[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]




  EXAMINING ACCESS AND QUALITY OF CARE AND SERVICES FOR WOMEN VETERANS

=======================================================================

                                HEARING

                               before the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                        THURSDAY, APRIL 30, 2015

                               __________

                           Serial No. 114-18

                               __________

       Printed for the use of the Committee on Veterans' Affairs



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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               CORRINE BROWN, Florida, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         MARK TAKANO, California
DAVID P. ROE, Tennessee              JULIA BROWNLEY, California
DAN BENISHEK, Michigan               DINA TITUS, Nevada
TIM HUELSKAMP, Kansas                RAUL RUIZ, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana             KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana             TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York                 JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American 
    Samoa
MIKE BOST, Illinois
                       Jon Towers, Staff Director
                Don Phillips, Democratic Staff Director

Pursuant to clause 2(e)(4) of rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
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both printed and electronic versions of the hearing record, the process 
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                            C O N T E N T S

                              ----------                              

                        Thursday, April 30, 2015

                                                                   Page

Examining Access and Quality of Care and Services for Women 
  Veterans.......................................................     1

                           OPENING STATEMENTS

Hon. Jeff Miller, Chairman.......................................     1
    Prepared Statement...........................................    38
Hon. Corrine Brown, Ranking Member
    Prepared Statement...........................................    39
Hon. Mark Takano.................................................     2

                               WITNESSES

Dawn Halfaker, Veteran...........................................     3
    Prepared Statement...........................................    41

Joy Ilem, Deputy National Legislative Director, National Service 
  and Legislative Headquarters, DAV..............................     6
    Prepared Statement...........................................    47

Lauren Augustine, Legislative Associate, Iraq and Afghanistan 
  Veterans of America............................................     7
    Prepared Statement...........................................    61

Patricia Hayes PhD, Chief Consultant for Women's Health Services 
  Office of Patient Care Services, VHA, U.S. Department of 
  Veterans Affairs...............................................     9
    Prepared Statement...........................................    66

    Accompanied by:
        Susan McCutcheon RN, EdD, National Mental Health Director 
            for Family Services, Women's Mental Health, and 
            Military Sexual Trauma, VHA, U.S. Department of 
            Veterans Affairs
    And
        Curtis Coy, Deputy Under Secretary for Economic 
            Opportunity, VBA, U.S. Department of Veterans Affairs

                        STATEMENT FOR THE RECORD

Veterans of Foreign Wars of the United States....................    87
Vietnam Veterans of America......................................    92
Statement of the Office of Inspector General.....................   104
The American Legion..............................................   114
Keith Kelly, Assistant Secretary for Veterans' Employment and 
  Training Service U.S. Department of Labor......................   118
 
  EXAMINING ACCESS AND QUALITY OF CARE AND SERVICES FOR WOMEN VETERANS

                              ----------                              


                        Thursday, April 30, 2015

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                                   Washington, D.C.
    The committee met, pursuant to other business, at 10:42 
a.m., in Room 334, Cannon House Office Building, Hon. Jeff 
Miller [chairman of the committee] presiding.
    Present:  Representatives Miller, Lamborn, Bilirakis, Roe, 
Benishek, Huelskamp, Coffman, Wenstrup, Walorski, Abraham, 
Zeldin, Costello, Radewagen, Bost, Brown, Takano, Brownley, 
Titus, Ruiz, Kuster, O'Rourke, Rice, McNerney, and Walz.

           OPENING STATEMENT OF CHAIRMAN JEFF MILLER

    The Chairman. The full committee will come to order. I 
appreciate again you all being here this morning for this 
oversight hearing, Examining Access and Quality of Care and 
Services for Women Veterans.
    Women have been serving our Nation in the Armed Forces 
since the Revolutionary War, but today more than ever. They are 
an important and an increasing population of veterans served by 
the Department of Veterans Affairs with their numbers expected 
to grow even as the veteran population as a whole in our 
country is slated to shrink.
    Women of the modern military excel in a variety of roles, 
as medics, pilots, civil affairs specialists, as officers, and 
enlisted. They follow in the footsteps of the WAVES and the 
WACs of World War II and the Nurse and Medical Specialist Corps 
of the Korean and the Vietnam wars.
    The service they provided was not dependent on their gender 
and the services the VA is charged to provide them while being 
respectful of their unique prospective needs and concerns 
should not be either.
    Women veterans are just that. They are veterans and as 
such, they are deserving of the same respect, the same 
attention, the same consideration that is afforded to the male 
veterans with whom they have served alongside.
    However, last year, the Disabled Veterans of America 
released a report that found serious gaps in every aspect of 
programs that serve women veterans. According to the DAV, the 
vast majority of these deficiencies result from a disregard for 
the differing needs of women veterans and are focusing on the 
80 percent solution for men who dominate in both numbers and in 
the public's consciousness. This is unacceptable.
    Today I will be requesting the Government Accountability 
Office to conduct an assessment of VA's ability to improve the 
healthcare access and quality of our women veterans. GAO last 
conducted an investigation on healthcare for women veterans in 
2010 and found that availability of services for women varied 
significantly across the VA healthcare system and that VA faced 
a number of key challenges in providing healthcare to women 
veterans.
    In the intervening five years, VA has made some strides in 
improving healthcare for women veterans, but too many gaps 
still remain, especially considering that just yesterday, GAO 
informed me that VA had yet to provide documentation to show 
that VA has, in fact, implemented two of the five 
recommendations that were made in that report.
    I am hopeful that through GAO's effort and this hearing we 
will discover the extent to which VA has improved services for 
women veterans, where challenges to quality care and services 
still exist, and how those gaps can be overcome once and for 
all both for the women who are in VA care today and for the 
thousands of women who will transition into VA care over the 
next several years.
    I again want to thank everybody for being here today, and I 
recognize Mr. Takano, for any opening statement he may have.

    [The prepared statement of Chairman Jeff Miller appears in 
the Appendix]

             OPENING STATEMENT OF HON. MARK TAKANO

    Mr. Takano. Thank you, Mr. Chairman, for holding this 
hearing, this important hearing on women veterans' health 
issues and the access to healthcare within the Veterans 
Administration.
    I know only too well the consequences of the increasing 
role that our women play in our Nation's defense. Within my own 
caucus, Tammy Duckworth of Illinois is a living example of 
women being put in the line of fire and the sacrifices they are 
making for our country.
    And there are women on both sides of the aisle who are 
serving our country valiantly and, as you say, their role is 
only going to increase as the nature of our voluntary military 
is going to need the increased participation of women in our 
Nation's defense.
    In particular today, I hope to explore issues such as an 
interoperability of record systems as a way of making a more 
seamless effort to connect healthcare services that women need 
that may be outside the VA. I see that as a major impediment. 
If we can make the electronic healthcare records more 
interoperable and more seamless, it will give us, I think, 
greater options to cooperate, have the VA cooperate on a 
private-public partnership basis.
    I am concerned about the payment delays. I was reading 
through some of the testimony of one of the women who was 
trying to obtain OB/GYN services and since there is a shortage 
within the VA, something we must address, we have to contract 
out. But the problem of contracting out is the fact that the VA 
is not timely in their payment.
    So these are all a bunch of, you know, important issues 
that we need to discuss. I know my colleagues have a lot of 
questions on both sides. I am very, very eager to begin this 
hearing.
    Thank you.
    The Chairman. Thank you very much, Mr. Takano.
    And every member on this committee on both sides of the 
aisle wants the best for the veterans that have served this 
Nation regardless of party affiliation, regardless of gender, 
and I think it is an appropriate time that we take today to 
hear from some of those who have worn the uniform of this 
Nation.
    So I would call our first panel of witnesses to come 
forward to the dais, if you would, and I will call you, the 
first and only panel.
    First on the panel is Dawn Halfaker, a veteran, a business 
owner, and a strong voice in the veteran community; Joy Ilem, a 
veteran and the Deputy National Legislative Director for the 
National Service and Legislative Headquarters of the Disabled 
American Veterans; Lauren Augustine, a veteran and a 
Legislative Associate for the Iraq and Afghanistan Veterans of 
America; Dr. Patricia Hayes, the Chief Consultant for Women's 
Health Services for the Department of Veterans Affairs' Office 
of Patient Care Services.
    Dr. Hayes is accompanied by Dr. Susan McCutcheon, VA's 
National Mental Health Director for Family Services, Women's 
Mental Health and Military Sexual Trauma, and Curtis Coy, VA's 
Deputy Under Secretary for Economic Opportunity.
    I appreciate you all being here today. Ms. Halfaker, you 
are recognized for your opening testimony.
    And I have to ask before how is the little one doing that I 
spent time with at the dedication of the Disabled for Life 
Memorial?
    Ms. Halfaker. Very good. Thanks for asking.
    The Chairman. Very good.

                   STATEMENT OF DAWN HALFAKER

    Ms. Halfaker. Mr. Chairman and members of the committee, 
thank you for holding this hearing and for inviting me to 
testify.
    The issues you are reviewing are of great concern to me as 
one whose military career was cut short after I was severely 
wounded in Iraq while serving there in 2004.
    I am very proud to have served in uniform and to continue 
to serve as an advocate for my fellow wounded warriors, 
veterans, and their families through affiliations with 
nonprofits like USO, Wounded Warrior Project, as well as my own 
service-disabled, veteran-owned business where I employ a lot 
of veterans and wounded warriors. I am also pleased to be able 
to advocate for my fellow women veterans by testifying today.
    Looking back and while the VA has come a long way since 
just a generation ago where there was no women's program and VA 
hospital could not provide women patients the most basic 
privacy, they have absolutely come a long way, but the 
department still has much to do and more work to close the gaps 
that DAV portrayed in its report, The Long Journey Home.
    VA care is an entitlement and a promise for those of us who 
served and I use its medical system proudly. I want the system 
to work to help our veterans and to ensure that the promise is 
kept for all veterans.
    My testimony today reflects what I have learned as a VA 
patient and focuses on my recent experience in getting 
maternity care through the VA. As the chairman alluded to, he 
had the pleasure of meeting my little guy. He is about a year 
old now and he is doing great. So thanks again for asking.
    Understandably the VA outsources maternity care, but its 
administrative stewardship of this service is so hands off that 
women veterans don't get enough support during this vulnerable 
period.
    The problems I have encountered are systemic, largely due 
to a wide gap between VA's detailed written directives and what 
the veterans actually experience. Consider VA's policy which 
among other things states that women veterans continue to get 
care through VA facilities during their pregnancies for 
management of any other conditions, coordination of care and 
information sharing between non-VA and VA providers is 
critical, and each facility must ensure seamless coordination 
of non-VA maternity care with VA care.
    While these are very sound policies, the expectations they 
set are largely piled on a single individual at each medical 
center called the maternity care coordinator. That individual 
actually has more than a dozen specific responsibilities.
    My coordinator failed to meet several of these 
responsibilities at critical points. So instead of experiencing 
seamless coordination of care, I felt abandoned at times and 
had to navigate some difficult challenges on my own.
    So where did things go wrong? Well, from the start, my 
maternity care coordinator handed me a list of DC area 
maternity care providers, but quickly warned that she couldn't 
really endorse any of these providers and I would need to go 
find a doctor on my own who would accept the VA contract at 
Medicare rates and would sign it.
    I had expected the medical center to have a network of OB/
GYN providers with whom it contracts. I was surprised to learn 
that it hadn't established any maternity care contracts which 
left me on my own to find obstetrical care.
    As it turned out, my choosing a George Washington 
University Hospital physician proved lucky because her office 
had actually treated another veteran patient, only one, but at 
least had learned how the VA contract works and was willing to 
sign it.
    I was also surprised to discover that VA is essentially a 
maternity care bill payer, but it doesn't even carry out that 
role very efficiently. For example, over the course of my 
pregnancy, my doctor routinely had lab work done. But because 
VA was very slow in paying the bills, the lab company began 
billing me directly.
    My maternity care coordinator apparently couldn't fix the 
problem and I soon got collection notices that nonpayment would 
jeopardize my credit.
    Things got worse. During the pregnancy, my doctor became 
concerned by signs suggestive of a fetal heart problem and 
referred me to Children's Hospital for an echocardiogram. That 
is the only facility in this area that does those.
    I notified my maternity care coordinator to get the needed 
approval but was told that it would take several weeks because 
the DC, VA had no established relationship with Children's.
    With my child's well-being potentially at risk, the idea of 
waiting weeks to get an okay just didn't seem right, but my 
coordinator wouldn't budge until I said I would record our 
conversation and alert my congressman. That finally sparked 
action and led to VA's arranging with Children's for the 
procedure. So thank you, Congress.
    The good news was that the testing revealed that there was 
no cardiac abnormality, but I was soon stuck in the middle 
again now getting bills from Children's. It took eight weeks 
and a conference call with the VA officials in two different 
offices to clarify that VA had paid Children's. But because its 
payment only covered a fraction of the charges, Children's 
demanded that I pay the difference, more than $1,700.
    After trying to unsuccessfully get my maternity care 
coordinator to resolve this Catch-22, I eventually learned that 
she had been out for several weeks with her own prenatal 
issues. Surprisingly nobody had been assigned to serve as a 
backup, so luckily my VA OIF/OEF coordinator and case manager 
happened to contact me and was willing to step in and resolve 
the problem.
    There is much room for improvement, so let me offer a few 
recommendations. Women veterans should be afforded access to 
high-quality maternity care. The burden should not be on the 
veteran to go find qualified OB/GYN care. Obstetrical care 
should not start with a pregnancy test as outlined in the VA 
handbook. It should start with preconception counseling to 
assure a woman is as healthy as possible before conception to 
promote her health and the health of her future children.
    If VA is going to outsource maternity care, it should be 
seamless and it must include the full range of maternity-
related service that a veteran may require. VA medical centers 
should contract with a single high-quality provider such as GWU 
or a network of providers similar to TRICARE so that the 
veterans can be assured of receiving excellent care where 
experienced clinicians are sensitive to the unique needs of 
women veterans and that veterans do not bear the cost 
associated with that care.
    Pregnancy is a vulnerable period in which women veterans 
should have reliable ongoing support and there can't be a 
single point of failure. I applaud VA's direction that pregnant 
veterans be assigned a maternity care coordinator, but that 
requires both adequate staffing and appropriate training to 
assure high-quality, consistent, ongoing, 24/7 service.
    Mr. Chairman, women veterans look to you and this committee 
to help assure that VA meets these challenges. Thank you for 
the opportunity to share my perspective and I am pleased to 
answer your questions.

