easily-
accessible and concise information and guidance about these
vital services when needed. Veterans should not need a third
party to help them navigate the VA system.
AWV believes that women veterans of all generations are
entitled to VA services that include women-only clinics, women
providers, holistic care, extended service hours, offsite care,
PTSD and MST peer support groups, and the availability of
childcare during clinic visits. But even with all of these
services, women must know they are eligible, they must be
enrolled, and they must have access to the VA.
Despite the VA's efforts and claims of educating and
reaching out to today's veterans, the message is not getting
through. Even minor changes in the delivery of this message can
have a huge impact.
As just one example, women veterans from all eras have
expressed to me that they would prefer to receive immediate e-
mail updates on VA benefits and services rather than periodic,
automatic mailings, which do not always get forwarded through
the postal system. AWV believes the best way to improve access
to the VA is for servicemembers to be educated and enrolled
into VA services while they are still on active-duty.
Briefings, workshops, and enrollment for VA benefits must
be mandatory and should be conducted by knowledgeable
representatives from the VA. Reaching out to all veterans prior
to their discharge from active-duty would address several
issues to include raising awareness and knowledge of
eligibility for benefits and care; allowing continuity of care
and eligibility from hospital to hospital; and offering
immediate availability of physical and mental health care when
needed rather than after lengthy and unknown waiting periods.
Veterans getting the care they need when they need it can
help prevent a number of extended issues which includes extreme
depression, which contributes significantly to the risk of
homelessness, substance abuse, and suicide.
In closing, our Nation's veterans from all eras answer this
country's call to service, and the VA has the unique and
rapidly-growing challenge of ensuring easily-accessible,
quality services for women veterans across the spectrum from
childbearing years to well beyond retirement.
On behalf of American Women Veterans, thank you for working
to honor and repay the service of all veterans through this
inclusive dialog, and we thank you for your commitment to
ensure the quality and scope of physical and mental health care
that today's American women veterans have earned by their
service.
Ladies, gentlemen, and Mr. Chairman, I thank you for your
time and consideration and welcome your questions.
[The prepared statement of Ms. Chase follows:]
Prepared Statement of Genevieve Chase, U.S. Army Reserve Veteran,
Operation Enduring Freedom; Founder and Executive Director, American
Women Veterans
Mr. Chairman and members of the Subcommittee, Thank you for
inviting us to testify today. My name is Genevieve Chase and I am the
Founder and Executive Director of American Women Veterans (AWV). On
behalf of my peers, I would like to thank you for your commitment and
dedication to serving the growing number of women veterans.
I am a veteran of combat operations in Afghanistan. While serving
in the Army Reserve, I volunteered for a 32-month active duty tour,
which included a deployment in support of Operation Enduring Freedom.
On April 7, 2006, our vehicle was attacked by a suicide vehicle-borne,
improvised explosive device. The car that hit our truck nearly
disintegrated. Although I suffered minor external injuries, the impact
of that explosion has continued to this day and I now know that we were
not adequately informed of the services available to us.
The reserve soldiers I served with were discharged from active
service with a five-minute out-briefing and a single sheet of paper
listing Web sites to access for VA services. What I recall from that
time was being focused on overwhelming issues like finding a job and
figuring out how I was going to make it in a civilian world that had
become somewhat foreign to me--not on the service related health issues
I would face in the months to come or how I would seek care for those
issues.
Weeks after returning home, I began to experience additional
symptoms that I now know to be characteristic of Post Traumatic Stress
(PTS) and mild Traumatic Brain Injury (TBI), such as: extreme guilt,
anxiety, panic attacks, and bouts of deep depression--in addition to
periods of consecutive days where I suffered exhaustion from insomnia
and lacked the energy to leave my apartment or speak to anyone.
During the past two years, I have gone to the VA Web site
repeatedly and called the VA to pursue an assessment and screening for
TBI and other related issues. After attempting to navigate through the
bureaucracy, I gave up, frustrated by an unclear Web site and
unfriendly service on the other end of the phone. I looked to the VA
for help when I most needed it, but never succeeded in completing my
enrollment, let alone actually receiving the care I needed. In
communicating with other veterans, I have found that I am hardly alone
in this.
While the VA struggles to catch up and provide adequate, gender
specific care to previous generations of women veterans, the total
number of women veterans is projected to double in the next 10 years.
It is vital that this Nation proactively address--immediately--the
broad spectrum of treatment needs for this significant increase in the
women veterans population. VA resources for women must expand to meet
the growing number of combat-experienced women; and women dealing with
PTS, Military Sexual Trauma (MST) and TBI must be able to find easily-
accessible and concise information and guidance about these vital
services when needed. Veterans should not need a third party to help
them navigate the VA system.
AWV believes that women veterans of all generations are entitled to
VA services that include women-only clinics, women providers, holistic
care, extended service hours, offsite care, PTSD and MST peer support
groups, and availability of childcare during clinic visits. But even
with all of these services; women must know they are eligible, must be
enrolled and must have access to the VA.
Despite the VA's efforts and claims of educating and reaching out
to today's new veterans, the message is not getting through. Even minor
changes in the delivery of this message can have a huge impact. As just
one example, many women veterans have expressed to me that they would
prefer to receive immediate email updates on VA benefits and services
rather than periodic automatic mailings which don't always get
forwarded through the postal system.
AWV beleives the best way to improve access to the VA is for
servicemembers to be educated and enrolled into VA services while they
are still on active duty.
Briefings, workshops and enrollment for VA benefits must be
mandatory, and should be conducted by knowledgeable representatives
from the VA. Reaching out to all veterans prior to their discharge
would address several issues to include:
Raising awareness and knowledge of eligibility of benefits
and care,
Allowing continuity of care and eligibility from hospital
to hospital, and
Offering immediate availability of physical and mental
health care when needed, rather than after lengthy and unknown waiting
periods.
Veterans getting the care they need, when they need it, can help to
prevent a number of extended issues to include extreme depression which
contributes significantly to the risk of homelessness, substance abuse
and suicide.
In closing, our Nation's veterans from all eras answered this
country's call to service and the VA has the unique and rapidly growing
challenge of ensuring easily accessible, quality services for women
veterans across the spectrum, from child-bearing years to those well
beyond retirement. On behalf of American Women Veterans, thank you for
working to honor and repay the service of all veterans through this
inclusive dialog, and we thank you for your commitment to ensure the
quality and scope of physical and mental healthcare that today's women
veterans have earned by their service.
Ladies, gentlemen and Mr. Chairman, I thank you for your time and
consideration and welcome your questions.
Chairman Akaka. Thank you very much, Ms. Chase.
Now we'll hear from Ms. Williams.
STATEMENT OF KAYLA M. WILLIAMS, U.S. ARMY VETERAN; BOARD
MEMBER, GRACE AFTER FIRE
Ms. Williams. Mr. Chairman and Members of the Committee,
thank you for hearing me speak today. On behalf of women
veterans, I would like to thank you all for your commitment to
meeting the changing needs of our Nation's veterans.
My name is Kayla Williams. I sit on the Board of Directors
of Grace After Fire, a non-profit dedicated to helping women
veterans.
As a soldier with the 101st Airborne Division, Air Assault,
I took part in the initial invasion of Iraq in 2003, and was
there for approximately 1 year. As an Arabic linguist, I went
out on combat foot patrols with the infantry in Baghdad.
During the initial invasion, my team came under small arms
fire. Later, in Mosul, we were mortared regularly. I served
right alongside my male peers. With our flak vests on during
missions, we were all truly Soldiers first.
However, it became clear upon our return that, as Senator
Murray noted, most people do not understand what women in
today's military experience. I was asked whether, as a woman, I
was even allowed to carry a gun; and I was also asked whether I
was in the infantry. This confusion about what role women play
in war today extends beyond the general public. Even VA
employees are still sometimes unclear on the nature of modern
warfare, which presents challenges for women seeking care.
For example, since women are supposedly barred from combat,
they may face challenges proving that their PTSD is service-
connected. It is vital that all VA employees, particularly
health care providers, fully understand that women do see
combat in Operations Iraqi Freedom and Enduring Freedom, so
that they can better serve women veterans.
Many of the other problems that women face when seeking
health care through the VA are by no means exclusive to women.
The transition from DOD to VA remains imperfect, despite
efforts to improve the process--lost records and missing
paperwork are frequent complaints. Despite a growing number of
community clinics and Vet Centers, many veterans face lengthy
travel times to reach a VA facility, which is a particular
burden during these tough, economic times. Often, other
barriers may disproportionately affect women.
For example, since women are more likely to be the primary
caregivers of small children, they may require help in getting
childcare to attend appointments at the VA. Currently, many VA
facilities are not prepared to accommodate the presence of
small children. Several friends have described having to change
babies' diapers on the floors of VA facilities because the
restrooms lacked even the most basic changing tables.
