[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]



 
               ISSUES FACING WOMEN AND MINORITY VETERANS

=======================================================================

                             JOINT HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                and the

                 SUBCOMMITTEE ON DISABILITY ASSISTANCE
                          AND MEMORIAL AFFAIRS

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                             JULY 12, 2007

                               __________

                           Serial No. 110-33

                               __________

       Printed for the use of the Committee on Veterans' Affairs




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                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South     RICHARD H. BAKER, Louisiana
Dakota                               HENRY E. BROWN, Jr., South 
HARRY E. MITCHELL, Arizona           Carolina
JOHN J. HALL, New York               JEFF MILLER, Florida
PHIL HARE, Illinois                  JOHN BOOZMAN, Arkansas
MICHAEL F. DOYLE, Pennsylvania       GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada              MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado            BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas             DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana                GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California           VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota

                   Malcom A. Shorter, Staff Director

                                 ______

                         SUBCOMMITTEE ON HEALTH

                  MICHAEL H. MICHAUD, Maine, Chairman

CORRINE BROWN, Florida               JEFF MILLER, Florida, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
PHIL HARE, Illinois                  JERRY MORAN, Kansas
MICHAEL F. DOYLE, Pennsylvania       RICHARD H. BAKER, Louisiana
SHELLEY BERKLEY, Nevada              HENRY E. BROWN, Jr., South 
JOHN T. SALAZAR, Colorado            Carolina

                                 ______

       SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS

                    JOHN J. HALL, New York, Chairman

CIRO D. RODRIGUEZ, Texas             DOUG LAMBORN, Colorado, Ranking
PHIL HARE, Illinois                  MICHAEL R. TURNER, Ohio
SHELLEY BERKLEY, Nevada              GUS M. BILIRAKIS, Florida

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

                               __________

                             July 12, 2007

                                                                   Page

Issues Facing Women and Minority Veterans........................     1

                           OPENING STATEMENTS

Hon. Michael Michaud, Chairman, Subcommittee on Health...........     1
    Prepared statement of Chairman Michaud.......................    31
Hon. John J. Hall, Chairman, Subcommittee on Disability 
  Assistance and Memorial Affairs................................     3
    Prepared statement of Chairman Hall..........................    31
Hon. Doug Lamborn, Ranking Republican Member, Subcommittee on 
  Disability Assistance and Memorial Affairs.....................     2
    Prepared statement of Congressman Lamborn....................    32
Hon. Michael R. Turner...........................................     4
Hon. Gus M. Bilirakis, prepared statement of.....................    32

                               WITNESSES

U.S. Department of Veterans Affairs:
    Shirley A. Quarles, R.N., Ed.D., Chair, Advisory Committee on 
      Women Veterans.............................................    12
        Prepared statement of Dr. Quarles........................    33
    Colonel Reginald Malebranche, USA (Ret.), Member, Advisory 
      Committee on Minority Veterans.............................    14
        Prepared statement of Col. Malebranche...................    35
    Betty Moseley Brown, Ed.D., Associate Director, Center for 
      Women Veterans.............................................    27
        Prepared statement of Dr. Brown..........................    47
    Lucretia M. McClenney, Director, Center for Minority Veterans    29
        Prepared statement of Ms. McClenney......................    51

                                 ______

Disabled American Veterans, Joy J. Ilem, Assistant National 
  Legislative Director...........................................    21
    Prepared statement of Ms. Ilem...............................    41
Murdoch, Maureen, M.D., MPH, Center for Chronic Disease Outcomes 
  Research, Minneapolis Veterans Affairs Medical Center, 
  Minneapolis, MN, Veterans Health Administration, U.S. 
  Department of Veterans Affairs.................................    17
    Prepared statement of Dr. Murdoch............................    40
Rosenberg, Saul, Ph.D., Associate Clinical Professor of Medical 
  Psychology, University of California, San Francisco, CA........    15
    Prepared statement of Dr. Rosenberg..........................    37
Wilson, Hon. Heather, a Representative in Congress from the State 
  of New Mexico..................................................     4

                       SUBMISSIONS FOR THE RECORD

American Legion, Shannon L. Middleton, Deputy Director for 
  Health, Veterans Affairs and Rehabilitation Commission, 
  statement......................................................    54
Brown, Hon. Corrine, a Representative in Congress from the State 
  of Florida, statement..........................................    56
Miller, Hon. Jeff, Ranking Republican Member, Subcommittee on 
  Health, and a Representative in Congress from the State of 
  Florida, statement.............................................    56
Veterans of Foreign Wars of the United States, Dennis Cullinan, 
  Director, National Legislative Service, statement..............    56
Vietnam Veterans of America, Marsha Four, Chair, Women Veterans' 
  Committee, and John J. Rowan, National President, joint 
  statement......................................................    58
Women's Research and Education Institute, Susan Scanlan, 
  President, statement...........................................    62

                   MATERIAL SUBMITTED FOR THE RECORD

Post Hearing Questions and Responses for the Record:
    Hon. John J. Hall, Chairman, Subcommittee on Disability 
      Assistance and Memorial Affairs, Committee on Veterans' 
      Affairs, to Hon. R. James Nicholson, Secretary, U.S. 
      Department of Veterans Affairs, letter dated July 26, 2007.    64
    Hon. Michael H. Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs, to Shirley A. Quarles, 
      R.N., Ed.D., Chair, Advisory Committee on Women Veterans, 
      U.S. Department of Veterans Affairs, letter dated August 2, 
      2007.......................................................    81
    Hon. Michael H. Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs, to Colonel Reginald 
      Malebranche, USA (Ret.), Member, Advisory Committee on 
      Minority Veterans, U.S. Department of Veterans Affairs, 
      letter dated August 2, 2007................................    83
    Hon. Michael H. Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs, to Saul Rosenberg, Ph.D., 
      Associate Clinical Professor of Medical Psychology, 
      University of California, San Francisco, CA, letter dated 
      August 2, 2007 [NO RESPONSES WERE RECEIVED FROM DR. 
      ROSENBERG].................................................    85
    Hon. Michael H. Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs, to Joy J. Ilem, Assistant 
      National Legislative Director, Disabled American Veterans, 
      letter dated August 2, 2007................................    86
    Hon. Michael H. Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs, to Betty Moseley Brown, 
      Ed.D., Associate Director, Center for Women Veterans, U.S. 
      Department of Veterans Affairs, letter dated August 2, 2007    87
    Hon. Michael H. Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs, to Lucretia M. McClenney, 
      Director, Center for Minority Veterans, U.S. Department of 
      Veterans Affairs, letter dated August 2, 2007..............    90
    Hon. Michael H. Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs, to Shannon L. Middleton, 
      Deputy Director for Health, Veterans Affairs and 
      Rehabilitation Commission, American Legion, letter dated 
      August, 2, 2007............................................    91


                        ISSUES FACING WOMEN AND



                           MINORITY VETERANS

                              ----------                              


                        THURSDAY, JULY 12, 2007

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                      Subcommittee on Disability Assistance
                                      and Memorial Affairs,
                                                    Washington, DC.

    The Subcommittee met, pursuant to notice, at 10:00 a.m., in 
Room 334, Cannon House Office Building, Hon. Michael H. Michaud 
[Chairman of the Subcommittee on Health] presiding.

    Present from the Subcommittee on Health: Representatives 
Michaud and Hare.

    Present from the Subcommittee on Disability Assistance and 
Memorial Affairs: Representatives Hall, Hare, Lamborn, Turner, 
and Bilirakis.

             OPENING STATEMENT OF CHAIRMAN MICHAUD,
                     SUBCOMMITTEE ON HEALTH

    Mr. Michaud. The Subcommittee on Health will come to order. 
I'd like to thank everyone for coming today. This is a joint 
hearing with the Subcommittee on Disability Assistance and 
Memorial Affairs as well.
    Today we will examine the U.S. Department of Veterans 
Affairs (VA) programs regarding women and minority veterans. 
The face of the military is changing and so is the face of the 
veterans' population. According to the 2000 census, minorities 
make up over 14 percent of the existing veterans' population. 
The population of women veterans is projected to continue to 
rise from 6 percent in 2000 to 8 percent in 2010 and to 10 
percent in 2020.
    VA needs to consistently evaluate existing programs to 
address the needs of special groups and make changes when 
needed. I further believe that VA should implement new and 
innovative programs to help close the many gaps that exist 
today in delivering high-quality, safe health care and other 
benefits and services VA provides.
    Service in Operating Enduring Freedom (OEF) and Operation 
Iraqi Freedom (OIF) has created growing challenges for the VA 
in meeting the needs of women and minority veterans as they 
separate from service. We know that an unprecedented number of 
female servicemembers have been routinely exposed to combat or 
combat-like conditions. VA reports that the prevalence of 
potential post traumatic stress disorder (PTSD) among new OEF/
OIF women veterans treated at VA has grown from 1 percent in 
2002 to nearly 19 percent in 2006. Issues such as cultural 
differences, effective outreach, education, research and 
delivery of care should be carefully examined in an effort to 
provide the best possible service to these veterans.
    I hope that we will learn how the VA is meeting the needs 
of these populations, what challenges are on the horizon, and 
what we can do to provide veterans the best possible care 
available.
    At this time, I would yield to Mr. Lamborn who is the 
Ranking Member of the Disability Assistance and Memorial 
Affairs Subcommittee for an opening statement.
    [The prepared statement of Chairman Michaud appears on 
p. 31.]

            OPENING STATEMENT OF HON. DOUG LAMBORN,

           RANKING REPUBLICAN MEMBER, SUBCOMMITTEE ON
           DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS

    Mr. Lamborn. Thank you, Mr. Chairman, for recognizing me 
and I look forward to this hearing with you, with Mr. Hall from 
New York, with Mr. Turner and everyone else who can join us as 
we go through this hearing.
    I'm glad that we are having this hearing on the challenges 
facing minority and women veterans. I welcome our witnesses 
including my colleague from New Mexico Representative Heather 
Wilson. And I thank you all for your contributions to the 
Veterans' Affairs system.
    America's minorities and women of our great Nation are 
integral to the quality of our national security. Women make up 
nearly 10 percent of our Nation's 24 million living veterans. 
Women on active duty represent more than 15 percent of our 
armed forces. According to a 2005 Heritage Foundation study, 
about 25 percent of military recruits identify themselves as 
other than Caucasian. Further, military women are more likely 
to identify themselves as members of a racial or ethnic group 
than men.
    Our military has a higher percentage of some minorities 
such as African Americans, American Indians, Native Alaskans 
and Hawaiians and Pacific Islanders than the percentage of 
these minorities in the general population. These men and women 
are patriots. In more than 2 centuries of service to our 
country, women and minority servicemembers have created a rich 
legacy. This legacy has only been enriched by the intrepid and 
resolute accomplishments of their decedents in the global war 
on terror.
    Our challenge is to ensure that women and minority veterans 
indeed all veterans receive equal treatment for their 
qualifying service to our Nation. The VA Centers for Women and 
Minority Veterans and the Department's associated Advisory 
Committees are charged with increasing awareness of VA 
programs, with identifying barriers and inadequacies in VA 
programs, and with influencing improvement.
    We do not look to these VA programs to merely identify and 
report, we want them to influence policy and accept a measure 
of accountability for departmental results. In that regard, I 
will, of course, be very interested in hearing today about 
challenges facing women and minority veterans such as gender 
specific health care.
    I want to learn about disabilities more likely to effect 
minority veterans. I want to hear about the challenges facing 
veterans who wish to take advantage of economic opportunities 
in the public and private sectors. I will, however, especially 
want to learn today how the VA and it's component organizations 
are effectively rising to meet these challenges.
    Mr. Chairman, I yield back.
    [The prepared statement of Congressman Lamborn appears on 
p. 32.]
    Mr. Michaud. Thank you very much, Mr. Lamborn. And now I 
would like to yield to a gentleman who feels strongly about 
veterans' issues as well, Mr. Hall who is the Chairman for the 
Subcommittee on Disability Assistance and Memorial Affairs for 
an opening statement.
    Mr. Hall.

        OPENING STATEMENT OF CHAIRMAN HALL, SUBCOMMITTEE
         ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS

    Mr. Hall. Thank you, Chairman Michaud and Mr. Lamborn. I 
always enjoy serving with you on our Disability Assistance 
Subcommittee. Good morning, all.
    I would first like to say that I am honored to join Mr. 
Michaud in cochairing this hearing and I applaud the leadership 
he exercises on behalf of our veterans, especially on veterans 
health care issues. I would also like to thank the witnesses 
for joining the 2 Subcommittees this morning for a hearing to 
examine issues facing women and minority veterans.
    This rare joint hearing speaks volumes about how important 
these issues are to the Committee as a whole. I look forward to 
hearing from all of today's witnesses. I also want to apologize 
in advance for the fact that I am double booked in another 
Committee meeting and will have to leave and then come back in 
a little while so that I can hear as much testimony as 
possible. I will read the written testimony that I may miss in 
person.
    Women veterans are the fastest growing segment of the 
veteran population comprising 7 percent of the total veteran 
population and 5 percent of those using VA services. Over 14 
percent of veterans are from a racial or ethnic minority group 
with African Americans comprising the bulk at 9.7 percent 
according to 2000 U.S. Census figures. I am certain that the VA 
does its best to ensure that all veterans encounter no barriers 
to access and the receipt of veterans' benefits, treatment and 
services. However, the fact remains that the barriers in 
society at large that women and minorities often face might 
very likely translate into barriers in the smaller VA system.
    As such, Congress, in its wisdom, developed both the Center 
for Minority Veterans and the Center for Women Veterans in 1994 
to ensure that these veterans are fully integrated into the VA 
system. I look forward to hearing from both Centers as well as 
their separate Advisory Committees, which developed detailed 
reports to help inform the policies of the VA for women and 
minority veterans. I especially would like to learn the VA's 
and the Advisory Committee on Minority Veterans' views on the 
sunsetting provisions that would end the Advisory Committee in 
2009 and what, if any, plans it has to replace this vital 
organization.
    I know that Representative Gutierrez has introduced a bill, 
H.R. 674, that would prevent this from occurring. Getting rid 
of the Minority Veterans Advisory Committee would be a 
seriously troubling result in light of the recent findings by 
VA researchers that health disparities appear to exist in all 
clinical arenas and have a direct impact on the health outcomes 
for minority veterans.
    And last, but certainly not least, I welcome my colleague 
Congresswoman Heather Wilson, the only woman veteran in 
Congress. I am sure that all of our witnesses, including our 
experts and the veterans service organizations will provide 
critical insight on issues facing women and minority veterans, 
especially in light of returning OIF and OEF veterans.
    Thank you very much and I yield back, Mr. Chairman.
    [The prepared statement of Chairman Hall appears on p. 31.]
    Mr. Michaud. Thank you very much, Chairman Hall. Mr. 
Turner, do you have an opening statement?

          OPENING STATEMENT OF HON. MICHAEL R. TURNER

    Mr. Turner. Mr. Chairman, I want to thank both of the 
Chairmen for our proceeding with this hearing. This is very 
important and I want to congratulate and thank Heather Wilson 
for all of her efforts in Congress, not only to be a strong 
advocate for veterans in our military, but also to bring her 
experience to assist us so that we can also better serve. Thank 
you.
    Mr. Michaud. Thank you. Mr. Bilirakis, do you have an 
opening statement?
    Mr. Bilirakis. I'll submit my opening statement for the 
record, but I wanted to thank you for having this hearing. I 
also want to thank Congresswoman Heather Wilson for her great 
insight. And it is just a great subject and we need to 
concentrate more on minority veterans and women veterans. Thank 
you very much. I appreciate it.
    [The prepared statement of Congressman Bilirakis appears on 
p. 32.]
    Mr. Michaud. Thank you very much. It is my pleasure now to 
introduce our first panelist, Congresswoman Heather Wilson of 
New Mexico. I want to thank you very much for your willingness 
to come here and give us your expertise and your insight on 
these very important issues. Thank you for your leadership as 
well on these issues.
    So without further ado, Congresswoman Wilson.

STATEMENT OF HON. HEATHER WILSON, A REPRESENTATIVE IN CONGRESS 
                  FROM THE STATE OF NEW MEXICO

    Ms. Wilson. Mr. Chairman, thank you. And thank you very 
much for having this hearing today and bringing some focus on 
an issue very important to me.
    Now all of us are concerned about whether the VA health 
care system is meeting the needs of our current generation of 
veterans, but there is a special subcategory that sometimes I 
think gets overlooked. And the fact that you are having this 
hearing today says that the Congress and this Committee in 
particular cares about women veterans and whether they are 
getting the services that they need.
    In 1978, I got a one way ticket to Colorado Springs, 
Colorado, to attend the United States Air Force Academy in the 
third class with women. They opened the Air Force Academy to 
women when I was a junior in high school. And I got on the bus 
and went to the base of that big ramp at the front edge of the 
ramp part range in Colorado and walked up a ramp with huge 
letters over the top of it that said, ``Bring me men.''
    It took over 25 years to get that sign taken down. It is 
gone now, but some of us as women veterans think that maybe the 
VA health care system is now only experiencing the kind of 
integration that the military saw 20 years ago because my 
classmates and the women who went into the military in the 
seventies are now starting to retire. And, we also have women 
returning from combat zones with health care needs that we 
haven't seen in previous generations. So it creates a new 
challenge for the VA and I appreciate your willingness to look 
at this.
    Currently deployed in Iraq, 1 in 7 Americans deployed in 
Iraq and Afghanistan are women. They are doing jobs that in 
previous generations no women undertook in the military. And we 
need to orient our health care system toward the needs of both 
women and men. Women, frankly, face different obstacles when 
trying to get care from the VA, their needs are often 
different. Whether it is long term, whether the VA is going to 
be able to deal with the problems, whether it is osteoporosis 
or obstetrics/gynecology (OB/GYN) care or cancer screening and 
treatment or mental health issues and how they manifest 
themselves, they are often different needs. And we need to make 
sure that the VA is responsive to those needs.
    For example, if you are a veteran and you go to one of the 
clinics for a problem with PTSD at the VA hospital and they 
have a support group that is a bunch of guys, is that really 
where a woman feels particularly comfortable talking about her 
experiences? I am not sure I would. And I am not sure I would 
turn to the VA for the kind of care. Likewise, many women 
veterans do not even call themselves veterans. It is an 
interesting phenomena. But it is only now that women who have 
served in the military even use that term to describe 
themselves. And it is very different from men who have served. 
Someone, a fellow woman veteran gave me a tee shirt which I 
still have and wear from time to time around the house that 
says on the back of it, ``I am a veteran too.''
    Getting women to that point where they feel like they are 
veterans and they feel comfortable calling on the VA health 
care system, that the door is open to them, is a hurdle that we 
have to get over and the VA has to reach out to women veterans, 
I believe. In addition to those kinds of social or psycho-
social issues, there is a question of appropriate care. And 
while I haven't seen too many specifics incidences of problems 
in the VA health care system, I certainly had my share of them 
going through the U.S. Department of Defense (DoD) health care 
system and I can't imagine that the VA has magically addressed 
all of these problems without having to kind of go through 
their own learning curve.
    You know, for example, when I was on active duty and they 
had opened up flight school to women, you had to have a flight 
physical. Well a flight physical for women included an OB/GYN 
exam. The rules said that a flight physical had to be done by a 
flight surgeon, but the flight surgeons often times had only 
done their, you know, their last OB/GYN exam was in medical 
school and they didn't like it much when they did it the first 
time. So there were rules about how health care was to be 
provided for active duty women that weren't--there wasn't a 
most appropriate way to provide care. And I believe that those 
kinds of things probably exist in the VA health care system, 
but were only on the upward curve now with respect to the women 
that are getting care from the VA because their numbers have 
been so small, particularly the numbers of women veterans who 
are also combat veterans.
    In the 110th Congress, I have introduced a piece of 
legislation. It is a bipartisan commission on wounded women 
warriors. We focused a lot in the last year about the VA health 
care system and it's responsiveness to veterans overall. And 
all of us are keenly aware of the problems at Walter Reed and 
elsewhere on the care of our returning soldiers and veterans, 
but I think there is a subgroup we also need to look at. And I 
introduced this legislation to establish a 12 member bipartisan 
commission to bring some focus and expertise on this issue, to 
identify major problems and surface them at senior levels. The 
military did this in the seventies and eighties and it was very 
effective at identifying policies that needed to be changed, 
capabilities and services that needed to be expanded and 
provided and to better support our women in the military. And 
now I need to--I think we need to do a similar kind of thing 
for women veterans.
    Last month during debate on the military construction and 
VA Appropriations bill for fiscal year 2008, I offered an 
amendment that was accepted by voice that would devote $2 
million from the Administration's general operations expenses 
account to the Advisory Committee on Women Veterans. The intent 
of that amendment was to provide the funding for a bipartisan 
commission on wounded women warriors to look at these issues 
and identify problems and plans to make sure health care for 
women veterans is what it needs to be so that we can adequately 
meet their needs.
    We can't address the needs of women veterans unless we 
fully understand the problems. And I don't think we are yet 
fully at the point of fully understanding the problems within 
the VA health care system. And I think this Congress needs to 
make sure that we put ourselves on a path to do so.
    I thank you very much for holding this hearing today. And 
to the extent I can, I would be very happy to answer any 
questions you may have of me.
    Mr. Michaud. Thank you very much, Congresswoman Wilson. 
Just a quick question, do you get a lot of communication 
between women veterans that might not go to a male Member of 
Congress that know your experience? And what has been some of 
their concerns, if there is anything different than what you 
have already given in your testimony?
    Ms. Wilson. Sure. I think women sometimes feel more 
comfortable coming to me and it is I am sure it is--all of us 
come here with our own stories. And sometimes people will come 
where they feel more comfortable or feel somebody will get it. 
And so, yes, women veterans do come to me, both New Mexicans 
and some of the groups nationally or leaders nationally both 
veterans and active-duty servicemembers.
    Some of the kinds of issues is women's health care clinics 
at VA hospitals. We have had a problem in some VA hospitals 
including our hospital in New Mexico where several years ago 
they wanted to close the women's health care clinic. For some 
women being able to walk in and they are, you know, that they 
have a women's clinic is kind of important. Now there are a lot 
of ways and different models to provide that, but that was an 
issue. And it wasn't just an issue on the appropriateness of 
health care, it was the VA sending a message as to whether we 
are welcome here, or not, or do they want us to go somewhere 
else?
    And so that is an issue. I dealt with academy issues with 
respect to sexual assault, discrimination, those kinds of 
things come up. I was very active with Mr. Langevin of Rhode 
Island when women in Saudi Arabia were being asked to wear the 
abaya with the Muslim cloak while they were fighting to free 
the Afghan women from having to wear the burka. And they were 
required to wear by DoD policy, and we were able to change that 
by law. So, yes, women do come to me.
    Mr. Michaud. My last question, since there is not a large 
number of women veterans using VA facilities, trying to look on 
the fiscal side of the issue, do you think that VA should hire 
more women staff, or would it be more fiscally responsible to 
contract out the type of services a woman might need to help 
women veterans?
    Ms. Wilson. I think it is going to depend on the population 
served and, you know, we have clinics in all over New Mexico 
that are really quite small. And it so that a veteran can get 
primary care and in Truth or Consequences, New Mexico, without 
having to come all the way to Albuquerque. At the same time, 
the availability of services, particularly OB/GYN services in 
our major VA hospitals, I think is probably an issue. And the 
appropriateness of that care, whether it is by a contract 
doctor or an agreement with one of the universities or direct 
on-staff hire, and as you all know, the VA has had difficulty 
filling positions for a variety of reasons over time, but it is 
an issue of the appropriateness of care. And frankly, some 
women prefer to have a women doctor as an OB/GYN. And even the 
policy that says for most hospitals now you are a primary 
provider. If your health care is from a health maintenance 
organization, I can go to my primary care doctor. I can also 
get direct access to my OB/GYN. I believe that is currently VA 
policy, but making clear that you can go. You don't have to go 
through another gatekeeper. You can go directly. Those kinds of 
things I think are important to women.
    Mr. Michaud. Great. Thank you very much. Mr. Lamborn?
    Mr. Lamborn. I thank you, Mr. Chairman. In counting back 
the years, I think you were leaving Colorado Springs just as I 
was arriving there, because I moved there in 1987.
    Ms. Wilson. I graduated in 1982.
    Mr. Lamborn. Okay. How prevalent is the problem of women 
veterans being unaware that their military service qualifies 
them for VA health care? We are finding that male veterans are 
many times unaware of the benefits that they are entitled to.
    Ms. Wilson. I think you were right, Mr. Lamborn, that there 
is a problem of awareness of what benefits you are eligible for 
across the board. When I left the service, I didn't retire from 
the service, I left after 7 years as an officer. I had no clue, 
you know, that I left without any disability or any problems or 
anything. But I think most folks are pretty clueless. They, you 
know, we sign off on the forms and go on with our lives and 
things.
    So I think there does need to be outreach, but there really 
is a difference and it is starting to change, but women do not 
think of themselves. In my generation of women, we don't call 
ourselves veterans. I mean it doesn't, it didn't feel 
comfortable. It is starting to more, but if you don't even 
think of yourself as a veteran, it is unlikely that you are 
going to walk into the VA and say, ``I am a veteran and I want 
to see if I can get help.''
    Mr. Lamborn. Representative Wilson, you have made reference 
to that a couple of times now. Why do you think that is the 
case?
    Ms. Wilson. Because guys are veterans. You know, it is. And 
I don't, I think, probably for younger women, that is not the 
case. I think for our generation of women there is also an 
association that you are only a veteran if you were in combat. 
It is the veterans of foreign wars kind of standard. I even 
remember I had an uncle, a World War II veteran, and I was 
serving in the military. He is a loveable person and I thought 
the world of him. And he arranged for me to be a member of the 
American Legion Auxiliary, because I thought I should.
    Mr. Lamborn. Okay.
    Ms. Wilson. And I was on active duty in the military. And I 
thanked him so much and I was a member. But we didn't think of 
ourselves as being necessarily part of the group.
    Mr. Lamborn. Okay. Thank you. Now, the VA has brought 
authority to contract for care of women's veterans to contract 
out these services for care. Do you think non-VA professionals 
understand the unique needs of women who have served in the 
military, or are they subject to the same possible issues that 
the VA is?
    Ms. Wilson. The difficulty in the VA is that you are still 
dealing with a fairly small percentage of the clientele who are 
women. So they are not dealing with these issues in large 
numbers. I think that one of the areas we do need to look at is 
combat disabled veterans, and particularly some of the mental 
health issues that can manifest themselves differently among 
men and women. How do women approach mental health issues? How 
do they present themselves? What kinds of therapies are 
effective? And I having worked with children, mentally ill 
children, there are some differences among teens and young 
adults, men and women and what is affective? And I think we're 
going to need to take a look at that issue.
    And we know that there are large numbers of veterans 
returning with PTSD, acute PTSD as opposed to chronic PTSD, 
which we saw in the Vietnam cohort or we had been used to 
dealing with it in the Vietnam cohort. Do these 2 populations 
of women and men respond different, present differently, and 
what does that mean for the best kind of treatment, whether 
that is contract or whether that is within the actual VA 
system.
    Mr. Lamborn. Thank you. And my last question, to accomplish 
these goals that we are talking about today, should the VA have 
women's clinics? Should it better integrate women's health care 
into existing VA clinics or should it enhance the contracting 
out of care in community settings?
    Ms. Wilson. I like the idea of at least some point of 
presence. A women's clinic is a way of reaching out to women in 
a place particularly for OB/GYN care, cancer screenings, those 
kind of things, preventative health care. But this was one of 
the reasons why I think we need a high level commission to 
focus on things for a while to identify major issues and give 
us advice as legislators as opposed to all of us taking a wag 
based on personal experience or what we are seeing in our 
communities. Lets get some smart people together to really 
focus on this. Call in a lot of women veterans. It is amazing 
what they will tell when you turn off the microphones and close 
the doors and say, ``What is really happening? What works? What 
doesn't work? What regulations are you facing that are barriers 
to you?''
    And when we did that with women in the Defense Department, 
it was amazing. Some of the stupid rules and regulations that 
were barriers to women getting care.
    Mr. Lamborn. Well thank you for your answers. Thank you for 
your testimony today. And thank you for all the work that you 
are doing in this area. And most of all, thank you for your 
service to our country.
    Ms. Wilson. Thank you very much.
    Mr. Michaud. Mr. Hare.
    Mr. Hare. Thank you, Mr. Chairman. And thank you so much 
for coming this morning, Representative Wilson. I just had a 
comment, maybe a question. Well, actually, I was just thinking 
about what you said about a new generation of women veterans 
and perhaps that is because we see currently in Iraq, when 
causalities come, we are seeing a lot of women who are injured 
and who are losing their lives. I think it is very unfair to 
your generation, to our generation of veterans that preceded 
them that they are somehow forgotten. In other words, if they 
haven't served recently are they really veterans? I think that 
is sad.
    I guess what I would like to know from your perspective is 
what can we, and the VA do, to really bring the attention back 
to the people like yourself who have served honorably? We have 
a responsibility, I think, to and I have said this many times 
to this Committee to all of our veterans irregardless of what 
branch, irregardless of what their gender is. What can we do, 
do you think, to get the VA and to promote the type of benefits 
for veterans so that they--you know you just said you get women 
behind a door and you shut off the microphones and they will 
talk a lot. What could we do to enhance that and to be able to 
get more women to be able to understand that there are benefits 
available, and how to get them? Because I think it is terribly 
important that we do this.
    Ms. Wilson. A couple of things. First of all, I think it is 
important for the Congress as a Congress to establish a 
commission and say, ``Let's get some smart people and get some 
recommendations on what legislation and programs we need to 
support. I think that is important and it allows us to provide 
some leadership.
    One of the things that is important, and I heard someone 
slip recently in a position of public prominence, I don't want 
to identify them in a speech talking about our men in military. 
Our men overseas.
    Mr. Hare. Uh huh.
    Ms. Wilson. It was the first Persian gulf war when the 
lexicon of American public life changed for the first time. 
When you heard at that time, General Colin Powell, Brent 
Scowcroft, the first President Bush, the Members of Congress, 
for the first time they talked about our men and women in the 
Persian Gulf. The military had gone co-ed. And that was the 
first Cable News Network (CNN) war really where, you know, 
America was surprised that we had women helicopter pilots 
flying into harms way in front of the infantry forces. It was a 
major social change. But we can't go back, as I and that was 
just a slip, but I heard it. And when someone said, ``Our men 
in the military. Our men in Iraq and Afghanistan.'' Language 
matters, and people like me will hear that if you say it.
    I would also encourage, you there are now, there is at 
least in New Mexico and I think it is growing national 
movement. I look at all the flags behind you and all of us have 
the Jewish War veterans and the Purple Heart veterans and the 
American Legion and the VFW that all come to see us and see all 
of you annually. There is now a group starting and I think it 
is nationwide, but a chapter has started in New Mexico of a 
national Association of Women Veterans. We have to stand up 
first for ourselves. And I would encourage you to reach out to 
women veterans and ask them to come in and talk to you about 
what is going on with the VA in your community.
    And I am a member of some of those organizations of women 
veterans and there is an Association of Women Aviators that I 
am an honorary--well I am an associate member of I guess. I am 
not an aviator by profession. But those kinds of things I think 
help women to bring our issues to the floor just like the 
Reserve Officers Association does and make people aware of 
problems.
    So a commission, meet with people, and as leaders be 
careful to include us.
    Mr. Hare. Absolutely. I am sorry I came in late and I don't 
know if you mentioned this in your testimony or not, but do you 
have any idea of how many women veterans we are talking about 
think are being underserved or not being served?
    Ms. Wilson. In Afghanistan and Iraq, 1 in 7 Americans 
serving there is a woman. There have been over 2 million 
American women who have served this country in uniform in our 
history. Over 2 million and every single one of them was a 
volunteer.
    Mr. Hare. That is amazing. Thank you very much.
    Mr. Michaud. Thank you, Mr. Hare. Mr. Bilirakis?
    Mr. Bilirakis. Thank you, Mr. Chairman. I have one 
question. First of all, thank you for your testimony and 
enlightening us on this issue. Do you think it would be helpful 
if we had a program within the VA where women veterans can talk 
to women veterans and identify with them whether it is 
outreach, any kind of an issue. Would you think that would be 
helpful?
    Ms. Wilson. The VA does have an office for women's veterans 
that does outreach and so forth, but I actually think it is 
helpful to facilitate women coming together. At one time in my 
deep dark past, I served on the Defense Advisory Committee on 
Women in the Service after I had left the military but came 
back. And one of the great things about those conferences and 
meetings that we had was women in the military got together and 
there was cross talk.
    If you are in any group and you were talking about there is 
what 6 percent now? Between 6 and 8 percent of our veterans are 
women. That means in any room with 100 people there are only 6 
women. You are feeling a little isolated in any group. If you 
make the effort to pull women together so that you can get 
cross talk about what is going on in my State, in your State, 
and the health care system and so on, you get good ideas that 
come out of that and you help to identify problems.
    The VA does have an office for women veterans. I am not 
sure how much they really bring together in a working group 
kind of way, those kinds of colloquy to pull together women 
veterans in a circumstance where they are not out numbered. And 
to be able to take our shoes off and say, ``So what is going on 
in your State, because this one is a mess,'' or whatever it is. 
I think it would be helpful.
    Mr. Bilirakis. And maybe making sure that we mandate that 
there is one, at least one person at an out-patient clinic or 
the VA where the veteran can go to that individual, making sure 
that that is a women so they feel comfortable talking to them.
    Ms. Wilson. There are up sides and down sides to that, 
which is why I get back to lets pull some people together and 
make sure the system of care is responsible. If you created it 
at one VA hospital the women's office or the women's advocate 
in some ways that says to the rest of the system, ``Well, I 
don't have to deal with that. Go down to the women's office. 
Now that is not my job,'' as opposed to if you are a cancer 
specialist or the oncology department has to be taking into 
account possible screenings for breast cancer and cervical 
cancer, so integrating into the way the VA does it's business.
    But I do think that there is advantage, particularly in OB/
GYN, care to having systems set up so that women feel as though 
they are welcome here. There is a place for----
    Mr. Bilirakis. Sure.
    Ms. Wilson [continuing]. And they are not separate but 
equal or pushed out somewhere else.
    Mr. Bilirakis. Make sure that there is a women's counselor 
there available for them. Would you agree with that?
    Ms. Wilson. Yeah, I would. But I don't want to say, ``All 
right, we are going to create a space within the VA for women 
and this is the women's office and that is where we deal with 
that problem because we are the VA, and you know just stay over 
there. We have got a little office for you in the closet.''
    Mr. Bilirakis. Okay. Thank you very much. I appreciate it 
Mr. Chairman. Thank you.
    Mr. Michaud. Thank you very much. And once again, thank you 
very much, Congresswoman Wilson. We really appreciate you 
enlightening us on this particular area. And thank you for your 
service not only to your constituents back in your district, 
but also to your country. So thank you very much.
    Ms. Wilson. Thank you, Mr. Chairman. I appreciate it.
    Mr. Michaud. We will now move to our second panel. And I 
would ask that the members of the second panel to please come 
forward.
    I would like to thank the second panel. We have for the 
second panel Shirley Ann Quarles who is Chairwomen of the 
Advisory Committee on Women Veterans; Colonel Reginald 
Malebranche who is a member of the Advisory Committee on 
Minority Veterans; Saul Rosenberg, who is Clinical Psychologist 
at the University of California, San Francisco; and Maureen 
Murdoch who is a VA Medical Center doctor in Minneapolis.
    So I want to thank the panelists for coming today. I look 
forward to hearing your testimony. Why don't we start with Dr. 
Quarles and work our way down?
    Thank you once again for coming here this morning. Dr. 
Quarles?