    [The prepared statement of Dawn Halfaker appears in the 
Appendix]

    The Chairman. Thank you very much.
    Ms. Ilem, you are recognized for five minutes.

                     STATEMENT OF JOY ILEM

    Ms. Ilem. Thank you, Mr. Chairman, for inviting DAV to 
testify at this important hearing.
    Over the past decade of war, women have been a rapidly 
increasing and important component of the military services as 
you have noted. Women now routinely serve in occupations that 
put them in harm's way and combat and resulting in trauma, 
injury, and environmental exposures associated with modern 
warfare.
    And as you know and are aware, following military service, 
women are turning to VA in record numbers. In fact, the number 
of women seeking VA care has doubled, more than doubled in the 
past decade and continues to rise.
    As a disabled veteran and user of the system, I know 
firsthand what issues women veterans face when they seek care. 
The experiences of current wartime deployments have contributed 
to a number of new challenges and transition reintegration 
challenges for these servicemembers.
    As a result, DAV commissioned a study in 2014 to look at 
women transitioning from the military and the existing federal 
programs and services available to aid them in that transition. 
Our report, Women Veterans, The Long Journey Home, represents a 
comprehensive assessment of the existing policies and programs 
serving women across the federal landscape.
    One of DAV's key legislative priorities has been to ensure 
that women veterans are properly recognized for their military 
service and receive equal benefits and high-quality medical 
care services in the VA healthcare system.
    DAV's report notes that despite a government that provides 
a generous array of benefits to assist veterans with transition 
and readjustment following military service, gaps are evident 
for women in existing programs. And these gaps can impede a 
successful transition and negatively impact their health 
outcomes.
    The majority of these deficiencies, as you noted, result 
from a disregard from the differing needs of women veterans and 
historic focus on developing programs for men who are prominent 
in numbers and public consciousness.
    Research demonstrates that when compared to men, women 
veterans returning home from current wartime deployments are 
more likely to be divorced, a single parent, and unemployed 
after the service. They have higher rates of homelessness, at 
least twice as high as women nonveteran.
    Some have limited access to transitional and safe housing 
options, especially for homeless women with minor children, 
high rates of military sexual assault, and higher use of VA 
mental health services. Women also continue to report limited 
access to child care services as a barrier to needed 
healthcare.
    Despite the fact that VA has made tremendous progress to 
improve services for women, they still lack consistent access 
to a full range of gender-sensitive healthcare benefits and 
services.
    To correct these deficiencies, DAV makes a number of key 
recommendations including requiring every VA medical center to 
hire a gynecologist and appropriate staffing levels to meet 
demand for gender-specific services; implementation of gender-
specific clinical IT tools; improving access to gender-
sensitive mental health programs; tailored transition 
assistance, education, and career guidance programs; increased 
access to safe transitional beds and housing for homeless women 
veterans with children; improved access to specialized 
prosthetic items and treatment for MST; permanent authorization 
for child care services and women-focused post deployment 
readjustment retreats; and an effective plan for systemic 
culture change to ensure women experience a welcoming, safe, 
and private environment of care at all VA facilities.
    Over the history of our country, millions of women have 
answered the call to duty and put themselves at risk to 
preserve our Nation's security. They have kept their promise 
and served this country faithfully, many with distinction. Now 
it is time we keep our promise to them and we can do that by 
acknowledging their dedicated military service and serving them 
with greater respect, consideration, and care.
    Given the fact that more than half of the women veterans 
under VA care are service disabled, the department must step up 
its efforts to address their unique health maintenance needs, 
reallocate resources to do so, and ramp up clinical training 
for these high-priority VA beneficiaries with age-appropriate, 
customized care.
    This is a transformative moment for the VA. Secretary 
McDonald is leading an ambitious effort to change the 
department's overall culture and to direct resources where they 
will ensure VA healthcare services can meet the needs of every 
veteran who needs them. That cannot happen without a strong 
focus on women veterans and a detailed plan of action.
    For these reasons, we call on Congress to legislate and set 
a firm deadline of Memorial Day 2016 for action by the 
department to complete the steps outlined in DAV's report. This 
will ensure that women veterans have equal access to 
comprehensive, high-quality, gender-sensitive healthcare and 
benefits.
    Again, DAV appreciates the opportunity to testify before 
the committee today and I am happy to answer any questions you 
may have.

    [The prepared statement of Joy Ilem appears in the 
Appendix]

    The Chairman. Thank you very much.
    Ms. Augustine, you are recognized for five minutes.

                 STATEMENT OF LAUREN AUGUSTINE

    Ms. Augustine. Chairman Miller and distinguished members of 
the committee, on behalf of Iraq and Afghanistan Veterans of 
America, we would like to extend our gratitude for the 
opportunity to share our views and recommendations on improving 
women veterans' access to quality healthcare and service.
    As the leading post-9/11 veterans' empowerment organization 
with the most diverse and rapidly growing membership in 
America, we are proud to have a diverse group of women veteran 
members and leaders as part of our organization.
    This March, we launched our first women veterans' survey as 
part of an effort to understand more about women's experiences 
during and after service. Over 1,500 women veterans have 
responded so far.
    In addition to the survey, IAVA's research department 
traveled to seven cities across the country and spoke with 
dozens of women veterans in an ongoing series of focus groups. 
In speaking with our members across the country, we have 
narrowed our suggestions here today to three main points.
    First, VA, DoD, and the Nation at large must recognize 
women for their ongoing service to this country. Second, the VA 
specifically needs to expedite planned improvements to VA 
facilities to support and improve services and care for women 
at these facilities. And, finally, there must be a renewed 
focus on research to fully understand where gaps in services 
exist.
    Women have played a vital role in our military throughout 
history and their impact and contributions are continuing to 
grow and, yet, what IAVA has learned while traveling the 
country is that women veterans continue to encounter barriers 
to care and benefits including an overall culture that does not 
fully recognize or accept them as veterans.
    Last year during IAVA's advocacy campaign, Storm the Hill, 
one of our own leaders experienced a group of fellow veterans 
thanking her for her support while thanking her male colleagues 
for their service.
    Recent IAVA focus group data illustrate this type of 
disconnect is widely reported with less than 40 percent of 
women veterans reporting that they felt the U.S. treats their 
military service with respect.
    These frequent instances of dismissing or ignoring women's 
military service must change and nowhere is that more necessary 
than inside the walls of VA facilities. We suggest that as a 
first step, VA medical centers implement staff training 
programs to counter these assumptions.
    Additionally, the role of the women veterans' program 
manager should be strengthened to ensure this position is given 
the necessary authority to implement policies. The need for an 
inclusive environment is not restricted to the staff at the VA. 
Patient advocates must also be prepared to handle complaints 
related to harassment or individuals creating a hostile 
environment in order to enact actual culture change.
    Second, VA medical centers need specific operational and 
structural changes that support the needs of all veterans. In 
our recent focus groups, women consistently pointed out that 
they have had to endure long wait times to get care from a 
provider that they trust or who are trained in women-specific 
medical fields.
    While our women veterans' survey is still open, our initial 
analysis shows that about 70 percent of our respondents rate 
the VA as fair, poor, or very poor in their support provided to 
women veterans. Among those who have used private healthcare, 
only one in four rated private healthcare in the same 
satisfaction levels.
    And while the VA has made great strides to address these 
types of issues, there is still a need to ensure every VA 
medical center has appropriate facilities that are fully 
staffed to support the needs unique to women.
    From our initial survey results, only about half of those 
enrolled in VA care said the facility they last visited had a 
gynecologist on site and less than half reported a women's VETS 
coordination or program manager on site. These statistics and 
issues are not new, but the need to address the disparity in 
gender-specific care remains.
    Third and finally, there must be renewed emphasis on good 
data and reliable research into the experiences of women 
veterans. Gaps in services and improvements in care cannot be 
fully achieved unless they are fully defined.
    The VA has already taken steps in the right direction here 
with the establishment of the Center for Women Veterans, the 
renewal of the charter for the Advisory Committee on Women 
Veterans, and the recent Women's Health Research Conference.
    But the VA, DoD, and Department of Labor among other 
government agencies should make additional improvements to 
their research by incorporating gender and minority analysis 
into all reports to better inform gaps in services and 
programs. Specifically focusing on the VA, VBA must track and 
analyze all rating decisions by gender to ensure accurate, 
timely, and equitable rating decisions.
    I think what most sums up this testimony is the observation 
of a Vietnam veteran who attended one of our focus groups. She 
noted that while there may have been some progress, by and 
large, it has not been enough and certainly not fast enough. 
Many of the challenges that existed when she transitioned to VA 
care decades ago still exist.
    With the women veteran population only projected to 
increase, the time to address these issues is now. IAVA would 
like to thank you for bringing these issues to the forefront 
and giving us the chance to offer our views and the views of 
our members here today. Thank you for your time and attention.

    [The prepared statement of Lauren Augustine appears in the 
Appendix]

    The Chairman. Thank you very much.
    Dr. Hayes, you are recognized for five minutes.

