[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
H.R. 3636; H.R. 2972; H.R. 3036; H.R. 2798; H.R. 2645; H.R. 2681; H.R.
3224; H.R. 2982; H.R. 2752; H.R. 2628; H.R. 2816; H.R. 1527; H.R. 1163;
H.R. 3798; H.R. 3867; H.R. 4096; DRAFT BILL, TO ESTABLISH IN THE
DEPARTMENT OF VETERANS AFFAIRS THE OFFICE OF WOMEN'S HEALTH, AND FOR
OTHER PURPOSES
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
FIRST SESSION
__________
WEDNESDAY, SEPTEMBER 11, 2019
__________
Serial No. 116-31
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
40-889 WASHINGTON : 2021
--------------------------------------------------------------------------------------
COMMITTEE ON VETERANS' AFFAIRS
MARK TAKANO, California, Chairman
JULIA BROWNLEY, California DAVID P. ROE, Tenessee, Ranking
KATHLEEN M. RICE, New York Member
CONOR LAMB, Pennsylvania, Vice- GUS M. BILIRAKIS, Florida
Chairman AUMUA AMATA COLEMAN RADEWAGEN,
MIKE LEVIN, California American Samoa
MAX ROSE, New York MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire NEAL P. DUNN, Florida
ELAINE G. LURIA, Virginia JACK BERGMAN, Michigan
SUSIE LEE, Nevada JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR., DANIEL MEUSER, Pennsylvania
California STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN, W. GREGORY STEUBE, Florida
Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York
Ray Kelley, Democratic Staff Director
Jon Towers, Republican Staff Director
SUBCOMMITTEE ON HEALTH
JULIA BROWNLEY, California, Chairwoman
CONOR LAMB, Pennsylvania NEAL P. DUNN, Florida, Ranking
MIKE LEVIN, California Member
ANTHONY BRINDISI, New York AUMUA AMATA COLEMAN RADEWAGEN,
MAX ROSE, New York American Samoa
GILBERT RAY CISNEROS, Jr. ANDY BARR, Kentucky
California DANIEL MEUSER, Pennsylvania
GREGORIO KILILI CAMACHO SABLAN, W. GREGORY STEUBE, Florida
Northern Mariana Islands
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
----------
Wednesday, September 11, 2019
Page
H.R. 3636; H.R. 2972; H.R. 3036; H.R. 2798; H.R. 2645; H.R. 2681;
H.R. 3224; H.R. 2982; H.R. 2752; H.R. 2628; H.R. 2816; H.R.
1527; H.R. 1163; H.R. 3798; H.R. 3867; H.R. 4096; Draft Bill,
To Establish In The Department Of Veterans Affairs The Office
Of Women's Health, And For Other Purposes...................... 1
OPENING STATEMENTS
Honorable Julia Brownley, Chairwoman............................. 1
Honorable Neal P. Dunn, Ranking Member........................... 3
Honorable Max Rose, Member U.S. House of Representatives......... 5
Prepared Statement........................................... 71
Honorable Gus M. Bilirakis, Member, U.S House of Representatives. 6
Prepared Statement........................................... 72
Honorable Anthony Brindisi, Member, U.S House of Representatives. 7
Honorable Lauren Underwood, Member, U.S. House of Representatives 8
WITNESSES
Dr. Teresa Boyd, DO, Assistant Deputy Under Secretary for Health
for Clinical Operations, U.S. Department of Veterans Affairs... 10
Prepared Statement........................................... 39
Accompanied by:
Dr. Patricia Hayes, Chief Consultant, Office of Women's
Health Services
Dr. David Carroll, Executive Director, Office of Mental
Health and Suicide Prevention
Mr. Jeremy Butler, CEO, Iraq and Afghanistan Veterans of America. 23
Prepared Statement........................................... 56
Ms. Joy Ilem, National Legislative Director, Disabled American
Veterans....................................................... 24
Prepared Statement........................................... 58
Mr. Roscoe Butler, Associate Legislative Director, Paralyzed
Veterans of America............................................ 26
Prepared Statement........................................... 67
STATEMENTS FOR THE RECORD
Honorable Lou Correa, Member, U.S House of Representatives....... 73
Honorable Vicky Hartzler, Member, U.S House of Representatives... 74
Honorable Susie Lee, Member, U.S House of Representatives........ 75
Honorable Chris Pappas, Member, U.S House of Representatives..... 75
Honorable Elise Stefanik, Member, U.S House of Representatives... 76
Honorable Nydia Vel zquez, Member, U.S House of Representatives.. 77
Minority Veterans of America..................................... 77
The Military Women's Coalition................................... 82
The Veterans of Foreign Wars of the United States (VFW).......... 83
National Association of State Women Veteran Coordinators......... 88
Service Women's Action Network................................... 90
H.R. 3636; H.R. 2972; H.R. 3036; H.R. 2798; H.R. 2645; H.R. 2681; H.R.
3224; H.R. 2982; H.R. 2752; H.R. 2628; H.R. 2816; H.R. 1527; H.R. 1163;
H.R. 3798; H.R. 3867; H.R. 4096; DRAFT BILL, TO ESTABLISH IN THE
DEPARTMENT OF VETERANS AFFAIRS THE OFFICE OF WOMEN'S HEALTH, AND FOR
OTHER PURPOSES
----------
Wednesday, September 11, 2019
Committee on Veterans' Affairs,
U. S. House of Representatives,
Washington, D.C.
The Subcommittees met, pursuant to notice, at 10:08 a.m.,
in Room 210, House Visitors Center, Hon. Julia Brownley
[chairwoman of the Subcommittee on Health] presiding.
Present: Representatives Brownley, Lamb, Levin, Brindisi,
Rose, Cisneros, Dunn, Radewagen, Barr, and Steube.
Also Present: Representatives Sablan, Underwood, and
Bilirakis.
OPENING STATEMENT OF JULIA BROWNLEY, CHAIRWOMAN
Ms. Brownley. Good morning, ladies and gentlemen. I call
this legislative hearing to order. On this morning, we
recognize the lives lost in the terrorist attacks that occurred
on September 11. Since that time, upwards of 3 million
servicemembers have been deployed on more than 5.4 million
deployments. Seventeen percent of the servicemembers that have
volunteered to defend this country in what has become the
longest war in this Nation's history are women; they are
mothers, daughters, sisters, soldiers, airmen, sailors and
Marines, and those that were able to return home from the
battlefield deserve the same access to timely, high-quality
health care as their male counterparts. That is why during the
116th Congress the Health Subcommittee's key focus has been
ensuring equitable access to high-quality health care for our
Nation's heroes.
As chair of the Women Veterans Task Force, I am proud to
lead 78 Members of Congress in identifying gaps and
opportunities to achieve equity in access to health care
benefits, economic opportunities, and other resources for women
veterans. I am pleased that today's hearing includes 12 bills
that will improve equity for the delivery of health care for
women who have served in our Nation's Armed Forces.
Also, this month is Suicide Prevention Month, and it is
critical that we address the gender-specific mental health
needs of women veterans. Women veterans are nearly twice as
likely to die by suicide than women who have never served in
the military. Experiencing military sexual trauma, isolation,
and intimate partner violence increases the risk of suicide in
women veterans.
Suicide is preventable and several of the bills presented
at today's hearing provide additional resources to programs and
services known to decrease the risk of suicide in women
veterans. My bill, H.R. 2798, the Building Supportive Networks
for Women Veterans Act, provides reintegration counseling for
women veterans in retreat settings.
H.R. 3867, the Violence Against Women Veterans Act,
introduced by Ms. Velazquez, improves programs and services for
veterans who are survivors of intimate partner violence and
sexual assault.
Mr. Brindisi's bill, H.R. 2972, improves resources for the
women veterans call center and VA websites, so that women
veterans can easily obtain information about accessing benefits
and health care.
Research shows that these resources, and knowledge that
those resources exist, significantly reduce the risk of suicide
in women veterans.
Ranking Member Dunn, I understand from yesterday's Member
Day that Mr. Bergman has also introduced a bill related to
suicide prevention, and I would like to reiterate Chairman
Takano's commitment to work alongside you and Ranking Member
Roe to support VA's ability to connect veterans to the upwards
of 45,000 community-based organizations that seek to serve
them.
Women veterans are the fastest-growing demographic in the
veteran population, and it is clear that VA facilities must be
built, retrofitted, and staffed in accordance with that pace of
growth.
H.R. 3636, the Caring for Women Veterans Act, introduced by
Ms. Underwood; H.R. 3036, the Breaking Barriers for Women
Veterans Act, introduced by Mr. Rose; H.R. 4096, the Improving
Oversight of Women Veterans Care Act of 2019; and my bill, H.R.
3223, the Women Veterans Equal Access to Quality Care Act; all
ensure that VA is providing sufficient staff, training,
building, and retrofitting facilities, and maintaining an
environment of care standards wherever women veterans receive
taxpayer-funded care, whether at a VA facility or a community
care provider.
It is imperative that we eliminate all cultural and
physical barriers to women veteran's health care. Mr. Pappas'
bill, H.R. 2681, ensures VA is equipped to provide women
veterans with life-transforming prosthetics that are
specifically for their needs.
Over the past decade, VA conducted two studies to identify
barriers to care for women veterans. The most recent study,
completely nearly 5 years ago, enabled VA to identify necessary
changes to improve services for women veterans. More still must
be done. And Mr. Cunningham's bill, H.R. 2982, renews the
authorization for the barriers to care study to enable VA to
best serve women veterans by 2030 and beyond.
In the last 20 years, we have seen a significant shift in
the demographics of the veteran population. Not only is the
women veteran's population growing rapidly, but women veterans
are on average 15 years younger than male veterans and more
likely to be of reproductive age. That is why members of the
Women Veterans Task Force introduced three bills to improve
reproductive health care access for women veterans.
My bill, H.R. 3798, Equal Access to Contraception for
Veterans Act, eliminates co-payments for prescription
contraceptives, so that women veterans have the same access to
birth control as during their service.
For veterans who choose to become mothers, two bills will
give veterans peace of mind in the earliest days of their
newborn's lives. H.R. 2645, the Newborn Care Improvement Act,
introduced by Ms. Lee, doubles the number of days of newborn
health care coverage for children of veterans.
Mr. Allred's bill, H.R. 2752, the VA Newborn Emergency
Treatment Act, further expands coverage for newborns when
medically necessary and streamlines the billing process, so
that veterans are not unnecessarily burdened with debt after
the birth of a child.
In addition to today's legislation focused on women
veterans, we are also considering a number of bipartisan
measures that have been introduced by my Republican colleagues.
Last Congress, I was honored to join a number of Members of
this Committee to cosponsor the Long-Term Care Veterans Choice
Act, introduced by Congressman Clay Higgins. This measure is a
first step towards right-sizing VA's long-term care options by
offering veterans more opportunity to age at home.
As women are generally expected to live nearly 5 years
longer than men, ensuring VA is prepared to care for its aging
population is important to women veterans and the community at
large.
In addition, the legislation introduced by Congresswoman
Stefanik, H.R. 2816, the Vietnam Era Veterans Hepatitis C
Testing Enhancement Act of 2019, would allow VA to partner with
veterans service organizations to offer hepatitis C testing at
outreach events is an important step towards ensuring VA is
properly leveraging its existing partnerships to reach veterans
where they are.
As chair of this Health Subcommittee, I am truly proud of
the work we are doing here today; I am especially proud of the
way we are doing it in a bipartisan manner.
In closing, I would like to thank our witnesses for
appearing and I look forward to your testimony.
Ms. Brownley. Before I recognize Dr. Dunn for his opening
statement, I would like to note that I will not be asking
Members to waive their opening statements today, as is
tradition, so that the Members with legislation on today's
agenda are afforded the opportunity to issue statements in
support. While a few of the Members with legislation before us
today are not Members of this Committee, please note that each
has been given the opportunity to submit a statement for
today's record, as well as the opportunity to deliver remarks
in support of their legislation at yesterday's Member Day
before the Full Committee.
With that, I would like to recognize Ranking Member Dunn
for 5 minutes for any opening remarks he may wish to make.
OPENING STATEMENT OF NEAL P. DUNN, RANKING MEMBER
Mr. Dunn. Thank you, Chairwoman Brownley. After several
weeks away from Washington, it is good to be back with you,
working to serve our Nation's veterans.
Our agenda this morning is full, and I look forward to our
discussion.
Before yielding, I do say, I would like to say I have three
areas of regret and a little disappointment here, and that is
this is the second legislative hearing that this Subcommittee
has held in Congress and both of the agendas of those hearings
were set entirely by the majority without any input from the
minority, either Members or staff.
The witness list for this hearing did not include the
Member panel, which you mentioned just a moment ago. Typically,
Members who sponsor bills are invited to testify and contribute
to our conversations about their bills.
I note that the Committee Members with bills up for
consideration today, Committee Members with bills up today,
have been allowed to sit on the dais and testify on their
bills. And while most of the Democrat bills are sponsored by
the majority Members, only one of the Republican bills chosen
by the majority is sponsored by a Committee Member. Now, that
is probably unintentional, but it creates a perception of
imbalance.
By failing to provide the minority an opportunity to
provide input about bills to be considered, and further failing
to provide sponsors from both parties' equal opportunity to
advocate for their legislation, I think it runs somewhat
counter to the past practices of this Subcommittee. The VA and
its Subcommittees have uniquely been very bipartisan, and I
sincerely hope we will continue to conduct it that way.
Finally, had the minority been consulted in advance about
the agenda, there is one bill that we would have asked to be
included that has not been, that is H.R. 3495, the Improve
Well-Being for Veterans Act, which you referenced in your
opening statement. The Improve Act is bipartisan legislation,
it is sponsored by Congressman Bergman and Congresswoman
Houlahan. I note for the record that Congressman Bergman is
also Lieutenant General Bergman, the highest-ranking officer
and veteran ever to serve in Congress in the history of our
Nation. It is supported by many veterans service organizations
and by the VA, and, most importantly, it addresses what
Chairman Takano has stated repeatedly is this Committee's
single highest priority, preventing veteran suicide, by
creating a grant program to support entities that provide and
coordinate suicide prevention services for veterans and their
families in their local communities.
The Improve Act alone would not solve the national suicide
crisis that tragically takes the lives of 20 veterans a day,
but it could certainly be part of that solution. It would save
lives, and it is worthy of this Subcommittee's time and
attention.
When staff was first informed of today's hearing, after the
majority had already set the agenda and informed the VA of the
hearing, our staff requested to add the Improve Act to the
agenda, and that request by staff was denied. Letters were
subsequently sent to Chairman Takano by Secretary Wilkie and
followed by Ranking Member Roe requesting the Improve Act be
included. Chairwoman Brownley, I certainly hope that your staff
provided you copies of those letters and, to my knowledge, we
have had no response on those.
September is National Suicide Prevention Month and Chairman
Takano marked it on September 1st by calling for new solutions
and fast actions. One concrete way for this Committee to follow
that call would be debating the Improve Act without any
unnecessary delay. I regret that we are not doing that.
But, with that, I look forward to today's hearing and I
yield back. Thank you.
Ms. Brownley. Thank you, Dr. Dunn. I appreciate it.
And just to follow up on your remarks with regards to
Lieutenant General Bergman's bill, I assure you and the
Committee that our staff and Chairman Takano are prepared to
work through that bill to gain bipartisan support and,
hopefully, that particular bill will come forward to us at
another time. So I appreciate your comments there.
So now I would like to recognize Congressman Rose for 5
minutes for any opening remarks he may wish to make in support
of his bill.
OPENING STATEMENT OF MAX ROSE
Mr. Rose. Thank you, Chairwoman Brownley and Ranking Member
Dunn, for having this forum to provide due attention to the
pending legislation before us.
With respect to legislation impacting women veterans before
us, let me just say it is beyond clear that the women who
served alongside me in Afghanistan, who also served in Iraq and
who have generally put on our Nation's uniform in defense of
all that we hold dear, they deserve our support and national
investment now more than ever.
When these heroes come home, they aren't necessarily
greeted with a hero's welcome, although they are always thanked
for their services. Instead, they face challenges severely
disproportionate to their civilian and male counterparts, and
it is unacceptable.
Studies have shown women veterans have higher rates of
interpersonal trauma than male veterans, and this includes
military sexual trauma. There is little doubt that this plays a
role in higher instances of medical challenges than other
groups. And, tragically, women who served have a rate of
suicide that is nearly double than that of civilian women age
18 and over. It is Suicide Prevention Month and I want us to
fully appreciate the scope of that. We cannot let this persist.
And let me just say that, if you thank a female veteran for
their service when they come home, but nonetheless do not do
anything about the fact that they receive inadequate health
care at our VA institutions, then beyond that just being
hypocritical in nature, saying thank you for your service is a
disgraceful thing to be doing if we are not fixing this. Our
female veterans deserve so much better.
That is why I am proud to have introduced H.R. 3036, a
critical bipartisan piece of legislation to make sure
facilities at the VA are as equipped as possible to serve a
growing population of veterans. This bill would ensure funds to
support the physical infrastructure of our VA hospitals and
clinics for a woman veteran's care needs. It would require that
there is at least one full-time or part-time woman's primary
care provider within any given clinic or facility, and would
expand the woman veteran's health care mini-residency program,
which further protects against staffing concerns being a
barrier to access.
And, in addition to requiring the VA to produce relevant
reports as care is provided, this bill would require the VA to
establish a training module for community providers, because as
we see time and again through these hearings, these issues do
not end within the four walls of the VA.
After seeing the VA's testimony to this Subcommittee, I am
heartened the VA supports the intent of many provisions within
this bill and, while the VA is working on many of these goals,
we must ensure that our women veterans do not fall through the
cracks; that is not an option.
So, again, I urge all my colleagues to support this
legislation. I thank many of those who have cosponsored. And,
again, Madam Chairwoman, thank you again for the time.
[The prepared statement of Congressman Rose appears in the
Appendix]
Ms. Brownley. Thank you. Mr. Bilirakis.
OPENING STATEMENT OF GUS M. BILIRAKIS
Mr. Bilirakis. Thank you, Madam Chair, I appreciate it. I
would like to thank you again for--and the Ranking Member, of
course--for allowing me to sit on this Subcommittee hearing and
allowing me to speak on one of the bills being considered
today, my legislation, which is H.R. 2628, the Vet Care Act.
Many of my veteran constituents have come to me over the
years expressing their desire to add dental care to the VA's
medical benefits package. As you know, Madam Chair, the VA
currently on provides outpatient dental services to a limited
number of the disabled veteran population who have 100 percent
service-connected ratings, and then a couple other categories
as well, POWs and, again, anything that happened on the
battlefield as far as if it is service-connected regarding the
mouth area. But, again, some may be eligible, some veterans may
be eligible for the VA dental insurance program, which provides
a discount, a low-cost insurance plan provided by insurers, but
I believe we can do more to move this issue forward.
And I commend you, Madam Chair, for filing your bill as
well and I am very supportive of your bill.
Many small studies suggest that regular dental care equates
to lower overall health care costs and better health outcomes.
One such study published in the American Journal of Preventive
Medicine conducted by the University of Pennsylvania professor
Dr. Marjorie Jeffcoat, found that regular periodontal checkups
lead to reduced hospitalizations and overall medical cost
savings and care for chronic conditions such as heart disease,
cerebral vascular disease, including stroke and diabetes. And,
again, I think there are more chronic diseases that are
affected as well.
In light of these results, I worked directly with Dr.
Jeffcoat and Dr. Zack Kalarickal, who is a constituent of mine
from Wesley Chapel, Florida, we worked to develop the
parameters and replicate this type of study at the VA by
authorizing the Vet Care Act.
H.R. 2628, my bill, expands on this research to help
determine the potential health benefits to veterans and
potential cost savings to the VA associated with periodontal
care. The Vet Care Act would require the VA to create a 4-year
pilot program to provide dental services to 1500 veterans
diagnosed with type 2 diabetes. Each treated veteran will
receive appropriate periodontal evaluation and treatment on an
annual basis during the pilot. Throughout and at the conclusion
of the pilot, the overall health of the treated veterans will
be recorded.
These results will be compared to veterans who did not
receive treatment to determine if providing veterans with
dental care equates to fewer complications of chronic ailments.
If so, an analysis can be done to determine if the lower costs
of the overall health care due to fewer chronic ailments saves
the VA enough money to reallocate funds to provide more
veterans with dental care. It makes sense, as far as I am
concerned. The data recorded and collected by the VA would also
be able to be distributed to the research community for further
study.
Finally, at the end of the pilot program, the 4-year pilot
program, veterans who participate in the program will receive
administrative support and information from the VA on how they
may continue to obtain dental services and treatments in the
community for low to no cost, including information about
enrolling in the VA DIP program.
Now, I want to thank the non-profits and the dental
associations that offer care to our true heroes as well
currently.
In this way, we can ensure that we are providing continuity
of care for veterans in need of further treatment.
To conclude, if we are able to improve the VA health care
system by providing preventive dental services that lead to
fewer complications of chronic ailments, it not only shows that
we are looking at the long-term outlook of our veterans'
health, but it could also prove to be done in a cost-effective
manner.
The Vet Care Act is a practical, commonsense way to
demonstrate this approach for dental services, replicating
already established research in the community.
Again, I thank the chair and I thank the Ranking Member for
bringing this bill up for discussion at today's hearing, and I
look forward to continuing the conversation further.
Thank you and I yield back, Madam Chair.
[The prepared statement of Bilirakis appears in the
Appendix]
Ms. Brownley. Thank you, Mr. Bilirakis, and thank you for
your work on this important measure, and I am hopeful that we
will be able to find a path forward on this very, very
important issue. So, thank you for bringing this bill forward.
Congressman Brindisi, you are now recognized for minutes to
deliver any comments you may have in support of your bill, H.R.
2972.
OPENING STATEMENT OF ANTHONY BRINDISI
Mr. Brindisi. Thank you, Chair Brownley and Ranking Member
Dunn, for the opportunity to speak today about the importance
of improving VA services tailored to the needs of women
veterans. I would also like to thank the Committee for their
continued efforts this year to make VA more accessible and
equitable for our women veterans, and for Chairwoman Brownley,
for your leadership of the new Women Veterans Task Force, which
I am proudly a member of.
Women veterans are the fastest-growing demographic in the
veteran community. Women comprise nearly 10 percent of the
veteran population and that figure is expected to rise to 18
percent over the next 20 years. As a result, the number of
women veterans seeking care at the VA will certainly increase
and VA needs to be ready. However, 75 percent of women veterans
do not use VA health care, and face a number of inequalities in
a system that simply hasn't adjusted quickly enough to meet
their specific needs. That is why I introduced H.R. 2972, which
directs the VA Secretary to improve VA's communications
regarding services available to women veterans.
While VA has begun to offer text messaging as a way to
connect the Women Veterans Call Center, and I commend VA for
doing so, my bill would statutorily require VA to include a
text messaging capability at the Women Veterans Call Center.
The Women Veterans Call Center is staffed by female VA
employees who can provide and link women veterans to
information regarding resources available to them, and
requiring text message capabilities at the call center will
make it even more accessible.
Additionally, this bill would make navigating VA websites
easier by creating a central web page where women veterans can
access various information regarding the extensive resources
available to them within VA. This page would include the
locations of each VA medical center and community-based
outpatient center, as well as the name and contact information
of each women's health coordinator, and contact information for
staff from the Veterans Benefits Administration and the
National Cemetery Administration.
This bill would build on efforts by the VA and this
Committee to ensure all women veterans are aware of the hard-
won resources and benefits available to them, and where to turn
if they are struggling. I believe this bill is a positive step
forward towards making VA more accessible to women veterans and
I urge the Committee to support this legislation.
I want to thank Chairwoman Brownley, and I yield back the
balance of my time.
[The prepared statement of Congressman Brindisi appears in
the Appendix]
Ms. Brownley. Thank you, Mr. Brindisi.
[Audio malfunction in the hearing room.]
OPENING STATEMENT OF LAUREN UNDERWOOD
Ms. Underwood. Thank you, Chairwoman Brownley, for holding
today's hearing, and thank you and Dr. Dunn for permitting me
to join today's important panel. I appreciate you and Chairman
Takano's willingness to focus on and fight for what our women
veterans need.
Women veterans face a number of unique needs and
challenges, from access to clinically appropriate services at
VA facilities to mental health care. We need to act now to
address their needs, because the number of women veterans is
going to increase dramatically in the next decade.
I am proud to serve both on Chairwoman Brownley's Women
Veterans Task Force and on the Servicewomen and Women Veterans
Congressional Caucus, founded by my fellow freshman
Congresswoman Houlahan.
So I am thrilled that the Committee is moving forward today
on my legislation, H.R. 3636, the Caring for Our Women Veterans
Act. My bill directs the Secretary of Veterans Affairs to
submit an annual report to Congress on gender-specific care
available at VA facilities. This includes locations where women
veterans can access VA care; the numbers of women's health care
centers and women's health providers like OB/GYNs; and
recommendations for improving those facilities to better serve
women veterans.
The bill will provide an informed and sustainable roadmap
to providing high-quality, accessible care for women veterans.
I also want to highlight two critical health care issues
for women veterans that I have been working on this year. The
first is eliminating co-pays for contraceptives, breast cancer
screenings, and other preventative health care services for
veterans. Right now, civilians and active duty servicemembers
don't have to pay these co-pays, but veterans do. That is
unacceptable and we need to fix it.
Chairwoman Brownley has been a leader on this issue and I
am looking forward to working with her to close this loophole
and eliminate unfair health care costs for our veterans.
Lastly, I am proud to be introducing the ACE Veterans Act
today with Congressman Conor Lamb. This bill allows women
veterans to get a full year's supply of birth control at a time
at the VA. My focus is always on data-driven, evidence-based
policymaking, and so this bill builds off research showing that
a full year contraception dispensing improves health outcomes
for women and saves the VA money.
As this Committee moves forward on legislation to improve
health care for women veterans, I am excited to work on these
proposals and more.
Thank you again for holding today's hearing and to our
witnesses for being here. I yield back.
[Audio malfunction in the hearing room.]
[The prepared statement of Ms. Underwood appears in the
Appendix]
Ms. Brownley. --this Committee and a health care
professional is really invaluable, so we really appreciate you
being part of this and moving this important issue forward.
So are there any other Members that would like to deliver
any opening statements this morning?
Hearing none, we will move on to two great panels before us
today. I thank each of you for joining us today in what I hope
to be a fruitful discussion on these 17 bills.
For our first panel, we have Dr. Teresa Boyd, Assistant
Deputy Under Secretary for Health for Clinical Operations at
the Department of Veterans Affairs. Dr. Boyd is accompanied by
Dr. Patricia Hayes, Chief Consultant, Office of Women's Health
Services.
We are also joined by Dr. David Carroll, Executive Director
for the Office of Mental Health and Suicide Prevention at the
Department of Veterans Affairs.
I now recognize Dr. Boyd for 5 minutes for her opening
comments.
STATEMENT OF TERESA BOYD, DO
Dr. Boyd. Thank you and good morning. Good morning, Ms.
Chairman Brownley, Ranking Member Dunn, and Members of the
Subcommittee. Thank you for inviting us here today to present
our views on numerous bills, including those that address the
critical needs of women veterans, as well as other important
areas.
I also want to recognize the veterans service organizations
represented on the next panel, as I have seen personally how
much they contribute to our work on behalf of veterans and how
dedicated they are in our common mission to serve veterans.
I do need to thank you for your patience, as the submission
of my written testimony was delayed. Because I need to keep
this statement brief, I cannot address all 17 bills in my oral
statement, but they all touch on important topics. Of course,
the written testimony covers all the bills in detail, and we
are prepared to field questions on them today.
I would like to take a moment to briefly discuss a bill
that is not on today's hearing. H.R. 3495, the Improve Well-
Being for Veterans Act would help VA build partnerships with
community groups, who can offer direct help to veterans, who
are at risk of harming themselves. VA believes this legislation
will assist us in reaching the 14 of the 20 veterans dying each
day by suicide, who are not under VA care at the time of their
death.
It would fulfill a critical legislative component of the
administration's multi-faceted program to prevent veteran
suicide, and we strongly urge its consideration. We appreciate
that so many of the bills today are focused on meeting the
special needs of our women veterans. That is a priority of the
secretary, and a big focus of attention for VHA.
The VA supports the following bills, at the very least in
principle, relating the care of women veterans. Although for
some, we do believe there are important technical changes that
should be made, or we need to ensure that the initiatives are
adequately funded. We support H.R. 2645, which would increase
the period that VA is authorized to care for a newborn child.
And we also support in principle, H.R. 2752 regarding
transportation of those newborns when medically necessary.
For the latter bill, however, there are some significant
technical issues that would need to be worked through. H.R.
2798 concerns special retreat programs for women veterans
returning from long deployments. VA is enthusiastic about these
retreats. We have received very positive feedback from
participants who have said they now realize that they are not
alone, and that they have learned to trust themselves, and feel
that they are important.
The response has been so positive, we would like to expand
the scope of the bill for all veterans who are eligible for vet
center services, as long as we can secure adequate funding to
do so. We support H.R. 3798, which aims to further improve
veterans' access to contraceptives. Although we do have some
technical points to offer on this bill.
There are other bills concerning women veterans on the
agenda that we cannot offer our support today for the reasons
explained in detail in my written statement, even though we are
fully in line with the goals of the sponsors. In some
instances, we believe they are duplicative of existing programs
or initiatives, or are inconsistent with clinical practice. For
example, on the key importance of making sure our clinical
spaces are ideally configured for the needs of women veterans,
the subject of H.R. 3036, many of the actions called for in
that bill are already being undertaken. And for H.R. 2982,
which requires a study of barriers that women veterans
encounter in securing care from VA, we have in place an array
of initiatives that recognize those barriers and aim to remedy
them.
Regarding the draft bill that would establish the Office of
Women's Health, we believe that the current placement of the
Office of Women's Health Services is strategically aligned to
interact with all other clinical programs at the national level
that provides a conduit for coordination and collaboration
where services are similar.
For H.R. 4086, we understand why the Committee wants to get
a formal report on issues of concern to women veterans in the
context of care with community providers. However, the data
points required for the report would require the modification
of contracts with community providers, which given the extent
of care in the community would be disruptive. We would like to
discuss how the Committee could exercise oversight in this area
by other means.
H.R. 3867 is focused on an area of intensive nationwide
concern for veterans and non-veterans alike. The issue of
domestic violence and sexual assault. VA is totally in accord
with the goal of coordinating in the fullest way possible all
VA services across the board for victims of domestic violence
and sexual assault.
There are other provisions, however, that may be
duplicative of current programs and require technical changes.
VA is very engaged in this issue, and we would welcome further
discussion with the Committee. There are other bills on today's
agenda that concern issues not directly tied to the special
needs of women veterans, but which also touch on critical
subjects. We support H.R. 1527, which would allow VA to pay for
long-term care in what are known as our medical foster homes.
This option is something we are enthusiastic about, as it will
help reduce a barrier to the use of these homes.
For some veterans, a more homelike setting has great
advantages over traditional nursing home care. We look forward
to discussing some of the technical issues identified in our
written testimony.
H.R. 2628 concerns dental care for veterans. We support the
part of the bill regarding administrative support to those
providing dental care to veterans, separate from VA's
authority. Although we do have some technical comments. VA does
not, however, support Section 3 for several reasons.
We are concerned the bill would create disparities in the
overall application of dental eligibility by expanding access
to these benefits to veterans in participating locations, but
not elsewhere. We also believe the bill is far too prescriptive
in terms of its requirements, and that it is unnecessary
because the dental literature already strongly supports the
cost effectiveness of preventive dental care.
Before I conclude my statement, I know we all want to
acknowledge the veterans and servicemembers who were inspired
to serve our country in response to the attacks that occurred
18 years ago today on September 11th, 2001. We are eternally
grateful to you and all veterans and servicemembers for the
many sacrifices you and your families have made in order to
preserve our freedom as a Nation.
Thank you, again, for inviting us here today. My colleagues
and I are prepared to answer any questions you may have.
[The prepared statement of Dr. Teresa Boyd appears in the
Appendix]
Ms. Brownley. Thank you, Dr. Boyd. And I now recognize
myself for 5 minutes for questions. And the first question that
I wanted to ask is regarding Mr. Rose's bill, 3036. And in your
written testimony, I understand with so many bills that you
can't address each one in your opening comments today, and I
understand that, but I did read your written testimony and I
thank you for its thoroughness.
And you noted that the turnover for women's health
providers is 20 percent. And during the task force, we have
been traveling across the country, and having lots of visits,
both myself and staff, making these visits. And we have really
learned that the high rate of trauma within the women veteran
community that is taking place can cause secondary trauma
actually to the health care providers, because they are
listening to so many traumatic stories.
And so staffing shortfalls have made it even more
challenging for the providers because if there are less
providers, they have more tragic stories to hear. And so I
wanted to know really what the VA is learning--first, making
sure that you are doing exit surveys of these providers who are
leaving, and what you are learning from these exit surveys to
help inform us in terms of how to hold on to our health care
providers, particularly women health care providers and women
health care providers who are serving our women veterans.
Dr. Boyd. That is a great question. And I do believe that
next week, there will be another hearing with some subject
matter experts with regards to our hiring and our work force. I
will briefly state a few things and then let Dr. Hayes jump in.
One thing that we have started to do, and we don't have enough
data yet on it, but is to not wait until the exit--I mean, to
continue to go ahead and do that, but let's get in the habit of
asking folks, and learning why folks stay. Why our providers
stay? What keeps them here?
With regards to burn out and exhaustion, workload,
depersonalization, we pick that up more and more specifically
now on our all employee survey as well. So in a nutshell, we
have some tools that we are trying to connect the dots. But I
do want to give Dr. Hayes a little bit of time, because she has
specifics about the women's health providers.
Ms. Hayes. Good morning. You have pointed out some really
critical issues for us about the overburdened numbers of
women's health primary care providers. In fact, we have been
doing a deep dive on their burnout and on their retention
issues, talking to them, those sort of left having interviews.
What we are finding are a number of factors.
One is that the population has grown so fast and we haven't
gotten enough help, not enough providers in each site, and that
is sort of a topic of a lot of other things. We have been
talking about how to build that staff. One of the other factors
is that they frequently don't have the appropriate nursing
staff. So you can't take care of these women in a clinic
without the nursing staff and the other staff, such as social
work or pharmacy. So the staffing levels in the packed clinic
is one of our targets. And then just the tremendous sense, as
you were saying of the complexity of these patients with trauma
histories, and also several--usually several physical
comorbidities. These are very complex patients and it is too
much. We need to reduce the panel sizes.
What we are doing is attacking all of these issues. The
undersecretary and principal deputy have charged me with a
women's health modernization called an IPT. We have been
meeting approximately three times a week since June. We are
looking at these in a very deep dive way and coming up with
action plans for management that is coming back up to the
leadership, we are hoping within the next month or so. So we
are going to be informing the field where the problems are,
what are the things we know, and try and deal with the issue of
hiring more providers. But we will be getting into that a bit
more in this hearing, I imagine, because the primary care
provider recruitment issue is beyond women's health as well. It
is a problem nationally.
Ms. Brownley. Thank you, Dr. Hayes. And this Committee and
myself will be very interested to see what your deep dive
reveals, and what some of the solutions and policies moving
forward are. So I appreciate that. Well, I only have a few
seconds left, so I will end my questioning and hopefully can
get back to it. And so I will now yield to Dr. Dunn for 5
minutes for questioning.
Mr. Dunn. Thank you, Chairwoman Brownley. This question is
for Doctors Boyd and Carroll. Do you have formal views--it is
regarding, by the way, the Improve Wellbeing for Veterans Act.