 STATEMENT OF SHIRLEY A. QUARLES, R.N., ED.D., CHAIR, ADVISORY 
   COMMITTEE ON WOMEN VETERANS, U.S. DEPARTMENT OF VETERANS; 
  COLONEL REGINALD MALEBRANCHE, USA (RET.), MEMBER, ADVISORY 
  COMMITTEE ON MINORITY VETERANS, U.S. DEPARTMENT OF VETERANS 
AFFAIRS; SAUL ROSENBERG, PH.D., ASSOCIATE CLINICAL PROFESSOR OF 
 MEDICAL PSYCHOLOGY, UNIVERSITY OF CALIFORNIA, SAN FRANCISCO, 
CA; AND MAUREEN MURDOCH, M.D., MPH, CENTER FOR CHRONIC DISEASE 
OUTCOMES RESEARCH, MINNEAPOLIS VETERANS AFFAIRS MEDICAL CENTER, 
     MINNEAPOLIS, MN, VETERANS HEALTH ADMINISTRATION, U.S. 
 DEPARTMENT OF VETERANS AFFAIRS (ON BEHALF OF HERSELF AND NOT 
                              VA)

          STATEMENT OF SHIRLEY A. QUARLES, R.N., ED.D.

    Dr. Quarles. Thank you. Chairman Michaud, Chairman Hall and 
Members of the Subcommittees. I am Chair of the Department of 
Veterans Affairs Advisory Committee on Women Veterans and also 
a Colonel in the United States Army Reserve. I am pleased to 
testify today on behalf of the Department of Veterans Affairs 
Advisory Committee on Women Veterans regarding our views on: 
The Department of Veterans Affairs and how they serve women 
veterans through it's current programs; the present and future 
needs of women veterans, which is a growing population; VA 
strategies to meet those needs; and outreach efforts that are 
being conducted on women veterans.
    The Advisory Committee was established in 1983 by Public 
Law 98-160 and charged with advising the Secretary of Veterans 
Affairs on VA benefits and services for women veterans. The 
Committee submits a biennial report to the Secretary about 
findings and recommendations.
    The Advisory Committee on Women Veterans consists of 14 
members, men and women who are mostly veterans. As a means to 
obtain information regarding women veterans' services, and 
programs provided by the VA, the Committee conducts site visits 
to VA facilities throughout the U.S. During the site visits, 
the Committee tours the facilities, meets with senior leaders, 
and hosts an open forum for the local women veterans community. 
The forum provides an opportunity for open dialog to learn more 
about women veterans' experiences within the VA, to discuss 
issues, and for women veterans to raise questions regarding 
gender specific VA benefits and services.
    Another means for the Advisory Committee on Women Veterans 
to obtain information regarding services provided by the VA is 
by meeting twice a year at VA Central Office in Washington, DC. 
During these meetings the Committee has briefs from various 
program leaders. The Committee also submitted recommendations 
to the Secretary in their 2006 Report. The Committee made 23 
recommendations that addressed mental health, outreach, 
research, strategic planning, training, women veterans health 
program, and women veterans health program managers and 
coordinators and homeless women veterans.
    One recommendation that has already been implemented is the 
organizational realignment of the Women Veterans Health Program 
Office to Strategic Healthcare Group. This recent realignment 
elevated the Women's Health Program Office and provided it an 
opportunity to gain more expertise in the area of women's 
health.
    To address a strategy as it relates to VA meeting the 
present and future needs of women veterans, the Committee was 
able to witness first hand the need to provide mental health 
care during a site visit at Palo Alto VA Women's Center for 
Mental Health. Another strategy that the Committee recommends 
for future needs is through research studies. Research studies 
were recommended in both the 2004 and 2006 Advisory Committee 
on Women Veterans Reports.
    Also there is a current national survey that is being 
conducted to address the knowledge gap we have regarding women 
veterans. The final findings for this national survey will be 
submitted December of 2008. As it relates to outreach, the 
Advisory Committee on Women Veterans 2004 Report recommended 
that materials such as brochures, pamphlets, booklets, and fact 
sheets be published in both English and Spanish languages.
    The Committee also encourages increased partnership with 
the Federal, State, county agencies, and national veterans 
service organizations. Additionally, the Committee plans to 
participate in the upcoming 2008 National Summit for Women 
Veterans.
    The Advisory Committee on Women Veterans is grateful to the 
VA and to the Center for Women Veterans for taking care of our 
women veterans of yesterday, today, and the future.
    This concludes my formal testimony. I will be pleased to 
answer any questions.
    [The prepared statement of Dr. Quarles appears on p. 33.]
    Mr. Michaud. Thank you very much. Colonel.
    Dr. Quarles. Thank you.

     STATEMENT OF COLONEL REGINALD MALEBRANCHE, USA (RET.)

    Colonel Malebranche. Chairman Michaud, Chairman Hall, and 
Members of the Subcommittee, I am indeed honored to represent 
the Chairman of the Advisory Committee on Minority Veterans and 
give you our views on the services provided by the Department 
of Veteran Affairs.
    Pursuant to Public Law 103-146, the Committee is tasked 
with assessing the needs of the minority veteran population and 
reporting back to the Secretary on the effectiveness of the 
programs and services at meeting those needs. The Committee 
works in close coordination and collaboration with the Center 
for Minority Veterans and relies on the expertise of the Center 
for current information about VA programs, policies, and 
services.
    In it's 2006 report on the Greater Los Angeles Healthcare 
System, the Committee made 11 recommendations with the key 
issues being outreach, research, staff diversity, and seamless 
transition. During its visit to the Los Angeles Ambulatory Care 
Center, the Committee was dismayed by the staggering number of 
homeless veterans. Twenty-three percent of the 90,000 homeless 
population in Los Angeles were reported to be veterans. The 
Committee was encouraged though by the range of programs 
identified by VA for homeless veterans, yet the Committee was 
concerned that these programs may not reach the targeted 
audience.
    Outreach is a major challenge for the VA. At the townhall 
meeting, the Committee learned that the major issue was that 
minority veterans were unaware of their VA benefits and other 
VA services available. Transportation to VA Centers in major 
metropolitan, rural and isolated areas is an impediment for 
minority veterans. Accessibility, affordability, and distances 
to VA Centers are major problems affecting minority veterans.
    Much remained to be accomplished in the area of outreach. 
The Committee recognize that is not simply a VA issue. Several 
of its members have taken the mantle to assist the VA in its 
quest to reach out to minority veterans.
    Access to care is another challenge for VA. The plight of 
Alaskan natives and other minority veterans living in rural and 
isolated areas cannot be ignored. The challenge for VA is to 
develop and implement innovative programs which target those 
minority veteran populations. Rural and remote areas in Alaska 
and the Navajo Nation may be good targets to test rural health 
initiatives. VA could enter into a reimbursable agreement with 
Alaska natives organizations, Health and Human Services, and 
the Indian Health Service to reach out to minority veterans and 
provide all the services which fall within the realm of VA.
    The Committee applauds the strides made by VA in expanding 
its telehealth and telemedicine programs and its ability to 
reach a significant number of the minority veteran population.
    Mental health is and will become a major challenge. The 
Committee recognizes the efforts and the programs put forth by 
VA to support, identify, and care for service personnel who 
serve and are serving in OEF and OIF. The early identification 
of post traumatic stress disorder will certainly help in the 
observation and treatment of veterans who served in those 
areas. Yet, the Committee is concerned that the same level of 
services might not be readily available to minority veterans 
who have served in prior conflicts.
    Electronic health records are another part that we need to 
develop and embrace all services personnel with VA. The 
processing and adjudication of benefits seem to affect all 
veterans and to make them aware of their entitlements. The 
Veterans Claim Assistant Act of 2000 puts the onus on VA to 
maximize its assistance to all veterans.
    Senior staff diversity remains an issue at VA. The absence 
of minorities at the senior staff level has been, and continues 
to be, noticeable during site visits. Data presented and 
subscribed by VA suggest that VA's problems is limited to 
recruiting white females and Hispanic females, yet all the data 
maintained at VA suggested that minorities were not well 
represented at senior staff levels.
    The professionalism, the expertise shown by VA personnel 
was striking. There was a perception that most staff would 
endeavor to do anything or everything for a veteran. The 
challenge is to include minority veterans in that equation and 
that philosophy.
    Sir, I thank you for this opportunity to address the 
Subcommittee. And I would be happy to answer any questions. 
Thank you very much.
    [The prepared statement of Colonel Malebranche appears on 
p. 35.]
    Mr. Michaud. Thank you very much, Colonel. Dr. Rosenberg.

               STATEMENT OF SAUL ROSENBERG, PH.D.

    Dr. Rosenberg. Thank you both Chairmen and the Committee 
for inviting me this morning. I am Dr. Saul Rosenberg. I am a 
clinical psychologist. I did my very first clinical training at 
the Ann Arbor VA and it has stuck with me ever since. I 
currently teach and supervise interns in residence at the San 
Francisco VA, which is associated with University of 
California, San Francisco (UCSF) where I am on the faculty. I 
am not currently on the faculty or receive salary from the VA. 
So I am, I would say, independent of the VA and a friend of the 
VA.
    My interest is in mental health and what the needs are for 
screening returning troops, when troops screen positive what 
kind of diagnostic assessments are conducted, and what kinds of 
treatment recommendations are made, and how can we follow up 
treatments to make sure that the veterans are getting the most 
affective treatments.
    So we can start with screening. The DoD, and with the VA 
and the Deployment Center, have started the use of pre- and 
post-deployment questionnaires, which is a wonderful 
innovation. Soldiers coming back are filling out brief 
questionnaires regarding exposure to combat, regarding symptoms 
of PTSD, regarding possible exposure to roadside bombs and 
improvised explosive devices (IEDs). The returning soldier then 
has an interview with a primary care physician who goes over 
the form, and from that interview a determination is made 
whether they need to go on to more intensive evaluation and 
treatment.
    My colleagues at UCSF and the San Francisco VA recently 
completed a nationwide epidemiological study of veterans 
returning from Iraq. They studied over 100,000 veterans in VA 
health care facilities all across the country. They found a 
high prevalence of mental disorders. Mental disorders that fit 
the criteria of the diagnostic and statistical manual of the 
American Psychiatric Association were about 25 percent and 
about 5 percent had psycho-social and social relational 
problems.
    So almost a third of this sample had diagnosed mental 
disorders. Now these disorders were not based on just the 
screening form, they were based on the actual diagnosis. There 
have been reports about the prevalence of PTSD based on the 
screening form and so it is important to note the difference. 
This was an actual diagnosis.
    The sample, I think, was pretty representative of women and 
racial groups. And one of the positive things about the study 
is that they did break their results down by racial groups. A 
simple recommendation that I would make that would help us 
understand better the needs and the treatment outcomes of women 
and minorities is to ask researchers to include gender and a 
description of race, education, and marital status, all of 
those variables, when they are doing research so that we have 
an opportunity to look and see if in fact there are 
differences. Oftentimes you will see reports in the literature 
in which there is no comment at all about race or gender as if 
everyone is the same. Researchers should be aware of that.
    A related point is that the assessment of mental disorders 
requires a clinician to do an interview and often benefits from 
psychological test, which is my area of expertise. Now 
psychological tests have often been developed on a white 
middle-class population. And so psychologist know, and the 
American Psychological Association has put out papers on this 
topic, that there needs to be more what is called culturally 
sensitive and culturally competent assessment. Having an 
individual of this same race interview and test a veteran is a 
proxy in a way for that cultural sensitivity. What we care 
about is does the interviewer or the doctor, the evaluator is 
that person capable of empathizing with the experience of the 
person that they are evaluating? And more particularly, do they 
know anything about the values and preferences of that person? 
Particularly if that person comes from another culture. So 
there has been a move within the American Psychological 
Association to do culturally sensitive training and the result 
has been more satisfaction of individuals of a different race 
than the treating doctor when the treating doctor has gone 
through a training program that helped him be more culturally 
sensitive.
    In this sample of 100,000, women comprised 13 percent; 69 
percent were white; 18 percent were black; 11 percent Hispanic; 
and 2 percent came from other racial groups. The most striking 
finding in the study wasn't about race or gender, it was about 
the different risk of developing PTSD and mental disorders in 
our youngest veterans. Veterans between the ages of 18 and 24 
had dramatically higher risk of developing PTSD or mental 
disorder than veterans 40 years and over, irrespective of race.
    That is an important finding. And we have to think about, 
well how can we use this information? I have, like many of my 
academic colleagues, written papers and they get published in 
peer review journals and they are mostly read by other doctors 
and psychologists and clinical investigators. The serving the 
needs of the veterans returning from Iraq requires a different 
kind of research. At UCSF, we call it clinical and 
translational research, which means we need research on real 
patients, clinical research, but we have to translate that 
research into actual services that benefit patients and then 
study whether the treatments we are doing actually work.
    We can't expect providers to be going into the academic 
literature to find information they need about treating an 
individual. So, for example, this fact that young veterans are 
at much higher risk, that information belongs in a clinical 
practice guideline that comes up on the doctor's screen 
automatically as the doctor is seeing the patient in that age 
group. You are about to interview a patient between the ages of 
18 and 24 and a little alert or reminder comes up. A little 
pop-up comes up on the screen, ``This group, younger veterans, 
may be at more risk. Consider asking a few additional 
questions.''
    Mr. Michaud. Doctor, I was wondering, since your time has 
expired, could you please summarize? I am sorry to interrupt 
you.
    Dr. Rosenberg. The main point I want to make is the VA has 
conducted wonderful research and National Institute of Mental 
Health (NIMH) has conducted wonderful research. We need to 
bring that research into the clinical situation. The VA is an 
ideal place to do that because of its excellent electronic 
health record, VistA. What I am talking about is taking the 
next step, which is developing clinical practice guidelines 
within VistA and then the next step beyond that is developing 
clinical decision support systems. These are systems that can 
integrate biomedical and psycho-social data and suggest 
diagnosis or treatment plans and offer ways to evaluate how 
effective a treatment is.
    Clinical decision support has been used in medicine for 
decades. It has been relatively rare in mental health. And 
there is a possibility of a great contribution that could be 
made in mental health from clinical decision support systems.
    [The prepared statement of Dr. Rosenberg appears on p. 37.]
    Mr. Michaud. Thank you, Doctor. Dr. Murdoch.

            STATEMENT OF MAUREEN MURDOCH, M.D., MPH

    Dr. Murdoch. Thank you. Mr. Chairman and Members of the 
Subcommittees, thank you for the opportunity to appear before 
you today. Today I will present some findings from my team's 
research on possible disparities in PTSD disability awards 
among race and gender groups. I must note that the views 
presented here today are mine and do not necessarily represent 
the views of the Department of Veterans' Affairs. And they 
reflect the results of my studies and not necessarily the 
findings of others. And I also need to point out that 
unfortunately after this panel is done I am on service at 
Minneapolis and so I have to leave and catch a plane and go 
back to the hospital. So, I apologize for that.
    PTSD as you may know is the most common psychiatric 
condition for which veterans seek VA disability benefits. And 
long-term health studies indicate that women have a higher 
prevalence of PTSD than men and may be more susceptible to 
PTSD. Conversely, African American or black persons appear to 
have similar risk for PTSD compared to persons of other race or 
ethnic groups.
    In 2000, my colleagues and I began investigating if there 
were race and gender disparities in VA disability awards for 
PTSD. We assembled a representative sample of almost 5,000 men 
and women veterans who applied for disability benefits on the 
basis of PTSD between 1994 and 1998. We tested 4 hypotheses 
examining the relationships between PTSD symptoms severity, the 
level of disability, combat experience, and a race or gender 
differences as they impact the determination about service 
connection.
    Overall, the 3,337 respondents were highly symptomatic. 
About 80 percent met our definition for PTSD and 62 percent 
were service connected for PTSD. Concerning the relationship 
between PTSD and gender: PTSD service connection and gender, 
once we controlled for combat exposure, the effect of gender 
and service connection for PTSD became insignificant. However, 
because men had notably greater combat exposure they likewise 
had a higher rate of service connection.
    In our investigation of racial disparities we found that in 
our sample African Americans were just as likely to be service 
connected for disorders other than PTSD as the rest of the 
respondents. However, they were substantially and significantly 
less likely to be service connected for PTSD compared to the 
other respondents.
    The negative association between African American race and 
service connection for PTSD was not found for any other racial 
or ethnic group. Now among the veterans who actually got 
service connection PTSD the service connected rating or the 
degree of service connection awarded was similar regardless of 
race. So African American respondents had an average service 
connected rating of 43 percent--if they were service 
connected--and other veterans had an average service connected 
rating of 45 percent, if they were service connected.
    However, after fully adjusting for everything that we could 
think of, the estimated probability of being service connected 
for PTSD was 43 percent for African American veterans compared 
to 56 percent for other respondents; a 13 percent difference. 
Examining clinicians were about seven-tenths as likely to 
diagnose PTSD in African Americans as they were to diagnose 
PTSD in other veterans.
    When thinking about these results, there are several issues 
that need to be considered. First, the pool of respondents was 
selected based on their submitted claims for PTSD service 
connection. But our questions focused on their current health 
and adjustment status. It is distinctly possible that those 
with the greatest need at the time of their application have 
been receiving treatment and now may actually report better 
health outcomes then their peers.
    Second, the study relied on veterans' self-reports of their 
PTSD symptoms severity, the degree of disability and trauma 
history, which may not have been clinically accurate or 
universally consistent.
    So, I have a few recommendations. In order to strengthen 
and expand this research, I would suggest that future studies 
identify and evaluate veterans shortly after applying for PTSD 
disability benefits, instead of 2 years later as we did. And in 
addition, we need to collect and assemble more data from the 
claims file to supplement survey data. And finally, I would 
recommend that future studies investigate for possible 
disparities in disorders other than PTSD, when we think about 
service connection awards.
    Mr. Chairman and Committee Members, this concludes my 
statement. And I am pleased to respond to any questions that 
you may have. Thank you.
    [The prepared statement of Dr. Murdoch appears on p. 40.]
    Mr. Hare. Thank you, Doctor. And let me thank all the 
panelist for being here. I have a number of questions and I 
know, Doctor, you have to leave fairly soon. We will try to 
brief on this. I don't want you to be late getting back to work 
and getting in trouble on my account.
    So Ms. Quarles, I was pleased to see that the National 
Survey of Women Veterans is being implemented with results 
expected in December of 2008. In your estimation, what do you 
think are the 3 most prevalent or urgent issues facing women 
veterans today?
    Dr. Quarles. I think that, or the Committee feels that, 
issues that are facing women veterans today certainly access to 
care. And these are women veterans who live in the rural areas.
    Another concern that we feel the Advisory Committee has 
observed through briefings and visits is that primary care in 
the Community Based Outpatient Centers (CBOCs), in the clinics 
is the same as the services provided at the facilities.
    And also another concern that we are hearing through our 
open dialog from women veterans is that women veterans want to 
know that they can receive the same equal health care as their 
male veteran counterparts.
    Mr. Hare. To my knowledge, the VA has not yet held any type 
of summit or conference on OEF or OIF female veterans and the 
unique needs that are arising with women being in combat. Has 
the Advisory Committee looked into this and if so what have you 
found, if anything?
    Dr. Quarles. Well the Advisory Committee is learning 
through our briefs and through our visits that mental health 
care is certainly continuing to be an issue and that there is a 
need for mental health care to be enhanced throughout. One of 
the concerns we have is the training. Training for personnel 
with the VA as well as training for affiliated professionals 
who come to the VA to understand the women veterans population 
regarding unique needs they will have. And it is very important 
that we look at the continue monitoring of training for our 
professionals and the VA.
    Mr. Hare. Thank you. Colonel, I was just wondering in your 
testimony you stressed the absence of diversity at the senior 
staff level. When the Committee presented their concerns to the 
VA about this issue, how did they respond to you?
    Colonel Malebranche. They will look at it, sir, and then, 
however, though when we look at the data, the data that VA 
utilizes seems to suggest that their major problems is in the 
recruitment of white females and Hispanic females. However, all 
the data at VA suggests otherwise. So it appears to be an 
aspect of using the data that is available in terms of what it 
shows and then presenting that to--if you tell me that I can 
only recruit white female and Hispanic female that is all I am 
going to try to recruit.
    Mr. Hare. A big concern regarding the provisions of care to 
the minority veteran population is sensitivity to the cultural 
differences of minority veterans. For example, the differences 
in how to approach an Alaskan Native veteran community as 
opposed to Hispanic veteran community. Does the VA provide 
education to many of it's employees on cultural competencies 
and sensitivities, particularly to the frontline medical 
personnel, to your knowledge?
    Colonel Malebranche. Sir, I think there is an attempt at 
doing that for the staff. Alaska is a particular issue because, 
one, the location of really the population at risk and the 
ability to get to that population. The diverse dialects that 
they are spoken in Alaska. So it presents some different 
challenges. I think the challenge is basically to find means to 
use the Alaskan Native organization that already exist possibly 
even the U.S. Department of Health and Human Services or the 
Indian Health Service and enter into an agreement, reimbursable 
agreement or cooperative agreement that is going to target 
those population.
    Recently, Alaska probably had the largest deployment of 
Alaskan Natives to OEF and OIF. And those units are slowly 
coming back.
    Mr. Hare. Thank you. I guess this is both for Dr. Rosenberg 
and Dr. Murdoch or whoever would like to take a stab at this. 
You mentioned, and I know my time is running out, but I was 
interested in the testimony and your comments on the fact that 
African American veterans were about half as likely as other 
veterans to receive service-connected disability for post 
traumatic stress disorder. I am wondering from your perspective 
why this is happening. Do you have any thoughts on, why it is 
happening and what we can do to improve this? Because it seems 
to me to be grossly unfair here.
    Dr. Murdoch. That is an excellent question. I think that, 
first of all, keeping in mind the limitations of the study it 
would be extremely helpful to replicate it collecting better 
data. And second of all, to expand upon it to try and 
understand why those differences exist.
    Mr. Hare. Dr. Rosenberg.
    Dr. Rosenberg. That would cover it for me, but I would like 
the opportunity to add something of that----
    Mr. Hare. Sure.
    Dr. Rosenberg [continuing]. Unique needs of women veterans. 
The Institute of Medicine was asked to do a report on PTSD 
disability in veterans. It is an excellent report. And they 
expressed a concern that women are victims of sexual assault 
called military sexual assault. That those women victims are 
not getting sufficient treatment, identification, or disability 
determination. It is a lot harder to prove sexual assault than 
you were in combat. And the Institute of Medicine recommended 
much more attention be paid to understanding this phenomena of 
military sexual assault, doing everything we can to prevent it. 
And making sure that those individuals who are injured in that 
way do receive treatment, rehabilitation, and disability.
    Mr. Hare. Thank you, Doctor. Mr. Lamborn.
    Mr. Lamborn. Thank you Representative Hare. Dr. Murdoch, 
just to clarify something, I think you eluded to this, but I 
just wanted to make sure I understand. Did you document and 
verify the combat history disability status or PTSD diagnosis 
of the individuals in your study or did they self report those 
factors?
    Dr. Murdoch. We got the disability status from VBA records. 
They self-reported their PTSD, their combat exposure, and I 
forget the last one that you asked about.
    Mr. Lamborn. Combat history, disability status, and PTSD 
diagnosis.
    Dr. Murdoch. Yeah. So PTSD diagnosis and their disability 
status in terms of how disabled they reported themselves to be, 
those were self-report.
    And then we did take a small sample, 11 percent, where we 
also audited their claims file and tried to verify what they 
reported in the survey. And it seems that the--that their 
reports of PTSD matched up with the clinical diagnosis that 
they were being given in the claims file.
    Mr. Lamborn. And, Doctor, what was that percentage again?
    Dr. Murdoch. About 80 percent.
    Mr. Lamborn. That you audited their----
    Dr. Murdoch. Right. So about 80 percent met survey criteria 
for PTSD and then when we did the claims audit and looked for a 
clinical diagnosis by a qualified examiner in their claims 
file, 80 percent of them had a diagnosis of PTSD.
    Mr. Lamborn. Okay. Thank you. And I yield back to the 
Chairman.
    Mr. Hall. Mr. Bilirakis.
    Mr. Bilirakis. I don't have any questions.
    Mr. Hall. Okay. Thanks so much. Let me thank the panel and 
wish you a safe trip back to all of you. Thank you for taking 
the time to be here for this morning. Thanks so much.
    Dr. Murdoch. Thank you.
    Dr. Quarles. Thank you.
    Mr. Hall. Our next panelist is Joy Ilem who is the 
Assistant National Legislative Director for the Disabled 
American Veterans.
    Thank you, Ms. Ilem. Sorry for disappearing and then 
reappearing. You are now recognized for 5 minutes. Your written 
remarks will be submitted for the record.