Another friend, whose babysitter canceled at the last
minute, brought her infant and toddler to a VA appointment. The
provider told her that it was not appropriate, and that if she
could not find childcare, she should not even bother to come
in.
Facilities in which to nurse and change babies, increased
availability of telehealth or telemedicine, and/or childcare
assistance, or at least patience with the presence of small
children, would ease the burdens on all veterans with small
children, especially women.
Women in the military are also far more likely to be
married to other servicemembers. These women veterans must
worry not only about their own readjustments to civilian life,
but also the challenges their husbands may be facing. The VA
must consider the dual role that women veterans may be
balancing as both givers and seekers of care.
My husband, for example, sustained a penetrating Traumatic
Brain Injury in Iraq, and was medically retired from the
military. This impacted my decision not to reenlist because he
needed assistance that he simply was not getting. It was years
before I realized that, as both a caregiver and a veteran, I
needed to not simply suck it up and drive on as the military
taught, but rather had to reach out for help and support.
When struggling to cope with invisible wounds of war, such
as PTSD or in simply facing challenges readjusting post-combat,
peer support can be vital. However, there are things about
women's experiences in war zones that our male peers simply do
not understand.
They cannot truly know what it is like to fear not only the
enemy, but also sexual assault from your brothers in arms. They
may be aware of, but not fully able to empathize with the
challenges of facing regular sexual harassment, and they
certainly do not understand what it is like to feel invisible
as a veteran, as many women veterans do. It is, therefore,
vital that the VA provide times and/or places where women
veterans--especially those who may have experienced military
sexual trauma--can feel safe and comfortable in seeking help in
a community of their peers. These are all challenges that I am
confident every VA hospital can meet and overcome.
In 2006, I went to the VA Medical Center in Washington, DC.
My visit was uncoordinated, stressful, and confusing. The
facility did not smell clean and was crowded with veterans who
seemed to have poorly-managed mental health concerns. I was not
given clear information about what services were available to
me.
My husband also went to that VA in 2006. He was regularly
told that he was at the wrong clinic and sent from one office
to the other. Doctors gave him the impression that he and his
issues were an inconvenience at best. My husband's inability to
schedule timely, well-coordinated appointments eventually made
him give up on getting care from the VA at all.
We both began relying exclusively on TRICARE for all of our
medical and mental health needs, even though civilian providers
we see are less familiar with combat injuries and Post
Traumatic Stress.
My visit to the VA Medical Center in Martinsburg, West
Virginia, last month, however, was a stark contrast to both my
previous experience and the experiences that I have heard about
from other women veterans at some facilities.
There was a women's restroom clearly visible in the lobby.
It was clean. There was a changing table available. I was
treated as a veteran at all times, asked about my combat
experiences, and sensitively asked if I had experienced sexual
harassment or assault in the military. Providers carefully
coordinated my visit, ensured that I was aware of all available
resources, and followed-up promptly and thoroughly.
Their OEF/OIF integrated care clinic and newly-opened
women's clinic are models worthy of emulation, and I truly
believe that with continued advocacy and oversight, all VA
facilities can provide that same standard of care.
In order to best meet the needs of all veterans, I also
urge the development of enhanced relationships not only between
the DOD and VA, but also with those community organizations
that are ready and willing to fill gaps in services. Public-
private partnerships can allow all of us to come together to
meet the needs of our veterans in innovative and exciting ways.
I strongly urge that all legislators support S. 597, which will
help better meet the needs of women veterans.
Thank you all so much for working to assess VA's health
care services for women veterans and for your efforts to
improve care for all of our Nation's veterans.
[The prepared statement of Ms. Williams follows:]
Prepared Statement of Kayla M. Williams, Author: Love My Rifle More
Than You: Young and Female in the U.S. Army; Board of Directors, Grace
After Fire; Senior Adviser, VoteVets.org
Mr. Chairman and Members of the Committee, thank you for hearing me
speak today. On behalf of women veterans, I would like to thank you all
for your commitment to meeting the changing needs of our Nation's
veterans.
My name is Kayla Williams. As a Soldier with the 101st Airborne
Division (Air Assault), I took part in the initial invasion of Iraq in
2003, and was there for approximately one year. As an Arabic linguist,
I went on combat foot patrols with the Infantry in Baghdad. During the
initial invasion, my team came under small arms fire. Later, in Mosul,
we were mortared regularly. I served right alongside my male peers:
with our flak vests on during missions, we were all truly Soldiers
first.
However, it became was clear upon our return that most people did
not understand what women in today's military experience. I was asked
whether as a woman I was allowed to carry a gun, and was also asked if
I was in the Infantry. This confusion about what role women play in war
today extends beyond the general public; even Veterans Affairs (VA)
employees are still sometimes unclear on the nature of modern warfare,
which presents challenges for women seeking care. For example, being in
combat is linked to Post Traumatic Stress Disorder (PTSD), but since
women are supposedly barred from combat, they may face challenges
proving that their PTSD is service-connected. One of my closest friends
was told by a VA doctor that she could not possibly have PTSD for just
this reason: he did not believe that she, as a woman, could have been
in combat. It is vital that all VA employees, particularly health care
providers, fully understand that women do see combat in Operations
Iraqi Freedom and Enduring Freedom so that they can better serve women
veterans.
Many of the other problems that women face when seeking to get
health care through the VA are by no means exclusive to women: the
transition from DOD to VA remains imperfect, despite efforts to improve
the process. Lost records and missing paperwork are frequent
complaints. A woman I know who spent over twenty years in the Army
Reserves was turned away from her local VA hospital because she never
deployed to a combat zone; her paperwork was never even examined to
determine if she is indeed eligible for care. Despite a growing number
of community clinics and Vet Centers, many veterans face lengthy travel
times to reach a VA facility--a particular burden during tough economic
times.
Other barriers may disproportionately affect women. For example,
since women are more likely to be the primary caregivers of small
children, they may require help getting childcare in order to attend
appointments at the VA. Currently, many VA facilities are not prepared
to accommodate the presence of children; several friends have described
having to change babies' diapers on the floors of VA hospitals because
the restrooms lacked changing facilities. Another friend, whose
babysitter canceled at the last minute, brought her infant and toddler
to a VA appointment; the provider told her that was ``not appropriate''
and that she should not come in if she could not find childcare.
Facilities in which to nurse and change babies, as well as childcare
assistance or at least patience with the presence of small children,
would ease burdens on all veterans with small children.
Women in the military are also far more likely to be married to
other servicemembers; throughout the Department of Defense (DOD), 51.3%
of married female enlisted active duty personnel reported being in
dual-service marriages, compared to only 8.1% of their male
counterparts.\1\ These women veterans must worry not only about their
own readjustments, but also their husbands' challenges. The VA must
consider the dual role women veterans may be balancing as both givers
and seekers of care. My husband sustained a penetrating Traumatic Brain
Injury (TBI) in Iraq and was medically retired from the military. This
impacted my decision not to reenlist, because he needed assistance that
he simply was not getting. In addition, I was so focused on his
recovery that I barely considered my own needs. It was years before I
realized that as both a caregiver and a veteran I needed to not simply
``suck it up and drive on,'' as the Army taught, but rather had to
reach out for help and support.
---------------------------------------------------------------------------
\1\ ``Population Representation in the Military Services,'' Table
3.7, FY2004, available at: http://www.defenselink.mil/prhome/
poprep2004/enlisted--force/marital--status.html
---------------------------------------------------------------------------
When struggling to cope with invisible wounds of war such as PTSD,
or when simply facing challenges readjusting post-combat, peer support
can be vital. However, there are things about my experience as a woman
in a war zone that my male peers do not understand. They cannot truly
know what it is like to fear not only the enemy, but also sexual
assault from your brothers in arms. They may be aware of, but not be
able to fully empathize with, the challenges of facing regular sexual
harassment. And they certainly do not understand what it is like to
feel invisible as a veteran, as many women veterans do. It is therefore
vital that the VA provide times or places where women veterans,
especially those who may have experienced military sexual trauma, can
feel safe and comfortable seeking help in a community of their peers.
These are all challenges that I am confident every VA hospital can
meet and overcome. In 2006, I went to the VA Medical Center in
Washington, DC. My visit was uncoordinated, stressful, and confusing.
The facility did not smell clean and was crowded with veterans who
seemed to have poorly managed mental health concerns. I was not given
clear information about what services were available to me. My husband
also went to that VA in 2006; he was regularly told that he was in the
``wrong clinic'' and sent back and forth between multiple offices.
Doctors gave him the impression that he and his issues were an
inconvenience at best. My husband's inability to schedule timely
appointments that fit in with his schedule eventually made him give up
on getting care from the VA at all. We both began relying exclusively
on TRICARE for all our medical and mental health needs, even though the
civilian providers we saw were less familiar with combat injuries and
post-traumatic stress.