That is 3495. Do you have formal views and cost estimates
regarding the Improve Act for the VA, and would you--are you
able to provide those? Either, both?
Mr. Carroll. Good morning, sir. Yes, we do. I know we have
prepared them. We will make sure that the department gets them
to you if you have not received them.
Mr. Dunn. Yes. I appreciate that. Is it fair to say that
you are supportive of that Act?
Mr. Carroll. Yes.
Mr. Dunn. And, Dr. Boyd?
Dr. Boyd. Absolutely. We strongly support it.
Mr. Dunn. Do you think it could be funded out of existing
appropriations without impacting the department's internal
mental health or suicide prevention programs?
Mr. Carroll. Yes, a similar proposal was included in the
president's fiscal year 2020 appropriations budget. And so the
plan was to fund it out of current appropriations without any
impact or jeopardy to current programs.
Mr. Dunn. Thank you. You make me feel so much more
comfortable. I appreciate that. Dr. Boyd, regarding H.R. 1163,
do you know how many prospective hires each year are barred
from VA employment due to non-compete agreements with other
health care systems or private practices?
Dr. Boyd. I do not have that information.
Mr. Dunn. Is it something that is actually obtainable? I
mean, do you think you--do you have a sense of it?
Dr. Boyd. I have anecdotal after being in the field and
being a chief of staff. I think it is anecdotal and I am not
really--I wouldn't put a lot of credence in it. There will be a
hearing next week where there will be the workforce H.R. folks
involved, and they may have more, but I doubt at this point
that they do.
Mr. Dunn. Yeah. I would be interested to know that.
Certainly in my private practice, we saw those non-competes
crop up, even when I doctor was going into the VA, which I was
sort of surprised that that--but people are people, right?
Do you know, has your office--General Counsel Office
reviewed this piece of legislation, 1163, and do they have any
concerns regarding the potential legal challenges that could
arise as a result of this bill impacting existing non-compete
agreements?
Dr. Boyd. Yes, sir. There may be an unintended consequence,
especially for Section 2. It's possible that the former
employer may actually litigate.
Mr. Dunn. Yes.
Dr. Boyd. And that is not something that we want. And back
to your comment, if I just may. Really the VA is not in
competition with private sector. And so--
Mr. Dunn. And I perceive that just like you do.
Dr. Boyd. Yes.
Mr. Dunn. But nonetheless, I see these non-compete
agreements become stumbling blocks to treatment for veterans
and employment of doctors. You have an answer? Your general
counsel maybe has an answer.
Dr. Boyd. They do. Well, on that again, I can just go back
to my own experience in the field. I come from the private
sector. But then within the VA hiring physicians as a chief of
staff. And most of the time, it was the former employer did not
follow through on that non-compete, and that was just in my
experience.
Mr. Dunn. All right. Let's, I guess, since I am picking on
Dr. Boyd. Actually, I am enjoying your testimony. I am not
picking on you. On 2816, the Hepatitis Testing Enhancement Act,
first let me say 100,000 veterans cured of Hepatitis C. Never
did I think I would see that in my lifetime. That is such good
news. So congratulations. I know you have worked the number
down to 25,000. Keep going. How does the VA intend to continue
the screening, and the awareness on Hepatitis C?
Dr. Boyd. So it has been a multi-faceted approach. We are
down to the more difficult veterans to bring in to test, and to
not only test, but if they are positive, to actually treat. We
are down to those that are difficult to find, difficult to
locate, maybe some of the homeless veterans as well. And so we
continue. It is a multi-faceted, inter-disciplinary approach,
not only with the homeless programs but with our primary care,
women's--I mean, it is with all of our clinical.
We did send out a letter to all veterans that had not been
screened within that cohort. And that letter is an order--
Mr. Dunn. There is 100 percent screening on time of
separation from the military, am I correct?
Dr. Boyd. Now, that I am not sure. I would have to find out
about that.
Mr. Dunn. I think that is one good way to start the
screening. Although, you can get Hepatitis C as a veteran too.
Dr. Boyd. That is correct.
Mr. Dunn. Well, with that, we are out of time. I appreciate
your comments.
Dr. Boyd. Sure.
Mr. Dunn. Thank you. And I yield back, Madam Chair.
Ms. Brownley. Thank you, Dr. Dunn. Congressman Rose, you
are now recognized for 5 minutes.
Mr. Rose. Thank you, Madam Chairwoman. I wanted to first
off give you all an invitation to just speak to the issue of
frequency of deployments, as well as the time between
deployments, and any effect that you have seen this have on the
post-9/11 female veteran population, and any lessons that we
could potentially learn as we as a Nation conduct warfare in
years ahead.
Dr. Boyd. So I will pass that off to Dr. Carroll initially
to see his input on that, and then of course, Dr. Hayes will
have more specifics about the female deployments.
Mr. Carroll. Thank you for your question, sir. We are very
concerned about the impact of deployment on veterans. Male
veterans, female veterans, anyone who is in a deployed
situation. We know that deployment alone is not necessarily a
risk factor. It depends upon what occurs during that
deployment, the frequency of deployment. We have put into place
special programs for units that we know had particularly
difficult deployments. We are working with our partners to
create reunion events for them and bring them back together.
We know that the power of peer support and veteran to
veteran support is critically important. We are looking for
ways to extend that beyond the military life cycle itself, and
to the veteran experience, making sure that all providers are
aware of the impact of deployment, in making sure the community
providers are also educated about the risks that veterans may
have if they are seeing a community provider instead of one of
ours. Dr. Hayes?
Ms. Hayes. Thank you. I just want to bring up a couple of
things, and I am very grateful to the veterans who have
actually done a number of works published about this, as well
as the Disabled American Veterans within their journey home,
working on the issues for women veterans.
I think that there is a sense that for many women, they
have had to come home and deal with the family and children
issues, sort of postponing some of their own needs as they have
dealt with this. And also, that is one issue, and the
psychological family needs it, family therapy, things like that
that the vet centers can offer, but women sometimes postpone
those needs, and then get a little bit lost to our systems. And
some of the other challenges actually really are in the area of
employment.
And women have more difficult times getting into the right
kind of employment, and the levels of employment for any number
of reasons. But these are areas that then are very impactful in
their lives and concern us in the transition, and particularly
about the issues of self-harm and the risk during the
transition time.
Mr. Rose. And then did you have anything else in that
regard?
Dr. Boyd. Not at all. But it struck me when you asked the
question, going back to Ms. Chairwoman Brownley's comment, the
impact. I mean, it is just--it has kind of connected all the
dots to me about the impact on our providers and our staff that
meet these women veterans especially, whether at any point of
care.
Mr. Rose. So just lastly, I haven't heard much spoken
about, and maybe I might have missed this, but care management
programs and particularly efforts to meet patients, or future
potential patients' veterans where they are, calls, text
messages, knocking on their doors. This is the future of health
care and it is particularly important for the veteran
population because many of them are not seeking care. And they
are certainly not seeking care at the VA, and sometimes we,
based off our current systems, don't want them to.
So where do we stand on this and what do you think we
should be doing?
Ms. Hayes. I think a really important part of this is the
women veteran call center, which actually was set up to do
outgoing calls to women veterans who don't use VA services, may
not be connected and to inform veterans about eligibility,
appointments, cemetery, BVA. And we have touched 1.6 million
women through the outgoing call center.
The other part of the call center is obviously all of the
incoming calls and we wanted to make sure that calls and texts
were available. That is a primary triaging and information
service that we find very valuable to women. The other is care
management in terms of local care management. And we have
expanded the number of women's care managers, particularly in
the rural areas, and that is another part of our ongoing effort
right now to beef up that program to hire more women's care
managers to do exactly what you are talking about: hook up with
the veterans when they are in our clinics or in our facilities.
Mr. Rose. Is there any further improvements you think we
should be making to the care management program? Is it
adequately resourced right now?
Ms. Hayes. I think the resources are there within VA. I
think we need to right size it so that we have the right kinds
of services available.
Mr. Rose. What would that look like?
Ms. Hayes. It means moving people. You know, making sure we
have more care managers. It means even more devotion to this
hiring of primary care providers, social workers, nurses. It is
taking the resources we have and putting a greater focus on the
women veteran program within our own system.
Mr. Rose. Okay. Thank you.
Ms. Brownley. Thank you, Mr. Rose. I now recognize Mr. Barr
for 5 minutes.
Mr. Barr. Thank you, Madam Chairwoman. Thanks for holding
this hearing. Thank you for our panel for discussing the
legislative proposals before us. And first and foremost, let me
echo the sentiments of those expressed today. In memory of
those who sacrificed for our country, of course, the 3,000
Americans who lost their lives in the attacks in 9/11, also the
thousands of servicemen and women who were inspired to defend
our country in the aftermath of that great tragedy.
So many of these post-9/11 veterans now deserve and they
have earned the support of this Congress and the Department of
Veterans Affairs, and we appreciate all of your service in
support of those heroes.
Dr. Boyd, let me ask you a little bit about this Long Term
Care Veterans Choice Act, which I have been proud to co-
sponsor. I want to thank, first of all, my colleague
Representative Higgins, for introducing this legislation. And I
like this bill because it gives our veterans who need long term
care freedom and flexibility. They may not always want to go to
a traditional institutional nursing home, and we think of the
post-9/11 generation. These are young veterans, and especially
if they are disabled, they don't want to go to what they
consider a nursing home.
So this is a really good alternative, I think. Allowing
those veterans to live in a more intimate setting, like a
medical foster home makes sense for the well-being of the
veteran and can be facilitated at a fraction of the cost.
And I noted, Dr. Boyd, your comment about the net savings
estimate. So it is a win/win. Win for the taxpayer, win for the
veteran, and I really think this is a great opportunity.
The Lexington VA in my own district is proud to have a
medical foster home program, and a former medical director had
this to say about the program. ``The decision to leave the
privacy and familiarity of your own home to live in a strange
and unfamiliar environment is one of life's most difficult to
make. Our program gives veterans a palatable middle option.
Veterans live in the warmth and comfort of a medical foster
home of their choice. And this is an encouraging option for our
younger veterans injured in Iraq and Afghanistan who are too
disabled to live alone, but they are too young to live in a
nursing home.
Dr. Boyd, in your testimony, you state that only 200 of the
1,000 veterans living in MFHs currently would be eligible to be
paid for by the VA under this program. Can you explain why that
is?
Dr. Boyd. That is taking into account that their priority
1A veterans. But don't let this detour from this at all. We
easily have capacity to accommodate up to the 900 average daily
per year of veterans that would meet that criteria. This is a,
as you said, a win/win. First of all, the quality and
respecting the wishes and the preferences of our aging or our
needy population. So it goes long in line.
I visited with Ms. Chairman Brownley in a field hearing
once where we talked about the choose home initiatives and long
term care, and this coming up. And this is perfect. We strongly
support this bill.
Mr. Barr. Thank you. And I noted your technical suggestions
as well. You mentioned the one year timeline that the bill
gives you to get all the contracts in place. Would this work
like the MISSION Act's community care network? Opt in is region
2 in my area. They are going to take over for Tri-West, for
example. Would they get the contract for Lexington--for the
Lexington area if they are already operating in our region for
community care? How will that work?
Dr. Boyd. So the medical foster home is a separate entity.
I am not aware of this being part of our CCN, our community
care.
Mr. Barr. Community care. Okay.
Dr. Boyd. No, these are within the community.
Mr. Barr. Okay.
Dr. Boyd. Yes.
Mr. Barr. So it would not--
Dr. Boyd. Not to use it with community--
Mr. Barr. Part of the VA, not in the community care
network.
Dr. Boyd. That's correct.
Mr. Barr. Okay. MST really quickly. Can any of you all
think of potential barriers to care that exist for MST
survivors seeking care? And I want to ask that question in the
context of the MISSION Act. Of course, eligibility criteria is
whether or not it is in the veteran's best medical interest to
qualify to seek care in the community.
If an MST survivor were more comfortable with a provider in
the community than at the VA, how would they interact with the
community care criteria?
Mr. Carroll. We screen all veterans for military sexual
trauma that come into VA care. So it is a priority of focus for
us. In terms of-- and they can receive care at VA at no cost,
and we make sure that staff can refer people to our military
sexual trauma coordinators across our facilities. And we would
work with--if they are more comfortable in the community, we
would want them to go to the most appropriate resource to take
care of them.
Mr. Barr. Well, I appreciate that. I think the VA is
improving rapidly in addressing MST. And I know there is
legislation here today that we are considering that addresses
that as well for the VA. But a number of my, especially female
veterans who I represent, are very interested in accessing
community care for that specific issue. So we appreciate that,
and my time has expired, and I yield back.
Ms. Brownley. Thank you, Mr. Barr. And I just want to say I
concur with your support on Mr. Higgins' bill. I think it is a
great bill and hopefully we can move that forward.
So, Mr. Cisneros, you are now recognized for 5 minutes.
Mr. Cisneros. Thank you, Madam Chair. Thank you, everyone
on the panel, for being here today. I want to address a couple
things. Dr. Boyd, it has already been said, I think, like over
75 percent of women don't use the VA. It takes them almost
three years before they are connected to VA, if they do. I
mean, do you acknowledge that that is true?
Dr. Boyd. I would defer that overall to Dr. Hayes from her
expertise.
Ms. Hayes. Yes, those are accurate statistics. There is a
delay in seeking care. And what I would say, though, is we have
gone up from--where only 11 percent of women used our care when
I was first working on this, and now we are up to 25 percent,
but we are still way below the percentage of men who use VA.
Mr. Cisneros. Correct. We still have a long way to go.
Ms. Hayes. Right.
Mr. Cisneros. I mean, it is good that there is improvement,
but still a long way to go. We will acknowledge that. But, you
know, on bills like 2982, where you oppose some research being
done to find what are the barriers for women using VA care, and
also in Section 4 of 3867. The VA doesn't--thinks that a task
force that would help women expand--who will find out way
expanding services are available to veterans at risk of
pertaining to domestic violence, why that is necessary.
I mean, you both reference, or you reference in your
opening statement that both with the one in 3867 that there was
a study done or a task force created back in 2012 and 2013, and
this doesn't need to be done again. And also in 2982, you talk
about a study that was done in 2015, took down the barriers to
find out what are the barriers that keep women from seeking
care.
So if these studies have already been done, obviously, I
mean, we both acknowledge, or everyone acknowledges that more
needs to be done. Why would we not seek more data, more
information? Why would we not want to do a task force that
would provide us with the information to find out how women
could find out more information, or really to seek in regard to
domestic violence? Why won't the VA acknowledge that we need to
find more data, and to do these studies, and to do these task
force?
Dr. Boyd. Well, I will start with this. With regards to the
Violence Against Women Veterans Act that you referenced; I will
pass that off to Dr. Carroll in just a bit. But we have, and
thanking Congress for the 17 million back in fiscal year 2018
and 2019, we have a very, very strong assistance program for
the intimate partner violence assistant program.
We would suggest that that be the lead to take this
forward. We already have that in place, and I would like--if it
is okay, I would like Dr. Carroll just to give a little snippet
about that as well.
Mr. Carroll. It is an important area, and we know that
intimate partner violence is also a risk factor for suicide,
and so those two things, and being a woman, those--the
combination of factors is a great concern for us. With the help
of Congress, as Dr. Boyd mentioned, we did stand up the
intimate partner violence assistance program. There is a point
of contact at every facility.
We know that based upon evidence that if providers ask
about this and veterans feel comfortable talking about it with
their provider, that there is a significant chance, a
significantly greater chase that they are going to get out of a
dangerous situation and take action against that. And so I
think we have many things in place already. We are very happy
to move forward with it and to learn more from our experience,
and to learn from women veterans as they participate in that.
Mr. Cisneros. Your last task force was six years ago. There
are still, obviously, barriers for women to seek out these
services. Don't you think it is time to update and to kind of
maybe get a new task force together to find out what can we do
more to increase these numbers?
Ms. Hayes. If I could, we are sort of bifurcating two
different topics. One is about domestic violence, interpersonal
violence, and sexual assault. The other part is the survey that
you have recommended. We do, again. Now, I want to show you.
This is the 2015 survey. It is no small report. It didn't--we
took this. We have made recommendations. We have initiated
actions. We have those actions moving forward. We have them
going on. In addition, we have continued to talk to veterans in
a very critical way through something that is called the
veteran experience journey.
We have been working individually with veterans in various
parts of the country to have them describe what they need right
now today, and those experiences are being acted on. So we have
pain points for veterans, like getting into the system, finding
out about their benefits, getting better relationships with
their providers. Things that we would survey, but a survey just
gives the answers across the country. It doesn't get us to the
action.
We have gone more directly to veterans right now in real
time, and then we have design factors that are making them
happen. So we can explain more to you about what that is, but
frankly, the amount of money that it takes to do a study like
this, I have a sense that we are going to find the same answers
that we know about right now from the veterans. They have
difficulty with information, how to access, distance,
understanding the MISSION Act, all of these things that we can
work on today.
Mr. Cisneros. Yeah. Well, my time has expired, and the size
of the report doesn't really suggest that it is better, but
maybe we need to start asking different questions so we can get
these numbers up. We need to figure out how we can get women to
start using the VA benefits and to really seek treatment at the
VA that they are entitled to. And I am glad that you are up to
25 percent now, but that is still way below where it needs to
be.
So thank you very much for your time.
Ms. Brownley. Thank you, Mr. Cisneros.
Mr. Levin, you are just under the wire. You are now
recognized for 5 minutes.
Mr. Levin. Thank you, Chair Brownley.
As a member of the Women Veterans Task Force I appreciate
you holding this hearing on a number of bills addressing the
women veterans' health care needs. It is critical that we
tailor VA services to women veterans rather than asking them to
just adjust to a male-centric system.
One of the ways we can do this is by training our providers
at the VA and those we partner with in the community to better
understand the unique needs of women veterans.
I want to thank my colleague, Mr. Rose, for introducing the
Breaking Barriers for Women Veterans Act to work towards this
important goal.
Dr. Boyd, I would like to ask you about your testimony on
this bill. You mentioned that some clinics do not treat enough
women to justify a full-time women's health care provider and,
instead, train existing providers to treat both men and women.
Who trains these providers and how does the training
specifically address the needs of women veterans?
Dr. Boyd. Well, I will pass that on to Dr. Hayes. She can
give you a much more fluid answer. We're very confident in that
training. So, Dr. Hayes.
Dr. Hayes. We have an extensive training process. The
basis, it starts with a women self-mini residency. The
providers go for a week. They train with what is called
standardized patients to do pelvic exams. They also learn about
deployment issues, chronic pain, and they learn about
contraception and abnormal pregnancies, everything that they
need to have their skills updated on.
This year we trained over 700. We have trained over--it is
our own staff that trains, and some of us have trained the
trainer model, but it is our own highly proficient women's
health providers that do the training.
Mr. Levin. Thank you, Dr. Hayes.
Dr. Boyd, you also stated that the $1 million increase for
the women veteran's health care mini residency program would be
unnecessary, but also stated that past mini residencies have
had waiting lists because demand exceeds capacity.
If this is the case, can you explain why the VA does not
support a funding increase?
Dr. Hayes. If I may, this is a technical issue. In the bill
we were unclear whether this $1 million--first of all, whether
that is a ceiling and would actually crimp our style. We have
actually spent about $1 million right now.
It is the staff capacity to go on and do more training that
has left us with this problem of having people still on the
waiting list. We have done a number of initiatives to work on
that. One is our rural health initiative. We have started a new
team and have people go out to the rural sites where our
greatest need is and train them on site. So that is one of the
things that we are doing.
But we have just sort of reached the max of what we can do
right now, and that is why we have waiting lists. We could
expand it. We think the VA has within its resources to do this.
It is always great to get additional appropriations, but we
were concerned that you not limit us to $1 million--
Dr. Boyd. Right.
Mr. Levin. Okay.
Dr. Hayes [continued].--because we are already spending at
that level.
Mr. Levin. So it sounds like there--
Dr. Boyd. That is right.
Mr. Levin [continued].--is an opportunity for some
collaboration between yourselves and--
Dr. Boyd. That is correct.
Mr. Levin [continued].--staff to work out that language to
clarify.
Dr. Hayes. I would welcome that. Thank you.
Mr. Levin. That is good.
Dr. Boyd. Uh-huh.
Mr. Levin. Dr. Boyd, I am glad also that another one of the
bills we are reviewing today, the VA Hiring Enhancement Act,
would provide additional tools to recruit staff.
I hear from many veterans in my district in Southern
California that understaffing affects their ability to receive
health care in a timely manner. And as you noted in your
testimony, the provision allowing VA to recruit physicians
before they complete their residencies only applies to those
that enter a specialty field.
Could you explain why this authority is important in the
recruitment of both primary and specialty care providers?
Dr. Boyd. So a couple of things. In addition to the hiring
authority that we have, we can offer a job, if we have a slot
available, to a training resident within any facility, within
my facility, say. But they have to meet the requirements by the
time of employment.
And that is part of what we want to do. We want to hire the
ones that we train. They are there because they like the
community. They are invested. And just to be clear as well, we
have been afforded other hiring authorities and opportunities
from congress as well. The education debt reduction is huge.
That has been a huge success for us, as well as our retention
and our incentives in relocation.
So we can hire ahead of time and that is the best thing to
do. If you see a good candidate who is training, we want to
hire them. So we already had that authority. We don't think
that we--that, in fact, would be a duplicative authority for
us.
And next week, I don't know if you were here earlier, but
next week there will be a hearing and there will be specialists
in that workforce area and HR area that we have been consulting
with.
Mr. Levin. Thank you.
Dr. Boyd. You are welcome.
Mr. Levin. And I am out of time, but I want to again
commend the chair for her great work on the women veteran's
task force, and all of my colleagues on both sides of the aisle
for all their excellent work in service to our veterans.
Thank you very much.
Ms. Brownley. Thank you, Mr. Levin. And I don't see Mr.
Steube. He was here earlier. And so I will just say before I
excuse the panel that, Dr. Boyd, thank you for a pretty
comprehensive written statement. I think that you have made
some valid observations with some of these bills. There are
some places where we may not agree completely, but I hope that
over time we can work through these things and to see these
bills through and sent to the president's desk for signature.
So we will look forward to that work ahead of us.
And having said that, thank you for being here. And we will
excuse you and we will move onto our second panel.
Dr. Boyd. Thank you very much.
[Pause]
Ms. Brownley. Welcome to our second panel. Thank you for
being here. We have Mr. Jeremy Butler, Chief Executive Officer
for Iraq and Afghanistan Veterans of America. Next, we have Ms.
Joy Ilem, National Legislative Director of Disabled American
Veterans, and finally we are also joined by Mr. Roscoe Butler,
Associate Legislative Director for Paralyzed Veterans of
America. Thank you, again, for being here.
And I now recognize Mr. Butler for 5 minutes.
STATEMENT OF JEREMY BUTLER
Mr. Jeremy Butler. Thank you, ma'am.
Chairwoman Brownley, Ranking Member Dunn, and Members of
the Subcommittee on behalf of IAVA, thank you for the
opportunity to share our views on the pending legislation
today.
I would like to take a moment to say that I also appreciate
the opportunity to testify today on the anniversary of the
September 11th attacks. It was obviously a tragic day in our
country's history, but it was also a day that inspired many of
IAVA's members to join the military. And it is an honor to be
here with you all to work together to ensure that we are
getting them the best care that our veterans deserve.
Support and recognition of women veterans is an incredibly
part of IAVA's work. And as such, it is included in our 2019
big 6 priorities. We launched our groundbreaking, She Who Borne
the Battle campaign in 2017, focused on recognizing the service
of women veterans and closing gaps in care provided by VA.
IAVA chose to lead on this issue not only because it is
important to the nearly 20 percent of our members who are
women, but because it is important to our entire membership,
and it will help ensure the future of America's health care and
national security.
Two years ago IAVA worked with congressional allies to
introduce the bipartisan Deborah Sampson Act in the House and
the Senate. It called on the VA to modernize facilities to fit
the needs of a changing veteran population. Increased newborn
care, established new legal services for women veterans,
eliminate barriers faced by women seeking care, and increased
data tracking and reporting to ensure that women veterans get
care on par with their male counterparts.
The Deborah Sampson Act was not passed last session, but
IAVA recognized that some progress was made in support of women
veterans with key provisions of that legislation passed or
funded. With much more still to be done, though, IAVA strongly
supports passage of all of the provisions of the Deborah
Sampson Act. Many have been introduced by members of this
Subcommittee and across congress, and IAVA emphatically
supports the 6 Deborah Sampson Act bills being considered
today: H.R. 2645; 2681; 2798; 2972; 3036; and 3636.
IAVA also supports the VA Newborn Emergency Treatment Act.
Coupled with provisions in the Deborah Sampson Act, this will
finally allow the VA to adequately care for veteran mothers and
their babies.
To design precise policy solutions, we also need robust
data collecting, sharing and analysis to know the extent to
which women veterans are underserved. IAVA strongly supports 3
bills to address these shortcomings: The Improving Oversight of
Women Veterans Care Act; The Women's Veteran Health Care
Accountability Act; and Improving Benefits for Underserved
Veterans Act.
For women veterans who choose to seek care at VA, finding
quality providers who understand their needs can be difficult.
Not surprisingly, women veterans are more likely than their
male counterparts to seek care in the community, meaning they
are often seen by private care providers that may not
understand military service and its health impacts.
Our 2019 member survey found that while 70 percent of
respondents felt that VA clinicians understood the medical
needs of veterans, only 44 percent felt that non-VA clinicians
understood them. For these reasons IAVA supports the Women
Veterans Equal Access to Quality Care Act and the draft
legislation to establish the VA Office of Women's Health.
Since 2001 the number of women using VA services has
tripled. As more military women make the transition to civilian
life, it is paramount that DoD and VA are ready to support
them. That includes ensuring proper reproductive care for women
veterans and their spouses. Currently, women veterans do not
have the same access to contraceptives as their civilian
counterparts. That is unacceptable and it is why IAVA supports
the Equal Access to Contraception for Veterans Act.
Ensuring that the VA is able to accommodate the millions of
veterans who use it for access to medical care and benefits, it
is paramount to ensuring the lasting success and health of the
veteran population. About 48 percent of all veterans and about
55 percent of post-9/11 veterans are enrolled in VA care. Among
our survey respondents, 81 percent are enrolled in VA health
care, and the vast majority have sought care from VA in the
last year.
The VA has made incredible strides in modernizing its
operating systems, but VA also needs robust modern hiring
practices in order to compete for talent to fill their
overwhelming number of vacancies. To this end, IAVA supports
the VA Hiring Enhancement Act.
Members of the Subcommittee, thank you for your commitment
to ensuring women veterans receive care that is on par with
their male counterparts. And thank you for the opportunity to
share IAVA's views on these issues. I look forward to answering
any questions you have.
[The prepared statement of Jeremy Butler appears in the
Appendix]
Ms. Brownley. Thank you, Mr. Butler. And I now recognize
Ms. Ilem for 5 minutes.
STATEMENT OF JOY ILEM
Ms. Ilem. Thank you, Chairwoman Brownley, Ranking Member
Dunn, and Members of the Subcommittee.
DAV appreciates the opportunity to provide testimony on the
17 bills under consideration today. We thank the Subcommittee
for its focus on improving VA health care services and programs
for our Nation's women veterans.
Ensuring women have equal access to high quality,
comprehensive primary care and the specialized services VA
offers is a critical legislative priority for DAV. We are
pleased that many of the bills that we are providing comments
on today reflect recommendations made in DAV's 2018 report,
Women Veterans, The Journey Ahead, and comport with DAV
Resolution Number 020.
DAV offers our support for H.R. 2645 and H.R. 2752. These
bills improve VA's maternity care package and ensure VA can
secure appropriate contracts for VA sponsored community care
for women veterans and their newborns.
H.R. 2681 requires VA to submit a report on the
availability of prosthetic items for women veterans in VA.
While DAV supports the intent of this bill, under DAV
Resolution Number 383, we ask the Subcommittee to consider
broadening the scope of the study proposed to ensure the intent
of the legislation is fully realized.
Specifically, we want to ensure that women veterans have
access to high quality prosthetic items and prosthesis that
meet their expectations in fit, function and appearance.
DAV is also pleased to support H.R. 2798, a bill that would
establish a permanent counseling program in retreat settings.
This pilot has shown consistent improvements in participants'
ability to better manage PTSD symptoms and maintain learned
coping strategies. It also garners high satisfaction rates
among women who note peer interaction and networking is
especially helpful for long-term recovery from post-deployment
mental health challenges that many women veterans face.
DAV supports H.R. 2972, 2982 and H.R. 3036, bills which
focus on improving web-based resources and outreach to women
veterans, information about availability of women's health
services throughout the VA system, correcting environment of
care and staffing deficiencies for women's health, and
eliminating barriers to care.
H.R. 3224 seeks to ensure women veterans have access to
comprehensive gender specific care in all VA facilities, and
calls for a study on using extended care hours to better serve
veteran patients.
While DAV supports what we believe to be the overall intent
of this bill, we do ask that the definition of gender specific
services be added to the bill prior to its advancement. In our
formal statement, we express concern that without that
definition there could be an expectation that services such as
obstetrics and newborn care, which are generally provided in
the community, would be required in VA facilities.
H.R. 3636 and H.R. 4096 call for comprehensive reports that
include data on the women veteran population using VA, models
of care, access to care in the community, capital investment
planning, environment of care standards, and staffing levels
and provider training in women's health.
DAV believes the collection and summary of this data in one
report can be helpful for future planning to better meet the
needs of this growing population, and we are happy to provide
our support for these bills as well.
DAV also supports H.R. 3798, a bill that would eliminate
co-payments for contraceptive items and medication in
accordance with DAV Resolution Number 365.
H.R. 3867 seeks to create a national task force to
integrate VA programs with existing community resources to
better serve veterans who have experienced sexual assault and
domestic violence. DAV does not have a specific resolution
calling for such a task force or plan. However, we acknowledge
the impact that these issues have on many veterans, and have no
objection to a passage of this bill.
The final draft bill, women veterans bill being considered
today would establish an office of women's health within the
VA. This measure would provide the director of the office
control over all aspects of women veterans' health care,
including distribution of resources. DAV believes this change
is warranted and necessary for VA to address many long-standing
issues and the enhancement of the provision of care for women
veterans using VA and, therefore, supports the bill's passage.
Finally, DAV supports the remaining bills on the agenda
mentioned here today: H.R. 1163, the VA Hiring Enhancement Act;
H.R. 1527, the Long-Term Care Veterans Choice Act; H.R. 2628,
the Vets Care Center Act; and 2816, the Vietnam Era Veterans
Hepatitis-C Enhancement Act.
Chairman Brownley, that completes my testimony and I am
happy to answer any questions the Subcommittee may have.
[The prepared statement of Joy Ilem appears in the
Appendix]
Ms. Brownley. Thank you, Ms. Ilem.
And I now recognize Mr. Butler for 5 minutes.
STATEMENT OF ROSCOE BUTLER
Mr. Roscoe Butler. Thank you, Chairwoman Brownley.
Ms. Brownley. Mr. Roscoe Butler.
[Laughter]
Mr. Roscoe Butler. Thank you, Chairwoman Brownley, Ranking
Member Dunn, and Members of the Subcommittee.
Paralyzed Veterans of America would like to thank you for
the opportunity to submit our views on the important
legislation pending before the Committee.
The bills being reviewed today address a number of
challenges veterans are facing and will provide vital
assistance to help them overcome the pain and suffering from
domestic violence while improving oversight of women veterans'
health care and breaking down barriers for women veterans.
For the sake of time, and since you have my full written
statement, I would only discuss a few of the bills.
H.R. 1163. PVA encourages many efforts to bolster staffing
levels at VA facilities, particularly within the spinal cord
injury system of care which historically, data shows, is one of
the most difficult areas to recruit and retain physicians and
nursing staff.
We strongly support H.R. 1163, the VA Hiring Enhancement
Act which seeks to release physicians from non-compete
agreements for the purpose of serving at VA. Removing these
barriers would help encourage more of the best and brightest
doctors and nurse practitioners coming out of medical school to
pursue a career in the VA.
H.R. 2982. PVA also supports H.R. 2982, which directs the
Secretary of Veterans Affairs to conduct a study of the
barriers for women veterans to health care from the Department
of Veterans Affairs. A major concern for PVA members is the
accessibility of facilities.
Here are a few recent examples of the barriers PVA members
have experienced:
Women veterans having to sit in their wheelchairs outside a
Model 3 women veterans' clinic because the facility did not
have a system in place to alert staff that someone was waiting
to gain access into the clinic;
Poorly designed facilities that limit VA's ability to
provide medical care to people with severe or catastrophic
disabilities and not having the appropriate diagnostic
equipment on site to conduct mammography examinations on spinal
cord injury women veterans.
Identifying these and other kinds of barriers that women
veterans face is an important first step toward improving the
care they receive from VA.
H.R. 3224. Without additional clarification, PVA cannot
support H.R. 3224 as written. We are concerned that H.R. 3224
does not define the type of gender specific services VA is
required to provide. VHA Directive 1330.01(02), Health Care
Services for Women Veterans break down gender specific care
into several categories: Primary care and specialty care.
Paragraph j provides a list of gender specific specialty
services that must be available in-house to the greatest extent
possible.
Unless additional clarification is provided, VA could
interpret Congress's intent with this legislation as a
requirement to offer gender specific services in each VA
medical center or community based outpatient clinic. There are
a number of gender specific specialty services listed in VA's
directive that VA medical centers and community based
outpatient clinics are not capable of providing, particularly,
when it comes to maternity and newborn care.
In order to improve the bill and earn our support, this
legislation would have to include language clearly defining the
kind of gender specific services VA would be required to
provide.
Again, PVA appreciates this opportunity to express our
views on some of the many important pieces of legislation being
examined today, and I am available to answer any questions.
[The prepared statement of Roscoe Butler appears in the
Appendix]
Ms. Brownley. Thank you, Mr. Butler. And I want to thank
all of the witnesses today for your testimony, and even more
importantly thank you for your engagement on all of these very
important bills.
So I will now recognize myself for 5 minutes for
questioning.
And the first thing, the first question I wanted to ask
really is to Ms. Ilem since you referenced this around my bill,
the Office of Women's Health.
So, you know, what I am trying to get at here, basically
with a bill, is, you know, when we are looking for equity and
parity in terms of health services to women, you know, one
quick thing one would look at is if women veterans make up 10
percent of the veteran population and then you look at the
health care budget, roughly you should see, you know, 10
percent of the resources being spent on women's health. I mean,
that makes sense.
Medical directors across the country have a lot of
flexibility and authority in terms of how those resources and
spent. And in some cases, they may spend way beyond 10 percent
in their facility. In other cases, they won't.
So, you know, the intent here is to try to provide some
accountability and some oversight with regards to how resources
are being spent because reality, at the end of the day all of
these issues that we are raising comes down to money to be able
to provide the services, the staffing that we need to properly
address veterans' needs, and in this case women veterans'
needs.
So do you have any other ideas of how we go about that? Do
you think this is headed in the--you mentioned that it was
headed in the right direction, and I appreciate that, or if you
had any other sort of ideas?
Ms. Ilem. I think this proposal would be key to really
addressing what the congressional task force of women veterans
is really seeking to do, which is to take care of these long-
standing issues that have been around for some time. I mean, I
can just remember testifying on these same, many of these same
issues for, you know, more than a decade now.
I think the women's health services program office in VA
has the direction, has the data, has much of what they need.
They just need to be able to execute it. And I don't see that
they really have that authority at the level of where that
office is now.