   STATEMENT OF JOY J. ILEM, ASSISTANT NATIONAL LEGISLATIVE 
              DIRECTOR, DISABLED AMERICAN VETERANS

    Ms. Ilem. Thank you very much. Mr. Chairman and Members of 
the Subcommittees, thank you for inviting DAV to provide 
testimony on the present and future needs of women and minority 
veterans seeking services from the Department of Veterans 
Affairs.
    In June 2007 the VA Health Services Research and 
Development Service completed a systematic review of racial and 
ethnic disparities in the VA health care system. Researchers 
concluded that disparities appear to exist in all clinical 
arenas. According to the researchers, one key finding was 
especially troubling since it may indicate that disparities in 
health care delivery are contributing to real disparities in 
health outcomes.
    It is clear from the findings of this recent study that 
much more needs to be done in this area, therefore, we urge VA 
to continue it's research, to adjust policies, and to provide 
appropriate resources to eliminate racial disparities in VA 
health care.
    In preparing for this hearing, we also reviewed the most 
recent annual report available from the VA Advisory Committee 
on Minority Veterans. The Committee made a number of 
recommendations, but of special concern was the issue of 
outreach to minority veteran populations. We agree with the 
Advisory Committee that the VA should clarify it's policy with 
regard to outreach to ensure minority veterans are aware about 
their VA benefits.
    We support the recommendations made by the Advisory 
Committee and applaud it's continued efforts to increase 
awareness about minority veteran issues and advance the quality 
of 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 VA be responsive to the 
unique demographics of this population. In addition, VA must 
ensure that it's special disability programs are tailored to 
meet the unique health care concerns of women who have served 
in combat theaters and those who have suffered catastrophic 
disabilities as a result of military service.
    Researchers report that VA care for women veterans is 
fragmented. Researchers also found a number of barriers to 
delivering high quality health care to women veterans. 
Specifically, field reports of insufficient funding for women's 
health programs, competing local or network priorities, limited 
resources for outreach, inability to recruit specialists and an 
insufficient number of clinicians skilled in women's health. We 
urge VA to implement recommendations by researchers to address 
these barriers.
    Several years ago VA 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. We strongly 
encourage VA as it takes steps to advance this agenda to focus 
on research and programs that enhance VA's understanding of 
women veteran health issues and discover new ways to optimize 
health care delivery and improve health outcomes for this 
patient population.
    The challenge of addressing the unique health care needs of 
the newest generation of women veterans returning from combat 
theaters in Iraq and Afghanistan is daunting. In reviewing VA's 
health care utilization data we see increasing numbers of women 
veterans accessing VA health care and increasing rates of PTSD 
and other medical conditions among women who served in combat 
theaters.
    DoD and VA need to coordinate and improve sharing of data 
and women's health information. We also need to learn more 
about what barriers exist for women veterans trying to access 
VA care following deployments.
    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 in roles of women in the military, VA must also be 
prepared to anticipate the specialized needs of women who were 
sexually assaulted in the military or catastrophically wounded 
in combat theaters.
    Although it is anticipated that many of the medical 
problems of male and female veterans returning from combat 
operations will be the same, VA must address the health issues 
that pose special challenges for women.
    DAV has recommended that VA focus its women 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 its women health research 
agenda.
    Mr. Chairman, that concludes my testimony and I will be 
happy to answer any questions that you or Members of the 
Subcommittees may have. Thank you.
    [The prepared statement of Ms. Ilem appears on p. 41.]
    Mr. Hall. I thank you Director Ilem and thank all DAV 
members for their work and to their service.
    I first of all wanted to ask regarding your statement that 
it is unlikely that the past experiences of women veterans in 
the VA will serve as an accurate guide because of the unique 
experiences of women who served in OIF/OEF, particularly 
because of this ongoing exposure to combat conditions. Could 
you elaborate further, please, on why this is true and offer 
your opinion on a few things that the VA can do to prepare for 
the impending influx of women veterans of OIF/OEF?
    Ms. Ilem. Sure. Thank you for the question. I think that, 
you know, and this is--that came about as from talking to 
different mental health providers within the VA. And I think, 
you know, the equal access to health care for specialized 
programs for men and women is extremely important. And this 
newest generation of veterans returning are looking like there 
is some unique health concerns and mental health, perhaps 
mental health issues as well that need special attention.
    One of the things that I think would be important is to 
really talk to these women in terms of looking at the barriers 
for care that they perceive or have had and exist, you know, 
trying to access VA care. So just by doing the patient 
satisfaction report, I don't think you are going to see that 
within VA. Those are people that are using the VA system, but 
what about those that have met up with a barrier and aren't 
feeling that they, you know, can use VA health care or have had 
some problem getting that care.
    So I think it would be important to talk to them directly, 
for VA to hold focus groups with these women veterans. And 
people that have expressed a barrier to getting care for those 
services.
    Mr. Hall. You mentioned in your testimony that one of the 
Advisory Committee's recommendations was to expand outreach to 
all veterans, including minorities. Can you elaborate on what 
you believe would be useful and adequate measure to improve 
those outreach programs?
    Ms. Ilem. I think that, you know, just outreach in general 
is extremely important I mean to all veterans, obviously. And 
then with special attention, I think, as has been mentioned by 
the previous panel to looking at unique concerns of either 
minority populations or women veteran population. Things that 
you need to do specifically to outreach to them that they have 
found, you know, seems where there is a barrier. And make sure 
that things are culturally sensitive to some, you know, to 
their needs.
    And I think you know VA I think is trying to do a very good 
job in terms of the transitioning veterans that are coming out 
of the military, but I don't know how much focus in terms of 
outreach has been put on specifically minority veterans and 
women veterans. I think that, you know, we would like to see 
more being done in that area as well in terms of working with 
DoD to get on those bases to make sure the people as they are 
transitioning out are aware of their benefits.
    And then I know that VA is providing doing a letter to all 
veterans coming back from OEF/OIF, but you know probably 
continued follow up needs to be done. There are reports from 
the Women Veterans Advisory Committee that often these veterans 
go back to their communities and then just disappear or their 
work, you know, they have children, they have other things that 
they are trying to accomplish in their lives and they just 
don't get that message that there is great benefits out there 
in terms of VA health care and services that could help them.
    Mr. Hall. Thank you. You also mentioned that some women 
will suffer from severe PTSD, which will require more intensive 
evidence-based treatment. I am curious if you have noticed any 
difference between PTSD issues that women face compared to men? 
It is the old Mars and Venus thing. I have known that in the 
educational and psychological communities there is quite a lot 
awareness about the difference in how women perceive the world 
and react to it and how men do.
    Also with regard to women with children, the stress that 
they feel because of fear for their children or the stress that 
the children are feeling, that the women and mothers feed off 
of in some instances. In particular, is child care at VA 
facilities something that we should focus on more so that we 
remove that barrier to mothers who have no other option to seek 
treatment themselves when they have children at home?
    Ms. Ilem. Right. Right. Thank you for that question, those 
series of questions. I just spoke with a former VA mental 
health provider that for many years, that I really look to, 
that has been involved in this issue and participating on the 
Dole Shalala Commission as well. And you know, in talking to 
him about these evidence based treatments and how important 
they are and how case intensive they are. I asked him, you 
know, that very question, ``What are you seeing? What are women 
reporting or what are the doctors reporting that are seeing 
them, you know, that have had combat PTSD related and males? 
Are you putting males and females together? What are, you know, 
what is happening out there?''
    And it was interesting he noted that women are reporting 
and he is hearing from clinicians that they are--when women 
have combat related PTSD that they prefer to be with their 
fellow soldiers, so male and female. That seems to be 
appropriate. They feel that connection. They have been through 
the same thing, they have had similar experiences. And although 
there is some evidence-based treatment, I understand in current 
research of evidence-based treatment and that is specific to 
women, you know, that it is still the clinical move for putting 
them together in that environment appears to work best for them 
so far from what they are seeing.
    The difference is if it is the dual burden of sexual trauma 
and combat related, certainly women veteran may not feel 
comfortable being in an environment, you know, with male 
colleagues talking about something as personal as sexual 
assault. I am sure either a male or a female probably would 
have similar feelings.
    So you know that is more of a unique consideration in terms 
of being able to have the number of providers that are needed 
for this very intensive resource-based evidence-based 
treatments for PTSD. And making sure that clinicians not only 
are trained in it, but then have the time to work with these 
patients where it is, you know, on an outpatient basis but it 
may be very over a number of days a week, many hours a day.
    On the child care issue thinking long and hard on that. I 
mean certainly women often are the primary caretaker of women 
either if they are married or single parent. And attending the 
Evolving Paradigms seminar that VA put on conference out in Las 
Vegas, there was a panel on women veterans talking about their 
experiences. They were all from OEF or OIF. And I mean that was 
a real eye opener, but listening to women talk about sometimes 
having trouble re-connecting with their children because of the 
emotional distress that they are going through based on their 
experience in the military and exposure to combat.
    And if they are the primary caretaker that is obviously, 
you know, a real concern in the family to be able to have that 
re-connection and get them the help that they need in terms of 
re-connecting with their family and their children, but also if 
there are these evidence based treatments available, if they 
have child care as a responsibility and they can't afford child 
care then, you know, what is the option for them?
    So I am hoping that VA will their Women Veterans Program 
managers are excellent group of people that, you know, are very 
innovative and can think of ways to maybe connect with the 
community or to see what the need is out there. What they are 
hearing and seeing from women veterans and if that is something 
that they can do to either work with the community or a 
voucher. Do something to make sure they can also participate in 
those programs.
    Mr. Hall. Thank you very much for your generous and 
detailed response. My time has expired. I will now recognize 
Mr. Bilirakis.
    Mr. Bilirakis. Thank you Mr. Chairman, I appreciate it. 
Thank you Ms. Ilem. You did an outstanding job. Thanks for your 
testimony.
    In your written testimony you state that, ``Although the VA 
has improved health care services for women veterans . . . 
privacy issues for women veterans still exist at some VA 
facilities.'' That really concerns me. Are these deficiencies 
concentrated in a particular region of the country or are the 
spread out throughout the health care system? That is my first 
question.
    Ms. Ilem. I think in general, I mean, I would say first of 
all that VA has done a really good job in the last several 
years really trying to deal with this, especially the Center 
for Women Veterans and the Women's Health Program, to make sure 
that those deficiencies don't exist. However, from being a 
member of that Advisory Committee and traveling around the 
country and just as my position now I had the opportunity to 
visit many VA facilities and that is something that I am always 
on the look out for.
    And I think it is more of an issue that, you know, women's 
clinics where they have, you know, had to make room for them 
and they try to make a very nice area in most places, but 
sometimes it is a space issue in the VA health care system in 
general of where those clinics are located and what space they 
were provided.
    And occasionally we see that there is an issue when you 
come in with regard to privacy one thing comes to mind is just 
being a user of the VA health care system myself and being in 
the clinic, coming in. Great people. Everybody is very 
friendly, wants to make my visit go well and I hear the person 
speaking on the phone to a veteran with being very, very nice 
to them, but in the conversation they have named their name. 
They have talked about a particular medical issue that they 
have had. And that was information that, you know, that clinic 
is very small, it is very confined space. And everyone in that 
clinic can overhear that information. And to me that is a 
privacy issue, you know, that gives me concern.
    And I know that sometimes there is just not, you know, 
there needs to be more, maybe more awareness. If the space is 
not available where that receptionist can have a private 
conversation with a person on the phone they need to be made 
aware then about the, you know, what they are saying and 
knowing that other people in the waiting room can hear that.
    Mr. Bilirakis. Thank you very much. What role do the 
Advisory Committees on Minority and Women Veterans and the 
Center for Women and Minority Veterans planning and influencing 
VA policy.
    Ms. Ilem. What role do they play? I----
    Mr. Bilirakis. Yeah. No. Are they effective?
    Ms. Ilem. Yes. I think they are. It is really a committed 
group of veterans that have been willing to serve on those 
Committees. They are very active. They are usually in their 
other roles outside of the VA, active in women's issues. People 
take it upon themselves to do extra visits, to really, I think, 
they really take on these issues. And I think that they try 
very hard in their reports to report that information to the 
Secretary and to Congress. And I think it was great that there 
was an opportunity for them to testify today.
    And I just hope that, you know, people pay attention to 
those reports and that, you know, their energies are not 
wasted. That those recommendations are taken to heart and 
things are made better for these populations.
    Mr. Bilirakis. Okay. Thank you very much. Thank you, Mr. 
Chairman, appreciate it.
    Mr. Hall. Thank you, Mr. Bilirakis. And Ms. Ilem, thank you 
for your testimony and your answers to our questions. You are 
now excused. Give us a minute for our changing of the guard. 
Welcome to our panel 4 witnesses, Betty Moseley Brown, 
Associate Director of the Center for Women Veterans of the U.S. 
Department of Veterans Affairs; and Lucretia McClenney, 
Director of the Center for Minority Veterans of the U.S. 
Department of Veterans Affairs. Welcome.
    It is my understanding that we are going to have a vote 
called soon on the House floor, but we will begin and hope we 
can get through your testimony before they do that.
    Dr. Moseley Brown, you are recognized for 5 minutes. And 
your written statement is in the record.

 STATEMENT OF BETTY MOSELEY BROWN, ED.D., ASSOCIATE DIRECTOR, 
CENTER FOR WOMEN VETERANS, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
AND LUCRETIA McCLENNEY, DIRECTOR, CENTER FOR MINORITY VETERANS, 
              U.S. DEPARTMENT OF VETERANS AFFAIRS

            STATEMENT OF BETTY MOSELEY BROWN, ED.D.

    Dr. Moseley Brown. Chairman Hall and Members of the 
Subcommittees, I am pleased to testify today on behalf of the 
Department of Veterans Affairs and the Center for Women 
Veterans. The Center was established by Public Law 103-446 in 
November 1994 to oversee VA programs for women veterans. The 
Center's mission is to ensure that women veterans receive 
benefits and services on par with male veterans; and that VA 
programs are responsive to gender specific needs of women 
veterans; and that outreach is performed to improve women 
veterans awareness of services, benefits, and eligibility 
criteria. And, finally, that women veterans are treated with 
dignity and respect.
    The Center monitors these changes in services through 
briefings by the 3 VA administrations and assesses the impact 
these changes have on the delivery of care of our 1.75 million 
women veterans. As stated earlier, there are women veterans 
that still don't believe that they are women veterans, so part 
of our charge is to make sure that every woman who served knows 
that she too is a veteran.
    Regarding health care, in fiscal year 2006, the Veterans 
Health Administration served over 235,000 women veterans in our 
health system. This is a 5-year relative increase of 37.8 
percent. At each VA Medical Center there is a women veterans 
program manager and each regional office a women veterans 
coordinator to help our women to maneuver through the system of 
VA. We know that it can be difficult and those employees are 
there to help our women veterans coordinate for their benefits 
and services.
    Of the total number of women who have been discharged from 
active duty after deployment of Operation Iraqi Freedom and 
Operation Enduring Freedom, 37.5 percent have been to a VHA 
health care facility at least once.
    I would like to also state that there is a 2006 study 
cosponsored by Dr. Yano from Los Angeles that actually 
clarified which model of care women prefer. There was earlier 
discussion regarding if women wanted to go to a primary care 
facility or a gender specific type environment and VA is 
currently looking at that to see what women really want, what 
their needs are, and then to make changes regarding that.
    In the area of mental health, there are specialized women's 
mental health services. There are in-patient and residential 
programs for women veterans where the length of stay ranges 
from 28 days to 18 months. At every VA facility there is a 
designated military sexual trauma coordinator who serves as a 
point of contact for military sexual trauma issues.
    In fiscal year 2007, VA's Office of Mental Health Services 
established a military sexual trauma support team that is 
designed to help ensure that VA is in compliance with legally 
mandated monitoring of military sexual trauma screening and 
treatment.
    Currently, the VHA Office of Research and Development is 
supporting a broad portfolio focused on women's health issues. 
In 2001, this Office created a Center of Excellence for 
Research aimed at identifying factors which cause disparities 
in health outcomes across racial, ethnic, and gender lines, as 
well as promoting equity in health and health care.
    These Centers are co-located in 2 sites in Pittsburgh and 
Philadelphia; has 29 core investigators and have contributed 
over 128 peer reviewed scientific articles over the past 2 
years.
    We have been talking about health care, but I do want to 
add some things about benefits, because our women veterans are 
also concerned about benefits. In fiscal year 2006, Vocational 
Rehabilitation and Employment Program received 57,856 
applications of which almost 10,000 were female veterans. Also 
during fiscal year 2006, there was an increase in the percent 
of guaranteed home loans for our women veterans. The average 
loan amount was $173,923 and it went to over 17,000 women 
veterans.
    Also in fiscal year 2006, 8,442 women veterans used their 
education benefits under the Montgomery GI Bill. Part of our 
mission in the Center for Women Veterans is to attend some of 
the transition assistance program briefings that are held 
nationally. And we listen to what is stated and last year 8,541 
VA benefit briefings were given to both male and female 
servicemembers, including Guard and Reserve who were 
transitioning.
    I also wanted to state that to promote accuracy and 
consistency in the claims review process, VBA has taken a 
number of actions. For example, in the last 4 years, VBA has 
published guidance and conducted training for employees on a 
full range of issues related to PTSD claims adjudication--from 
development of the claim to proper application of the rating 
schedule. VBA and VHA are also working very closely regarding 
PTSD in modifying the examination request worksheet and 
template when a veteran applies for PTSD.
    In closing, I would like to say that the Center has 
developed a 25 most frequently asked questions booklet that I 
believe you have received. We created this booklet from 
thousands of inquiries from women veterans. It has been 
published in both English and Spanish and is on our website as 
well as VA's website.
    Next year, June 20 through the 22nd, we are going to hold a 
national Women Veterans Summit here in Washington, DC. We are 
planning to outreach to our military services, particularly our 
Reserves and National Guard. We are going to have workshops 
including ``Readjustment Counseling Service: Outreach and 
Transition Services for Veterans Families,'' ``Gender 
Differences: What the Data Shows,'' and workshops on mental 
health issues.
    Our Nation is proud of our women veterans and I am proud to 
be a women veteran and to serve our women veterans. This 
concludes my formal testimony, but I am pleased to take any 
questions.
    [The prepared statement of Dr. Moseley Brown appears on p. 
47.]
    Mr. Hall. Thank you very much for your testimony and for 
your service to our veterans and to our country. Ms. McClenney, 
I will now recognize you for a 5-minute statement. There is a 
vote that has just been called, but we are going to stay here 
and listen to you and then we may ask you to answer our 
questions in writing so that you don't have to sit here and 
wait for an hour or more while we are across the street voting.
    Ms. McClenney, your statement is in the record and you are 
recognized for 5 minutes.

                STATEMENT OF LUCRETIA McCLENNEY

    Ms. McClenney. Thank you Chairman Hall and Members of the 
Subcommittee. I appreciate the opportunity to come before you 
today to discuss the mission of the Center for Minority 
Veterans and address your specific questions on the Department 
of Veterans Affairs service to minority veterans through its 
current programs, present and future strategies addressing the 
needs of this growing population, and out reach efforts being 
conducted by VA to minority veterans.
    Like the Center for Women Veterans, the Center was created 
by Public Law 103-446 in November 1994. The Director of the 
Center serves as primary advisor to the Secretary and Deputy 
Secretary of Veterans Affairs on all matters related to 
minority veterans.
    The role of the Center is primarily one of advocacy for 
minority veterans. Pursuant to Public Law, the Center's primary 
emphasis is on veterans who are African Americans, Asian 
Americans, Pacific Islanders, Hispanics and Native Americans 
including American Indians, Alaska Natives, and Native 
Hawaiians.
    To establish a national presence and to ensure issues are 
addressed at the local level, the Secretary directed the 
appointment of Minority Veterans Program Coordinators (MVPCs) 
at each VA health care facility, Regional Benefits Office, and 
National Cemetery. There are approximately 300 MVPCs serving 
across the Nation.
    The Center provides training to the MVPCs in cultural 
competency and outreach strategies. These coordinators educate 
their facility personnel to the needs of the minority veterans 
in their local communities and promote the use of VA benefits 
and services by minority veterans. In addition, the 3 
administrations each have a designated central office MVPC 
Liaison. The Center's staff meets monthly with these liaisons 
and quarterly with the senior leadership of each administration 
to discuss outreach activities and to benchmark best practices.
    The Advisory Committee on Minority Veterans advises the 
Secretary and Congress on VA's administration of benefits and 
services and makes recommendations in an annual report to 
address unmet needs of the minority veteran population. The 
Center facilitates the Committee's outreach to minority 
veterans by ensuring they are kept abreast of VA's policies and 
programs that may impact minority veterans and coordinates the 
logistics and travel for all site visits and business meetings 
for the Committee. In addition, the Center tracks the 
Department's action taken on the Committee's recommendations.
    The needs of our Nation's 4.7 million minority veterans are 
not unlike the needs of minorities throughout our Nation. Some 
of these may include access to medical facilities, especially 
for veterans living in rural, remote, or urban areas. 
Disparities in health care centered on diseases that 
disproportionately affect minorities, homelessness, 
unemployment, limited medical research and limited statistical 
data related to minority veterans. VAs strategies to meet the 
needs of minority veterans include but are not limited to the 
following: VA is improving access to care as evidenced by the 
significant increase in outpatient clinics. For example, in 
1995, VA had only 102 community based outpatient clinics and by 
2007, 872 ambulatory care and outpatient clinics were in 
operation.
    VA is addressing homelessness in the minority population by 
partnering with community stakeholders and expanding VA's grant 
and per diem program. The Center is working with VHA's Office 
of Health Services Research and Development Service to target 
minority groups and encourage minority veterans participation 
in research programs.
    The Center has staff who serves as veteran liaisons for 
each of the 5 minority groups that we are mandated to oversee. 
They establish active partnerships with veterans service 
organizations as well as internal and other external 
stakeholders to increase awareness of minority veterans issues 
and develop collaborative strategies to address unmet needs.
    Mr. Chairman, this concludes my prepared statement.
    [The prepared statement of Ms. McClenney appears on p. 51.]
    Mr. Hall. Thank you, Ms. McClenney.
    Ms. McClenney. I would be happy to answer any questions.
    Mr. Hall. Thank you so much for your work, for your 
statement, for the service that you give to our veterans and to 
our country. If Mr. Bilirakis would agree, which I think he 
does, neither of us have the power to control the schedule on 
the floor of the House. But some day, maybe we will.
    We appreciate your patience and we are sorry we can't ask 
you questions now. We do have a number of them, but we will 
submit them to you in writing. If you would be so kind as to 
respond in writing, we would appreciate that.
    Ms. McClenney. It will be an honor, sir.
    Dr. Moseley Brown. Yes.
    Mr. Hall. Once again, thank you very much. This hearing is 
adjourned.
    [Whereupon, at 11:45 a.m., the Subcommittee was adjourned.]



                            A P P E N D I X

                              ----------                              

             Prepared Statement of Hon. Michael H. Michaud,
                    Chairman, Subcommittee on Health
    The Subcommittee on Health will come to order. I would like to 
thank everyone for coming today.
    This is a joint hearing with the Subcommittee on Disability 
Assistance and Memorial Affairs.
    Today, we will examine the Department of Veterans Affairs programs 
regarding women and minority veterans.
    The face of the military is changing and so is the face of the 
veteran population. According to the 2000 Census minorities make up 
over 14 percent of the existing veteran population. The population of 
women veterans is projected to continue to rise, from 6 percent in 
2000, to 8 percent in 2010 and to 10 percent by 2020.
    VA needs to constantly evaluate existing programs to address the 
needs of these special groups, and make changes when needed.
    I further believe that VA should implement new and innovative 
programs to help close the many gaps that exist today in delivering 
high quality, safe health care and the other benefits and services VA 
provides.
    Service in Operations Enduring Freedom and Iraqi Freedom has 
created growing challenges for VA in meeting the needs of the women and 
minority veterans as they separate from service.
    We know that an unprecedented number of female servicemembers have 
been routinely exposed to combat or combat like conditions.
    VA reports that the prevalence of potential PTSD among new OEF/OIF 
women veterans treated at VA has grown from 1 percent in 2002 to nearly 
19 percent in 2006. This represents a considerable and disturbing 
increase.
    Issues such as cultural differences, effective outreach, education, 
research and delivery of care should be carefully examined in an effort 
to provide the best possible service to these veterans.
    I hope that we will learn how VA is meeting the needs of these 
populations, what challenges are on the horizon and what we can do to 
provide these veterans with the best possible care available.

                                 
                Prepared Statement of Hon. John J. Hall,
  Chairman, Subcommittee on Disability Assistance and Memorial Affairs
    Good morning.
    I would first like to say that I am honored to join Mr. Michaud in 
cochairing this hearing and I applaud the leadership he exercises on 
behalf of our veterans, particularly on veteran health care issues.
    I would also like to thank the witnesses for joining the 2 
Subcommittees this morning for a hearing to examine issues facing women 
and minority veterans. I think this rare joint hearing speaks volumes 
about how important these issues are to the Committee as whole and I 
look forward to hearing from all of today's witnesses.
    Women veterans are the fastest growing segment of the veteran 
population, comprising 7% of the total veteran population and 5% of 
those using VA health services.
    Over 14% of veterans are from a racial or ethnic minority group 
with Blacks comprising the bulk at 9.7% (2000 U.S. Census figures).
    I am certain that the VA does its best to ensure that all veterans 
encounter no barriers to access in the receipt of VA benefits, 
treatment and services.
    However, the fact remains that the barriers in the society at large 
that women and minorities often face, might very likely translate into 
barriers in the smaller VA system.
    As such, Congress in its wisdom developed both the Center for 
Minority Veterans and the Center for Women Veterans in 1994 to ensure 
that these veterans are fully integrated in the VA system.
    I look forward to hearing from both Centers, as well as their 
separate Advisory Committees, which develop detailed reports which help 
to inform the policies of the VA for women and Minority veterans.
    I especially would like to learn the VA's and the Advisory 
Committee on Minority Veterans' views on the sunsetting provisions that 
would end the Advisory Committee in 2009 and what if any plans it has 
to replace this vital organization. I know representative Gutierrez has 
introduced a bill, H.R. 674 that would prevent this from occurring. 
Getting rid of the Minority veterans' Advisory Committee would be a 
seriously troubling result in light of recent findings by VA 
researchers that health disparities appear to exist in all clinical 
arenas and have a direct impact on the health outcomes for minority 
veterans.
    Last, but certainly not least, I welcome my colleague Congresswoman 
Heather Wilson, the only woman veteran in Congress.
    I am sure all of our witnesses, including our experts and the VSOs, 
will provide critical insight on issues facing women and Minority 
veterans, especially in light of returning OIF/OEF veterans.
    Thank you.

