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Needs of Women Veterans Subject of Congressional Hearings

This week, the Senate and House Veterans’ Affairs Committees held hearings on how to bridge the remaining gaps in health care for women veterans.

 

Senate Veterans’ Affairs Committee

 

On July 14, the Senate Veterans’ Affairs Committee held a hearing, “Women Veterans: Bridging the Gaps in Care.”

 

Chair Daniel Akaka (D-HI) said, “Women veterans are the fastest growing segment of veterans. In 1998, when VA [Department of Veterans Affairs] first began providing care to women, they were only four percent of the veteran population. Today, the percentage of women veterans is nearing eight percent and [is] expected to rise substantially over the next two decades. So it is appropriate that we ask now, ‘Is VA meeting the needs of women veterans?’ Many women veterans in need of services fall through the cracks because VA doesn’t have a thoroughly gender-focused range of care set up to catch them. There are many obstacles that veterans face access to health care and homelessness are two of them and many veterans, women veterans in particular, are struggling to get the services they deserve.”

 

Ranking Member Richard Burr (R-NC) said, “According to the VA budget submission, in 2007, just over 146,000 women veterans used gender-specific health care services at VA. In 2008, despite the growing number of women veterans that I talked about, there were over 141,000 users of the system, a decline of three percent from one year to the next. The question this committee must ask is ‘Why?’ Do women veterans feel comfortable coming to a hospital system largely comprised of male patients? Does VA provide the unique services required by women veterans? Does it provide these services in enough locations to make travel convenient? When VA cannot provide quality care, does it use services that already exist in the community that are specific to the needs of women?”

 

Randall Williamson, director of Health Care at the Government Accountability Office (GAO), discussed the GAO’s report on VA facilities for women veterans: “The VA facilities we visited provided basic gender-specific and outpatient mental health services to women veterans on site, and some facilities also provided specialized gender-specific or mental health services specifically designed for women on site. All of the VAMCs [VA medical centers] we visited offered at least some specialized gender-specific services on site, and six offered a broad array of these services. Among CBOCs [community-based outpatient clinics], other than the two largest facilities we visited, most offered limited specialized gender-specific care on site. Women needing obstetric care were always referred to non-VA providers. Regarding mental health care, we found that outpatient services for women were widely available at the VAMCs and most vet centers we visited, but were more limited at some CBOCs…In general, women veterans had access to female providers for their gender-specific care: of the 19 medical facilities we visited, all but four had one or more female providers available to deliver basic gender-specific care.”

 

 

With regard to privacy, Mr. Williamson added that “All facilities were fully compliant with at least some of VA’s privacy requirements; however, we documented observations in many clinical settings where facilities were not following one or more requirements. Some common areas of noncompliance included the following: None of the VAMCs or CBOCs we visited ensured adequate visual and auditory privacy at check-in in all clinical settings that are accessed by women veterans. In most clinical settings, check-in desks or windows were located in a mixed-gender waiting room or in a high-traffic public corridor…In exam rooms where gynecological exams are conducted, only one of the nine VAMCs and two of the eight CBOCs we visited were fully compliant with VA’s policy requiring exam tables to face away from the door…Only two of the nine VAMCs and one of the eight CBOCs we visited were fully compliant with VA’s requirement that exam rooms where gynecological exams are conducted have immediately adjacent restrooms. In most of the outpatient clinics we toured, a woman veteran would have to walk down the hall to access a restroom, in some cases passing through a high-traffic public corridor or a mixed-gender waiting room…At four of the nine VAMCs we visited, proximity of private restrooms to women’s rooms on inpatient or residential units was a concern…In two of these four settings, access to the shared restroom was not restricted by a lock or a keycard system, raising concerns about the possibility of intrusion by male patients or staff while a woman veteran is showering or using the restroom…At seven of the nine VAMCs and all 10 of the CBOCs we visited, we did not find sanitary napkins or tampons available in dispensers in any of the public restrooms.”