I know in VA's testimony they indicate that, you know, they
feel it is positioned appropriately for them to carry out, but
we would respectfully disagree. I think this will be key. They
have got a plan. They just need to execute it. And they have
the support of the leadership in the secretary in VA to really
address these problems and take care of the staffing issues,
the deficiencies, the cultural issues that they want to
address. They have noted all of these things and they have a
provision of services that they want to provide.
So I hope that this will be--this bill will be considered
and move forward because I see it is key in overall work that
you and the Committee and the Subcommittee are trying to do.
Ms. Brownley. Great. Thank you very much.
Do the Mr. Butlers have any comments?
[Laughter]
Mr. Jeremy Butler. I don't have anything to add.
Ms. Brownley. Okay. Very good.
You know, and this question is really to anyone and all of
you on the panel. You know, three of today's bills address
improving reproductive health care access for women veterans.
Can you add any additional services that the VA should be
providing that would improve reproductive health for women?
Mr. Jeremy Butler. I am happy to jump in.
Yeah. I think a number of important issues are discussed in
the legislation that is being discussed today. But beyond that,
one of the recommendations that we have that IAVA has in our
policy agenda is around expanding access to and funding for in
vitro fertilization. I think IVF is another one of those areas
where you have a disconnect between services available to
active duty servicemembers and then what is available to
veterans.
And this is an especially important question for our
membership because we do have a younger cohort, many of whom
have deferred parenthood perhaps until their time in service
was over because those demands in service were so great. And so
increasing these accesses to things around fertility and
childcare is very important to our membership.
Ms. Brownley. Thank you.
Mr. Butler.
Mr. Roscoe Butler. I don't have anything additional to add,
but I would like to bring to your attention the issue of
mammography exams for women veterans in wheelchairs.
VA facilities, most VA facilities, while they may have a
mammography machine to do the exam, they don't have the
appropriate equipment. So most of the time women have to sit in
their wheelchairs. If they are a large woman, it is difficult
to raise.
There are certain equipment that they can purchase that
will make it much easier for them to do their exams. And if
they complete the exam without the woman getting out of the
wheelchair, it is not going to be the appropriate type of
examination that really should be done.
So I would ask that they really look at that and expand
upon the type of equipment that they purchase and procure for
women particularly who are in wheelchairs.
Thank you. Thank you for adding that and bringing that up.
And I will say that you have an extraordinary representative
who came to my office, a woman in a wheelchair talking about
this issue, and she was quite persuasive.
So thank you very, very much.
And with that I recognize Dr. Dunn for 5 minutes.
Mr. Dunn. Thank you, Chairwoman Brownley.
I want to start with saying that we fully expect that some
of the items that are coming through in these bills suggest
like they have cost implications to the VA. And what we would
like to do is secure, you know, the VSS, all of them, you being
lead dogs as it were on the VSS, to work with us here in
congress and with the VA specifically, that what we can do in
our jurisdictions to get offsets for some of these costs
because hopefully we can find some of the money right there.
You know, so please address that.
Mr. Jeremy Butler. I think we often caution about this
discussion where the pay come from other veteran benefits. I
don't necessarily have the answer as to where the money should
come from, but what I can say is our membership is adamant that
it should not come by reducing other benefits that go to
veterans. We fought this battle just last year I think it was
around the GI Bill, when there was an attempt to maybe make
some cuts on the GI Bill payments to have money go to another
veterans' benefit.
We always want to ensure that our veterans are getting the
care that they deserve and the support they deserve and the
benefits that they deserve, but we should not be cannibalizing
one program to fund another one, especially when both of those
programs are equally necessary and important.
Mr. Roscoe Butler. PVA echoes Jeremy's concerns and would
not support taking away funding from one program to support
another program. We have to find a common way to support all of
the bills being presented today. And we, the PVA, supported all
of the bills today with one exception.
So whatever the common ground that we can reach, but we
echo Jeremy's concern.
Ms. Ilem. I think my colleagues have addressed our same
concerns; that certainly we want to be able to work with the--
with you and your staff on this agenda because we think it is
so critical and so important.
But, you know, we do have those considerations in mind when
it comes to taking away from one veteran to serve another
veteran. And we want to make sure that services that are being
provided to women veterans have--we have equal access to care
which has been a problem--
Mr. Dunn. My thought was actually more about programs that
are either no longer viable or they are replaced with newer
programs, or there are some programs that overfunded. There is
extra money sitting in some parts of the VA. And I think we can
all identify efficiencies in offices. Certainly, I identified a
lot of efficiencies in my offices over time.
Next question, Ms. Ilem, I read your testimony. I liked it.
But there was one jarring, I kind of kept coming back to it.
You said you thought that the--well, let me get the paragraph
here. ``We believe the VA health has different responsibilities
than the health care industry in general.''
I have worked in both VA and, you know, civilian health
care and active duty health care. What do you think is
different about it? I mean, other than you have a unique
population.
Ms. Ilem. Well, definitely I think in that reference for
the--that was on Bill 1163 we were talking about the
responsibility of VA to train, the training responsibility that
they have had for training our Nation's clinicians. So--
Mr. Dunn. So training, you think that is the unique part of
it, that they have to do training?
Ms. Ilem. Well, not just the training of clinicians, but
that has been one of their major functions within the
department.
Mr. Dunn. I remember.
[Laughter]
Ms. Ilem. Yes. You know, so many clinicians are trained
through VA and they do have some additional responsibilities
that, you know, we don't see so much in the general sector, and
a very specialized mission and some very specialized programs.
So I think we were just trying to make the point that VA is
a unique health care system in itself, you know.
Mr. Dunn. All right. So I thought I traveled pretty fluidly
between the different programs and, you know, it is about
taking care of people. Certainly, you know, I like taking care
of military people especially, but that is why I did it for a
long time. But I just--it kind of kept coming back like what is
different, what is different. All right.
So the last thing is I want to ask you to help, again, as
advocates for services in the VA for the Hepatitis-C program.
We talked earlier with the first panel. You know, we have cured
100,000 veterans of Hepatitis-C. That is amazing. That is just
amazing.
When I was practicing 20 percent of surgeons would
terminate their career because they caught Hepatitis from a
patient during surgery, you know, accidentally, needle pricks.
So this is a big, big deal. It is close to my heart. I want
you to get the word out to the veterans.
Thank you very much.
Ms. Brownley. Thank you, Dr. Dunn.
Mr. Lamb, you are recognized for 5 minutes.
Mr. Lamb. Thank you, Madam Chairwoman, and thank you for
holding this important hearing and advancing all these bills.
We have a lot of work to do in this area, and I think those of
us who served in uniform more recently know that there is just
absolutely no excuse for any veteran, man or woman, feeling
that when they leave the service the VA services are not for
them.
So I think we are starting to make a big impact on that
now. But one of my concerns that we see across problems faced
by the VA is difficulty in connecting with the people who we
are intending these new services and reforms to reach.
And so I am sure you have addressed it a little bit
already. I apologize for coming in late. But I just wanted to
throw it open to any of the three of you about whether you can
advise us on what we can do to better reach into the wider
veteran population that is not enrolled in VA services or that
are enrolled once and didn't like the experience and has never
used it again, to advertise some of these new things that we
are passing, to invite people back in.
And I guess kind of a subset of that, if you have had any
experience with it already is what are the implications for
community care. Obviously, community care has been expanded. A
lot of new services and new patients will be eligible for all
of that. Are you seeing excitement or interest in community
care among women veterans, particularly those maybe who haven't
used the VA much before? Anyone who can weigh in on that.
Ms. Islam. Sure. I would love to take the opportunity to
talk about that.
While we support community care and we want women veterans
who feel they need access to care in the community or may need
because VA can't provide certain services, obviously we want
that to happen. We think it is really critical, though, during
this implementation phase of the MISSION Act that VA is really
instrumental in being the coordinator of that care as those
women veterans go to the community.
As you heard from the first panel today, so many women
veterans have complex--the women who are being seen in VA have
complex medical health histories and challenges. Their veteran
experience is really important and VA can help train those
providers that are going to be in their network to make sure if
they are seeing a woman veteran, here are the things that we
know about this women veteran population and to be sensitive
about and the gender sensitivities and cultural sensitivities
around military sexual trauma especially.
So I think that is going to be critical, and for VA to be a
real partner because we know some women veterans have had a
really negative experience in VA. But at VA we do want them to
reach out. So many changes have been made. Just over the past,
you know, 10 years we have seen incredible changes.
I am a woman veteran. I use VA. I have for 20 plus years. I
have seen those changes firsthand and I think they would really
benefit for coming to VA, especially those who have service
connected disabilities, obviously those who have catastrophic
injuries, our OEF/OIF population, so key. You know, they have
had several deployments and, you know, over time there is
really so many benefits in VA with their specialized programs.
So I hope that VA will be able to do some additional
outreach to those, come back, try the VA, we are there for you,
and improve services.
Mr. Lamb. I think that is an excellent point.
Mr. Butler, did you want to--
Mr. Jeremy Butler. Yeah. I was just going to echo Joy's
statements about MISSION Act and community care. And then just
add maybe around your question on getting word out and
everything. You know, I was in a similar case. When I
transitioned off of active duty in 2005, I didn't really
understand the VA. It wasn't really something that was talked
about when you are on active duty. I think once you start to
hear about it when you are out of active duty, you generally
hear the more negative things rather than the positive things.
So I think as VA care continues to improve and there are
more positive stories coming out, 1, I think you're going to
have a more understood idea in the veteran community that it is
a positive place to go. But then there also just needs to be
better interaction, I think, with the non-profit organizations,
with community care organizations to understand how to access
the VA.
I have been in this business for 4 years now and it still
is incredibly complex to me to understand how one accesses the
VA to begin with.
Mr. Lamb. No, it is, and that seems to be the most
important hurdle. What I always hear, at least, is that once
people finally get enrolled and are in and they know that they
are in, at least in Western Pennsylvania they are happy. They
think the VAs are great. But we have a hard time getting people
over that initial obstacle.
So I think that is what we can all work on. And I think
your groups play a really important role in that. So please
continue to challenge us as to how we can support you to
recruit new people and get better information to those that are
there.
And with that, Madam Chairwoman, I yield back.
Ms. Brownley. Thank you, Mr. Lamb.
Mr. Barr, you are recognized.
Mr. Barr. Thank you, again, Madam Chairwoman, for holding
this hearing and thank you for considering legislation that
supports and recognizes our women veterans and newborns and
their kids, and looking at ways to eliminate barriers for women
veterans to access the VA.
I would note, Chairwoman Brownley, that I was happy to
support your bill, H.R. 840, earlier in this congress, the
Veterans Access to Child Care Act. One of those barriers is
needing to provide women veterans with childcare so that they
can have the time to go seek veterans care.
I would urge you and Chairman Takano to consider the VA
Child Care Protection Act, which we offered as a motion to
recommit and then we also offered it as an amendment in the
last mark up to the Cisneros bill.
And then in July we introduced a separate bill because I
think there was some commentary that it needed to be separate
from the Cisneros bill, the VA Child Care Protection Act, to
make sure that employees of the VA are not a threat to our
children, so that that wouldn't be an additional barrier for
women veterans seeking access to care.
And just to remind the Committee, we did send a letter on
July 19th with 10 republican Members of this Committee to the
Chairman asking for a hearing. We have not yet heard a
response. I just bring that to your attention, Chairwoman
Brownley, because we would like to work with you on that issue.
Mr. Butler, in your testimony you point out that while the
VA provides care team support to the medical foster homes, it
does not have the authority to pay for the costs of those
medical foster homes. As a result, veterans must use personal
or other funding sources should they choose this alternative
rather than nursing homes.
And I appreciate your association, support and endorsement
of the Long Term Care Veterans Choice Act to support more of
your members having access to these MFHs.
Can you or any of the other colleagues on the panel
describe what funding sources veterans do use to pay for this
care and obviously the hardship that that creates?
Mr. Jeremy Butler. I can't necessarily speak specifically
to that, but what I do know is that financial hardships are one
of the main reasons that veterans come to our organization
seeking support. And a lot of those financial hardship cases
are underpinned by trying to pay for medical care that they
need.
We have a rapid response referral program that veterans and
family members can reach out and work with social service
professionals that are employed by IAVA. And this is one of the
most frequent things that they hear about. It is financial
hardship, and then when they start to dig into what the cause
of the financial hardship, it is paying for medical care.
So that is kind of a high level--
Mr. Barr. Yeah.
Mr. Jeremy Butler [continued].--answer to your question. It
is not exactly specific.
Mr. Barr. Can you speak to the quality difference or the
quality of life differences that veterans may experience, those
who live in these medical foster homes versus traditional
nursing homes? Any of your members of any organizations can
speak to that.
Ms. Ilem. We just have heard that, and I think some members
on the Committee today have mentioned, especially for younger
veterans who maybe have experienced a TBI, can't live
independently, but could really benefit from living in a
medical foster home environment versus a long-term perhaps
nursing home, one of the community living centers.
So I think it really adds to their dignity, to their
quality of life, what they want to achieve even though they
have undergone, you know, a serious injury or disability.
So I think the medical foster home is just an excellent
program and I really hope that we can make sure there is no
disincentive for any service disabled veteran to choose that
access or that option.
Mr. Roscoe Butler. And I would just add, it adds to their
independence, being able to live outside of a nursing home
facility. And then overall, as Ms. Ilem mentioned, their
quality of life dramatically improves living in a medical
foster home versus being in a--
Mr. Barr. Thank you, Mr. Butler.
Mr. Roscoe Butler [continued].--community nursing home.
Mr. Barr. And, Ms. Ilem, one last question for you. With
regard to your testimony on H.R. 3867, the Violence Against
Women Veterans Act, I was interested in your testimony that
there was a study that women are re-traumatized when they are
attempting to obtain care in the VA, and that those occurrences
are all too common.
Are we seeing the setup of nationwide community care under
MISSION Act in a way that would get women veterans, or men
veterans, who are uncomfortable in the VA because of re-trauma,
being re-traumatized, are we seeing the MISSION Act give an
alternative to those veterans who don't feel comfortable in a
VA and want to choose community care to deal with MST?
Ms. Islam. Well, VAs recent harassment study, I think, is
just really alarming for a lot of us. We know that some women
veterans coming to VA reporting, you know, being harassed while
seeking care, and that has been a disincentive for them to go.
And these are generally probably the ones who most need that
care.
So I think here in the community for some women veterans it
may be the answer, but I hope that that is a temporary thing. I
really hope VA, which they have talked about today, that they
are addressing these issues full force, full on. Their culture
has to change, making sure that every veteran feels welcome at
VA. And obviously no veteran should be harassed, male or
female, coming to VA.
And we don't want it to--we don't want that to remain. I
mean, we know that is a problem, and I grant it to VA for
actually bringing that research forward. And we have been
hearing that for some time. And, you know, if that is
prohibiting somebody from going, we want them to get care then.
That might be something that they could consider in the
community.
But we certainly don't want that to just be the only
place--
Mr. Barr. Right.
Ms. Islam [continued].--they can go. We want it to be fixed
within VA.
Mr. Barr. Absolutely.
Thank you. Thank you. And I yield back.
Ms. Brownley. Thank you, Mr. Barr. You can never say I
never gave you extra time.
[Laughter]
Ms. Brownley. Mr. Bilirakis, you are recognized for 5
minutes.
Mr. Bilirakis. Thank you. Thank you, Madam Chair. I
appreciate it very much.
Yeah. My questioning will be regarding H.R. 2628, the Vet
Care Act, which I introduced.
The VA has expressed concerns--this is for the entire
panel. We will start with, is it--well, whoever wants to go
first. The VA has expressed concerns about apparent disparities
created in H.R. 2628, the Vet Care Act, pilot programs,
eligibility standards.
Given the logic of the VA, it seems to me that every pilot
program VA has ever operated could also be viewed as creating
disparities in care for veterans. Indeed, this argument could
be applied across the board to all valid controlled clinical
research done in science and in medicine. There will always be
limitations and exclusions.
Considering the current eligibility criteria for dental
care in the first place, can you explain why you agree that
this pilot program is a reasonable way to take a first step
into assessing the specific benefits of preventive dental
medicine at VA such as the one in H.R. 2628? Whoever would like
to go first, please.
Mr. Roscoe Butler. I will try and address it.
But as we said in our written testimony, oral health has a
major impact on their physical health, and gum disease is often
associated with diabetes, heart disease and many other serious
medical conditions.
So a large number of veterans who receive care from the VA
are not getting the appropriate dental care needed, and which
could later add to other complications of health complications.
Mr. Bilirakis. Thank you.
Anyone else, please?
Ms. Ilem. DAV has been a longtime advocate of dental care
for all veterans, being within a comprehensive care package. As
we know, anybody who has health insurance, I mean, dental
insurance is an important part of that complete package of
care. And we have long wanted to make sure that veterans have
access to that.
So I think your bill is very reasonable in terms of a start
to look at the conditions, as Mr. Butler indicated, that are
prevalent in the veteran population and to kind of mirror the
study as a first step of really offering that benefit.
Mr. Bilirakis. Anyone else?
Mr. Jeremy Butler. Just to agree. I never understood the
disconnect between dental care and medical care. I think, you
know, we all, I think, are in agreement here that it is the
whole health that is the important part here and they should be
seen as one thing. So we are very much in agreement.
Mr. Bilirakis. Thank you very much.
And I want to reemphasize that Dr. Jeffcoat from the
University of Pennsylvania, who is the former dean of the
dental school there, actually helped me craft this bill. She
actually conducted the study and I worked with a dentist in my
community as well, Dr. Zack Kalarickal, who is a good friend.
But let me go ahead and ask one more question. The VA has
expressed some concerns that the pilot in the vet care program
would lead to veteran dissatisfaction if the pilot disqualifies
certain veterans who receive examinations for dental care and
are deemed to need surgery.
H.R. 2621, however, specifically authorizes the VA to
provide administrative support to ensure those veterans can
receive the treatment that they may need.
My thought is that the patient is better off than before
because they have been alerted to a treatable problem having
received a free examination compared to previously which must
be seen as a significant benefit to the veteran with diabetes.
To the panel, do you think your members would be
dissatisfied with the pilot program outlined in this bill,
especially considering the end goal? And we know what the end
goal is, and I appreciate the chairwoman working with me on
this particular issue because we all want veterans who qualify
for health care under the VA ultimately to get dental care.
So whoever would like to go first, please respond to that.
Ms. Islam. I think veterans would understand your
explanation and, certainly sometimes just even having that
first opportunity to really identify, I have a problem and
there is an issue here, and hopefully the assistance to, you
know, get that care, that they wouldn't be dissatisfied. They
may want to make--you know, they would love to be able to have
that access to a full treatment.
But I think it is a first good step and it is something. So
certainly we would be supportive of that. And I think most
veterans would agree with your logic.
Mr. Bilirakis. Thank you.
Mr. Roscoe Butler. I agree with Ms. Ilem. And an informed
veteran is a happy veteran to the most part. Knowing that they
have a condition that they didn't know they had, and then
what's the recourse for taking care of that condition then
becomes the issue for the veteran if they can't get it in the
VA. But not knowing you have a condition is of really not a
good thing which could lead to other complications.
Mr. Jeremy Butler. Yeah. Agreed. I am still in the Navy
Reserves and I have to get a dental checkup from a Navy dentist
every couple of years. And it simply is to make sure that you
have a proper level of dental care. If they find something
wrong with you, the Navy, the Department of Defense isn't going
to pay to cover it for you. They alert you that you need to go
out and get that taken care of on the private side.
If that is the way we are handling our reservists, then I
think veterans would understand that it is the same thing; that
you are getting access to a determination that you need some
support and then you can go from there. So I think they would
be okay with it and understand it.
Mr. Bilirakis. Yeah. And under the legislation we
authorize, after the pilot program, the caregiver, the dentist
will refer them possibly to a non-profit or the insurance
program. And that will be very helpful as well. But I think it
is dangerous not to get the examination.
So thank you very much, Madam Chair. I appreciate it. I
yield back. I guess I am over time. I apologize.
Ms. Brownley. Yes. You, too, can never say--
[Laughter]
Ms. Brownley [continued]. --that you have never had extra
time on this Committee.
Well, this concludes our questioning. And, you know, before
I close, I wanted to just thank the VA staff for saying through
the second panel. That doesn't happen every time when the VA
comes to our hearing. So we appreciate that very, very much.
And I just want to conclude with just a few remarks, and to
say first that we have--I think this has been a good hearing. I
am very excited about these proposed bills. But, first, we have
a long way to go until we uphold the promise that we have made
to our veterans, and this includes achieving equity for our
women veterans.
And, second, the VA must plan ahead for rapid growth of the
women's veteran population. And I think many of these bills
sort of address that. And the bills discussed today gives VA
the tools to identify gaps and opportunities to plan for that
growth and allocate resources accordingly.
So, again, before I conclude I just want to reemphasize my
hope for this Subcommittee and that we continue to work in a
bipartisan manner. I look forward to continuing to work closely
with Ranking Member Dunn as we have already done and will
continue to do. And bipartisanship in this Committee, that is
the only way we are going to get to good results for our
veterans.
So I thank all of our witnesses for their expertise and my
colleagues for their interest.
And with that, Dr. Dunn, would you like to make any closing
comments?
Mr. Dunn. Thank you very much, Chairwoman Brownley. I just
want to say thank you as well to both panels. I think, you
know, it has been a good exchange. I think you see the interest
level in veterans' affairs, you know, throughout the congress
and the administration. It is reflected in the budget as well.
So I would--VA continues to be the single largest source of
my constituent services' problems, I guess. The people come.
They run afoul of the system. So anything we can do to help
that system, you know, we are doing it on a one by one basis
back home, but you guys could do the whole thing at once. So we
appreciate everything that you do up here in helping us with
that.
And I agree. Working with Ms. Brownley on a bipartisan
basis, we should be able to get something accomplished. In the
last session it was the single most productive Committee, I
believe, wasn't it? Yeah. The VA Committee was the single most
productive bill-wise Committee in the congress, in the last
session of congress. Let's see if we can do that.
Thank you.
Ms. Brownley. Hear. Hear.
So with that, all Members will have 5 legislative days to
revise and extend their remarks, and include extraneous
material.
Without objection, the Subcommittee stands adjourned.
[Whereupon, at 12:05 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Teresa Boyd, DO
Chairwoman Brownley, Ranking Member Dunn, and Members of the
Subcommittee. Thank you for inviting us here today to present our views
on several bills that would affect VA health programs and services.
Joining me today are Dr. Patricia Hayes, Chief Consultant, Office of
Women's Health Services, and Dr. David Carroll, Executive Director,
Office of Mental Health and Suicide Prevention.
Madame Chairwoman, while it is not on today's agenda, we have taken
the opportunity to include in this testimony VA's views on H.R. 3495,
the Improve Well-Being for Veterans Act, because of the urgency of
addressing the issue of Veteran suicide. H.R. 3495 would fulfill a
critical legislative component of the Administration's multi-faceted
program to prevent Veteran suicide.
H.R. 1163 VA Hiring Enhancement Act
Section 2 of this bill would amend title 38, United States Code
(U.S.C.), by adding a new section 7414 to restrict the applicability of
non-VA covenants not to compete to the appointment of certain VHA
personnel, specifically those appointed under 38 U.S.C. section 7401.
Section 2 would further require an individual appointed to such a
position to agree to provide clinical services at VA for a duration
beginning from the date of their appointment and ending on the latter
of either 1 year after the date of appointment, or the termination date
of any covenant not to compete that was entered into between the
individual and the non-VA facility. The Secretary would have the
authority to waive this particular requirement.
VA has concerns with section 2 of this proposed bill and requests
the opportunity to discuss the bill further with the Committee.
Section 3 of the bill would amend section 7402 to permit VHA to
make a contingent appointment as a VHA physician on the basis of the
physician completing their residency training.
VA also has concerns with this section and requests an opportunity
to further discuss. With regard to section 3, VA recommends removing
the language regarding the completion of a residency leading to board
eligibility, subsection (b)(1)(B)(i), since the requirement for
residency training is provided in the published VA physician
qualification standard (VA Handbook 5005, Part II, Appendix G2).
Physicians must have completed residency training or its equivalent,
approved by the Secretary in an accredited core specialty training
program leading to eligibility for board certification. Approved
residencies are as follows:
Those approved by the accrediting bodies for graduate
medical education, the Accreditation Council for Graduate Medical
Education (ACGME) or American Osteopathic Association (AOA), in the
list published for the year the residency was completed; or
Other residencies or their equivalents which the local
Professional Standards Board determines to have provided an applicant
with appropriate professional training. The qualification standard also
allows for facilities to require VA physicians involved in academic
training programs to be board certified for faculty status.
VA also recommends removing the language regarding an offer for an
appointment on a contingent basis, subsection (b)(1)(B)(ii), since VA
may currently provide job offers to physicians pending completion of
residency training. There are no restrictions in statute or VA policy
on making job offers contingent upon completing residency training and
meeting other requirements for appointments as physicians within VHA.
If this needs to be clarified in statute, VA suggests including the
information in a new subsection (h) as follows: Section 7402 of title
38, U.S.C., is amended by adding at the end the following subsection
(h): ``(h) The Secretary may provide job offers to physicians pending
completion of residency training programs and completing the
requirements for appointments under subsection (b) by not later than 2
years after the date of the job offer.''
H.R. 1527 Long-Term Choice Veterans Care Act
H.R. 1527, the Long-Term Care Veterans Choice Act, would amend
section 1720 to add a new subsection (h) providing authority for the
Secretary to pay for long-term care for certain Veterans in Medical
Foster Homes (MFH) that meet Department standards. Specifically, the
bill would allow Veterans, for whom VA is required by law to offer to
purchase or provide nursing home care, to be offered placement in homes
designed to provide non-institutional long-term supportive care for
Veterans who are unable to live independently and prefer to live in a
family setting. VA would pay MFH expenses by a contract or agreement
with the home. VA would be limited to furnishing care and services, and
paying for MFH care, to no more than a daily average of 900 Veterans in
any year. One condition of providing support for care in an MFH would
be the Veteran's agreement to accept Home Based Primary Care or Spinal
Cord Injury Home Care program furnished by VA. These amendments would
take effect October 1, 2020, and VA would be authorized to carry out
this program for a period of 3 years.
VA endorses the concept of using MFHs for Veterans who meet the
appropriateness criteria to receive such care in a more personal home
setting. VA endorsed this idea in its Fiscal Year (FY) 2018, 2019, and
2020 budget submissions and appreciates the Committee's consideration
of this concept. Our experience has shown that VA-approved MFHs can
offer safe, highly Veteran-centric care that is preferred by many
Veterans at a lower cost than traditional nursing home care. VA
currently manages the MFH program at over two-thirds of our medical
centers, partnering with homes in the community to provide care to
nearly 1,000 Veterans every day. However, Veterans are solely
responsible for the expenses associated with MFH care today. Of the
1,000 Veterans in MFHs currently, 200 would be eligible for care at the
MFH at VA expense under this bill. Our experience also shows that MFHs
can be used to increase access and promote Veteran choice-of-care
options. We appreciate that the bill would provide VA more than 1 year
to implement this new benefit, as this would provide VA sufficient time
to ensure contracts or agreements are in place, and that policies and
regulations, if needed, are in effect.
While VA fully supports the MFH concept, we would look forward to
working with you to resolve a few technical issues in this bill. For
example, the limitation in proposed subsection (h)(2), regarding a
limit ``in any year'' of a ``daily average'' of 900 or fewer Veterans
receiving care, is ambiguous; it is unclear how the limitation to a
given year qualifies the daily average and how VA could operationalize
this effectively. VA would like to work with the Committee to ensure VA
can effectively incorporate MFHs into the continuum of authorized long-
term services and support available to Veterans. We are happy to
provide the Committee with technical assistance on this matter and are
available for further discussion.
VA estimates that, if enacted, this bill would cost approximately
$6.2 million each year for administrative expenses associated with the
program, with total administrative expenses reaching $18.72 million.
However, we estimate that the resulting savings from paying for MFH
care in lieu of nursing home care would result in net savings of $16.10
million in FY 2021, $29.21 million in FY 2022, and $43.03 million in FY
2023 for a total net savings of $88.34 million over the 3-year program.
H.R. 2628 VET CARE Act of 2019
H.R. 2628 contains two substantive sections affecting VA's
provision of dental care benefits. Section 2 of the bill would amend
section 1712 to include a new subsection (d) that would authorize VA to
furnish administrative support (including information for the provider
to share with Veterans regarding the VA Dental Insurance Program) to
persons providing dental care to Veterans separate from VA's authority.
VA strongly supports this section, if amended. We sought similar
authority for a community partnered collaboration to expand dental care
for Veterans in the FY 2020 budget request. VA has limited statutory
authority to furnish dental care to Veterans. This section would
authorize VA to provide administrative support for the provision of
needed dental care in the community to Veterans who are not eligible to
receive that dental care from VA. The section would authorize VA staff,
in the scope of their normal duties, to work with community dental
providers approved by the Secretary to coordinate and schedule dental
appointments for these Veterans in the community.
We believe the bill should be amended, however, to not limit the
provision of administrative support to providers of dental care; we
anticipate that in many cases, VA medical support assistants or
providers would be offering administrative support directly to
Veterans, advising them of the availability of pro bono or other
services from community providers furnishing care independently from
VA. We would be happy to work with the Committee to provide the
necessary amendments for this purpose. We also recommend a technical
amendment to replace the ``; and'' with a period at the end of
subsection (d)(2)(B), as that subparagraph is not followed by a
subparagraph (C) and subsection (e), as redesignated, would not
logically be connected to or qualify the rest of subsection (d)(2).
We estimate this section would have no cost to the Department.
Section 3 would require VA to carry out a pilot program to provide
outpatient dental services and treatment, and related dental
appliances, to participating Veterans at no cost to these Veterans. The
purpose of the pilot program would be to determine whether there is a
correlation between Veterans receiving such services and treatment, and
the Veterans suffering fewer complications of chronic ailments, thereby
yielding a lower cost of care. To be eligible to participate in the
pilot program, a Veteran would have to be: (1) enrolled in VA health
care; (2) ineligible for dental care under section 1712; (3) not
receiving regular periodontal care; (4) between 40 and 70 years of age;
and (5) diagnosed with type 2 diabetes. Eligible Veterans would have to
elect to apply for the program, and any eligible Veteran who applies
for the pilot program would receive an initial periodontal evaluation,
including vertical bitewing radiographs. If an eligible Veteran
diagnosed with periodontal disease required surgery, the Veteran would
be disqualified from participating in the pilot program. Subsection (c)
would require VA to enroll at least 1,500 eligible Veterans for the
pilot program, giving preference to Veterans with service-connected
disabilities that increases in accordance with the Veterans' disability
ratings in a manner that ensures one-third of eligible Veterans
enrolled in the pilot program have been diagnosed with no or mild
periodontitis, and two-thirds of eligible Veterans enrolled in the
pilot program have been diagnosed with moderate to severe
periodontitis. VA would have to begin the pilot program within 180 days
of the date of the enactment of this Act and carry out the pilot
program for a 4-year period. VA would have to carry out the pilot
program in five VA facilities, with one such facility in each of five
Veterans Integrated Service Networks (VISN) the Secretary considers
appropriate for the pilot program. Each facility would have to serve
not more than one-fourth and not fewer than one-sixth of the Veterans
enrolled in the pilot program, in approximately even proportions of
Veterans categorized under subsection (c). VA would be required to make
timely and appropriate periodontal therapy available to Veterans with
moderate to severe periodontitis. Each eligible Veteran who elected to
receive treatment would receive an annual dental evaluation, during
which the periodontal health of the Veteran would be reassessed and
recorded for purposes of determining the severity of the Veteran's
periodontitis. VA would have to collect and record data regarding the
health of treated Veterans, including events, treatments, and outcomes;
these data would have to be made available for analysis by qualified
researchers. VA would have to provide standardized instructions to all
physicians and dentists who work in facilities selected for the pilot
program to ensure consistent evaluation and care for Veterans enrolled
in the pilot program. VA would also have to provide each Veteran
enrolled in the pilot program with an orientation and information
before any care was provided under the pilot program, as well as an
exit interview that includes information regarding how such Veterans
may obtain dental services and treatment after the pilot program ends.
VA would have to notify institutions of higher education that offer
degrees in periodontology about the pilot program so that such
institutions may engage in similar studies regarding private
periodontal care for Veterans. VA would have to submit a report of
findings to Congress within 18 months of the conclusion of the pilot
program. Finally, VA would be required to administer the pilot program
under such regulations as the Secretary would prescribe, including best
practices regarding informed consent and study registration.
VA does not support section 3 of the bill. We are concerned the
bill would create disparities in the overall application of dental
eligibility under section 1712 by expanding access to these benefits to
Veterans in participating locations but not elsewhere. We believe this
could have the unintended consequence of Veteran dissatisfaction. We
have serious concerns about the provision in the bill that would
disqualify from treatment a Veteran who has been comprehensively
examined and for whom surgery has been deemed necessary. This would be
unethical and against VA's core values and professional standards of
care. Dis-enrolling Veterans who have advanced periodontal disease
after examination could be a stressor on Veterans who believed VA had
their best interests in mind in treating their conditions. Also, as a
time-limited program, VA is concerned about how it would manage care
authorized near the end of the pilot program, as some Veterans may
actually be worse off if they received only a portion of a fuller
episode of care.
We also believe the bill is far too prescriptive in terms of its
requirements. For example, the bill provides that an eligible Veteran
is one between 40 and 70 years of age. This could result in a situation
where a Veteran is eligible at the beginning of the pilot program but
becomes ineligible during the course of the pilot program (e.g., the
Veteran is 68 years old at the start of the pilot but turns 70 during
the pilot program). As written, the Veteran would no longer be eligible
and could no longer receive benefits under this program, which could
result in fragmentation of care. The requirements concerning enrollment
and prioritization in subsection (c) are ambiguous and appear to
conflate two different decision criteria: level of service-connected
disability and severity of periodontitis. It is also unclear what VA
would be required to do if there was insufficient interest among
Veterans meeting the specific eligibility criteria such that VA could
not enroll 1,500 Veterans in the pilot program. The criteria for
selecting facilities are similarly ambiguous and could result in
unintended consequences, if, for example, one facility (particularly a
smaller or rural facility) simply could not keep up with demand at
larger (particularly urban) facilities and fell below the one-sixth
threshold. The preceding is not an exhaustive list of our technical
concerns with the bill, but it is demonstrative that the bill is too
prescriptive to be implemented effectively.
Finally, we believe Section 3 of the bill is unnecessary because
the dental literature already strongly supports the cost-effectiveness
of preventive dental care. There is a large volume of scientific
evidence supporting preventive dental care for individuals with
conditions such as Type II diabetes to reduce the morbidity of tooth
loss associated with periodontal disease. It is unclear how this
proposed pilot program would further advance science and reduce overall
health care costs. A controlled, well-defined, and sanctioned research
project would be a more appropriate vehicle. The proposed legislation
would not provide scientifically rigorous and valid findings because it
does not adopt the structure and methodology of a controlled research
project. The purpose of the legislation is to ``determine'' if there is
a correlation based on treatment, but we do not believe VA could make
such a determination given the parameters of the pilot program in the
bill.
VA estimates that section 3 would cost $3.72 million in the first
year, $3.83 million in the second year, and $15.56 million over 4
years.
H.R. 2645 Newborn Care Improvement Act of 2019
H.R. 2645 would amend section 1786 to increase from 7 to 14 the
number of days after the birth of a child for which VA may furnish
covered health care services to the newborn child of a woman Veteran
who is receiving maternity care furnished by the Department and who
delivered the child in a facility of the Department or another facility
pursuant to a Department contract for services related to such
delivery. Not later than 31 days after the start of each fiscal year,
VA would be required to submit a report to Congress on such services
provided during the preceding fiscal year, including the number of
newborn children who received such services during that fiscal year.