                                 
  Prepared Statement of Hon. Doug Lamborn, Ranking Republican Member,
       Subcommittee on Disability Assistance and Memorial Affairs
    Thank you Mr. Chairman for recognizing me. I thank you for holding 
this hearing on the Challenges Facing Minority and Women Veterans.
    I welcome our witnesses, and thank you all for your contributions 
to the veterans' affairs system.
    America's minorities and the women of our great Nation are integral 
to the quality of our National security. Women make up nearly 10 
percent of our Nation's 24 million living veterans. Women on active 
duty represent more than 15 percent of our armed forces.
    According to a 2005 Heritage Foundation study, about 25 percent of 
military recruits identify themselves as other than Caucasian; further, 
military women are more likely to identify themselves as members of a 
racial or ethnic group than men.
    Our military has a higher percentage of some minorities--such as 
African Americans, American Indians, Native Alaskans and Hawaiians, and 
Pacific Islanders--than the percentage of these minorities in the 
general population. These men and women are patriots.
    In more than 2 centuries of service to country, women and minority 
servicemembers have formed a glorious legacy. That legacy has only been 
enriched by the intrepid and resolute accomplishments of their 
descendents in the global war on terror.
    Our challenge is to ensure that women and minority veterans--indeed 
all veterans--receive equal treatment for their qualifying service to 
our Nation.
    The VA centers for women and minority veterans and the department's 
associated advisory Committees are charged with increasing awareness of 
VA programs, identifying barriers and inadequacies in VA programs, and 
influencing improvement.
    We do not look to these VA programs to merely identify and report. 
We want them to influence policy and accept a measure of accountability 
for departmental results.
    In that regard, I will of course be very interested in hearing 
today about the challenges facing women and minority veterans, such as 
gender-specific health care.
    I want to learn about disabilities more likely to affect minority 
veterans. I want to hear about the challenges facing veterans who wish 
to take advantage of economic opportunities in the public and private 
sectors.
    I will also, however, especially want to learn today how VA and its 
component organizations are effectively rising to meet those 
challenges.
    Mr. Chairman, I yield back.

                                 
              Prepared Statement of Hon. Gus M. Bilirakis,
         a Representative in Congress from the State of Florida
    I want to thank Chairman Hall and Chairman Michaud for scheduling 
today's joint hearing on the issues facing women and minority veterans. 
As a new Member of the Veterans' Affairs Committee, I am glad that we 
will be examining how women and minority veterans are being treated 
within the Department of Veterans' Affairs.
    The numbers of women and minorities serving in our military 
continues to grow, and consequently, their ranks among our Nation's 
veterans' population is also rising. As a result of the changing 
demographics of our military personnel, I believe it is important for 
our Committee to examine the challenges that face women and minority 
veterans as they transition back into civilian life.
    We must also ensure that they have access to the services and 
benefits that they have earned through their service to our country. I 
am anxious to hear from our witnesses to learn more about how we 
improve the services provided to women and minority veterans.
    Thank you, Mr. Chairman. I look forward to working with you and our 
colleagues on the VA Committee on these important issues.

                                 
     Prepared Statement of Shirley A. Quarles, R.N., Ed.D., Chair,
                 Advisory Committee on Women Veterans,
                  U.S. Department of Veterans Affairs
    Chairman Hall, Chairman Michaud, and Members of the Subcommittees, 
I am pleased to testify today on behalf of the Department of Veterans 
Affairs Advisory Committee for Women Veterans regarding our views on: 
how the Department of Veterans Affairs (VA) serves women veterans 
through its current programs; the present and future needs of a growing 
women veterans population; the strategies VA has for meeting these 
needs; and outreach efforts that are being conducted by VA for women 
veterans.
    The Advisory Committee on Women Veterans (ACWV) was established by 
Public Law 98-160 in 1983. The Advisory Committee is charged with 
advising the Secretary of Veterans Affairs on VA benefits and services 
for women veterans, assessing the needs of women veterans, reviewing VA 
programs and activities designed to meet the needs of women veterans, 
and developing recommendations that address unmet needs of women 
veterans. The Advisory Committee submits a biennial report to the 
Secretary of Veterans Affairs that delineates the Committee's findings 
and recommendations.
    The Advisory Committee on Women Veterans consist of 14 members 
(women and men) most are veterans; who have served across all services 
of the Armed Forces. This Committee is supported by the Center for 
Women Veterans with advisors and ex-officio members from the Department 
of Defense (DoD), Veterans Benefits Administration (VBA), Veterans 
Health Administration (VHA), National Cemetery Administration (NCA), 
Department of Labor (DoL), and the Department of Health and Human 
Services (HHS).
How is the Department of Veterans Affairs (VA) serving women through 
        its current programs?
    As a means to obtain information regarding women veterans' services 
and programs provided by VA on health care and benefits, the Advisory 
Committee on Women Veterans (ACWV) conducts site visits to VA 
facilities throughout the U.S. Additionally, the ACWV tours the 
facilities and meets with senior leaders to discuss services and 
programs available to women veterans. During the site visits, the ACWV 
also hosts open forums with the local women veterans' community to 
encourage open dialog from women veterans to share their experiences 
within VA, to discuss issues, and to raise questions related to gender 
specific VA benefits and services.
    As another means to obtain information regarding women veterans' 
services and programs provided by VA, the ACWV meets twice a year at VA 
Central Office (VACO) and receives briefings from the Veterans Health 
Administration (VHA), Veterans Benefits Administration, (VBA), National 
Cemetery Administration (NCA), Office of Research and Development 
(ORD), and other staff offices. These briefings update the Committee on 
the status of VA programs and how these programs address the needs of 
women veterans. During these meetings, members have the opportunity to 
question presenters about services in their area of concentration and 
share their observations and concerns from site visits. The Advisory 
Committee uses information gathered from the site visits and briefings 
to formulate recommendations to the Secretary of Veterans Affairs in 
the biennial reports. The Center for Women Veterans provides support to 
the ACWV during their site visits and meetings at VACO.
    In the 2006 Report of the Advisory Committee on Women Veterans, the 
Committee made 23 recommendations that addressed behavioral and mental 
health care, health care, military sexual trauma (MST), outreach, 
research studies, strategic planning, training, women veterans health 
program, women veterans program managers and women veterans 
coordinators, and homeless women veterans.
    One recommendation that has already been implemented was to 
organizationally realign the Women Veterans Health Program Office to 
the status of a Strategic Healthcare Group. With the recent elevation 
of the Women Veterans Health Program to the Women Veterans Health 
Strategic Healthcare Group, it has positioned the office to gain 
expertise in the population of women veterans, strategically plan for 
health care delivery and provide leadership in clinical knowledge of 
this unique group of women and to catalyze optimal integration of women 
veterans health issues across all VHA programs and offices. VA strives 
to be the lifetime provider of health care services to women veterans 
and exceed their expectations for care during each phase of their 
lifecycle. Additionally, VA aims to be a world leader in innovative and 
high quality for women veterans.
    In the area of women veterans health program, the Advisory 
Committee on Women Veterans 2006 Report recommended that VA ensure that 
the Center for Women Veterans is provided an annual update on the 
effectiveness of the responsibilities of the VHA Women Veterans Program 
Managers. VHA leaders and the Acting Chief Consultant, Women Veterans 
Health Strategic Healthcare Group (formerly known as Women Veterans 
Health Program), briefed the Committee on this issue at the February-
March 2007 Advisory Committee for Women Veterans meeting. Additionally, 
the Acting Chief Consultant and the Women Veterans Health Strategic 
Healthcare Group work closely with the Center for Women Veterans on 
issues that are frequently referred to Women Veterans Program Managers 
in field facilities.
    The submission of the 2006 Report to Congress was at the discretion 
of the Secretary for Veterans Affairs; a strong supporter of the 
Advisory Committee on Women Veterans. As a courtesy to this Committee, 
the Secretary agreed to forward the report to Congress during May 2007.
What are the present and future needs of these growing populations and 
        what strategies does VA have for meeting them?
    One area the Advisory Committee for Women Veterans was able to 
witness first hand the present needs of women veterans' mental health 
care was at our site visit in June 2007 to the Women's Mental Health 
Center in Palo Alto, CA. The Women's Trauma Recovery Program (WTRP) is 
a 60-day residential post-traumatic stress disorder (PTSD) and military 
sexual trauma (MST) treatment program.
    The future needs can be met through research and studies 
specifically on women veterans. In the 2004 and 2006 Advisory Committee 
on Women Veterans Reports, research and studies have been recommended. 
The last national survey of female veterans was conducted in 1985, 
leaving VHA policy makers and managers with limited information with 
which to adequately plan for future health care services for women 
veterans. To address this knowledge gap, the WVHSHG commissioned Donna 
Washington, MD, MPH, VA Greater Los Angeles HSR&D Center of Excellence, 
to conduct a national Survey of Women Veterans. The objectives of the 
National Survey of Women Veterans are: (1) identify the current 
demographics, health care needs, and VA experiences of women veterans; 
(2) determine how health care needs and barriers to VA health care use 
differ among women veterans of different periods of military service, 
e.g., OEF/OIF versus earlier periods; and (3) assess women veterans 
preference for and perceived value of different types of VA 
interventions to improve access and quality. The survey will enroll 
from 2,500 to 3,200 women veterans across the Nation, including equal 
numbers of VA users and nonusers. The final report will be submitted by 
December 31, 2008. The initial funding award was for $870,400.
What outreach efforts are being conducted by VA to women veterans?
    We continue to outreach to the women veterans' community with 
increased emphasis with our partnerships with federal, state, and 
country agencies, national veterans service organizations and community 
organizations. To enhance collaboration and better serve our women 
veterans, appointed advisors and ex-officio representatives from HHS, 
DoL, DoD, and VA Administrations (VHA, VBA and NCA) serve on the 
Advisory Committee on Women Veterans. The Center's Director, Dr. Irene 
Trowell-Harris serves as an ex-officio member of the Defense Advisory 
Committee on Women in the Services (DACOWITS). In this role, she 
ensures that DoD and VA, as a team, address military and women 
veterans' health and benefits issues.
    The 2004 Advisory for Women Veterans Report recommended that 
brochures and outreach materials that are currently only available in 
English be translated in Spanish. VA has distributed brochures, 
pamphlets, fact sheets, and booklets in Spanish from VHA, VBA and NCA. 
Numerous benefit fact sheets and other informational materials, printed 
in Spanish, are available on VA's Internet web site at www.va.gov.
    The Advisory Committee on Women Veterans plans to participate in 
the 2008 National Summit on Women Veterans Issues to be held in 
Washington, DC during June 2008 and to facilitate a townhall meeting to 
better serve our women veterans.
    The Advisory Committee on Women Veterans is grateful to the VA and 
the Center for Women Veterans on their vision and professional efforts 
to take care of our women veterans of yesterday, today, and the future.
    This concludes my formal testimony. I will be pleased to answer any 
questions.

                                 
    Prepared Statement of Colonel Reginald Malebranche, USA (Ret.),
            Member, Advisory Committee on Minority Veterans,
                  U.S. Department of Veterans Affairs
    Chairman Michaud, Chairman Hall, and Members of the Subcommittees, 
I am indeed pleased to represent the Chairman of the Advisory Committee 
on Minority Veterans, give you our views on the services provided by 
the Department of Veterans Affairs (VA) to Minority Veterans; on VA's 
present and future strategies addressing the needs of this growing 
population; and VA's outreach efforts toward Minority Veterans.
    The Advisory Committee on Minority Veterans (Committee) was 
established in November 1994, pursuant to Public Law 103-146. The 
Committee is tasked with assessing the needs of minority veteran 
populations, and reporting back to the Secretary on the effectiveness 
of VA programs and services at meeting those needs. The Committee works 
in close coordination and collaboration with the Center for Minority 
Veterans (Center) and relies on the expertise of Center staff for 
current information about VA programs, policies and services.
    The Advisory Committee on Minority Veterans members are appointed 
by the Secretary, and serve at his/her discretion. The majority of the 
Committee members are veterans and are representative of the 5 minority 
groups--African American, Asian American, Hispanic, Pacific Islander, 
Native American (including Alaskan Native, American Indian, and Native 
Hawaiian).
    As a means of obtaining information regarding the delivery of 
health care and services to minority veterans, the Committee conducts 
an annual site visit to a selected VA facility with a high density of 
minority veterans. During these visits, the Committee tours the 
facilities and meets with senior VA officials to discuss services and 
programs available to minority veterans. The Committee also hosts open 
forums with Veteran Services Organizations with the local veterans, to 
encourage them to discuss issues, problem areas, and seek information 
related to VA benefits and services.
    The Committee meets once a year at VA Central Office and receives 
briefings from the VA Senior leadership, the Center for Minority 
Veterans, Veterans Health Administration (VHA), Veterans Benefits 
Administration (VBA), National Cemetery Administration (NCA) and other 
staff offices. These briefings update the Advisory Committee on the 
status of VA programs and address issues and concerns raised during the 
site visits.
    In its 2006 Report on the Greater Los Angeles Health Care System, 
April 3-7, 2006, the Advisory Committee made eleven recommendations, 
with the key issues being Outreach, Research, Staff Diversity, Seamless 
Transition, and the Native American Veteran Housing Loan Program.
    During its visit to the Los Angeles Ambulatory Care Center, The 
Committee was dismayed by the staggering number of homeless veterans. 
Twenty-three percent (23% or 21,424) of the 90,000 homeless populations 
in Los Angeles were reported to be veterans. The Committee was 
encouraged by the range of programs identified by VA for homeless 
veterans. Yet, the Committee was concerned that those programs may not 
reach the targeted audience. There was insufficient evidence that 
outreach programs had been designed and publicized to a level to ensure 
that homeless minority veterans were aware of their existence. The 
Committee believed that similar situations may affect the homeless 
veteran population throughout the Continental United States and its 
Territories.
What outreach efforts are being conducted by VA to minority veterans?
    Outreach is a major challenge for the VA. During its sessions with 
Veteran Services Organizations, and with minority veterans, at its 
townhall meeting, the Committee learned that the major issue was that 
minority veterans were unaware of their VA benefits, and other VA 
services available. The Committee recognized that VA made strides to 
reach out to minority veterans and inform them of their benefits and 
the services available. The Committee noted that VA had developed and 
distributed comprehensive and illustrative pamphlets. However, the 
Committee believes that additional resources such as publishing and 
distributing a veterans' magazine similar to the VA employee magazine 
Vanguard, could be utilized to inform veterans of their entitlements.
    Transportation to VA centers, in major metropolitan, rural and 
isolated areas, is a major impediment for minority veterans. 
Accessibility, affordability, and distances to VA centers are major 
problems affecting minority veterans. Although Veterans Services 
organizations and many non-profit organizations provide some forms of 
relief, the Committee noted that a major segment of the minority 
veterans were not within easy or affordable reach to VA centers.
    Much remained to be accomplished in the area of outreach. The 
Committee recognized that it is not simply a VA challenge. Several of 
its members have taken the mantle to assist VA in its quest to reach 
out to minority veterans. Committee members head Veterans Services 
Organizations and insure that the VA's efforts are well publicized and 
supported. Others visit medical centers and hold informal meetings with 
minority veterans to ensure that those veterans, and/or their family 
members/friends/acquaintances are aware of their entitlements and 
benefits.
    The challenge to reach all minority veterans will require a 
concerted effort of VA, other Federal and state agencies, Veterans 
Services Organizations, Members of the Committee, and the public to 
make sure that all veterans are keenly aware of their entitlements.
What are the present and future needs of those growing populations and 
        what strategies does VA have for meeting them?
Access to Care
    Minority veterans' access to care is a major challenge for VA, 
particularly for minority veterans in large metropolitan areas, in 
rural and isolated areas. For example the plight of Alaska Natives, 
living in rural and isolated areas of the state, cannot be ignored; and 
neither can the plight of minority veterans living in rural and 
isolated areas within the Continental United States. The challenge for 
VA is to continue to develop and implement innovative programs which 
target those minority veteran populations.
    Rural and remote areas such as Alaska and the Navajo Nation may be 
good areas to test rural health initiatives. VA could enter in a 
reimbursable agreement with all Alaska Natives' organizations, the 
Health and Human Services and Indian Health Service to reach out to all 
minority veterans and provide all the services, which fall within the 
realm of the VA.
    The Committee applauds the strides made by VA in expanding its 
telehealth and telemedicine programs, and its ability to reach a 
significant number of the minority veteran population. Yet, those 
programs are not stand alone, and will require significant investment 
and training.
Mental Health
    Mental health is and will become a major challenge. The Committee 
recognizes the efforts and the programs put forth by VA to support, 
identify, and care for soldiers, sailors and airmen, who have served in 
Operation Enduring Freedom and Operation Iraqi Freedom theaters of 
operations. The early identification of Post Traumatic Stress Disorder 
will certainly help in the observation and treatment of all veterans 
who served in those areas. Yet, the Advisory Committee is concerned 
that the same level of services might not be readily available to 
minority veterans who have served in prior conflicts.
    The Committee is also concerned that an interoperable electronic 
health record has not been developed to embrace all Uniformed Services 
personnel.
Benefits
    The processing and adjudication of benefits seem to affect all 
veterans. The Committee recognized the initiatives approved by the 
Congress to improve the processing and adjudication of benefits by VA. 
The Veterans Claims Assistance Act of 2000--Public Law 106-475--puts 
the onus on VA to maximize its assistance to all veterans and to make 
them aware of their entitlements.
Staff Diversity
    Senior staff diversity remains an issue at VA. The absence of 
minorities at the senior staff level has been and continues to be 
noticeable during site visits. Data presented and subscribed by VA 
suggests that VA's problem is limited to recruiting white females, and 
Hispanics. Yet, other data maintained at VA suggested that minorities 
were not well represented at senior staff levels. The Committee was 
concerned at the inconsistency of the data, and its implications for 
minority veterans and the minority population at VA.
How is the U.S. Department of Veterans Affairs (VA) serving minorities 
        through its current programs?
    The professionalism, the expertise shown by VA personnel was 
striking. The Committee noted in several instances that VA's efforts in 
most areas were only limited by personnel and time. There was a 
perception that most staff would endeavor to do all possible for a 
veteran. The challenge is to include minority veterans in that equation 
and philosophy.
    VA's strides in supporting veterans are especially noteworthy. 
Thank you for this opportunity to address the Subcommittees. I would be 
happy to address any questions you may have.

                                 
              Prepared Statement of Saul Rosenberg, Ph.D.,
          Associate Clinical Professor of Medical Psychology,
              University of California, San Francisco, CA
    Mr. Chairman, thank you for inviting me to this joint hearing of 
the Subcommittees on Health and Disability Assistance and Memorial 
Affairs to discuss the needs of women and minority veterans. My name is 
Dr. Saul Rosenberg. I have been engaged in assessing and treating 
veterans and civilians with Posttraumatic Stress Disorder (PTSD) for 
many years. As a clinical psychology intern at the Ann Arbor VAMC I 
learned that to be an effective therapist I had to understand the 
cultural experiences, preferences and values of the individual I was 
trying to help. The lessons I learned as a trainee I have taught to 
interns and psychiatry residents at the San Francisco VAMC. I am not 
employed by the VA nor do I represent the VA.
    With my colleagues in the Dept. of Psychiatry at the University of 
California, San Francisco and the San Francisco VAMC I have 
participated in the development of diagnostic interviews and 
psychological tests to help counselors and therapists better understand 
the psychological problems that contribute to social isolation. Social 
support from families, friends, Vet Centers and veterans' service 
organizations play a huge role in healing the body, mind and spirit.
    My current professional interest is in the development of public-
private partnerships, between University of California campuses, 
affiliated military hospitals and VAs, governmental agencies, 
foundations and the private sector to improve access to evidence-based, 
cost-effective mental health diagnostic and treatment services. I 
believe that public-private partnerships are essential to reduce the 
disparities in access to mental health services for racial and ethnic 
minorities, native Americans, rural populations, women, children, the 
elderly and all underserved and vulnerable populations.
    My colleagues at UCSF and the SFVAMC recently published the first 
detailed report on the prevalence of mental health and psychosocial 
problems, with a breakdown by gender and race, for over 100,000 
veterans first seen at VA health care facilities. The prevalence of 
mental disorders was high: over 30% had a diagnosed mental disorder or 
psychosocial problem. Posttraumatic Stress Disorder (PTSD) was the most 
common diagnosis, and more than half of those diagnosed with a mental 
disorder had 2 or more mental health diagnoses.
    Women comprised 13% of the sample; 69% were White, 18% were Black, 
11% were Hispanic and 2% came from other racial groups. The likelihood 
of receiving a diagnosis for PTSD or another mental disorder was the 
same for women and men and across all racial groups. The most striking 
finding in the study had to do with age and not with race or gender. 
The youngest veterans, between 18 and 24 years of age, had a 
significantly higher likelihood of being diagnosed with PTSD or another 
mental disorder, compared to veterans 40 years and older. The youngest 
men and women, Whites, Blacks and Hispanics, were more vulnerable to 
stress than those who were over 40 years of age. The results of this 
study point to the importance of funding programs that target the early 
identification and treatment of PTSD in the youngest servicemen and 
women.\1\
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    \1\ Karen H. Seal, MD, MPH; Daniel Bertenthal, MPH; Christian R. 
Miner, PhD; Saunak Sen, PhD; Charles Marmar, MD, ``Bringing the Ware 
Back Home: Mental Health Disorders Among 103 788 U.S. Veterans 
Returning from Iraq and Afghanistan Seen at Department of Veterans 
Affairs Facilities'' Arch Intern Med. 1007, 167, 476-482.
---------------------------------------------------------------------------
    In this study, most mental disorders were identified in primary 
care and non-mental health settings within a few days of the first 
visit to a VA clinic. The detection of PTSD, depression and substance 
abuse in primary care settings is crucial in order to initiate 
treatment which can prevent chronic mental disorders and disability. 
This study shows that the emphasis the VA is placing on the early 
detection of mental disorders in primary care settings has been 
effective.
    Clinical research on the screening and psychological assessment of 
mental and substance abuse disorders and suicide risk in primary care 
deserves continued funding. Evidence-based clinical guidelines for the 
detection of PTSD, substance abuse and suicide risk should be 
continuously evaluated. The most effective protocols should be 
disseminated to all settings where veterans receive care, including the 
private sector.
    For many years, The VA, DoD, National Institute of Health (NIH) and 
the National Institute of Mental Health (NIMH) have supported research 
on evidence-based diagnostic tools and treatments for PTSD, depression 
and substance abuse. I have been grateful to the NIMH for supporting my 
own research. Like most academics, I have published my research in peer 
reviewed journals. However I now believe that research that benefits 
patients needs to be delivered to health care providers when they need 
it--at the point of care.
    The VA--more than any other public or private institution--is in 
the best position to implement computer-aided decision support for 
mental disorders at the point of care. The VA is the largest integrated 
delivery system that provides mental and behavioral health care. In 
addition, the VA has VistA, the oldest and most robust Electronic 
Health Record (EHR). The delivery of clinical practice guidelines 
matched to a patient's diagnosis and delivered directly into to a 
patient's EHR at the point of care deserves the highest priority. In 
addition, efforts now underway to develop portable longitudinal 
Personal Health Records that injured veterans can take with them 
wherever they seek care deserve continued support.
    Too much excellent research that could benefit veterans is buried 
in professional journals; we need one place to accumulate all the data 
from all the studies so that health care providers can learn from past 
experience and share knowledge about the best ways to treat and 
rehabilitate injured veterans. All researchers and contractors who 
receive Federal funding for health related projects should be 
encouraged to deposit their data in a secure, private and confidential 
data base. Investigators and contractors should be encouraged to report 
results by gender and race to insure that treatments are available that 
are attuned to the experiences, culture, values and preferences of 
injured veterans and their families.
    Many servicemen and women returning from Iraq have been exposed to 
roadside bombs and improvised explosive devices. Never before have so 
many soldiers received simultaneous injuries to their brain and mind. 
There is much that we have to learn about the diagnosis and cognitive 
rehabilitation of Traumatic Brain Injuries (TBI) from powerful bombs. 
These blast injuries are not the same as concussions resulting from a 
car accident or a sports injury. Thorough screening and comprehensive 
neurological and neuropsychological assessment is essential to 
characterize these injuries and to maximize the prospects for recovery, 
a good quality of life and the ability to work, contribute and 
participate in a community.
    Most veterans receive their health care outside the VA system. I am 
especially concerned about the lack of coverage provided by private 
health insurance plans for neuropsychological assessment. Many private 
insurance companies will pay over $1,000 for neuroimaging studies but 
refuse to pay for the costs of comprehensive neuropsychological 
testing. Proper neuroimaging studies are essential but they cannot 
measure cognitive functioning, like the ability to sustain and focus 
attention or short-term memory--only neuropsychological tests can do 
that. Congressional hearings that investigate the treatment of veterans 
with TBI should invite neuropsychologists and representatives of 
professional neuropsychological associations to provide testimony on 
this issue. Before the DoD and VA outsource the treatment of military 
personnel and veterans with brain injuries to private facilities they 
should have the assurance that unwarranted restrictions on 
neuropsychological assessment are the exception rather than the rule.
    The VBA has acknowledged a backlog of over 400,000 disability 
claims awaiting disability determination. The VBA has acknowledged that 
the waiting time to complete disability examinations is unacceptably 
long.
    According to a 2007 Institute of Medicine (IOM) report regarding 
disability determination for veterans, the methodology the VBA uses for 
determining disability is outmoded and does not reflect current 
knowledge about the assessment of functional impairments. The IOM 
recommended development of pilot programs to immediately award partial 
disability to veterans who meet presumptive criteria for a disabling 
mental disorder. Implementing the IOM's recommendations would assure 
that injured veterans received immediate help and financial support 
while waiting--sometimes for years--for their claims to be adjudicated.
    The IOM also recommended funding demonstration projects to 
implement the International Classification of Functioning, Health and 
Disability published by the World Health Organization. The IOM pointed 
out that we need better description and quantification of functional 
capacities that promote involvement. Projects should be encouraged that 
map the full range of impairments and also the full range of functional 
capacities. A major goal of rehabilitation is to reengage the disabled 
veteran and promote social connections. Injured veterans need to be 
engaged in their communities, working, volunteering and connecting with 
friends and veterans.
    Wide variability exists between military and VA disability ratings 
and across different regions of the U.S. I am especially concerned 
about the possibility of racial disparities in disability ratings for 
PTSD. In a presentation to the Institute of Medicine, Dr. Charles 
Engel, the Director of the Deployment Health Clinical Center, reported 
that African American veterans were about half as likely as other 
veterans to receive service connected disability for PTSD (Medical Care 
2003;41(4):536-549). This issue deserves urgent attention. Culturally 
sensitive assessment tools need to be developed to insure that 
consistent and equitable procedures are implemented and that any racial 
disparities that exist are eliminated.
    A 2007 Institute of Medicine (IOM) report, PTSD Compensation and 
Military Service, recommended that new methods should be developed to 
identify women who are victims of military sexual assault. Because PTSD 
from sexual assault is more difficult to prove than PTSD resulting from 
combat, the IOM recommended that more attention should be focused on 
the prompt identification and treatment of women who are victims of 
sexual assault and that better procedures be established for awarding 
disability compensation.
    A 2007 report form the DoD Task Force on Mental Health has called 
for more attention to the prevention of mental disorders and the 
building of resilience and coping strategies to deal with the stress of 
deployment. The report stated:

        ``The mission of caring for the psychological health of the 
        military has fundamentally changed--new programs are needed--to 
        meet current and future demands for a full spectrum of services 
        including: resilience-building, assessment, prevention, early 
        intervention, and provision of an easily accessible continuum 
        of treatment for psychological health of service members and 
        their families in both the Active and Reserve Components. There 
        are not sufficient mechanisms in place to assure the use of 
        evidence-based treatments or the monitoring of treatment 
        effectiveness'' \2\
---------------------------------------------------------------------------
    \2\ Defense Health Board Task Force on Mental Health (2007). An 
achievable vision: Report of the Department of Defense Task Force on 
Mental Health. Falls Church, VA; Defense Health Board; ES 2-3

    Currently, health information technology contracts and clinical 
research are conducted along parallel separate tracks. I recommend that 
contracts and research be funded for joint projects that integrate 
health services research and health information technology. Programs 
like the VA Special Fellowship Program in Medical Informatics provide a 
bridge for connecting patients, providers and researchers to health 
information technologies. The next generation of providers will be 
increasingly sophisticated in utilizing cutting edge technologies for 
telemedicine such as those being developed by the Telemedicine and 
Advanced Technology Research Center (TATRC).
    A recent study by Dr. Charles Marmar at the San Francisco VAMC and 
UCSF and his colleagues across the country, found predictors of PTSD 
for police and other first responders following a disaster or critical 
incident.\3\ This study measured personal characteristics 
prospectively--prior to exposure to a stressful event. Factors that 
predicted chronic and severe PTSD symptoms and greater functional 
impairments included the use of maladaptive coping strategies, 
especially self-medication with alcohol. In contrast, police officers 
who had a strong social support network after exposure to a critical 
stressful incident, exhibited less symptoms and impairments in 
functioning and were more likely to return to duty. The National 
Institute of Mental Health has generously funded research on 
vulnerabilities and protective factors related to the development of 
PTSD; congress should continue to support these promising initiatives.
---------------------------------------------------------------------------
    \3\ Charles R. Marmar; Shannon E. McCaslin; Thomas J. Metzler; 
Suzanne Best; Daniel S. Weiss; Jeffery Fagan; Akiva Liberman; Nnamdi 
Pole; Christian Otte; Rachel Yehuda; David Mohr; and Thomas Neylan, 
``Predictors of Posttraumatic Stress in Police and Other First 
Responders'' Ann. N.Y. Acad. Sci. 1071: 1-18 (2006).
---------------------------------------------------------------------------
    The Mental Illness Research, Education and Clinical Centers 
(MIRECC) were established by Congress to translate clinical research 
and best practices in mental health care into tangible benefits for 
patients of the VA. The MIRECCs are conducting research on post-
deployment mental disorders, PTSD, substance abuse and suicide 
prevention. In addition, the MIRECCs produce clinical educational 
programs. These excellent programs deserve continued support and new 
programs should be funded, such as centers of excellence for the study 
of resilience--an idea promoted by the DoD Task Force on Mental Health.
    The Telemedicine and Advanced Technology Research Center (TATRC) 
was established by congress to implement innovative telemedicine and 
technology projects to deliver medical expertise anywhere it is needed. 
Technologies developed by TATRC to help injured servicemen and women on 
the battlefield, and in remote rural communities, can be transferred to 
the private sector. Like many technology projects sponsored by the VA, 
the benefits accrue not only to veterans and their families but to the 
whole community. VistA, the VA's EHR is being installed around the 
world; countries that cannot afford to spend millions of dollars to 
develop an EHR can install VistA for a tiny fraction of the cost of 
commercial EHR.
    Thank you for your support for research and for the education and 
training of the clinicians who provide health care to injured veterans. 
I will be happy to answer any questions.