 STATEMENT OF PATRICIA HAYES, ACCOMPANIED TODAY BY MR. CURTIS 
 COY, VETERAN BENEFITS ADMINISTRATION, DEPUTY UNDER SECRETARY 
FOR ECONOMIC OPPORTUNITY, AS WELL AS DR. SUSAN MCCUTCHEON, THE 
  VHA'S NATIONAL MENTAL HEALTH DIRECTOR FOR FAMILY SERVICES, 
       WOMEN'S MENTAL HEALTH, AND MILITARY SEXUAL TRAUMA

                  STATEMENT OF PATRICIA HAYES

    Ms. Hayes. Good morning, Chairman Miller, Mr. Takano, and 
distinguished members of the House Committee on Veterans' 
Affairs. Thank you for the opportunity to discuss the high-
quality care and support that VA is providing to our women 
veterans.
    The number of women veterans enrolling in VA healthcare has 
increased rapidly, placing new demands on a VA healthcare 
system that has historically treated mostly men.
    In fiscal year 2014, there were more than two million women 
veterans in the United States and of those women veterans, over 
635,000 are enrollees to include more than 400,000 users of VA 
healthcare services.
    To address this growing number of women veterans who are 
eligible for VA healthcare, VA is strategically enhancing 
services and access for women veterans.
    In 2008, VA first identified the necessary actions for 
ensuring that every woman veteran has access to VA primary 
care. Since then, our plan for delivering care to women 
veterans has basically come to fruition.
    VHA's Women's Health Services oversees program and policy 
development for women's health and provides strategic support 
to implement positive changes in the provision of care for all 
women veterans.
    Women's Health Services works to ensure that timely, 
equitable, high-quality, comprehensive healthcare services are 
provided in a sensitive and safe environment at VA facilities 
nationwide.
    VA Women's Health Services' programs include comprehensive 
primary care, women's health education, reproductive health, 
communication, and partnerships. To provide the highest quality 
of care to women veterans, VA offers women veterans trained and 
experienced, designated women's health providers who can 
provide general primary care and gender-specific primary care 
in the context of a long-term patient and provider 
relationship.
    Today designated women's health providers are available at 
all VA medical centers and 90 percent of community-based 
outpatient clinics. With the launch of such a large-scale 
change in services, Women's Health Services recognized the need 
to assess the progress towards implementation of high-quality 
programs focused on women veterans.
    We evaluate all our women veterans' health programs through 
several mechanisms and in addition, VHA uses an independent 
contractor to conduct detailed site visits to objectively 
assess the implementation of services for women veterans 
nationwide.
    Also, recent analysis indicates that VHA outperforms 
private and public sector healthcare in many quality 
performance measures. As a recognized leader in the provision 
of high-quality healthcare, VHA initiated efforts to address 
gender disparity, a problem that actually affects healthcare 
nationwide.
    Since 2006, VHA's Office of Informatics and Analytics has 
analyzed all the external peer-review program data by gender 
and published a quarterly gender report on the Web site. Over 
the years, we have been working very hard to close the gender 
disparities gap.
    In fiscal year 2008, VHA launched a concerted women's 
health improvement effort focusing on providers' attention on 
gender disparity data. And from 2008 to 2011, VA saw a 
significant reduction in gender disparity for many measures.
    At the close of 2013, small gender gaps existed in only a 
few measures including cholesterol management in high-risk 
patients, diabetes care, and rates of influenza vaccination. VA 
continues to address such key clinical issues and others 
including cardiac care to improve women veterans' health.
    VA recognizes the importance of providing services to women 
veterans over their life span. VA provides a full continuum of 
mental health services to women veterans including outpatient, 
inpatient, and residential treatment options. VA also 
recognizes the significance that support groups and 
partnerships with our local communities have in the transition 
and recovery of women veterans.
    A number of programs connect women veterans and veterans 
with families with healthcare, employment, financial 
counseling, and housing.
    In conclusion, our mission at VA is to care for those who 
shall have borne the battle as well as their families and 
survivors. We are providing the highest-quality healthcare for 
today's women veterans while actively working to meet the needs 
of those who will come to us in the future.
    We have made significant strides in recent years. However, 
we still have much to do as VA continues to focus on the 
nationwide effort to enhance the language, the practice, and 
the culture of VA to be more inclusive of women veterans. We 
will continue to improve our efforts to provide high-quality, 
timely healthcare to our women veterans and we appreciate this 
committee's ongoing support in doing so.
    Mr. Chairman, this concludes my testimony and my colleagues 
and I are prepared to answer any questions that you or other 
committee members may have.

    [The prepared statement of Patricia Hayes appears in the 
Appendix]

    The Chairman. Thank you very much, Dr. Hayes.
    I will yield myself five minutes for questioning.
    Dr. Hayes, I would go to your written statement where you 
say that VA intends to address the hiring of gynecologists and 
improve access by expanding on-site gynecological services and 
the support as we implement the Choice Act.
    My question is, how many gynecologists does VA anticipate 
hiring using the funds that were provided in the Choice Act for 
staffing and how much Choice Act funding totally will be 
allocated to this effort?
    Ms. Hayes. Sir, I would like to first make sure that we 
understand that gender-specific healthcare for women is 
available at every site both through the primary care gender 
provider, that is the designated women's health provider is 
going to do the PAP smears, mammograms, birth control, and 
preconception counseling.
    In addition, we now have access to gynecology at 117 of our 
facilities on site. Everywhere else, they are referred to 
community providers in order to have the highest-quality care 
for women in that community.
    We are right now in the process of looking at those 35 
sites. As you know from our work on the Choice staffing, 
Section 301, we are looking at a workforce management model 
that will tell us exactly how many gynecologists we need at 
each and every site, not just the ones that have only one at 
this time and those that have none on site.
    So I am not able to answer your question directly about the 
number and about the money that we will be using for those 
sites.
    The Chairman. If you would as you go through the process 
provide the committee with the data that you do develop.
    How many of the gynecologists that you intend to hire are 
going to be full time versus part time?
    Ms. Hayes. I also don't know the exact answer to that. We 
are recognizing that a gynecologist on site has many roles. One 
is to conduct gynecology clinic and to perform surgeries both 
inpatient and outpatient. But they also have the role of 
helping to oversee the care of women in the emergency 
department and also to help teach primary care providers in the 
best care of women.
    So it may well be possible that these could be full-time 
providers with part of their time providing on that site, 
emergency room, and one of the things that we would also like 
to enhance is the use of telehealth gynecology so that women in 
the remote areas can be seen in those clinics without having to 
travel to the main site.
    The Chairman. In her written statement, Ms. Halfaker paints 
a powerful illustration for how she puts it, VA's 
administrative stewardship of maternity care is poor and causes 
unnecessary trauma.
    Dr. Hayes, I hope that you take her testimony and use it as 
a guide on how to improve maternity care for women veterans 
which will become increasingly important as the committee 
continues to examine how to expand fertility service for 
service-disabled veterans.
    And at one point in her testimony, and I actually wrote it 
down, she talked about some of the most critical maternity care 
expectations are piled on a single individual, the medical 
center's maternity care coordinator, who in Ms. Halfaker's case 
failed at critical points to meet her responsibilities at very 
key times.
    Ms. Halfaker.
    Ms. Halfaker. Thank you, Mr. Chairman.
    I would say that, and I apologize for going over the time a 
little bit, so I had to cut my oral testimony short, but what I 
wanted to say was include a couple of my fellow combat 
veterans, women who have also had children, one of those 
members serves in Congress, both use the VA at a different 
location. I was here at the DC, VA. And both had the same 
issues.
    And, in fact, I will just say Melissa Stockwell, one of our 
other combat veterans, she is still kind of in, I guess, 
financial peril trying to, you know, juggle bill paying, that 
she has gotten a lot of bills from the VA and--or, excuse me, 
not from the VA, but from wherever she got her care, that the 
VA has not paid and it has been several months since she had 
her child. And so I know that that has been very hard on her 
and her family.
    So, you know, I have a couple data points. I haven't 
interviewed, you know, a lot of women veterans, but I know that 
the ones I have talked to, they all really focus in on the bill 
paying issue where, you know, women veterans are stuck in the 
middle between the VA's fee office and the providers that are 
providing the care and somehow end up getting a lot of those 
bills.
    So I think that is one of the biggest issues and then 
trying to find a provider is the other big issues. There is a 
lot of great facilities in this area, so I was very lucky to 
end up at George Washington University Hospital where I got 
great care, but, unfortunately, for other women veterans, they 
may not know where to go and that can very much be a problem 
for them.
    The Chairman. Thank you very much.
    My time has expired, but I was struck by Ms. Halfaker's 
comments that not only had VA failed to establish contracts 
with local providers to provide maternity care to women 
veterans, but was so slow in reimbursing one of the non-VA care 
providers that she was forced to be billed. And the 
consternation that caused was probably not a good thing. And in 
a second round, I probably will talk about that issue.
    Mr. Takano.
    Mr. Takano. Mr. Chairman, before I begin, I would like to 
ask unanimous consent that Ranking Member Brown's full written 
statement be entered into the record.
    The Chairman. It will be entered into the record in the 
appropriate place without objection.

    [The prepared statement of Ranking Member Corrine Brown 
appears in the Appendix]