VA supports H.R. 2645, subject to the availability of
appropriations. A newborn needing care for a medical condition may
require treatment extending beyond the current 7 days that are
authorized by law. Additionally, the standard of care is to have
further evaluations during the first 2 weeks of life to check infant
weight, feeding, and newborn screening results. Pending these results,
there may be a need for additional testing and follow-up. There are
also important psychosocial needs that may apply, including monitoring
stability of the home environment or providing clinical and other
support if the newborn requires monitoring for a medical condition.
Extending care to 14 days would provide time for further evaluations
appropriate for the standard of care, as well as sufficient time to
identify other health care coverage for the newborn.
We estimate the bill would cost $12.9 million in FY 2020, $13.9
million in
FY 2021, $69.6 million over 5 years, and $142.3 million over 10
years. The FY 2020 President's Budget did not include any funding for
H.R. 2645 in FY 2020 or FY 2021.
H.R. 2681 Report on Prosthetic Items for Women Veterans
H.R. 2681 would require VA, not later than 1 year after the date of
the enactment of this Act, to submit to Congress a report on the
availability from VA of prosthetic items made for women Veterans,
including an assessment of the availability of such prosthetic items at
each VA medical facility.
VA provides comprehensive prosthetic and sensory aids and services
that support and optimize the health and independence of all Veterans,
regardless of gender. VA defines the term ``prosthetic'' as an item
that replaces a missing or defective body part. For women Veterans,
specifically, prosthetic items include: post-mastectomy items; wigs for
alopecia; long-acting reversible contraception (e.g., intrauterine
devices); maternity support belts items; and vaginal dilators.
While VA supports providing Congress clear information at the end
of each fiscal year on the types of prosthetic items, quantities of
such items, and the amount expended on women Veterans, VA does not
support providing an assessment of the availability from VA of
prosthetics made for women Veterans because the report required by this
bill would be incongruent with current clinical practice and
procurement processes. The provision of a prosthetic item begins with
the Veteran's appointment with a VA or community provider, who assesses
the Veteran's prosthetic needs and submits a prescription or consult
for a prosthetic item to the local VA medical center (VAMC) Prosthetic
and Sensory Aid Service (PSAS). The type and variety of prosthetic
items that a local facility maintains onsite will vary based upon their
patient population, patients' needs, and the uniqueness of prosthetic
items. Most prosthetic items are purchased from commercial sources. As
a result, the report would not provide meaningful information as to the
availability of these items for women Veterans.
H.R. 2752 VA Newborn Emergency Treatment Act
H.R. 2752 would expand the scope of benefits for newborn children
of women Veterans by authorizing VA to furnish transportation necessary
to receive covered health care services. The bill also would allow VA
to furnish more than 7 days of health care services to a newborn child
and to provide transportation necessary to receive such services, if
such care is based on medical necessity, including cases of
readmission.
VA supports, in principle, providing medically necessary
transportation benefits for newborns. The bill presents, however, a few
technical concerns, such that we do not support the bill in its current
form. For example, it would allow VA to ``waive'' a debt that a
beneficiary owes for medically necessary transportation provided for a
newborn that was incurred prior to enactment of this Act. VA would
generally have no ability to waive such a debt because the debt would
not be owed to VA; further, VA would not have been a party to the
transportation agreement or arrangement entered into by the beneficiary
and a third party. In addition, the bill's exception to the otherwise
applicable 7-day limitation on the duration of services is sweeping in
scope. We would welcome the opportunity to discuss this to better
understand the Committee's intent.
We further note that if the Committee intends to advance both H.R.
2645 and H.R. 2752, steps should be taken to ensure that the changes
proposed are consistent with each other. VA would be happy to work with
the Committee to ensure the amendments made by the two bills are
complementary and not contradictory.
H.R. 2798 Building Supportive Networks for Women Veterans Act
H.R. 2798 would direct VA to provide reintegration and readjustment
counseling services, in a retreat setting, to women Veterans who are
recently separated from service in the Armed Forces after prolonged
deployments.
VA agrees that providing these retreats is beneficial to women
Veterans; however, other Veteran and Servicemember cohorts could also
benefit from this treatment modality. While VA appreciates the intent
of this bill, we request that the bill language be amended to allow VA
the ability to conduct these retreats for all Veteran or Servicemember
cohorts eligible for Vet Center services and that appropriate resources
be provided through the appropriations process. Examples include those
who have experienced military sexual trauma, Veterans and their
families, and families that experience the death of a loved one while
on active duty. Also, rather than creating a separate biennial report,
as would be required by the bill, VA recommends that this bill amend
section 7309 to include a report on this program as part of the annual
report to Congress on the activities of the Readjustment Counseling
Service.
We estimate the bill would cost approximately $483,000 in FY 2020,
approximately $500,000 in FY 2021, $2.59 million over 5 years, and
$5.67 million over 10 years. The FY 2020 President's Budget did not
include any funding for H.R. 2798 in FY 2020 or FY 2021.
H.R. 2816 Vietnam-Era Veterans Hepatitis C Testing Enhancement Act of
2019
H.R. 2816 would require VA, not later than 180 days after the date
of the enactment of this Act, to carry out a 1-year pilot program to
make Hepatitis C testing available to covered Veterans at certain
outreach events organized by Veterans Service Organizations (VSO).
Covered Veterans would mean a person who served in the active military,
naval, or air service between February 28, 1961, and May 7, 1975, and
was discharged or released therefrom under conditions other than
dishonorable, regardless of whether such person is enrolled in VA
health care. VA would have to select five VISNs in which to carry out
the pilot program, with two such networks predominantly serving rural
areas and three predominantly serving urban areas. If at least 350,000
Veterans were tested for Hepatitis C by the termination of the pilot
program, VA would be required to expand the program to all VISNs not
later than 1 year after the date on which the pilot program ends. Not
later than 180 days after the date on which the pilot program ends, VA
would have to submit a report to Congress on the number of covered
Veterans tested for Hepatitis C under the pilot program and a list of
resources needed to expand the pilot program to all VISNs for the
length of time necessary to test all covered Veterans for Hepatitis C.
No additional funds would be authorized to carry out the requirements
of this Act; VA would have to implement this authority using amounts
otherwise authorized to be appropriated to VA for the express purpose
of providing Hepatitis C-related care.
VA does not support this bill. Testing Vietnam Era Veterans and
other Veterans at risk for chronic infection by the Hepatitis C virus
(HCV), as well as Veterans who are not at increased risk but simply
wish to be tested, remains a high priority for VA. The most recent HCV
testing data for the general U.S. population show that as of 2016, only
14.1 percent of individuals born between 1945 and 1965 had been tested
for HCV. By comparison, in 2016, 75.1 percent of Veterans in VA care
had been tested for HCV.
We are concerned that VA would face significant legal, ethical, and
practical barriers to implementation of this bill. As currently
constructed, this bill raises a very serious ethical issue because it
authorizes VA to test Veterans for HCV but not to provide anti-viral
treatment, follow-up laboratory testing, or diagnosis and treatment of
comorbidities (such as substance use and alcohol use disorders) that
can interfere with anti-viral treatment. On a practical level, VA would
need to have a mechanism to be notified by a VSO about when and where
HCV testing outreach events would be held, with sufficient time to
prepare for participation (e.g., ordering rapid test kits, logistics,
etc.) and to provide for VA employees to attend these events outside of
official duty hours and locations (e.g., clinician time/overtime pay,
liability for use of a personal car/access to a VA car, etc.). The HCV
testing model on which this bill is based involves holding HCV testing
events at local VSO offices (e.g., an American Legion post). VA
clinical staff and eligibility officers have attended such events, but
the actual testing has been done by non-VA personnel because the
individuals who come to the event are not known to be eligible for or
enrolled in VA care. This bill uses a different model in which VA would
perform the testing. This introduces the following very significant
challenges:
The VA laboratory would be using a rapid initial
screening test that requires follow-up confirmatory testing for any
positive results. There would not be any mechanism for logging,
accessioning, and testing blood specimens for follow-up testing.
Results from confirmatory testing are generally not
available for several days. Again, because these individuals are not
enrolled in VA care, there would not be a mechanism for contacting the
Veteran to provide results.
VA does not currently have authority to provide
individualized follow-up assessments and counseling to individuals who
test positive. This could create immediate and serious ethical
conflicts for VA clinical staff. For example, if a Veteran who tests
positive wants advice on informing his or her spouse, VA clinicians
would have very limited (if any) ability to respond in detail.
Performing the specified test requires oversight by a
laboratory possessing a current, valid Clinical Laboratory Improvement
Amendments (CLIA) certificate. It is not clear how willing VA
laboratory directors would be to perform such testing outside of a VA
facility because of legitimate concerns about jeopardizing the
laboratory's CLIA certificate.
The automatic trigger provision in section 2(d) raises legal
concerns as well. It states that if at least 350,000 Veterans are
tested for Hepatitis C by the termination date, the Secretary shall
expand the program to all VISNs not later than 1 year after the date on
which the pilot program ends. However, this would create an uncertain
legal authority for such expansion. By its terms, subsection (c)
directs VA to act to expand the program not later than 1 year after the
pilot program ends; however, subsection (a) would be VA's only
authority to make Hepatitis C testing available to Veterans who were
not enrolled in VA health care, and this authority is limited to the 1-
year pilot program. Also, subsection (c) clearly provides that the
program terminates 1 year after the program begins. Consequently, it
does not appear the bill would provide VA an adequate statutory basis
to furnish testing to Veterans who were not enrolled in VA health care
after completion of the pilot program. This subsection also has
technical issues that create further ambiguity, namely its failure to
use the term ``covered Veteran'' and its failure to specify whether the
350,000 Veterans tested must be tested under the pilot program (rather
than generally). As of December 31, 2018, VA had screened 78.2 percent
of the approximately 2.4 million Vietnam Era Veterans currently in VA
health care, and across the system, there are approximately 527,000
Vietnam Era Veterans remaining to be tested.
We further note that the reporting requirement in section 2(e)(2)
would require VA to report to Congress a list of the resources needed
to expand the pilot program to all VISNs for the length of time
necessary to test all covered Veterans for HCV. However, not all
Veterans who are eligible for testing are willing to be or interested
in being tested. While VA can offer Hepatitis C testing to these
individuals, it is a personal decision on the part of the Veteran to
agree to testing; thus, VA cannot guarantee that all Veterans with HCV
will be tested.
Finally, we note that the bill appears to be overly inclusive, as
it applies to all Veterans who served on active duty during the Vietnam
era, whether or not the Veteran served in the Republic of Vietnam.
Under 38 U.S.C. 101(29)(B), the Vietnam era for Veterans who did not
serve in the Republic of Vietnam began August 5, 1964, and ended May 7,
1975. The bill would create an inequity in terms of Vietnam era
Veterans' access to benefits by using the earlier date of February 28,
1961, for all Vietnam era Veterans, regardless of their service in the
Republic of Vietnam.
H.R. 2972 Improving Communications Related to Services for Women
Veterans
H.R. 2972 contains two sections. Section 1 would require VA to
expand the capabilities of the Women Veterans Call Center to include a
text messaging capability.
VA supports the intent of section 1 but does not believe this
section is necessary because VA already implemented text messaging
capabilities at the Women Veterans Call Center in April 2019. Similar
to the existing call line and online chat, women Veterans who text 1
(855) 829-6636 will be connected with Women Veterans Call Center
representatives, who are all women, and who can answer general
questions about benefits, eligibility, and services specifically for
women Veterans. Text messaging is available Monday through Friday 8
a.m. to 10 p.m. EST, and on Saturdays from 8 a.m. to 6:30 p.m. EST.
Section 2 would require VA to survey VA Internet Web sites and
information resources in effect on the day before the date of the
enactment of this Act and publish an Internet Web site that serves as a
centralized source for the provision to women Veterans of information
about the benefits and services available to them from VA. The Web site
would have to provide to women Veterans information regarding all
services available in the district in which that Veteran is seeking
services, including with respect to each VAMC and Community-Based
Outpatient Clinic (CBOC) in the applicable VISN, the name and contact
information of each women's health coordinator; a list of appropriate
staff for other benefits available from the Veterans Benefits
Administration (VBA), the National Cemetery Administration (NCA), and
such other information as VA considers appropriate. VA would be
required to ensure the information published on the Web site is updated
not less frequently than once every 90 days. In carrying out this
section, VA would have to ensure that the outreach conducted under VA's
suicide prevention program (outreach and education for Veterans and
families) includes information regarding the Web site required by this
bill. VA would be authorized to use only funds made available to it to
publish information on VA Web sites to implement this requirement.
VA supports this section. VA has over 75 programs across VBA, VHA,
and other business lines that offer transition benefits and services to
transitioning Servicemembers. Transition programs that address the
needs of women include the Women Veterans Health Care program in VHA;
the Center for Women Veterans program within VA's Central Office; and
the VA Transition Assistance Program (TAP) within VBA. VBA includes on
its Web page, https://www.benefits.va.gov/persona/veteran-women.asp,
information on VA benefits available to all Veterans (including women),
links to women's health coordinators, links to health resources, and
instructions on how to apply for VA benefits. VA TAP, which is offered
through the Office of Transition and Economic Development (TED),
recognizes the importance of providing programs and initiatives that
support women Veterans. VA TAP Benefits and Services curriculum, for
example, covers gender-specific health care to address the particular
needs of female Veterans. The Participant Guide, which Servicemembers
have as a reference as they continue their transition, includes more
details on available services and programs for women Veterans. Should
this section of the bill be enacted, TED would include directions for
transitioning women Servicemembers to access the Web site in its TAP
briefings. Also, VA has in place at each VAMC a Web site specific to
women Veterans that highlights the services available and provides
information for a point of contact at the facility. In addition, VA
offers two national Web sites that offer facility location information.
VA does not believe this section would result in any additional
costs.
H.R. 2982 Women Veterans Health Care Accountability Act
H.R. 2982 would require VA to enter into a contract with a
qualified independent entity or organization to conduct a comprehensive
study of the barriers to the provision of comprehensive health care by
VA encountered by women Veterans. In conducting this study, VA, through
the contractor, would have to survey women Veterans who seek or receive
care from VA, as well as women Veterans who do not seek or receive such
care or services; administer the survey to a representative sample of
women Veterans from each VISN; and ensure that the sample of women
Veterans surveyed is of sufficient size for the study results to be
statistically significant and a larger sample size than the National
Survey of Women Veterans in FY 2007-2008. In conducting the study, VA
would be required to build on the work of this survey from 2007-2008,
as well as the Study of Barriers for Women Veterans to VA Health Care
2015. VA would be required to conduct research on the effects of the
following on the women Veterans surveyed in the study: the perceived
stigma associated with seeking mental health care services; the effect
of driving distance or availability of other forms of transportation to
the nearest medical facility on access to care; the availability of
child care; the acceptability of integrated primary care, women's
health clinics, or both; the comprehension of eligibility requirements
for, and the scope of services available under, hospital care and
medical services; the perception of personal safety and comfort in
inpatient, outpatient, and behavioral health care facilities; the
gender sensitivity of health care providers and staff to issues that
particularly affect women; the effectiveness of outreach for health
care services available to women Veterans; the location and operating
hours of health care facilities that provide services to women
Veterans; and such other significant barriers as VA considers
appropriate. VA would be required to ensure that the head of the Center
for Women Veterans and the Advisory Committee on Women Veterans reviews
the results of the study, and that the head of each of these entities
submits findings with respect to the study to the Under Secretary for
Health. Not later than 30 months after the date of the enactment of
this Act, VA would be required to submit to Congress a report on the
study required by this bill. The report would have to include
recommendations for such administrative and legislative actions as VA
considers appropriate, including the findings of the Center for Women
Veterans, the Advisory Committee on Women Veterans, and the Under
Secretary for Health.
VA does not support this bill. VA conducted an extensive study of
the barriers to health care for women Veterans in 2013 and released the
results of the report to Congress in 2015. The scope of this proposed
legislation is a study identical to that 2013 study. VA is already
implementing initiatives that address the identified barriers.
VA offers comprehensive primary care for women Veterans and ensures
that any woman Veteran seeking VA care receives complete primary care
from one primary care provider at her preferred site. VA has enhanced
provision of care to women Veterans by focusing on the goal of
developing Women's Health Primary Care Providers (WH-PCP) at every site
where women access VA. VA has at least two WH-PCP at all of VA health
care systems. In addition, 90 percent of CBOCs have a WH-PCP in place.
VA is in the process of training additional providers to ensure that
every woman Veteran has an opportunity to receive her primary care from
a WH-PCP.
VA has responded to the growing number of women Veterans by
offering a wide range of mental health services to meet their unique
needs. Such services include psychological assessment and evaluation,
outpatient individual and group psychotherapy, acute inpatient care,
and residential-based psychosocial rehabilitation. Specialty services
are offered to target problems such as PTSD, substance use problems,
depression, sexual trauma, and homelessness.
VA launched an End Harassment program at every VAMC in the summer
of 2017. Through increased awareness, education, reporting, and
accountability, VA is working to address this issue. VA's efforts hinge
on awareness and education, followed by accountability. We have
launched messaging, including ``it's not a compliment, it's
harassment'' directed primarily at educating male Veterans that these
actions are harmful and unacceptable. Employees have been trained on
these cultural change efforts, including an awareness of the
experiences of women Veterans and ways to intervene and respond.
Cultural change efforts continue as we develop updated resources,
training, and associated messaging; accountability through the local
VAMC Director is a critical element.
The End Harassment training was developed at the VA Central Office
level as a tool for VA sites to use to create an awareness of and
educate staff on the issue of women Veterans being harassed by male
Veterans, as well as to introduce intervention strategies. Necessary
variation exists at VA sites related to processes for staff training,
as well as reporting and tracking of various types of Veteran
complaints. As such, leadership at the local level is responsible for
identifying and communicating these processes and actions.
In 2019, in collaboration with research subject matter experts from
the Women's Health Practice Based Research Network (PBRN), VA will
conduct a more detailed care study in which PBRN sites will be asked to
respond to questions about whether their facility delivered End
Harassment training, which types of staff were trained, and how women
Veterans can report incidents of harassment at their facilities.
H.R. 3036 Breaking Barriers for Women Veterans Act
H.R. 3036 contains five substantive sections. Section 2 would
require VA to retrofit existing VA medical facilities with fixtures,
materials, and other outfitting measures to support the provision of
care to women Veterans. Not later than 180 days from the date of the
enactment of this Act, VA would have to submit to Congress a plan to
address deficiencies in the Environment of Care (EOC) for women
Veterans at VA medical facilities. Subsection (c) would authorize the
appropriation of $20 million to carry out this section, in addition to
amounts otherwise made available for these purposes.
VA does not support section 2. VA has already recognized the
importance of meeting the health care needs of our women Veterans. We
recently updated VHA Directive 1330.01 to clarify definitions and
provide objective privacy and dignity requirements that have been
incorporated into updated facility design requirements through issuance
of a design alert. Facilities are on course to fully address the health
care needs and EOC privacy and dignity issues, regardless of the type
of service or setting, through operational and non-recurring
maintenance (NRM) funding sources, as appropriate. The NRM program is
being used to make corrections for significant deficiencies. Also,
physical facility compliance with privacy and dignity standards have
been incorporated into VHA's EOC survey tool, which is used by all VA
medical facilities to assess patient care spaces and identify any
needed corrections or alterations. EOC survey tool results are tracked
by both local facility and Network leadership, as well as oversight at
the national level; existing survey tool reports can be used as a basis
for informing Congress on compliance without the need for an additional
report, as this bill would require. The specific reporting requirements
in subsection (b) would unnecessarily redirect resources needed for the
delivery of care and maintenance of the patient EOC.
We estimate the one-time report required by section 2 would cost
$450,000.
Section 3 would require VA to ensure that each VA medical facility
has not fewer than one full-time or part-time WH-PCP whose duties
include, to the extent possible, providing training to other VA health
care providers on the needs of women Veterans.
While VA supports the intent of this section, we do not support
enactment because it is unnecessary. VA already has the authority to
employ WH-PCP at all of our health care systems, and in addition, 90
percent of CBOCs have a WH-PCP in place. For many community sites,
though, there is no justification to hire a full-time designated WH-PCP
due to the small number of women Veterans assigned to the clinic. In
these cases, VA trains an existing provider who will treat both men and
women Veterans instead. There is approximately a 20-percent turnover
each year for women's health providers, so training new providers is a
constant need.
Section 4 would authorize to be appropriated $1 million for each
fiscal year for the Women Veterans Health Care Mini-Residency Program
to provide opportunities for participation in such program for primary
care and emergency care clinicians. These amounts would be in addition
to amounts otherwise made available for such training.
VA supports the concept of mini-residencies but does not believe
this is necessary. VA's efforts to train clinicians to meet the needs
of an ever-increasing number of women Veterans seeking care has
included large scale initiatives to deploy core curricula covering the
highest priority topics in women's health care through mini-
residencies. VA has developed four mini-residency programs in recent
years and trained more than 5,800 clinical providers since 2008. .The
four programs are Women's Health Mini- Residency for Primary Care
Providers (Physicians, NPs, PAs); Women's Health Mini- Residency for
Primary Care Nurses (RNs/LPNs/LVNs); Women's Health Mini-Residency for
Primary Care Providers and Nurses (Interprofessional curriculum
designed for providers and RNs); and Women's Health Mini- Residency for
Emergency Care Providers and Nurses (Interprofessional). VA offers
mini-residency programs as large, national training conferences each
year. Current mini-residencies held to date have had waiting lists as
demand has exceeded capacity. VA is also providing contract training to
VA facilities through computer-based women's health modules completed
in advance of the contract training team arriving at the clinic to
deliver a 1-day training for interactive, hands-on activities, and
breast and pelvic exam instruction. This training delivery will enhance
the opportunity for clinicians to attend trainings and reduce the
amount of time they need to be away from clinical care.
We estimate section 4 would result in additional costs of $1
million each year.
Section 5 would require, not later than 1 year after the date of
the enactment of this Act, VA to establish a training module that is
specific to women Veterans and make it available to community providers
who furnish care on VA's behalf.
VA supports the intent of this section but does not believe it
necessary. VA recognizes that women Veterans are more likely than their
male counterparts to obtain care in the community, and VA is developing
a training module for community providers who care for women Veterans
to be attuned to their unique needs. Key competencies in the module
will cover military history, caring for Veterans with complex medical
conditions, coordinating care between VA and community providers, and
identifying VA resources for help. This learning module will reside on
a virtual platform available for providers furnishing care on behalf of
VA.
Section 6 would require VA to conduct a study on the use of the
Women Veteran Program Manager program at VA to determine if the program
is appropriately staffed at each VAMC, whether each VAMC is staffed
with a Women Veteran Program Manager, and whether it would be feasible
and advisable to have a Women Veteran Program Ombudsman at each VAMC.
Not later than 270 days after the date of the enactment of this Act, VA
would have to submit to Congress a report on the study conducted under
this section. Subsection (c) would require VA to ensure that all Women
Veteran Program Managers and Women Veteran Program Ombudsmen receive
the proper training to carry out their duties.
VA agrees that the information required by section 6 would be
useful but does not support this legislation because it is unnecessary.
VA has self-reported data on the Women Veteran Program at each VAMC.
The Women's Assessment Tool for Comprehensive Health (WATCH) is an
annual report that assesses the Women's Health Program in VA medical
facilities. The self-assessment enhances national and local strategic
planning for the development of women's health programs. In addition,
VA recently developed a women Veterans integrated project team (IPT)
charged with focusing efforts on improving the experience of women
Veterans by addressing capabilities impacting critical focus areas. The
IPT is charged with transforming the culture and operation of VA by
developing innovative solutions to create access to high quality health
care with a respectful, safe, and welcoming environment for women
Veterans by ending harassment and addressing capacity gaps, gender
disparities, variation in women's health program implementation, and
care coordination.
H.R. 3224 To Provide Increased Access to VA Medical Care for Women
Veterans
H.R. 3224 would create a new section 1720J regarding medical
services for women Veterans. Subsection (a) of this new section would
require VA ensure that gender-specific services are continuously
available at every VAMC and CBOC. Subsection (b) would direct the
Secretary to conduct a study to assess the use of extended hours as a
means of reducing barriers to care, the need for extended hours based
on interviews with women Veterans and employees, and the best practices
and resources required to implement the use of extended hours. Finally,
subsection (c) would require VA submit to Congress by September 30 of
each year a report on VA's compliance with subsection (a).
We agree with the aims of the legislation but do not support it as
written. We fully agree with the intent of the legislation, to ensure
that women Veterans are able to receive timely, high-quality care, but
we are concerned that, as drafted, it is unworkable. Specifically,
concerning the proposed section 1720J(a), we are concerned about the
phrase ``continuously available'' and what it is intended to mean. Very
few health care services within VA or any health care system are
available around the clock, every day; even if the phrase was only
meant to convey continuous availability during business hours, there is
still no guarantee that providers would be constantly available, as
there may be periods of time when a provider is on leave or when a
vacancy has occurred that takes some time to fill. This could
potentially have significant resource implications depending upon the
intended effect. We also note that the term ``gender specific
services'' is unclear; this could apply to both men and women Veterans.
It is also unclear if this is intended to refer to gender-specific
primary care services for women or more advanced services such as
obstetrics and gynecology (for women) or urology (for men). We note
that VA recently implemented two provisions of the VA Maintaining
Internal Systems and Strengthening Integrated Outside Networks
(MISSION) Act of 2018, the Veterans Community Care Program under
section 1703 and the urgent care benefit under section 1725A, that
expand access to timely care, particularly urgent or emergent
conditions. These new initiatives may relieve some of the need for VA
facilities to have extended hours of operation.
We believe section 1720J(b) is unnecessary in part because VA has
already established extended hours of care to reduce barriers to access
and has promoted new modalities, such as telehealth, to make it easier
for Veterans to obtain care. We can provide data, both quantitative and
qualitative, regarding some of the elements of the study required by
subsection (b), and we would be pleased to discuss our findings with
the Committee.
We would greatly appreciate the opportunity to meet with the
Committee further to discuss these and other issues to improve this
legislation. Given the unclear scope of the legislation, we are unable
to provide a cost estimate for this bill at this time but note that it
could have significant resource implications depending on the intended
effect.
H.R. 3495 Improve Well-Being for Veterans Act
H.R. 3495 would require VA to provide financial assistance to
eligible entities approved under this section through the award of
grants to provide and coordinate the provision of services to Veterans
and Veteran families to reduce the risk of suicide. VA would award a
grant to each eligible entity whose application was approved by VA. VA
could establish a maximum amount to be awarded under the grant,
intervals of payment for the administration of the grant, and a
requirement for the recipient of the grant to provide matching funds in
a specified percentage. VA would ensure, to the extent practicable,
that financial assistance is equitably distributed across geographic
regions, including rural communities and Tribal land. VA also, to the
extent practicable, would need to ensure that financial assistance is
distributed to provide services in areas of the country that have
experienced high rates or a high burden of Veteran suicide and to
eligible entities that can assist Veterans at risk of suicide that are
not currently receiving health care furnished by VA.
VA would have to give preference in the provision of financial
assistance to eligible entities providing or coordinating (or who have
demonstrated the ability to provide or coordinate) suicide prevention
services or other services that improve the quality of life of Veterans
and their families and reduce the factors that contribute to Veteran
suicide. Each grant recipient would have to notify Veterans and Veteran
families that services they provide are being paid for, in whole or in
part, by VA. If a grant recipient provided temporary cash assistance to
Veterans or Veteran families, the recipient would have to develop a
plan, in consultation with the beneficiary, to ensure that any
beneficiary receiving such temporary cash assistance is self-sustaining
at the end of the period of eligibility for such assistance.
VA would require each grant recipient to submit an annual report
describing the projects carried out with VA's financial assistance; VA
would also specify to each recipient the evaluation criteria and data
and information to be included in the report, and VA could require
entities to submit additional reports as necessary. An eligible entity
seeking a grant would submit a form to VA containing such commitments
and information as VA considers necessary to carry out this section.
Each application would have to include a description of the suicide
prevention services to be provided, a detailed plan describing how the
entity proposes to coordinate and deliver suicide prevention services
to Veterans not currently receiving care furnished by VA (including an
identification of community partners, a description of arrangements
currently in place with such partners, and identification of how long
those arrangements have been in place), a description of the types of
Veterans at risk of suicide and Veteran families proposed to be
provided suicide prevention services, an estimate of the number of
Veterans at risk of suicide and Veteran families that would be provided
services (including the basis for the estimate and the percentage of
those Veterans not currently receiving VA care), evidence of the
experience of the applicant (and the proposed partners) in providing
suicide prevention services (particularly to Veterans at risk of
suicide and Veteran families), a description of the managerial and
technological capacities of the entity, and other application criteria
VA considers appropriate.
VA would be required to provide training and technical assistance
to eligible entities under this section regarding the data that must be
collected and shared with VA, the means of data collection and sharing,
familiarization with and appropriate use of any tool to measure the
effectiveness of the financial assistance VA provided, and how to
comply with VA's reporting requirements. VA would have to establish
criteria for the selection of eligible entities that have submitted
applications. In establishing these criteria, VA would have to consult
with Veterans Service Organizations (VSO), national organizations
representing potential community partners of eligible grant recipients,
organizations with which VA has a current memoranda of agreement or
understanding related to mental health or suicide prevention, State
Departments of Veterans Affairs, national organizations representing
members of the reserve components of the Armed Forces, Vet Centers,
organizations with experience in creating measurement tools for
purposes of determining programmatic effectiveness, and other
organizations VA considers appropriate.
VA would have to develop measures and metrics for grant recipients
in consultation with the same group of entities or organizations.
Before issuing a Notice of Funding Availability under this section, VA
would have to submit to Congress a report containing the criteria for
the award of a grant under this section, the tool to be used by VA to
measure the effectiveness of the use of financial assistance provided
under this section, and a framework for the sharing of information
about entities in receipt of financial assistance under this section.
VA could make available to grant recipients certain information
regarding potential beneficiaries of services, including confirmation
of the status of a potential beneficiary as a Veteran and confirmation
of whether a potential beneficiary is currently receiving or has
recently received VA care.
VA's authority to provide financial assistance would end on the
date that is 3 years after the date on which the first grant is
awarded. Not later than 18 months after the date on which the first
grant is awarded, VA would have to submit a detailed report on the
provision of financial assistance under this section. Not later than 3
years after the date on which the first grant is awarded, VA would have
to submit to Congress a follow up on the interim report containing the
same elements and a final report on the effectiveness of the financial
assistance provided through this authority, an assessment of the
increased capacity of VA to provide services to Veterans at risk of
suicide and Veteran families as a result of this financial assistance,
and the feasibility and advisability of extending or expanding the
provision of financial assistance.
Eligible entities would be: (1) an incorporated private institution
or foundation that is approved by VA as to financial responsibility and
no part of the net earnings of which incurs to the benefit of any
member, founder, contributor, or individual and that has a governing
board that would be responsible for the operation of the suicide
prevention services provided under this section; (2) a corporation
wholly owned and controlled by an organization meeting the same
requirements; (3) a tribally designated housing entity (as defined in
section 4 of the Native American Housing Assistance and Self-
Determination Act of 1996 (25 U.S.C. 4103)); or a community-based
organization that is physically based in the targeted community and
that can effectively network with local civic organizations, regional
health systems, and other settings where Veterans at risk of suicide
and the families of such Veterans are likely to have contact. Suicide
prevention services would be services to address the needs of Veterans
at risk of suicide and Veteran families and includes outreach; a
baseline mental health assessment; education on suicide risk and
prevention; direct treatment; medication management; individual and
group therapy; case management services; peer support services;
assistance in obtaining any VA benefits for which the Veteran or
Veteran family may be eligible; assistance in obtaining and
coordinating the provision of other benefits provided by the Federal
Government, a State or local government, or an eligible entity;
temporary cash assistance (not to exceed 6 months) to assist with
certain emergent needs; and such other services necessary for improving
the resiliency of Veterans at risk of suicide and Veteran families as
VA considers appropriate. Veteran family would mean, with respect to a
Veteran at risk of suicide, a parent, a spouse, a child, a sibling, a
step-family member, an extended family member, or any other individual
who lives with the Veteran. VSOs would be those organizations
recognized by VA for the representation of Veterans included as part of
an annually updated list available online.
VA strongly supports this bill. VA's efforts to reduce the
incidence of suicidal ideations and behavior (and suicide completions)
among all Veterans could be complemented by partnering with community-
based providers who are able to replicate VA's suicide prevention
programs in the community and to connect with Veterans that are
currently beyond VA's reach. This novel approach would assist VA in
reaching more of the 14 of the 20 Veterans dying each day by suicide
who are not under VA care at the time of their deaths; effective
partnering with eligible grantees would be key to our being able to
reduce, if not prevent, the number of these tragic occurrences.
Additionally, the legislation aligns with VA's proposal submitted with
the President's FY 2020 budget. This proposal has been identified as
the Secretary's top legislative priority and the legislation provides
the necessary authorities clinicians believe will help the Department
combat suicide among Veterans. Lastly, we note that the legislation is
aligned with the President's strategic taskforce to combat suicides in
the Nation. The taskforce will assist in planning and providing
strategic guidance with our stakeholders allowing VA to operate and
implement the grant program. The need for this legislation is evident
and will enhance and increase the suicide prevention measures the
Department is currently taking to combat and reduce suicides in the
Nation.
We offer one comment for the Committee's consideration, but we
emphasize that this is not an issue that would alter VA's position on
the bill. The definition of ``risk of suicide'' in section 2(k)(4)
would include exposure to or the existence of any of the specified
conditions. We believe this definition is overly broad and recommend
instead allowing the Secretary to implement this definition by
regulation to include the addition of a process for determining degrees
of risk of suicide based on consideration of the factors set forth in
section 2(k)(4). Risk is obviously variable, ranging from no risk to
high risk. Even without this recommended change, the bill would give VA
sufficient authority to prefer applicants that ensure their services go
to those Veterans who have the highest risk of suicide.
We estimate the bill would cost $19.10 million in FY 2021, $28.36
million in FY 2022, and $37.70 million in FY 2023, for a total cost of
approximately $85.16 million over the 3-year period of the program.
H.R. 3636 Caring for Our Women Veterans Act
H.R. 3636 contains three substantive sections.
Section 2 of the bill would require VA to submit to Congress a
report on the use by women Veterans of health care from VA. The first
report would be required not later than 90 days after the date of the
enactment of this Act, and VA would be required to submit annual
reports thereafter. Each report would need to include the number of
women Veterans who reside in each state; the number of women Veterans
in each state who are enrolled in VA health care; the number of
enrolled women Veterans who received VA health care at least one time
in the previous year; the number of women Veterans who have been seen
at each VA medical facility in the previous year; the number of
appointments that women Veterans had at each VA medical facility; an
identification of the medical facility in each VISN with the largest
rate of increase in patient population of women Veterans (if known);
and an identification of the medical facility in each VISN with the
largest rate of decrease in patient population of women Veterans (if
known).
We have no objection to this section; the data requested by
Congress are currently collected by VA, and we believe producing the
report would result in no additional cost.