                                 
           Prepared Statement of Maureen Murdoch, M.D., MPH,
             Center for Chronic Disease Outcomes Research,
      Minneapolis Veterans Affairs Medical Center, Minneapolis, MN
  Veterans Health Administration, U.S. Department of Veterans Affairs
                         (on behalf of herself)
    Mr. Chairman and Members of the Subcommittees, thank you for the 
opportunity to appear before you today to present findings from my 
team's research on possible disparities in PTSD disability awards among 
race and gender groups. I must note the views presented today are mine 
and do not necessarily represent the views of the Department of 
Veterans Affairs (VA) and reflect the results of my studies and not 
necessarily the findings of other research.
Background
    PTSD is the most common psychiatric condition for which veterans 
seek VA disability benefits. Long-term health studies indicate women 
have a higher prevalence of PTSD than men, and may be more susceptible 
to PTSD. Conversely, African American or blacks appear to have similar 
risks for PTSD compared to whites.
    In 2000, my colleagues and I began investigating if there were race 
and gender disparities in VA disability awards for post-traumatic 
stress disorder (PTSD). We assembled a representative sample of almost 
5,000 men and women veterans who applied for PTSD disability benefits 
between 1994 and 1998.
    We developed and tested 4 hypotheses:

    1.  Veterans reporting more severe PTSD symptoms would be more 
likely to be Service-Connected for PTSD than veterans reporting less 
severe PTSD symptoms.
    2.  Veterans reporting more severe disablement would be more likely 
to be Service-Connected for PTSD than veterans reporting less 
disablement.
    3.  Veterans with combat experience would be more likely to be 
rated Service-Connected for PTSD than veterans not in combat.
    4.  These 3 covariates (PTSD symptom severity, degree of 
disability, and combat exposure) would explain any race or gender 
differences in VA PTSD disability awards.

Results of the Studies
    Overall, the 3,337 respondents were highly symptomatic. About 80 
percent met our definition for PTSD and 62 percent were service 
connected for PTSD. Our results yielded several interesting findings. 
Concerning the relationship between PTSD service connection and gender, 
despite fewer major medical complications and superior physical 
functioning, women's overall role functioning was similar to men's. 
Almost 94 percent of men and 29 percent of women reported at least some 
combat exposure. Most importantly, once combat exposure was controlled, 
the effect of gender on service connection for PTSD became 
insignificant. Specifically, more than 90 percent of combat-injured 
veterans, regardless of gender, became service-connected for PTSD. 
Those with higher levels of combat exposure were substantially more 
likely than those with lower levels to be service connected for PTSD. 
Since men had notably greater exposure to combat, they likewise had 
higher rates of service connection. In sum, instead of a gender bias in 
awards for PTSD service connection, we found evidence of a combat 
advantage that disproportionately favored men and adversely affected 
women.
    We also compared PTSD symptom severity and Social Adjustment scores 
of veterans reporting sexual assault and combat exposure. We found, on 
average, veterans reporting combat alone had marginally less severe 
PTSD symptoms than those reporting sexual assault. Veterans reporting 
only combat exposure also reported significantly better Social 
Adjustment Scores than those reporting sexual assault. Men and women 
who reported sexual assault were equally unlikely to be service 
connected for PTSD.
    In our investigation of racial disparities, we found that the 
African Americans in our sample were just as likely to be service 
connected for other disorders, but were substantially and significantly 
less likely than other respondents to be service connected for PTSD. 
The negative association between African Americans and service 
connection for PTSD was not found for any other racial or ethnic group. 
Among veterans receiving service connection for PTSD, the service-
connected rating was almost identical, regardless of race--an average 
rating of 43 percent for African Americans versus 45 percent for all 
other veterans. Controlling for gender, African Americans' modified 
combat exposure scores were similar to other veterans, but African 
Americans were significantly less likely to have a documented combat 
injury. With full adjustment, the estimated probability of being 
awarded service connection for PTSD was 43 percent for African American 
veterans compared with 56 percent for other respondents. Examining 
clinicians were about seven-tenths as likely to diagnose PTSD in 
African Americans as they were for other veterans, although this 
difference was not statistically significant.
Discussion About the Studies
    There are several issues warranting consideration when evaluating 
this research. First, the pool of respondents was selected based upon 
their submitted claims for PTSD service connection, while our questions 
focused on their current health and adjustment status. It is distinctly 
possible that those with the greatest need at the time of their 
application have been receiving treatment and may now actually report 
better health outcomes than their peers. Second, the study relied on 
veterans' self-reports of their PTSD symptom severity, degree of 
disability, and trauma history, which may not have been clinically 
accurate or universally consistent.
Recommendations
    In order to strengthen and expand this research, future studies 
should identify and evaluate veterans shortly after applying for PTSD 
disability benefits. In addition, we need to collect and assemble more 
data from the claims files. Finally, future studies should investigate 
claims for disorders other than PTSD.
    Mr. Chairman, this concludes my statement. I am pleased to respond 
to any questions you or the Subcommittee members may have. Thank you.

                                 
                   Prepared Statement of Joy J. Ilem,
  Assistant National Legislative Director, Disabled American Veterans
    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).
MINORITY VETERANS
    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 decisionmaking 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.
WOMEN VETERANS
    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 10 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-
nineties VA reorganized from a predominantly hospital-based delivery 
care model to an outpatient health care 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 health 
care decisionmaking; 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 
health care 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 health care needs of women veterans and 
demands on the VA health care 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 1 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 1 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; health care 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 health care 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 10 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 1 year following the incident. It is our understanding 
that after the 1 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 health care 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.

                                 
 Prepared Statement of Betty Moseley Brown, Ed.D., Associate Director,
     Center for Women Veterans, U.S. Department of Veterans Affairs
    Chairman Hall, Chairman Michaud, and Members of the Subcommittees, 
I am pleased to testify today on behalf of the Department of Veterans 
Affairs (VA) about services in VA for women veterans. Particularly, I 
will address how VA serves women veterans through its current programs, 
how present and future strategies will address the needs of this 
growing population, and what outreach efforts are being conducted by VA 
to women veterans. The Center for Women Veterans was established by 
Public Law No. 103-446 in November 1994 to oversee VA programs for 
women veterans. The Center's mission is to ensure that women veterans 
receive benefits and services on par with male veterans; that VA 
programs are responsive to gender-specific needs of women veterans; 
that outreach is performed to improve women veterans' awareness of 
services, benefits and eligibility criteria; and that women veterans 
are treated with dignity and respect. The Director, Center for Women 
Veterans, acts as the primary advisor to the Secretary and Deputy 
Secretary on all matters related to policies, legislation, programs, 
issues, and initiatives affecting women veterans.
How is the Department of Veterans Affairs (VA) serving women through 
        its current programs?
    The Center for Women Veterans monitors changes in services through 
briefings by the 3 VA administrations and assesses the impact these 
changes may have on the delivery of services for the Nation's 1.75 
million women veterans--from programs for homeless women veterans with 
children, elderly women veterans, women veterans living in rural areas, 
and for those women still unaware they, too, are veterans, since many 
do not identify themselves as such. The Center regularly monitors VA 
briefings during Transition Assistance Programs to ensure that active 
duty women are provided access to information on the benefits and 
services available to them as veterans prior to their release from 
active duty.
    The Advisory Committee on Women Veterans was established by Public 
Law 98-160 in 1983. The Advisory Committee is charged with advising the 
Secretary of Veterans Affairs on VA benefits and 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. The Advisory Committee submits 
a biennial report to the Secretary incorporating the Committee's 
findings and recommendations.
    As a means of obtaining information regarding the delivery of 
health care and services to women veterans, the Advisory Committee 
conducts site visits to VA facilities throughout the country. In 
addition, the Advisory Committee tours the facilities and meets with 
senior officials to discuss services and programs available to women 
veterans. During site visits, the Advisory Committee also hosts open 
forums with the women veterans' community, encouraging women veterans 
to discuss issues and ask questions related to VA benefits and 
services. The Advisory Committee meets twice a year at VA Central 
Office (VACO) and receives briefings from the Veterans Health 
Administration (VHA), Veterans Benefits Administration (VBA), National 
Cemetery Administration (NCA) and other staff offices. These briefings 
update the Committee on the status of VA programs and respond to 
concerns raised during the site visits. The Advisory Committee uses 
information from these site visits and briefings in its biennial 
reports to the Secretary.
    In the 2006 Report of the Advisory Committee on Women Veterans, the 
Advisory Committee made 23 recommendations. Some of the key report 
issues included outreach, behavioral and mental health care, military 
sexual trauma, health care, research and studies, strategic planning, 
training, and women veterans who are homeless. The 2006 Report has been 
provided to Congress.
    Regarding women veterans health program, the Advisory Committee, in 
its 2006 Report, recommended VA ensure the Center is provided an annual 
update on the effectiveness of the VHA Women Veterans Program Managers 
Program. VHA officials, including the Women Veterans Health Strategic 
Healthcare Group (formerly known as Women Veterans Health Program), 
briefed the Center and Advisory Committee members on this issue at the 
February- March 2007 meeting of the Advisory Committee. In addition, 
the Women Veterans Health Strategic Healthcare Group works closely with 
the Center on issues that are frequently referred to Women Veterans 
Program Managers in field facilities.

      In FY 2006, the VHA served 235,901 women veterans in our 
health system. By comparison, in FY 2001 VHA served 171,161 women 
veterans. This is a 5 year relative increase of 37.8 percent.
      In FY 2006, 14 percent of the census-projected number of 
all women veterans utilized VHA services. This compares to 22 percent 
of all male veterans utilization.
      Of the total number of women who have been discharged 
from active duty after deployment in Operation Iraqi Freedom and 
Operation Enduring Freedom (OIF/OEF), 37.5 percent, or 25,960 women 
veterans, have been to a VHA health care facility at least once. This 
compares to a male utilization rate of 32 percent for OIF/OEF veterans.
      There are 22 VA health care facilities that have 
dedicated, comprehensive women's center space.

    VHA's Women Veterans Health Strategic Healthcare Group (WVHSHG) 
studies the continuum of care available to women veterans through an 
annual Plan of Care-Clinical Inventory Report. This Report surveys 
availability of all related types of physical and mental health 
services for women at each medical facility. Every facility has a 
designated Women Veterans Program Manager to serve as program 
administrator, veteran advocate and referral source to appropriate 
care; this report also tracks their time allotment.
    In addition, in 2006 WVHSHG cosponsored Elizabeth Yano, PhD, MSPH, 
Deputy Director VA Greater Los Angeles HSR&D Center of Excellence and 
Associate Professor at UCLA, to survey VISN Leadership, facility and 
program directors regarding provision of care models in women's health 
in VHA. We expect delivery of this report in late 2007, informing VHA 
of the provision of primary care to women veterans through models of 
specialized women's health clinics and in models of mixed-gender 
primary care sites, including community based outpatient sites. This 
study will clarify which models of care for women provide the best 
performance outcomes and higher patient ratings of care.
    Realizing the current influx of returning women veterans will 
increase the number of women seen by VHA in the next several years, VHA 
has initiated programs to identify interested primary care providers 
and provide them with intensive training in women's health. The needs 
assessment for this program will be implemented in September 2007 
through VA's Employee Education Service efforts. This program will be 
especially important in addressing the health care needs of rural 
women. We also recognize that the majority of women veterans new to VHA 
are of childbearing age and could be at risk for birth defects from 
some prescription medications. This presents new challenges which we 
are addressing through initiatives in pharmacy management and provider 
education.
    VHA is committed to expanding the focus of women veterans' health 
care beyond the issues of gender specific screening for breast and 
cervical cancer. In the United States, heart disease is the number one 
cause of death in women, and WVHSHG has proposed initiatives in 
improved management and prevention for heart disease risk including 
cholesterol, weight management and smoking cessation. On June 22, 2007, 
VHA's Office of Public Health and Environmental Hazards awarded 2 
clinical demonstration grants specific to smoking cessation programs 
for women veterans.
    Another focus area for women veterans' health is prevention and 
detection of cancers, particularly colorectal cancers, through improved 
screening of women veterans. We are evaluating factors related to the 
fact that fewer women than men receive colorectal cancer screening, 
both within VA and in community samples.
Mental Health
    There are specialized women's mental health services in VHA:

      Specialized inpatient and residential programs for women 
veterans--these programs are for women who need more intensive 
treatment and support. While in these programs, women live either in 
the hospital or in a residence with other women. Length of stay for 
these programs ranges from 28 days to 18 months.
      Inpatient and residential programs with cohort treatment 
for women or separate women's wings--these are programs for women who 
need more intensive treatment and support, like the specialized 
inpatient and residential programs discussed above. However, these 
programs accept both men and women and accept women in groups at 
specific start dates or have separate space for women.
      Women's Stress Disorder Treatment Teams (WSDTTs)--these 
are specialized outpatient mental health programs that focus on the 
treatment of Post Traumatic Stress Disorder and other problems related 
to trauma.
      Women's Homelessness Programs--although many VA 
homelessness programs serve women, there are also programs specific for 
women veterans that provide services for those who are homeless or at 
risk of becoming homeless.
      Military Sexual Trauma (MST) Coordinators--every VA 
facility has a designated MST Coordinator who serves as a point of 
contact for MST-related issues. Vet Centers also have specially trained 
sexual trauma counselors.
      Sexual Trauma Treatment Provided in Residential or 
Inpatient Settings--there are programs that offer sexual trauma-
specific treatment in a residential or inpatient setting. Programs 
range from those solely dedicated to the treatment of sexual trauma; to 
those with a special track emphasizing the treatment of sexual trauma; 
to those with 2 or more staff members with expertise in sexual trauma 
who, in the context of a larger program not focused on sexual trauma, 
provide treatment targeting this issue.
      MST Support Team--In FY07, VA's Office of Mental Health 
Services (OMHS) established a Military Sexual Trauma (MST) Support Team 
that is designed to help ensure that VA is in compliance with legally 
mandated monitoring of MST screening and treatment. The team also helps 
to coordinate and expand legally mandated education and training 
efforts related to MST, and to promote best practices in the field.
      National Training Initiatives in Evidence-Based Practices 
for PTSD--there are currently 2 national initiatives to train 
therapists in evidence-based practice for PTSD being funded by VA's 
Office of Mental Health. The first one is to train and support 
therapists to conduct cognitive processing therapy (CPT), a highly 
effective treatment for PTSD and related symptoms. The second therapy 
is an exposure therapy for PTSD called prolonged exposure. There have 
been a number of studies supporting the use of exposure treatment for 
PTSD.
      In addition, there is a wide range of services for women 
available through VA's Readjustment Counseling Services and Vet Center 
Programs. Female veterans who served in combat theaters are eligible 
for the full range of readjustment services as provided by VA's Vet 
Center Program. Since the onset of the Vet Center program, women 
veterans have been provided outreach services to promote early 
intervention and access to VA care, preventive educational services, 
counseling for substantive readjustment problems (including war-related 
PTSD services), family counseling and employment related services. 
Since 1993, female veterans of any era have also been able to access 
military related sexual trauma counseling at Vet Centers. Vet Centers 
promote the hiring of female veteran service providers at equal to or 
higher than the representation of women in the military. Access to care 
for women veterans is also promoted through the Vet Center program's 
working group. The working group is composed of female staff members 
who assist management by educating their fellow Vet Center staff on the 
contributions made by women in the military and exploring gender-
related issues to promote gender-sensitive services to women veterans.

Research
    Currently, the VHA Office of Research and Development (ORD) is 
supporting a broad portfolio focused on women's health issues, 
including studies on diseases prevalent solely or predominantly in 
women [e.g., certain types of cancer (breast, cervical, ovarian), 
lupus, human papillomavirus (HPV) and hormonal effects on diseases in 
post-menopausal women], research focusing on women subjects (e.g., PTSD 
in women, osteoporosis in women, multiple sclerosis in women) and 
research on the health care of women veterans.
    ORD's efforts to support research that will improve the health care 
of the growing number of women veterans can be categorized in 3 areas:

      Research assessing VA's organization of care for women 
veterans and the implications for improved quality of care.
      Research on the unique experiences of women veterans 
regarding risks, treatment and health care outcomes related to sexual 
and other military traumas.
      Research examining the general health care needs and 
service utilization of women veterans.
      In 2001, VA's Office of Research and Development created 
a Center of Excellence for Research aimed at identifying factors which 
cause disparities in health outcomes across racial, ethnic, and gender 
lines, as well as ways for promoting equity in health and health care. 
This center, co-located at 2 sites (Pittsburgh and Philadelphia), has 
29 core investigators who have contributed over 128 peer-reviewed 
scientific articles over the past 2 years.

Veterans Benefits Administration

      In fiscal year 2006, Vocational Rehabilitation and 
Employment Program (VR&E) received 57,856 applications of which 9,895 
were female veterans. During the entire fiscal year, VR&E had 52,982 
active participants of which 12,627 were female veterans.
      In fiscal year 2006, 193,112 female veterans received 
compensation for a service-connected disability.
      In fiscal year 2006, the percent of guaranteed loans was 
increased for women veterans with 12.2 percent in FY06 with 17,355 
loans to women veterans at an average loan amount of $173,923.
      In fiscal year 2006, 8,442 women separating from service 
used their education benefits under the Montgomery GI Bill (MGIB). 
Since the inception of the MGIB, 214,369 female veterans have used 
their benefits under Chapter 30 of the program. This represents a 72.7-
percent rate of usage.
      There are 58,086 female veterans covered under the 
Veterans Group Life Insurance (VGLI) program. The total amount of 
coverage in force for female veterans is $17.6 billion for an average 
coverage of $123,300.
      Presented and participated in 8,541 VA benefits briefings 
attended by 393,345 active duty military service members including 
Guard and Reserve members.
      To promote accuracy and consistency in the claims review 
process, VBA has taken a number of actions. For example, in the past 4 
years, VBA has published guidance and conducted training for employees 
on the full range of issues related to PTSD claims adjudication--from 
development of the claim to proper application of the rating schedule.
      VBA and VHA have worked collaboratively to modifying the 
examination request worksheets and the examination templates related to 
PTSD. This ensures that the information gathered during the exam is 
uniform and sufficient to make the determinations concerning 
entitlement and degree of impairment.

What are the present and future needs of these growing populations and 
        what strategies does VA have for meeting them?
    The last national survey of female veterans was conducted in 1985, 
leaving VHA policy makers and managers with limited information with 
which to adequately plan for future health care services for women 
veterans. To address this knowledge gap, the WVHSHG commissioned Donna 
Washington, MD, MPH, VA Greater Los Angeles HSR&D Center of Excellence, 
to conduct a national Survey of Women Veterans. The objectives of the 
National Survey of Women Veterans are: (1) identify the current 
demographics, health care needs, and VA experiences of women veterans; 
(2) determine how health care needs and barriers to VA health care use 
differ among women veterans of different periods of military service, 
e.g., OEF/OIF versus earlier periods; and (3) assess women veterans 
preference for and perceived value of different types of VA 
interventions to improve access and quality. VA will survey between 
2,500 and 3,200 women veterans across the Nation, including equal 
numbers of VA users and nonusers. The survey began in April of 2007 and 
the final report will be submitted by December 31, 2008.
    The recent elevation of the Women Veterans Health Program to the 
Women Veterans Health Strategic Healthcare Group has positioned the 
office to gain expertise in the population of women veterans, 
strategically plan for health care delivery and provide leadership in 
clinical knowledge of this unique group of women and to catalyze 
optimal integration of women veterans health issues across all VHA 
programs and offices. We aim to be a world leader in innovative and 
high quality care to women veterans.
What outreach efforts are being conducted by VA to women veterans?
    We continue to outreach to the women veterans' community with 
increased emphasis on our partnerships with Federal, state, and county 
agencies, national Veterans Service Organizations and community 
organizations. To enhance collaboration and better serve our women 
veterans, representatives from the Department of Health and Human 
Services (HHS), the Department of Labor (DoL), the Department of 
Defense (DoD), and VA Administrations (VHA, VBA and NCA) serve on the 
Advisory Committee on Women Veterans as appointed ex officio members. 
The Center's Director serves as an ex officio member on the Defense 
Advisory Committee on Women in the Services (DACOWITS). In this role, 
she ensures that DoD and VA collaboratively address military and women 
veterans' health and benefits issues.
    The Center published the 25 most Frequently Asked Questions from 
women veterans in English and Spanish based on thousands of inquiries 
from women veterans. These questions are posted on the Center's website 
and the VA website.
    The next National Summit on Women Veterans Issues will be June 20-
22, 2008. We are planning to outreach to the military services, 
particularly the Reserves and National Guard. We are planning various 
workshops, including ``Readjustment Counseling Service: Outreach and 
Transition Services for Veterans Families,'' ``Gender Differences: What 
the Data Shows,'' and ``Mental Health Issues.'' Our previous summit was 
attended by over 300 women veterans, Federal, state and veteran 
advocates and developed recommendations for how to better serve women 
veterans.
    Since October 2001, the Center staff has completed nearly 100media 
interviews and hundreds of keynote speeches, participated in veterans 
forums, and monitored Transition Assistance (TAP) sessions and veterans 
briefings. To ensure veterans' issues are addressed quickly during 
forums, VA has assigned local women veterans program managers from VA 
Medical Centers and women veteran coordinators from Regional Offices to 
accompany Center staff to answer general questions and see that health 
care and benefit issues raised regarding individual cases receive 
immediate attention. In addition, Center staff works closely with 
numerous other VA advisory Committees and councils, DoD, DoL, HHS, 
Women's Policy, Inc., state and local agencies, and VSO's to address 
and resolve women veterans issues.
    VA is grateful for the work of the Advisory Committee because its 
activities and reports play a vital role in helping VA assess and 
address the needs of women veterans.
    This concludes my formal testimony. I will be pleased to answer any 
questions.

                                 
         Prepared Statement of Lucretia M. McClenney, Director,
   Center for Minority Veterans, U.S. Department of Veterans Affairs
    Chairman Hall, Chairman Michaud, and Members of the Subcommittees, 
I appreciate the opportunity to come before you today to discuss the 
mission of the Center for Minority Veterans and address your specific 
questions on the Department of Veterans Affairs (VA) service to 
minority veterans through its current programs; present and future 
strategies addressing the needs of this growing population; and 
outreach efforts being conducted by VA to minority veterans.
Center for Minority Veterans
    The Center for Minority Veterans was created by Public Law 103-446, 
in November 1994. The Director of the Center serves as primary advisor 
to the Secretary and Deputy Secretary of Veterans Affairs on all issues 
related to minority veterans.
Our Mission
    The mission of the Center for Minority Veterans includes serving in 
an advisory role to the Secretary and Deputy Secretary on the adoption 
and implementation of policies and programs affecting veterans who are 
minorities; making recommendations to senior VA officials for the 
establishment or improvement of programs; promoting minority veterans' 
use of benefits; analyzing and evaluating complaints made by or on 
behalf of minority veterans; and consulting with, and providing 
assistance and information to external local, state and Federal 
stakeholders.
Who We Serve
    The Center serves all veterans regardless of race or ethnicity, but 
pursuant to Public Law 103-446, the Center's primary emphasis is on 
minority veterans. Specifically, veterans who are: African Americans, 
Asian Americans, Pacific Islanders, Hispanics, or Native Americans, 
including American Indians, Alaska Natives, and Native Hawaiians.
How is the Department of Veterans Affairs (VA) serving minority 
        veterans through its current programs?
Minority Veterans Program Coordinators (MVPC)
    To establish a national presence and to ensure issues are addressed 
at the local level, the Secretary of Veterans Affairs in 1995 directed 
the appointment of Minority Veterans Program Coordinators (MVPCs) at 
each VA Health Care Facility, Regional Benefits Office and National 
Cemetery. There are approximately 300 MVPCs across the Nation. The 
Center provides training to MVPCs in cultural competency and outreach 
strategies. These coordinators educate and sensitize facility personnel 
to the needs of minority veterans in the community and promote the use 
of VA benefits, programs and services by minority veterans. In 
addition, the Veterans Health Administration (VHA), Veterans Benefits 
Administration (VBA) and National Cemeteries Administration (NCA) each 
have designated a Central Office MVPC Liaison. The Center staff meets 
monthly with these liaisons and quarterly with the senior leadership of 
each Administration to discuss outreach activities, issues and concerns 
that impact minority veterans.
    The Center has converted the coordinators' annual written report to 
a quarterly web based report to provide greater visibility on their 
outreach efforts, identify opportunities for improvement, benchmark 
best practices and recognize the Minority Veterans Program Coordinator 
of the Quarter and Year for each Administration.
Advisory Committee on Minority Veterans (ACMV)
    The Advisory Committee on Minority Veterans (ACMV) was also 
established under Public Law 103-446. The Committee is composed of 
veterans of all ranks and services appointed by the Secretary. Members 
represent the 5 minority groups the Center is mandated to oversee. The 
Committee advises the Secretary and Congress on VA's administration of 
benefits and provision of health care to minority veterans; assessing 
the needs of minority veterans, reviewing VA programs and activities 
designed to meet those needs and developing recommendations to address 
unmet needs.
    The Committee submits an annual report to the Secretary 
incorporating its findings and recommendations. In order to assess the 
delivery of health care services and benefits, the Committee conducts 2 
meetings annually (one site visit and 1 business meeting). During the 
site visits the Committee tours VA facilities (of all 3 
Administrations), meets with senior officials to discuss services and 
programs available for minority veterans, and conducts Town Hall 
meetings for local veterans and the community to hear firsthand their 
concerns and/or issues. The Committee meets once annually at VA Central 
Office (VACO) and receives briefings from VHA, VBA and NCA and other 
staff offices. These briefings provide the Advisory Committee an update 
on current VA policies and programs and afford them the opportunity to 
discuss their findings and concerns impacting minority veterans.
What are the present and future needs of this growing population and 
        what strategies does VA have for meeting them?
Needs of Minority Veterans:
    In many instances, any challenges that minority veterans encounter 
as they seek services from VA are magnified by the adverse conditions 
in their local communities. These challenges may include access to VA 
medical facilities (especially for American Indians, Alaska Natives, 
and Pacific Islanders, and other veterans residing in rural, remote or 
urban areas), disparities in health care centered on diseases and 
illnesses that disproportionately effect minorities, homelessness, 
unemployment, lack of clear understanding of VA claims processing and 
benefit programs, limited medical research and limited statistical data 
related to minority veterans.
    Cultural competency and diversity training assist VA employees when 
serving our very diverse minority veteran population.
VA Strategies to Meet the Needs of Minority Veterans include but are 
        not limited to the following:

      Access to VA medical care has been addressed by 
dramatically increasing the number of Community Based Outpatient 
Clinics (CBOC). In 1995, VA had 102 Community Based Outpatient Clinics 
and by 2000, VA had 600 Community Based Outpatient Clinics. In the 
second quarter of 2007, 872 Ambulatory Care and Outpatient Clinics were 
in operation. One hundred Operation Enduring Freedom and Operation 
Iraqi Freedom Patient Advocates have recently been assigned to assist 
our newest veterans as they seek care from VA.
      VA is addressing homelessness in the minority veteran 
population by partnering with community stakeholders; enhancing 
outreach activities; and expanding VA's Grant and Per Diem Program.
      In 2001, VA's Office of Research and Development created 
a Center of Excellence for Research aimed at identifying factors which 
cause disparities in health outcomes across racial, ethnic, and gender 
lines, as well as ways for promoting equity in health and health care. 
This center, co-located at 2 sites (Pittsburgh and Philadelphia), has 
29 core investigators who have contributed over 128 peer-reviewed 
scientific articles over the past 2 years.
      The Center is working with VHA's Office of Health 
Services Research and Development and the Center for Health Equity 
Research Program to target minority groups such as the Tuskegee Airmen, 
Buffalo Soldiers, Montford Point Marines, and National Congress for 
American Indians by actively encouraging minority veteran's 
participation in research programs.
      Since 2003, VHA has encouraged minority veterans to 
voluntarily self identify by racial and ethnic groups to assist in data 
retrieval of minority veteran demographics and utilization of VA 
services and benefits.
      VA's Office of Patient Care Services is developing a 3 
year phased educational cultural competency curriculum for clinicians 
and administrative leadership.
      Native American traditional healing has been recognized 
as an additional avenue to pursue to enhance clinical outcomes. Several 
VA medical centers have sweat lodges, and some VA facilities utilize 
the fee basis program to secure the services of Native American 
healers.
      To promote accuracy and consistency in the claims review 
process, VBA has taken a number of actions. For example, in the past 4 
years, VBA has published guidance and conducted training for employees 
on the full range of issues related to PTSD claims adjudication--from 
development of the claim to proper application of the rating schedule.
      VBA and VHA have worked collaboratively to modifying the 
examination request worksheets and the examination templates related to 
PTSD. This ensures that the information gathered during the exam is 
uniform and sufficient to make the determinations concerning 
entitlement and degree of impairment.
      VBA's Native American Veteran Direct Loan Program (NADL) 
enables a Native American veteran or a veteran who is married to a 
Native American veteran to use their VA home loan guaranty benefit on 
Federal trust land. The program began as a pilot in 1992 and was made 
permanent by Public Law 109-233, The Veterans Housing Opportunity and 
Benefits Act of 2006. Nearly 550 loans have been made to eligible 
veterans in 14 states and 3 U.S. territories. 71 tribal governments and 
3 territorial governments have participated in the program.
      With enactment of Public Law 109-461, The Veterans 
Benefits, Health Care, and Technology Information Act of 2006, on 
December 22, 2006, the National Cemetery Administration (NCA) may now 
award grants to Tribal Organizations for the establishment, expansion 
and improvement of veteran cemeteries on trust lands.
      NCA strives to accommodate the special needs of Native 
American veterans. This includes active participation in meetings with 
tribal nations, the encouragement of participation in new VA national 
cemetery dedications, and accommodating the religious customs during 
committal services at VA national cemeteries.