    Mr. Takano. Thank you, Mr. Chairman.
    Ms. Halfaker.
    Can you also tell me, besides the billing issue, was there 
an issue also with your medical records being available to the 
VA and how did that play into your care?
    Ms. Halfaker. Sure. So as far as the medical records go, I 
think in the VA handbook there is a policy that states that the 
provider will have to send the medical records back to the VA. 
I don't really have any visibility into that process, whether 
that did or didn't happen.
    But I know that I have tried to get a follow-up appointment 
at the VA numerous times and there continues to be a lot of 
delays. I think that they are experiencing a large number of 
women veterans at the DC, VA right now and so it has been hard 
to get a follow-up appointment. Some of that is on me with my 
schedule, but it is also, you know, a several-month wait time 
right now.
    So they are advising us to use the Veterans Choice Act and 
get purchased care, so I am trying to get signed up for that 
right now which is also another process within itself. So since 
having my child a year and a month ago, 13 months ago, I have 
not been able to get back into the VA to find out whether or 
not they have my medical records and follow-up with kind of a 
routine OB/GYN appointment.
    Mr. Takano. Is the delay in your appointment somehow 
related to the medical records issue or is that not relevant or 
you don't know?
    Ms. Halfaker. Sir, I don't know.
    Mr. Takano. Ms. Ilem, you have insight into this?
    Ms. Ilem. I mean, it sounds like from talking with Ms. 
Halfaker, you know, it could be an issue of demand as well. You 
know, when they are telling you it is going to be several 
months for, you know, a basic appointment in a facility, the 
volume has increased, you know, for a number of people.
    But I would add, you know, for a long time, the DC, VA did 
not have mammograms on site and we went right across the street 
to have those done. The unfortunate thing is when you would 
come back for your appointment, the VA clinician would ask you 
did you have your mammogram and what were the results.
    And, you know, we would constantly say, I mean, you have a 
contract across the street. Why are you not getting those 
results and why are they not being forwarded and put in my 
record in a timely manner?
    So I think that continues to be a problem at sites where 
they have to go off site for mammograms.
    Mr. Takano. Dr. Hayes, can you at all shed some light on to 
the untimeliness of the payments and just what we can do to get 
this unstuck?
    Ms. Hayes. Certainly, Mr. Takano. We have known previously 
because of the fact that about 30 percent of women do have to 
use non-VA care that there have been difficulties in care 
coordination and payment.
    Some of these issues actually have been dealt with very 
directly by the move to the Chief Business Office from all of 
the remote fee-basis personnel now being under the management 
of VA's Central Office, Chief Business Office in the last 
couple of months that that change has occurred.
    I think the more important thing is that with the advent of 
the PC3 contract, within the contract, there are guidelines for 
timeliness of getting the person into care within--a consult 
within seven days, making sure that the bill now goes through 
the PC3 contractor. And so the VA is paying the contractor 
directly and they are resolving the issues locally.
    That hasn't fixed it. We knew for quite some time that 
payment and slow payment has been a challenge. We also know, 
though, and what is disappointing about this case is that there 
has not been the right kind of case management and care 
coordination from the side where our women veteran program 
manager and others have failed the veteran in this case and it 
sounds like in others to navigate that so that we do have ways 
that balance billing should not happen for veterans. They 
shouldn't be getting bills from private sector providers.
    Mr. Takano. What do you have to say about Ms. Halfaker's 
suggestion that VA contract with, you know, a single source, a 
big source where there may be, you know, a large array of OB/
GYN or gender-specific services available?
    Ms. Hayes. There is a couple of angles to that. One is in 
our larger sites, there have been contracts in place and they 
must follow all of the GSA contracting rules which are very 
complex, of course, but they do allow for that.
    The other thing, though, as I said about the PC3 contract, 
that does, in fact, enroll a network of providers. Some of the 
problems with having a central contract in the past have been 
that it has been, say, at University of Philly, but those who 
live further away can't, therefore, participate in that. The 
OB/GYN care needs to be relatively close to their home so that 
when they deliver, they are nearby.
    So we actually think that the network of a PC3 type 
contract is the better way to enroll outside providers into VA 
OB/GYN care and that has been happening.
    Mr. Takano. Mr. Chairman, my time is up. Thank you.
    The Chairman. Thank you.
    Dr. Roe, you are recognized.
    Dr. Roe. Thank you, Mr. Chairman.
    Having spent 31 years in this business of delivering babies 
and so forth, this is something I happen to finally know 
something about. So I have a lot of questions and really 
amazing to hear Ms. Halfaker. And for you veterans out there, 
thank you for your service and I say that as a fellow veteran. 
Thank you.
    I found it astonishing that you wouldn't have--at home 
where I am, the VA, we have a VA. We have a group of OB doctors 
in my practice, 11. At the time I was in practice, five of us 
were veterans and so we coordinated with them. I don't know 
that I ever got a record from the VA. If I had a question, I 
just called the provider out at the VA which was a nurse 
practitioner and said why did you send this patient over here.
    That has been an issue getting the information from the VA 
to me. Why in the world the VA--Medicare actually, they don't 
pay a lot, but they pay pretty timely. And I can't imagine why 
the VA can't write a check. How hard is that to do? And you 
should have a contract like any other insurance plan does that 
you agree to, the physician agrees to, and we take that on.
    And, look, most of us out there, either veteran physicians 
or nonveterans, are more than happy to take care of veterans. I 
can tell you right now our practice takes care of any veteran 
that wants to show up.
    And what I just heard Dr. Hayes say the GSA contracting 
rules are very complicated. Well, that runs a lot of providers 
off. You just don't want to fool with it. I mean, it is such a 
hassle. That should be easy as pie to do and it ought to happen 
yesterday.
    And the fact that you had to have an echo, and thank 
goodness your baby was fine, didn't have to have any further 
treatment or anything, that should be the least of your 
worries. The fact is you should be worrying about your 
pregnancy and your outcome of your baby, not the Children's 
Hospital sending you a bill. And that ought to be fixed 
yesterday so you don't worry about that anymore.
    And, Dr. Hayes, a question to you. How do you explain when 
you tell me about all these things that the VA--and, by the 
way, they are doing a lot better. I want to thank you for that. 
But how do you explain in the focus group that Ms. Augustine 
talked about 70 percent of the support services they describe 
as fair, poor, or very poor?
    I mean, if I had an evaluation of my practice was that, I 
would have been making some changes ASAP.
    Ms. Hayes. Yes.
    Dr. Roe. How when your testimony was very rosy, there is a 
provider everywhere, but that is not the perception these 
patients are having----
    Ms. Hayes. I understand your question.
    Dr. Roe [continuing]. How do you explain that?
    Ms. Hayes. I can't speak to the survey that they have, but 
I do know that we do have sites. As I said, ten percent of our 
community-based outpatient clinics do not have designated 
women's health providers yet, so I don't know to what extent 
the veterans who responded to the survey may be represented of 
folks attending those clinics. We are working to increase that.
    We also know that those who have designated women's health 
providers are very highly satisfied. So, yes, it is a contrast 
in data, but I think, you know, we can't just focus on the data 
but on fixing the problem.
    Dr. Roe. Well, I mean, if you don't know what the problem 
is, you can't fix it. I think----
    Ms. Hayes. Right.
    Dr. Roe [continuing]. You have to know what the data is. 
And, Ms. Augustine, I think you had what, 1,500? Maybe it 
wasn't a double blind, randomized trial that we would, but 
still surveying 1,700 people or 1,500, whatever it was, is 
pretty accurate. Could you comment on that?
    Ms. Augustine. So the survey is still ongoing and the 
analysis is still being done on that. And I would like to speak 
to the point that was brought up about the 70 percent of 
respondents. That was with the VA as a whole rating the VA as 
fair, poor, or very poor in their support provided to women 
veterans.
    We also have a data point that--once again, the survey is 
still open, so respondents are still coming in and the analysis 
is still being done, but thus far, about 65 percent feel the VA 
adequately provides female practitioners and access to female-
specific care. So approximately one in three do not. So that 
would be in line with what Dr. Hayes is mentioning. The 70 
percent is the VA overall.
    Dr. Roe. Overall. Thank you for that.
    And I think basically when you see a volume increase, in 
our practice, what we did when we would--I would go to church 
and somebody would say I can't get an appointment with you for 
four or six months. We would hire a new provider and we knew 
that pretty quickly. And we responded to that because we had to 
provide those services in the community.
    And I think the VA has been very slow to respond to the 
demand. Any comments, Dr. Hayes.
    Ms. Hayes. I think it follows with my comments that we are 
aggressively looking at the workforce issues, exactly where do 
we strategically expect additional increase, where do we have 
gaps right now, and proposing that we make sure we hire up in 
those sites. That really is part of our workforce planning 
right now.
    Dr. Roe. And I think the physician-patient relationship, 
back to Ms. Halfaker, I was the maternity care coordinator for 
my patients for 30 years and if you came to me, I made sure 
that you got the services you needed to take care of you. And 
that is what somebody needed to do and fell down on that. I 
think that is exactly what you pointed out was this gap that 
was missing there.
    If you were my patient, you knew exactly who to come to 
with your problems and our office took care of those problems 
so you didn't have to walk out thinking about that. What was 
happening to you was that was not happening. When this person 
was removed or was gone or for whatever reason, there was no 
one to step in and fill that void for you as I understand that.
    Ms. Halfaker. Congressman Roe, if I could just add to that. 
I think an important point was made by Ms. Augustine about, you 
know, there is the policies that are written in the Women's 
Health Program Office which are excellent and they have done an 
excellent job in trying to push this out.
    But it does take the larger organization at the leadership 
level, at the VISN level to say we are going to hire these 
people. We are going to be in tune with our women veteran 
program managers that are telling us these are the services 
that are needed.
    And I think that point is really important that we need 
throughout the system to make sure they get the support they 
need for what they know. They have put down the policies. They 
put down the programs, but the reality on the ground is what is 
showing here.
    Dr. Roe. I yield back, Mr. Chairman. Thank you.
    The Chairman. Thank you.
    Ms. Brownley, you are recognized.
    Ms. Brownley. Thank you, Mr. Chairman.
    I wanted to talk a little bit about child care for our 
veterans. And last week, I introduced legislation and many of 
my colleagues here who are supporting that legislation to make 
permanent and expand the VA's successful child care pilot 
program.
    I want to particularly thank you, Ms. Ilem, and the 
disabled vets for your support on the bill.
    I just wanted to ask maybe all of you if you want to weigh 
in on what we have learned from the pilot program and what we 
know of the role of child care for women in terms of accessing 
timely health services.
    Ms. Halfaker. Well, I will start out, but we thank you so 
much for introducing that bill. This has been an ongoing issue 
over the last decade. Any surveys, major surveys that were done 
identified child care, access to child care as a barrier for 
many veterans in general, both men and women.
    And the pilots that were done have been deemed to be very 
successful and I think Dr. Hayes could talk more about that. 
But as it is an issue, you know, we have seen the new clinic 
out at DC. We were so pleased to see is they renovated and 
revised that clinic to include area for child care there as 
well. And we are hearing from more women, DAV's Women Veterans' 
Advisory Committee, that are coming in. Some facilities having 
even done it not just in the women's clinic but various areas 
around the facility.
    We see more and more a younger population of women coming 
into the system and older veterans that may be grandparents 
that are now responsible for the children and having that, 
being able to bring them along in an environment that they feel 
comfortable in, you know, has been very helpful, I think, for 
so many women and men.
    Ms. Brownley. Any others?
    Ms. Augustine. I can also echo similar statements from 
IAVA's perspective. Our members have consistently said that 
child care is a barrier to care and providing child care helps 
to remove some barriers. And for several years now, it has been 
a policy agenda statement of ours to expand child care services 
at VA facilities because the pilot program has been so 
successful and so widely appreciated.
    Ms. Brownley. Thank you.
    Ms. Hayes. VA has recommended that we be given permissive 
authority to provide child care in order to meet the exact 
kinds of needs that we are seeing here and that locally, 
veterans could have a voice in how to set that up, how 
communities might participate in it.
    Ms. Brownley. Thank you.
    Dr. Hayes, I wanted to ask you. You talked a little bit 
about the closing of the gender disparity gap, as you called 
it. And I wanted to understand sort of the measurement of that 
and what that kind of means.
    And is it sort of an average of overall services for women 
within the VA? Are you able to disaggregate more rural areas 
where I think we might have, you know, bigger issues than we do 
in the urban areas? Could you talk a little bit about that 
measurement? And we are always looking for tools of how we 
monitor these issues to make sure that we are on the right 
trajectory for improvement and is this a measurement that we 
can be looking at?
    Ms. Hayes. Certainly. When we talk about gender disparity 
data, we are actually looking at clinical prevention measures, 
so whether you get your flu shot or not, whether you get 
mammograms or not, and whether you have your lipids measured. 
These are health measures that are put out by national groups 
outside the VA and VA has always been higher than the private 
sector or Medicare, Medicaid on these measures.
    One of the things that hasn't been addressed nationally 
outside of the VA or earlier in the VA is that women actually--
overall, women's healthcare is poor. We don't do as good a job 
on cardiac disease in women, on flu shots in women nationally. 
And so VA saw that while we did better across the board, we 
didn't do as well in these issues regarding prevention measures 
in men and women. We have basically set forth to tackle that 
measure.
    I do want to address another part of your question which is 
we are looking at implementation of women's healthcare, what 
are we offering for women at various sites, and the variability 
in how well we provide healthcare for women.
    We have a number of different measures including site 
assessments and a dashboard, as we call it, for looking at how 
well are we getting these policies in place, how many women are 
assigned to designated women's health providers. We have these 
types of measures and we are putting those out now on a semi--
the dashboard is once every six months. The other measures are 
annual and we have roll-up reports on those. So we are looking 
at the variability across our system and how well we do those.
    Ms. Brownley. Thank you, Doctor.
    And I yield back.
    The Chairman. Thank you very much.
    Mr. Coffman, you are recognized.
    Mr. Coffman. Thank you, Mr. Chairman, for holding a hearing 
on this important subject.
    And thank you, members of this panel, for sharing your 
views with our committee.
    I believe it is absolutely critical that the VA adopt 
policies to meet the needs of our Nation's growing number of 
women veterans. The rapidly increasing demographic shift of the 
American veteran population is really quite stunning. The 
number of women veterans using VHA between 2003 and 2012 nearly 
doubled. Twenty percent of new recruits now are women while in 
2012, it was only 6.5 percent of VA's patient population were 
women.
    To address this dramatic shift last month, I introduced the 
Women Veterans Access to Quality Care Act. The bill requires VA 
to ensure the availability of OB/GYN healthcare services at all 
VA medical centers to improve its healthcare facilities to meet 
the needs of our women veterans and to hold hospital directors 
publicly accountable for women's healthcare outcomes at their 
facilities.
    I am thrilled that the Vietnam Veterans of America signaled 
its full support for my bill in its statement for the record 
submitted to the committee today, and I look forward to working 
with all of you on the panel as well and with my colleagues on 
the dais to make sure that we get the bill right and ensure our 
women veterans are getting the healthcare that they deserve and 
invite all my committee members to join me in this effort.
    Ms. Augustine, in your testimony today, you noted the 
survey conducted by the Iraq and Afghanistan Veterans of 
America that found 56 percent of respondents felt that the VA 
provided an adequate number of women practitioners. Only 41 
percent believe the VA provided an adequate number of doctors 
specializing in women's care and only 34 percent said the VA 
adequately provided specialized facilities for women.
    Do you think that VA's current policies to place, quote, 
``designated women's health providers,'' unquote, is adequate 
