Joy J. Ilem
Messrs. Chairmen and Members of the Subcommittees:
Thank you for inviting the Disabled American Veterans (DAV) to provide testimony at this joint hearing on the present and future needs of women and minority veterans seeking services from the Department of Veterans Affairs (VA). You have called a hearing on important topics that demand attention by the Committee, the VA, and the Department of Defense (DoD).
In June 2007 the VA Health Services Research & Development Service (HSR&D) released a new report, Racial and Ethnic Disparities in the VA Healthcare System: A Systematic Review.
For many years, the VA has expressed its commitment to eliminating ethnic disparities in health care to ensure equal access and quality health care for all veterans using VA services. Researchers systematically reviewed the existing evidence on disparities to determine which clinical areas racial and ethnic disparities are prevalent within VA, described what is known about the sources of those disparities and qualitatively synthesized that knowledge to determine the most promising avenues for future research aimed at improving equity in VA health care.
Researchers looked at a number of clinical areas including: arthritis and pain management; cancer; cardiovascular diseases; diabetes; HIV and Hepatitis C; mental health and substance abuse; preventative and ambulatory care; and rehabilitative and palliative care. The findings of the study concluded that disparities appear to exist in all clinical arenas and a number of reasons were offered as to why disparities exist. More notably, researchers commented in nearly each case that the underlying causes of these disparities were not explored or remain unclear. One key finding was that in studies examining quality indicators representing immediate health outcomes—such as control of blood sugar, blood pressure, or cholesterol—non-white veterans generally fared worse than whites. The researchers noted that this finding was especially troubling since it may indicate that disparities in health care delivery are contributing to real disparities in health outcomes. It was also noted that fewer studies examined Hispanics, American Indians, and Asians and that in general, disparities in the VA appear to affect African American and Hispanic veterans most significantly.
The study relates specific sources of disparities and offers a number of future research recommendations to further elucidate and reduce/eliminate racial disparities in VA health care including:
- Designing decision aids and information tools for minority veterans with a focus on literacy, language and cultural issues
- Interventions to make patients more active participants in their health care decisions
- Improved communication strategies for patients and clinicians to help strengthen patient-provider relationships
- Additional studies to determine sources of variation in clinical judgment by patient race
- Interventions to promote evidence-based decision making by providers
- Interventions to provide support to veterans to improve adherence to medication and treatment plans
It is clear from the findings of this recent study that much more needs to done in this area. We urge VA to continue its research and provide appropriate resources and policies to eliminate racial disparities in VA health care.
In preparing for this hearing we also reviewed the most recent annual report (July 1, 2006) available from the VA Advisory Committee on Minority Veterans. The Advisory Committee made a number of recommendations including: improved outreach to all veterans including minority veterans; expansion of internet based access to VA benefits and health care with particular attention given to cultural and linguistic diversity; continued research to help eliminate barriers for minority veterans to access health care and other benefits; increased attention to minority veterans living in rural areas, increase staff diversity; hire minority veterans from Operation’s Enduring and Iraqi Freedom (OEF/OIF) to ensure sensitivity to a new generation of minority veterans seeking benefits and health care services from VA; improve coordination between VA and DoD to ensure basic information about VA benefits and services is made available to newly returning minority veterans from OEF/OIF. Of special concern to the Advisory Committee was the issue of outreach versus marketing. The Committee reported that field facilities may be under the impression that they are prohibited from marketing including conducting outreach to minority veteran populations. We agree with the Advisory Committee that this interpretation of policy is a serious impediment to minority veterans’ knowledge of their VA benefits.
We support and applaud the Advisory Committee for its continued efforts to increase awareness about minority veteran issues and advance the quality of the services minority veterans currently receive.
With increasing numbers of women serving in the military, and with more women veterans seeking VA health care following military service, it is essential that the VA be responsive to the unique demographics of this veteran population cohort. In addition, VA must ensure that its special disability programs are tailored to meet the unique health concerns of women who have served in combat theaters and those who have suffered catastrophic disabilities as a result of military service.