My visit to the VA medical center in Martinsburg, West Virginia in
June 2008, however, was a stark contrast to my own previous experience
and the stories I have heard from veterans about some other facilities.
There was a women's restroom clearly visible in the lobby; it had a
changing table. I was treated as a veteran at all times, asked about my
combat experiences, and sensitively asked if I had experienced sexual
harassment or assault in the military. Providers carefully coordinated
my visit, ensured that I was aware of all available resources, and
followed up both promptly and thoroughly. Their OEF/OIF Integrated Care
Clinic and newly-opened Women's Clinic are models worthy of emulation,
and I truly believe that with continued advocacy and oversight, all
facilities can provide the same standard of care.
In order to best meet the needs of all veterans, I also urge the
development of enhanced relationships not only between the DOD and VA
but also with those community organizations that are ready and willing
to fill gaps in services. Public-private partnerships can allow all of
us to come together to meet the needs of our veterans in innovative and
exciting ways.
Thank you for working to assess the VA's health care services for
women veterans, and for your efforts to improve care for all our
Nation's veterans.
Chairman Akaka. Thank you very much, Ms. Williams.
Ms. Olds?
STATEMENT OF JENNIFER OLDS, U.S. ARMY VETERAN ON BEHALF OF
VETERANS OF FOREIGN WARS
Ms. Olds. Mr. Chairman and Members of the Committee, I
would like to thank you and the VFW for the opportunity to
testify today.
My name is Jennifer Olds, and I served in the U.S. Army
during the first Gulf War from 1990 to 1992.
During my time in the military, I experienced multiple
incidences of military sexual trauma. As a result of my
experiences in the military, I suffer from severe and chronic
PTSD.
Some of the health conditions that resulted from that
severe and chronic PTSD involved both physiological and
psychological effects. Some common psychological effects that
have been stated before are flashbacks, nightmares, insomnia,
distrust of society, constant fear, depression, and becoming
suicidal. I also suffered from physical ailments because of the
PTSD, which include things like nervous issues, anxiety
attacks, panic disorders, dizzy spells, ulcers, and I had
shingles twice in my 20s.
As I look back over the treatment that I have received from
the VA, I find a list of things that I think has
comprehensively helped me to recover to the place that I am
today, which is significantly much better than I was 15 years
ago. Among this list include the availability of counseling
from the Vet Centers in the Portland, Oregon, VA; and, also,
being assigned a psychiatric nurse practitioner who tried to
provide medications to help me with sleeping because getting
sleep can help improve your ability to handle all the other
effects of PTSD.
Eventually, about 10 years after my initial start in the VA
system, I finally allowed them to provide anti-anxiety
medications, which, in combination with other things, seemed to
help me improve quite a bit.
One of the things I believe that had a severe impact on
turning my life around was my admittance into the vocational
rehabilitation program. That gave me a reason to stop being
suicidal or at least to start fighting my suicidal ideations
and allowed me to look forward to my future.
Not long after, a few years later, I was given the
opportunity to participate in some PTSD research. It was a
research study at the VA comparing cognitive studies--cognitive
therapy--against exposure therapy. I was randomized into the
exposure therapy program and participated in it. It was a 10-
week, intense, grueling program that asked me to recollect and
discuss a traumatic event.
So, it is not a program that is easy for people to get
through, but, if you can, and you are like me, you benefit
significantly.
As I also look back, I realize the importance of having
holistic care. Because I suffered not only psychological
issues, but physical issues, being able to get the support from
both sides of the coin was very helpful, as well.
Finally, and I think most importantly, as we look at
providing care for vets or women vets in particular--with the
kinds of backgrounds that we tend to have, I think with PTSD
and military sexual trauma--having very patient, understanding,
good-fit providers is key. If we have someone that we are
unhappy with or we feel does not understand us, we are not
going to go. So, finding people that have the patience and
endurance to stick with us until we are able to sort of work
for ourselves, I think, is very important.
As I look forward to the future for things that I think
would be helpful for the VA system to implement, the first
thing that comes to my mind is location.
I spent an hour-and-one-half driving each way to my
counseling appointments, not to mention the amount of time I
spent in my counseling appointments, and those combined ended
up being at least 4 hours per day, 3-5 days per week. That does
not bode well for working.
Also, as I think back on my original discharge, I, again,
was not given any information. I had no idea that there was
stuff available for me; and really, there was not, as I look
back for PTSD and women specifically.
But I had gotten so suicidal that I sought my own care from
a private institution where I utilized my own private
insurance. That only covered 2 weeks at the most. It only
covers a portion of that amount, so, my family had to take on
the burden of the additional costs. So, my point of this is:
getting acceptance right into the VA system immediately is
important.
I also think that we need to think about women veterans as
individuals. I do not think there is a one-size-fits-all. I
have listed a number of things that I felt were extremely
beneficial to me, but there were other options that came up
that were available to me that I did not take advantage of
because they were not good fits for me.
An example of this is a counselor that tried to provide
EMDR, another type of therapy for PTSD. While it has been
proven to be very effective, it was not a type of therapy that
I felt was fitting for me at the time.
So, being able to look at the individual and examine what
they themself need, then providing a variety of options to pick
from, I think, is important, as well.
One of the other things I think that we need to provide is
education for everyone--for providers, for women vets, and for
the public--on what the VA can offer and how the VA provides
care for the women, sort of an around the world picture for
everyone.
As I have looked at the care that has been offered for
women vets, I have come up with a conclusion like what some of
the other people have said. I believe that if we have some of
what I call ``information sessions'' for women or ``for vets by
vets'' sessions in helping them understand how to navigate the
system and to move forward with the different kinds of options,
which is important, as well. If I had had that, I may have
started some things earlier in my treatment plan. And I would
be one to volunteer to do that for other vets because I feel it
is important to help others get their life back sooner than
some of us have.
And, finally, I think we need to reduce the stigma that the
VA has in the system in general. While I go out and speak
positively about my experiences from the VA--because I have had
numerous, wonderful experiences from the Portland, Oregon, VA--
there are other people who do not, and we need to reduce the
amount of incidences like this that prevent the VA system from
getting the good reputation that it can deserve.
I understand there are differences from VA to VA, but, in
general, reducing that stigma, I think, will help encourage
vets to use the system.
So, Mr. Chairman, this concludes my statement. I would be
happy to answer any questions you or the other Members of the
Committee may have. Thank you for your time.
[The prepared statement of Ms. Olds follows:]
Prepared Statement of Jennifer Olds, B.S., M.B.A., U.S. Army Veteran on
Behalf of Veterans of Foreign Wars of the United States
Mr. Chairman and Members of the Committee: I would like to thank
you and the Veterans of Foreign Wars of the United States (VFW) for the
opportunity to testify today.
My name is Jennifer Olds, B.S., M.B.A., and I am from Forest Grove,
Oregon. When I enlisted at 18 years old, I was voraciously positive
about what life could offer and had much to look forward to. I was
college oriented in high school taking college prep classes like
physics, chemistry, college writing, etc., as well as athletic, engaged
to be married and strong in my faith. I served on active duty in the
U.S. Army during the first Gulf War, from 1990-1992. While in the Army
I was exposed to Military Sexual Assault situations numerous times,
either trying to protect myself, or the other female soldiers around
me. This was my own ``battle field.'' Once discharged, I became
increasingly aware of my new symptoms of PTSD.
Some examples of my PTSD involved the following:
1) While I was driving, I was constantly in belief that someone was
out to harm me, constantly watching to see who was following me home,
driving out of the way to make sure no one was following me, thus
experienced intense fear and anxiety attacks while driving,
2) While at restaurants I needed to sit in the corner, or against
the wall and would be on constant guard evaluating who was out to harm
me or my family. If one of them needed to run to the bathroom I would
be extremely on edge until their return. If anyone asked me what was
discussed during dinner at the restaurant, I couldn't tell you since I
was so busy paying attention to the potential bad guys around us.
3) I was no longer engaged upon my return from the military and had
not dated for over 10-years since my discharge. Finally, When in my
home I had to have every curtain closed, window and door locked, and
was constantly freaked out about who was driving by or walking by
because I truly believed they were scouting me out and would eventually
be back to harm me.
After a year of continued daily battles with insomnia, nightmares,
flashbacks, anxiety attacks, depression, with situations described in
the previous paragraph, it became clear to me that this way of living
was something I no longer wished to deal with. I no longer felt that
life would be worth living if that is all I had to look forward to. I
became extremely depressed and suicidal, and had no knowledge of how to
help myself.
When I became suicidal I met with my family and asked them for
help, since I had no idea what needed to be done and frankly was in no
position to help myself. They suggested I enter a program at a hospital
facility where I was admitted but the insurance coverage ran out within
two weeks and I was discharged owing thousands of dollars to them,
which my family had to take on. Within a week or so, I was desperate
for help, as I knew I was still suicidal and finally was admitted to
the Portland VAMC where again I was discharged within two weeks. I was
told I didn't belong there and that staying any longer would force them
to send me to the Salem ``crazy ward,'' a place I was sure would ruin
my future. Again I was sent home with nowhere to go or seemingly any
help.