What outreach efforts are being conducted by VA to minorities?
    The Center for Minority Veterans has staff who serve as veteran 
liaisons for each of the 5 minority groups: African Americans, Asian 
Americans, Pacific Islanders, Hispanics and American Indians and serve 
as consultants to the Minority Veterans Program Coordinators. They 
establish partnerships with Veterans Service Organizations as well as 
internal and external stakeholders to increase awareness of minority 
veteran issues and develop collaborative strategies to address unmet 
needs. The Center has active partnerships with VA's Center for Veterans 
Enterprise, National Veterans Employment Program, Women Veterans Health 
Program, and Health and Human Services' Center for Medicare and 
Medicaid Services who are active participants in our community outreach 
efforts and presenters in our biennial training conferences.
Other active partnerships with minority organizations include, but are 
        not limited to:
    African Americans--Congressional Black Caucus, NAACP and The 
National Urban League
    Hispanics/Latinos--American GI Forum and League of United Latin 
American Citizens (LULAC)
    Native American--National Congress of American Indians, United 
South and Eastern Tribes, Navajo Nation Washington Office, and the 
White House Indian Affairs Working Group
    Asian/Pacific Islanders--Japanese American Veterans Association and 
Federal Asian Pacific Americans Council
    VA is most appreciative of the outstanding accomplishments of the 
Advisory Committee on Minority Veterans and the Minority Veterans 
Program Coordinators because their outreach activities and reports are 
critical in helping VA assess and address the needs of minority 
veterans.
    This concludes my prepared statement. I would be happy to answer 
any questions you may have.

                                 
     Statement of Shannon L. Middleton, Deputy Director for Health,
     Veterans Affairs and Rehabilitation Division, American Legion
    Mr. Chairman and Members of the Subcommittee:
    Thank you for this opportunity to submit The American Legion's 
views on VA's programs addressing women and minority veterans. The 
American Legion commends the Subcommittees for holding a hearing to 
discuss these very important issues.
Programs Serving Women and Minority Veterans
    The Center for Women Veterans and the Center for Minority Veterans 
were established by Congressional mandates to ensure that the needs of 
the growing populations of women and minority veterans are reflected in 
policies implemented and services and benefits provided by the 
Department of Veterans Affairs (VA). Through these offices, VA has 
improved access to benefits and services for women and minority 
veterans and shaped policy addressing the provision of health care for 
female veterans.
    The Center for Women Veterans' activities include monitoring 
changes in VA policy to ascertain the impact of the changes on the 
delivery of services to homeless women with children, rural and elderly 
women veterans, and minority women veterans; ensuring that active duty 
women are provided access to information on VA benefits and services 
available to them, prior to their release from active duty; conducting 
outreach to allow women veterans to express their needs and concerns; 
ensuring that VA research initiatives include adequate consideration 
for the effects of the military experience on women veterans; and 
working with Veteran Service Organizations (VSO) to disseminate 
information. The Center for Women Veterans also serves as a conduit 
through which the Advisory Committee on Women Veterans makes 
recommendations to the Secretary of VA.
    The Center for Minority Veterans' activities include ensuring that 
minority veterans are aware of VA programs, benefits, and services; 
conducting outreach initiatives to allow minority veterans to voice 
concerns; making VA benefits and health care services more accessible 
to minority veterans; and making recommendations on how VA can better 
serve minority veterans. The Center for Minority Veterans also supports 
an advisory Committee and works with the Center for Women Veterans to 
address concerns faced by minority women veterans.
    The VA offers a full continuum of comprehensive medical services to 
include disease prevention, primary care, women's gender-specific 
health care, acute medical/surgical, substance abuse and mental health 
treatment, domiciliary, rehabilitation and long-term care options.
Present and Future Needs
    The current Global War on Terror illustrates a few deficiencies in 
services provided for women veterans. Never before have women service 
members been engaged in constant combative environments. Participation 
in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) 
has forced them to expand their military roles to ensure their own 
survival, as well as the survival of their units. They sustain the same 
types of injuries that their male counterparts endure. Any future women 
veterans' research conducted by VA will need to take into consideration 
the physical effects of combat on women veterans, not just mental 
effects of combat and military sexual trauma (MST).
    Since women veterans are sometimes the family's sole care givers, 
services and benefits designed to promote independent living for 
combat-injured veterans will need to consider other needs--like child 
care during rehabilitation. This dynamic should also be considered more 
when designing domiciliary and homeless women veteran programs. Not 
making provisions that would accommodate the children of homeless women 
veterans would bring more devastation to an already unstable home life 
and may actually be a deterrent for seeking assistance from the VA.
    Providing quality health care in a rural setting has proven to be 
very challenging, given factors such as limited availability of skilled 
care providers and inadequate access to care. Even more challenging 
will be VA's ability to provide treatment and rehabilitation to rural 
veterans, to include women veterans, who suffer from the signature 
ailments of the on-going Global War on Terror--traumatic blast injuries 
and combat-related mental health conditions. VA's efforts need to be 
especially focused on these issues.
    Gaining access to the nearest facility providing gender-specific 
services can prove even more of an obstacle, since the nearest facility 
may be a Community Based Outpatient Clinic (CBOC) which may not offer 
these services.
    The American Legion believes veterans should not be penalized or 
forced to travel long distances to access quality health care because 
of where they choose to live. Women veteran who reside in rural areas 
need to have improved timely, access to gender-specific care. We urge 
VA to improve access to quality primary and specialty health care 
services--to include gender-specific services--using all available 
means at VA's disposal, for veterans living in rural and highly rural 
areas.
    Some minority veterans, especially those who suffer from combat-
related injuries, have to rely on family and friends as care givers. In 
this situation, communication can literally be a matter of life, or 
death. Some of these care givers may not speak English as their first 
language. When there is a language barrier, there is a great chance 
that the veteran may not be informed of benefits and services to which 
he/she may be entitled and coordinating rehabilitation or care becomes 
daunting.
    VA has made the effort to have several of its brochures printed in 
Spanish and is attempting to make staff and health care providers more 
knowledgeable about cultural diversity. However, given the diverse 
make-up of the veteran population, materials and outreach have to 
address more than Spanish-speaking populations. The American Legion 
believes that VA needs to remove any hindrance that prevents veterans 
from obtaining the care they have earned through their military 
service.
VA Outreach Efforts
    The Center for Women Veterans outreach activities include: a 
national Summit on Women Veterans Issues to address emerging needs 
facing female veterans and provide information about VA benefits and 
services that female veterans have earned through their military 
service; creation of the Women Veterans Frequently Asked Questions 
pocket guide; and conducting townhall meetings and community forums.
    The Center for Minority Veterans provides veteran outreach through 
minority veteran program coordinators, who inform minority veterans of 
VA benefits and services on the local level; collaboration with VA's 
Office of Small and Disadvantage Business Utilization (OSDBU) to 
cosponsor business outreach activities to sponsor business and 
entrepreneurial outreach conferences for minority and disabled 
veterans; and through the Advisory Committee for Minority Veterans, 
conducts site visits and townhall meetings.
    The VA utilizes opportunities to address veteran service 
organizations (VSO) to disseminate information. These opportunities or 
information exchanges include: participating in VSOs annual conventions 
and training conferences; collaborating in writing informative articles 
for membership magazines and newsletters; and inviting VSOs to 
participate in focus groups/work groups and planning for outreach 
activities. By participating in activities sponsored by the various 
VSOs, VA provides information to advocates who directly work with and 
for veterans to ensure that they receive the quality of care and 
benefits to which they are entitled.
    The Center for Women Veterans, the Center for Minority Veterans and 
the Office of Research and Development eagerly participate in The 
American Legion's annual Convention and training conferences. They 
provide speakers to address specific topics affecting women and 
minority veterans.
    Again, thank you for allowing the American Legion this opportunity 
to present its views on women and minority veterans. We look forward to 
working with the subcommittees and VA to improve access to quality 
health care for all veterans.

                                 
                    Statement of Hon. Corrine Brown,
         a Representative in Congress from the State of Florida
    Thank you, Mr. Chairman for holding this hearing.
    I am pleased to hear the testimony from the many interested parties 
today.
    As we are all aware, the face of the military has changed 
dramatically over the last 10 years. With the all-volunteer force the 
military is made up of now, more minorities and women are choosing this 
career.
    I am sure you have noticed, I am both a woman and a minority. This 
issue is very important to me.
    The total veteran population in the United States and Puerto Rico, 
is about 24 million. The population of women veterans approaches 2 
million. Florida is the third largest state with the women veterans.
    Almost 20 percent of the veterans in this country, in the 2000 
census, are of a minority.
    Is the VA addressing the needs of this changing military? Are they 
adequately addressing the needs of the increasing number of women and 
minorities coming out of the minorities?
    I look forward to the answers of these and other questions as the 
hearing moves forward.
    Thank you again, Mr. Chairman.

                                 
                     Statement of Hon. Jeff Miller,
           Ranking Republican Member, Subcommittee on Health,
       and a Representative in Congress from the State of Florida
    Thank you, Chairman Michaud.
    I ask unanimous consent that my statement be included in the 
record, and that I may have 5 legislative days to revise and extend my 
remarks.
    It is good to be here with our colleagues from the Subcommittee on 
Disability Assistance and Memorial Affairs, and I would like to welcome 
Chairman Hall and Ranking Member Lamborn.
    We have seen both women and minorities answer the call of duty in 
growing numbers and it is vitally important that we make sure that 
there are not any barriers for these veterans to access VA benefits and 
services, and that VA provides specialized services to meet their 
unique needs.
    Seven percent of our Nation's veterans or roughly 1.7 million are 
women. My home state of Florida is 1 of the 5 States with the largest 
number of women veterans, with over 132,000. As the number of women 
serving in the active duty, guard and reserve continue to increase, so 
must our over oversight to monitor the activities of VA to serve this 
population.
    I am pleased to see our colleague, Representative Heather Wilson 
from New Mexico before the Subcommittees. She holds the distinct honor 
of being the only woman veteran of the United States Congress. 
Previously, she testified before the Health Subcommittee in the 107th 
Congress. I look forward to her testimony and to learn how VA's 
performance in meeting the specialized needs of women veterans has 
evolved over the past 5 years.
    Similarly, there are over 3.8 million minority veterans, accounting 
for roughly 15 percent of the veteran population according to the 2000 
Census. We need to be aware of the actions VA is taking to support the 
use of VA benefits, programs, and services by minority veterans; to 
target outreach efforts through community networks and to initiate 
activities that educate and sensitize staff to the unique needs of 
minority veterans.
    I thank all of our witnesses for joining us today. Your testimony 
will provide us insight into how well VA is attending to the specific 
needs of women and minority veterans and help us to identify gaps in 
services and necessary improvements with respect to both benefit and 
health care programs including outreach and mental health treatment.
    Thank you and I yield back the balance of my time.

                                 
                     Statement of Dennis Cullinan,
                Director, National Legislative Service,
             Veterans of Foreign Wars of the United States
    MESSRS. CHAIRMEN AND MEMBERS OF THE SUBCOMMITTEES:
    On behalf of the 2.4 million members of the Veterans of Foreign 
Wars of the U.S. (VFW) and our Auxiliaries, I would like to thank you 
for allowing us to express our views on this very important and timely 
subject.
    According to recent Department of Veterans Affairs and Military 
Services data 10% of all veterans are women and 15% of today's active 
duty military are women. VA has made vast improvements in care and 
services provided to female veterans in the last 10 years, but with 
increasing numbers of females deployed to Iraq and Afghanistan a 
system-wide change may be in order. VA must be prepared to meet the 
needs of the increasing number of women veterans who will be seeking 
health care services, including mental health care and ensure that its 
special disability programs are tailored to meet their unique health 
concerns, especially those who have served in combat.
    VFW is concerned that although VA has markedly improved the way 
health care is provided to women veterans, deficiencies still arise in 
the area of privacy and delivery of services across the Veterans 
Integrated Service Networks (VISN). The Independent Budget, of which 
VFW is a co-author, found that the model used for delivery of primary 
health care to women veterans using VA health care services is 
variable. The trend has been to move away from full-service women's 
health clinics dedicated to both primary and gender-specific health 
care to providing mixed gender primary care teams and contracting out 
other more specific gender care.
    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 
dismantled and female veterans were assigned to primary care providers 
on a rotating basis. The report also found that this further reduced 
the ratio of women to men using VA, making it more unlikely that a 
clinician will gain clinical knowledge to develop and maintain 
expertise in women's health.
    VFW believes that VA needs to increase the priority given to women 
veterans and take the necessary steps to focus on research and programs 
that enhance their understanding of women veterans' health issues. This 
will enable them to evaluate which health care delivery model 
demonstrates the best clinical outcomes for women. VA must ensure that 
clinicians caring for women veterans are knowledgeable about women's 
health and that they participate in ongoing education about the health 
care needs of women and be competent to provide gender-specific care to 
women. They must also ensure that its specialized programs for post-
traumatic stress disorder, spinal cord injury, prosthetics and 
homelessness are equally available to women veterans as to male 
veterans. Most importantly VA needs to increase its outreach efforts 
toward this population as women veterans tend to be less aware of their 
veteran status and eligibility for benefits than their male 
counterparts.
    VFW believes that the future needs of women veterans can only be 
met through continued research and studies specifically tailored toward 
women veterans. VA should collaborate with DOD to collect critical 
information about the health care needs of women veterans to identify 
current priorities of returning female servicemembers. An improved 
environment of sharing data and health information between Departments 
is essential to ensuring a truly seamless transition from military 
service to veteran status.
    We are pleased to hear that a national survey currently being 
conducted by the Women Veterans Health Strategic Healthcare Group 
(WVSHCG) will survey 2,500 to 3,200 women veterans across the Nation, 
including VA users and non-users. The objectives of the survey include 
identifying the current demographics, health care needs and VA 
experiences of women veterans. It will also address how health care 
needs and barriers to VA health care differ among periods of service 
including OEF/OIF veterans and earlier periods and last assess women 
veterans' preference for and perceived value of types of VA services 
and how to improve access to care. We look forward to reading the 
findings of the report due out in December 2008.
    The challenges facing minority veterans are both similar and 
different to those facing women veterans. Barriers to service and 
health care access among minority veterans remain prevalent within the 
VA system. VA's Health Services Research and Development Service 
released a report in June 2007 entitled Racial and Ethnic Disparities 
in the VA Healthcare System: a Systematic Review. The findings of the 
study concluded that disparities appear to exist in all clinical areas 
of VA. Most troubling was the fact that researchers commented in nearly 
each case that the underlying cause of these disparities were not 
explored or remained unclear.
    The study did offer a number of future research ideas to help 
reduce racial disparities within VA--the VFW acknowledges that 
increased outreach and marketing geared toward literacy, language and 
cultural issues is a start. Studies centered on diseases and illness 
that disproportionately affect minorities, along with creating an 
environment where patients are more active participants in their health 
care decisions are also keys to change. Materials (federal benefit 
handbooks, brochures and other materials) printed and made available in 
Spanish are also critical.
    We would also like to recognize recommendations made in the July 1, 
2006 report of the (VA) Advisory Committee on Minority Veterans (ACMV).
    The ACMV conducts site visits and meets with VA officials in 
preparation for their annual report of recommendations to better 
service minority veterans. Their input as to what improvements need to 
be made is invaluable. Some of the current recommendations include:

      Coordination with local, Federal and state veterans 
services organizations in VA outreach activities.
      Periodic Town Hall meetings to discuss minority veteran 
issues/concerns.
      Expanding and improving Internet-based access to VA 
benefits/health care with particular attention given to cultural and 
linguistic diversity.
      Full-time Minority Outreach Coordinators.
      More staff diversity in VA facilities.
      Research that focuses on minority veterans issues to help 
understand potential barriers to access and find ways to eliminate the 
barriers.
      More funding for minority veterans programs.

    We applaud the efforts VA has made to reach out to identify and 
care for the current generation of returning veterans but much remains 
to be done to improve care and services provided all veterans, in 
particular women and minority veterans. VA must continue to work to 
provide an appropriate environment so that all veterans can access the 
health care, benefits and services they have so deservedly earned.
    Mr. Chairman and Members of the Subcommittees, this concludes the 
VFW testimony. We again thank you for including us in this important 
discussion.

                                 
    Statement of Marsha Four, Chair, Women Veterans' Committee, and
      John Rowan, National President, Vietnam Veterans of America
    Good morning Chairman Michaud, Chairman Hall, and Ranking Member 
Miller, Ranking Member Lamborn and distinguish Members of these 
Subcommittees. Thank you for giving Vietnam Veterans of America (VVA) 
the opportunity to offer our comments for the record on the issues 
facing Women Veterans.
WOMEN'S HEALTH ISSUES
    According to figures supplied by the Department of Defense (DoD), 
20% of new recruits are women, almost 15 percent of America's active 
duty military is women, and nearly half of them have been deployed to 
Iraq and Afghanistan (i.e., 1 in 7 Americans deployed to Iraq is a 
woman). This has particularly serious implications for the VA health 
care system because the VA itself projects that by 2010, over 14 
percent of all veterans will be women, compared with 2 percent in 1997. 
The VA has made vast improvements in treating women veterans since 
1992. However, this increase in potential health care system ``users'' 
coupled with returning female OIF and OEF veterans, who, in particular, 
face a variety of co-occurring ailments and traumas heretofore unseen 
in the VA health care system, we believe that the VA is in need of 
ramping up its efforts to bring into modern times, the delivery of its 
medical and mental health care to women veterans. Even today, some 
women continue to report a less than ``accepting'', ``friendly'', or 
``knowledgeable'' attitude or environment both within the VA and/or by 
its third party vendors. This may, in part, be the result of a system 
that has evolved principally on the medical needs of the male veteran. 
Reports also indicate that in mixed gender residential programs women 
remain fearful and unsafe.
    Compounding the emotional turmoil for women are wounds and injuries 
that range from life-changing--the loss of limbs and brain injuries--to 
temporary, such as infections and rashes. Although some of the short-
term health problems are likely tied to the harsh realities of war, 
where women can go weeks without a shower and spend months hauling gear 
and lifting heavy weapons in triple-digit heat, the VA has found 29 
percent of the women veterans it evaluated returned with genital or 
urinary system problems, 33 percent had digestive illnesses and 42 
percent had back troubles, arthritis and other muscular ailments.
    This obviously points up the need for a well-conceived and well-
implemented long-range plan for health care services and delivery for 
our women veterans. To VVA's knowledge there is no such plan that 
exists today. As we have already noted, the VA has taken great strides 
in the past 15 years toward improvement of the quality of care for 
female veterans, but there is always room for improvement. While it is 
fair to say that the quality of care at most VA facilities is equal to 
that of any other medical system in the world, it does not help women 
veterans who cannot access that fine care because it's not available.
DELIVERY OF SERVICES
    Providing care and treatment to women veterans by professional 
staff that have a proven level of expertise is vital in delivering 
appropriate and competent gender-specific care. It is not sufficient to 
simply have training in internal medicine. Women's health care is a 
specialty recognized by medical schools throughout the country. 
Providers who have both a knowledge base and training in women's health 
are able to keep current on health care and its delivery as it relates 
to gender. In order to maintain proficiency in delivering care and 
performing procedures, these providers must meet experience standards 
and maintain an appropriate panel size. This cannot occur if women 
veterans are lost in the general primary care setting. It is critical 
that women receive care from a professional who is experienced in 
women's health. If attention is not given to defining qualified 
providers, it will be a detriment to the quality of care provided to 
women veterans.
    VVA does, however, feel comprehensive women's health care clinics 
are most desirable where the medical center populations indicate 
because comprehensive consolidated delivery systems present increased 
advantage to the patients they serve.
    Vietnam Veterans of America (VVA) believes women's health care is 
not evenly distributed or available throughout the VA system. Although 
women veterans are the fastest growing population within the VA, there 
seems to remain a need for increased focus on women health and its 
delivery. It seems clear that although VACO may interpret women's 
health as preventative, primary and gender specific care, this 
comprehensive concept remains ambiguous and splintered in its delivery 
throughout all the VA medical centers. Many view women's health as only 
a GYN clinic. As you are aware, throughout medical schools across the 
country and in the current health care environment, women's health is 
viewed as a specialty onto itself and involves more that gender 
specific GYN care. VVA is hopeful that the revision of VHA Services for 
Women Veterans, Handbook 1330.1, and its recommendations for an 
integrated primary care/mental health model of service delivery will 
pass concurrence. Additionally, that after concurrence it will be 
strongly supported and recommended to all medical centers in the VHA 
system.
    VVA supported VHA's past creation of ``Centers of Excellence'' for 
women veterans' health. We believe these should be evaluated for 
standard compliance and re-established. These Centers of Excellence are 
an investment in innovative health care delivery specifically 
addressing the unique needs of women, serving as a model in prevention, 
education, outreach, and research programs. This emphasis could lead to 
the creation of VA training fellowships in women's health care. These 
centers could also assist in the recruitment and retention of women 
health care specialists.
    There are increasing numbers of women veterans of childbearing age. 
More than 62 percent of all women veterans are under 45, and of women 
veterans seeking health care from the VA, 56 percent are under 45. 
Providing for the cost of maternity services but not providing newborn 
care for a reasonable post-delivery period presents an unfair financial 
burden to the woman veteran. It could additionally compromise adequate 
health care for her newborn. VVA seeks legislation to provide contract 
care, for up to 14 days post-delivery, for infants born to women 
veterans who receive delivery benefits through the VA and are in need 
of this extended care.
WOMEN VETERAN PROGRAM MANAGERS
    The duties, responsibilities, advocacy, oversight and reporting of 
the VA Women Veteran Program Managers, as defined in their handbook 
(1330.2), are substantial. As such, it is not difficult to understand 
why VVA stands with a firm resolve to call for the VA to provide the 
Women Veteran Program Managers with a minimum of 20 hours per week to 
accomplish the responsibilities of the position. VVA believes that 
these significant duties and responsibilities are essential and should 
not be minimized in light of the collateral duties they usually must 
perform. `Further, we believe that while each VISN must designate, 
support, and utilize one of its Medical Center Woman Veteran Program 
Managers as the VISN Women Veteran Program Manager, we believe 
additional time must be allocated for these increased duties and 
responsibilities.
PTSD AND SUBSTANCE ABUSE
    The VA counts PTSD as the most prevalent mental health malady (and 
one of the top illnesses overall) to emerge from the wars in Iraq and 
Afghanistan, but the VA is facing a wave of returning veterans who are 
struggling with memories of a war where it's hard to distinguish 
innocent civilians from enemy fighters and where the threat of suicide 
attacks and roadside bombs hovers over the most routine mission. 
Moreover, the return of so many veterans from Afghanistan and Iraq is 
squeezing the VA's ability to treat yesterday's soldiers from Vietnam, 
Korea, the Cold war, and World War II. Top VA officials have said that 
the agency is well-equipped to handle any onslaught of mental health 
issues and that it plans to continue beefing up mental health care and 
access under the administration's budget proposal released in mid-
February.
    Yet according to a GAO report issued in November 2006, the VA did 
not spend all of the extra $300 million budgeted to increase mental 
health services and failed to keep track of how some of the money was 
used. The VA launched a plan in 2004 to improve its mental health 
services for veterans with PTSD and substance-abuse problems. To fill 
gaps in services, the department added $100 million for mental health 
initiatives in 2005 and another $200 million in 2006. That money was to 
be distributed to its regional networks of hospitals, medical centers, 
and clinics for new services. But the VA fell short of the spending by 
$12 million in 2005 and about $42 million in fiscal 2006, said the GAO 
report. It distributed $35 million in 2005 to its 21 health care 
networks but didn't inform the networks the money was supposed to be 
used for mental health initiatives. VA medical centers returned $46 
million to headquarters because they couldn't spend the money in FY'06.
    More troubling, however, is the fact that the VA cannot determine 
to what extent about $112 million was spent on mental health services 
improvements, or new services in 2006. In September 2006, the VA said 
that it had increased funding for mental health services, hired 100 
more counselors for the Vet Center program, and was not overwhelmed by 
the rising demand. That money is only a portion of what VA spends on 
mental health. The VA planned to spend about $2 billion on mental 
health services in FY'06. But the additional spending from existing 
funds on what the VA dubbed its Mental Health Care Strategic Plan was 
trumpeted by VA officials as a way to eliminate gaps in mental health 
services now and services that would be needed in the future.
    Furthermore, an investigation by McClatchy Newspapers in early 
February of this year found that even by its own measures, the VA isn't 
prepared to give returning veterans the care that could best help them 
overcome destructive, and sometimes fatal, mental health ailments. For 
example, the McClatchy report found that VA mental health care is 
extremely inconsistent and highly variable from state to state and from 
facility to facility. In some places, there is no mental health care, 
while at others, veterans may get individual psychotherapy sessions, or 
in others, they meet mostly for group therapy.
    Some veterans are cared for by psychiatrists; others see social 
workers. Some veterans get in quickly. Others wait. Once they're in the 
door, some veterans get visits of 75 to 80 minutes, while others get 20 
to 30-minute appointments. In other words, the VA's mental health 
system is nonexistent for many of the veterans it is supposed to be 
serving.
    Last, the nature of the combat in Iraq and Afghanistan is putting 
service members at an increased risk for PTSD. In Iraq, close-quarters 
urban combat is unpredictable, with a constant risk of roadside bombs. 
Troops end up feeling out of control of their surroundings, a major 
risk factor for PTSD. Service members are serving multiple tours, and 
the intensity of the conflict is constant.
    In these wars without fronts, ``combat support troops'' are just as 
likely to be affected by the same traumas as infantry personnel. This 
has particularly important implications for our female soldiers, who 
now constitute about 16 percent of our active-duty fighting force. 
Returning female OIF and OEF troops face ailments and traumas of other 
sorts. For example, studies conducted at the Durham, North Carolina 
Comprehensive Women's Health Center by VA researchers have demonstrated 
higher rates of suicidal tendencies among women veterans suffering 
depression with co-morbid PTSD. And according to a Pentagon study 
released in March 2006, more female soldiers report mental health 
concerns than their male comrades: 24 percent compared with 19 percent. 
In addition, roughly 40 percent of these women warriors have 
musculoskeletal problems that doctors say likely are linked to carrying 
too-heavy and ill-fitted equipment. A considerable number--28 percent--
return with genital and urinary system infections. In addition, there 
are gender-related societal issues that make transitioning tough.
    For example, women are more likely to worry about body image 
issues, especially if they have visible scars or amputations, and their 
traditional roles as care givers in civilian life can set them back 
when they return. They are the ones who have traditionally had the more 
nurturing role within our society, not the ones who need nurturing. 
Although the VA has, after much prodding by Congress, finally come to 
implement services to women to treat PTSD and other after-effects of 
military sexual trauma at VA medical centers, there are very few 
clinicians within the VA who are prepared to treat combat situation-
induced PTSD as opposed to MST-induced PTSD. Additionally, there are 
already cases where returning women service personnel have a 
combination of the 2 etiologies, making it extremely difficult for the 
average clinician to treat, no matter how skilled in treating either 
combat-incurred PTSD in men, or MST-induced PTSD in women. Because of 
the number of women who are now de facto combat veterans and because of 
the nature of the conflicts in both Afghanistan and particularly Iraq, 
VVA believes that we have entered a whole new world of mental health 
needs for our veterans.
    Furthermore, VVA believes there is a need for increased VA research 
specifically focused on women veterans' health care issues. For 
example, as of August 2006 VA data showed that 25,960 of the 69,861 
women separated from the military during fiscal years 2002-06 sought VA 
services. Of this number approximately 35.8 percent requested 
assistance for ``mental disorders'' (i.e., based on VA ICD-9 
categories) of which 21 percent was for post traumatic stress disorder 
or PTSD, with older female vets showing higher PTSD rates. Also, as of 
early May 2007, 14.5 percent of female OEF/OIF veterans reported having 
endured military sexual trauma (MST). Although all VA medical centers 
are to have MST clinicians, very few clinicians within the VA are 
prepared to treat co-occurring combat-induced PTSD and MST. These 
issues singly are ones that need address, but concomitantly create a 
unique set of circumstances that demonstrates another of the challenges 
facing the VA. The VA will need to directly identify its ability and 
capacity to address these issues along with providing oversight and 
accountability to the delivery of services in this regard. VVA believes 
that the VA has twelve programs that address PTSD in women veteran, but 
they are not exclusively for MST (some are general PTSD programs), and 
not all are gender specific programs.
    As previously mentioned, studies conducted at the Durham, North 
Carolina Comprehensive Women's Health Center by VA researchers have 
demonstrated higher rates of suicidality among women veterans suffering 
depression, substance abuse and co-occurring PTSD. But at the present 
time there are only 3 VA women's residential treatment centers for PTSD 
and substance abuse in the country (i.e., a fourth with 8 beds is 
scheduled to open later this summer in the Boston area).
    VVA calls upon this Committee to appoint a task force within the VA 
to begin work to produce a reasonable and practical plan of how VA can 
best reach this ever increasing veteran cohort in the coming years, 
providing them a delivery model of inclusive comprehensive and 
integrated care.
    Few of us can know the dark places in which those who have suffered 
as the result of rape and physical violence must live every day for the 
rest of their lives. It is a very long road to find the path that leads 
them to some semblance of ``normalcy'' in order to feel the free, 
outside of the secluded, lonely, fearful, angry corner into which they 
have been hiding. A concern for the environment of the delivery of 
services also exists in the residential programs of the VA. Most, if 
not all residential programs, are designed for treatment of mental 
health problems. The veterans of these programs are a very vulnerable 
population. This was particularly brought to our attention in regard to 
women veterans, who, in light of the high incidence of past sexual 
trauma, rape, MST, and domestic violence find it difficult, if not 
impossible, to share residential programs with male veterans. They 
openly discuss their concern for a safe treatment setting, especially 
on units where the treatment unit layout does not provide them with a 
physically segregated, secured area. They also discuss the need for 
gender specific group sessions, in light of the nature of some of their 
personal and trauma issues. VVA asks that all residential treatment 
areas be evaluated for the ability to provide and facilitate this 
environment and that medical center facilities develop cost plans to 
address this accommodation.
    This submission points to the need for a well-conceived and well-
implemented long-range plan for medical and mental health care services 
and delivery for our women veterans. VVA has not been made aware that 
any such inclusive comprehensive plan exists today. As we have already 
noted, the VA has taken great strides in the past 15 years toward 
improvement of the quality of care for female veterans, but there 
exists a need for increased attention, followed by enhancement of 
programs and services, in a concerted effort to meet the increasing 
demand and complexity of women's health. This enhancement will 
certainly put a demand on the ever-present budget. VVA respectfully 
requests that women's health care be evaluated for budgetary 
consequences and that Congress considers this when determining the 
dollars required to meet these needs. VVA also respectfully requests 
that continued oversight be requested of the VA in regard to the issues 
of this submission and those of others during this hearing. While it is 
fair to say that the quality of care at most VA facilities is equal to 
that of any other medical system in the world, it does not help women 
veterans who cannot access that fine care because it's not available.
    Vietnam Veterans of America thanks the Committee for this 
opportunity to provide submitted testimony.