Although VA has markedly improved health care services for women veterans over the past ten years, privacy issues at some facilities and other deficiencies still exist. VA needs to monitor and enforce, at the network and local levels, the legislation, regulations, and policies specific to health care services for women veterans. Only then will women veterans receive high quality primary and gender-specific care, continuity of care, and the privacy they expect and need at all VA facilities.
Messrs. Chairmen, there has been a trend in the Veterans Health Administration (VHA) to move away from comprehensive or full-service women’s health clinics for the purpose of providing both primary and gender-specific health care to women veterans. According to VA, less than half of its facilities surveyed provide care to women through mixed gender primary care teams and refer women to specialized women’s health clinics for gender-specific care. As you are aware, in the mid-1990s VA reorganized from a predominantly hospital-based delivery care model to an outpatient healthcare delivery model focused on preventative and health maintenance care. While we supported that shift, we are concerned about the incidental impact of the primary care model on the quality of health care delivered to women. VA’s 2000 conference report “The Health Status of Women Veterans Using Department of Veterans Affairs Ambulatory Care Services” noted that with the advent of primary care in VA, many women’s clinics were being dismantled and that women veterans were assigned to primary care teams on a rotating basis, essentially without regard to gender. Findings from the report indicated that this practice further reduced the ratio of women to men in any one practitioner’s caseload, making it even more unlikely that the clinician would gain the clinical exposure necessary to develop and maintain expertise in women veterans’ health. We understand that a follow-on study is currently being conducted and we look forward to those findings.
VA acknowledges that full-service women’s primary care clinics that provide comprehensive care, including basic gender-specific care, are the optimal milieu for providing care to women veterans. Or, in cases where there are relatively low numbers of women being treated at a given facility it is preferable to assign all women to one primary care team in order to facilitate the development and maintenance of provider clinical skills in women’s health. VA also notes that the health care environment directly affects the quality of care provided to women veterans and has a significant impact on the patient’s comfort, privacy, feeling of safety, and sense of welcome.
According to VA researchers, although women veterans surveyed reported that they prefer receiving primary and gender-specific health care from the same provider or clinic, in actuality, their care is fragmented, with different components of care being provided by different clinicians with variable degrees of coordination and expertise of caring for women. Additionally, researchers found a number of barriers to delivering high quality health care to women veterans. Specifically, insufficient funding for women’s health programs, competing local or network priorities, limited resources for outreach, inability to recruit specialists, lower numbers of women veterans’ caseloads, limited availability of afterhours emergency health services, and an insufficient number of clinicians skilled in women’s health.
VA Researchers made several recommendations to address these barriers, including concentrating women’s primary care delivery to designated providers with women’s health expertise within primary care or women’s health clinics; enhancing provider skills in women’s health; providing telemedicine access to experts to aid in emergency healthcare decision making; and, increasing communication and coordination of care for women veterans using fee-basis or contract care services. We are pleased that funding has been approved for VA researchers to study the impact of the practice structure on the quality of care for women veterans and fragmentation of care for women veterans including unmet healthcare needs for women with chronic physical and mental health conditions.
Messrs. Chairmen, VA previously established women’s health as a research priority to develop new knowledge about how to best provide for the health and care of women veterans. In 2004, VHA’s Office of Research and Development held a groundbreaking conference, “Toward a VA’s Women’s Health Research Agenda: Setting Evidence-Based Research Priorities for Improving the Health and Care of Women Veterans.” The participants of the conference were tasked with identifying gaps in understanding women veterans’ health and health care and with identifying the research priorities and infrastructure required to fill these gaps. In April 2005, a special solicitation was issued for research proposals to assess healthcare needs of women veterans and demands on the VA healthcare system in targeted areas, such as mental health and combat stress, military sexual trauma (MST), post-traumatic stress disorder (PTSD), homeless women veterans, and differences in era of service (e.g., Iraq vs. Gulf war). An entire issue of the Journal of General Internal Medicine was dedicated to VA research and women’s health in March 2006. Published findings included articles on why women veterans choose VA health care; barriers to VA health care for women veterans; health status of women veterans; PTSD and increased use in certain VA medical care services; and, MST.
