VVA Testimony VVA Testimony
VVA Testimony
 

Statement for the Record
Submitted By
 Thomas J. Berger, Ph.D.
Senior Analyst for Veterans’ Benefits & Mental Health Issues
And
Marsha Four, Chair, VVA National Women Veterans Committee
Before the
U.S. House of Representatives
Veterans Affairs Committee
Subcommittee on Health
H.R. 1211, Women Veterans Health Care, H.R. 784, H.R. 785 and Emergency Treatment in Non-VA Facilities

March 3, 2009

 
 

Mr. Chairman, Ranking Member Brown, Distinguished Members of the House Veterans’ Affairs Subcommittee on Health and honored guests, Vietnam Veterans of America (VVA) thanks you for the opportunity to present our statement for the record views on this important veterans legislation being presented before this subcommittee today.

It is indisputable that the number of women in the military has risen consistently since the two percent cap on their enlistment in the Armed Forces was removed in the early 1970s. This has resulted in an increased number of women we can now call “veterans”, and most assuredly, will have a direct bearing on the number of women who will be knocking on the door of the VA in the very near future. A focus on the capacity and capability of the VA to equitably and effectively provide care and services must be a priority today. Planning and readiness is essential for the future. These responsibilities also require oversight and accountability in order to meet both VA and veteran goals, objectives, requirements, standards, and satisfaction, along with agency advancement.

While much has been done over the past few years to advance and ensure greater equity, safety, and provision of services for the growing number of women veterans in the VA system, these changes and improvements have not been completed implemented throughout the entire VA system. In some locations, women veterans still experience significant barriers to adequate health care and oversight with accountability. Thus VVA asks the new Secretary to ensure senior leadership at all VA facilities and in each VISN to be held accountable for ensuring that women veterans receive appropriate care in an appropriate environment.

Additionally, there is much to learn about women veterans as a separate patient cohort within the VA. Women’s Health is now studied as a specialty in every medical school in the country. It has moved far beyond that of obstetrics and gynecology. Gender has an impact on nearly every system of the body and mind. This has great significance in the ability of any health care system to provide the most appropriate, comprehensive, and evidence-based scientific treatment and care. This also has a direct effect on the delivery system along with staff requirements to meet the needs of women now utilizing the VA health care system, as well as for those new women veterans who will be coming into the system in the future.

The VA has already identified that our country’s new women veterans are younger and that they expect to use the system more consistently. For example, in December 2008, the VA reported the of the total 102,126 female OIF-OEF veterans, 42.2 percent of them have already enrolled in the VA system, with 43.8 percent using the system for 2 – 10 visits. Among these returning veterans, 85.9 percent are below the age of 40 and 58.9 percent are between 20 and 29. In fact, the average age of female veterans using the VA system is 48 compared with 61 for men. Therefore it is clear that the needs of women veterans are growing and already taxing the VA system, which historically has focused on an older population.

The 110th Congress put forward two bills related to women veterans S.2799 and H.R. 4107 that unfortunately were not finalized with passage. So VVA is pleased to see the reintroduction of such legislation with H.R.1211 and applauds the efforts of this committee to bring women veterans’ health care to the forefront of attention in the 111th Congress. However, VVA does wish to make comments on a number of specific provisions included in this proposed legislation.

Title I: Studies and Assessments of Department of Veterans Affairs Health Services for Women Veterans:

Section 101: Study of Barriers for Women Veterans to Health Care from the Department of Veterans Affairs – Section 101(a)(4)

VVA believes that this study is vital to understanding today’s women veterans and that building on the “National Survey of Women Veterans in Fiscal Year 2007-2008” is a referenced starting point. However, VVA also believes that there is a need to expand several elements in this section. For example, Section 101(a)(4) should include a survey of sufficient size and diversity to be statistically significant for women of all ethnic groups and service periods.

Section 101(b) – VVA believes that this study should identify the “best practices” that facilities utilize to overcome identified barriers.

Section 101(b)(2) – VVA believes that with the fragmentation of women’s health care services there needs to be consideration for driving time/transportation to medical facilities that offer specialty care as well as primary care.

Section 101(d)(1) – While VVA holds great respect for and recognizes the important work of both the Office of the Center for Women Veterans and that of the Advisory Committee on Women Veterans, this section as written would limit the initial review, creating unnecessary delays. Rather, VVA believes that this study should also go immediately to these two entities, plus the VA Undersecretary for Health, the Deputy Undersecretary for Quality and Performance, the Deputy Undersecretary for Operations, the Office of Patient Care Services, and the Chief Consultant for the Women Veterans Health Program for review and recommendations, which in turn are then forwarded to the Deputy Undersecretary for action to remove or ameliorate the identified barriers.

Section 101(e)(2) – VVA recognizes that this section requires that 30 months after the VA publishes the 2007-08 National Survey of Women Veterans that the VA Secretary in turn is required to report to Congress on the barriers study and what actions the VA is planning. However, in reality, this means that the information/directions contained in the ’07-08 report is/are put “on hold” for two and a half years. Therefore VVA believes that the Secretary’s report to Congress should also include what actions – if any -- have transpired both during the survey and the 30 month hiatus.

Section 102(1) – VVA believe this section should include appropriate language directing the study format to include the use of evidence-based “best practices in care delivery.