Section 3 of the bill would require VA to submit to Congress a
report on the use by VA of general primary care clinics, separate but
shared spaces, and women's health centers as models of providing health
care to women Veterans. The first report would be required not later
than 90 days after the date of the enactment of this Act, and VA would
be required to submit annual reports thereafter. Each report would need
to include the number of VA facilities that fall into each model
described disaggregated by VISN and state; a description of the
criteria VA used to determine which model is most appropriate for each
VA facility; an assessment of how VA decides to make investments to
upgrade facilities to the next higher-level model; a description of any
plans VA has to upgrade facilities from the lowest-level model (general
primary care clinics) to another model; an assessment of whether any
facilities could be upgraded to the next higher-level model within
planned investments under the strategic capital investment planning
process (SCIP); an assessment of whether any facilities could be
upgraded to the next higher-level model with minor modifications to
existing plans under SCIP; and an assessment of whether VA has a goal
for how many facilities should fall into each such model.
VA does not support this section. VA has empowered local facilities
to determine the appropriate model of care with input from the women
Veterans they serve. We emphasize that the same services are provided
at all facilities, regardless of the model they use. We disagree with
the assumption in this section that these models are inherently
hierarchical with some better than others. The intent behind having
three different models of care is to allow VA facilities to be flexible
and responsive to local needs. Many factors, such as the patient
population and available space, influence these decisions.
Section 4 would require VA to submit a report to Congress on VA
staffing relating to the treatment of women. The first report would be
required not later than 90 days after the date of the enactment of this
Act, and VA would be required to submit annual reports thereafter. Each
report would need to include the number of women's health centers; the
number of patient aligned care teams relating to women's health; the
number of full- and part-time gynecologists; the number of designated
women's health care providers; the number of health care providers who
have completed a mini-residency for women's health during the previous
year and the number that plan to participate in such a mini-residency
in the following year; and the number of designated women's health care
providers who have sufficient female patients to retain their
competencies and proficiencies. Data for all of these would need to be
disaggregated by VISN and state, except for the number of women's
health care providers, which would be disaggregated by facility.
We do not support this section because we do not believe it is
necessary. VA has already implemented these requirements through WATCH.
H.R. 3798 Equal Access to Contraception for Veterans Act
H.R. 3798 would amend section 1722A to prohibit VA from requiring a
Veteran to pay an amount for any contraceptive item or service for
which coverage under health insurance coverage is required without
imposition of any cost-sharing requirement pursuant to section
2713(a)(4) of the Public Health Service Act (42 U.S.C. 300gg-13(a)(4)).
VA supports this bill, subject to the availability of
appropriations and technical amendments. We believe this bill would
help further improve the access of contraceptives to Veterans,
particularly those who have lower incomes.
We believe the bill language would exempt from copayment liability
the provision of contraceptives. We are unsure, though, of the intended
meaning of the phrase ``or service,'' and whether this is meant to
exempt from copayments the medical appointments related to the
provision of contraception. The bill clearly exempts the medications
from copayments by amending section 1722A. However, copayments for
appointments related to the furnishing of medications, including
contraceptives, are established for certain Veterans in a different
statutory provision, section 1710, which is unamended by the bill. We
note there may be significant administrative and technical difficulties
in identifying and exempting only certain appointments from copayments,
so if the Committee had this intent, we would appreciate the
opportunity to discuss this further. We recommend the phrase ``or
service'' be removed, as well as the cross-reference to section
2713(a)(4) of the Public Health Service Act (42 U.S.C. 300gg-13(a)(4)).
VA estimates the lost revenue for medication copayments would be
approximately $396,000 in FY 2020, approximately $414,000 in FY 2021,
$2.07 million over 5 years, and $4.18 million over 10 years. The bill
would result in much greater losses of revenue if it exempted from
copayment liability appointments related to contraceptive care. The FY
2020 President's Budget did not include the potential lost revenue for
H.R. 3798 in FY 2020 or FY 2021.
H.R. 3867 Violence Against Women Veterans Act
H.R. 3867 contains five substantive sections.
Section 2 of the bill would state the purpose of this Act is to
better integrate the medical, housing, mental health, and other
benefits provided by VA with existing community-based domestic violence
and sexual assault services to provide a more efficient and coordinated
network of support for Veterans experiencing domestic violence or
sexual assault and to better understand the impact of domestic violence
and sexual assault on Veterans, particularly female Veterans.
VA has no comments on this section.
Section 3 of the bill would require VA to carry out a program to
assist Veterans who have experienced or are experiencing domestic
violence or sexual assault in accessing VA benefits, including
coordinating access to medical treatment centers, housing assistance,
and other VA benefits. VA would be required to carry out this program
in partnership with domestic violence shelters and programs, rape
crisis centers, state domestic violence and sexual assault coalitions,
and such other health care or other service providers who serve
domestic violence or sexual assault victims as determined by VA,
particularly those providing emergency services or housing assistance.
In carrying out this program, VA could conduct training for community-
based domestic violence or sexual assault providers on identifying
Veterans; coordinating with VA health care providers; and connecting
Veterans with appropriate housing, mental health, medical, and other VA
financial assistance or benefits. VA could also conduct assistance to
service providers to ensure access of Veterans to domestic violence and
sexual assault emergency services, particularly in underserved areas
(including services for members of Indian tribes), as well as such
other outreach and assistance as VA determines necessary. VA would be
authorized to establish local coordinators to provide local outreach
under this program; each coordinator would have to be knowledgeable
about: (1) the dynamics of domestic violence and sexual assault,
including safety concerns, legal protections, and the need for the
provision of confidential services; (2) the eligibility of Veterans for
VA benefits and services that are relevant to recovery from domestic
violence and sexual assault, particularly emergency housing assistance,
mental and other health care, and disability benefits; and (3) local
community resources addressing domestic violence and sexual assault.
Each coordinator would be required to assist domestic violence shelters
and rape crisis centers in providing services to Veterans.
VA does not oppose section 3 subject to the availability of
appropriations, but we believe technical edits could improve the bill,
and we would appreciate the opportunity to work with the Committee in
this regard. VA is committed to serving Veterans whose health and
safety may be at risk as a result of experiencing domestic or intimate
partner violence. VA developed a plan for implementation of a domestic
violence and intimate partner violence assistance program in 2013,
before launching the program in 2014. We appreciate Congress' support
of these efforts through the inclusion of $17 million in the FY 2018
and FY 2019 appropriations acts. Earlier this year, VA published a
policy, VHA Directive 1198, Intimate Partner Violence Assistance
Program, that mandates every VAMC identify a program coordinator and
implement the full array of intimate partner violence-related
programming in collaboration with internal and external stakeholders.
This policy requires that every VA medical facility implement and
maintain an Intimate Partner Violence Assistance Program (IPVAP), and
that Veterans, their intimate partners, and employees impacted by
intimate partner violence have access to services including resources,
assessment intervention, and referrals to VA or community agencies as
deemed appropriate and clinically indicated. During the VA Benefits and
Services briefing of the Transition Assistance Program (TAP), all
transitioning Servicemembers are provided information on VA's IPVAP and
its available resources. The TAP briefing also explains gender-specific
health care services available for women Veterans that address their
unique health care needs; information on mental health care and
emergency care services for women with actionable information is also
provided. Central to the IPVAP is the need to provide screening for
intimate partner violence to identify Veterans who are at risk,
consistent with the U.S. Preventive Services Task Force recommendations
to, at a minimum, screen all women of childbearing age. Screening
allows our trained staff and providers to offer education, promote
prevention, and identify those at risk to provide immediate crisis
management and safety planning and intervention. The IPVAP works with
the National Domestic Violence Hotline to offer outreach, resources,
and safety planning for Veterans and their intimate partners, including
hotline advocates who are available to chat every day. VA's Women
Veterans Call Center is also available to provide additional guidance
on benefits and resources.
VA estimates section 3 would cost $21.1 million in FY 2020, $21.9
million in FY 2021, $113.85 million over 5 years, and $258.18 million
over 10 years. The FY 2020 President's Budget did not include any
funding for H.R. 3867 in FY 2020 or FY 2021.
Section 4 would require VA, in consultation with the Attorney
General and the Secretary of Health and Human Services, to establish a
national Task Force to develop a comprehensive national program, that
includes integrating VA facilities, services, and benefits into
existing networks of community-based domestic violence and sexual
assault services, to address domestic violence and sexual assault among
Veterans. The Task Force would be required to consult with
representatives from not fewer than three national organizations or
state coalitions with demonstrated expertise in domestic violence
prevention, response, or advocacy, as well as such organizations or
coalitions representing underserved or ethnic minority communities with
such demonstrated expertise.
The Task Force would be required to review existing VA services and
policies and develop a comprehensive national program to address
domestic violence and sexual assault prevention, response, and
treatment. It would also have to review the feasibility and
advisability of establishing an expedited process to secure emergency,
temporary benefits including housing or other benefits for Veterans who
are experiencing domestic violence and sexual assault. It would also
have to review and make recommendations regarding the feasibility and
advisability of establishing dedicated, temporary housing assistance
for Veterans experiencing domestic violence or sexual assault and
identify any requirements regarding domestic violence assistance or
sexual assault response and services that are not being met by VA, as
well as make recommendations on how VA can meet such requirements. In
addition, the Task Force would have to review and make recommendations
regarding the feasibility and advisability of providing direct
services, or contracting for community-based services, for Veterans in
response to a sexual assault, including through the use of sexual
assault nurse examiners, particularly in underserved or remote areas
(including services for members of Indian tribes). The Task Force would
also be responsible for reviewing the availability of counseling
services provided by VA and through peer network support and providing
recommendations for the enhancement of such services to address the
perpetration of domestic violence and sexual assault and the recovery
of Veterans, particularly female Veterans, from domestic violence and
sexual assault. Finally, the Task Force would have to review and make
recommendations to expand services available to Veterans at risk of
perpetrating domestic violence. The Task Force would be required to
report annually to the VA Secretary and to Congress on its activities,
including any recommendations for legislative or administrative action.
VA does not support this section because it is unnecessary given
that VA convened a similar Task Force in 2012 and 2013. This earlier
Task Force provided a very thorough review of the needs of Veterans and
their partners, relevant research, and a review of resources leading to
14 recommendations for the implementation of a comprehensive,
enterprise-wide program of integrated services for Veterans who
experience or use intimate partner violence, their intimate partners,
and VA employees impacted by such violence. VA's Intimate Partner
Assistance Program has a national level leadership council that has
many members from the original Task Force. Assembling a new Task Force
would be duplicative, result in unnecessary costs, and could
potentially deter the progress already being made. We also note that
this section, as drafted, would appear to subject the Task Force to the
Federal Advisory Committee Act (5 U.S.C. Appendix 2) in one or more
ways. It is unclear if the drafters intended this result or not, but we
would be happy to work with the Committee on this issue if needed.
Section 5 would require VA, in consultation with the Attorney
General, to conduct a national baseline study to examine the scope of
the problem of domestic violence and sexual assault among Veterans and
spouses of Veterans.
We do not believe this section is necessary, but we do not oppose
it. VA recognizes the value of proceeding with data-driven decisions
for program expansion. VA investigators are already conducting research
in this area and have been doing screening, although such work has not
surveyed spouses of Veterans. We would appreciate the opportunity to
discuss this work with the Committee to determine if any additional
action is needed. Research to gather metrics around the various
elements to be addressed, including intimate partner violence use and
experience for men and women Veterans, domestic violence experience,
and types and prevalence of sexual assault inside and outside the
context of intimate partner relationships is important, but there are
many inherent challenges in conducting a Veteran-specific study on
these sensitive issues. Such a project would require a well-funded
research team to design and conduct the study, with specific costs
contingent upon the scope, design, and length of the study.
Section 6 would amend the authorizing statute for VA's Advisory
Committee on Women Veterans, 38 U.S.C. 542, by requiring the Advisory
Committee on Women Veterans to include in its biennial report an
assessment of the effects of intimate partner violence on women
Veterans.
We do not support this section. We are concerned that an assessment
of the effects of intimate partner violence would require identifying
resulting issues, medical conditions, and other effects (such as
homelessness, criminal behavior, or divorce) that could require
judgments based on partial or incomplete information. This could result
in data being skewed or statistically insignificant. These concerns
would be further amplified through underuse of VA health care by women
Veterans, such that the population analyzed is not representative of
women Veterans as a whole.
H.R. 4096 Improving Oversight of Women Veterans' Care Act of 2019
Section 2 of H.R. 4096 would create a new section 1730D that
requires VA to submit to Congress an annual report on the access of
women Veterans to gender-specific services under contracts, agreements,
or other arrangements with non-VA medical providers. The report would
have to include data and performance measures for the availability of
gender specific services, including the average wait time between the
Veteran's preferred appointment date and the date on which the
appointment is completed; the average driving time required for
Veterans to attend appointments; and the reasons why appointments could
not be scheduled with non-VA medical providers. Gender-specific
services would be defined to mean mammography, obstetric care,
gynecological care, and other services as considered appropriate.
VA does not support section 2. Many of the specific data points
identified are not currently included in VA's contracts, agreements, or
other arrangements for obtaining community care; as a result, VA would
have to renegotiate or modify these contracts, agreements, and other
arrangements, which could be costly and would impose additional
administrative burdens. Some providers may choose to drop out of
network, rather than comply with these burdens, which would diminish
Veterans' access to care. While VA does collect some of the data
elements, other requirements, such as gender specific services
(Mammography, obstetric care, and gynecological) are not specifically
tracked or identifiable. Moreover, some Veterans eligible to receive
community care choose to see providers who are farther away from their
home; this could complicate any meaningful analysis of the reported
data.
We estimate the costs of this section would exceed $1.5 million in
FY 2020.
Section 3 of this bill would require VA establish a policy under
which the EOC standards and inspections at VA medical facilities
include an alignment of the requirements for such standards and
inspections with the VHA women's health handbook; a requirement for the
frequency of such inspections; a delineation of the roles and
responsibilities of staff at the VAMC who are responsible for
compliance; and the requirement that each VAMC submit to the Secretary
a report on the compliance of the VAMC with the standards. The policy
also would have to provide that, for the purposes of the End of Year
Hospital Star Rating, no VAMC is eligible for a five-star rating unless
it meets the EOC standards. Not later than 180 days after the date of
the enactment of this Act, VA would have to submit a written
certification to Congress that the required policy has been finalized
and disseminated to all VAMCs.
VA does not support this section as written. VA believes amendments
could be made such that VA would not oppose it. Specifically, we
recommend amending section 3(a)(1)(C) to clearly assign responsibility
to the VAMC Director and VISN Director for EOC compliance. VA further
recommends section 3(a)(1)(D) be amended to have the Directors of each
medical facility report to the Under Secretary for Health, rather than
to the Secretary. The Under Secretary for Health is directly
responsible to the Secretary for VHA operations. VA does not support
section 3(a)(2) and recommends its omission. Compliance with EOC
standards should not be determinative of whether a facility otherwise
furnishes high-quality care that would earn a five-star rating under
the Strategic Analytics for Improvement and Learning Value Model.
Regarding section 3(b) and the reporting requirement, we do not believe
180 days would be a sufficient amount of time to prepare this report.
We recommend this be revised to provide VA 270 days.
Draft Bill Establishing the Office of Women's Health
The draft bill would create a new section 7310 that would require
the Under Secretary for Health to establish and operate in VHA the
Office of Women's Health, which would be located in VA Central Office.
The Office would be led by the Director of Women's Health, who would
report to the Under Secretary for Health. The Office would have to be
provided the staff and support as necessary to carry out effectively
its functions, including providing a central office for monitoring and
encouraging VHA activities with respect to the provision, evaluation,
and improvement of women Veterans' health care services; developing and
implementing standards for care for the provision of health care for
women Veterans; monitoring and identifying deficiencies in standards of
care for the provision of health care to women Veterans, providing
technical assistance to medical facilities to address and remedy
deficiencies, and performing oversight of implementation of standards
of care for women Veterans; monitoring and identifying deficiencies in
standards of care for the provision of health care for women Veterans
through the Veterans Community Care Program and providing
recommendations to the Office of Community Care to address and remedy
any deficiencies; overseeing distribution of resources and information
related to women Veterans' health programs; promoting the expansion and
improvement of clinical, research, and educational activities with
respect to women's health care; providing recommendations with respect
to the amount of funds to be requested for women Veterans, including,
at a minimum, recommendations to ensure that such amount of funds
either reflect or exceed the proportion of enrolled women Veterans;
providing recommendations to the Secretary with respect to modifying
the Veterans Equitable Resource Allocation (VERA) system to ensure that
resource allocations reflect the health care needs of women Veterans;
and carrying out other duties as the Under Secretary for Health may
require.
VA would be required to implement each recommendation made by the
Director with respect to modifying the VERA system; however, if the
Secretary chose not to implement such a recommendation, the Secretary
would be required to notify Congress within 30 days of such a
determination and provide the reasoning for the determination and an
alternative to such recommendation. The bill would also establish the
standards of care for the provision of health care for women Veterans
in VA to include a requirement for at least one designated women's
health primary care provider at each VA medical center and CBOC,
training for all personnel at each VA medical facility on preventing
and addressing harassment at VA medical facilities, and other
requirements as determined by the Under Secretary for Health. The
Director would have to provide to Congress an annual report on the
actions taken by the Office, any identified deficiencies related to
VA's provision of care to women Veterans and the standards of care
established in this section, a description of the funding and personnel
provided to the Office and whether additional funding or personnel are
needed, and other information that would be of interest to Congress.
VA does not support the draft bill. VHA currently has an Office of
Women's Health Services that reports to the Office of Patient Care
Services under the Deputy Under Secretary for Health for Policy and
Services. The Chief Consultant in charge of the Office of Women's
Health Services is a member of the Senior Executive Service; creating a
new Office and Director would merely be renaming a position that is
currently encumbered, as the duties and functions would be the same.
The current placement of the Office of Women's Health Services is
strategically aligned to interact with all other clinical programs at
the national level, and this alignment provides a conduit for
coordination and collaboration where services are similar. This
arrangement also supports the alignment of patient needs when primary
care or specialty services are identified.
Conclusion
We note, as a general matter, that given the overlapping nature of
some of the bills on the agenda today that the Committee proceed
carefully in advancing legislation to ensure that any bills reported by
the Committee make complementary changes to VA's authorities, rather
than conflicting ones. We would be pleased to work with the Committee
in this effort.
This concludes my statement. Thank you for the opportunity to
appear before you today. We would be pleased to respond to questions
you or other Members may have.
Prepared Statement of Jeremy Butler
Chairwoman Brownley, Ranking Member Dunn, and Members of the
Subcommittee, on behalf of Iraq and Afghanistan Veterans of America
(IAVA) and our more than 425,000 members worldwide, thank you for the
opportunity to share our views, data, and experiences on the pending
legislation today.
I took over as CEO of the organization in February following the
transition of our Founder, Paul Rieckhoff, to our Board of Directors,
and I have been proud to take the helm of this incredible organization.
I joined the Navy in 1999 and was commissioned as a Surface Warfare
Officer. I served on active duty for 6 years to include deploying in
2003 on the USS Gary (FFG-51) in support of the initial invasion of
Iraq. I transitioned into the Navy Reserve in 2006, and I continue to
serve today.
Support and Recognition of Women Veterans
As the leading Veterans Empowerment Organization for the post-9/11
generation of veterans, IAVA has the distinct honor of representing the
cohort of veterans with the largest female population. We are also very
proud that, though women represent 11% of all veterans, our membership
is roughly 20% female.
Support and Recognition of women veterans is an incredibly
important part of our work; it is why it is included in our Big Six
priorities for 2019, along with Combating Suicide, Defending Veterans
Education Benefits, Reforming Government, Support for Injuries from
Burn Pits and Toxic Exposures, and Support for Veteran Medicinal
Cannabis Use.
Over the past few years, we have fought to attain support for women
veterans' issues. From health care access to reproductive health
services to a seismic culture change within the veteran community,
women veterans are now finally being elevated on Capitol Hill, inside
the VA, and nationally. In 2017, IAVA launched our groundbreaking
campaign, #SheWhoBorneTheBattle, focused on recognizing the service of
women veterans and closing gaps in care provided to us by VA.
Nevertheless, there is still a lot of work to be done.
IAVA made the bold choice to lead on an issue that was important to
not just the nearly 20% of our members who are women, but to our entire
membership and that will help ensure the future of America's health
care and national security. We continue to fight hard for top-down
culture change in VA for the more than 700,000 women who have served
since 9/11, including 345,000 who have deployed to Iraq or Afghanistan
in support of the most recent wars.
This is why in 2017, IAVA worked with Congressional allies on both
sides of the aisle and in both chambers to introduce the Deborah
Sampson Act. This bill called on the VA to modernize facilities to fit
the needs of a changing veteran population, increasing newborn care,
establishing new legal services for women veterans, and eliminating
barriers faced by women who seek care at VA. This bill would have also
increased data tracking and reporting to ensure that women veterans are
getting care on par with their male counterparts.
Although the Deborah Sampson Act, the centerpiece of IAVA's She Who
Borne The Battle campaign, was not passed in the 115th Congress, IAVA
recognizes that some progress has been made in support of women
veterans, with key provisions of that legislation passed or funded in
the last two years. These hard-fought victories included funding to
improve services for women veterans, such as research on and
acquisition of prosthetics for female veterans, increased funds for
gender-specific health care, women veterans' expanded access and use of
VA benefits and services, improved access for mental health services,
and for supportive services for low income veterans and families to
address homelessness.
While we have seen greater awareness and progress toward improving
services for women veterans, there is so much more we can do. Toward
this goal, IAVA strongly supports passage of all of the provisions of
the Deborah Sampson Act. Many of those provisions have been introduced
by members of this Subcommittee and across Congress. To this end IAVA
emphatically supports the six Deborah Sampson Act bills being
considered today, H.R. 2645, H.R 2681, H.R. 2798, H.R. 2972, H.R. 3036,
and H.R. 3636. Collectively these bills would expand newborn care,
ensure VA facilities have a women's health care provider and gender
specific services for veterans, allow women to receive counseling in
retreat settings, increase reporting on women who use VA services, and
increase the availability of female prosthetics. IAVA thanks the
Subcommittee for their commitment to ensuring women veterans receive
care that is on par with their male counterparts.
In addition to the increase in newborn care under several Deborah
Sampson Act provisions, IAVA supports another bill in front of the
Subcommittee today, the VA Newborn Emergency Treatment Act (H.R. 2752).
This legislation would allow VA to reimburse the cost of emergency
transportation related to newborn care. Coupled with provisions in the
Deborah Sampson Act this will finally allow VA to adequately care for
veteran mothers and their babies.
Without quality data collection and analysis, there is no way to
know the extent to which women veterans are underserved. To date,
limited useful and timely data exists. To design precise policy
solutions and to hold accountable every agency in the continuum of
care, we need robust data collection, sharing, analysis, and
publication. It is for these reasons that IAVA strongly supports three
bills to address this issue, Improving Oversight of Women Veterans'
Care Act (H.R. 4096), the Women Veterans Health Care Accountability Act
(H.R. 2982), and Improving Benefits for Underserved Veterans Act (H.R.
4165). These bills will increase reporting and allow all of us to find
and fill gaps in care for women veterans.
For women veterans who choose to seek care at VA, finding quality
providers who understand the needs of women veterans can be difficult.
While VA has made some progress improving female-specific care for
women veterans, including expanding the services and care available
within VA, there is still much progress needed. Women veterans are more
likely than their male counterparts to seek care in the community,
meaning they are often seen by private care providers that may or may
not understand military service and its health impacts. IAVA's 2019
member survey underscores this as it found that while 70% of
respondents felt that VA clinicians understand the medical needs of
veterans, only 44% felt that non-VA clinicians understood them
personally. For these reasons IAVA supports the Women Veterans Equal
Access to Quality Care Act (H.R. 3224) to ensure women veterans have
access to health care providers who are well qualified and with whom
they feel comfortable and understood. In addition to the Draft
Legislation to Establish the VA Office of Women's Health, in order to
create a new office that will not only monitor VA's women-specific
services, but create recommendations on how VA can improve their
services to ensure that women veterans receive the health care that
they have earned.
Since 2001, the number of women using VA services has tripled. As
more military women make the transition to civilian life, it is
paramount that DoD and VA are able and ready to support them. Part of
that care means ensuring proper reproductive care and support for women
veterans and their spouses. Currently, women veterans do not have the
same access to contraceptives as their civilian counterparts. That is
unacceptable. It is for these reasons that IAVA supports the Equal
Access to Contraception for Veterans Act (H.R. 3798).
Modernize Government to Support Today's Veterans
According to a 2017 DoD report, more than 5,200 servicemembers, men
and women, reported being sexually assaulted in 2017. Since only a
fraction of sexual assaults are ever reported, this number is only the
tip of the iceberg, and it is an increase of 10% from the previous
year. Additionally, VA reports that about 29% of women veterans and 1%
of male veterans report experiencing military sexual trauma (MST). The
Violence Against Women Veterans Act (H.R. 3867) seeks to improve the
services provided by VA for veterans who are victims of sexual assault
and domestic violence by requiring an integration of those services
with proven, existing community-based programs that serve domestic
violence or sexual assault victims. In addition, this legislation would
create a task force to review existing policies as well as develop a
national program to address both domestic violence and sexual assault
in the veteran community. IAVA insists on continuing efforts to help
survivors of sexual assault and domestic violence come forward, so they
can seek the care they need, bring the perpetrator to justice, and
prevent future assaults by that perpetrator, and is supportive of this
legislation.
Millions of veterans rely on VA for both health care and benefits.
Ensuring that the system is able and agile enough to accommodate the
millions of veterans who use its services is paramount to ensuring the
lasting success and health of the veteran population. About 48% of all
veterans and about 55% of post-9/11 veterans are enrolled in VA care.
Among IAVA member survey respondents, 81% are enrolled in VA health
care, and the vast majority have sought care from VA in the last year.
Over the past few years, VA has made incredible strides in modernizing
its operating systems both internally and externally. This needs to
continue outside of just infrastructure, but also with their hiring
practices. VA needs robust, modern hiring practices in order to compete
for talent to fill their overwhelming number of vacancies. To this end,
IAVA supports the VA Hiring Enhancement Act (H.R. 1163), which will
allow VA to better compete with the private health care industry and
update the hiring practices within VHA.
The Veteran Early Treatment for Chronic Ailment Resurgence through
Examinations (VET CARE) Act (H.R. 2628) would create a pilot program to
expand dental care to veterans that have certain chronic conditions.
This type of care has been proven to increase overall health, and
reduce health care costs. It is for these reasons that IAVA supports
this legislation.
VHA's Medical Foster Home program (MFH), provides a non-
institutional long-term care alternative for eligible veterans.
However, while VA provides care team support to MFHs, it does not have
the authority to pay for the cost of MFHs. As a result, veterans must
use personal or other funding sources should they choose this
alternative rather than nursing homes. The Long Term Care Veterans
Choice Act (H.R. 1527) would change this and allow veterans to have
more options when choosing their long-term care by authorizing VA to
cover the cost of MFHs, during a three year period, up to 900 eligible
veterans. IAVA supports the passage of this legislation.
The Vietnam Era Veterans Hepatitis C (HCV) Testing Enhancement Act
(H.R. 2816) would provide for a pilot project to study the benefits of
implementing enhanced eligibility for all Vietnam and Vietnam Era
veterans access to existing Hepatitis C testing through VA. Many
Vietnam Era veterans were unknowingly exposed to HCV during their
service and may still go undiagnosed. Without treatment, HCV can lead
to a multitude of long term health problems including liver cancer and
other serious health problems. Many Vietnam era veterans that are not
connected to VA are unable to receive free HCV testing, and for those
reasons IAVA supports the expansion of free HCV testing for Vietnam era
veterans.
Members of the Subcommittee, thank you again for the opportunity to
share IAVA's views on these issues today. I look forward to answering
any questions you may have and working with the Subcommittee in the
future.
Prepared Statement of Joy J. Ilem
Chairwoman Brownley and Members of the Subcommittee:
Thank you for inviting DAV (Disabled American Veterans) to testify
at this legislative hearing of the Subcommittee on Health. As you know,
DAV is a non-profit veterans service organization comprised of more
than one million wartime service-disabled veterans that is dedicated to
a single purpose: empowering veterans to lead high-quality lives with
respect and dignity. DAV is pleased to offer our views on the bills
under consideration by the Subcommittee today.
H.R. 1163, the VA Hiring Enhancement Act
DAV believes the Veterans Health Administration's (VHA) employee
vacancy number of over 43,000, which includes 39,500 health-related
positions across all VHA medical facilities, is a problem that should
be mitigated by Congress.\1\ While VHA is experiencing challenges
similar to the private health care industry that is facing a national
shortage of health care professionals, we believe VHA has different
responsibilities than the health care industry in general.
---------------------------------------------------------------------------
\1\ https://catalog.data.gov/dataset/va-mission-act-section-505-
data
---------------------------------------------------------------------------
Title 38 of the United States Code mandates VA assist in the
training of health professionals for its own needs and those of the
nation. For over 70 years, in accordance with VA's 1946 Policy
Memorandum No. 2, VA works in partnership with this country's medical
and associated health profession schools to provide high quality health
care to America's veterans and to train new health professionals to
meet the patient care needs within VA and the nation. This partnership
has grown into the most comprehensive academic health system
partnership in history.
VHA conducts the largest education and training effort for health
professionals in the United States. In 2018, nearly 121,000 medical
trainees received some or all of their clinical training in VA. VA's
physician education program is conducted in collaboration with 144 of
the152 Liaison Committee on Medical Education accredited medical
schools and 34 Doctor of Osteopathic Medicine granting schools (AOA-
accredited medical schools). In addition, more than 40 other health
professions are represented by affiliations with over 1,800 unique
colleges and universities. Among these institutions are Minority
Serving Institutions including Hispanic Serving Institutions and
Historically Black Colleges and Universities.
Congress should do all that it can to fully leverage this
``upstream'' access to the pipeline of health care professionals. DAV
fully supports efforts to recruit, retain and develop a skilled VHA
clinical workforce to meet the needs of veterans, which H.R. 1163, the
VA Hiring Enhancement Act, is proposing to do.
This bill would allow VA, on a contingent basis, to begin both
recruiting and hiring physicians up to two years before they complete
their residency, as well as physicians who have completed their
residencies leading to board certification. These contingent appointed
physicians would be required to satisfy VHA's requirements to receive a
permanent appointment.
In addition, an applicant for VA employment would be released from
any ``non-compete'' agreements between that applicant and their
previous employer. Employees appointed with this understanding would be
required to serve out the length of their non-compete agreement within
their VA position or serve in that position for at least one year
(whichever is longer).
We applaud the goal of this legislation aimed at creating a larger
applicant pool for qualified medical professionals to treat our
service-disabled veterans without sacrificing the high quality of care
VA provides. DAV Resolution No. 089 calls for effective recruitment,
retention and development of the VA health care workforce. Because this
measure attempts to reduce barriers for employment at VA for
physicians, we are pleased to support the bill's passage.
H.R. 1527, the Long-Term Care Veterans Choice Act
Currently, subject to available appropriations, VA is required to
provide nursing home care to enrolled veterans who are in need of
nursing home care due to a service-connected disability or who are in
need of nursing home care and have a service-connected disability rated
at 70 percent or more.\2\
---------------------------------------------------------------------------
\2\ 38 U.S.C. Sec. 1710, 1710A
---------------------------------------------------------------------------
VA provides such institutional long-term service and support
through VA owned and operated Community Living Centers (CLC), Community
Nursing Homes (CNH) and State Veterans Homes (SVH) spending over $6
billion in fiscal year 2018. In addition, VA spent over $4 billion
across these three settings for service-connected veterans with an
average daily census of over 23,000.
H.R. 1527 would help VA better spend these funds and serve more
veterans while providing high quality care in a setting service-
connected veterans prefer-a Medical Foster Home (MFH). MFHs are a safe
and proven alternative to nursing homes by which veterans with serious
chronic disabling conditions requiring nursing home level of care are
able to receive these services through VA's Home-Based Primary Care
program, and the MFH attendant.
Veteran participation in the MFH program is voluntary and veteran
residents report very high satisfaction ratings. Moreover, VA indicates
it pays more than twice as much for the long-term nursing home care for
many veterans than it would if VA was granted the proposed authority to
pay for VA MFHs.\3\
---------------------------------------------------------------------------
\3\ VA Fiscal Year 2020 Budget Submission, Volume II--Medical
Programs and Information Technology Programs, VHA-269.
---------------------------------------------------------------------------
Currently, the administrative costs for VA per veteran in the MFH
program, including the cost of Home Based Primary Care, medications and
supplies average less than $65 per day. However, service-connected
veterans who qualify for nursing home care fully paid for by the
government, must pay the full cost for room, board, and personal
assistance to live in a MFH. These veterans who would otherwise choose
to reside in a Medical Foster Home but are unable to pay approximately
$1,500 to $3,000 per month are not able to avail themselves of this
benefit, so many are placed in nursing homes at a cost to VA of about
$7,000 a month.
This measure would address this inequity by giving VA a three-year
authority to pay for a limited number of service-disabled veterans to
reside in a VA-approved MFH and save taxpayers from having to shoulder
the higher cost of nursing home care-a reasonable approach when
providing VA new authority.
Chairwoman Brownley, as the veteran population continues to age,
the need for more cost-effective long-term care services will continue
to grow. Home-based community programs like MFHs will enable VA to meet
the needs of aging service-connected veterans in a manner closer to
independent living than institutionalized care. With the passage of
this bill, service-disabled veterans would have the option of care that
more closely aligns with their independence, protects their dignity and
helps maintain their quality of life.
DAV is pleased to support H.R. 1527, the Long Term Care Veterans
Choice Act, in accordance with DAV Resolution No. 372, which calls for
legislation to improve the comprehensive program of long-term services
and supports for service-connected disabled veterans regardless of
their disability ratings.
H.R. 2628, the VET CARE Act of 2019
H.R. 2628, the Veterans Early Treatment for Chronic Ailment
Resurgence through Examinations Act, or the ``VET CARE Act of 2019,
would establish a four-year pilot program for at least 1,500 veterans
to receive dental care in one VA medical center within five different
Veterans Integrated Service Networks (VISNs). The program would
prioritize enrollment of service-disabled veterans and would enroll
mostly veterans with moderate to severe periodontal conditions. The
bill also requires VA to assess the health outcomes of veterans who
participate in the program in order to explore the effect of
periodontal care on chronic health care conditions. The bill further
requires VA to work with appropriate dental schools to further
investigate any potential such correlation.
The link between oral health and disability has been clearly
established in medical literature. Patients who are medically
compromised are more prone to oral disease, including periodontitis. If
untreated, advanced periodontitis may lead to tooth loss and destroy
tissue, bone and ligaments within the mouth. These outcomes can result
in impaired functionality, productivity and quality of life for those
with the condition.
We understand this bill seeks to replicate studies in the veteran
patient population that is different than the civilian patient
population in that veterans who use VA for health care are typically
older and more likely to be diagnosed with several health conditions.
Equally important, the prevalence of costly medical conditions in this
veteran patient population is projected to increase.
DAV strongly supports this legislation in accordance with DAV
Resolution No. 185, which calls on VA to offer comprehensive dental
care to all service-connected veterans. We believe a pilot program such
as this is a measured and reasonable way to assess the full costs and
benefits associated with regular and preventive dental care for
service-connected veterans and help policy makers in improving VA's
current arcane and limited eligibility criteria for dental care.
H.R. 2645, Newborn Care Improvement Act of 2019
This legislation seeks to improve the care VA provided to women
veterans by extending VA's authority to reimburse fees for newborn care
from seven to 14 days. Women veterans using VA health care have high
burdens of service-connected disabilities and many have delayed
childbirth to accommodate their military careers. Both of these factors
can affect women veterans' pregnancies and put them at greater risk of
adverse outcomes, including premature labor and delivery of low-birth
weight newborns.