to address the needs of your membership?
    Ms. Augustine. Based on what we are hearing from our 
members like you read in our new survey which is updated data, 
there is still a population that is being under-served in those 
needs. We know that the VA is doing their due diligence to try 
to meet those needs.
    What we are hoping to see is that it is done quickly, that 
there is adequate staffing levels to meet the demands so that 
there aren't situations like we have heard about this morning, 
and that moving forward, the increasing number of women 
veterans, particularly the younger generation coming in that is 
that increase, is getting the services that they need in a 
timely manner.
    Mr. Coffman. Okay. And thank you for your service as well.
    Ms. Augustine. Thank you.
    Mr. Coffman. Ms. Halfaker, thank you for your service to 
the United States Army as an MP. Was that in Iraq?
    Ms. Halfaker. Yes, sir.
    Mr. Coffman. Do you think that the VA's designated women's 
health providers are adequate given these figures?
    Ms. Halfaker. I would say no.
    Mr. Coffman. Okay. In 2010, the GAO found that VHA was not 
complying with its own privacy policies for women veterans. For 
example, check-in areas were in busy, mixed gender areas. 
Gynecological exam rooms did not have adjacent restrooms and 
examination tables were facing entryways.
    Anybody in the panel, based on your personal experiences or 
based on the feedback of your membership, if GAO did the same 
review today, what would they find?
    Ms. Augustine. I can speak to a member I talked with last 
week said that exact same thing. The women's clinic in her 
local medical facility was located directly next to the 
pharmacy, right next to the front door. It was always busy. In 
fact, there was people from the pharmacy who then came into the 
women's clinic because there was no longer seating available in 
the pharmacy. So there was certainly a lack of privacy that she 
shared concerns with.
    Mr. Coffman. Okay. Yes.
    Ms. Ilem. I would just say some of the infrastructure 
issues that are throughout VA, you know, have especially 
impacted on women's health with the safety and privacy issues. 
Many of the facilities had very small locations for their 
women's clinic initially.
    They have been moved around a lot and being able to put in 
for construction and infrastructure changes, you know, is, you 
know, a slow process, as you know, throughout VA. So I think 
that has been a problem, an overarching problem for women's 
health clinics.
    Mr. Coffman. Yes.
    Ms. Halfaker. And so I would just say that that was my 
experience about two years ago at the DC, VA Medical Center 
which is the only place that I have gotten care at the VA, but 
now they have built a new state-of-the-art facility that does 
not have those issues and is adequate.
    Mr. Coffman. Thank you, Mr. Chairman. I yield back.
    Ms. Walorski [presiding]. Thank you.
    The chair recognizes Ms. Titus for five minutes.
    Ms. Titus. Thank you.
    I also want to thank the chairman for holding this hearing. 
He may recall that I sent him a letter last October that was 
signed by all the members on this side asking for us to look 
into the issue of women's health. So I am very glad that we are 
doing that.
    I am also awaiting the results of an IG's investigation 
that we requested that looks into some of these very same 
topics, the issues of privacy, gender-specific care, and 
meeting other kind of healthcare needs.
    I would just ask first very quickly, Dr. Hayes, Nevada has 
about 22,000 women veterans and that is probably a low 
estimate. We have got a brand new hospital in Las Vegas. Can 
you tell me how many gynecologists we have on staff?
    Ms. Hayes. I know that you have at least one, but I don't 
know how many full-time positions you have for gynecology, you 
have both in Reno and in Las Vegas.
    The issue sometimes, though, doesn't look that clear when 
we look at making sure that we have the right healthcare for 
women at all the sites and that we make sure we have enough 
primary care providers. As you have heard here, we still have 
some gaps to fill with regard to that.
    And as we make sure that gynecology is used for the scarce 
resource that it is in our country which is the abnormal 
conditions, making sure that we can do surgery for women, for 
hysterectomies, so we are still trying to manage that in the 
way that makes for the best sense for our women.
    Ms. Titus. If you would get me those numbers, I would 
appreciate it. Thank you.
    Ms. Augustine, you know that far too often women aren't 
recognized as veterans by their peers. They don't even really 
self-identify as veterans so they don't receive the respect 
that they deserve. Also, they don't tend to get the information 
they need about what services are available and then they don't 
use those services. So I think this is a cycle that we need to 
break, especially for our new young women veterans, the newest 
generation post 9/11.
    Do you have any advice to the VA about what we can do to 
bring about some kind of cultural transformation?
    Ms. Augustine. Sure. So the culture change that I mentioned 
in my testimony is certainly a first step. There are some 
additional things that can always be done. For starters, every 
time I receive mail from the VA, it has the wonderful quote 
from Abraham Lincoln, but the male pronouns are an initial 
telling me right away this is for he and him and not for me as 
a her.
    So I think that would be a great step. I have appreciated 
the change in vocabulary from VA personnel. I have heard 
several times over the past month for those instead of using 
he. But when I get mail that says he, that is an initial 
something telling me right off the bat that it is not for me.
    I also think from our members' perspective that 90 percent 
of them have not participated in the peer support program but 
would like to. And I think that opening up peer support 
programs for women would help bring them together and get them 
to have a cultural change within themselves and ourselves, I 
should say, to be proud of their service and to be more willing 
to self-identify.
    Ms. Titus. Thank you. I think that is a very simple change 
that we should make in our correspondence.
    Ms. Ilem, I would also thank you for all the work that DAV 
has done on this topic and your report, The Long Journey Home, 
is a good play book for us to use as we continue to address 
this topic.
    One of the challenges that I hear, too, is that when women 
have a bad experience at the VA, then they don't want to go 
back. Is there some way that we can get the word out that 
things are changing, that things are improving, and that they 
should give it another shot?
    Ms. Ilem. We absolutely want, you know, to make sure that 
women can take advantage of all of the positive things that VA 
has to offer, especially in the very specialized services that 
they provide oftentimes for PTSD, for military sexual trauma 
treatment, for blindness, burns, amputations.
    And we want VA to be that provider and they do need to step 
up their efforts in terms of this cultural change and 
especially during this big transformative moment. It is a real 
opportunity for them to make sure that throughout the 
organization that they are looking at every program office to 
say are we meeting the needs of our women veterans and they 
should invite women veterans in to talk about their experiences 
with VA and embrace that to be able to improve those services.
    Ms. Titus. Thank you.
    Just one last thing to anybody on the panel. I would like 
to go back to Ms. Brownley's comments about child care. I am 
very supportive of her bill. Another thing I hear from women 
veterans, though, or student veterans that they need child care 
support so they can go back to school and take advantage of the 
GI Bill to get an education to better provide for their family.
    Is this something that you hear about? I am working on a 
bill on that. I would appreciate your help and your advice. Do 
you hear women talk about the need for child care when they go 
back to college?
    Ms. Ilem. We are hearing through Student Veterans of 
America and some of the organizations that are working more 
closely on the campuses that that can be an issue. Certainly I 
think it is something, you know, that we really, you know, need 
to look at and we are certainly happy to work with your staff 
in looking into that more.
    Ms. Titus. Thank you.
    Ms. Augustine. The same comment, yes.
    Mr. Coy. I am sorry. I would also suggest that--I visit 
lots of college campuses with our GI Bill students and you are 
right. It is not a woman veteran issue. It is a family issue 
for many of our student veterans. And we look at many of these 
campuses. We promote that kind of thing. We look forward to 
working with you on your bill to see if we can do even more.
    Ms. Titus. Thank you very much.
    Thank you, Madam Chairman.
    Ms. Walorski I wanted to add my thanks as well, ladies, for 
being here, for all of you for coming today, and thank you for 
your service.
    I worked a little bit with military sexual assault and I am 
wondering, I guess to anybody on the panel, but to Dr. Hayes, 
it seems that when we really just a couple of years ago started 
really working together on solutions for this unbelievable 
amount of military sexual assault, and I also serve on the 
Armed Services Committee which it really came to my attention 
there and many of us have been involved with that nationwide, 
so do you see long-term--you know, it seems like right now we 
have got a lot of military sexual assault women coordinators in 
a lot of facilities now in the VA and especially the larger 
ones. Some of the CBOCs even in my area have service 
coordinators as well. That seems to have tied up so many of 
these loose ends about coordination of care, about the 
vulnerability of feeling like nobody is following up.
    When you look at the kind of issues that Ms. Halfaker 
described, when the VA looks at the model for success for being 
able to treat female veterans, is the MST kind of a model of 
what you are following as you are kind of putting these 
building blocks together to deal with more women coming in and 
be able to treat them adequately and with first-class 
healthcare?
    Ms. Hayes. Absolutely. I appreciate the fact that the MST 
points of contacts have really shown a way to coordinate care 
within our system. And I would actually like to turn to Dr. 
McCutcheon a little bit about some of those points in terms of 
what we have learned.
    Ms. McCutcheon. Thank you, Dr. Hayes.
    And thank you for your recognition of the MST coordinator.
    Yes, we do have an MST coordinator at every facility across 
the country. As you mentioned in some CBOCs, we also have MST 
coordinators. I think it is a wonderful infrastructure for us 
and we have been taking care of those veterans who have 
experienced MST. More and more veterans are actually seeking 
treatment who have screened positive in our system.
    So we see that as good news. It is a collateral position 
and some of the positions that Dr. Hayes has spoken about are 
actually full-time positions. And so there is more dedication. 
If you know any of our MST coordinators, they are typically 
psychologists or social workers, so they also have 
responsibilities as clinicians to provide mental healthcare.
    So the MST coordinator is an administrative position, but 
thank you for recognizing them.
    Ms. Walorski Absolutely. And I don't know if this question 
would be for you, Dr. McCutcheon, or Dr. Hayes. So as more 
women are coming into the military and more OB/GYN services 
need to be available, more pregnancies identified, more women 
accessing that kind of help, what happens, for example, for--
and I was just asking this question to my colleague, Dr. 
Wenstrup--what happens when a woman becomes pregnant in the 
field somewhere?
    She is active duty. She becomes pregnant. She leaves. And 
are there specialists in the VA as there are for the whole area 
of prosthetics, Walter Reed, you know, one of the best places 
in the world that has become the prosthetic maker?
    What if these women are coming from areas of harm, 
toxicities, things that could be identified that could be 
harmful passed on to a child? Is there anybody in the country 
that the VA looks at and says, you know, if there is a question 
about what she was exposed to prior to this birth or even after 
this birth, where does she go?
    And if that is not available in your area or you are in a 
rural area, what do you do? Who do you ask and is that a fee-
based service to a specialist somewhere and who would that be?
    Ms. Hayes. Well, you ask excellent questions because we 
have been very attuned to the issues about what are the effects 
of military service on women. And so there is a number of 
points in which this is critical.
    One is our whole department that does look at exposure 
issues in the Office of Public Health and we work very closely 
with them about whether any of these toxins could have a 
reproductive health effect. And for quite a few years now, we 
have looked at everything from depleted uranium to water to 
airborne issues.
    Ms. Walorski. Yes.
    Ms. Hayes. The other thing is I have an OB/GYN on my staff 
who is director of reproductive health and we have consistently 
looked at how to get information to the field about how to 
evaluate the military experience. Where was this woman?
    The good news is at this point in time, we do not see 
patterns of reproductive health effects from military service. 
That is a really important message, but we are not stopping to 
look. You know, it continues to be an active issue for VA. If 
someone were to have a consideration about that possibility, we 
certainly would hook them up with a high-risk OB if we thought 
there was something going on.
    Ms. Walorski. I appreciate it. Thank you very much.
    And the chair yields to Ms. Kuster for five minutes.
    Ms. Kuster. Thank you very much.
    And I want to thank the chair for her leadership on the 
military sexual assault issue and we continue to work on this 
as a bipartisan issue and one that men and women on both sides 
of the aisle care a great deal about.
    Thank you all for your service to our country and to those 
of you at the VA for your service to our veterans.
    I want to focus in. We are very fortunate. I am from New 
Hampshire. We work out of the White River Junction VA Hospital 
and the Manchester, New Hampshire. It is not a full-service 
hospital, but one of the things that we have in both of those 
locations is brand new facilities in very old historic 
hospitals but brand new facilities for women.
    And I just want to commend to my colleagues the notion that 
when these were being designed, they actually brought in women 
veterans, worked very, very closely particularly around I would 
say sort of mental health and level of comfort issues.
    The design for the White River Junction for the entrance 
was very carefully thought through so that women would feel 
safe in this facility, would feel safe coming and getting care. 
I believe it is an all female staff for the services. So just a 
lot of thought went into asking the women veterans what is it 
that you need to come in and get the care that, you know, we 
are here to provide.
    And I want to commend that all around the country that 
approach and to be, as we always talk about on this committee, 
veteran-centric and in this very case very sensitive.
    I have worked with the chair on her concerns on military 
sexual trauma and I just wanted to follow-up with all of you 
about the availability of care for sexual assault survivors and 
what more we could be doing. Do you see any gaps? We would be 
more than happy to follow-up with legislation, but just if you 
have any thoughts on that topic or more broadly mental health 
issues generally, PTSD, traumatic brain injury, any of those 
thoughts that you might have.
    Ms. Ilem. I would first say, you know, VA provides some of 
the state-of-the-art best care for survivors of sexual assault, 
male and female population. And in that vein, you know, we want 
to make sure that the providers themselves have the time to 
provide the evidence-based treatments that we know work in 
treatment and be able to spend the time with these veterans 
that they need.
    They are often very complex cases, you know, suicidal 
ideation, other substance use disorders associated with 
depression, you know, along with PTSD. So we have expressed 
some concern, you know, to really want to look at those 
staffing levels in terms of, you know, VA has said that they 
have met a minimum standard across the country.
    And Dr. McCutcheon could probably talk to that more, but I 
think our concern is, you know, has there really been an 
independent study done about staffing levels and the number of 
hours that it takes for the prescribed treatments that VA, you 
know, does have available in their arsenal.
    And we have heard from providers in the past that they 
don't, you know, feel that they have the time to spend with 
veterans that they want and to do PTSD treatment. So that would 
be my point on that.
    Ms. Kuster. Thank you.
    Any of the others or, Dr. McCutcheon, if you would like to 
weigh in.
    Ms. McCutcheon. If I may follow-up from some of the 
comments from Ms. Ilem. We report to Congress every year on our 
capacity to provide MST-related mental healthcare. And the 
report this year shows that every facility across the country 
does have that capacity to provide that care.
    And also what Ms. Ilem said is that we are very proud that 
we are able to offer the gold standard of treatment for our 
veterans who have experienced MST. As you know, MST is not a 
diagnosis, but there are many diagnoses associated with MST 
with posttraumatic stress disorder being the most frequently, 
most prevalent diagnosis.
    And so at the VA, we do train our clinicians on these gold 
standards of cognitive processing therapy, prolonged exposure. 
We also provide evidence-based therapies for depression. So we 
have this as part of our clinical treatment.
    And you are right also to mention that we have many men in 
our system that have also experienced MST. And up to three 
years ago, there were actually more males in our healthcare 
system than women. And so we also give the same attention to 
our males who have had this experience.
    Ms. Kuster. Well, I just want you all to know that we have 
a focus on this, that we want to make sure to first of all stop 
the practice completely and protect all of our servicemen and 
women, but that we will continue to follow this very closely.
    And thank you. I yield back.
    Ms. Walorski. Thank you.
    The chair recognizes Dr. Wenstrup for five minutes.
    Dr. Wenstrup. Thank you, Madam Chair.