 

 

Patricia Hayes, chief consultant for the Women Veterans Strategic Health Care Group at the Department of Veterans Affairs, described some of the VA’s initiatives, saying, “In March 2008, the former under secretary for health charged a workgroup to define necessary actions for ensuring every woman veteran has access to a VA primary care provider capable of meeting all her primary care needs, including gender-specific and mental health care, in the context of a continuous patient-clinician relationship. This new definition places a strong emphasis on improved coordination of care for women veterans, continuity, and patient-centeredness. In November 2008, the workgroup released its final report identifying recommendations for delivering comprehensive primary care. These recommendations included: (1) delivering coordinated, comprehensive primary women’s health care at every VA health care facility by recognizing best practices and developing systems and structure for care delivery appropriate to women veterans; (2) integrating women’s mental health care as part of primary care, including co-locating mental health providers; (3) promoting and incentivizing innovation in care delivery by supporting local best practices; (4) cultivating and enhancing capabilities of all VA staff to meet the comprehensive health care needs of women veterans; and (5) achieving gender equity in the provision of clinical care.”

 

 

Ms. Hayes continued, “To achieve the goal of providing comprehensive primary care for women veterans, VA has designed three models to promote the delivery of optimal primary care. Under the first model, women veterans are seen within a gender neutral primary care clinic. Under the second model, women veterans are seen in a separate but shared space that may be located within or adjacent to a primary care clinic. Under the third model, women veterans are seen in an exclusive separate space with a separate entrance into the clinical area and a distinct waiting room. In this scenario, gynecological, mental health, and social work services are co-located in this space. Each of these models can be tailored to local needs and conditions to systemize the coordination, continuity, and integration of women veterans’ care. One-third of VA facilities have already adopted the third model of comprehensive primary care delivery and found it to be very effective. Access and wait times are better at sites where gender-specific services are available in an integrated women’s primary care setting, regardless of whether the care was delivered in a separate space (such as a women’s clinic) or incorporated within general primary care clinics. VA facilities that have established a ‘one-stop’ approach to primary care delivery have already reported higher patient satisfaction on care coordination for contraception, sexually transmitted disease screening, and menopausal management.”

 

 

“Research plays an integral role in developing the most appropriate health care delivery model for women veterans and providing access to high quality health care services,” said Joy Ilem, deputy national legislative director for Disabled American Veterans (DAV). She continued, “DAV is pleased that VA’s Office of Research and Development (ORD) supports a comprehensive women’s health research agenda, and [that] VA has intensified its research on women’s health in the last decade…ORD currently supports a broad research portfolio that includes: studies on diseases prevalent solely or primarily in women; hormonal effects on diseases in post-menopausal women; PTSD and other post-deployment mental health concerns among women; and osteoporosis and multiple sclerosis in women. Gender disparities have also been analyzed and highlighted in addition to the disparities in some types of preventative care among spinal cord injured women veterans that include the need for special equipment and body adjustments required to perform care. HSR&D [Health Services Research & Development] is also currently funding 27 research projects that examine the health and health care of women veterans; the consequences of military sexual trauma and other military traumas; PTSD treatment in women; screening and utilization as well as post deployment access and reintegration issues; utilization; outcomes and quality of care for women veterans related to ambulatory care; chronic mental and physical illness, alcohol misuse, breast cancer, and pregnancy outcomes. HSR&D is also in Phase II of a study examining VA’s approaches for delivering care to women veterans while another is assessing the implementation and sustainability of VA women’s mental health clinics. These studies include OIF/OEF [Operation Iraqi Freedom/Operation Enduring Freedom] populations.”