                                 
                      Statement of Susan Scanlan,
          President, Women's Research and Education Institute
   Military Women and Women Veterans and Stress Urinary Incontinence
    On behalf of the Women's Research and Education Institute (WREI), I 
appreciate the opportunity to submit this written testimony to the 
Committee. I am Susan Scanlan, President of the Women's Research & 
Education Institute. For thirty years, WREI has provided timely 
information and expert issue analysis about women and their families to 
policymakers and the public.
    For nearly that long, WREI has been one of the few, if not the only 
progressive organization with a nonpartisan focus on the rights and 
responsibilities of women in uniform. The Women in the Military project 
was established in 1983, and is now headed by Captain Lory Manning, a 
veteran of 26 years of service in the U.S. Navy. This project provides 
research and analysis of issues of importance to military women and 
female veterans to legislators, the media, scholars, and the general 
public. WREI publishes Women in the Military: Where they Stand, now in 
its 5th edition, and we also hold a Women in the Military Conference 
every other spring.
    Women veterans are the second fastest growing segment of the 
veteran population. By 2040, it is estimated that women will exceed 11% 
of the veteran population. Women veterans today are younger, more 
ethnically diverse, and have fewer socioeconomic resources than 
previous generations of military women. In addition, the changing 
nature of war and its porous battlefields means servicewomen--and men--
are faced with new health risks.
    I want to bring to the Committee's attention a health condition 
that affects up to 30% of military women--namely, stress urinary 
incontinence (SUI). At our May 2007 Women in the Military Conference, 
Lieutenant Colonel Irene Rosen, M.D., Assistant Chief of Family 
Medicine at Madigan Army Medical Center in Fort Lewis, Washington, 
reported that genitourinary problems are the fifth most common disease 
and non-battle injury (DNBI), and accounted for 5% of hospital 
admissions during Desert Shield/Storm. The VA Health Services Workgroup 
also identified urinary incontinence among women veterans as a high-
priority issue for research.
    Stress urinary incontinence is the involuntary leakage of urine 
associated with laughing, coughing, sneezing, sexual, and recreational 
activities. The condition is caused by a variety of factors, most 
commonly childbirth, and often restricts the social, professional, and 
personal lives of an estimated 15 million women in the U.S. alone. 
Physical fitness requirements and the demands of military life put both 
men and women, but particularly women, at risk for SUI during and after 
their military service. Environmental barriers in the field often limit 
access to hygienic measures and can lead to urinary tract infections 
that can lead to incontinence.
    According to Dr. Rosen's research, 30% of female soldiers reported 
urinary incontinence in the field. Similarly, Dr. Roger Dmochowski, a 
professor of urology and researcher at Vanderbilt University, cited 
studies that found that 30% of female parachutists reported 
experiencing urinary incontinence when they hit the ground. An April 
2001 article entitled ``Urinary Incontinence in Vulnerable Populations: 
Female Soldiers'' published in Urologic Nursing (attached) reported the 
following additional statistics:

      Nearly one-third of 450 female soldiers in field-oriented 
environments at Fort Lewis had significant problems with exercise-
induced urinary incontinence.
      At Fort Benning, 100% of active duty women airborne 
trainees (n=10) who had no incontinence before airborne training 
demonstrated SUI after training.
      In a study involving 563 female soldiers from several 
units at Fort Lewis, Fort Benning, and Fitzsimons Army Medical Center, 
33% reported UT during physical training.
      24% reported urine loss during recreational activities 
such as exercise and walking and 30% reported urine loss during the 
annual 2-mile physical fitness run.
      Field exercises, which involve long road marches with 
heavy field backpacks, precipitated urinary incontinence.
      Alarmingly, 30% of active duty military women with SUI 
reported restricting fluid intake in order to control symptoms.
      Women veterans of the Persian Gulf War have a higher 
proportion of genitourinary problems than other populations.
    Given that approximately 20% of the total U.S. military active duty 
force in the future will be women, it is important for the military--
both the Department of Defense and the Veterans Health Administration--
to address this growing problem.
    As Dr. Rosen's research found, lack of awareness or embarrassment 
or reluctance concerning SUI may preclude optimal prevention and 
treatment of this common problem. This research reinforces the results 
of a June 2007 Lewin Group report, Prevalence and Treatment Patterns of 
Pelvic Health Disorders Among U.S. Women, which found that 
approximately 50 to 75 percent of women who likely have SUI fail to 
tell their health care providers about their symptoms and, therefore, 
are never properly diagnosed and treated.
    Non-treatment of SUI can put women at increased risk for numerous 
physical, social, and psychological conditions. Avoidance of exercise 
and an active life, depression, loss of self-esteem, loss of a sense of 
control over one's life, social withdrawal, and sexual dysfunction 
related to embarrassment, are just a few of the potential physical, 
psychological, and social impacts associated with non-treatment of SUI. 
Withdrawal from physical and social activities can lead to a reduction 
in physical well-being, which may in turn lead to obesity, diabetes, 
heart disease, and other medical complications.
    In order to properly diagnose and treat SUI, Dr. Rosen recommends 
educating and screening military women and veterans for the condition, 
and providing appropriate treatment. Walter Reed Army Medical Center's 
Internet fact sheet on stress incontinence (which was last updated in 
September 2004) recommends the following treatments:

      Practicing good hygiene.
      Learning and practicing Kegel pelvic floor muscle 
exercises.
      Weight loss, smoking cessation, and cough suppression.
      Biofeedback, electrical stimulation, or special weights 
to strengthen pelvic muscles.
      Wearing absorbent underpants or incontinence pads.
      A pessary (support device) made of rubber or other 
materials to fit inside the vagina for support.
      Surgery.

    With regard to medications, alpha-adrenergic drugs or estrogen 
therapy may be prescribed.
    Walter Reed's list of treatments fails to include Renessa, an FDA-
cleared non-surgical treatment for SUI that would be particularly 
beneficial in the military and VA health care settings. This procedure 
is a non-surgical approach that can be performed in the convenience of 
a physician's office or other outpatient setting. It takes less than 30 
minutes and involves the use of radiofrequency energy to treat tissue 
targets within the lower urinary tract. Most importantly, the procedure 
allows women to return to their duties quickly. Most patients return to 
normal activities within 24 hours, and heavy lifting within days, not 
weeks.
    It is my understanding that this procedure has already been 
performed at several military facilities, including Dr. Rosen's 
institution--Madigan Army Medical Center, Evans U.S. Army Community 
Hospital (Fort Carson, CO), and Travis Air Force Base in California. A 
non-surgical option for the treatment of SUI would also be an 
attractive option for female dependents of military men.
    As Members of Congress know, FDA approval does not automatically 
lead to the adoption of new medical technologies. The Veterans Health 
Administration and the Department of Defense should do more to ensure 
that women veterans and active duty women are educated about stress 
urinary incontinence, screened, and provided with access to the full 
range of FDA-approved treatments--including non-surgical procedures--to 
address this debilitating condition.
    Thank you for the opportunity to submit this testimony and bring 
this important women's health issue to the attention of the Veterans' 
Affairs Committee.
          POST-HEARING QUESTIONS AND RESPONSES FOR THE RECORD

                                     Committee on Veterans' Affairs
         Subcommittee on Disability Assistance and Memorial Affairs
                                                     Washington, DC
                                                      July 26, 2007

Honorable R. James Nicholson
Secretary
Department of Veterans Affairs
Washington, DC 20420

Dear Mr. Secretary:

    In reference to our Subcommittee hearing on Issues Facing Women and 
Minority Veterans on July 12, 2007, I would appreciate it if you could 
answer the enclosed hearing questions.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all Full 
Committee and subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively on letter size paper, 
single-spaced. In addition, please restate the question in its entirety 
before the answer.
    Please provide your response to Orfa Torres and fax your responses 
to Orfa at 202-225-2034. If you have any questions, please call 202-
225-9756.

            Sincerely,
                                               JOHN J. HALL
                                                           Chairman

                                 ______
                                 

                        Questions for the Record
                  The Honorable John J. Hall Chairman
      Subcommittee on Disability Assistance and Memorial Affairs,
                  House Committee on Veterans' Affairs
                             July 12, 2007
               Issues Facing Women and Minority Veterans
Questions for Center for Minority Veterans
    Question 1: Please explain in detail what the VA is doing to 
address the findings in the report entitled Racial and Ethnic 
Disparities in the VA Health System, dated June 2007, which found that 
health disparities exist throughout all of the VA and that these 
disparities in treatment yielded poorer health outcomes for minority 
veterans.
    Response: The Department of Veterans Affairs' (VA) Office of 
Research and Development (ORD) within the Veterans Health 
Administration (VHA) is continuing to support a broad portfolio of 
research into health care disparities. While earlier ORD-funded 
research focused on identifying disparities, more recently funded 
studies have highlighted important determinants explaining ethnic 
minority health care disparities, such as patient-physician 
communication, patient attitudes and health literacy; suggesting that 
patients, providers, health care facilities and health care systems may 
all contribute to these disparities. Accordingly, ORD has issued a 
priority solicitation for research proposals to develop and evaluate 
interventions to reduce racial and ethnic disparities in health care. 
ORD understands that interventional studies aimed at these sources, as 
well as other identified sources, may playa significant role in 
promoting equitable health care services among all veterans.
    ORD strives to obtain adequate representation of minorities in its 
funded clinical trials. ORD requires potential investigators to 
acknowledge its policy to include women and minorities in clinical 
research.
Questions for Center for Women Veterans
    Question 1: The Committee is aware that the Director of the Center 
reports to the Secretary.
    Question 1(a): Does the Center provide any type of annual updates 
to the Secretary?
    Response: The Center for Women Veterans (CWV) provides quarterly 
reports on its outreach activities, performance measures and financial 
obligations to the Secretary. The CWV director presents updates on key 
issues related to women veterans at the Secretary's senior staff 
meetings; and provides a monthly update on its key activities to the 
Deputy Secretary.
    Question 1(b): Please describe the Center's annual performance 
goals?
    Response: CWV's annual performance goals are linked to VA's 
Strategic Goal 2 and its Enabling Goal.
    Strategic Goal 2 is to ensure a smooth transition for veterans from 
active military service to civilian life. In order to achieve this goal 
VA's operational objective is to increase awareness of, access to, and 
use of VA health care, benefits and services. CWV's goal (in support of 
VA's goal) is to attend transition assistance program (TAP) briefings 
and assess the quality of the briefing materials and its focus on women 
veteran-specific issues.
    VA's Enabling Goal is to apply sound business principles, and one 
of the objectives to meet this goal is to improve communications with 
veterans, employees and stakeholders about VA's mission, goals and 
current performance as well as benefits and services that VA provides. 
CWV's goal linked to this is to facilitate, sponsor, or attend 
collaborative meetings with agencies representatives and stakeholders; 
and community-based forums for women veterans. CWV also has as its 
goals to provide prompt responses to inquiries and resolve complaints 
timely.
    Question 1(c): How does the Secretary measure the Center's 
effectiveness in meeting its performance goals?
    Response: The Secretary measures CWV's effectiveness in meeting its 
performance goals by reviewing its quarterly and annual reports.
    Question 2: The Center provides administrative support to the 
Advisory Committee and the Advisory Committee through its site visits 
prepares reports which are transmitted to the Secretary and then to 
Congress.
    Question 2(a): Please explain what if any interface occurs between 
the Center and the Advisory Committee.
    Response: There is extensive interface that occurs between CWV and 
the Advisory Committee on Women Veterans (ACWV). CWV collects data, 
provides written materials on key issues, and obtains subject matter 
experts to address ACWV at its bi-annual meetings and annual site 
visits to a medical center. CWV and ACWV collaborate on developing 
legislative proposals affecting women veterans; and annual 
Congressional meetings. CWV hosts ACWV meetings, arranges lodging, 
transportation and conference room space. CWV introduces new ACWV 
members to VA, and arranges ethics briefings.
    Question 2(b): For the recommendations made by the Advisory 
Committee, and for which the VA concurs, who is responsible for 
ensuring implementation of the recommendations?
    Response: VHA, Veterans Benefits Administration (VBA), and National 
Cemetery Administration (NCA), along with various staff offices are 
responsible for implementing the recommendations of ACWV. CWV tracks 
the status of recommendations to ensure implementation; and requests 
briefings on unresolved recommendations at ACWV bi-annual meetings.
    Question 2(c): How are these missives sent down throughout all of 
the VA?
    Response: CWV assigns each recommendation to the appropriate 
administration or staff office, and then monitors and follows up as 
needed.
Questions for VA
MINORITY VETERANS
    Question 1: It seems as if both Directors of the Centers and the 
Advisory Committees report directly to the Secretary.
    Question 1 (a): Please explain the working relationship, if any, 
between the Centers and the Advisory Committees and the VA (Secretary's 
office) and the Advisory Committees?
    Response: Both the Center for Minority Veterans (CMV) and CWV fall 
under the Office of the Secretary. The directors of CMV and CWV serve 
as the primary advisors to the Secretary and Deputy Secretary on all 
issues related to minority and women veterans and serve as the 
designated Federal officials to the Advisory Committee on Minority 
Veterans (ACMV) and ACWV. CMV and CWV facilitate ACMV's and ACWV's 
outreach to minority and women veterans by ensuring they are kept 
abreast of VA's policies, programs, and services that may impact 
minority and women veterans, and coordinating the logistics and travel 
for all site visits and business meetings. In addition, CMV and CWV 
track VA's action taken on ACMV and ACWV recommendations.
    Question 1(b): Whose role is to ensure that there are no 
disparities in the receipt of benefits and services for these veterans?
    Response: CMV, CWV, ACMV, and ACWV identify needs of minority and 
women veterans and make recommendations to address unmet needs. The 
administrations and staff offices are responsible for ensuring that the 
areas highlighted as in need of improvement are addressed in a timely 
manner. It is every VA employee's responsibility to ensure all veterans 
are treated equally without regard to sex, race, or ethnicity.
    The Secretary directed the appointment of the minority veterans' 
program coordinators (MVPC) to be located at each VA health care 
facility, regional office and national cemetery, thus ensuring that 
issues regarding benefits and services for minority and women veterans 
are addressed at the local level. CMV provides oversight, and training 
to the MVPCs in cultural competency and outreach strategies. MVPCs 
educate facility personnel to the needs of minority veterans in the 
community. MVPCs promote the use of VA benefits, programs and services 
by minority veterans. In addition, each administration has a designated 
MVPC liaison at VA central office. CMV staff meets monthly with these 
liaisons and quarterly with the senior leadership of each 
administration to discuss outreach activities, issues and concerns that 
impact minority veterans.
    VHA medical facilities have specially designated outreach 
coordinators who conduct outreach to various populations (i.e., 
minority veterans, women veterans, homeless veterans, former prisoners 
of war, recently separated veterans) to provide these individuals 
information about VA health care issues. VHA central office provides 
guidance and support to these coordinators.
    VHA has implemented various programs within the networks to ensure 
that the issues and needs of minority veterans are adequately 
addressed. Some examples of this in action are:

      Veteran Integrated Service Network (VISN) 15's Diversity 
Implementation Plan a 3 pronged approach to implementing diversity 
within the Heartland Network.
      Fargo VA Medical Center's (VAMC) Comprehensive Diversity 
Management Program dedicated to promoting diversity awareness through 
training with special emphasis on outreach programs, and clinical 
guidelines to promote the concept of culturally competent care and 
quality improvement in various community partnerships. In collaboration 
with the Dakotas VA Regional Office, veterans service organizations, 
and the Social Security Administration, the Fargo VAMC sustained 
outreach efforts on 7 of the 8 Native American Nations and cosponsored 
with Indian Health Services (IHS) the first Annual/Tribal Open House.
      Southern Arizona VA Healthcare System (VAHCS) is 
recognized for its sustaining leadership, governance, and incorporation 
of diversity management into strategic business plans. The Southern 
Arizona VAHCS sponsored the first Annual Diversity Day that 
incorporated educational information on special emphasis groups and 
MVPCs.

    In addition, VHA's Office of Research and Development (ORD) 
continues to support a broad portfolio in health disparities research. 
While earlier ORD-funded research focused on identifying disparities, 
more recently funded studies have highlighted important determinants 
explaining ethnic minority health care disparities, such as patient-
physician communication, patient attitudes and health literacy, 
suggesting that patients, providers, health care facilities and health 
care systems may all contribute to these disparities. Accordingly, ORD 
has issued a priority solicitation for research proposals to develop 
and evaluate interventions to reduce ethnic minority health care 
disparities. ORD understands that interventional studies aimed at these 
sources, as well as other identified sources, may play a significant 
role in promoting equitable health care services among all veterans.
    VBA regional offices have also specially designated outreach 
coordinators who conduct outreach to various populations (i.e., 
minority veterans, women veterans, homeless veterans, former prisoners 
of war, recently separated veterans) to provide these individuals 
information about VA benefits and services. VBA central office provides 
guidance and support to these coordinators to ensure that they provide 
all needed services and benefits. VBA coordinators work closely with 
their counterparts in VHA, NCA, veterans service organizations, and 
other Federal and State agencies to provide complete assistance to all 
veterans.
    In addition to its outreach coordinators, VBA uses the systematic 
technical accuracy review (STAR) to assess accuracy of claims 
processing decisions made at all regional offices. VBA also regularly 
conducts site visits to regional offices to ensure that policies and 
procedures pertaining to compensation and pension are consistent 
nationwide. During these site visits outreach practices are reviewed to 
ensure activities are reaching targeted groups.
    NCA conducts local and national initiatives in an effort to 
identify minority veterans. The outreach practices to these veterans 
include all national cemetery directors having the responsibility to 
identify groups of veterans within the service area of their cemetery 
and providing information about VA memorial benefits to these 
individuals. NCA regularly attends 10 to 12 national conferences each 
year to increase awareness of memorial benefits among minority groups.
    NCA memorializes every deceased veteran who has served honorably in 
the Armed Forces, regardless of their race, sex, religion, or national 
origin. Every day the 1,500 employees of NCA commemorate the service of 
America's veterans at 125 national cemeteries, where more than 2.7 
million gravesites are maintained. NCA provides headstones and markers 
for placement on the graves of eligible veterans, provides Presidential 
Memorial Certificates to veterans' loved ones, and assists States and 
tribal governments in the construction of veterans' cemeteries.
    Question 2: In the Minority Advisory Committee's last Report dated 
July 2006, it recommended that the VA clarify and disseminate its 
policies pertaining to the issue of marketing, as it had observed 
during its field visits to VA facilities that the confusion served as a 
``serious impediment'' to minority veterans' knowledge of their VA 
benefits and VA health care entitlements. What has the VA done to 
educate staff at VA facilities of the rescission of this 2002 rule 
regarding marketing? Please explain.
    Response: VA supports an extensive array of outreach efforts to 
inform and educate veterans about their eligibility for health care, 
benefits, and other services. In fact, VA strongly encourages its 
leadership and staff to participate in community activities as a forum 
for outreach. Every separating service member receives a letter from 
the Secretary to advise them on how they might receive VA benefits 
(including health care). Additionally, VA is working closely with the 
Department of Defense (DoD) to ensure that returning Global War on 
Terror (GWOT) veterans are aware of the services VA offers. One example 
is the post deployment health reassessment activity (PDHRA) which 
provides outreach, education, screening for deployment-related health 
conditions and readjustment issues, outreach and referrals to military 
treatment facilities (MTFs), VA health care facilities, TRICARE 
providers and others for additional evaluation and/or treatment.
    Question 3: The IOM in its report Separate and Unequal regarding 
Healthcare and Health Disparities found that Minorities receive 
disparate health care treatment regardless of income or insurance 
status and that as a direct result, they suffer higher mortality and 
morbidity rates. Has the VA performed any research to determine whether 
there are parallels in the VA health care and benefits system? Are you 
aware of any parallels that translate in poorer health and benefits 
outcomes for minority veterans?
    Response: Because of its structure, VA's health care system 
provides unique opportunities for researchers to distinguish racial and 
ethnic differences from economic differences in health care. Minorities 
are well represented in ORD's cooperative studies program clinical 
trials and currently comprise 20 percent of participants in trials that 
have ongoing recruitment.
    ORD funds a research center of excellence for health equity 
research and promotion. Its mission is to reduce disparities and 
promote equity in health and health care among vulnerable groups of 
veterans and other populations. The center's research agenda is based 
on the natural progression of research projects from detecting 
unrecognized disparities, to identifying and understanding reasons for 
these disparities, to designing interventions to promote equity in 
health care among vulnerable populations.
    ORD also funds a targeted research enhancement program to 
understand racial and ethnic variations in health outcomes for chronic 
diseases. The goals of this program are to advance knowledge on racial 
and ethnic variations in care by focusing on patient trust and patient 
preferences for care, and to evaluate the incremental effect of these 
patient level factors on racial and ethnic disparities in health 
outcomes for chronic medical conditions such as diabetes and 
hypertension.
    Examples of recently completed ORD-sponsored health disparities 
research include:

      While demographics and health experiences vary by race 
among women veterans, race was not significantly associated with any 
primary care domain (i.e., patient preference for provider, 
interpersonal communication, accumulated knowledge and coordination) or 
satisfaction among women receiving care at VA (Journal of General 
Internal Medicine, Vol. 21, October 2006, 1105)
      There are no significant racial differences in general 
innovativeness between Black and White veterans, but White veterans had 
higher medical technology innovativeness scores

          Medical technology innovativeness scores correlated 
        with a greater likelihood that veterans would be favorably 
        oriented to new medical devices and prescription drugs
          Both Black and White veterans with low innovativeness 
        scores were hesitant to accept a new medical device, but White 
        veterans were more likely to adopt a new prescription than 
        Black veterans
          More Black than White veterans expressed discomfort 
        with taking risks (Journal of General Internal Medicine, June 
        2006)

      Black veterans had less severe coronary artery disease 
than White veterans, and treating physicians' estimates of the 
probability of coronary disease were similar for Black and White 
veterans

          Findings suggest that despite less frequent use of 
        coronary angiography, Black veterans who undergo the procedure 
        are at lower risk for having coronary obstructive disease than 
        White veterans who undergo the procedure (Journal of the 
        American College of Cardiology, May 2006)

      Black patients appear to have lower trust in physicians 
regarding lung cancer treatment because of poorer physician-patient 
communication

          Physician communication was perceived as less 
        supportive, less partnering and less informative, accounting 
        for Black patients' lower trust in physicians (Journal of 
        Clinical Oncology, Vol. 24, 2006 Feb 20. 904)

      End of life wishes vary among racial and ethnic groups, 
as a result of divergent views regarding health care, spirituality, 
family and dying (Journal of the American Geriatrics Society, Vol. 54, 
No.1, January 2006)
      There are ethnic variations in the use of nicotine 
replacement therapy (NRT) among smokers receiving care from VA, with 
Black and Hispanic smokers about half as likely as White smokers to use 
NRT to quit smoking

          These disparities were not explained by social, 
        physiologic or psychological factors or by facility differences 
        in prescribing policy of tobacco dependence medications 
        (American Journal of Health Promotion, Nov/Dec 2005, 20 
        (12):108)

      Black and White patients in VA displayed similar 
knowledge about coronary heart disease (CHD) risk factors. However, 
Black patients had

          Less specific knowledge, such as the difference 
        between ``good'' and ``bad'' cholesterol
          More fear related to physical activity after a CHD 
        diagnosis
          Belief that racism contributed to stress as a risk 
        factor (Patient Educ. Couns. 2005 May;57(2):225-31)

      Hispanic and Black VA patients had a higher frequency of 
severe diabetic retinopathy

          This was not accounted for by traditional risk 
        factors (Diabetes Care 28: 19541958, 2005)

      In the year following prostate specific antigen (PSA) 
testing, Black patients strictly under VA care were more likely to
          Know about their PSA test
          Have higher rates of urology referrals and prostate 
        biopsies
          However, for Black patients under partial VA care, 
        these differences did not occur (Am J Public Health. 2004 
        Dec;94(12):2076-8)

      Black veterans in VA had poorer outpatient access to 
mental health services than White veterans during 1995-2001

          On some measures their access to care improved 
        relative to White veterans (Adm. Policy Mental Health. 2003 
        Sep;31(1):31-43)

      In VA stroke patients referred to inpatient 
rehabilitation

          No racial differences in proportion of patients 
        referred or in the intensity of rehabilitation
          However, there was less recovery of function in Black 
        patients (Stroke. 2003 Apr;34(4): 1027-31)

      No significant systematic differences in post traumatic 
stress disorder (PTSD) treatment or outcome between White, Black and 
Hispanic VA patients overall (Med Care. 2002 Jan;40(1 Suppl):I52-61)
      In a VA administrative database (28,934 White and 7,575 
Black), Black patients had lower mortality rates than White patients at 
30 days and 6 months in

          Pneumonia
          Angina pectoris
          Congestive heart failure
          Chronic obstructive pulmonary disease
          Diabetes
          Chronic renal failure (JAMA. 2001 Jan 17;285(3):297-
        303)

    It is important to note that ORD-sponsored studies focus on health 
and health care related research and not on the services provided by 
VBA or NCA.
    ORD did, however, recently fund a study examining racial 
disparities in PTSD disability awards. The study reported a significant 
difference in Black veterans odds of being service connected for PTSD 
compared to other veterans' odds, and this could not be explained by 
variation in PTSD symptom severity, degree of disablement or race 
differences in combat exposure. Among veterans who were awarded PTSD 
disability benefits, the service-connected rating (``degree of service 
connection'') did not vary by race (Medical Care. 2003;41(4):536-549).
    Past ACMV reports findings/recommendations have addressed minority 
veterans' perceptions of disparities in the VA claims process. VBA 
presently does not collect racial or ethnics data that can be used to 
make a comparative analysis. VBA has responded that it will give 
consideration to collecting this data as it modifies its business 
practices.
    Question 4: The Advisory Committee also recommended that the DVA 
design, develop and fund research agendas focusing on minority veteran 
issues in order to inform minority veterans and those entities serving 
the minority community of potential barriers to access. Please update 
the Committee on efforts to promote this recommendation and eliminate 
this barrier.
    Response: ORD strives to disseminate its research results to all 
applicable parties. While this is accomplished primarily through 
publication of research results in scientific journals and 
presentations at scientific meetings, ORD also publishes a variety of 
publications highlighting recent research advances, such as its monthly 
Research Currents newsletter. A diverse audience, including VA staff, 
Congressional staff and veterans service organizations (VSO) receives 
Research Currents newsletter. ORD also supports speakers and 
information booths about its research programs and projects at numerous 
VSO meetings and conventions, including organizations such as the 
Montford Point Marine Association that was established to perpetuate 
the legacy of the first African Americans who entered the United States 
Marine Corps from 1942 to 1949, at Montford Point Camp, New River, NC. 
Finally, ORD maintains a Web site containing information on research 
programs and recent findings (http://www.research.va.gov). and so do 
many of its centers of excellence (http://
www.cherp.research.med.va.gov).
    In addition, ORD has been working with CMV to develop other 
mechanisms for disseminating research results to veterans. Currently, 
CMV's Web site has a link to the ORD Web site for research related to 
minority veterans.
    Question 5: Has the VA performed research to identify barriers that 
prevent minority veterans from accessing and using their benefits? Has 
the VA identified any culturally appropriate practices that would 
support greater participation in VA benefits and services by minority 
veterans as advocated by the Committee? (p.21).
    Response: ORD has funded extensive research examining barriers to 
health care for minority veterans and, in recent years, considerable 
attention has been focused on cultural factors that affect the use of 
VA health care services, and potentially the health care status and 
outcomes of veterans. Those areas where potential barriers, cultural 
factors and other contributors to racial disparities in VA health care 
have been identified in ORD-sponsored research are summarized below.