Fortunately I was assigned a psychiatric NP who patiently saw me
over the next several years with little improvement from me. You see,
our visits went something like this, I would be unable to continue a
stream of thought, as the anxiety increased and I would become blank
and unable to figure out my thoughts or feelings. This made the process
very difficult, but so did making the appointments given the stigma. I
didn't want others to know about, or me to actually realize about
myself.
I met with a representative of Paralyzed Veterans of America (PVA)
who asked the right questions and helped me realize and seek help from
the VA for the treatment of PTSD. Initially, I was sent to the Vet
Center that was located over an hour drive away from my home.
Eventually that therapist moved on, and I was assigned a new one who
wanted to do EMDR. I was in no position to do EMDR and told the new
therapist this many times and it seemed an endless conversation so I
stopped going altogether. At this point I only maintained a working
relationship with my Psychiatric NP who had the strength of a horse
with enduring patience with my slow progress.
Over the course of my treatment with the VA, I was given the
opportunity to go to college under the VOC REHAB program, which was a
turning point for me. This opportunity inspired me to want to live, and
to fight the constant suicidal ideations. Getting over this hurdle took
time, but college was certainly one of the many steps that have
eventually given me some solace on life. By the time I was finishing up
my undergraduate degree, a serious life event forced me to begin
looking at old trauma wounds and I began to focus efforts with my NP.
Eventually, after a few more years in treatment, my fabulous NP
suggested I participate in the research study comparing cognitive
therapy with exposure-based therapy. I said I would, because I wanted
my life back, that is, the voracity and charge to live life and be
happy.
I participated in this grueling 10-week program that asked me to
repeatedly discuss one of my traumatic events. I had intense anxiety
attacks, dizzy spells, nausea, etc., while I was undergoing this
therapy. It was not long after the completion of this treatment, that
my family and friends became aware of the changes I was making, little
known to me at the time. Eventually I came to see that I now could
partake in conversations with others and actually hear what they were
talking about and know what was going on in their lives. Within a few
years I was dating again after quite some time. I have decreased
nightmares, no longer watch who's following or walking by my house, and
even enjoy a night full of sleep more often. I am extremely delighted
with the caregivers at the Portland VA and think if not for them, I
would not be where I am today.
To say I had PTSD should not be summarized by mental capacities
only. I made several visits to the doctors for dizzy spells, chest
pains, skin issues, nervous ticks, ulcers, stomach/bowel issues and the
shingles x2, all while in my 20's. Most of the time these things were
``undiagnosable,'' but I have come to realize over the last 15 years
that much of these were stress related. That is, I believe PTSD caused
not only mental issues, but numerous physical issues as well. A person,
like me, can become overwhelmed with the array of issues one can
experience simply from PTSD, and become quite discouraged on how to
tackle it all.
I have a few suggestions on how I think we can encourage others to
get help and improve their PTSD symptoms:
1) encourage support groups and speakers from others like
themselves who have actually improved from PTSD.
2) Provide them with names of providers who have enormous patience.
3) Provide holistic approaches, and specific focused treatment: I
truly believe that one size does not fit all.
For example, Eye Movement Desensitization and Reprocessing Therapy
(EMDR) is a comprehensive, integrative psychotherapy approach often
used for MST. Although I did not feel comfortable with this type of
treatment, it may work for some and exposure-based therapy may work for
others, or perhaps medications in addition or on their own may also be
the best way.
Today I am able to do things that I have not been able to do in a
long time, and I also find myself void of other previous behaviors,
which were not positively affecting my life. All these changes are not
only very encouraging, but seem to continue to yield way to yet more
and more ``platforms'' on which to continue with more positive changes.
I have seen these abilities and actions of change as extremely exciting
and very positive, and so have my family and friends who have known the
struggles I have had to deal with since my time in the Army. My life is
continuing to improve.
I have watched PVA make significant changes that have improved the
care to all veterans and am extremely pleased with my care. This
process of dealing with PTSD has been a learning experience for me as
well as many at the VA.
Mr. Chairman this concludes my statement, I would be happy to
answer any questions you or the other Members of the Committee may
have.
Chairman Akaka. Thank you very much, Ms. Olds, for your
testimony, and all of you here.
Several of you mentioned the importance of VA providers to
understand and acknowledge that women can experience combat
while serving in the military.
How would you recommend VA and women veterans educate their
providers about this in order to help them provide better care
for women veterans?
Ms. Chase. Senator, I think----
Chairman Akaka. Ms. Chase?
Ms. Chase [continuing]. In terms of recognizing combat and
raising awareness about that, there are several military
occupational specialties within the Army and across the
services that have women who are engaging in activities outside
of the wire. Some of these include our intelligence teams, our
medics, our truck drivers, our civil affair soldiers, our
military police, and even sometimes our finance and supply
sergeants and NCOs, and officers.
I think the best way to get people to understand and to pay
attention is to connect the two. I think if we could provide or
somehow get together statements and maybe even personal
testimony or a team of people that address the Veterans Affairs
directly--to some of these service providers and some of these
clinics in their local areas--and say, ``I am a real person and
I am standing in front of you to tell you that I served in
combat, and I need you to hear me.'' I think that would be more
impactful than anything else that we could give them on a memo
or an e-mail.
Chairman Akaka. Yes, Ms. Williams?
Ms. Williams. Another option that may help people
understand a little more viscerally would be to have viewings
of the Lioness documentary about women serving in combat
available at VA facilities perhaps over lunch hour or in some
way that providers would have a chance to watch it.
Chairman Akaka. Ms. Ilem?
Ms. Ilem. I would just note that I think the Lioness
documentary probably most exemplifies a great opportunity for
them to really see and hear female veterans in their own
voices. Either that or other short videos that VA has done on a
number of issues related to TBI and OEF/OIF population and
mental heath issues--reintegration issues. A video on women
veterans specifically would be an excellent opportunity for
providers to see something short, and told in women veterans'
own words for them to be able to connect.
Ms. Chase. And, Senator, I would like----
Chairman Akaka. Ms. Chase?
Ms. Chase [continuing]. To caveat that. Sorry.
The Lioness documentary is a phenomenal and fantastic
documentary. However, it is specifically about a particular
team of women called the Lionesses who were embedded with
combat teams and infantry teams. We also need to recognize and
make sure that they are aware that there are very many jobs out
there--there are a lot of women every day on different jobs in
different capacities, in different branches of service--that
are serving outside the wire in combat every day, and not just
that one specific team specific to that movie or documentary.
Ms. Christopher. Mr. Chairman?
Chairman Akaka. Ms. Christopher?
Ms. Christopher. I agree with the fellow panelists on what
they're suggesting. The one thing that I would like to note
though, to be quite frank, is trainings can be very boring. I
mean, whether you are watching a PowerPoint or a video or
listening to someone talk, I mean, I think that in order for it
to be truly effective, there needs to be dialog, and it needs
to be interactive.
And I think there should be a Q and A portion. When we do
our trainings through Swords to Plowshares, we open ourselves
up for questions. We actually refer to it as ``an uncomfortable
questions panel,'' and we encourage the clinicians to ask us--
to clarify MOSs and military terminology--and to ask us our
opinion on treatment that has worked for us and that has not;
and we make it extremely candid, and I think that it has helped
immensely. The feedback has been so positive.
So, I just definitely stress the interactive component for
a successful training.
Chairman Akaka. Thank you.
We will have a second round of questions. So, let me call
on Senator Murray for her questions.
Senator Murray. Thank you very much, Mr. Chairman.
First of all, thank you all for your service to the
country. I really appreciate what all of you have done, and
going beyond the service now to come and talk with us about the
important issue that we are discussing today. I just want to
reiterate that I really do appreciate that.
While it is the official policy of the military that women
can not serve in combat, many of you talked about your
experiences, whether it is Traumatic Stress Syndrome, being
close to IED explosions, or being injured.
Given the fact that women are serving in combat roles, have
you found that this combat experience is reflected in DD-214ss?
Ms. Williams. My own certainly was reflected on my DD-214s.
It shows that I was awarded the service medal for my time in
Operation Iraqi Freedom; and, also, if it ever were to become a
question, I also received Army medals and the paperwork that
support those details of what experiences they were earned for,
which is another way people can show their experience. But I
know that is not universally the case. I was just lucky enough
that that was true for me.
Senator Murray. How about others of you?
Ms. Chase?
Ms. Chase. When we get our DD-214ss, it states in there
whether or not you served and in what theater, and it also
states your job. I was also awarded the combat action badge.