According to VA, younger women in childbearing years who use VA are
particularly likely to be service-connected-noting that in fiscal year
2015, almost three-quarters (73%) of its younger women veterans (18-44
years old) had service-connected disabilities.\4\ Additionally,
pregnant veterans with mental health conditions and injuries affecting
their ability to procreate are liable to experience problematic
pregnancies, including problems with labor and delivery that may
threaten the life of the veteran and her newborn. VA must continue
using its comprehensive maternity health coordination protocol and
provide additional time for veterans and their newborns to recover from
birth problems that are often related to their service-connected
conditions.
---------------------------------------------------------------------------
\4\ Sourcebook: Women Veterans in the Veterans Health
Administration. 2015, p. 35.
---------------------------------------------------------------------------
DAV is pleased to support H.R. 2645 based on recommendations in our
2018 publication, Women Veterans: The Journey Ahead, which calls for
legislative remedies to extend authority to reimburse care for newborns
and DAV Resolution 020, which calls on VA to enhance health services
for service-disabled women veterans.
H.R. 2681, a bill to direct the Secretary of Veterans Affairs to submit
to Congress a report on the availability of prosthetic items for women
veterans from the Department of Veterans Affairs.
H.R. 2681 would require the VA Secretary to report on the
availability of prosthetic items made for women veterans at all VA
medical facilities.
Although the number of women with limb amputations who use VA is
small (2%)\5\, across the lifespan, more than half of women (and men)
in VHA care rely on VA prosthetic and sensory aids services for
important devices and services. In fiscal year 2016, this encompassed
233,005 women veterans.\6\ VA provides a wide variety of medical
devices to support or replace a body part or function, from hearing
aids and glasses to walkers, wheelchairs, home oxygen and other durable
medical equipment.\7\ Services also cover specialized needs for women,
such as maternity items, including maternity support belts; breast
pumps and nursing bras; post-mastectomy items such as a breast
prosthesis; swimsuits and bras; and intrauterine devices or pelvic
floor strengtheners.
---------------------------------------------------------------------------
\5\ Meeting Minutes of the Advisory Committee on Women Veterans.
2017
\6\ Meeting Minutes of the Advisory Committee on Women Veterans.
2017
\7\ https://www.va.gov/budget/docs/summary/
fy2020VAbudgetVolumeIImedicalProgramsAndInformationTechnology.pdf p.
65.
---------------------------------------------------------------------------
Despite this progress, VA is still having difficulty sourcing
prostheses that fit women due to a lack of prosthetic options for women
in the wider marketplace. One avenue for alleviating this issue, 3D
printing, is something both VA and DoD are actively researching through
an interagency work group and ongoing collaboration with the Food and
Drug Administration, and DoD at the Walter Reed National Medical Center
Printing Lab. Walter Reed's 3D Medical Application Center uses
computer-aided design and manufacturing technologies to fabricate
custom medical models, implants, prostheses and prosthetic parts. They
have helped print custom prostheses for holding a fishing rod, wearing
ice skates or getting around without strapping on full prosthetic legs.
The technology and lab has obvious applications for women veterans,
who often have issues with prosthetic fit, function and appearance. At
a VA Innovation Creation Challenge in 2015, a team worked on an idea
from a veterans advocate for a socket that would allow veterans to use
a single lower-leg prosthesis while swapping attachments for different
uses. VA funding has also been received for a 2018 research project to
develop a new system to 3D print custom energy-absorbing feet to fit
any shoe size that would incorporate a quick disconnect system to
change foot and shoe combinations. Until 3D printers are more widely
available, women veterans with prosthetic needs should be made aware
that the 3D Medical Application Center accepts referrals for custom
prostheses or attachments from any VA or DoD provider.
VA also has plans to collect data on women who use a prosthesis,
including funding prosthetic research that will help optimize women's
upper-limb prostheses. However, because VA has a very small population
of women prostheses users, VA and DoD research communities would
benefit from collaborating with industry and academia to expand the
number of women in the eligible research population who can be
recruited to participate in comprehensive research studies to advance
prosthetic science for women. VHA established the Amputee Veterans
Registry to help target care and has plans for a second phase to add
outcome measures to help researchers identify best practices. In 2017,
VA established the Prosthetic Women Emphasis Group to also determine
best practices and appropriate prosthetic needs of women veterans.
Additionally, VA's Rehabilitation and Research Development Service was
selected for and received funding for three studies focused on the
needs of women veterans with limb loss.
Madam Chair, we believe that some of the initiatives we describe
above will help women obtain more appropriate prosthetic items, but we
also believe Congress could fulfill its oversight duties more
successfully by broadening the approach of information collected. We
believe every VA medical center will report that it makes prosthetics
available to women and may also provide data on the number of women
veterans the prosthetic service has served. Unfortunately, that
information is not enough to answer questions about the delivery of
high-quality prosthetic items that are satisfactory to veterans.
Instead, DAV recommends surveying a representative sample of the
50,000 veterans in the Amputee Care program to assess their
satisfaction with prosthetics furnished or procured by VA that replace
appendages (or their functions) to ensure that the approach each
medical facility uses to fit, customize and train veterans in the use
of their prosthetic device is satisfactory and results in a product
that meets veterans' expectations in terms of appearance and usability.
Because they are a small portion of the user population, women veterans
should be oversampled to ensure their representation in the results. A
broader representative survey would allow VA to identify specific
problems within subpopulations such as women, service-connected
veterans or combat-injured veterans. It might also allow VA to target
specific medical centers or points within the process that are less
satisfactory to veterans. We believe these findings would allow for
better remedies to address any challenges within the system.
DAV supports the intent of H.R. 2681, but hopes that Representative
Pappas and the Subcommittee would be amenable to broadening the scope
of the survey and information collected about the availability of
prosthetic items for women veterans in VA.
H.R. 2752, a bill authorizing VA to furnish medically necessary
transportation for newborn children of certain women veterans
H.R. 2752 would authorize VA to reimburse expenses for medically
necessary transportation for newborns of women veterans and allow the
Secretary to waive a debt or reimburse a veteran previously billed for
such service.
As we discussed in our justification for supporting H.R. 2645,
women veterans in their childbearing years have many risk factors,
including a high burden of service-connected conditions, which can
endanger their pregnancies and negatively impact birth outcomes. This
makes it more likely their newborn children might require more advanced
care and require medical transport to a specialized pediatric medical
facility. For these reasons, we strongly support this measure and urge
its swift passage.
DAV supports H.R 2752 as an important measure to enhance women
veterans' health care as called for by DAV Resolution No. 020 by
ensuring a robust maternity health care benefit.
H.R. 2798, Building Supportive Networks for Women Veterans Act
Madam Chair, this bill would establish a permanent counseling
program in retreat settings for women veterans newly separated from
military service. We believe these programs can offer women veterans
important opportunities to network with other women with shared
experiences in an environment conducive to healing and recovery-based
care.
DAV has supported the Boulder Crest program and stated our strong
support for it and similar programs in our 2018 publication, Women
Veterans: The Journey Ahead. These programs are born of the concept
that post-traumatic stress can create opportunities for growth and a
learning environment for veterans with similar experiences. The bill
also requires that VA conduct an assessment to determine outcomes of
these retreats and a biennial report. Preliminary data on these
retreats thus far has shown significant improvements in participants'
ability to better manage post-traumatic stress symptoms and maintain
learned coping strategies.
DAV Resolution No. 020 supports improvements in programs and
services for women veterans and allows us to strongly support H.R.
2798, the Building Supportive Networks for Women Veterans Act.
H.R. 2816, Vietnam-Era Veterans Hepatitis C Testing Enhancement Act of
2019
H.R. 2816, the Vietnam-Era Veterans Hepatitis C Testing Enhancement
Act of 2019, would increase access to testing for Hepatitis C for
Vietnam-era veterans. Specifically, the bill would establish a one-year
pilot within five Veterans Integrated Service Networks to conduct such
testing at outreach events coordinated by veterans service
organizations such as national or regional conventions or other
community events.
DAV recognizes the importance of spreading awareness of hepatitis C
to this cohort of veterans, in addition to assuring that more veterans
are aware of their status relative to this viral infection and their
treatment options if they screen positive for the disease.
DAV has no specific resolution on this matter, but it is in line
with providing comprehensive health care services to all eras of
veterans; therefore, we have no objection to the bill's favorable
consideration.
H.R. 2972, a bill to direct the Secretary of Veterans Affairs to
improve the communications of the Department of Veterans Affairs
relating to services available for women veterans, and for other
purposes.
H.R. 2972 would ensure that the VA Women Veterans Call Center has
text messaging capability. While we understand that the Women Veterans
Call Center already has the capability of receiving and sending text
messages through its central call number, 1-855-VAWOMEN or 1-855-829-
6636, we appreciate the legislative assurance that the texting capacity
will remain in place. The bill would also require VA to maintain a
webpage with up-to-date listings of women veterans' coordinators and
contact information for representatives assisting women in the Veterans
Benefits, Health and National Cemetery Administrations. This resource
would also list important health services provided within the network
at each medical facility and community-based outpatient clinic to
ensure women know what services are available in the location they are
seeking care.
Madam Chairwoman, in accordance with DAV Resolution No. 020, we
support having these resources available for women veterans to enhance
VA's outreach efforts, and, thus we are pleased to support H.R 2972.
H.R. 2982, Women Veterans Health Care Accountability Act
The Women Veterans Health Care Accountability Act seeks to identify
and remedy barriers women veterans encounter in accessing VA health
care. The legislation would require the VA Secretary to survey women
veterans-both those who use VA health care as well as those who do not-
to better understand their reasons for not using VA services. The
survey will question women veterans about their perceptions of safety
in VHA facilities, access to services, and stigmas or barriers they may
express about seeking treatment for sensitive issues such as military
sexual trauma, mental health conditions or substance abuse disorders.
The legislation also requires VA to identify strategies and make
recommendation for addressing any issues identified by the survey.
According to the VA, while there was a 175% increase in the number
of women veterans using VA health care from 2000 to 2015, only 22% of
women veterans, compared with 28% of men who are veterans, use VA
health care.\8\ Over the past decade, VA has made many improvements in
the way it manages the care of women using the system and launched
several campaigns to increase awareness about women veterans'
eligibility for VA benefits and services. VA has also sought to address
long-standing cultural issues, including sexual harassment of women
veterans seeking care at VA facilities by male veterans that prevent
some women veterans from seeking the care they need, yet these problems
persist.\9\
---------------------------------------------------------------------------
\8\ Sourcebook: Women Veterans in the Veterans Health
Administration, Volume 4, p.18.
\9\ Dyer KE, Potter SJ, Hamilton AB, Luger TM, Bergman AA, Yano EM,
Klap R. Gender Differences in Veterans' Perceptions of Harassment on
Veterans Health Administration Grounds. Women's health issues :
official publication of the Jacobs Institute of Women's Health. 2019
Jun 25; 29 Suppl 1:S83-S93.
---------------------------------------------------------------------------
Findings from an independent detailed survey as proposed in the
bill, that build upon barrier to care studies conducted in 2008 and
2015 may assist the VA in developing strategies to tackle some of the
ongoing concerns and issues that prevent women veterans from accessing
VA health care. Conducting research to examine women veterans
perception of personal safety, gender sensitivity, comfort, sense of
welcome, effectiveness of outreach efforts, access to child care and
operating hours for VA services may also add value in better
understanding the overall women veterans patient experience and help to
improve services for this population.
DAV supports H.R 2982 in accordance with DAV Resolution No. 020,
calling for VA to enhance women veterans' health care programs and
assist them in overcoming barriers that may affect their ability to
obtain necessary medical care.
H.R. 3036, Breaking Barriers for Women Veterans Act
H.R. 3036, the Breaking Barriers for Women Veterans Act would
correct environmental, structural, and staff deficiencies to ensure
VA's delivery of high-quality health care to women veterans. The bill
would authorize $20 million to assist VA in addressing deficiencies it
identifies in annual environment of care surveys to assure that the
privacy, security and dignity of women patients is upheld at each VA
medical center. It would also require VA to ensure it had at least one
full-time or part-time women's health primary care provider at each
facility and authorize $1 million to develop more in-house expertise by
offering mini-residency training to VA primary care and emergency
physicians and other independent practitioners. The bill would also
require VA to develop a training curriculum for community care
providers treating women veterans and conduct a study to determine the
staffing and training needs for Women Veterans' Program Managers and
whether an ombudsman for women veterans at each VA facility is
warranted.
By authorizing the resources necessary, the legislation will better
ensure that women veterans have expert care for gender-related issues
wherever they seek such care within the VA or in sponsored settings.
We strongly support H.R. 3036 in accordance with DAV Resolution No.
020, which supports enhancing women's health care programs to ensure
equity for women veterans seeking VA health care.
H.R. 3224, to provide for increased access to Department of Veterans
Affairs medical care for women veterans.
This measure seeks to ensure women veterans have access to
comprehensive gender-specific VA medical services at all its clinical
points of care. While we appreciate and concur with the general intent
of this bill-the definition of gender-specific care and services is not
included in the bill text. While current VHA directives (1330.01,02),
outline what gender-specific services must be available in VA to the
greatest extent possible-when such services are not available, VA is
authorized to contract for such services in the community. Certain
types of care, such as maternity and obstetric care (and newborn), is
generally provided to women veterans in the community due to lack of
volume and VA's lack of expertise in providing such care. Likewise,
mammography services are not available at all VA locations due to low
volume and frequently provided in the community. Without the gender-
specific services definition, the bill's overall intent is unclear.
Additionally, H.R. 3224 calls for a study on extended care hours
and the best practices and resources required to implement the use of
extended hours at VA medical clinics and facilities.
Women veterans are, on average, younger than their male peers (48.4
v. 63 years old) and face a number of barriers when seeking care. Many
women veterans struggle to maintain single-parent households, full-time
employment or education track, or provide caregiving to an aging
parent. Extended clinical hours at VA points of care may be an
additional means of making services available to these women and we
would be interested in the Committee's findings and recommendations
based upon such a study.
While DAV is able to support the provisions in the bill related to
a study on extended hours and best practices, we request the
Subcommittee amend the bill to clarify the definition of gender-
specific services prior to advancing H.R 3224.
H.R. 3636, Caring for Our Women Veterans Act
The Caring for Our Women Veterans Act would require the VA
Secretary to submit a report on the number of women veterans who reside
in each state; the number of women veterans who are enrolled in VA care
and have received care in the past year; the number of women veterans
seen at each VA medical facility over the past year; VISNs with the
largest increase of women veteran users; models of care used by VA to
treat women veterans and how VA makes such determinations about the
appropriate use of such models in each facility; and VA staffing
available for the care and treatment of women veterans.
The measure also requires an assessment on strategic capital
investment planning, including modifications and upgrades for women
veterans and information on staffing levels, including the number of
full and part-time gynecologists within the Department, the number of
patient-aligned care teams in women's clinics, and the number of
providers who have completed a mini-residency and serve as a women's
health provider.
DAV believes this information is essential to the development of
Veterans Integrated Service Network marketing plans and any future
modernization and capital restructuring efforts. While DAV believes
much of this information is currently available through the Department,
we agree a comprehensive assessment that provides all the required
information in one report would be useful information for Congress and
interested stakeholders. We therefore suggest the Subcommittee work
closely with the Women's Health Program Office to determine any
potential amendments to the bill regarding the collection of
information needed to ensure the intent of the measure is fully
realized. Fully understanding the impact of increasing use of VA
services by women veterans and what resources and future plans are
needed is essential to better serving this population.
DAV is pleased to support H.R. 3636, which comports with
recommendations made in our report Women Veterans: The Journey Ahead
and DAV Resolution No. 091, which calls upon VA to modernize its health
care infrastructure.
H.R. 3798, Equal Access to Contraception for Veterans Act
H.R. 3798, the Equal Access to Contraception for Veterans Act,
would limit charging veterans copayments for contraceptive items/
medications furnished by the VA.
Access to contraception is part of providing comprehensive health
services. However, cost sharing can be a barrier for some veterans who
need health care services or treatment. Many private health plans have
eliminated copayments for beneficiaries for preventative care, in part
because it is often significantly less expensive than having to treat
various health conditions or stabilize chronic diseases.
We are able to offer our support for H.R. 3798, as the measure is
in accordance with DAV Resolution No. 365, which calls for the
reduction or elimination of all copayments for health care for service-
connected veterans obtaining care within VA and DoD medical facilities.
H.R. 3867, Violence Against Women Veterans Act
H.R. 3867, the Violence Against Women Veterans Act, would create a
comprehensive new program to improve supportive services for women
veterans who have experienced domestic violence or sexual abuse.
The measure calls for the establishment of a national task force
(Task Force) on veterans experiencing domestic violence or sexual
assault for the purpose integrating VA programs with community agencies
and resources such as housing and benefit programs, rape crisis
centers, shelters for women who are fleeing abusive partners, and other
appropriate state and community programs meeting the needs of these
individuals. The Task Force would include the VA Secretary working in
consultation with the Attorney General and the Secretary of Health and
Human Services. In addition, the bill requires VA to conduct a baseline
study of domestic violence and sexual assault among veterans and
spouses of veterans and an assessment of effects of intimate partner
violence and the Secretary could assist with establishing VA
coordinators who would help train community providers to identify and
connect veterans with needed VA services, care and benefits.
The DoD and VA continue to confront the worsening epidemic of
military sexual trauma and its consequences. There are high rates of
women who experience sexual trauma within the military (according to
DoD's most recent survey of personnel, 6.2% of service women reported
experiencing unwanted touching and many more (24.2%) report having
experienced some form of harassment within the past 12 months.) A
significant number of these women (1/5 of those assaulted) report
having experienced both.\10\
---------------------------------------------------------------------------
\10\ Department of Defense Annual Report on Sexual Assault in the
Military Fiscal Year 2018. P. 9
---------------------------------------------------------------------------
VA does not have the authority to change the policy and culture
within the military services, but it can and should make changes in its
own culture to ensure that women are not re-traumatized in the process
of obtaining care for the mental health challenges these all-too common
occurrences bring. According to a recent study, VA found that many
women veterans (about 20%) are experiencing sexual harassment from male
patients while seeking care within its facilities.\11\
---------------------------------------------------------------------------
\11\ Dyer KE, Potter SJ, Hamilton AB, Luger TM, Bergman AA, Yano
EM, Klap R. Gender Differences in Veterans' Perceptions of Harassment
on Veterans Health Administration Grounds. Women's health issues :
official publication of the Jacobs Institute of Women's Health. 2019
Jun 25; 29 Suppl 1:S83-S93.
---------------------------------------------------------------------------
VA reports also indicate a high burden of intimate partner violence
experienced by women veterans using VA services that exceed those of
civilian women. Specifically, about one-third of women veterans
compared to one-fourth of civilian women experience intimate partner
violence.\12\
---------------------------------------------------------------------------
\12\ Dichter, M.E, et al. (2011). Intimate partner violence
victimization among women veterans and associated heart health risks.
Womens health Issues. 21 (suppl 4): S190-S194.
---------------------------------------------------------------------------
Sexual trauma and domestic violence can lead to post-traumatic
stress disorder, depression, anxiety, substance use disorders and other
mental health conditions. Violent domestic attacks on women veterans
have also been associated with traumatic brain injury (TBI) (about 25%
of veterans experiencing intimate partner violence have a history of
TBI and 12.5% have current symptoms).\13\ Any of these conditions can
affect a survivors ability to live healthy, productive and economically
stable lives.
---------------------------------------------------------------------------
\13\ Iverson, KM, et al. (2017). Traumatic brain injury and PTSD
symptoms as a consequence of intimate partner violence. Comprehensive
psychiatry 74: 80-7.
---------------------------------------------------------------------------
These findings indicate a compelling need for a comprehensive
program for women veterans experiencing these types of violence. VA
prescribes to a whole-health model of care that integrates supportive
services and care coordination that allow them to address the array of
issues that often accompany trauma, and require income assistance,
housing, legal services and specialized medical and mental health care
and substance-use treatment. VA's program for homeless veterans
provides an excellent example of a successful collaborative model of VA
and community providers.
While we support the provisions in this measure focused on ensuring
veterans using VA services who have experienced sexual trauma or
domestic violence have access to supportive services aimed at recovery,
DAV does not have a resolution calling for formation of a National Task
Force that would integrate VA assets into community-based networks of
care for survivors of sexual and domestic abuse. We note however, that
VA does not have the breadth and scope of services provided in the
community for these veterans who would likely benefit from VA
leveraging community resources from agencies and programs with
expertise in these area therefore, we have no objection to passage of
the bill.
H.R. 4096, Improving Oversight of Women Veterans' Care Act of 2019
H.R. 4096, the Improving Oversight of Women Veterans' Care Act of
2019, requires an annual report to determine veteran access to gender-
specific services such as mammograms, obstetric and gynecological care
through VA's community care program.
As VA implements the Veterans Community Care Program (VCCP) as
required under the VA MISSION Act of 2018, it is increasingly important
that VA identify means of assuring that VA network community care
providers are required to meet the same quality standards as VA
providers are required to meet and that community care is commensurate
with VA's whole health model of care. H.R. 4096 requires information on
average wait times, drive times, and reasons why appointments could not
be scheduled with a community provider.
H.R. 4096 would also require VA to standardize environment of care
and VA's inspections and reporting procedures to align with VHA's
women's health handbook. It would further disqualify high-performing VA
medical centers (based upon Strategic Analytics for Improvement and
Learning (SAIL) quality measures from being awarded a 5-star rating if
they are not in compliance with environment of care standards for women
veterans clinics outlined in the handbook.
Ensuring the appropriate facility design and staff composition is
critical to easing women veterans concerns about their safety, privacy
and dignity and will help to ensure comprehensive high quality care at
all VA points of care. For these reasons, we strongly support H.R.
4096, in accordance with DAV Resolution No. 020.
Draft bill, to establish in the Department of Veterans Affairs, the
Office of Women's Health and for other purposes
Chairwoman Brownley, DAV is happy to lend its support to your draft
bill establishing an Office of Women's Health within the VHA. The
Office would be responsible for evaluation, oversight and improvement
of women veterans' health services in VA and in the community;
development and implementation of standards of care; and identifying
and correcting deficiencies in standards of care for women.
Additionally, the Office would oversee distribution of resources for
these purposes and promote expansion and improvement of clinical,
research and educational activities with respect to women's health
services within the Department. We believe this change will
significantly improve the tracking and use of centralized funding for
women's programs ensuring resources are used for intended purposes, and
specifically, allowing VA to address long-standing issues affecting
women veterans' access to comprehensive gender-specific health care.
The current Women's Health Services office is understaffed and
lacks control over resources to assure that administrative priorities
of the office are implemented. Without control over resources, the
director is beholden to other program offices and facility director's
priorities that may not be in line with the women's health program
office priorities. This hampers the full resourcing of the women's
health centers which are widely regarded as the model that is most
likely to ensure high-quality, comprehensive care and satisfaction for
women veterans. It creates challenges in training and hiring designated
women's health providers in facilities that lack them in order to
ensure appropriate care for women veterans at all sites of care. It
also hampers the ability to ensure that awareness campaigns and
campaigns to address sexual harassment, and increase the awareness of
women's special needs are given appropriate support.
While DAV does not have a resolution specifically calling for the
establishment of an Office of Women's Health, we have addressed the
need to elevate the program to that status in our report, Women
Veterans: The Journey Ahead.\14\ Given existing and persistent
challenges within the Department to address many issues related to
women veterans, we support this draft measure as it may be a necessary
prerequisite to establish such an office to ensure that women's health
care programs can be enhanced in a manner that ensures the equity and
availability in women's services as we call for under DAV Resolution
No. 020.
---------------------------------------------------------------------------
\14\ DAV. Women Veterans: The Journey Ahead. P. 3.
---------------------------------------------------------------------------
Chairwoman Brownley, this concludes my testimony. Thank you for
inviting DAV to testify at today's hearing. I would be pleased to
address any questions related to the bills under consideration by the
Subcommittee.
Prepared Statement of Roscoe Butler
Chairwoman Brownley, Ranking Member Dunn, and members of the
Subcommittee, Paralyzed Veterans of America (PVA) would like to thank
you for this opportunity to provide our views on some of the pending
legislation you will be reviewing today.
H.R. 3867, the ``Violence Against Women Veterans Act''
PVA supports H.R. 3867, the ``Violence Against Women Veterans
Act.'' We believe that any veteran-male or female-who experienced
domestic violence or sexual assault while serving on active duty should
have access to appropriate health care and services to help them
overcome the trauma they encountered while serving our nation at home
and abroad. When VA is not able to provide the needed care or services,
this legislation would authorize the Secretary of Veterans Affairs (VA)
to establish partnerships with domestic violence shelters and programs;
rape crisis centers; state domestic violence and sexual assault
coalitions; and such other health care or service providers.
Partnerships like these could help veterans who experienced domestic
violence receive the care and services they need and deserve.
H.R. 4096, the ``Improving Oversight of Women Veterans' Care Act of
2019"
PVA supports H.R. 4096, the ``Improving Oversight of Women
Veterans' Care Act of 2019.'' This legislation would require the Under
Secretary for Health to submit to Congress an annual report on the
ability of women veterans to access gender-specific care in the
community, including the average waiting period between the veteran's
preferred appointment date and the date on which the appointment is
completed, reasons VA could not fulfill the appointment, and the
driving time required for appointments. It would also require each
medical facility to report to the Secretary, on a quarterly basis, the
compliance and noncompliance of the facility with the environment care
standards for women veterans, as defined in Veterans Health
Administration (VHA) Directive 1330.01(1). Each report is to name the
person at the facility who is responsible for compliance and provide
the facility plan to strengthen the environment of care standards.
According to a December 2016 U.S. Government Accountability Office
Report (17-52), VHA does not have data and performance measures for
women veterans' access to gender-specific care delivered through the
Veterans Choice Program. However, VHA does collect data to evaluate
women veterans' access to gender-specific care received through PC3 - a
different community care program. The report also found VHA does not
have accurate or complete data regarding medical centers' compliance,
or noncompliance with the environment of care standards for women
veterans.
If VA cannot meet the needs of women veterans and refers them to
providers in the community, then VA must still ensure that the care is
quality, appropriate care that best meets the veterans' needs. Holding
VA and community care providers to different standards is unacceptable.
VA must be able to ensure the care a veteran receives, whether provided
by VA or in the community, is the best clinical option available. As
such, Congress must have the data to conduct the appropriate oversight
on that care.
H.R. 1163, the ``VA Hiring Enhancement Act''
PVA encourages many efforts to bolster staffing levels at VA
facilities, particularly within the Spinal Cord Injury System of Care,
which the historical data shows is one of the most difficult areas to
recruit and retain physicians and nursing staff. We strongly support
the ``VA Hiring Enhancement Act,'' which seeks to release physicians
from ``non-compete agreements'' for the purpose of serving at VA. It
would also allow VA to begin recruiting and hiring physicians on a
contingent basis up to two years before they complete their residency.
These contingent-appointed physicians would still have to satisfy VA's
requirements in order to receive a permanent appointment. Removing
these barriers would help encourage more of the best and brightest
doctors and nurse practitioners coming out of medical school to pursue
a career with VA.
H.R. 2628, the ``Veterans Early Treatment for Chronic Ailment
Resurgence through Examinations Act of 2019'' or the ``VET CARE Act
of 2019"
PVA supports H.R. 2628, which would expand eligibility for VA
dental care to certain veterans. Studies show a person's oral health
has a major impact on their physical health and gum disease is often
associated with diabetes, heart disease, and many other serious medical
conditions.
Even though dental benefits are the bridge to health and wellness,
VA closely rations these services citing the severe underfunding of its
dental departments. Currently, VA dental care is limited to a small
number of veterans such as those who are 100 percent disabled or have a
service-connected dental condition, former prisoners of war, and
homeless veterans. Dental care may also be available if a dental
condition is aggravating a service-connected condition or complicates
treatment of that condition.
Simply put, the VET CARE Act would require VA to establish a four-
year pilot program for older veterans with type 2 diabetes. Since the
VA spends most of its health care costs on treating veterans with
chronic conditions like diabetes, expanding dental coverage to these
individuals will help improve their overall health and may bring those
costs down.
H.R. 2681, to direct the Secretary of Veterans Affairs to submit to
Congress a report on the availability of prosthetic items for women
veterans from the Department of Veterans Affairs
PVA supports H.R. 2681 which directs the VA Secretary to submit to
Congress a report on the availability of prosthetic items for women
veterans from VA. Female veterans are more likely than male veterans to
receive a prosthesis that does not properly fit. This can cause these
women additional medical problems, such as socket burn, and higher
rates of hip and knee osteoarthritis. Women veterans in need of
prosthetics appliances are on an increase, and VA must ensure
prosthesis for women veterans meet all of their health and social
needs.
H.R. 2816, the ``Vietnam-Era Veterans Hepatitis C Testing Enhancement
Act of 2019"
PVA supports this legislation which directs VA to carry out a one-
year pilot program making hepatitis C testing available to covered
veterans at outreach events organized by veterans service organizations
(VSOs). Veterans who have this disease need to be identified in order
to receive treatment for it. We believe that increasing outreach
through VSOs will facilitate these efforts.
H.R. 2982, the ``Women Veterans Health Care Accountability Act''
PVA supports H.R. 2982, which directs the VA Secretary to conduct a
study of the barriers for women veterans to health care from VA.
Accessibility at VA facilities to gender-specific care has been an area
of concern for many of our members.
Ingress/Egress
The first hurdle women veterans may encounter is the entrance to
the woman's health clinic. Many clinics were hastily established so
they did not receive the careful level of planning necessary to ensure
wheelchair users could enter the facility. For example, the entrance to
a VA women's health care clinic we recently visited did not have an
automatic door for patients to use. To complicate matters further, the
entrance was not visible to staff so they could not see if a patient
outside required assistance, nor was there an external bell for the
patient to alert someone. In this case, it was an outside entrance, so
any patient needing assistance would be exposed to the elements until
someone came along to help them.
Accessible Exam Rooms
Accessibility to doctors' offices is essential in providing medical
care to people with severe or catastrophically disabilities, but often
this is the next hurdle a women veteran may encounter at VA. Some of
VA's exam rooms are too small to accommodate a women veteran in a
wheelchair and a portable lift. Other rooms may not be big enough for a
larger wheelchair to enter at all. A portable lift would be unnecessary
if the examination rooms had a built-in lift to hoist a women veteran
from her wheelchair to the examination table, but many women's health
clinics do not have these lifts installed.
Barriers like these tend to make individuals with severe
disabilities less likely to get their routine preventative medical
care. It is a major concern because wheelchair users face the insidious
health threat of having to sit all day. Loss of muscle tone and
diminished circulation cause pressure sores to develop, and it is very
important that seemingly minor problems like these be detected and
treated early before turning into major, and possibly life-threatening,
problems. However, if the patient is unable to enter the exam room or
be placed upon the exam table, the physician will be forced to examine
the patient in her wheelchair, diminishing the quality of the exam and
any care provided.
Mammography Examinations
Some VA medical centers do not have diagnostic equipment to conduct
mammography examinations. For the facilities that do, wait times are
excessively long (two months or longer), or the equipment is
inaccessible for women veterans in wheelchairs, particularly
quadriplegics. While there are mammography machines that allow women
with physical disabilities to lay on an exam table, not every VA health
care facility has this type of equipment.
In light of these concerns, we believe that H.R. 2982 should
specifically address the need to evaluate the barriers faced by women
veterans with spinal cord injuries and disorders in receiving proper
gender-specific health care.
H.R. 3036, the ``Breaking Barriers for Women Veterans Act''
Making VA facilities work for women veterans is the goal of H.R.
3036. This legislation directs VA to ensure each of its medical
facilities has at least one full or part-time women's health primary
care provider; provides $1 million in funding each fiscal year for a
Women Veterans Health Care Mini-Residency Program; and ensures that
providers in the community network are equipped with training nodules
specific to women veterans. To verify that these standards are being
met, the bill also instructs VA to conduct a study to make sure that
staffing levels specific to women veterans are appropriate. PVA
supports H.R. 3036 because it will strengthen VA's ability to deliver
easily accessible, high quality care for women veterans at VA
facilities.
Discussion Draft, to amend title 38, United States Code, to establish
in the Department of Veterans Affairs the Office of Women's Health,
and for other purposes
VA's Center for Women Veterans was established by Congress in
November 1994 (P.L. 103-446) to monitor and coordinate VA's
administration of health care and benefits services, and programs for
women veterans. It also serves as an advocate for a cultural
transformation (both within VA and in the general public) in
recognizing the service and contributions of women veterans and works
to raise awareness of the responsibility to treat women veterans with
dignity and respect. Establishing a separate Office of Women's Health
would elevate the good work currently being done by the Women's Health
Services Program Office; therefore, we support this proposed
legislation.
H.R. 2645, the ``Newborn Care Improvement Act of 2019"
PVA supports H.R. 2645 which would raise the number of days a
newborn under VA care could stay in the hospital from 7 to 14. Most
newborn births are without complications, but if problems develop, the
infant may be required to remain in the hospital for an undetermined
period. H.R. 2645 ensures the newborn is covered for a greater period
of time so women veterans and their families can focus on their child's
health rather than worrying about how to pay for the hospital bill.
H.R. 2752, the ``VA Newborn Emergency Treatment Act''
VA's current newborn care authority provides hospital care but does
not cover emergency transportation when medically necessary
transportation is required. PVA supports H.R. 2752 which would
authorize the VA Secretary to furnish medically necessary
transportation for newborn children of certain women veterans. This
common sense legislation will ensure that women veterans are not forced
to think about the cost of such transportation when considering
emergent care options for their newborns.
H.R. 2798, the ``Building Supportive Networks for Women Veterans Act''
PVA supports H.R. 2798, the ``Building Supportive Networks for
Women Veterans Act,'' which would make the existing pilot on counseling
in retreat settings for newly separated women veterans a permanent
program. This legislation provides VA with the authority to extend the
program using the same measurements and eligibility requirements. PVA
supported the original program established by the ``Caregivers and
Veterans Omnibus Health Services Act of 2010'' and has been pleased to
see it continue.
In surveys conducted after the program, participants consistently
showed better understanding of how to develop support systems and to
access resources at VA and in their communities. The OEF/OIF women
veterans at these retreats are most often coping with effects of severe
Post-Traumatic Stress and Military Sexual Trauma. They work with
counselors and peers, building on existing support. If needed, there is
financial and occupational counseling. To be eligible, women veterans
must have been deployed in OEF/OIF, and have completed at least three
sessions of counseling in the past six months.
The program, managed by the Readjustment Counseling Service, has
been a marked success since its inception in 2011. The results have
been overwhelmingly positive for women veterans, who experience
consistent reductions in stress symptoms as a result of their
participation. Other long-lasting improvements included increased
coping skills. It is essential for women veterans that Congress make
this program permanent. We believe the value and efficacy of this
program is undeniable.
H.R. 1527, the ``Long-Term Care Veterans Choice Act''
PVA supports the ``Long-Term Care Veterans Choice Act'' which would
authorize VA to enter into contracts or agreements for the transfer of
veterans to non-VA adult foster homes for certain veterans who are
unable to live independently. PVA believes that VA's primary obligation
involving long-term support services is to provide veterans with
quality medical care in a healthy and safe environment. This should
include access to a medical foster home as desired by the veteran.
As it relates to veterans with a catastrophic injury or disability,
it is PVA's position that adult foster homes are only appropriate for
disabled veterans who do not require regular monitoring by licensed
providers, but rather have a catastrophic injury or disability and can
sustain a high level of independence. When these veterans are
transferred to adult foster homes, care coordination with VA's
specialized systems of care is vital to the veterans' overall health
and well-being.