    If I may for a second go to one of your points you were 
making if someone becomes pregnant while on active duty in the 
field that initially they would be treated. They would go to 
DoD care rather than VA, but the same issues apply whether it 
is, you know, immediately at that time or down the road once 
they are out of uniform.
    And I want to thank all of you for your service in uniform 
and what you are doing today.
    And, Mr. Coy, welcome back. It is good to see you.
    Ms. Augustine, you brought up a very good point about the 
words of Lincoln as you enter the building. And, you know, I 
was pleased when the secretary came in. That was one of the 
first things that he did is address that issue and make it 
ubiquitous for both male and female. And I think that is 
important today.
    Obviously, you know, our highest priority is to get people 
into care and the situation that we are faced with today in the 
VA is understanding that we have, I use this figuratively, we 
have patients in the ambulance and they need to get to care. So 
the discussions of the changes we are making and expanding and 
things like that, those are all good, but does it help someone 
today.
    So my question is, how much demand are you seeing for women 
to go outside the VA and is the demand there because the 
services aren't there or they prefer to go outside the VA for 
whatever reason? What are you finding in that regard?
    Ms. Hayes. Women have had to use outside VA services in the 
VA system now for quite a number of years and, as I said, about 
30 percent of women in a given year do use non-VA care whether 
it is through the contract PC3 fee basis and now we certainly 
openly use the Choice card for women as well as men. There is a 
slightly higher number of women proportionately using the 
Choice card than men. We are tracking it. We are just beginning 
to look into it.
    Dr. Wenstrup. Yes.
    Ms. Hayes. But as part of our ongoing look at what is it 
that women need and how are we going to be able to best get it 
for them. Surprisingly, though, not all of the care has always 
been for gender-related care. When we look at care outside the 
VA, women need the whole gamut of care.
    Dr. Wenstrup. Yes.
    Ms. Hayes. And I think that kind of reflects things like 
the high musculoskeletal injuries, so we have women using 
physical therapy outside the VA, home health assistance in the 
elderly veteran. You know, our range of veterans is the whole 
age range.
    And so we continue to study what it is and to increase 
services in-house. I think sometimes there is a question about 
why we use so much non-VA care for women and it really isn't a 
budgetary issue. It is an issue of making sure we have the 
highest quality for care inside the VA.
    So we don't set up a mammogram until we have a critical 
mass of women and we can bring the right specialists in-house, 
for example. And I think sometimes that gets confusing when we 
look at, well, why do we have such high non-VA care use. And it 
is really about making sure that we have the right providers in 
place to provide the high-quality care. And sometimes that 
means in the community.
    Dr. Wenstrup. Yes. And I appreciate that. I mean, what is 
best for the patient----
    Ms. Hayes Right.
    Dr. Wenstrup [continuing]. And what do we need right now. 
And to be honest with you, you know, and in other hearings and 
as we probe into where we are going with the VA, we don't even 
really know what it costs within the VA compared to private 
sector because they can't really tell how much we are spending 
on all our physical plant and everything else.
    So that is down the road. We need to get to that point and 
so that we can provide not just with women's care but all care 
and how we are doing it the best, but I appreciate it.
    Mr. Coy, a question for you, if I could. There are steps 
that the Department of Labor Veterans' Employment and Training 
Services are taking and also Vocational Rehab and Employment 
Services.
    Are there differences per se in the counseling that a woman 
gets compared to a man? Are there certain things that are 
different there as we look ahead or as we are doing it today?
    Mr. Coy. Thank you, Doctor.
    I have got two or three different ways to answer that with 
respect to transition and then with respect to just sort of 
everyday situations.
    With respect to transition, we, as you know, have 
completely revamped the Transition Assistance Program in the 
last couple years. And what we are dedicated to do is making 
sure that all of our departing servicemembers are informed 
consumers of their VA benefits.
    We have over 300 benefits advisors that do these TAP 
classes. Thirty-five percent of them are women, 90 percent are 
veterans, and four percent are spouses of servicemembers as we 
are out there. So each one of those benefits advisors is 
keeping an eye out for some of those things that women, those 
women, departing women servicemembers may need or want.
    With respect to VRE and those services, as you know, VRE 
services are case management services. They are individualized 
services for each of those veterans, whether they are a man or 
a woman. So we do that case management on an individual basis 
there.
    Dr. Wenstrup. Thank you. I yield back.
    Dr. Roe [presiding]. Mr. O'Rourke, you are recognized for 
five minutes.
    Mr. O'Rourke. Thank you, Mr. Chairman.
    I yield one minute of my time to Mr. Walz.
    Mr. Walz. I thank the gentleman for the courtesy.
    And thank you all for being here and help us tackle this 
issue.
    Dr. Hayes, I understand cultural change takes time, but I 
am wondering if you could do one thing for me. I wonder if you 
could capture the name of this warrior that Ms. Halfaker talked 
about, capture that the bills weren't paid, give it to one of 
your assistants here and pay the bill this week. That is one 
less thing they should worry about and that lets us solve that.
    I thank the gentleman. I give him back his time.
    Ms. Hayes. We will absolutely take care of that. Thank you.
    Mr. O'Rourke. Thank you, Mr. Walz. Thank you.
    Dr. Hayes, reclaiming my time, I was noting my colleague 
from New Hampshire's comments about a women's clinic at the VA 
there and she talked about an all female staff who are helping 
veterans in her community.
    In El Paso, Texas, the community I serve and represent, I 
hear persistently from veterans about our women's clinic and 
its shortcomings, one of which is that there is one OB/GYN 
provider who is part time, who is male, and many of the 
veterans who speak at my town hall meetings, women veterans say 
that those who have experienced military sexual trauma are very 
uncomfortable with that situation.
    When we talked to the VA about that, they say that they 
cannot discriminate based on gender in hiring and they are not 
going to make any changes to that situation.
    In addition, we have the problem that we only have a half-
time provider and you have wait times to get an OB/GYN 
appointment of up to six months, maybe longer, but six months 
is a number that we know to be true from some of the veterans 
we work with.
    Dr. Hayes, how do you respond to that? How would you guide 
me in improving that situation and working with VA to make it 
better?
    Ms. Hayes. I would like to work very closely with you on 
that particular issue and anyone that is having that issue 
about gender of provider because of a number things. As I think 
Ms. Ilem pointed out, we already have a policy that says that 
we will honor a veteran's request for gender of provider 
whether it is in-house or whether we use non-VA care for that.
    So that only sort of stop gaps the measure, though. The 
other one I would question is the issue about hiring and we 
already know that we have received waivers from the Office of 
Personnel Management when we know that we have a preponderance 
of a need for a female provider. And so we can go directly to 
that situation.
    It does show the need that we have to look at each 
provision of gynecological care and we are starting to do that. 
I have already got appointments for a number of places. We are 
talking to the directors about this. We realize that our policy 
isn't making it to the ground in terms of the needs.
    And so we will look at the need there, how many GYNs do 
they have. Some women do not have the preference for a female 
GYN, but many do and we are looking at being able to provide 
that in-house wherever possible.
    Mr. O'Rourke. Thank you.
    You know, your answer alone right now is helpful to us. 
Perhaps there is a communication breakdown in El Paso in terms 
of what they believe they can or cannot do----
    Ms. Hayes. Right.
    Mr. O'Rourke [continuing]. When it comes to serving the 
needs of women veterans in El Paso. So appreciate your answer. 
But, yes, I want to followup with you and let's make this 
situation better.
    Ms. Hayes. Let's do it.
    Mr. O'Rourke. So thank you.
    And then for the other panelists in the remaining two 
minutes that we have, I would love to get your thoughts on 
whether the focus should be to continue to build up capacity 
within the VA or, Ms. Halfaker, I thought you made some 
important comments about creating or pushing for excellence in 
how that care is referred, how it is paid for, and how it is 
coordinated.
    When I read that the secretary is trying to hire 28,000 
unfilled positions within the VA, I worry about focusing on 
building something up and not capitalizing on capacity that is 
within the community. So if you wouldn't mind addressing that. 
And if there is time, I would love to hear from Ms. Ilem and 
Ms. Augustine as well.
    Ms. Halfaker. Sure. Thank you.
    I firmly believe that I think that it is taking too long to 
staff. I mean, we have been hearing about these staffing issues 
for quite some time. There has always been issues at the DC, VA 
where I go. And, you know, they can't seem to resolve those 
staffing issues and so, you know, we continue to wait six 
months. You know, five to six months is usually the average 
wait time at least for me. So I would say that, you know, we 
are better served.
    Finally I called just very recently to try to make an 
appointment as I alluded to earlier in my testimony and, you 
know, they referred me to the Veterans Choice and said that I 
could call this 1-800 number if I wanted to try to get an 
appointment sooner if I was eligible to get enrolled in that.
    And I have not followed up on that yet to call that 1-800 
number, but, you know, given all that, I would think that, you 
know, the VA is best served to have some kind of network where 
care can be provided seamlessly and, you know, information can 
be efficiently shared between the VA and, you know, the outside 
provider.
    Mr. O'Rourke. Thank you.
    And, Ms. Ilem and Ms. Augustine, I am out of time. So if 
you wouldn't mind, I would love to get your responses for the 
record or we could follow-up after the hearing.
    Thank you. Mr. Chair, I yield back.
    Dr. Roe. Thank you, Mr. O'Rourke.
    Mr. Costello, you are recognized for five minutes.
    Mr. Costello. Thank you, Dr. Roe.
    First let me just say that as a new member of the Veterans' 
Affairs Committee that it is very gratifying to be able to work 
on issues like this with Congresswoman Brownley and Titus and 
Ranking Member Brown, Congresswoman Rice, Congresswoman 
Walorski, as well as Congressmen O'Rourke, Coffman, Roe, 
Wenstrup, Walz, and others.
    The bipartisan focus on what is the most nonpartisan of 
issues which is making sure that those unique issues to female 
veterans related to healthcare access and opportunity and our 
collective desire to improve them is something that I think we 
should emphasize indicates that we do want to solve problems 
and make improvements in our country and that this committee is 
doing that. And I applaud Chairman Miller and Ranking Member 
Brown for this hearing.
    I have a broad brush of a question for all of you 
collectively. As we await review and recommendations from the 
IG on the letter that we had transmitted, what are the few 
areas where we need to focus our efforts in the next several 
years for female veterans? And I would open that up both on the 
employment side and obviously on the access to healthcare side.
    Ms. Ilem. I would just say one major gap that I think VA 
really needs the committee's support on is making sure about 
the implementation of the gender-specific clinical IT tools. 
There are a number of IT tools that are, you know, very gender 
specific that I know some of them have been pending for years 
in terms of the implementation and if you are able to provide 
some sort of push forward to make sure those go to the front of 
the line because many of them are life safety issues and 
providing better care for women.
    Ms. Augustine. I will add to that and say that from our 
members, we are hearing that mental healthcare is one of the 
most critical aspects for improvement within the VA in addition 
to meeting the capacity of the need that is continuing to grow.
    Ms. Hayes. I think that you can tell from our focus that we 
know we need to meet the gaps in terms of resources and 
staffing primary care, boots on the ground to serve our women 
veterans. That is absolutely number one.
    We are implementing some of the changes that Ms. Ilem 
responded to and this will help us do better care coordination. 
We also have a number of apps and other ways for maternity 
tracking, maternity care coordination, some of these issues 
that have been brought up today. We already have some of the 
fixes in the pipeline, but the pipeline needs to move fast. I 
think those are really the key points for us and mental health.
    Mr. Coy. I will just add. You mentioned employment. As the 
DAV report pointed out, you know, there is really no good 
definitive data as to why women veterans seem to have a higher 
unemployment rate, although we know the demographics of women 
are much different than--of women veterans than they are of 
male veterans. Women veterans certainly are younger, more 
diverse, and certainly more educated than their male 
counterparts.
    We have seen, though, employment figures drop somewhat 
dramatically since 2011 to 2014. In fact, 9.7 to about 5.3 
today. But I think there is a lot more information that we need 
to get with that respect and we need a bigger push on making 
sure that women veterans are afforded all of those employment 
opportunities that everyone else is.
    Mr. Costello. So following up Congressman Wenstrup's 
question related to DoL Veterans' Employment and Training 
Service, is it just a function of focusing more within the 
framework of what exists to make sure that female veterans 
receive the attention or is even more of a curriculum change or 
something additive? I mean, I know that you said you are still 
looking into that, so that may be an unfair question because 
you are still looking into that, but any illumination on that 
point I would appreciate.
    Mr. Coy. I think it is a vexing question that we have been 
looking at and trying to understand as well. I think in the TAP 
curriculum, we have a number of things going for and some 
things going against.
    For example, a lot of times people are six months out or 
four months out. They are thinking about getting out and moving 
and doing all those things and not focused on those kinds of 
things. How do we make sure that those benefits and those 
things that we can help veterans including women veterans are 
done after they transition out as well?
    Mr. Costello. Thank you.
    Dr. Roe. Thank you.
    Ms. Brown, you are recognized for five minutes.
    Ms. Brown. Thank you.
    First of all, let me just say I want to thank the chairman 
because I have wanted this hearing for over a year and I am 
very excited about having it.
    Thank all of you for your service and for being here today 
because I think this is very helpful.
    As we develop a comprehensive program for women and as, 
women are the fastest growing group of veterans, how are we 
going to best address the needs as, I understand that there 
will be some challenges?
    I personally used to go through to Bethesda for treatment. 
Now I go to George Washington Hospital. I like going where it 
is all women in the facility. Several years ago, women told the 
committee they didn't like going into the VA because men--would 
do catcalls.
    So I say how in the world can we address that? We did in 
Jacksonville at the clinic because women have a separate 
entrance which works. Some of the other women say they don't 
want that.
    So as we develop this program, what is the best to 
alleviate this? I think in some of the programs if the program 
is in the community, we have the Choice Program, so that a 
veteran can go outside of the system if the system is not 
working.
    So we can start with Dr. Hayes.
    Ms. Hayes. Certainly. Your point is well taken, 
Representative Brown, because of the issues that women veterans 
need to have a voice in what is happening at their site. And so 
we heard about women being able to talk about how they wanted 
the women's center set up.
    But I also would say that there are a number of women who 
say I don't want----
    Ms. Brown. Yes.
    Ms. Hayes [continuing]. A separate women's clinic. And so 
what has to happen at that site is what we do have at many 
sites. We have a separate women's clinic and we have women's 
providers in the more general gender neutral primary care 
clinics integrated with the clinic so a women veteran does have 
a choice within our system as to how to receive her care.
    But listening to the women in that site, in that community, 
I think is the only way we can provide the best care.
    Ms. Brown. Anyone else?
    Ms. Augustine. Sure, I can add to that. I will say based on 
our preliminary survey data that 70 percent of women veterans 
that responded feel that VA provides a comfortable and safe 
environment and 30 percent do not. And I think what that 
reflects is the need to really listen to the women veterans on 
the ground as has been repeated so far.
    And I think another point where that can be gathered is in 
peer support groups. We had a vast majority of respondents who 
wanted that sort of system where they could provide feedback 
about many different things including the care they are 
receiving at the VA. And I think that would be a wonderful 
opportunity to receive that feedback and implement community-
based solutions.
    Ms. Ilem. Absolutely. And the culture just at the highest 
levels and throughout the organization is important because 
women veterans aren't just going to be exclusively in that 
women's clinic. I mean, they may be able to provide all those 
primary care and some gender specific. They may have to go to 
lab, X-ray throughout the system to specialty clinics.
    We want to make sure that throughout that system, that VISN 