However, that is not an automatic award. It's not an automatic
entitlement. It is something that is submitted by your chain of
command, and if it is not submitted or the paperwork gets lost
or it does not go through, then you do not have that, as well.
And it also is not a qualifier. A lot of people do not
perceive it to mean that you were actually in combat or
directly engaging the enemy. So, that policy needs to be
changed or reworded to reflect that women are, in fact, serving
in combat and they are, in fact, on missions outside of the
wire. Regardless of whether or not they are going outside the
wire and they are inside an FOB or a PRT, when you have mortars
that are incoming daily and you have no idea where they are
coming from, that is combat; and the perception, I think, needs
to be changed. I think the perception would be helped if the
wording in the policy was changed, as well.
Senator Murray. Ms. Williams, you mentioned that you were
both a caregiver and a care seeker. Your husband was in the
military. I assume that it is fairly common for a woman to be
married to a fellow military officer and be in the same
position.
What can be done to help us better care for women veterans
who are not only dealing with their own readjustment issues,
but are dealing with spouse or children, as well?
Ms. Williams. You are right, the percentages are very high.
I think that it is important that care be more comprehensive.
Among active-duty, enlisted, married, female servicemembers,
over 50 percent are married to other servicemembers, compared
to only 8 percent of their male peers. My husband and I were
both enlisted.
I know the VA is trying very hard to do outreach. I once
got a call, for example, asking if I had sustained a Traumatic
Brain Injury as part of their outreach effort to make sure that
they are catching everybody. And I said, no, I did not; but I
am glad you called because my husband did and our family is in
shambles right now. I do not know how to hold myself together
and my family together and keep my job, and I am struggling
really hard here. And he said, well, I cannot really help you
with that; I am calling to ask if you have suffered a brain
injury.
And that is the way that I think we can try to make sure
that we are addressing entire family needs. If you have a
servicemember who has sustained an injury making sure that
their family is being taken care of both while they are in the
DOD and once they have transitioned to VA care, is an important
step.
I know the VA does not cover care for family members, but
if they learn that the spouse is also a veteran, it is
important that they take an extra step, reach out and contact
them proactively, and ask if they need help as a caregiver. Of
course, this does apply to both male and female spouses; its
just that the number of female spouses giving care is much
higher.
Senator Murray. I hear a lot from women about the access of
childcare being a barrier to go to the VA. Several of you
mentioned this in your testimony, and I do not think a lot of
people realize that if you tell a woman that there is no
childcare, they just simply do not go. That is it. They do not
get their health care.
For all of the panelists, do you think that the VA
providing childcare services would increase the number of women
who go to the VA and get the care that they need?
Ms. Ilem. I would say definitely. I think researchers have
repeatedly shown this as a barrier for women veterans, and that
is the frustration. How many research surveys do you have to do
when women keep repeatedly saying this is a barrier for them to
access care? And I think it was Kayla who mentioned an
experience of someone who was told it is inappropriate for them
to bring their child with them. At some of these very
personalized appointments for mental health or other things, it
may be very difficult, but they have no other choice.
So, I think it would definitely be a benefit and we would
see an increase in the number of women veterans who would
probably come to VA.
Senator Murray. Ms. Williams?
Ms. Williams. I definitely think that user traits of the VA
would increase if women knew that they had childcare available.
There are a variety of innovative ways that we could try to
address the problem of women having to balance their needs for
childcare with their needs to get services. Among them would be
increasing the availability of telehealth or telemedicine,
where women do not have to necessarily go all the way to a
remote facility, spending 4 hours trying to get to and from and
then be in care.
There are also opportunities for innovative programs.
For example, the VA has small business loans available. If
they could provide loans to women veterans who want to provide
childcare at facilities near VA facilities, that would be a
great way to try to marry these two needs.
There are also a lot of community organizations that stand
ready and waiting to help that would be happy just given a
small office to staff it with volunteers and be able to help
provide that care for the time that a women has to be in an
appointment.
And I think as many others have said, the specific
solutions may vary by location, but there are a lot of
innovative ways that we could forge public-private partnerships
to try to meet these needs.
Senator Murray. OK. Excellent.
Mr. Chairman, I have gone way over my time. I need to get
to another committee for mark-up, but I love the video idea of
showing the Lioness documentary at VA facilities. I think it,
at the very least, opens peoples' eyes to the fact that women
have served in very important roles and will maybe open that
little door in their head to think oh, wow, women really have
served our country in amazing ways and they do need the care
and the respect and the services that they have earned.
I would love to see another documentary about all the other
things that women have done and start helping people everywhere
really recognize the important service that women are
providing.
So, I thank all of you. And, Mr. Chairman, thank you so
much for having this hearing today.
Chairman Akaka. Thank you very much, Senator Murray.
Senator Begich?
Senator Begich. Thank you very much, Mr. Chairman.
Like Senator Murray, at around 11:30, I am going to have to
depart for a meeting. This is a very interesting panel, and I
want to thank you for your service, and also for your insight
in the day-to-day utilization of the VA services and what can
be done. I have a couple of questions.
I am going to look through my notes here and try to reread
my handwriting, as each one of you were speaking, and I am
going to make a couple of comments. It is not necessary for you
to respond.
I am kind of looking to Dr. Hayes. If you could follow-up
with at least me and if the Committee so desires on a couple of
things--one being the childcare issue.
I remember a circumstance in Anchorage, Alaska. My wife and
I had our first child, who was 1 year old when I got elected.
In my office we had at least a crib in there at any given time
and there were probably toys scattered throughout. I can
remember a colonel from the Army coming over and introducing
himself to me with his spouse and their 2-year-old, who also
came into my office; and I think because I created an
environment that showed it was OK, it made a big difference. I
would not ever imagine that 5 years ago a colonel from the Army
would bring his 2-year-old to the mayor of the city where they
were being stationed. That would never probably have happened,
but we created an environment for that.
So, you had mentioned the childcare, each one of you, as
critical.
The question I would have, Dr. Hayes, you had mentioned
legal counsel may have some issues with this. I would like to
get whatever they write up, if they do, on childcare. I would
like to see that because the one thing I know about attorneys--
and, no offense, I am not one--but they will always tell you
why something cannot happen versus why something should happen.
And, so, if you approach them in a way that when they give you
the answer why it cannot happen, which is probably the
likelihood, can you ask them what can change to make it happen?
That is what I think many of us are talking about or are
going to be interested in because I agree with you, if the
facility does not have childcare--facilities for both women and
men--it is a problem. And, so, if you could do that, that would
be fantastic.
A couple of you mentioned training and successful training,
and I agree with you, it is ``boring.'' The trainings I have
had to go to when they are not interactive are boring.
I'll look to you first, Ms. Christopher.
In your interactions, how do the clinic folks come to you?
In other words, do they volunteer to come to your training?
What happens? How does that work? Does the VA require it? I
would say no to that, but it is a set up question. But how does
it work? How do you get folks to participate from the clinical
side, the professionals?
Ms. Christopher. Honestly, we have been very lucky.
Actually, the DOD liaison to the Palo Alto Polytrauma Center
actually invited me and my colleagues to join the National
Center PTSD Clinical Training Program. He actually cut his time
in half to develop a community panel because he thought it was
important. And, honestly, I found that the DOD liaisons have
been extremely instrumental in bridging the gap between the VA
and the community, which I think is fantastic.
When it comes to the VA clinician trainings that we have
done, honestly, we have approached them and we have gotten
really good feedback, and I think in the Bay Area, there is
some really good dialog. But, no, we----
Senator Begich. No outcome yet?
Ms. Christopher. To suggest it.
Senator Begich. OK. Do you have something, again, you could
share at least with me in any written document that is
specifying what you would like to propose to the VA?
For example, we did this with community police training in
Anchorage when we saw an opportunity because we had a lack of
understanding within our police department in regards to the
cultural diversity of our city. We have 90-plus languages
spoken in our school district--a very diverse community--so, we
integrated that into our training. We kind of forced it at
first because it was a structure, and police are paramilitary,
so they have similar structures, procedures, and processes; and
change is not necessarily high on the list.
I would be interested in, Ms. Christopher--and I think it
was Ms. Williams who also talked about training--any of you
that have some suggestions of how to then have a discussion
with the VA on how they can make that a little better. I would
be very interested in that, if you could.
Ms. Christopher. Yes, Senator.
Senator Begich. And whoever else would be willing to do
that.
In connection to that, again, I am going to kind of veer
through you to Dr. Hayes.
I would be very interested if the VA actually surveys their
clients for results of VA clinics because--I am just guessing--
even though in theory they are all same, they operate
differently.
The example you gave, Ms. Williams, was your positive
experience in the last clinic you had gone to. It was very
positive and there are some good things that occurred there.
But that varies clinic to clinic. I would be curious if, Dr.
Hayes, you could provide that. Ms. Williams, if you could tell
me again where that was. I did not write it down quick enough.
