Statement for the Record
Thomas J. Berger, Ph.D.
Senior Analyst for Veterans’ Benefits & Mental Health Issues
Marsha Four, Chair, VVA National Women Veterans Committee
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
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
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.