 

 

Kayla Williams, a veteran of the U.S. Army, discussed the challenges facing women veterans in need of mental health services, saying, “[I]t became clear upon our return that most people [do] not understand what women in today’s military experience. I was asked whether as a woman I was allowed to carry a gun, and was also asked if I was in the infantry. This confusion about what role women play in war today extends beyond the general public; even Veterans Affairs (VA) employees are still sometimes unclear [about] the nature of modern warfare, which presents challenges for women seeking care. For example, being in combat is linked to post-traumatic stress disorder (PTSD), but since women are supposedly barred from combat, they may face challenges proving that their PTSD is service-connected. One of my closest friends was told by a VA doctor that she could not possibly have PTSD for just this reason: he did not believe that she as a woman could have been in combat. It is vital that all VA employees, particularly health care providers, fully understand that women do see combat in Operations Iraqi Freedom and Enduring Freedom so that they can better serve women veterans.” Ms. Williams added, “Other barriers may disproportionately affect women. For example, since women are more likely to be the primary caregivers of small children, they may require help getting child care in order to attend appointments at the VA. Currently, many VA facilities are not prepared to accommodate the presence of children; several friends have described having to change babies’ diapers on the floors of VA hospitals because the restrooms lacked changing facilities. Another friend, whose babysitter cancelled at the last minute, brought her infant and toddler to a VA appointment; the provider told her that was ‘not appropriate’ and that she should not come in if she could not find child care. Facilities in which to nurse and change babies, as well as child care assistance or at least patience with the presence of small children, would ease burdens on all veterans with small children.”

 

 

Tia Christopher, women veterans coordinator for the Iraq Veterans Project, Swords to Plowshares; Jennifer Olds, an Army veteran on behalf of the Veterans of Foreign Wars; and Genevieve Chase, a veteran and executive director of the American Women Veterans; also testified.

 

 

House Committees

 

 

On July 16, the House Veterans Affairs Subcommittees on Health, and Disability Assistance and Memorial Affairs held a similar hearing, “Eliminating the Gaps: Examining Women Veterans Issues.”

 

 

Health Subcommittee Chair Michael Michaud (D-ME) said, “As a committee, we have taken key steps towards realizing this goal of equal health care and benefits for women. First, under the leadership of Chair [Bob] Filner [(D-CA)], we held a roundtable discussion on May 20, 2009 when we heard from women veterans representing veteran service organizations and their auxiliary organizations [see The Source, 5/22/09]. The roundtable participants identified many issues, which included military sexual trauma, combat post-traumatic stress disorder, denied benefits claims and lengthy appeals, barriers to health care utilization, and health care research on women veterans. Another example of this committee’s commitment to women veterans is our work on H.R. 1211, the Women Veterans Health Care Improvement Act, which was introduced by [Rep.] Stephanie Herseth Sandlin [(D-SD)]. My subcommittee favorably reported this bill to the full committee in early June and this important legislation passed the House recently on June 23, 2009 [see The Source, 6/26/09].”

 

Disability Assistance and Memorial Affairs Subcommittee Chair John Hall (D-NY) said, “Even when [women] do report incidences of harassment or assault, perpetrator conviction rates are only five percent, so these reports are seen as unsubstantiated. This result is especially unfair given that 78 percent of female service members reported some form of sexual harassment according to a DoD [Department of Defense] survey. Studies have shown that for generations women veterans have been less likely than men to be granted service connection for their post-traumatic stress disorder, even though data shows women are more likely to report symptoms and seek treatment…The future of the military will be more reliant on the selfless service and the sacrifices of this nation’s daughters, her mothers, and her sisters. Coming home must be free of abuse, disparity, and inequality so that transitioning female service members can continue to be productive employees and community leaders while maintaining healthy lifestyles and raising families.”

 

Anuradha Bhagwati, former captain and current executive director of the Service Women’s Action Network (SWAN), provided several recommendations for improving care for women veterans, saying that Congress should require, “that the VA remedy the shortage of female physicians, female mental health providers, and MST [military sexual trauma] counselors at VA hospitals nationwide. Also require that the VA provide the option of female-only counseling groups for female combat veterans, and female- as well as male-only counseling groups for female and male survivors of MST. Require the VA to implement a program to train, educate, and certify all staff, including administrative and medical, in federal Equal Opportunity regulations and MST, to reduce a discriminatory and hostile atmosphere toward women veterans. Require the VA to increase accessibility of fee-based care for veterans (both male and female) who have been diagnosed with military sexual trauma. Require day care facilities for veterans who are parents, as well as more flexible evening or weekend hours for working veterans and parents, at every VA hospital. Require the VA to conduct a study into what percentage of claims are denied with a breakdown by gender as well as type of injury/condition, including both combat-related PTSD, and PTSD or other conditions resulting from MST. Require that VBA [Veterans Benefits Administration] claims officers undergo intensive training and education in MST and MST-related medical conditions. Require that the VBA’s  submission requirements for MST claims reflect a reasonable standard, such as proof of MST counseling during or after service, and diagnosis of MST-related medical conditions. Require the DOD to conduct a retention study to determine the total impact of MST on re-enlistment rates of service members.”