The one you had a very good experience in.
Ms. Williams. Yes, sir. I have had negative experiences at
the DC VA. And, just on my way here this morning, I shared with
a woman in uniform that I was coming here, and she said she is
in the process of retiring. She just went to the DC VA, and had
the same experience that I did. She said that it seemed unclean
to her and very disorganized, and there were people there
clearly struggling to cope. It can be nerve-racking when you
are seeking care to worry that that is your future. So I said,
go to the one in Martinsburg, West Virginia.
We live out near Dulles airport, and from there, it takes
just as long to get into D.C. as it does to go all the way out
to West Virginia based on the lovely traffic we all face. And
the Martinsburg facility is doing great.
There are obviously areas that they could improve on, as
well. They are undergoing construction. So, currently, the OEF/
OIF clinic is collocated with the mental health outpatient
clinic, which at first I found a little off-putting, but when
they said that was because of the ongoing construction to
improve the facility, I thought that was great and it is really
a wonderful model.
Senator Begich. That is great. Thanks for telling me which
clinic that was which helps me get a little better
understanding.
The last think I will just mention, triggered by the
discussion of telemedicine, that Alaska, because of our
ruralness and remoteness, telemedicine is a very powerful tool,
and it is very valuable in a lot of ways. So, I know we have
had very positive comments and conversations with the VA about
telemedicine and their interest in expanding that.
I know from my State, it is a critical path to delivery
because we do not have a VA hospital, for one. We have clinics.
And then, in remote areas, we have nothing. And it is very
difficult because there are no roads to get from one place to
the next. So, I appreciate your comments on telemedicine from
another perspective. You know, I see it from a rural
perspective. I appreciate your comments from women veterans'
perspective, is another access point that is a positive one. So
thank you for that.
Mr. Chairman, I will end there. It is a very enlightening
panel in a lot of ways because of your direct contact,
utilization, and work with other folks. So, thank you very much
for this insight.
Chairman Akaka. Thank you very much, Senator Begich.
Hearing what has gone on here, I just want to inform
everyone that the Committee's legislation S. 252 has provisions
making childcare more available by using an existing childcare
program and providing reimbursement to those getting care. So,
that is in that bill and this is something, of course, as we
have discussed, that certainly can be used here with helping
all women.
One of my major goals is to create a seamless transition
for servicemembers as they leave the military and become
veterans.
As women veterans, what do you perceive as a major gap in
this transition process, and how would you recommend we fix it?
Ms. Williams?
Ms. Williams. Sir, I think one thing that will go a long
way toward fixing some of the problems--and it is my
understanding it is at least in the trial process now in some
locations--would be electronic medical records.
Having to hand-carry your own medical records when you
leave the DOD system and take them to the VA system, and the
fear that some piece of paper will get lost--a vital piece of
paper proving what has happened to you in the past--is very
difficult and stressful, and may be even more of a challenge
for veterans who may have sustained a Traumatic Brain Injury or
be struggling with mental health concerns. So, I think that the
implementation of universal electronic medical records will go
a long way toward fixing that problem.
Also, there can be big challenges in terms of benefits.
When my husband was medically retired from the military,
there was a gap between that time and when he started getting
his VA benefits. During that time, we were so financially
insecure that both of us ended up going on unemployment, which
was a deeply humiliating experience for two proud and honorable
combat veterans--to be reduced to that while we were waiting
for his VA benefits to start coming in, and I was waiting for
my job to get started.
So, trying anything that can help smooth and ease that
transition would help. I think efforts to get VA exams done for
those servicemembers who have been injured in the military so
that they can have a more seamless transition in terms of
benefits is another step in the right direction.
Chairman Akaka. Thank you.
Ms. Chase?
Ms. Chase. Senator, as a Reservist, when you come off of
active-duty, which can be multiple times during your military
career--especially if you have been activated several times--
one of the biggest issues is that we are handed our records,
and then it comes on you to keep and maintain those records
throughout the duration for however long you will need them.
Once you are handed your medical records, that is it. That
documentation does not flow from what is or may have been put
into a computer system at a care facility that you were at even
to another care facility while on active-duty orders from base
to base, much less from when you are on DOD and then into the
VA System.
So, that enrollment period where the records directly
transfer from your active military service and they follow you
throughout your VA service or throughout your VA eligibility
time, it is important, it is significant, and I cannot stress
and say enough about how vital it is to have that to also prove
combat service. If a woman or any veteran has served in combat
and has been seen or treated by a physician or a physician's
assistant while on active-duty, then it would flow right into
their VA eligibility and into the computer system. So, it will
alleviate so many of the other issues that we are seeing.
Chairman Akaka. Thank you very much.
Are there any other--Ms. Olds?
Ms. Olds. Mr. Chairman, thank you.
I want to follow-up with the medical records topic.
That was one of the biggest problems with me getting care
when I first got out back in 1992. To this day, no one has
found my records, and, of course, that caused a significant
delay in getting benefits from the VA. It took almost 3 years
and Councilwoman Furse to get involved. So, having access to
our medical records, having them transferred without anyone
having an opportunity to lose them, I think, is significantly
important.
And, also, giving information to people about what benefits
they can get, I was not given any. I had no idea I had benefits
coming until I met with someone at the PVA and they asked the
right questions.
So, information and medical record availability, I think,
are probably the two big ones as far as us getting our access
into the VA system when we get out.
So, thank you.
Chairman Akaka. Thank you.
Ms. Christopher?
Ms. Christopher. Mr. Chairman, when I got out of the
military, I did not think that I had any benefits. It was due
to a volunteer writing an op-ed in the Seattle Times that I
found out about the Military Sexual Trauma Program, and that I
might be eligible.
Needless to say, when I arrived, I had to fight for my
eligibility. I have an honorable discharge, but the
circumstances are a bit more complicated, so, it was the clerks
that I really had to fight with to get seen to get treatment.
Once I did finally prove that I was a veteran and that I
was entitled to treatment for MST, I got great care by the
doctors that I got there. But it was an uphill battle, and
having to prove again and again my trauma and that I am a
veteran has definitely affected me. And, let me tell you, it
was very validating to finally be rated by the VA.
I have witnessed having OEF/OIF advocates and case managers
nowadays since the process is so much easier for new veterans,
and I am so glad that the VA has those. However, most
veterans--newly-separated servicemembers--are not always aware
that these positions exist.
So, again, referring back to the community: when veterans
come into my clinic or when we are doing briefings, I ask them,
hey, do you know about this office in the VA; or I hand out a
business card and personally introduce them to my VA
counterparts. So, my point is that the community is still a
really integral tool in accessing VA health care.
Chairman Akaka. Ms. Ilem?
Ms. Ilem. I would say that things have changed a lot since
I got out of the military in the mid-80s when there was little-
to-know information. I definitely did not recognize myself as a
veteran; did not know that I had access to the VA; and did not
even recognize that I was entitled to service-connected
benefits for disabilities incurred during service until I met
DAV folks.
So, I think VA is on the right track now in terms of a
number of outreach efforts when people are coming back from
deployments--trying to outreach with them then, get them
enrolled in VA care at that point, and giving them
information--but also then doing follow-up letters and follow-
up phone calls.
The unfortunate thing is, as we heard from Ms. Williams,
when somebody from VA does call, if they would have the ability
to just adapt a little bit and take into account that, yes,
they were calling on this particular veteran, but others need
help--to be able to refer them and simply go ahead and take
care of these people. That is going to be key in terms of
continued follow-up until the time when that veteran is ready;
and maybe catch them at a point when they realize they have
access to these benefits and are in need of them.
Chairman Akaka. Thank you very much, Ms. Ilem.
First, I want to thank you for the sacrifice you have made
for our country; and for the kind of help you are giving us in
trying to support our women veterans, I want to thank all of
you for being here today.
We have heard about a lot of good initiatives VA is
undertaking to increase the quality and access to care for
women veterans. However, we also heard that there is much more
that could be done, especially in the areas of outreach and
education about these services; and you mentioned medical
records and also the electronic shift that needs to come.
All our Nation's veterans, both men and women, deserve the
best quality of health care, and I will continue to work to
make sure that they receive it.
I look forward to working with VA and others to find
solutions to the gaps in care for our women veterans.
Thank you all, again, for being here today. You have been
very helpful.
This hearing is now adjourned.
[Whereupon, at 11:10 a.m., the hearing was adjourned.]
A P P E N D I X
----------
Patient Satisfaction Scores by Gender Using CAHPS Report Provided by
Veterans Health Administration, U.S. Department of Veterans Affairs
______
Prepared Statement of Marsha (Tansey) Four, RN, Chair,
Woman Veterans Committee, Vietnam Veterans of America
Good morning Mr. Chairman, Ranking Member Burr, and distinguished
Members of the Senate Veterans' Affairs Committee. Thank you for giving
Vietnam Veterans of America (VVA) the opportunity to submit our
statement for the record regarding VA Health Care Services for Woman
Veterans. VVA supports swift passage of S. 252, ``The Veterans Health
Care Authorization Act of 2009;'' however, we would like for additional
language to be included in Section III, regarding woman veterans health
care which was missing from H.R. 1211, the Women Veterans Health Care
Improvement Act that was passed by the House.