We have strongly encouraged VA, as it takes steps to advance this agenda, to focus on research and programs that enhance VA’s understanding of women veterans’ health issues and discover new ways to optimize health care delivery and improve health outcomes for this patient population.
Addressing the Needs of Women Veterans Who Served in Operations Enduring and Iraqi Freedom (OEF/OIF)
According to the VA Women Veterans Health Program Office, as of August 31, 2006, approximately 70,000 women have served and separated from military service in OEF/OIF. Among this group nearly 37.2 percent, or 25,960, have sought and received health care from VA since separation from military service (up from 32.9 percent, or 15,903, in the previous year). According to VAthe prevalence of potential PTSD among new OEF/OIF women veterans treated at VA from fiscal year 2002-2006 has grown dramatically from approximately one percent in 2002 to nearly 19 percent in 2006.
The challenge of addressing the health care needs of the growing number of women veterans exposed to combat with and without obvious injury is daunting. In the future, the needs will likely be significantly greater with more women seeking access to care, increased health care utilization, and a more diverse range of medical conditions. It is unlikely the past experience of women veterans in the VA will serve as an accurate guide because of the unique experiences of women who have served in OEF/OIF.
Equal access to quality mental health services is critical for women veterans, especially women veterans who have readjustment problems associated with serving in a combat theater or those who have suffered sexual or other trauma during military service. The VA Women’s Health Project, a study designed to assess the health status of women veterans who use VA ambulatory services, found that active duty military personnel reported rates of sexual assault higher than comparable civilian samples, and there is a high prevalence of sexual assault and harassment reported among women veterans accessing VA services. The study noted and we agree, that it is “essential that VA staff recognizes the importance of the environment in which care is delivered to women veterans, and that VA clinicians possess the knowledge, skill, and sensitivity that allows them to assess the spectrum of physical and mental conditions that can be seen even years after assault.”
According to VA, approximately 19 percent of the women screened between fiscal years 2002 and 2006 responded “yes” to experiencing MST, compared to one percent of men screened. In response to these reports, VA established a committee to explore ways to address the mental health needs of women veterans and to improve mental health services to women who have experienced MST. In 2006, VA developed an MST support team under its mental health service to specifically work with MST coordinators in the field to better monitor tracking, screening, treatment, and training programs for MST. VA is yet to implement earlier recommendations made by the Mental Health Strategic Health Care Group Subcommittee on Women’s Mental Health, including development of an MST provider certification program, providing separate sub-units for inpatient psychiatry and other residential services, and improved coordination with DoD on transition of women veterans. We encourage VA revisit these recommendations.
Given the increasing role of women in combat deployments and with more than 70,000 women now having served in OEF/OIF combat theaters, we are pleased that VA’s Women’s Health Science Division of VA’s National Center for PTSD is evaluating the health impact of combat service on women veterans, including the dual burden of exposure to traumatic events in the war zone and MST. According to the center, although there is no current empirical data to verify MST is occurring in Iraq there have been numerous reports in the popular press citing cases of sexual misconduct. In the center’s Women’s Stress Disorder Treatment Team, of 49 returning female veterans, 20 (41 percent) reported MST.
The Center notes that anecdotal reports from OEF/OIF veterans suggest a number of unique concerns that have a more direct impact on women than their male counterparts returning from combat theaters, including lack of privacy in living, sleeping, and shower areas; lack of gynecological health care; healthcare impact of women choosing to stop their menstrual cycle; health consequences of dehydration and chronic urinary tract infection. There are also reported findings that suggest distinct differences in homecoming, including that women may be less likely to have their military service recognized or appreciated; possible differential access to treatment services; and possible increased parenting and financial stress. Additionally, women may be more likely to seek help for psychological difficulties.