 

 

Dawn Halfaker, vice president of the board of directors for the Wounded Warrior Project, expressed the need for increased outreach to women veterans: “Despite significant advances in VA health care for women veterans, researchers have found that many women veterans are unaware of the existence of VA women’s health care services or of their eligibility for such VA care. Such findings, along with research indicating that women veterans may have adverse perceptions about VA care, highlight the importance not only of providing more information to this population, but of overcoming perceptions and misperceptions. We see a need for aggressive, targeted outreach that takes account of research showing that women veterans who have experienced military sexual assault experience more distrust directed at medical staff, and reduced willingness to seek further help at military and VHA facilities than women who have sought treatment related to sexual assault at civilian facilities.” Ms. Halfaker added, “VA certainly has attempted to increase its outreach to new veterans, and better inform them regarding their health care eligibility, as well as on readjustment and psychological health issues. But no single step can be expected to change the paradigm for women veterans who may view VA as a system for older male veterans, or who may have concerns about the quality of its care or who having experienced sexual trauma in service may be distrustful of government-provided care. In that regard, there is a clear need for an aggressive approach to eliminating the barriers that deter at least some returning women veterans from pursuing needed help. We propose, in this regard, that Congress direct VA to employ, train, and deploy peers (other women OIF/OEF veterans, including those who have had readjustment or mental health issues) to conduct outreach to women OIF/OEF veterans, including one-on-one outreach efforts to address negative perceptions and build trust.”

 

Dr. Irene Trowell-Harris, director of the Center for Women Veterans at the VA said, “The [Advisory] Committee [on Women Veterans] is charged with advising the secretary on VA benefits and health services for women Veterans, assessing the needs of women veterans, reviewing VA programs and activities designed to meet those needs, and developing recommendations addressing unmet needs. Many of the recommendations made by the Advisory Committee have been instrumental in transforming VA to assist in meeting the needs of women veterans and to help bridge the gaps in services and benefits.” She continued, “To address the challenges of enhancing primary care for women veterans, VA has done the following: elevated the Women Veterans Health Program Office on VA’s organizational chart to the Women Veterans Health Strategic Health Care Group, as part of VA’s readiness for the influx of new women veterans. This group provides programmatic and strategic support to implement positive changes in the provision of care for all women veterans; employed a full-time Women Veterans Program Manager at every VA health care facility; initiated implementation of comprehensive primary care (including gender specific care) at every VA site; ensured accurate representation of the women veterans population through analysis and data; expanded the women’s health knowledge base among VA providers; sought to recruit primary care physicians who have knowledge and interest in women’s health; started to integrate mental health with primary care to enable a comprehensive women’s health care program; started to change the overall culture of VA to be more inclusive of women veterans, and recognize their military service and contribution to this nation.”

First Sergeant Delilah Washburn, USAF (Ret.), president of the National Association of State Women Veterans Coordinators, Inc. and regional director of the Texas Veterans Commission; Janice Krupnick, professor of the Department of Psychiatry and director of the Trauma and Loss Program at Georgetown University Medical Center; Phyllis Greenberger, president and chief executive officer of the Society for Women’s Health Research; Bradley G. Mayes, director of the Compensation and Pension Service for the Veterans Benefits Administration at the VA; Patricia M. Hayes, chief consultant for the Women Veterans Health Strategic Health Group at the Veterans Health Administration; and Lawrence Deyton, chief public health and environmental hazards officer at the Veterans Health Administration, also testified.