This bill requires the veteran to receive VA home health services
as a condition to being transferred. As such, PVA believes that if a
veteran with a spinal cord injury or disorder is eligible and willing
to be transferred to an adult foster home, the VA must have an
established system in place that requires the VA home-based primary
care team to coordinate care with the VA Spinal Cord Injury (SCI)
Center and the SCI primary care team that is in closest proximity to
the adult foster home. When caring for a veteran with a catastrophic
injury or disability this specialized expertise is extremely important
to prevent and treat associated illnesses that can quickly manifest and
jeopardize the health of the veteran. Thus, these veterans must also be
regularly evaluated by specialized providers who are trained to meet
the needs of their specific conditions.
H.R. 2972, to direct the Secretary of Veterans Affairs to improve the
communications of the Department of Veterans Affairs relating to
services available for women veterans, and for other purposes
PVA supports H.R. 2972 which would expand the capabilities of VA's
Women Veterans Call Center by including a text messaging capability and
establishing a single website where women veterans can find information
about the benefits and services available to them. The call center
already has text messaging capability, but the benefit of having a one-
stop resource for information on women veterans' health care and
benefits cannot be overstated.
H.R. 3224, to amend title 38, United States Code, to provide for
increased access to Department of Veterans Affairs medical care for
women veterans
Without additional clarification, PVA cannot support H.R. 3224 as
written. Subsection 1720J(a) would require that the Secretary ensure
that gender-specific services are continuously available at every VA
medical center and community-based outpatient clinic. However, H.R.
3224 does not define the type of ``Gender-Specific Services'' VA is
required to provide. VHA Directive 1330.01(02), Health Care Services
for Women Veterans breaks down gender-specific care into several
categories, e.g., primary care and specialty care. It is gender-
specific specialty care which concerns PVA. VHA Directive 1330.01(02),
paragraph j, provides a list of gender-specific specialty services that
must be available in-house to the greatest extent possible. If gender-
specific specialty services are not available in-house, such services
must be provided through non-VA medical care, contractual or sharing
agreements, academic affiliates, or other VA medical facilities within
a reasonable traveling distance (less than 50 miles).
Unless additional clarification is provided, VA could interpret
Congress's intent with this legislation as a requirement to offer all
gender-specific services in each VA medical center or community based
outpatient clinic. There are a number of gender-specific specialty
services listed in the directive that VA medical centers and community-
based outpatient clinics are not capable of providing-particularly when
it comes to maternity and newborn care.\1\ PVA recommends that this
legislation be amended to include language defining the types of
gender-specific services that VA would be required to provide.
---------------------------------------------------------------------------
\1\ VHA DIRECTIVE 1330.01(2), "Health Care Services for Women
Veterans"
---------------------------------------------------------------------------
H.R. 3798, the ``Equal Access to Contraception for Veterans Act''
The Affordable Care Act (ACA) prevents individuals with insurance
from being charged pharmaceutical co-payments for all 11 categories of
preventive medicine as determined by the U.S. Preventive Task Force and
Centers for Disease Control and Prevention. Yet, with VA being exempt
from the ACA, Section 1722A(a)(3) requires VA to charge for these
categories with exemptions provided by the Secretary for immunizations
and smoking cessation. Veterans are experiencing a disparity in co-
payment requirements for the remaining nine categories including
contraceptives women veterans receive from the pharmacy. PVA supports
H.R. 3798 which eliminates this undue and unjust barrier to accessing
birth control that only women veterans and the uninsured must face.
Again, PVA appreciates this opportunity to express our views on
some of the many important pieces of legislation being examined today.
We look forward to working with the Subcommittee to improve the quality
and accessibility of health care for women veterans, and to enhance the
quality of health care benefits for veterans in general.
footnotes (1)
STATEMENTS FOR THE RECORD
Honorable Max Rose
Thank you, Chairwoman Brownley, and Ranking Member Dunn, for having
this forum to provide due attention to the pending legislation before
us. We are faced here with an issue of persistent disparities of health
care access between male and female veterans. The Department of
Veterans' Affairs (VA) has an influx of women veterans entering their
systems but they have been unable to keep up with increased demand.
Funding for health services specifically for women in VA has
increased about 16% over the last five years, totaling just over $500
million in 2019. But that figure is less than 1% of overall veterans'
health spending, even though women veterans represent one of the
fastest growing populations using VA health care. The number of women
using Veterans Health Administration services has also tripled since
2001, a group expected to grow much larger in the coming years.
However, as our women veterans seek health care, they are either
faced with a lack of resources to meet their specific needs or they
must jump through hoops due to administrative delays and short
staffing. It is alarming to see that women make up both 10% of the
veteran population, and nearly 16% of the active-duty military force,
yet there are still major questions as to whether VA can effectively
serve this large portion of current and future veterans.
There needs to be an increase in resources and H.R. 3036, The
Breaking Barriers for Women Veterans Act, would be an important first
step in bridging the gender health care gap. This bill would require
the VA to implement improvements to better serve women veterans,
including upgrading existing medical facilities. Additionally, the VA
must ensure its medical facilities have at least one full-time or part-
time women's health provider, and establish training modules for
community providers that are specific to women veterans.
The VA needs to be able to properly serve these women and their
health care needs. Women veterans shouldn't have their health put at
risk because their local VA facility doesn't have the appropriate
resources to take care of them or because they need to wait extended
periods of time due to administrative delays.
I would like to thank Paralyzed Veterans of America, Iraq and
Afghanistan Veterans of America, and Disabled American Veterans for
their support of this legislation, along with the bipartisan group of
colleagues currently co-sponsoring.
Thank you for your consideration, and I urge the passage of this
legislation.
Honorable Gus M. Bilirakis
Chairwoman Brownley, Ranking Member Dunn, and distinguished members
of the Subcommittee, as a fellow member of the House Veterans Affairs
Committee and former member of this Subcommittee, I would like to thank
you all for the opportunity to present this statement regarding my
bill, H.R. 2628, the Veterans Early Treatment for Chronic Ailment
Resurgence through Examinations Act, or the VET CARE Act.
I have been proud to serve on this Committee during my entire
tenure in Congress and have always said that caring for Veterans is one
of my top priorities. I am also proud to represent Florida's 12th
Congressional District, which is home to thousands of Veterans in the
Tampa Bay area.
Many of my Veteran constituents have come to me over the years
expressing their desire to add dental care to the VA's medical benefits
package. Currently, the Department of Veterans Affairs (VA) provides
outpatient dental care for a limited number of the Veteran population -
specifically 100% rated service-connected disabled Veterans. It also
provides dental services to Veterans who are disabled due to a specific
debilitating dental condition. Otherwise, the access that many Veterans
have to these services is limited. Some may be able to sign up for the
VA Dental Insurance Program (VADIP), which provides a discounted, low-
cost insurance plan provided by private insurers. But I believe we need
to do more to move this issue forward.
The old saying goes an ounce of prevention is worth a pound of
cure, and many small studies suggest that regular dental care equates
to lower overall health care costs and better health outcomes. One such
study published in the American Journal of Preventive Medicine,
conducted by University of Pennsylvania professor Dr. Marjorie
Jeffcoat, found that regular periodontal checkups lead to reduced
hospitalizations and overall medical cost savings in care for chronic
conditions such as cardiovascular disease, cerebral vascular disease,
and diabetes. It is off this study that I based the VET CARE Act, which
would expand this research to determine the potential health benefits
to Veterans and the potential cost savings to the VA associated with
periodontal care. My bill would require the VA to create a four-year
pilot program to provide dental services to 1,500 Veterans diagnosed
with type-2 diabetes, at five selected VA Medical Centers. To be
eligible for the pilot, Veterans must not already be receiving regular
periodontal care. Additionally, Veterans with service-connected
disability ratings would receive preference for participation.
Each treated Veteran will receive appropriate periodontal
evaluation and treatment on an annual basis during the pilot.
Throughout and at the conclusion of the pilot, the overall health of
the treated Veterans will be recorded. Those results will be compared
to Veterans outside the pilot to determine if providing Veterans with
dental care equates to fewer complications of chronic ailments. If so,
an analysis can be done to determine if the lower costs of overall
health care due to fewer chronic ailments saves the VA enough money to
reallocate funds to provide more Veterans with dental care. The data
recorded and collected by the VA would also be able to be distributed
to the research community for further study.
Finally, at the end of the four-year pilot period, Veterans who
participated in the program will receive information on how they may
continue to obtain dental services and treatment in the community,
including information about enrolling in VADIP. Currently, VA is
prohibited from advising its patients to go to non-profits and other
providers in the community for dental care. H.R. 2628 would amend
section 1712 of Title 38 to enable VA providers to have that
conversation with those Veterans who apply for the pilot program by
giving them a list of those potential providers in the community and
advising patients of opportunities for dental care through VADIP and
other partners in the community for low to no cost dental care. One
example of this is the ``Stars, Stripes, and Smiles'' event that my
office has hosted annually with our local West Pasco Dental Association
to provide oral health care for Veterans' untreated dental pain and
infections free of charge. In this way, we can ensure that we are
providing the essential continuity of care for Veterans in need of
further treatment.
I believe we must give Veterans the health care they have earned
and deserve. If we can improve on this care by providing preventive
dental services that leads to fewer complications of chronic ailments,
it not only shows that we are looking at the long-term outlook of their
health, it could also prove to be cost-effective. The VET CARE Act is a
practical, common-sense way to demonstrate this approach for dental
services, replicating already established research in the community.
To conclude, I am proud of the work that this Committee has
consistently done over the years on a bipartisan basis for our nation's
Veterans, our true American heroes. I am grateful that the Subcommittee
has continued this bipartisan tradition by bringing my bill up for
further discussion, and I once again thank the Subcommittee for giving
me the chance to express my support for this important legislation for
the record. I welcome the opportunity to continue the conversation
further, discuss any questions or concerns you may have, and to find
common ground to advance policy solutions that help our Veterans and
their families.
Honorable J. Luis Correa
Chairwoman Brownley, Ranking Member Dunn, and Members of the
Subcommittee, I thank you for the opportunity to submit testimony in
support of my bipartisan legislation: H.R. 4096, the ``Improving
Oversight of Women Veterans' Care Act.''
According to the U.S. Department of Veterans Affairs (VA), there
were over 2 million women veterans in 2016. Although women represent
the fastest growing cohort of veterans, women veterans continue to face
challenges in receiving health care services.
In 2016, the Government Accountability Office (GAO) reported that
the Veterans Health Administration (VHA) had limited information on VA
medical centers' (VAMCs) compliance with environment of care standards
for women veterans. VHA policies require that VA medical facilities
meet certain privacy and safety factors, conduct regular inspections,
and report instances of noncompliance. Yet, of the VAMCs inspected, GAO
found that noncompliance, such as the lack of privacy curtains in
examination and inpatient rooms, had not been reported. Additionally,
GAO found that VHA did not have performance measures for monitoring
women veterans' access to gender-specific care provided by non-VA
physicians under the then-Veterans Choice Program.
In response, the ``Improving Oversight of Women Veterans' Care
Act'' directs VA to establish and disseminate environment of care
standards and inspection policies to VAMCs. To encourage compliance,
VAMCs will be ineligible for a five-star end of year rating unless the
facility meets the environment of care standards. Additionally, the
bill requires VA to submit an annual report to Congress regarding women
veterans' accessibility via community care to gender-specific health
care services, such as maternity care.
It is important that VA evolve and adapt to ensure that women
veterans receive health care in a timely, dignified, and safe manner.
Chairwoman Brownley and Ranking Member Dunn, I want to thank you
for the inclusion of my bipartisan bill on the agenda today. I
appreciate the work that the Members of this Subcommittee do to ensure
quality health care for our nation's veterans, and I look forward to
working with you all to move this policy forward.
Honorable Vicky Hartzler
Chairwoman Brownley, Ranking Member Dunn, and distinguished members
of the Subcommittee, I want to applaud you for your commitment and
dedication to improving outcomes for our veterans and for allowing me
to share my views on the Department of Veterans Affairs' (VA) critical
staffing issue that is impacting the care our veterans receive.
Our veterans deserve the best. Unfortunately, top-notch care is
often hampered by a shortage of doctors at the VA. I believe that this
bill, which I introduced along with Representatives Bost, Correa,
Lesko, Mooney, Rouzer, and Wilson will help the VA fill some of these
vacancies. Our bill has three main provisions.
First, it would allow physicians to be released from non-compete
agreements only for the purpose of serving in the VA for at least one
year. Non-compete agreements are supposed to prevent a physician from
building up a patient base, and then taking those patients with them as
they set up their own practice. A physician moving to the VA simply
does not fit that description. This provision would ensure that a non-
compete agreement is never used to keep a physician from serving
veterans at a VA facility, and only applies to such a circumstance.
Second, our bill updates the minimum training requirements for VA
physicians. Completion of a medical residency is widely accepted as
standard comprehensive training for clinical physicians in the United
States. However, current law only requires that a physician be licensed
in order to treat veterans. In the case of some medical specialties,
the difference between licensing and completing residency can represent
six years of training. Some have suggested that this provision would
exacerbate the shortage of physicians at the VA by shrinking the pool
from which the VA can hire. However, the VA currently hires almost
exclusively those physicians which have completed residency training,
so this provision would not result in such an impact.
Others have rightly submitted that veterans are largely satisfied
with the quality of care they receive at the VA. They, therefore,
submit that we do not need to legislate a higher standard. I contend
that as long as Congress sees fit to impose any standard on the VA
regarding those caring for veterans, we have a duty to ensure that the
standard is appropriate. Completion of residency training is the
accepted standard in this nation, and we should never expect veterans
to accept anything less. This is a common-sense update to something
Federal law already addresses and ensures that only fully trained
physicians care for those who have served our nation.
Finally, our bill would place veterans' hospitals on a level
playing field with the private sector when it comes to recruiting
timelines. Often, private sector health care providers begin recruiting
medical residents as they begin their final year of residency,
sometimes even earlier. Most residents have school debt they will need
to start paying off-an average of $190,000. During residency they treat
patients and work upwards of 80 hours a week, sometimes with single
shifts up to 28 hours. These residents-rightfully motivated to secure a
post-residency job with better pay and better hours-often accept a
solid job offer from the private sector before VA recruiters are able
to get their recruiting process started.
Our bill authorizes VA recruiters to make job offers to physicians
up to 2 years prior to fulfilling all of the VA's requirements,
contingent on meeting all requirements before they begin treating
veterans. It offers job security to medical residents who want to work
at the VA when they complete their training and allows VA facilities
and recruiters to shore up appointments further in advance, helping
them to plan and forecast medical workforce needs. VA recruiters are
already pitching a great opportunity for physicians, and we owe them
policies that make them as competitive as possible with private sector
recruiters. I believe that advancement of this legislation will help
begin to fill the VA's many vacant health care positions.
We've worked closely with this Committee's staff, VA recruiters,
and VSOs on this bill, and I'm pleased to report that it has garnered
wide support and formal endorsement from 10 VSOs including the American
Legion, Blinded Veterans Association, AMVETS, Disabled American
Veterans and Paralyzed Veterans of America. We are forever indebted to
the brave men and women who serve in uniform and we owe them our
continued support as veterans. It's my hope we can work together to
move this bill to the House floor soon.
Thank you, again, for your time and consideration.
Honorable Susie Lee (NV-03)
September 9, 2019
Chairman Takano, Ranking Member Roe, Chairwoman Brownley, and
Ranking Member Dunn, Today I speak to the importance of my legislation,
the Newborn Care Improvement Act, to the needs of veterans -
particularly women.
As you may know, currently, veterans are eligible to receive seven
days of newborn care following the birth of their baby, after which
they must find and sign up for health insurance for their newborn. Very
often, the new mothers receiving medical care from the Department of
Veterans Affairs (VA) face challenges with time, finances, and
complicated insurance choices while adapting to the new challenges of
parenthood. My bipartisan legislation would double the available time
of newborn care to fourteen days, providing additional time for a
veteran to find the best health coverage for the needs of their family
and baby.
I am proud to have introduced this critical, bipartisan legislation
and know that it is one piece of a pivotal movement in improving the
care provided to our women veterans at the VA. As I have said before,
and want to reaffirm, again, our women veterans deserve the best health
care and maternal care available to them and their families. Starting a
family can be an overwhelming time for any parent, making it even more
important to ensure our veterans have the resources and time they need
to get the best maternal care possible.
I ask my colleagues to join me in passing this legislation and help
improve the lives of the veterans in my district and across our
grateful nation.
Honorable Chris Pappas (NH-01)
Good morning to my esteemed colleagues and members of the House
Veterans Affairs Subcommittee on Health. I appreciate the opportunity
to submit my statement for the record in support of the passage of my
bill, H.R. 2681, concerning the availability of prosthetics for women
veterans.
Earlier this year, I was shocked to learn that many of our female
veterans are forced to use prosthetic items that were originally
designed for men. Prosthetics designed for a different gender are not
just cosmetically different, but in practice they may have differences
that make a difficult transition even more burdensome for our veterans.
For instance, a prosthetic item designed for a man will likely be on a
larger scale and proportion than one designed for a woman. So, while a
female veteran may receive a prosthetic for a lower leg injury whose
socket technically fits, the foot of the device is likely to be much
larger than her own. This creates additional problems in her
rehabilitation process and is very often emotionally difficult.
My bill, co-sponsored by Representative Elise Stefanik (NY-21),
requires VA to assess the availability of prosthetic items made
specifically for female veterans available at VA medical facilities and
to present their findings to Congress. This will give us a better idea
of what options currently exist and where we can work with VA to ensure
that our female veterans have access to prosthetic items that enhance
their quality of life.
Women represent roughly 16% of the United States active duty force,
18% of the officer corps, and the 2,000,000 female veterans in our
country represent the fastest group of veterans. They serve honorably
and openly alongside their male counterparts and return home from
deployment with the same psychological and physical wounds. When they
do, they deserve to know that they will receive the highest-quality,
specialized care that we can provide - and that includes prosthetic
items that are specifically designed for them.
I appreciate the Subcommittee's time and consideration and urge the
passage of my bill.
Thank you.
Honorable Elise M. Stefanik
Good morning Chairman Takano, Ranking Member Roe, and members of
the Committee. I am grateful for the opportunity to testify before the
House Veterans' Affairs Committee and discuss issues very important to
my district. I proudly represent New York's 21st Congressional
District-where nearly one in ten adults is a veteran. That's what makes
the work of this Committee deeply personal to me and my constituents.
Tomorrow the Subcommittee on Health will discuss and debate several
important pieces of legislation concerning Veterans' health care, many
of which have a special focus on improving the access and quality of
care for women veterans. I applaud the Committee, as well as your
staffs, for focusing on this ever-important topic.
Another topic that the Subcommittee will discuss tomorrow is
H.R.2816, the Vietnam Era Veterans Hepatitis C Testing Enhancement Act.
This is an incredibly important bill. To help my colleagues understand
why, I would like to share a story with you:
In 1970, Danny Kaifetz, a young man from the North Country,
volunteered to serve in the United States Marine Corps while the
country was embroiled in the Vietnam War. Danny completed training at
Parris Island, and went on to Jungle Warfare School and Combat Infantry
Training at Camp Lejeune. At some point during training-as any one of
my colleagues who has been through boot camp knows-all the recruits
were lined up, like a factory assembly line, and were inoculated with
the necessary vaccinations. Back then the Armed Forces, to include the
Marine Corps, used the Ped-O-Jet air inoculation device, or ``jet-
gun,'' to quickly vaccinate one recruit to the next. And as difficult
as it for us to image today, medics were not required to sterilize the
devices in between the inoculations. In fact, page 38 of the operator's
manual, explicitly states ``sterilization not requiredbetween
injections.'' As we now know, this practice exposed thousands of
recruits to dangerous, and often deadly, blood-borne diseases.
Contamination happened without discrimination-to volunteers and to
those who were drafted. To those who went on to serve honorably for
several years and those who didn't make it through training. To those
who saw combat and bear the emotional burdens of a horrific war and
those who, through some good fortune, were spared.
Danny Kaifetz thought he was one of the lucky ones who was able to
serve his country and fellow Marines without going to combat. He
proudly fulfilled his duty and was distinguished with the Meritorious
Service Medal at the completion of his service contract. But,
unbeknownst to him, Danny did not leave the military unharmed.
Nearly forty years later, in 2011, Danny was diagnosed with
Hepatitis C. He sought and received treatment at the VA, and today Mr.
Kaifetz will tell you with gratitude that he owes his life to the
outstanding medical staff at New York VA.
As you all know, Congress dedicated significant resources to enable
the VA to test and treat veterans for the hepatitis C virus, and VA has
made significant progress to date. However, these efforts primarily
focus on Veterans enrolled in the VA, testing only 78% of the two
million Vietnam-era Veterans enrolled in VA care. Estimates indicate as
many as 1 in 10 of the eight million surviving Vietnam Era
servicemember may be infected with hepatitis C due to the cross-
contamination. Of those who do not meet VA eligibility criteria, as
many as seven million are considered at high-risk for hepatitis C
infection and unaware of their status. Our veterans deserve better.
The Vietnam Era Veterans Hepatitis C Testing Enhancement Act
focuses on Hepatitis C screening and does not take away from the VA's
efforts, rather enhances them. Furthermore, the bill is budget neutral
by utilizing resources previously allocated by Congress through the
Honoring America's Veterans and Caring for Camp Lejeune Families Act
(P.L.112-154). The concept has proven successful at a local level due
to the extraordinary efforts led by my constituent, Danny Kaifetz, and
American Legion Post 1619. We owe it to a generation of veterans to
provide this valuable screening tool. I urge my colleagues to join the
American Liver Foundation, the AIDS Institute, and Vietnam Veterans of
America to support H.R.2816.
Mr. Chairman and Ranking Member, I thank you for the opportunity to
speak with you today. And I thank the entire Committee and staff for
the invaluable work you do to support our nation's heroes. I look
forward to working with you. I yield back.
Honorable Nydia Velazquez
Mr. Chairman Takano, Ranking Member Roe, and members of the
Committee, I submit this written statement today in support of H.R.
3867, the Violence Against Women's Veterans Act of 2019. Although
military sexual trauma (MST) is not a new issue, it currently lacks
resources to combat it effectively. Every sexual assault in the
military is a failure to protect the men and women who have volunteered
to defend us. Today I'd like to thank the Committee for considering my
legislation that will better help our servicemembers who have been
victims of domestic violence.
Based on a 2014 study examining prevalence of MST, it is estimated
that one-third of females in the military screen positive for MST, and
the rates are higher for younger veterans.\1\ MST refers to sexual
harassment or sexual assault that occur in military settings. MST is
the leading cause of post-traumatic stress disorder among female
veterans resulting in many other mental health issues surpassing combat
trauma.\2\
---------------------------------------------------------------------------
\1\ Cichowski, Sara et al. ``Female Veterans' Experiences with VHA
Treatment for Military Sexual Trauma.'' Federal practitioner: for the
health care professionals of the VA, DoD, and PHS vol. 36,1 (2019): 41-
47.
\2\ O'Brien BS, Sher L. ``Military sexual trauma as a determinant
in the development of mental and physical illness in male and female
veterans.'' International Journal of Adolescent Health and Medicine.
vol 25,3 (2013): 74-269
---------------------------------------------------------------------------
The number of women servicemembers and veterans is at an all-time
high, with continued growth expected. Yet women servicemembers continue
to face serious challenges in service; approximately 1 in 4 experience
sexual assault or sexual harassment. Women veterans who experienced MST
are more likely to suffer adverse outcomes such as mental health
conditions, substance use, discharge from the military, unemployment,
and homelessness. Sadly, women veterans make up the fastest-growing
segment of the homeless population.\3\
---------------------------------------------------------------------------
\3\ Hamilton AB, Poza I, Washington DL. ``Homelessness and trauma
go hand-in-hand'': pathways to homelessness among women veterans.
Women's Health Issues: Official publication of the Jacob's Institute of
Women's Health. vol. 21 (2011): 9-203
---------------------------------------------------------------------------
For many of our veterans, the biggest battle of their lives will
not be fought during deployment, but with the difficult memory of their
abusers replaying in their minds. It is heartbreaking to think that our
veterans, individuals who have fought for our freedoms, would have to
endure this hardship.
For these reasons we need to improve the services provided by the
VA. The Violence Against Women Veterans Act seeks to accomplish this by
requiring an integration of VA services with proven, existing
community-based programs that serve domestic violence or sexual assault
victims.
With the establishment of the National Task Force on Domestic
Violence, H.R. 3867 enables us to gather information on how to best
provide comprehensive support to our veterans and seeks to create a
network of local coordinators that facilitate cooperation between the
VA and social services and assist domestic violence shelters and rape
crisis centers in providing services to veterans. This is a vital
component considering the number of sexual assaults reported by members
of the U.S. armed forces is about a third of the total reported in a
confidential survey of servicemembers.
Currently the VA does not have a comprehensive national program to
address intimate partner violence (IPV). Notably, H.R. 3867 requires
the Advisory Committee on Women Veterans to conduct an assessment of
the effects of IPV on women. This required assessment, jointly with the
VA convened Domestic Violence Task Force will define the scope of and
design a plan for evaluating domestic violence among Veterans.
We can and must play a role in helping women veterans understand
symptoms that they experience, to recognize MST and IPV, to know where
to seek help and directly connect our Veterans with the help they need
to improve the quality of their lives.
Members of the U.S. Army, Navy, Air Force, Marines, and Coast Guard
courageously take an oath of enlistment to support and defend the
United States. It is our obligation to take care of those who serve.
Minority Veterans Of America (MVA)
Prepared by: Lindsay Church, Executive Director
with inputs from Katherine Pratt, Director of Advocacy, and Kiersten
Down, Board of Directors
Chairwoman Brownley, Ranking Member Dunn, and distinguished members
of the House Veterans Affairs Committee, Subcommittee on Health; on
behalf of the Minority Veterans of America, an organization dedicated
to creating community belonging and advancing equity for minority and
underrepresented veterans, we thank you for the invitation to submit a
statement for the record today and to share our position regarding
legislation to support women veterans at the Department of Veterans
Affairs.
Summary
As an organization, Minority Veterans of America (MVA) is pleased
to see that Congress is taking steps to address issues of disparate
health care for women and pre-9/11 veterans in the Department of
Veterans Affairs (VA). The recent attention to and support of women
veterans that the House of Representatives has taken with the
introduction of the Women Veterans Task Force has resulted in
legislation that works to address the concerns that organizations who
serve women veterans have been bringing forward for years.
We are disappointed that much of the proposed legislation has not
taken an intersectional approach and seeks to address one subpopulation
of veterans in a binary way that fails to understand how other
identities such as race, gender orientation (i.e. transgender and
gender non- conforming veterans), LGBTQ status, or religious identity
factor into the lives of our women veterans. This is important,
especially in the area of research surrounding the barriers that women
veterans experience when accessing their VA benefits. While women
veterans broadly are in need of unique and increased medical care, the
same can be said for transgender veterans who continue to receive
inadequate and incomplete care through the VA system.
Additionally, few of these bills include any reference to funding
or allocation of money to complete the task addressed. We understand
that many of these bills are requests for action, but in order for the
legislation to be properly implemented, they should be supported with
at least the promise of an increase in funds to ensure that the task is
accomplished properly.
Finally, it would be worthwhile to see greater reference to
collaboration with existing centers that can support the requisite
changes to the VA system. Of note, the Center for Women Veterans should
serve as an excellent resource to answer the questions asked in HR 3636
and for implementing a centralized website as proposed in HR 2972. It
is telling that in 2019 we don't even know how many women veterans are
in each state nor do we understand how or if they use their VA benefits
for their health care. These pieces of legislation are an excellent
first step at better serving and understanding women veterans, but we
would like to see more intersectionality and consideration beyond the
binary in these and future bills.
HR 2628
Veterans Early Treatment for Chronic Ailment Resurgence through
Examination Act of 2019
We support the Department of Veterans Affairs enacting legislation
and changes to expand access to dental coverage broadly. The current
levels at which dental coverage is offered covers only a small portion
of the veteran community. In the communities we serve, particularly
veterans of color who face greater health disparities and student
veterans who do not have access to dental coverage through other means,
this coverage is desperately needed. Currently, many veterans struggle
to find adequate access to dental insurance and for this reason, their
oral health suffers greatly after service.
The greatest concerns we have regarding this legislation center on
the limiting nature of the qualifications for the pilot. Of greatest
concern is the age limitation which states that a veteran must be
between the ages of 40 and 70 years old. As we struggle to find ways to
better serve the youngest generation of our nation's veterans, this
limitation effectively eliminates a large portion of the veterans who
served after 9/11. Additionally, the disqualification of individuals
who are in need of periodontal surgery limits access to care for those
with the most severe dental needs.
The position of MVA is that dental care should be broadened to
serve a greater portion of our community. The current level of care for
most veterans is unacceptable as we recognize the link between better
oral health and improved health outcomes. This pilot legislation seeks
to prove what civilian institutions, such as the U.S. Department of
Health and Human Services and the Mayo Clinic, have already proven -
better oral health leads to improved health outcomes.
HR 2645
Newborn Care Improvement Act of 2019
MVA supports the extension of the coverage for newborn care for
women veterans from the current seven days to the 14 days. The issue
with this legislation is that there is little known about maternity
care or maternity benefits that the VA provides or can provide. Many
women veterans are unaware of the benefits that are currently offered
and the current materials available, even on the Center for Women
Veterans' site are ambiguous and does not provide details on what, if
any, care is provided.
For this legislation to be impactful, it will be important to
understand how many veterans are currently using this benefit and how
the outreach about these benefits can be expanded. It should not be the
veterans responsibility to navigate a process that is convoluted, the
information needs to be readily available and easily accessible. In
addition, there is concern among providers that women veterans are not
being admitted to community care within the window of 30 days that the
VA holds as the standard. The next step to improving this benefit is to
assess what the wait time is for expectant mothers between when the
referral is issued by the provider and when they are admitted by the
community based provider.
HR 2681
MVA supports seeking to better understand the availability of
prosthetics available to women veterans. In order to be inclusive of
all women veterans, this legislation will need to include prosthetic
availability for transgender veterans. The prosthesis necessary for
transgender veterans are both medically necessary and, in the absence
of the VA performing gender affirming surgeries, is the best that the
VA currently offers to our transgender veterans. The availability of
these devices should not be limited to specific hospitals or areas of
the country.
HR 2752
VA Newborn Emergency Treatment Act
MVA supports the expansion of newborn emergency treatment. This
legislation to amend the current code to include transportation for
newborn children in emergency situations will require further
clarification as to who ``certain women veterans'' are. This
legislation and outreach about the services available need to be
targeted in nature to ensure that the communities of women veterans who
experience the highest rates of premature birth and other
complications, primarily women of color, have this information
available to them. It is imperative now that marginalized populations
gain access to pre- and post-natal care.
HR 2798
Building Supportive Networks for Women Veterans Act
As an organization, MVA supports the reintegration of women
veterans through means that support the holistic transition of the
individual. It is our belief that alternative treatments create
opportunities for veterans to choose the methods that work best for
them in their process or journey. It is not, however, our position that
the VA should be facilitating these retreat settings themselves. There
are currently many retreat style programs that exist in the community
that are doing excellent work. Rather than creating new programs, the
VA should contract with or allocate funding to support programs with
proven records of success. With the current lack of confidence of the
women veteran community broadly, it is not prudent to create a program
that requires more trust on the part of the veteran without a proven
track record of supportive care.
Additionally, we would like to see that veterans of all genders
have access to the same treatment setting to support better
reintegration. Without offering this to the entire community, there is
a chance of creating a greater stigma for women veterans as they take
advantage of these programs.
Finally, the limitation of access to those who have returned from
prolonged deployments severely limits the number of women veterans who
can take advantage of a program designed to help them more successfully
reintegrate. Women veterans encounter a range of traumas such as Post-
Traumatic Stress, Traumatic Brain Injury, and rape and sexual assault,
among others, while serving that could benefit from this type of
program.
HR 2972
MVA supports the existence of a centralized website for women
veterans though, the creation of a new site seems duplicative in
nature. If the VA seeks to create this site to ensure that there is
easily accessible information available to women veterans, it will be
imperative to integrate this site with the current site administered by
the Center for Women Veterans. Rather than creating anything new and
causing confusion for the user, the current site should be overhauled
and usability testing conducted to ensure it is accessible for
individuals with differing abilities.
HR 2982
Women Veterans Health Care Accountability Act
MVA supports the study of health barriers impacting women veterans'
access to care. In order for this study to be comprehensive, it is
imperative that it be extended in the following ways:
Expansion of questions surrounding the stigma of seeking mental
health care services to include seeking mental and physical health care
services at the VA specifically. While there is a stigma in the
community of veterans broadly regarding receiving mental health
treatment, there is also a stigma that is just as strong against using
any form of VA care. It is important to note where women veterans feel
most comfortable receiving their mental health care to expand services
in this manner.
Expansion of questions surrounding the personal safety and comfort
of patients as well as the gender sensitivity of staff and providers at
VA facilities to include behavior carried out by patients. While it is
extremely important to include questions regarding staff and providers
at the VA, it is often not only the providers that are the perpetrators
of behavior that makes women veterans feel unsafe or unwelcome in VA
facilities. This will be important to developing solutions and
strategies for addressing the concerns of women veterans.
Introduce a question about the VA's motto to gauge the impact to
the community of women veterans. As it stands, the VA's motto is
outdated and does not include women or gender diverse individuals. In
this study of the barriers to access, this is an important topic to
understand the feelings of the community and how the motto contributes
to a culture that is exclusionary to women veterans.
Additionally, the results of this study should be mandatorily
reviewed by each department of the VA that serves women veterans. This
information is imperative to creating truly inclusive programs and
should not be siloed within the Center for Women Veterans. To impact
the necessary changes, all departments of the VA need to be involved in
helping to create solutions to the issues that women veterans are
experiencing across the organization.
HR 3036
Breaking Barriers for Women Veterans Act
MVA supports facility upgrades to better serve women veterans
across the VA health care system. The appropriation of $20 million to
support this legislation along with additional funding to provide
training to providers of health care for women veterans in the
community is important to ensuring this legislation is executed
properly. We encourage the addition of greater oversight measures to
this legislation to ensure that all monies are distributed to the
necessary infrastructure upgrades and not reallocated to other projects
and priorities in a flat funded organization.
HR 3224
As an organization, we are supportive of the expansion of the VA's
hours to ensure that women veterans are able to access their care on
schedules that work with their own. The issue with this legislation is
that the VA is already struggling with being understaffed and is barely
able to serve the veterans who are waiting for care within their normal
hours. Should this legislation be enacted, especially without the
promise of additional monetary support, it's unclear as to if this can
be accomplished. As a whole, the VA needs to place an emphasis on
filling the alarming number of vacancies system-wide and ensure that
the veterans using the system, in its current iteration, are able to
receive care as well as looking at extending the hours of operation.
HR 3636
Caring for Our Women Veterans Act
MVA believes that it is imperative that the VA maintain accurate
reporting regarding the number of women veterans using the VA for their
care. It is telling that in 2019, the number of women veterans in each
state using care is not readily available with the VA's Center for
Women Veterans already in existence.
When these surveys are being conducted at VA facilities across the
country, numbers should also be collected on other identities that can
inform care and point to underserved populations. It is the
recommendation of MVA that reporting also be conducted across identity
groups such as race/ethnicity, gender orientation (i.e. cis-, trans-,
and non-binary), sexual orientation (if disclosed), and religious
identity. These identities can help to better assist the VA and
Congress to identify underserved populations and more accurately
prescribe actions that will address the department's deficiencies
through providing culturally appropriate care.