Title II: Improvement and Expansion of Health Care Programs of the Department of Veterans Affairs for Women Veterans

Section 201 – VVA asks that particular reflective consideration be given to the following -- VVA seeks a change in this section of the proposed legislation that would increase the time for the provision of neonatal care from 14 to 30 days, as needed for the newborn children of women veterans receiving maternity/delivery care through the VA. Certainly, only newborns with extreme medical conditions would require this time extension. VVA believes that there may be extraordinary circumstances wherein it would be detrimental to the proper care and treatment of the newborn if this provision of service was limited to solely 14 days. If the infant must have extended hospitalization, it would allow time for the case manager to make the necessary arrangements to arrange necessary medical and social services assistance for the women veteran and her child. This has important implications for our rural woman veterans in particular. And this is not to mention cases where there needs to be consideration of a woman veteran’s service-connected disabilities, including toxic exposures and mental health issues, especially during the pre-natal period.

Section 202 – VVA has concerns about the VA establishing a “certification” program. In order to be valid, VVA believes that such a certification program be based upon and modeled after those already utilized by many professional organizations. Such a certification program would lend itself well to oversight and accountability. Too many VA certification programs now consist of only a one-hour training class or reading materials.

Section 202(e)(2) – Although this section calls for reporting the number of women veterans who have received counseling, care and services under subsection (a) from “professionals and providers who received training under subsection (4)”, VVA asks “Who in the VA is already trained and holds professional qualifications under these subsections”?

A Concern of Non-inclusion – During the 110th Congress, VVA was heartened to see that the S.2799 legislation included a “Long Term Study of Health of Women Veterans of the Armed Forces Serving Operation Iraq Freedom and Operation Enduring Freedom”. However, VVA is extremely disappointed to see that any mention of this proposed study is missing from H.R. 1211 which is currently under consideration by the 111th Congress. As you know, the second round of the National Vietnam Veterans Readjustment Study was never completed by the VA, even though it was mandated by Congress to do so. VVA urges you not to let this opportunity be lost again on a statistically significant and diverse population of veterans. With regard to women veterans and the NVVRS, if and when the VA is ever held accountable and again directed to complete this important study, VVA is extremely interested in the issue of auto-immune diseases found in the study.

As time, social environments, and veterans’ population demographics change, there are also cultural expectations based on scientific advancements in healthcare that elicit a re-definition of women veterans’ needs in the VA system. Knowing the needs is vital to understanding and meeting them. The VA has recognized many of the needs of women veterans by actually creating interest groups comprised of not only VA staff, but veterans as well. For example, there is recognition that younger women veterans are also working women who need flexible clinic and appointment hours in order to also meet their employment and child-care obligations. They also need to have sexual health and family planning issues addressed, along with the needs of infertility and pre-natal maternity. And there are unanswered questions and concerns about the role of exposures to toxic substances and women’s reproductive health.

The new woman veterans also need increased mental health services related to re-adjustment, depression, and re-integration, along with recognition of differences among active duty, Guard, and reserve women. The VA already acknowledges the issue of fragmented primary care, noting that in 67 percent of VA sites, primary care is delivered separately from gender specific health care – in other words, two different services at two different times, and in some cases, two different services, two different times, and two different delivery sites. The VA also notes that there are too few primary care physicians trained in women’s health, and at a time when medicine recognizes the link between mental and medical health, most mental health is separate from primary care. VVA seeks to ensure that every woman veteran has access to a primary care provider who meets all her primary care needs, including gender specific and mental health care in the context of an on-going patient-clinician relationship; and that general mental health providers are located within the women’s and primary care clinics in order to facilitate the delivery of mental health services.

Vietnam Veterans of America applauds the VA for elevating its Office of Women’s Health to the Strategic Health Care Group level. With this action, the VA has “pumped up” the volume on the attention and direction of the VA regarding woman veterans. But there remains much to be learned about women veterans as a health care cohort. Data collection and analytical studies will provide increased opportunities for research and health care advancement in the field of women’s health, as well as offer evidence-based “best practices” models and innovative treatments.

The VA is a massive health care system that possesses challenges for the new Secretary, VA leadership, and all those VA employees who provide and deliver care treatment, and services to our nation’s veterans. VVA is hopeful that any shortfalls can be turned into positive action with resolve through a progressive implementation plan which turns hopeful plans into reality.

H.R. 784, VVA has no objections to the proposed emendation of Title 38, U.S. Code which directs the Secretary of Veterans Affairs to submit quarterly reports to Congress on vacancies in mental health professional positions in Department of Veterans Affairs medical facilities.

H.R. 785, VVA generally supports the bill as written; however, we suggest that there be an evaluation report after one year of operations. The legislation should be passed as the pilot program to provide outreach, training and evaluation to certain college and university mental health centers relating to the mental health of veterans of Operations Iraq Freedom and Operation Enduring Freedom.

Emergency Treatment in Non-VA Facilities, VVA is pleased to support the proposed emendation to Title 38, United States Code, to expand veteran eligibility for reimbursement by the Department of Veterans’ Affairs for emergency treatment in a non-Department facility.

As you may well remember from several previous appearances before this committee, VVA has addressed the problems associated with the VA’s paradigm for delivery of health care. Until very recently this paradigm has been predicated on placing resources where there is a large concentration of veterans eligible for services. In other words, the chief mechanism for service delivery of veterans’ health care has been in or near large urban centers. However, those service men and women fighting our current wars in Iraq and Afghanistan (and elsewhere) comprise the most rural fighting force since before World War I.

The Department of Defense reports that over 40 percent of our current military force originates from towns and communities of 25,000 or less. What this means is that we collectively must re-think the paradigm of how we deliver medical services, including emergency medical services, to veterans in need.

The proposed emergency care legislation is a good start in toward testing what is going to work in regard to delivering quality health care services to veterans (including demobilized National Guard and Reserves) who live in less populous areas of our country, and deserves to be enacted and implemented as quickly as possible.

VVA thanks this committee for the opportunity to submit testimony for the record.

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