We are pleased the Center is looking at gender differences in mental health, MST in the war zone, and gender differences in other stressors associated with OEF/OIF service and homecoming. We understand a number of research initiatives/projects are focused on treatment of PTSD in women, enhancing sensitivity toward and knowledge of women veterans and their healthcare needs among VA staff, and MST among Reserve components of the armed forces.
Some women will suffer from severe PTSD which will require more intensive evidence based treatment. VA has conducted ground breaking research on evidence based treatment for PTSD, including a recent study that established the efficacy for women. The most effective approaches often require intensive outpatient or residential care. Lack of adequate child care is a significant problem for women requiring such care, as is transportation to treatments which require frequent, even daily attendance. Furthermore, while the establishment of the efficacy of these approaches is an important first step, they will only have an impact on the thousands of women veteran affected when they are fully deployed throughout the VA system and easily accessible to patients. This is not currently the case, as acknowledged by the National Center representative in recent testimony before the President's Wounded Warriors Commission.
We recognize that VA is attempting to address the needs of women veterans returning from combat theaters in a variety of ways and has provided guidance for medical facilities to evaluate the adequacy of programs and services for returning OEF/OIF women veterans in anticipation of gender-specific health issues. We understand that the Women Veterans Health Program Office and the local women veterans’ program managers (WVPMs) have partnered with the VA Seamless Transition Office to provide information during National Guard, Reserves, and family member demobilization briefings on VA services and programs for women veterans. VA should continue to strengthen its partnership with the DoD to ensure a seamless transition for women from military service to veteran status. An improvement in sharing data and health information between the Departments is essential to understanding and best addressing the health concerns of women veterans. Unlike female veterans from previous conflicts, this new cohort of female veterans has been routinely exposed to combat in Iraq. It is imperative to acknowledge that we do not fully understand the barriers that may prevent OEF/OIF women from accessing VA care. We do know from recent studies of OEF/OIF active duty and reserve component personnel that stigma is a major in accessing mental health services; with over 40% reporting that stigma would impact their access. Furthermore, we must acknowledge that we will never adequately understand the barriers to seeking VA care by only studying the minority of female veterans who actually receive care, as is the case with VA patient satisfaction surveys.
Therefore, DAV makes the following recommendations to better serve women veterans returning from combat theaters.
- VA and DoD should collaborate to conduct surveys of recently discharged active duty women and recently demobilized female reserve component members that fully assess the barriers that they perceive or have experienced to seeking health care through VA. These surveys should include assessments of the effect of sigma, driving distance, absence of child care, understanding of VA eligibility and services, user friendliness of VA services for those who have attempted to access care, cultural sensitivities that differentially affect women, and other key potential barriers.
- VA should quickly disseminate and deploy resources to make evidence based PTSD treatment easy accessible for women veterans across the country, and explore options for providing child care for those needing it to attend treatment.
- DoD should fund a prospective, population-based health study of women who served in OEF/OIF. An epidemiologic study with at least a ten year follow-up is needed. This study should be carried out by DoD, VA and University researchers collaboratively.
- VA should conduct a comprehensive assessment of its Women Veterans’ Health Programs, including specialized programs for women who are homeless or have substance-use and/or mental health issues, and develop an action plan to improve services for this population and projected future needs of OEF/OIF women veterans.
- VA’s sexual trauma programs should be enhanced.
- Family counseling programs should be expanded and enhanced to meet the needs of the spouses and children of veterans who have served in combat theaters. These mental health programs are critical to veterans and their families after military deployments.
- Each VA Medical Center should establish a consumer council that includes veterans’ service organizations, family members, and veterans including OEF/OIF veterans to ensure that care is veteran centered.
- VA’s Women Veterans and Minority Advisory Committees should include representative(s) who served in Iraq and Afghanistan.