director, the hospital director, and each department is really 
looking out for women and making sure that their attention, you 
know, has been paid to them and their needs and that they are 
not being called out or there is something inappropriate 
happening that needs to, you know, be addressed immediately at 
the, you know, location.
    Ms. Brown. I am very interested in your comments because 
you indicated that you received a Choice card and you didn't 
follow-up, You have yet to enroll.
    Ms. Halfaker. Yes, ma'am. I have not actually enrolled in 
the Choice Program yet. My understanding, there is an 
enrollment process. And so I literally had a conversation with 
the VA women's clinic a couple days ago and just haven't had 
time because they told me that I couldn't get an appointment 
for several months because they were full and that they were, 
you know, experiencing high volume patients.
    And so they told me to call the 1-800 number for the 
Veterans Choice Program. So I haven't done that yet, but just 
to me, that is not a very efficient way to refer patients into 
that program. You would think that they would have kind of a 
more defined protocol as to how I would then, you know, go get 
my care through the Veterans Choice.
    Ms. Brown. I learned at my workshop in Jacksonville if a 
veterans calls that number, they get a list of physicians in 
the area and they can make a referral right then. With a wait 
time less than 30 days.
    I would like for you to follow-up and then follow-up with 
us because I want to know because it is supposed to be 
seamless.
    Ms. Ilem. And----
    Ms. Brown. Yes.
    Ms. Ilem [continuing]. I would just mention, too, because 
Ms. Halfaker had noted earlier that when she was referred out 
for her maternity----
    Ms. Brown. Yes.
    Ms. Ilem [continuing]. Care originally that she was asked 
to go find a provider and to negotiate that contract with that 
provider to see if they would accept the VA Medicare rate. And, 
you know----
    Ms. Brown. That was the Choice Program. That is not 
necessary.
    Ms. Ilem. Right. But it shouldn't even be for fee basis if 
they wanted to use that method. I mean, the veteran should not 
be put in the middle of trying to negotiate that contract.
    Ms. Brown. Absolutely. That is right.
    Ms. Ilem. VA should be doing that once they have selected a 
provider, but I think also the point taken that often women 
veterans want the referral of VA----
    Ms. Brown. Yes.
    Ms. Ilem. --to make sure they are going to go to a quality 
provider that is certified and, you know----
    Ms. Hayes. I would also like to add, though, that we won't 
want to lose Ms. Halfaker to VA care. She is a VA patient in 
our clinic. What has failed here is that we didn't make her a 
follow-up appointment. We knew when her baby was going to be 
born. We didn't make her the follow-up appointment she needed 
nine, ten months down the road.
    I think the real issue here is about our care coordination. 
And while she certainly has the choice to find a new primary 
care provider, I would rather have us bring her back into our 
fold in an appropriate way and not be told that she has to wait 
months for an appointment. She is an established patient with 
us.
    Ms. Brown. What are your feelings about that, Dr. Hayes.
    Ms. Hayes. Well, our maternity care coordinator----
    Ms. Brown. Yes.
    Ms. Hayes [continuing]. Which we already heard were major 
problems in her case, but that person should be calling her 
monthly following up on how she is doing, should set up her 
follow-up appointments with the VA, and know if something goes 
wrong, know how she is doing, see if she needs supports after 
her pregnancy, talk to her about her mental status and her 
psychosocial issues and her supports all the way along.
    That is our model for maternity care coordination because 
we know they are outside our system. It is a fragmented system. 
We didn't do what we needed to do for her and that is what I am 
saying. Clearly she is our patient. We want her to be part of 
our fold. If she wants Choice, that is fine, but I am hearing 
her say that wasn't the answer to what she wanted.
    And so we can go both ways with her, but I would like to 
say that we need to do a much better job in maternity care 
coordination, have more people in place, and make sure this 
happens for our veterans.
    Ms. Brown. Absolutely. Absolutely.
    Dr. Roe. Thank you.
    Dr. Benishek, you are recognized for five minutes.
    Dr. Benishek. Thank you, Mr. Chairman.
    Well, I am a father of a female veteran, so I certainly 
understand some of those issues. And, frankly, I am a little 
chagrined to hear the story about, you know, call this 800 
number and then see what happens. And it seems like she should 
be able to get an appointment, you know, not have to make 
another call and then you don't know who is going to be at the 
end of that call or what is going to happen.
    It seems like we need to have a better system of referral 
when we are dealing with providers outside the VA system. And I 
certainly understand that that would maybe need to be because, 
I mean, you are not going to have a gynecologic or obstetric 
service at a VA hospital because it is going to be sporadic as 
far as the need.
    But I am somewhat concerned about the availability of 
staff. So what has changed? Ms. Hayes, you are sort of a part 
of it, right? Have they improved the number of providers in 
areas around the country so that you don't have to call an 800 
number? Can a patient get a gynecologist referral without, you 
know, an actual appointment, without having to call around?
    Ms. Hayes. Absolutely. We have increased the number of 
providers many, many fold. You know, we went from having only 
about 30 sites that had women's clinics. Now we have 2,500 
trained providers over the last several years. Our issue is we 
haven't been going fast enough for the number of women coming 
in our doors.
    And, you know, we have been aware of that, but it hasn't 
gotten down to every level, every community-based outpatient 
clinic, every main site. They haven't----
    Dr. Benishek. Are you talking about physicians that are in 
your clinics or this is physicians in the community that are 
taking care of veteran patients through some contract or 
through the Choice Program?
    Ms. Hayes. There are a number of ways that we can take care 
of veterans in the community. One is what used to be called fee 
basis, the non-VA care. Those are not contract. Those are 
individual authorizations.
    In addition, we have what is called contract. PC3 is our 
acronym for it. That is a network of providers that are 
contracted through the PC3 provider. What that means is----
    Dr. Benishek. No. I am familiar.
    Ms. Hayes. Right.
    Dr. Benishek. I am familiar. What I want to know is----
    Ms. Hayes. So the veteran can be sent to a specific 
provider. And then the third option for veterans is the Choice 
card. And right now it is set up so that if the clerk is saying 
you have--what Ms. Halfaker said is accurate. They are provided 
a phone number because they are called and they are saying I 
need a Choice option. And the 800 number gives them a list of 
providers that they can see in their area for that condition.
    Dr. Benishek. It doesn't sound like the best of techniques 
because it leaves the onus on the patient to find the provider. 
I mean, it seems to me that a patient is seeing a provider 
within the VA, here, call this number and make an appointment. 
Why can't the appointment just be made while the patient is in 
contact with you?
    Ms. Hayes. I think it is in terms of what many of our 
veterans want about an outside provider that they actually want 
to see. That is part of why the system was set up that way. But 
I appreciate your comment that for a veteran who doesn't know 
exactly, rather would see VA, we need to do something different 
in terms of care coordination on that end.
    Dr. Benishek. All right. Thank you.
    Where are you in your hiring for providing specialty care 
like gynecology? I mean, where are you in your process? Do you 
have enough of those providers or what is the story there?
    Ms. Hayes. We are not clear on whether this issue is really 
recruitment. We are looking at the 35 sites that do not have 
gynecology on site. And many of them have fewer than a thousand 
women. So in terms of workload, that is not why we are looking 
at this. We are looking at it in terms of making sure the 
knowledge base is on site.
    And so the issue of our workforce and what we exactly need 
is one that we are doing a close study on right now as part of 
our overall workforce planning model. And I don't have the 
answers for you right now exactly what we need at those sites.
    Dr. Benishek. But do all the CBOCs have a staffing plan or 
do they have a referral plan? I mean, if Ms. Halfaker walks 
into a CBOC in my district, is she going to get an 800 number? 
Where will the gynecologist be?
    Ms. Hayes. She will be referred through the non-VA care or 
the PC3. It would be only if she said I want to use the Choice 
Act because in a community-based outpatient clinic, we don't 
have gynecology on site.
    Dr. Benishek. Right.
    Ms. Hayes. Likely either the main facility or they would 
use telehealth or they would use a non-VA care arrangement in 
order to get the gynecologist that they are working with.
    Dr. Benishek. All right. Thank you. I am out of time.
    Dr. Roe. Dr. Benishek, thank you.
    If anyone has any further questions, I will open a second 
round, but only for two minutes because we have a fairly busy 
agenda this afternoon. I guess Ms. Titus should be first, yes.
    Ms. Titus. Thank you all. I appreciate the information you 
provided us.
    One thing that bothers me is when you say you don't have a 
gynecologist, but you have a person who will give a PAP smear 
and a mammogram. I would ask every woman in this room how many 
of you go for those annual exams to a general practitioner as 
opposed to a gynecologist? I do not think you would see very 
many hands go up.
    Ms. Hayes. Well, if I could say, one of the things that 
VA----
    Ms. Titus. No. I just want to make that point.
    The second point I want to make, though, is to give a shout 
out to a young woman whose name is Nadine Noky and she lives in 
Venice, Florida. And she is an Iraq veteran. And it goes to 
that point of culture transformation.
    She said she wanted people to know she was a veteran. She 
was proud of that, but she couldn't find anything to wear. 
Everything was designed for men. So she started her own T-shirt 
company called Lady Brigade. She prints T-shirts that say this 
is what a veteran looks like that fit women or one that says 
any girl can wear heels, but it takes a woman to wear combat 
boots or another one that says mother, sister, soldier.
    I got to give her credit for that. I mean, what a great way 
to wear your pride on your T-shirt. I just want to tell her I 
think that is great that she is doing it.
    Thank you, Mr. Chairman.
    Dr. Roe. Thank you.
    Mr. O'Rourke. Thank you, Mr. Chair.
    So I do get a chance to hear from Ms. Ilem and Ms. 
Augustine on how we balance staffing up to an adequate level 
within the VA, but also acknowledging that we are unlikely to 
get to the idea on the near future and that as Ms. Halfaker 
suggested, we need to promote excellence and coordination of 
care.
    And so, Ms. Ilem, if we could start with you.
    Ms. Ilem. I think the coordination of care point is 
absolutely essential and I think Dr. Hayes has referred to 
that. You know, I think, you know, keeping women veterans in 
the VA system to make sure that they can have comprehensive 
care and the benefits from the system, everything that it has 
to offer, especially for service-disabled veterans, and when 
there is an issue of, you know, staffing levels, I mean, we 
know people leave, we know people--they have trouble recruiting 
in certain locations.
    I think assisting that woman veteran and making sure that 
there is really that care coordination piece which is an 
overall problem, not just for women, but I think for women 
veterans, it is especially important is because a high number 
or a high percentage have to use outside care.
    And that is really what VA researches have indicated. We 
don't know what happens when you go outside of VA. We don't 
have the data. And they are working hard now to really look at 
women, specifically women veterans and the impact of military 
service on their care, so they are going to have better care at 
VA, a better opportunity, and to keep them in when they can and 
better coordinate that care when they can't.
    Ms. Augustine. I would echo what Ms. Ilem said. We think 
that the VA can provide excellent care for veterans that is 
specific for veterans and unique to veterans, but we also want 
to make sure they are receiving that care in a timely manner. 
And if that is not being met, then outside care is necessary. 
And above all of that, coordination between that outside care 
and the VA is critical to maintaining a strong bridge between 
the two groups.
    Mr. O'Rourke. Thank you.
    Dr. Roe. I thank the gentleman for yielding.
    Ms. Brown, you are recognized.
    Ms. Brown. Thank you.
    I have to tell this quick story. When I was first elected 
in 1992, the Orlando Hospital was closing because of BRAC. We 
contracted the Department of Defense and the facility was given 
to VA. Female veterans need separate facilities where their 
examination can be conducted. There is a lot that goes into the 
planning and making sure that the facilities is accommodating 
for women veterans.
    But, Dr. Hayes, my question pertains to research. Very 
little research has been done on women veterans, whether it is 
through VA or through the National Foundation of Health.
    What are we doing to make sure that certain ailments 
pertaining to women veterans that benefit the entire American 
fabric once we do this research, where are we?
    Ms. Hayes. I would thank you for the question because I 
think actually we have done a significant amount of research. 
And my office works very closely with VA office research and 
also with NIH and the Office of Women's Health and HHS in order 
to put forth an agenda for research on women.
    And about half of that research has been on mental health 
issues in women veterans and making sure that our treatments 
for women are as robust as they are, have already been shown as 
they are for men.
    We have published more research on women veterans in the 
last four or five years than in the previous 25 years combined. 
But more than that, we have established a practice-based 
research network in VA so that now any research, you can't say, 
well, I don't have enough women to do research on because we 
have about 150,000 women veterans that are subject to that 
possible pool of research subjects.
    So I would say that we need to continue to look at our 
research agenda, but that we have really done a lot to make 
sure that the issues for women veterans are represented in the 
research portfolio.
    Ms. Brown. Good. Would you give us an update as to where we 
are on some of the research that has been done? You say you 
published it, but we would like to have that information so we 
could share it with other members.
    Ms. Hayes. Certainly. We can certainly provide that to you. 
And we also have a Web site that we have for veterans and for 
the public that is a synthesis of research in the VA. Be happy 
to send you that as well.
    Ms. Brown. Thank you.
    And thank you, Mr. Chairman. And thank you--yes, ma'am.
    Ms. Ilem. And if I could just mention one thing on the 
research. They have included the VSOs on that. Some of the 
premier researchers, Dr. Becky Yano within VA have reached out 
to the VSO community. And I have made recommendations to IAVA 
and others to make sure that they have us included on their 
work groups.
    Ms. Brown. A lot has changed because at one point, women 
were not included in a lot of the research and in the 
specimens, the trial specimens. So that has changed.
    Ms. Hayes. Absolutely it has changed. And I appreciate your 
reminder that we reached out and we have an oversight or a 
commentary committee of veterans about the research, about the 
direction of the research, about the issues that we are looking 
at in research because that is really critical to us being able 
to do the right research on women veterans.
    Ms. Brown. Thank you.
    Thank you, Mr. Chairman.
    Dr. Roe. Thank you.
    And I would ask the ranking member if she has any closing 
remarks?
    Ms. Brown. I just want to thank you all for your service 
and thank you for your testimony. I am looking forward to the 
second panel.
    Dr. Roe. Thanks very much. This is the only panel.
    In closing, Dr. Hayes, thank you for your work that you are 
doing. Obviously things have improved, I think dramatically to 
VA as far as women's health issues are concerned. So thank you 
for your perseverance in doing that.
    Always take some bullet points away from the hearings when 
you hear the testimony. And one is pay the bills. That is not 
very hard. Well, bill will do that. That should be fixable 
today, tomorrow, whatever.
    Number two, just like any other insurance plan, if I have a 
private insurance plan, I have a group of providers on there 
that my insurance plan has worked out for me to go see. And if 
I don't like that, next year when I get my insurance plan, I 
will get a different plan.
    So I think the VA ought to be looking at trying to provide 
a list of providers. That was clearly a problem when they had 
to go out and seek these on their own. I think that is 
something the VA can do for the veteran.
    And thirdly, I heard that we need someone to make sure that 
there is a--I mean, in my situation, it is a physician-patient 
relationship--to make sure that someone coordinates that care. 
And there is care that the VA needs to send out because, as you 
pointed out, maybe in some places, there is just not enough 
patients to keep somebody there. So we need to have someone in 
those facilities and make sure that you knock all those hurdles 
away from people so it doesn't get so frustrating that some of 
them will just quit looking.
    So I think those are the few things I would like to see. 
And then on the Veterans Choice card, I was informed that we 
are going to have a hearing in a couple of weeks on that which 
I think we should. There are certainly some hiccups out there 
that have been pointed out to me already.
    But I want to thank all of you all for being here and your 
great testimony has really been helpful to me. The committee 
will be possibly submitting further questions to you all. I 
would appreciate a quick response on that.
    Without any further comments, the meeting is adjourned.
    [Whereupon, at 12:33 p.m., the committee was adjourned.]