It is indisputable that the number of women in the military has
risen consistently since the 2 percent cap on their enlistment in the
Armed Forces was removed in the early 1970s. This has resulted in an
increased number of women we can now call ``veterans'', and most
assuredly, will have a direct bearing on the number of women who will
be knocking on the door of the VA in the very near future. A focus on
the capacity and capability of the VA to equitably and effectively
provide care and services must be a priority today. Planning and
readiness is essential for the future. These responsibilities also
require oversight and accountability in order to meet VA and veteran
goals, objectives, requirements, standards, and satisfaction, along
with agency advancement.
While much has been done over the past few years to advance and
ensure greater equity, safety, and provision of services for the
growing number of women veterans in the VA system, these changes and
improvements have not been completely implemented throughout the entire
VA system. In some locations, women veterans still experience
significant barriers to adequate health care. Thus, VVA asks Secretary
Shinseki to ensure senior leadership at all VA facilities and in each
VISN to be held accountable for ensuring that women veterans receive
appropriate care in an appropriate environment by appropriate staff.
There is much to learn about women veterans as a separate patient
cohort within the VA. Women's Health is now studied as a specialty in
every medical school in the country. It has moved far beyond that of
obstetrics and gynecology. Gender has an impact on nearly every system
of the body and mind. This has great significance in the ability of any
health care system to provide the most appropriate, comprehensive, and
evidence-based scientific treatment and care. This also has a direct
effect on the delivery system along with staff requirements to meet the
needs of women now utilizing the VA health care system, as well as for
those new women veterans who will soon be accessing the system in the
days and years to come.
The VA has already identified that our country's new women veterans
are younger and that they expect to use the system more consistently.
For example, in December 2008, the VA reported that of the total
102,126 female OIF-OEF veterans, 42.2 percent of them have already
enrolled in the VA system, with 43.8 percent using the system for 2-10
visits. Among these returning veterans, 85.9 percent are below the age
of 40 and 58.9 percent are between 20 and 29. In fact, the average age
of female veterans using the VA system is 48 compared with 61 for men.
The needs of women veterans have yet to be fully identified or
recognized * * * these needs are growing and already taxing the VA
system, which historically has focused on an older male population.
As time, social environments, and veterans' population demographics
change, there are also cultural expectations based on scientific
advancements in health care that elicit a re-definition of women
veterans' needs in the VA system. Knowing the needs is vital to
understanding and meeting them. The VA has recognized many of the needs
of women veterans by actually creating interest groups comprised of not
only VA staff, but veterans as well. For example, there is recognition
that younger women veterans are also working women who need flexible
clinic and appointment hours in order to also meet their employment and
child-care obligations. They also need to have sexual health and family
planning issues addressed, along with the needs of infertility and pre-
natal maternity. And there are unanswered questions and concerns about
the role of exposures to toxic substances and women's reproductive
health.
VVA requests that this Committee continue to focus on treating
women veterans who are homeless with children, victims of sexual
trauma, and provide funding for additional caseworkers and mental
health counselors, a women's mental health treatment program, and a
comprehensive mental health study of returning female soldiers.
Studies and Assessments of Department of Veterans Affairs Health
Services for Women Veterans
VVA believes that this study is vital to understanding today's
women veterans and that building on the ``National Survey of Women
Veterans in Fiscal Year 2007-2008'' is a referenced starting point and
this study should be included as language in the bill as similar to
H.R. 1211 to expand a survey of sufficient size and diversity to be
statistically significant for women of all ethnic groups and service
periods.
VVA believes that this study should identify the ``best practices''
that facilities utilize to overcome identified barriers.
VVA believes that with the fragmentation of women's health care
services there needs to be consideration for driving time/
transportation to medical facilities that offer specialty care as well
as primary care.
While VVA holds great respect for and recognizes the important work
of both the Office of the Center for Women Veterans and that of the
Advisory Committee on Women Veterans, this section as written would
limit the initial review, creating unnecessary delays. Rather, VVA
believes that this study should also go immediately to these two
entities, plus the VA Undersecretary for Health, the Deputy
Undersecretary for Quality and Performance, the Deputy Undersecretary
for Operations, the Office of Patient Care Services, and the Chief
Consultant for the Women Veterans Health Program for review and
recommendations, which in turn are then forwarded to the Deputy
Undersecretary for action to remove or ameliorate the identified
barriers.
VVA recognizes that this requires 30 months after the VA publishes
the 2007-08 National Survey of Women Veterans that the VA Secretary in
turn is required to report to Congress on the barriers study and what
actions the VA is planning. However, in reality, this means that the
information/directions contained in the 1907-08 report is/are put ``on
hold'' for two and a half years. Therefore VVA believes that the
Secretary's report to Congress should also include what actions--if
any--have transpired both during the survey and the 30 month hiatus.
Independent Study on Health Consequences of Women Veterans of Military
Service in Operation Iraqi Freedom and Operation Enduring
Freedom
VVA believes this section should include appropriate language
directing the study format to include the use of evidence-based ``best
practices in care delivery.''
During the 110th Congress, VVA was heartened to see that the
S. 2799 legislation included a ``Long Term Study of Health of Women
Veterans of the Armed Forces Serving Operation Iraq Freedom and
Operation Enduring Freedom.'' However, VVA is extremely disappointed to
see that while calling for ``a study on health consequences for women
veterans of service on active duty in the Armed Forces in deployment in
Operation Iraqi Freedom and Operation Enduring Freedom;'' it eliminates
the longitudinal aspect contained in S. 2799 of the 110th Congress.
As you know, the second round of the National Vietnam Veterans
Readjustment Study was never completed by the VA, even though it was
mandated by Congress to do so. VVA urges you not to let this
opportunity be lost again on a statistically significant and diverse
population of veterans. It is an important element to a study that will
bring long term identification and understanding and of the long term
implication of military service during this period of history when the
role and duties of women veterans has far expanding the service of
women in the past.
Report on Full-Time Program Managers for Women Veterans Programs at
Medical Centers
VVA applauds the VA for recognizing the need and importance of the
requirement for a full time Woman Veteran Program Manager at all VA
medical center. However, VVA feels this action falls short of providing
these managers with the reporting process that is commensurate with
their full duties and responsibilities. Consistency is vital in
recognizing the true tracking of the work they perform and in
evaluating the issues of their mission. VVA believes this position is
most significant and demands that this position's reporting line should
also be significant and not determined by individual medical centers.
It is known that reporting lines are varied from medical center to
medical center. In some instances the reporting of identified items of
the Woman Veteran Program Manager is moved forward through the medical
center hierarchy based, not on the desire of the Woman Veteran Program
Manager, but of other staff who are selective on what is actually
``moved up the chain of command'' at the medical centers. VVA calls for
the Undersecretary of Health to define the reporting line for the Woman
Veteran Program Managers as that of the Chief of Staff at each medical
center. This action backs up the initial significance that the VA
recognized when elevating the position to full time. It brings
significant investment in the importance of meting the needs of women
veterans in its vast health system. If not, a true reporting of the
work of the Woman Veteran Program Managers and the issues of women
veterans could fall into the vast dark pit of the unknown. The work of
the Woman Veteran Program Managers is vital to recognizing not only the
needs but also providing clear information for program and process
formation but also on establishing even possible research
opportunities.
Improvement of Health Care Programs of the Department of Veterans
Affairs for Women Veterans
VVA asks that particular reflective consideration be given to the
following--VVA seeks a change in this section of the proposed
legislation that would increase the time for the provision of neonatal
care from 14 to 30 days, as needed for the newborn children of women
veterans receiving maternity/delivery care through the VA. Certainly,
only newborns with extreme medical conditions would require this time
extension. VVA believes that there may be extraordinary circumstances
wherein it would be detrimental to the proper care and treatment of the
newborn if this provision of service was limited to solely 14 days. If
the infant must have extended hospitalization, it would allow time for
the case manager to make the necessary arrangements to arrange
necessary medical and social services assistance for the women veteran
and her child. This has important implications for our rural woman
veterans in particular. And this is not to mention cases where there
needs to be consideration of a woman veteran's service-connected
disabilities, including toxic exposures and mental health issues,
especially during the pre-natal period.
Training and Certification for Mental Health Care Providers on Care for
Veterans Suffering from Sexual Trauma
VVA has concerns about the VA establishing a ``certification''
program. In order to be valid, VVA believes that such a certification
program be based upon and modeled after those already utilized by many
professional organizations. Such a certification program would lend
itself well to oversight and accountability. Too many VA certification
programs now consist of only a 1-hour training class or reading
materials.