At a recent VA National Conference: Evolving Paradigms—Providing Health Care to Transitioning Combat Veterans—one track focused on women veterans who served in Iraq. A panel discussion by those women was very revealing about their unique experiences in the military and the impact of that service on their physical and mental health, as well as their existing impressions of access to VA services post-deployment. The women who participated in this panel, as well as other women who have served in combat theaters, could offer valuable insight on the impact of military experience on this new generation of women veterans. We understand that VA had planned to convene a focus group of approximately 50 women veterans of the wars in Iraq and Afghanistan to examine gaps in service and how VA could better meet the needs of this group. It is not clear whether VA still plans to convene such a group, but DAV believes this could stimulate an effective policy debate within VA and greatly benefit this new generation of women veterans.
Finally, some women serving in the military may suffer the dual burden of combat exposure and MST. While the DoD has established an office to deal with the incidence of sexual trauma, the conditions of a combat theater, quartering and lack of personal security offer special threats to women. VA and DoD need to better coordinate policies and treatment for transitioning women veterans who suffer readjustment issues related to combat exposure and/or have suffered MST. With increasing pressure to address MST, DoD established a Sexual Assault Prevention & Response Office (SAPRO). Veterans now have the option to file either a “restricted” or “unrestricted” report of sexual assault in the military. In the case of a “restricted” report there is no investigation or legal action sought on behalf of the veteran but he or she will have access to medical treatment, counseling and advocacy support. Records detailing the assault and medical findings are kept for one year following the incident. It is our understanding that after the one year period if the veteran has not filed an unrestricted report any evidence collected including records of the incident will be destroyed. It is our hope that VA will collaborate with the SAPRO to ensure these records are either provided to the veteran or put in safe keeping. If a veteran is diagnosed with a mental health or physical disorder related to the assault during military service the records at the time of the assault would be essential in supporting the veterans claim for service-connection.
As we see growth in the number of women veterans using VA health care services, we also expect to see increased VA health care expenditures for women’s health programs. Unfortunately, VA medical center administrators are under continued pressure to streamline programs and impose every efficiency practicable. Often, smaller programs, such as programs for women veterans, are at risk of discontinuation. The loss of a key staff member responsible for delivering specialized healthcare services or developing outreach strategies and programs to serve the needs of women veterans, can threaten the overall success of a program.
Women veterans program managers (WVPM) and benefits coordinators are another key component to addressing the specialized needs of women veterans. These program directors and benefits coordinators are instrumental to the development, management, and coordination of women’s health and benefits services at all VA facilities. Given the importance of this position, DAV is concerned about the actual amount of time WVPMs are able to dedicate to women veterans issues and if they have appropriate administrative support to carry out their duties. According to VA, 71 percent of all WVPMs serve in a collateral role. Only 20 percent reported they were allocated more than 20 administrative hours per week to fulfill their program responsibilities during the fiscal year. With increasing numbers of women veterans, VA WVPMs must have appropriate support staff and adequate time allocated to successfully perform their program duties and to conduct outreach to women veterans in their communities. Increased focus on outreach to these veterans is especially important because they tend to be less aware of their veteran status and eligibility for benefits than male veterans.
In closing, VA needs to ensure priority is given to women veterans’ programs so quality health care and specialized services are available equally for women and men. VA must continue to work to provide an appropriate clinical environment for treatment, even where there is a disparity in numbers. Given the changing roles of women in the military, VA must also be prepared to anticipate the specialized needs of women veterans who were sexually assaulted in military service or catastrophically wounded in combat theaters, suffering amputations, blindness, spinal cord injury, or traumatic brain injury. Although it is anticipated that many of the medical problems of male and female veterans returning from combat operations will be the same, VA facilities must address the health issues that pose special challenges for women. DAV has recommended that VA focus its women’s health research on finding the health care delivery model that demonstrates the best clinical outcomes for women veterans. Likewise, VA should develop a strategic plan along with DoD to collect critical information about the health status and care needs of women veterans with a focus on evidence-based practices to identify other strategic priorities for women’s health research agenda.
Messrs. Chairman, this concludes my testimony and I will be happy to address questions from you or other Members of the Subcommittees.