                                APPENDIX

               Prepared Statement of Chairman Jeff Miller

    The Committee will come to order.
    Thank you all for joining us for today's oversight hearing, 
``Examining Access and Quality of Care and Services for Women 
Veterans.''
    Women have been serving our nation in the Armed Forces 
since the Revolutionary War but--today more than ever--they are 
an important and increasing population of veterans served by 
the Department of Veterans Affairs with their numbers expected 
to grow even as the veteran population as a whole is projected 
to shrink.
    The women of the modern military excel in a variety of 
roles--as medics, pilots, civil affairs specialists--as 
officers and enlisted.
    They follow in the footsteps of the WAVES and the WACS of 
World War II and the Nurse and Medical Specialist Corps of the 
Korean and Vietnam wars.
    The service they provided was not dependent on their gender 
and the services the VA is charged to provide to them--while 
being respectful of their unique perspectives, needs, and 
concerns--should not be either.
    Women veterans are just that--veterans--and, as such, they 
are deserving of the same respect, attention, and consideration 
that is afforded to the male veterans with whom they served 
alongside.
    However, last year, the Disabled American Veterans (DAV) 
released a report that found serious gaps in every aspect of 
programs that serve women veterans.
    According to DAV, ``[t]he vast majority of these 
deficiencies result from a disregard for the differing needs of 
women veterans and a focusing on the eighty-percent [80] 
percent solution for men who dominate in both numbers and the 
public consciousness.''
    That is unacceptable.
    Today, I will be requesting the Government Accountability 
Office (GAO) conduct an assessment of VA's ability to improve 
the healthcare access and quality of women veterans.
    GAO last conducted an investigation on healthcare for women 
veterans in 2010 and found that availability of services for 
women varied significantly across the VA healthcare system and 
that VA faced a number of key challenges in providing 
healthcare to women veterans.
    In the intervening five years, VA has made some strides in 
improving healthcare for women veterans but too many gaps 
remain.
    [Especially considering that, just yesterday, GAO informed 
me that VA had yet to provide documentation to show that VA had 
implemented two of the five recommendations made in that 
report. Awaiting Final GAO Confirmation]
    I am hopeful that, through GAO's effort and this hearing, 
we will discover the extent to which VA has improved services 
for women veterans, where challenges to quality care and 
services still persist, and how those gaps can be overcome once 
and for all--both for the women who are in VA care today and 
for the thousands of women who will transition into VA care 
over the next several years.

                                 

          Prepared Statement of Ranking Member, Corrine Brown

    Thank you, Mr. Chairman, for calling this hearing today.
    In the 14 years of war and sacrifice following 9/11, 
American women have stepped up in greater numbers than ever 
before to defend their country by joining the military.
    Across the services, women have put their lives on the line 
in Iraq and Afghanistan. One hundred sixty one have lost their 
lives in the effort. Another 1,003 have suffered life-altering 
physical wounds. And in all, 280,000 have served and returned 
home to transition back into civilian life.
    Today, women are the fastest growing group of veterans. 
There are currently 2.2 million of them who are eligible for 
benefits and services through the Department of Veterans 
Affairs. These are hard earned benefits designed to assist 
female veterans through the all too often difficult transition 
process. However, according to the Department of Veterans 
Affairs, more than one-third don't even self-identify as 
veterans. It is taking time for the country as a whole to 
recognize, understand and acknowledge their contributions 
because with less than one percent of the population serving, 
so few Americans are in direct contact with any servicemember, 
much less a female servicemember.
    I would like to applaud the VA for their hard work and 
dedication in this area. I know that Patricia Hayes has been 
the lightning rod for VA focusing on the needs of women 
veterans. VA has taken great strides in the past two decades to 
ensure facilities and services are available for those who 
choose to seek services at VA and close the gender gap.
    Having said that, Mr. Chairman, we know much more needs to 
be done. I am somewhat amazed that even at the VA, we hear 
women veterans are often sidelined by VA employees and other 
veterans who assume they are the wives or daughters 
accompanying the male veterans there. The VA has had to retool 
its signage because until recently, women soldiers were not 
represented in the photographs on the walls or depicted in the 
pictures in the pamphlets veterans receive at VA facilities.
    When asked, women veterans say they want timely, high 
quality, gender-specific care. They want it in an atmosphere of 
recognition and respect where there are opportunities for 
social interaction, and they tend to need help with child care 
and transportation to make appointments. What this means is 
that if the VA is to fulfill its obligation to all veterans, 
primary care, mental health and specialty care must be gender-
specific, comprehensive and integrated specifically to meet 
women veterans' needs.
    I have three bills I want to mention at this hearing today 
that I believe will help VA in this mission.
    The first is H.R. 1575, a bill I introduced that would 
expand and make permanent a successful pilot program providing 
mental healthcare in retreat settings for recently returned 
women warriors who have been diagnosed with PTSD.
    The second bill, H.R. 1948, introduced by Health 
Subcommittee Ranking Member Brownley, extends the VA's 
authority to provide drop off child care at VA medical centers 
and Community Based Outpatient Clinics so veterans caring for 
children do not have to miss appointments. I am pleased to be 
an original cosponsor of this legislation.
    The third bill, H.R. 2054 I have introduced, requires that 
gender specific services be continuously available at every VA 
medical center and community based outpatient clinic. It also 
directs that the necessary personnel be hired and contracts 
signed to provide gender specific services based on 
Departmental standards, demand, and the projected growth of the 
demand.
    Mr. Chairman, I want to thank the witnesses for being here 
this morning. I look forward to the ideas and suggestions and 
yield back.


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