Additionally, data should be collected regarding the number of
patients who used the VA multiple times in the year and the number of
patients that have only used their benefits once. These data sets will
point to patient retention and attrition more accurately.
Lastly, in regards to the number of providers at each facility
dedicated to the care of women veterans, it is important for the
community to understand what the goal is in regards to the ratio of
patients to providers is. In some cases, staff sizes are larger and
more able to adequately support and serve the women veterans in that
area or region but in smaller cities and rural areas, there are very
few dedicated providers. What is the long-term goal or outcome?
HR 3867
Violence Against Women Veterans Act
MVA opposes HR 3867 as it is written as the language of this bill
is extremely problematic and has the potential to further stigmatize
women veterans. While we recognize and support the need for expanded
services for survivors of military sexual assault and sexual violence
as well as survivors of domestic violence, this legislation further
marginalizes women by identifying them as the primary community that
experiences rape, sexual assault, and domestic violence. While women
have higher instances of sexual assault and violence per capita, there
is still a large population of male and gender diverse survivors that
need access to this same level of care but may not feel included by the
title of this bill and the binary gender references throughout.
This legislation also does not take into account that members of
the LGBTQ community experience greater instances of sexual violence in
the civilian population than their heterosexual counterparts in the
general public. In the absence of the military collecting and reporting
on the LGBTQ status of servicemembers, the assumption must be made that
the military population is reflective of the general population. As we
engage with and support the minority and underrepresented veteran
community, we see a direct correlation between a history of sexual
assault and violence and our members' LGBTQ status. Members who are
LGBTQ are more likely to be survivors of rape or sexual assault while
serving than their heterosexual counterparts.
Additionally, HR 3867 only accounts for veterans and the
coordinated care network to serve them but does not account for or
discuss collaboration with the Department of Defense where many
instances of sexual assault and domestic violence begin. This bill,
while intended to be holistic in nature, does nothing to move toward a
culture of prevention.
Bill to establish in the Department of Veterans Affairs the Office of
Women's Health
MVA supports Congresswoman Brownley's legislation proposing the
creation of the Office of Women's Health as well as the Director of
Women's Health in the VA. The creation of this office will allow for
greater oversight of the overall care available to women veterans. As
this legislation is introduced, it will be important to include a
funding note that will allow for this legislation to be enacted and the
office to be funded. The expansion of care and oversight of the
offerings to women veterans is imperative to the overall success of the
VA's women veteran program. Moving forward, we would like to see
collaboration with the VA's current Center for Women Veterans to ensure
that silos are not created within the system and that both offices are
able to work side-by-side to achieve better care for our women
veterans. This legislation and the prioritization of women veterans in
the VA system is long overdue.
Additionally, we recommend that this and all legislation intended
to support women veterans explicitly note the support of transgender
women veterans and veterans who do not identify as women but are in
need of gynecological care. This will ensure equitable access for all
women veterans in the VA system.
Military Women's Coalition (MWC)
Chairwoman Brownley, Ranking Member Dunn and members of the
Committee, thank you for the opportunity for the Military Women's
Coalition to provide a statement for the record on the health
legislation before the Committee today.
Background: The MWC is a national coalition of formal and informal
organizations who work collaboratively to serve and support US active
duty, Guard, reserve, Veteran and retired service women by uniting and
elevating their voices to influence policy and improve their well-
being. Our vision is that someday military women are fully integrated,
equally respected and equally supported members of the military and
veteran community and their contributions are recognized as essential
to national defense. Currently there are 18 organizations in the
Coalition from across in the nation.
Better Health care for Women Veterans: Members of the MWC are
particularly concerned about the health care provided to women veterans
as good care has often been lacking in many areas. The MWC is
encouraged to see so many efforts underway to rectify failures and
shortcomings in the existing system. Although the MWC supports all of
the legislation under consideration we strongly support the following
legislation:
HR 3636
HR 2972
HR 2645
HR 2681
HR 3224
HR 2752
HR 2628
HR 2816
HR 1527
HR 3798
HR 3867
HR 4096
Draft Bill
A few members of the MWC expressed reservations about some of the
proposed legislation. Their concerns had to do with vague language,
costs and redundancy.
HR 3036 There were concerns about cost and therefore execution of
this legislation.
HR 2798 There were concerns about cost and the vagueness of the
language in this legislation.
HR 2982 Several organizations felt that another study is a waste of
money because the needs have already been identified in other studies.
HR 1163 Several organizations abstained from providing support or
opposition to this legislation.
This statement is submitted on behalf of the Military Women's
Coalition by Ellen L. Haring, the Coalition Steering Committee Chair.
Sincerely,
Ellen L. Haring, PhD
Steering Committee Chair
Military Women's Coalition
MWC Steering Committee Organizations
Service Women's Action Network
Women in Military Service For America
Protect Our Defenders
GA Military Women
Service: Women Who Serve Pink Berets
Red Feather Ranch
WINC: For All Women Veterans
Northeast Florida Women Veterans
Combat Female Veterans Families United
Veteran Women Enterprise Center
Veterans Of Foreign Wars (VFW)
CARLOS FUENTES, DIRECTOR
NATIONAL LEGISLATIVE SERVICE
Chairwoman Brownley, Ranking Member Dunn, and members of the
Subcommittee, on behalf of the women and men of the Veterans of Foreign
Wars of the United States (VFW) and its Auxiliary, thank you for the
opportunity to provide our remarks on legislation pending before this
Subcommittee.
H.R. 1163, VA Hiring Enhancement Act
Section 2
The VFW supports this section which would remove barriers for
employment of health care providers who were required to sign a non-
compete contract with previous employers. By removing this barrier more
medical professionals who want to treat veterans would be able to
pursue a career at the Department of Veterans Affairs (VA) medical
facilities.
Section 3
This section is intended to authorize VA to hire physicians who are
in the process of completing a residency and to codify training
requirements for VA providers. The VFW is concerned that this section
may unintentionally limit VA's authority to offer contingent employment
offers to physicians who are completing a residency. Section 206 of
Public Law 115-46, VA Choice and Quality Employment Act of 2017,
authorized VA to hire students and recent graduates. This section may
limit such authority to a two-year period for physicians. The VFW
recommends removing such limitation.
H.R. 1527, Long-Term Care Veterans Choice Act
The VFW supports this legislation which would authorize VA to enter
into contract agreements for non-VA medical foster homes. By expanding
this option of long-term care to veterans who are unable to live
independently but do not want to be institutionalized, Congress would
be providing veterans with the ability to receive the care they need
while also maintaining their quality of life. The VFW urges Congress to
pass this legislation, which would provide more options for veterans to
decide what form of long-term care is right for them.
H.R. 2628, VET CARE Act of 2019
The VFW supports this legislation which would improve dental care
provided to veterans by VA through a pilot program, and expand outreach
regarding the VA Dental Insurance Program (VADIP). While the VFW would
prefer to see legislation that would expand eligibility for VA dental
care to all veterans who are eligible for VA health care, the VFW
supports this bill.
For the past five years, the VFW has partnered with Student
Veterans of America (SVA) to select ten student veterans from across
the country to research and advocate for the improvement of an issue
that is important to veterans. VFW-SVA fellow and George Washington
University student Tammy Barlet focused her semester-long research
project on dental health for veterans. In her research, Tammy found
that four out of 10 veterans describe their oral health as poor to fair
and that veterans are at higher risk of developing gingivitis compared
to their civilian counterparts. Lifestyle behaviors such as poor eating
habits, smoking, and chewing tobacco; mental illness, including
depression, anxiety disorder, and post-traumatic stress disorder; toxic
exposures; rural versus urban environments; gender; and polypharmacy
are some of the factors that increase a veteran's risk of developing
gingivitis. Tammy also found that a healthy smile is linked to job
security. In fact, VA is currently authorized to extract teeth from
veterans who are inpatients, but does not have the authority to replace
such teeth with prosthetics or dentures unless the veterans is
otherwise eligible for VA dental care. The VFW has heard from veterans
who felt embarrassed to attend employment interviews or go back to work
with missing teeth.
There is a large disparity between VA and Department of Defense
(DoD) dental coverage, which can have a significant impact on the
health and quality of life for veterans. To this day, servicemembers
are required to maintain a high level of dental readiness, to the
extent that they are placed on a non-deployable status if they fail to
receive a dental evaluation every year. However, only veterans who are
100 percent service-connected disabled, certain homeless veterans, and
those who have a service-connected dental condition are eligible for VA
dental care. The majority of veterans enrolled in VA health care are
unjustly denied access to VA dental care. Instead, they are offered the
ability to purchase dental insurance through VA, which has high costs
and poor coverage. VFW members who are asked for feedback on VADIP
report that it is better than nothing. Those who have worn our nation's
uniform deserve the best, not ``better than nothing.''
However, it is important for veterans to know that VADIP is an
option. For that reason, the VFW supports requiring VA to provide
information on VADIP to veterans. The VFW would recommend that the
Subcommittee expand the outreach requirement to include outreach at all
VA medical centers and through the VA Welcome Kit. All VA health care
enrolled veterans are sent a VA Welcome Kit which details their VA
benefits. The only mention in the kit of dental care is in reference to
a one-time appointment veterans are able to receive if they are within
180-days from their military service separation date.
This draft legislation would create a pilot program to expand
dental care services to veterans who are enrolled in VA at five
locations across the country. The pilot is also limited to 1,500
veterans who are between 40 and 70 years of age, do not receive regular
periodontal care, and have been diagnosed with type 2 diabetes. The VFW
understands that veterans who need dental care access the most must be
prioritized, but would urge the Subcommittee to expand the eligibility
to include all veterans enrolled in VA health care.
H.R. 2645, Newborn Care Improvement Act of 2019
The VFW supports this legislation, which would expand VA's
authority to provide health care to a newborn child, whose delivery is
furnished by VA, from seven to 14 days post-birth.
My wife and I are expecting our first child this month and recently
discussed our options for providing him with health care coverage.
Before this month, VA was my only health care option. I am fortunate
that the VFW's employee-sponsored health care plan open enrollment was
this past month, so I was able to enroll in the VFW's employee-
sponsored health insurance so my son can have health coverage after he
is born. If he were born before the open enrollment period, I would
have needed to wait months or up to a year to enroll him. Women
veterans in my situation may not be so lucky. Women veterans who rely
on VA health care for their maternity care have seven days to find
health care coverage for their child. The time following the birth of a
child is a hectic time for new parents. Whether their newborns have
health care coverage is the last thing on their minds.
According to the Centers for Disease Control and Prevention,
newborn screenings are vital to diagnosing and preventing certain
health conditions that can affect a child's livelihood and long-term
health. The VFW understands the importance of high-quality newborn
health care and its long term impact on the lives of veterans and their
families. To align this bill with common practice in the private
sector, the VFW urges the Subcommittee to expand the time a newborn
child is covered by VA to 30 days. Doing so would ensure newborns
receive the proper post-natal health care they need.
H.R. 2681, to direct the Secretary of Veterans Affairs to submit to
Congress a report on the availability of prosthetic items for women
veterans from VA
The VFW supports this legislation, which would require VA to review
whether VA provides prosthetics that meet the needs of women veterans.
VFW members have reported being prescribed VA prosthetic items such as
shoes and eyeglasses, but not being able to receive them because VA did
not have women's shoes or frames they could use. The VFW supports an
audit of availability of such items.
H.R. 2752, VA Newborn Emergency Treatment Act
The VFW supports this legislation which would expand VA's current
authority to cover the cost of emergency transportation for eligible
newborn babies. Under current law, VA is authorized to provide seven
days of medical coverage for newborn children, but that coverage does
not include emergency transportation if a newborn requires treatment
that is not available at the medical facility where the child was born.
The VFW has long supported expanding the length of time a veteran's
newborn child is provided medical coverage by VA, and believes also
expanding current legislation to include emergency transportation is
common sense. If a veteran gives birth to a child who then has an
emergency medical situation which the birthing facility is unable to
address, VA must cover the cost of transporting such newborn to a
facility that can provide the required care. Veterans in this situation
are already under a great deal of stress, and it is unjust to then add
the burden of emergency transportation costs.
H.R. 2798, Building Supportive Networks for Women Veterans Act
This legislation would establish a permanent program of retreat
counseling services for women veterans. The VA pilot counseling retreat
program has served as an invaluable tool to help newly discharged
veterans seamlessly transition back to civilian life. The VFW supports
making this program permanent.
Another successful program created by the Caregivers and Omnibus
Health Services Act of 2010 is the child care pilot program. This
program has been well received by veterans at all four pilot sites and
has also contributed to the success of the counseling retreat program.
The VFW has heard from veterans who say they could not have completed
their treatment programs if not for the services offered through VA's
child care pilot program.
The VFW thanks the Subcommittee and Chairwoman Brownley for
securing House passage of H.R. 840, the Veterans' Access to Child Care
Act, which would make the child care pilot permanent. The VFW is
hopeful that the Senate would follow your lead and pass it as well.
H.R. 2816, Vietnam-Era Veterans Hepatitis C Testing Enhancement Act of
2019
This legislation would require VA to host outreach events with
veterans organizations to expand hepatitis C (HCV) testing. The VFW
agrees with the intent of the bill, but does not believe it is needed.
The VFW lauds VA for its efforts to test for and cure HCV. It
recently announced that the VA health care system has cured more than
100,000 veterans with HCV. In an effort to maximize outreach, VA has
reached out to veterans organizations and made itself available for
organizations that would like to host testing evets, similar to what is
required by this legislation. VA medical staff is present at the VFW
National Convention every year and has conducted such testing.
The VFW does support the provision to require VA to report to
Congress activities it conducts as part of the HCV campaign.
H.R. 2972, to improve the communications of VA relating to services
available for women veterans
The VFW supports this legislation, which would rightfully expand
the authority of the VA Women Veterans Call Center to communicate via
text message, and ensure women veterans are able to easily connect with
women's health coordinators at their VA medical facilities.
H.R. 2982, Women Veterans Health Care Accountability Act
This legislation would require VA to conduct a comprehensive study
of women veterans health care. The VFW supports this bill and has a
recommendation to improve it.
In 2016, the VFW conducted a survey of nearly 2,000 women veterans
as a way to evaluate the performance of VA in caring for women
veterans. Over the past three years, we have worked with VA and
Congress to address health care, identity and outreach, and
homelessness issues identified in the survey. We found that women
veterans overwhelmingly prefer to receive their health care from women
primary care providers, and are more likely to be satisfied with their
VA health care experience when they receive care from female providers.
VFW members reported concerns regarding gender-specific
competencies in specialty clinics. For example, veterans reported
having problems finding prosthetic options suitable for women, leaving
them with no choice but to use uncomfortable products that do not fit
properly. In orthopedics, veterans reported that doctors fail to treat
them with their gender in mind. VFW members have also voiced concerns
about the lack of gender-specific training for mental health care
providers. The VFW thanks the Subcommittee for considering this
legislation which would commission a study to evaluate whether VA has
been successful in addressing these issues, and require it to develop a
plan to further improve health care for women veterans.
The VFW survey of women veterans also found that older women
veterans were less likely to report receiving disability compensation,
but equally as likely to have been injured or made ill as a result of
their military service. Similarly, older veterans were less likely to
report that they use VA health care, but equally as likely to report
being eligible for VA health care than their younger counterparts. We
were also concerned that several respondents who reported being 55-
years-old and older believed they did not rate the same benefits as
their male counterparts, which is an egregious misperception that must
be addressed. No veteran should be left to wonder what, if any, VA
benefits she is eligible to receive. It must be clear that women
veterans have earned the exact same benefits as male veterans. That is
why the VFW urges the Subcommittee to expand the scope of the study to
include an analysis of non-health care programs and benefits that serve
women veterans.
H.R. 3036, Breaking Barriers for Women Veterans Act
The VFW support this legislation which would require VA to evaluate
whether VA's infrastructure must be modified to meet the health care
and privacy needs of women veterans, increase staffing, and establish
women-centric training for community care providers.
Barriers to health care is a significant concern for VFW members.
Particularly, VA must be more proactive than reactive when it comes to
access to gender-specific care for women veterans. As the women veteran
population continues to grow, VA must ensure it provides care and
services tailored to their unique health care needs. Veterans deserve
access to the best treatment and care this nation has to offer. That is
why it is crucial for VA to outfit existing facilities with basic
necessities, such as curtains for privacy in women's clinics. These
clinics also need to maintain at least one primary care provider with
expertise in women's health who is able to train others.
However, the VFW recommends removing the option of one part-time
provider. A part-time provider would limit access to care for woman
veterans and decrease the provider's ability to maintain gender-
specific expertise. While we understand that not every VA medical
facility can have a doctor who devotes 100 percent of clinical time
exclusively to women veterans, it is unacceptable for veterans to wait
for care simply because the provider at their facility is only there on
certain days of the week. The primary duty of Designated Women's Health
Primary Care Providers must be to care for women veterans, but some
should have the ability to see male veterans to fill their schedules or
panels. Regardless, the VFW believes that all VA medical facilities
must have at least one full-time provider trained to care for the
unique needs of women veterans.
H.R. 3224, to provide for increased access to VA medical care for women
veterans
The VFW supports this legislation, which would require VA to
continually make available gender-specific services. VFW members have
reported facing delays or barriers to accessing gender-specific
services at remote locations and at facilities that have the demand for
gender-specific service, such as mammogram machines, but have failed to
do so or have inaccessible services. The VFW does suggest, however,
that the report required by this legislation include data on timeliness
of gender-specific services. Some facilities may have gender-specific
services available, but wait times prevent veterans from utilizing
them.
H.R. 3636, Caring for Our Women Veterans Act
The VFW supports this legislation, which would require reports on
staffing and locations that provide care to women veterans. All three
reports required by this bill are due 90 days following enactment of
the bill and annually thereafter. To ensure uniformity in reporting,
the VFW recommends consolidating the three reports into one
comprehensive report.
H.R. 3798, Equal Access to Contraception for Veterans Act
This legislation would require VA to provide veterans contraceptive
items without copayments. The VFW cannot support this bill because it
is too narrow. The VFW recommends the Subcommittee consider and advance
H.R. 3932, Veterans Preventive Health Coverage Fairness Act. The VA
formulary currently carries all categories of pharmaceuticals deemed
preventive by the U.S. Preventive Services Task Force. However, VA is
exempt from requirements to provide preventive care and services
without cost-shares.
Cost is a significant barrier for veterans who use VA health care,
whom have been found to have lower income on average than veterans who
do not use VA health care. There are currently 11 categories of
preventive medications found to be effective by the U.S. Preventive
Services Task Force, which include contraceptives and aspirin to lower
the risk of cardiovascular disease. Cardiovascular disease is the
number one cause of death in the United States and is highly prevalent
among the veteran population. Additionally, folic acid is recommended
for pregnant women to prevent neural tube defects. It is unjust to
require women veterans to pay for the cost of medication to prevent
such birth defects. Vitamin D is another preventive medicine which is
often prescribed to prevent bone fractures, which benefits traumatic
brain injury patients with hindbrain injuries. There is also breast
cancer prevention medication which is useful not just for individuals
with a family medical history of breast cancer, but for Camp Lejeune
toxic water survivors who have been found to suffer from increased
rates of breast cancer. These pharmaceuticals have been found to
prevent possible deadly disease and to lower long-term health care
costs.
This legislation would leave out veterans who are in need of other
preventive medicines. That is why the VFW calls on the Subcommittee to
consider and pass H.R. 3932, Veterans Preventive Health Coverage
Fairness Act, which would eliminate this inequity and ensure veterans
have access to lifesaving preventive medicine.
H.R. 3867, Violence Against Women Veterans Act
The VFW supports this legislation, which would enhance VA's efforts
to address domestic violence and sexual assault. While the language of
the bill does not explicitly limit the program, study, and taskforce
created by this bill to women veterans, the VFW recommends the
Subcommittee make clear that such provisions apply to all veterans.
Sexual assault continues to be a problem within DoD for all active,
reserve, and guard components and for veterans of all backgrounds
without regard to age, gender, or race. Most survivors of military
sexual trauma (MST) are males, but women are disproportionately
affected. While DoD continues to increase its efforts to reduce or
eliminate sexual trauma within the military service, the number of
servicemembers affected by MST is slow to decline. The VFW agrees that
a collaborative effort in awareness, reporting, prevention, and
response among all branches of the Federal and state governments is
needed.
VA has a national MST screening program that screens all patients
enrolled in VA for MST. National data from this program reveals that
about one in four women, and one in 100 men, respond affirmatively to
having experienced sexual trauma while serving their country. All
veterans who screen positive are offered a referral for free MST-
related treatment, but notably does not trigger the VA disability
claims process. Previous years of VA data show growing numbers
exceeding 100,000 veterans receive care for MST-related treatment.
In fiscal year 2017, 3,681 men and 8,080 women submitted claims to
VBA for health problems related to MST. Of those claims, 55 percent of
claims from males and 42 percent of claims from females were denied.
This is why the VFW encourages Congress to continue its oversight
efforts on VA care related to MST and VBA's process of handling MST
claims. It can take many years for survivors to even acknowledge a
trauma occurred, and sharing details with advocates and care providers
can be extremely difficult. Survivors of sexual assault often report
they feel re-traumatized when they have to recount their experiences to
compensation and pension examiners. Therefore, we encourage VA to
employ the clinical and counseling expertise of sexual trauma experts
within the community to ensure VA can provide the care and benefits
sexual assault survivors deserve.
H.R. 4096, Improving Oversight of Women Veterans' Care Act of 2019
The VFW supports this legislation which would require VA to report
on gender-specific community care, and increase compliance of VA women
veterans health care policies.
Due to a lack of capacity of gender-specific services at VA medical
facilities, women veterans are often required to rely on community care
for services such as mammography, obstetric care, and gynecological
care. In the VFW's women veterans survey, nearly 40 percent of women
who reported using VA community care said they did so for gender-
specific services. This legislation would ensure veterans who rely on
community care are provided the best possible care available and would
ensure such care complies with best practices.
This legislation would also require increased compliance with VA's
women veterans health care policy. However, it references a women's
health handbook that the VFW was unable to find. VA has published
Veterans Health Administration (VHA) Directive 1330.01, which
establishes standards for the delivery of health care to women veterans
and specifies the roles and responsibilities of staff. VA often issues
directives and guidance to the field, but fails to conduct the
appropriate quality assurance to verify compliance. The VFW supports
requiring VA to enforce compliance with VHA Directive 1330.01.
Draft bill to establish in VA the Office of Women's Health
The VFW support this legislation, which would establish an officer
of Women's Health to provide centralized monitoring and standardized
implementation of VA women veterans health care policy and programs.
The VFW has enjoyed a great partnership with the VHA Patient Care
Services Women's Health Services office. This office has been integral
in ensuring VA is ready and able to provide high-quality care for women
veterans. Elevating this important office would ensure more can be done
for the brave women who have worn our nation's uniform.
National Association Of State Women Veteran Coordinators (NASWVC)
Chairwoman Julia Brownley, Ranking Member Dr. Neal Dunn, and
members of the Subcommittee on Health, on behalf of the National
Association of State Women Veteran Coordinators thank you for this
opportunity to share support for Women Veterans nationwide.
Today is a small but vital step toward progressing the quality of
life for Women Veterans across the country. The National Association of
State Women Veteran Coordinators (NASWVC) has worked tirelessly to
ensure that our voices do not go unheard. We are an alliance which
represents Women Veterans from all of America and her territories, from
the sandy beaches of Florida, to the snow-capped mountains of Alaska
and into the proud territories of Puerto Rico and Guam. On this day, we
are proud to stand as one in such a venue.
Women Veterans are the fastest growing Veteran group. We total
approximately 2 million and account for over 9% of the U.S. Veteran
population but are projected to account for 15% by the year 2025.
Currently, women account for 22% of enrollees in military academies - a
sharp increase in only a few decades. Their graduation rates are
currently on par with their male counterparts.\1\
---------------------------------------------------------------------------
\1\ https://www.rand.org/pubs/research--briefs/RB9496/index1.html
---------------------------------------------------------------------------
The National Association of State Women Veteran Coordinators
recognizes that there are four pressing issues facing Women Veterans
today: 1) Military sexual trauma (MST) 2) Homelessness 3) Suicide and
4) Access to health care. Because these issues are all linked together
as both negative outcomes and risk factors, NASWVC has made them
priority issues, or pillars, upon which we will base our education,
policy, and outreach for the next year. While each of the bills before
the Committee are important, NASWVC has chosen seven to overwhelmingly
endorse, as they are each tied intrinsically to one or more of our
stated priority areas.
HR2681: While in service, Women Veterans experienced the problems
that are associated with wearing gear designed for men (for example,
flak vests, which can leave permanent scarring on the hips), and once
discharged report to the VA for care only to find that the same
conditions exist. While a woman is pregnant her center of gravity and
balance will be greatly different. Wearing a prosthetic designed for a
man will indeed hinder her mobility during much of her pregnancy.
Properly fitted prosthetics, from insoles to artificial limbs, are
important for both physical and mental health and can define for a
Woman Veteran not only how she feels about herself but the importance
she sees the VA placing on her as a Veteran. It can go so far as to
determine whether she returns to the VA for care. This is why NASWVC is
happy to support HR2681.
HR2982, HR3036, and HR3636: Substance use, mental health disorders,
eating disorders, and MST are all risk factors associated with suicide
and homelessness. The VA offers care specific to each of these issues
for Women Veterans, yet not enough Women Veterans are using these
services because of barriers to care or accessibility issues. Barriers
to care for Women Veterans in many ways look different than they do for
men. Aside from commonalities such as wait times, Women Veterans also
report that safety, child care, comfort, and appropriate, and properly
trained providers can all be barriers to obtaining care at the VA.
Additionally, one in three Women Veterans experienced some form of
military sexual trauma while on active duty\2\, which has been
associated with increased physical health symptoms, impaired health
status, and more chronic health problems in veterans\3\. Obtaining
physical and mental health care can mitigate the symptoms and reduce
the negative outcomes of MST and the other risk factors, making early
and ongoing access to health care vital. In 2015, 22% (or approximately
456,000) Women Veterans, used VA health care. What's more notable,
however, is the difference in use among those who are enrolled and not
using VA health care (13 .5%) or are not enrolled (64.1%)\4\
---------------------------------------------------------------------------
\2\ Iovine-Wong, P.E., C. Nichols-Hadeed, J. T. Stone, et al. 2019.
Intimate partner violence, suicide, and their overlapping risk in women
veterans: a review of the literature. Military Medicine.
\3\ Suris, A. Lind, L. 2008. Military Sexual Trauma : A Review of
Prevalence and Associated Health Consequences in Veterans, Trauma
Violence Abuse DOI: 10.1177/1524838008324419
\4\ The Past, Present and Future of Women Veterans, Department of
Veterans Affairs, National Center for Veterans Analysis and Statistics,
February 2017
---------------------------------------------------------------------------
The Department of Veterans Affairs has found that among Veterans
with suicide ideation, there is a substantial decrease in risk between
those who use and those who do not use the VA. Since 2001, the rate of
suicide among Veterans who use the VA increased by 8%, while among
those who did not use the VA it increased by 38.6%. However, when
examining that difference through a gender lens, the rate difference
for Women Veterans is more obvious, at 4.6% increase for women who use
the VA vs 98 % those who do not\5\. Analyzing the data in this way,
becomes more apparent that reducing barriers and connecting women to
services is a vital step in helping to reduce suicide attempts.
---------------------------------------------------------------------------
\5\ https://www.va.gov/opa/publications/factsheets/Suicide--
Prevention--FactSheet--New--VA--Stats--070616--1400.pdf
---------------------------------------------------------------------------
Environmental factors are indeed often listed by Women Veterans as
a barrier to care at the VA. While steps have been made to reduce these
factors within Women's Health Clinics, departments outside Women's
Health Clinics where women must receive services that extend beyond
their reproductive and breast health (e.g. lab, internal medicine,
oncology, etc.) are too often unfriendly environments for Women
Veterans in the VA. Environmental factors could run the gamut from the
arrangement of chairs in waiting rooms to an exam room with no curtain,
which leaves the veteran exposed when the door opens.
Truly integrated care is a consideration that is also a challenge
outside Women's Health Clinics. It means not receiving a letter
addressed to ``Mr.'' (or not being called Mr. when in the waiting
room); not having the option of a female provider - especially when you
have MST or another form of personal trauma; not having to wear ``one
size fits all'' drawstring pants that are four sizes too big; or not
being forced to wear pajamas cut for a man's body yet being disallowed
to wear a brassiere or undershirt and feeling exposed. While those who
have not experienced such trauma may consider these small things, they
can mean the difference between feeling comfortable and safe enough to
get the needed care versus resorting to detrimental self-help
practices. These small examples are easy to remedy but such simple
things can be important. Ensuring that these changes happen not just in
larger medical facilities but are also examined and changed in
Community Based Outpatient Clinics will be a critical to step to
removing barriers for women veterans.
Supporting Women Veterans in the U.S. and territories and serving
all Women Veterans regardless of status for over 20 years, the NASWVC
offers its full support for HB2982, HR3036, and HR3636. We recommend
that throughout the nation the NASWVC along with the state level Women
Veteran coordinators be involved as partners throughout each of the
survey processes.
HR 2798: The National Association of State Women Veteran
Coordinators acknowledge that one-third of women in the military screen
positive for MST\6\, and some surveys have shown this number to be as
high as 59% (2016 Oregon survey of women veterans\7\). PTSD is one of
the three most prevalent diagnostic issues Women Veterans face\8\; and
sexual assault is more likely to result in symptoms of PTSD than are
most other types of trauma, including combat\9\, yet there remains a
scarcity of retreat centers for Women Veterans in the United States
that address MST, and for many women this is not something they seek
care for until decades after separation. There are large sections of
the country where there are no retreat options available. Recent
research by the Department of Defense has found that the rate of sexual
assault, rape, and harassment during active duty increased 30% from
2016 to 2018. While women are 20% of the military, they are 63% of
assault victims\10\. Given the overwhelming number of Women Veterans
who live with military sexual trauma, NASWVC recommends that Military
Sexual Trauma be listed specifically as one of the Covered Services for
retreat settings for Women Veterans newly separated. Given the
importance of early intervention and treatment that can help ameliorate
risk factors for homelessness, suicide, and substance abuse, NASWVC
wholeheartedly supports HR2798.
---------------------------------------------------------------------------
\6\ Klingensmith K, Tsai J, Mota N, et al. Military sexual trauma
in US veterans: results from the national health and resilience in
veterans study. J Clin Psychiatry. 2014;75(10):e1133-e1139.
\7\ https://www.oregon.gov/odva/Connect/Documents/FinancialReports/
2016%20ODVA%20Women%20Veterans%20Health%20Care%20Study.pdf
\8\ https://www.womenshealth.va.gov/WOMENSHEALTH/
latestinformation/facts.asp
\9\ https://www.mentalhealth.va.gov/docs/top--10--public.pdf
\10\ https://www.sapr.mil/sites/default/files/DoD--Annual--Report--
on--Sexual--Assault--in--the--Military.pdf
HR 3867: Women Veterans are at a higher risk (approximately 33%)
than civilian women (24%) for experiencing intimate partner violence
during their lifetime\11\. Although the VA does offer IPV services, the
survivors may not use the VA for a variety of reasons. For a variety of
reasons, however, including accessibility, but they may be willing to
utilize their community crisis intervention services. These community
services can be the first line of defense for women seeking safety and
shelter and to help prevent survivors and their families from having to
choose between becoming homeless and having to remain with their
abuser. Partnering with community crisis centers and state coalitions
offers the Department of Veterans Affairs another opportunity to
provide partner training on serving women veterans, and it provides
increased opportunities to enroll women in VA for benefits and services
vital to their well-being. Like MST, IPV is also a risk factor for
homelessness. NASWVC supports the passage of HR3867.
---------------------------------------------------------------------------
\11\ Iovine-Wong, P.E., C. Nichols-Hadeed, J. T. Stone, et al.
2019. Intimate partner violence, suicide, and their overlapping risk in
women veterans: a review of the literature. Military Medicine.
HR4096: State Women Veteran Coordinators work one-on-one with Women
Veterans and frequently hear that there are insufficient gender-
specific or gender-inclusive services at the VA. Moreover, Women
Veterans speak to this as a barrier, citing this as a reason for not
returning. It is not unusual for Women Veterans, especially those who
have MST, to prefer women providers. Too often, however, the VA's
answer to a request for a female provider is ``if there is one
available.'' It is not unusual for the Woman Veteran to not know until
she shows up that the provider is a male, which can cause her to feel
as though she has no choice but to submit to the uncomfortable
experience. This experience may drive her decision to not return to the
VA for care. Having staff that is sensitive to the unique experiences,
challenges and issues faced by Women Veterans instead of seeing them as
problematic or inconvenient will go far in enhancing the environment of
care for Women Veterans at the Department of Veterans Affairs. NASWVC
members are in nearly every state and are happy to partner with their
local VA medical facilities as women's health team members and
participate in inspection and improvement teams. NASWVC strongly
supports HR4096
Thank you for the opportunity to provide a platform for the voices
that often go unheard. Any progress that can be made toward providing a
better quality of life for women veterans is paramount. Legislation is
a major step in the right direction.
On behalf of the National Associate of State Women Veterans
Coordinators, again, we thank you.
Service Women's Action Network (SWAN)
Chairman Takano, Ranking Member Poe and members of the Committee,
thank you for the opportunity for the Service Women's Action Network to
provide a statement for the record on the health legislation before the
Committee today.
Background: SWAN members have consistently expressed
dissatisfaction with the quality, completeness and ease of access to
health care provided to women veterans by the Department of Veterans
Affairs. Their view is that the great disproportion between the
percentage of male and female veterans who access VA health care steers
VA to health care policies, practices and allocations of fiscal and
personnel resources to the needs of men.'
Better Health care for Women Veterans: Both the Department of
Veterans Affairs and Congress have taken actions over the years to
safeguard women veterans' access to quality health care, but too often
these efforts have fallen short both with respect to ease of access and
to quality and completeness of the care given to women. Women will soon
constitute 20% of the veterans' population. SWAN is pleased to see that
the House Veterans Affairs Committee is considering the following
legislation which should bring women veterans closer to receiving their
earned health care with the same ease, quality and completeness as
their brother veterans. SWAN, therefore, supports all of the bills
under consideration by the Committee today.
We put particular importance on, and, therefore, strongly support
the following:
H.R 2645 which raises to 14 days the emergency care that newborns can
receive when necessary.
H.R. 2681 which requires a report on the availability of prosthetic
items tailored to women's needs and bodies.
H.R. 2752 which provides medically necessary transport for newborns.
H.R. 2972 which directs the Secretary of Veterans Affairs to improve
communications to women veterans about the VA services available to
them.
H.R. 2982 which directs the Secretary of Veterans Affairs to conduct a
study on the barriers women veterans face when trying to access VA
health care.
H.R. 3036 which directs the Secretary of Veterans Affairs to provide a
plan on the requirements to retrofit VA facilities and staffing to
better support women veterans' health care.
H.R. 3224 which requires VA to conduct a study on extending the hours
during which women veterans can obtain routine health care at VA
medical facilities.
H.R. 3798 which limits co-pays for contraceptives.
H.R. 4096 which requires an annual report to Congress on veterans'
access to gender-specific services under the newlv let Communitv
Care contracts.
Thank you for the opportunity to comment on this legislation.\1\
---------------------------------------------------------------------------
\1\ Disabled Veterans of America, February 2017, "The Past, Present
and Future of Women Veterans" states that 92.5% percent of users are
men while only 7.5 percent are women--
---------------------------------------------------------------------------
Sincerely,
Ellen L. Haring, PhD
Colonel, US Army retire
CEO, Service Women's Action Network
[all]