Although this section calls for reporting the number of women
veterans who have received counseling, care and services under
subsection (a) from ``professionals and providers who received training
under subsection (4)'', VVA asks ``Who in the VA is already trained and
holds professional qualifications under these subsections''?
Care for Newborn Children of Women Veterans Receiving Maternity Care
VVA asks that particular reflective consideration be given to the
following--VVA seeks a change in this section of the proposed
legislation that would increase the time for the provision of neonatal
care to 30 days, as needed for the newborn children of women veterans
receiving maternity/delivery care through the VA. Certainly, only
newborns with extreme medical conditions would require this time
extension. VVA believes that there may be extraordinary circumstances
wherein it would be detrimental to the proper care and treatment of the
newborn if this provision of service was limited to less than 30 days.
The decision for extended would require professional justification. If
the infant must have extended hospitalization, it would allow time for
the case manager to make the necessary arrangements to arrange
necessary medical and social services assistance for the women veteran
and her child. This has important implications for our rural woman
veterans in particular. And this is not to mention cases where there
needs to be consideration of a woman veteran's service-connected
disabilities, including toxic exposures and mental health issues,
especially during the pre-natal period, multiple births and pre-mature
births. Prenatal and neonatal birthrate demographics (including
miscarriage and stillborn data) would seem to be an important element
herein.
Delivery of Services
Considering the ever increasing percentage of women veterans in the
homeless veteran population and the extraordinary occurrence of this in
the OEF/OIF homeless veteran population, one can see that their
presence in the VA system will affect all levels of service, delivery,
treatment, and care. Advocacy for them within the VA will be paramount.
Vietnam Veterans of America 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.
The new woman veterans also need increased mental health services
related to re-adjustment, depression, and re-integration, along with
recognition of differences among active duty, Guard, and reserve women.
The VA already acknowledges the issue of fragmented primary care,
noting that in 67 percent of VA sites, primary care is delivered
separately from gender specific health care--in other words, two
different services at two different times, and in some cases, two
different services, two different times, and two different delivery
sites. The VA also notes that there are too few primary care physicians
trained in women's health, and at a time when medicine recognizes the
link between mental and medical health, most mental health is separate
from primary care. VVA seeks to ensure that every woman veteran has
access to a primary care provider who meets all her primary care needs,
including gender specific and mental health care in the context of an
on-going patient-clinician relationship; and that general mental health
providers are located within the women's and primary care clinics in
order to facilitate the delivery of mental health 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.
Research
Vietnam Veterans of America applauds the VA for elevating its
Office of Women's Health to the Strategic Health Care Group level. With
this action, the VA has ``pumped up'' the volume on the attention and
direction of the VA regarding woman veterans. But there remains much to
be learned about women veterans as a health care cohort. Data
collection and analytical studies will provide increased opportunities
for research and health care advancement in the field of women's
health, as well as offer evidence-based ``best practices'' models and
innovative treatments.
As discussed by Phyllis Greenberger, President and CEO of the
Society for Women's Health Research, at a recent Roundtable on Women
Veterans before the House Committee on Veterans' Affairs, Ms.
Greenberger stated that the focus of The Society clearly demonstrated
that sex and gender differences exist throughout all conditions that
affect women differently, disproportionately or exclusively and
research needs to be done to identify those differences and understand
their implications for diagnosis and treatment. She discussed the
unknown in regard to the influence of hormones on not only the bodily
process of the women's medical and mental care but also its influence
on the regime of medication prescribed by the care providers and
utilized by women veterans. This is especially true with medications in
the mental health arena.
It is well recognized that biological differences related to
hormones affect mental health risks, rates of disorders and course of
those disorders. Research had indicated that estrogen and progesterone
influence brain function and stress response. Some women experience
increased vulnerability to depression during times of reproductive
endocrine changes such as premenstrual, postpartum and perimenopausal
periods. VVA believes more funding needs to be available for research
into sex differences and better coordination is needed among VA centers
throughout the country to increase the number of women in clinical
trials to understand the differences and their implication for
treatment.
Suicide Risk
Last, but just as important, VVA is deeply concerned about the high
suicide risk among women veterans as reported at the American
Psychiatric Association's May 2009 meetings in San Francisco. A 2007
longitudinal study of women veterans, which followed individuals for a
period of 12 years, suggests that women who have been in the military
have a 3fold increased risk for suicide compared with nonmilitary
women. Furthermore, female veterans are more likely to be young and use
firearms to commit suicide compared with their civilian counterparts,
who tend to choose other methods--commonly drug overdose. Data for this
study came from the National Health Interview Study and was then linked
with data from the National Death Index. It is important to note that
this study was population-based and therefore, the findings are
applicable to all military personnel and not just those in the Veterans
Affairs (VA) health system.
The VA is a massive health care system that possesses challenges
for woman veterans, who are encouraged to seek treatment at VA
facilities; but not many do. Treatment of women veterans at various
facilities throughout the country are not ``women'' friendly. We are
hopeful that any shortfalls can be turned into positive action for our
so woman veterans who deserve the same care and treatment because of
their service and sacrifice to this country.
In closing, VVA would like to personally thank Senator Patty
Murray, for her hard work and dedication to our woman veterans, for
without Senator Murray, VVA believes that this hearing today would not
be possible. We thank this Committee for the opportunity to submit
testimony for the record.
______
Prepared Statement from Anuradha K. Bhagwati, MPP, Executive Director,
Service Women's Action Network (SWAN)
My name is Anuradha Bhagwati. I am a former Captain in the U.S.
Marine Corps. I currently serve as Executive Director of the Service
Women's Action Network (SWAN), a non-partisan, non-profit organization
founded by female veterans, based out of New York City. SWAN
specializes in policy analysis, advocacy, and legal services for all
servicewomen, women veterans, and their families.
Despite the progress the Veterans' Health Administration has made
in addressing the recent influx of women veterans into the VA system,
the challenges in delivering adequate health care services to women
veterans remain numerous and daunting.
Every day, SWAN receives calls from frustrated, disappointed, and
traumatized women veterans looking for legal assistance or personal
support due to inadequate health care, or mistreatment and harassment
by staff or male patients at VA hospitals. Many women justifiably give
up on the VA, as their traumas and conditions rapidly deteriorate into
drug and alcohol abuse, homelessness, or suicide.
The epidemic of Military Sexual Trauma (MST)--sexual harassment,
assault and rape--which has yet to be fully recognized by the Armed
Forces, has also yet to be adequately integrated into the daily
operations of VA hospitals.
MST screening at hospitals around the Nation appears to be
inconsistent, at best. A shortage of female physicians and counselors,
a rapid turn-over of inexperienced residents, a preponderance of
culturally conservative administrative staff, and poorly trained or
unprofessional medical staff contributes to a lack of understanding
about how to treat veterans who suffer from symptoms related to MST.
However, I must emphasize that regardless of medical condition,
women veterans, when compared to their male counterparts, are largely
subjected to unequal treatment at VA facilities nationwide. The
following anecdotes illustrate just a few of the VA's institutional
failures to deliver proper health care to women veterans:
One Iraq veteran who checked herself into inpatient
psychiatric care during a particularly bad PTSD episode, was forced to
share a bathroom with male veterans, including a peeping tom. When she
told her nurse she felt uncomfortable eating her meals with male
veterans, the nurse threatened that she would not be fed at all.
An Afghanistan veteran--a single mother--who was raped in
theater by a fellow servicemember, cannot bear to enter a VA facility
out of sheer terror of re-triggering the trauma from her assault. Like
many other women veterans, she pays for counseling out of pocket so as
not to subject herself to further trauma.
One veteran recently received her annual pap smear with a
male gynecologist who did not enforce the requirement to have a female
staff member present during the examination. When this veteran
mentioned to the gynecologist that she had experienced MST, he left the
room and barked down the hall, ``We've got another one!''
Many of these examples illustrate a larger point: that the VA
requires an enormous cultural shift recognizing the sacrifices and
specific needs of women veterans.
recommendations to bridge the gaps in care for women veterans
1. Require that the VA remedy the shortage of female physicians,
female mental health providers and MST counselors at VA hospitals
nationwide. Also require that the VA provide the option of female-only
counseling groups for female combat veterans, and female- as well as
male-only counseling groups for female and male survivors of MST.
2. Require the VA to implement a program to train, educate, and
certify all staff, including administrative and medical, in Federal
Equal Opportunity regulations and MST, to reduce a discriminatory and
unwelcoming atmosphere toward women veterans.
3. Require the VA to increase accessibility of fee-based care for
veterans (both male and female) who have been diagnosed with Military
Sexual Trauma.
4. Require day-care facilities for veterans who are parents, as
well as more flexible evening hours for working veterans, at every VA
hospital.