      Veteran medical knowledge and information sources. 
Minority and nonminority veterans differ in their degree of familiarity 
with and knowledge about medical interventions. This difference stems 
from different levels of experience with those interventions among 
minority vs. non-minority veterans and their families, friends, and 
communities; from different amounts of information conveyed by health 
care providers; and from different levels of health literacy and 
understanding among veterans. Different knowledge and information may 
affect patients' perceptions of, or degree of uncertainty about, the 
necessity and benefits of medical interventions in relation to their 
risks. Uncertainty about the necessity of interventions may in turn 
reduce patients' willingness to accept and adhere to them. Several 
studies indicate that minority veterans are less informed about their 
care, compared to non-minority veterans, and that this difference 
affects decisionmaking.
      Veteran trust and skepticism. Minority veterans tend to 
harbor less trust and more skepticism about the benefits of medical 
interventions, relative to their risks. These perceptions appear to be 
influenced by lack of familiarity with medical interventions, by 
historical or personally experienced discrimination, and for some Black 
veterans in particular, by a reliance on religious and spiritual 
avenues for coping with illness as opposed to medical therapies. 
Studies in our review suggest that minority veterans are more skeptical 
of information provided by health care professionals, as compared to 
non-minority veterans. It is important, however, not to misconstrue 
this skepticism as unwarranted. Nonminority veterans' general lack of 
skepticism may be more problematic if it leads to acceptance of 
unnecessary or undesired care.
      Racial/cultural milieu. Some have suggested that a more 
racially and culturally congruent health care environment (including 
racially concordant health care providers) for minority veterans may 
elevate trust, reduce skepticism, and enhance the acceptability of 
care. Two studies directly examined this issue and found that Black 
veterans experienced better interactions and fared somewhat better 
clinically, when cared for by Black vs. White providers. Another study 
suggested that Black patients in group therapy might fare better when 
grouped with other Black patients.
      Patient participation. Several studies suggest that 
minority veterans are less active participants in their care as 
compared to non-minority veterans. Minority veterans tend to ask fewer 
questions of their providers, who in turn provide less information. 
Less information may lead to lower acceptance of and adherence to 
medical interventions. In addition, lower patient participation 
diminishes the strength of the patient-provider partnership, which may 
in turn lead to less investment by both parties in following 
recommended care plans, and to lower trust and greater skepticism among 
minority veterans.
      Clinician judgment. Studies suggest that clinicians' 
diagnostic and therapeutic decisionmaking varies by veteran race. The 
degree to which this differential decisionmaking is based on clinical 
factors vs. non-clinical factors, including racial stereotypes, is 
unclear. For instance, in one study clinicians judged Black veterans to 
be less appropriate candidates for coronary interventions, even after 
accounting for chart-documented variables. The degree to which this 
judgment reflected undocumented clinical factors vs. non-clinical 
influences was not clear. Similarly, clinicians prescribe opioid 
medications less frequently to Black vs. White veterans and are more 
likely to diagnose Black veterans presenting with mental illness as 
having psychotic vs. affective disorders. The degree to which these 
phenomena are driven by racial differences in co-existing substance 
abuse disorders, by cross-cultural misunderstanding of symptom 
presentations, or by racial bias, remains unclear.
      Veteran social support and resources. Minority veterans 
may have fewer social support and other external resources to help with 
both illness management and decisionmaking. This is particularly 
relevant in that minority veterans may rely more heavily on external 
resources than on health care professionals for information and 
support. This may particularly affect adherence and decisionmaking 
around high-risk procedures.
      Health care facility characteristics. Some disparities 
are at least partly explained by the fact that minority and non-
minority veterans tend to receive care at different VA medical centers 
(VAMCs). In some cases, VAMCs that disproportionately serve minority 
veterans have fewer available services or deliver lower quality care 
overall than VAMCs serving predominantly non-minority veterans. This 
potential source of disparities, however, remains under-explored. It 
should be noted that many studies have demonstrated disparities within 
single VAMCs, suggesting that system-level factors are unlikely to 
explain all observed disparities.

    CMV and ORD have collaborated to provide a link from the CMV Web 
site to the ORD Web site to provide veterans information related to VA 
research initiatives. Minority veterans program coordinators (MVPC) 
were provided cultural competency training during their biennial 
training conference in June of 2007.
    At CMV's request, ORD has provided briefings to our MVPCs during 
the biennial MVPC training conferences and to minority groups such as: 
Tuskegee Airmen, Buffalo Soldiers, Montford Point Marines, and the 
National Association of Black Veterans.
    Question 6: Please advise what the VA is doing with regard to its 
land use policies that allow greater flexibility to make business 
decisions that would result in more funds for ancillary programs such 
as those that address outreach to minority veterans and homeless 
veteran populations.
    Response: VA has been using its enhanced use (EU) leasing program 
to turn underused land and buildings into transitional housing for 
homeless veterans. This has been successful in 12 instances providing 
housing to more than 550 homeless veterans; and will be used more in 
the future as properties are identified via the Capital Asset 
Realignment for Enhanced Services (CARES) reuse studies, VA's own 
internal site review initiative, and individual initiatives presented 
by homeless providers through a sponsoring VAMC.
    In addition VA has numerous sharing agreements and sort term leases 
that are allowing more than 2 dozen nonprofit organizations to provide 
transitional housing to more than 1,300 homeless veterans. The more 
than half of all veterans seen in VA's homeless providers grant and per 
diem program are identified as minority. The largest single program for 
women veterans in the country is operated on the grounds of the VAMC at 
Coatesville, Pennsylvania.
    Question 7: The Advisory Committee observed that staff diversity 
during its Los Angeles VA facilities was not representative of the 
Minority Veteran population, especially with regard to the higher pay 
grades and for African Americans, Hispanics, and Americans Indians. The 
ACMV noted that this appears to be a systemic problem throughout VA. 
Please advise what the VA is doing to ensure staff diversity in these 
subsets of veterans.
    Response: The Los Angeles Regional Office (RO) has 221 employees 
serving approximately 737,000 veterans. Of the 221 employees, 40.7 
percent are veterans. Within that number, minorities comprise the 
following: 15.4 percent Black, 8.6 percent Hispanic, 1.4 percent Native 
American, and 2.7 percent Asian American and Pacific Islander American. 
Of the veteran employees at the higher grade levels, GS-12 and above, 
53 percent are minority veterans.
    VA work force is comprised of 74 percent women and minorities; 
24.43 percent of the work force is Black, 7 percent Hispanic, 1 percent 
Native American, and 6.24 percent Asian American. Veterans make up 33 
percent of VA's work force. Of employees at a GS-13 and above, 38 
percent are minorities.
    VHA work force is comprised of 75 percent women and minorities; 24 
percent of the work force is Black, 7 percent Hispanic, 1 percent 
Native American and 7 percent Asian American. Veterans make up 31 
percent of VHA's work force. Of employees at a GS-13 and above, 30 
percent are minorities.
    VHA has consistently provided career development training 
opportunities designed to prepare all VA employees with knowledge and 
skills necessary to perform in higher grades. These programs include 
the technical career field program (TCF)-GS-5-9; the leadership, 
effectiveness, accountability, development program (LEAD)-GS-11-13; the 
executive career field candidate development program (ECFCDP)-GS-1314/
nurse IV/physician tier 2), and Leadership VA (LVA)-G8-13 and higher. 
The percentages of minority participation for these programs in FY 2006 
were: LEAD, 27.12 percent; TCF, 29.90 percent; ECFCDP, 20 percent; and 
LVA, 24.29 percent.
    VBA's work force of over 13,000 employees is comprised of 69 
percent women and minorities; 27 percent of the work force is Black, 6 
percent Hispanic, 2 percent Native American, and 3 percent Asian 
American. Veterans make up 48 percent of VBA's work force. Of employees 
at a G8-13 and above, 51 percent are minorities.
    The Under Secretary for Benefits aggressively supports hiring 
veterans as reflected in the high percentage of veterans in the 
workforce. Within the next 18 months, VBA plans to hire more than 2,000 
employees. Recruitment of veterans and any underrepresented minority 
groups will be a focus of this hiring effort.
    NCA's work force is comprised of 49 percent women and minorities; 
20 percent of the work force is Black, 9 percent Hispanic, 1.55 percent 
Native American and 3.58 percent Asian American. Veterans make up 72 
percent of NCA's work force. Of employees at a GS-13 and above, 64 
percent are minorities.
    NCA strives to increase the percentage of women and minorities in 
the ranks of leadership by providing career development training. In 
2006, 40 percent of the participants in the training program for 
cemetery directors were women and 30 percent were Black. In this year's 
class, 33 percent are women, 22 percent are Black, and 11 percent are 
Hispanic.
    Staff offices' work force is comprised of 59 percent women and 
minorities; 22 percent of the work force is Black, 6 percent Hispanic, 
1 percent Native American, and 5 percent Asian American. Veterans make 
up 40 percent of staff offices' work force. Of employees at a G8-13 and 
above, 44 percent are minorities.
    Question 8: The ACMV also recommended that the VA should hire OIF/
OEF Minority veterans into the agency to ensure departmental 
sensitivity to a new generation of minority veterans seeking services.
    Question 8(a): What processes has the VA put into place to advance 
this recommendation?
    Response: VA remains committed to hiring veterans, particularly 
disabled veterans and those transitioning from active service in OEF/
OIF. VA's National Veterans Employment Program (NVEP) continues to 
advance efforts by the Department to employ veterans VA-wide, promoting 
or participating in targeted outreach and recruiting events nationally. 
VA is a regular participant of the DoD Hiring Heroes Career Fairs, the 
Annual Road to Recovery Conference hosted by the Coalition to Salute 
America's Heroes and other events targeting seriously injured and 
wounded OEF/OIF servicemembers transitioning to the civilian work 
force. NVEP has also helped establish veteran employment coordinators 
(VEC) at human resource facilities throughout the department to lead 
local efforts to attract, recruit, and retain veterans in VA.
    VHA's fiscal year (FY) 2007 equal employment opportunity 
Initiatives were to increase the representation of individuals with 
targeted disabilities, particularly increasing the veterans and 
disabled veterans, and the number of minorities and women in the 
qualified applicant pool. To enhance the employment of OEF/OIF minority 
veterans and people with disabilities, VHA will continue to network 
with military installations, State vocational rehabilitation services, 
the Work force Recruitment Program, and community organizations (i.e. 
job accommodation networks and computer electronic accommodation 
program). VHA has an overall plan to increase the number of people with 
targeted disabilities. Each VISN director was asked to increase the 
employment of individuals with targeted disabilities to 1.5 percent in 
FY 2007, and incremental increases to 2.2 percent by FY 2011. It is 
anticipated that this effort will also increase the number of disabled 
veterans in the Department's work force.
    VHA has appointed 98 transition patient advocates (TPA) since March 
2007 when the Secretary authorized 100 new positions in VA's continuing 
commitment to help severely injured OEF/OIF veterans and their families 
navigate VA's system for health care. The TPAs serve as the point of 
contact for these veterans transitioning to VA from military treatment 
facilities. As in other recruitment activities, selecting officials 
were instructed to make every effort to ensure a representative number 
of women and minority candidates were selected. VHAs commitment of 
hiring OEF/OIF veterans was demonstrated during this recruitment effort 
by including qualification requirements that targeted these veterans. 
VHA continues to aggressively use the special veteran appointing 
authorities, including the veterans' recruitment appointment, the 
veterans' preference program for disabled veterans, and the Veterans 
Employment Opportunities Act 1998.
    Currently, no means exists to identify employees who are OEF/OIF 
veterans, minority or otherwise. VA has addressed this issue with the 
Office of Personnel Management (OPM). So, until OPM establishes a code 
for OEF/OIF veterans, much in the same way Vietnam Era veterans were 
coded, their numbers in VA and the rest of the Federal work force will 
remain unknown. Certain programs (i.e. Coming Home to Work) can 
possibly provide raw numbers of OEF/OIF veterans hired, but when it 
comes to sorting them demographically, that presents a greater 
challenge.
    Question 8(b): For instance has the VA established processes at the 
Cabinet level to ensure that all applicable agencies are engaged?
    Response: VA participates with the Department of Labor (DoL), 
Department of Transportation and DoD in the transitional assistance 
program (TAP) to provide servicemembers who are within 6 months of 
discharge or 2 years of retirement with information and assistance they 
need to transition to civilian life.
    Question 8(c): Can the VA seamlessly help these veterans 
transition?
    Response: In January 2005, VA established a permanent Office of 
Seamless Transition which reports through VA/DoD coordination officers 
to the Principal Deputy Under Secretary for Health and is composed of 
representatives from VHA and VBA, as well as an active duty Marine 
Corps officer and an Army officer. Since its inception, the seamless 
transition program has achieved numerous accomplishments that result in 
great strides toward the seamless transition of OEF/OIF servicemembers 
into civilian life, including minority and women veterans. The ability 
to register for VA health care and file for benefits prior to 
separation from active duty is the result of the seamless transition.
    VA/DoD social work liaisons and VBA benefit counselors are now 
located at 10 military treatment facilities (MTFs) to assist active 
duty servicemembers as they transfer from MTFs to VAMCs. In addition, 
our VHA liaisons help newly wounded servicemembers and their families 
plan a future course of treatment for their injuries after they return 
home. VA nurses, social workers, benefits counselors, and outreach 
coordinators advise and explain the full array of VA services and 
benefits. VHA staff has coordinated over 7,900 transfers of OEF/OIF 
servicemembers and veterans from a MTF to a VA medical facility. Active 
duty Army liaison officers are assigned to each of the 4 VA polytrauma 
rehabilitation centers to assist servicemembers and their families from 
all branches of service on issues such as pay, lodging, travel, 
movement of household goods, and non-medical attendant care orders.
    The Office of Seamless Transition established an OEF/OIF Polytrauma 
Call Center to assist our most seriously injured veterans and their 
families with clinical, administrative, and benefit inquiries. The Call 
Center which opened February 2006, is operational 24 hours a day, 7 
days a week to answer clinical, administrative, and benefit inquiries 
from polytrauma patients and their families. In addition, the Call 
Center has contacted 950 veterans since February 2007. Through these 
outreach phone calls, we have been able to provide these veterans 
additional assistance with health or benefits concerns.
    VA has implemented an automated tracking system to track 
servicemembers and veterans transitioning from MTFs to VA facilities. 
As part of this system, VHA implemented a 2007 performance measure to 
ensure VHA assigns a case manager to seriously injured servicemembers 
being referred from a MTF to a VA treatment facility in a timely 
fashion. This performance measure monitors the percent of severely ill/
injured servicemembers and veterans who are contacted by their assigned 
VA case manager within 7 days of notification of transfer to the VA 
system.
    In April 2007, VA integrated the tracking system with DoD's joint 
patient tracking application (JPTA) which tracks servicemembers from 
the battlefield through Landstuhl, Germany, to MTFs in the States. The 
new application, known as the veterans tracking application (VTA), is a 
modified version of DoD's JPTA--a web-based patient tracking and 
management tool that collects, manages, and reports on patients 
arriving at MTFs from forward-deployed locations. VTA is compatible 
with JPTA and allows the electronic transfer of DoD medical data JPTA 
on medically evacuated patients to VA on a daily basis.
    VA is participating in DoD's post deployment health reassessment 
(PDHRA) program for returning deployed servicemembers at Reserve and 
Guard locations by providing information on VA care and benefits, 
enrolling interested Reservists and Guardsmen in the VA health care 
system, and arranging appointments for referred servicemembers. Since 
its inception, over 121,721 Reserve and Guard members have completed 
the PDHRA on-site screen resulting in over 27,755 referrals to VA 
facilities and 13,848 referrals to vet centers.
    In order to ensure that OEF/OIF combat veterans receive high 
quality health care and coordinated transition services and benefits as 
they transition from the DoD system to the VA, VA developed a robust 
outreach, education and awareness program. The signing of a memorandum 
of agreement (MOA) between the National Guard and VA, in May 2005, and 
the formation of VA/National Guard State coalitions in each of the 54 
States and territories now provides the opportunity for VA to gain 
access to returning troops and families as well as join with community 
resources and organizations to enhance the integration of the delivery 
of VA services to new veterans and families. This is a major step in 
closer collaboration with the National Guard soldiers and airmen. A 
similar MOA is being developed with the U.S. Army Reserve Command and 
the U.S. Marine Corps at the national level. VA and the National Guard 
Bureau teamed up to train 54 National Guard transition assistance 
advisors who assist VA in advising Guard members and their families 
about VA benefits and services.
    VA participates in TAP workshops to provide servicemembers who are 
within 6 months of discharge or 2 years of retirement with information 
and assistance as they transition to civilian life. Part of the 
briefing conducted by DoL includes reviewing servicemembers' job 
seeking skills and allowing them to use DoL services to obtain 
employment following separation from service. At this time DoD does not 
make attendance at TAP briefings mandatory for servicemembers. The 
Marine Corps is the only branch of service that requires all 
discharging and retiring Marines to attend TAP. Currently just over 50 
percent of all eligible servicemembers attend TAP. Following TAP 
briefings VA military service coordinators are available on most 
military bases to meet with interested servicemembers to discuss VA 
services and benefits.
    The Secretary of Veterans Affairs sends a personal ``thank you'' 
letter together with information brochures to each returning OEF/OIF 
veteran based on lists routinely provided by the DoD. These letters 
provide information on health care and other VA benefits, toll-free 
information numbers, and appropriate VA Web sites for accessing 
additional information. In addition, VA and DoD are collaborating to 
ensure VA is notified of severely ill or injured servicemembers 
transitioning to civilian life. Under this initiative, DoD is 
transmitting the names of servicemembers entering Do D's physical 
evaluation board (PEB) process. This list enables VA to contact active 
duty servicemembers to inform them of VA benefits and health care 
services available to them and to assist them in accessing these 
services.
    Question 8(d): Has the VA pursued the collection of DoD data 
identifying the upcoming release/discharge of minority servicemembers 
within 90 days of their release to assist the VA with outreach to the 
service member?
    Response: VA and DoD are collaborating to ensure VA is notified of 
severely ill or injured servicemembers transitioning to civilian life. 
Under this initiative, DoD is transmitting the names of servicemembers 
entering DoD's physical evaluation board (PEB) process. This list 
enables VA to contact active duty servicemembers to inform them of VA 
benefits and health care services available to them and to assist them 
in accessing these services. In addition the Secretary of Veterans 
Affairs sends a personal ``thank you'' letter together with information 
brochures to each returning OEF/OIF veteran based on lists routinely 
provided by the DoD. These letters provide information on health care 
and other VA benefits, toll-free information numbers, and appropriate 
VA Web sites for accessing additional information.
    Question 9(a): How does the Center/VA identify Minority Vets?
    Response: CMV uses the U.S. Census data to identify minority 
veterans. In order to identify minority veterans using VA health care 
services, veterans applying for enrollment in the VA health care 
system, or for nursing home, domiciliary or dental benefits, veterans 
(or their legal proxies) must complete the 1010 EZ form. The form 
includes 2 questions, similar to those used in the 2000 Census, asking 
the applicant to self-identify Spanish, Hispanic or Latino ethnicity 
(yes or no) and to self-identify race (one or more). This information 
is self-reported, is strictly voluntary, and a disclaimer is offered 
that any information collected is used for statistical purposes only. 
Enrollment and benefit eligibility decisions are not influenced by the 
answer to one or both of these questions, including a non-response. 
Once a veteran is enrolled, information on ethnicity and race is not 
routinely collected, although it may be referenced in the enrollee's 
confidential electronic health record.
    Since 1999, VHA has conducted comprehensive nationwide surveys 
designed to provide input into estimates of enrollees' demand for 
health care services. Surveys consist of telephone interviews with 
random stratified samples of enrolled veterans. Recognizing that good 
administrative data on race and ethnicity are lacking, the 2005 survey, 
for the first time, asked respondents their race and ethnicity.
    Question 9(b): What are your outreach practices to these subsets of 
veterans for VA facilities to ensure equitable access to benefits?
    Response: CMV has program analysts who serve as veterans liaisons 
for each of the 5 minority groups: Asian Americans, Blacks, Hispanics, 
Native Americans, and Pacific Islander Americans. They establish 
partnerships with VSOs as well as internal and other external 
stakeholders to increase awareness of minority veterans' issues and 
develop collaborative strategies to address unmet needs.
    VHA has developed a wide range of outreach programs in response to 
the health care and other benefits needs of veterans and their 
families, which focus on minority, women, newly separated and younger 
veterans, as well as on their health care providers. Many of these 
represent ``lessons learned'' from VA's experiences responding to the 
outreach, education, health care and other benefits needs of minority 
and women veterans returning from the 1991 gulf war, and from the 
Vietnam War.
    These include:

      Since 2005, VA has published and distributed over 250,000 
brochures titled VA Reaching Out to Women Veterans.
      VA's Secretary sends a letter to all newly separated OEF/
OIF veterans, based on records provided by DoD, thanking them for their 
service, welcoming them home, and providing basic information about VA 
health care and other benefits.
      Expanded VA provider education on combat health care 
including:

          Preparing for the Return of Women Veterans from 
        Combat Theater, USH IL 10-2003-011, on special care needs for 
        women OEF and OIF combat veterans;
          A Guide to gulf war Veterans Health originally for 
        1991 gulf war combat veterans, remains relevant for OEF/OIF 
        combat veterans;
          Endemic Infectious Diseases of Southwest Asia, on 
        infectious disease risks not typically seen in North America;
          Military Sexual Trauma on recognition and treatment 
        of health problems related to military sexual trauma;
          Post-Traumatic Stress Disorder (PTSD): Implications 
        for Primary Care on PTSD diagnosis, treatment, referrals, 
        support and education;
          Traumatic Amputation and Prosthetics for patients 
        with traumatic amputations, their rehabilitation, primary and 
        long-term care, prosthetic, clinical and administrative issues.

      Publish the quarterly OIF and OEF Review newsletter 
mailed to all separated OEF/OIF veterans (nearly 700,000 as of May 
2007) and their families, on VA health care and assistance programs for 
these newest combat veterans.
      Published and distributed more than 1 million copies of 
brochure A Summary of VA Benefits for National Guard and Reservists 
Personnel, which summarizes health care and other benefits available to 
this special population of combat veterans upon their return to 
civilian life.
      Published Health Care and Assistance for U.S. Veterans of 
Operation Iraqi Freedom, a brochure on basic health issues for that 
deployment.
      Developed and distributed the VA Health Care and Benefits 
Information for Veterans, wallet card concisely summarizing all VA 
health and other benefits for veterans, along with contact information, 
in a single, wallet-sized card for easy reference.
      Promoted eligibility rules providing reservists and 
active duty personnel who served in a designated combat zone such as 
Afghanistan or Iraq with 2 years of free VA health care, in posters, 
information letters and news letters for veterans.
      Developed a clinical reminder (part of VA's computerized 
reminder system) to assist VA primary care clinicians in providing 
timely and appropriate care to new combat veterans.
      Sponsored a 3-day National Conference on Providing Health 
Care for a New Generation of Combat Veterans Returning From OEF/OIF, 
April 10-12, 2007, in Las Vegas, Nevada to sharpen VA's response to new 
and transitioning combat veterans coming to VA, and to the new physical 
and behavioral health care challenges they bring with them. The 
national conference attracted 1,400 primary care providers from around 
the country, including social workers, psychologists and mental health 
professionals, physicians, physician assistants, nurses and others who 
provide direct care to new combat veterans returning from Afghanistan 
and Iraq.

    VBA's outreach efforts are designed to reach a broad spectrum of 
veterans, generally irrespective of race. However, each regional office 
has specially designated outreach coordinators who conduct outreach to 
various populations, including minority veterans, to provide these 
individuals information about VA benefits and services. MVPCs are also 
available to respond to requests concerning VA benefits and services.
    NCA conducts local and national initiatives in an effort to 
identify minority veterans. The outreach practices to these veterans 
include all national cemetery directors having the responsibility to 
identify groups of veterans within the service area of their cemetery 
and providing information about VA memorial benefits to these 
individuals. NCA regularly attends 10 to 12 national conferences each 
year to increase awareness among minority groups of memorial benefits.
    Question 9(c): How do they differ for non-minority vets?
    Response: Minority veterans experience many of the same challenges 
that all veterans experience. However, minority veterans have 
experienced and often experience racial/ethnic discrimination or lack 
of cultural sensitivity more often than non-minority veterans. Minority 
veterans are more likely to be effected by chronic diseases, 
disparities in health care, homelessness, and unemployment.
    Question 10: During its last site visit to the Los Angeles 
Ambulatory Center, the ACMV was overwhelmed by the staggering number of 
homeless veterans. In Los Angeles, it was reported that the veterans' 
homeless population comprised 23 percent of the total 90,000 total 
population in Los Angeles. Despite the fact that Los Angeles has the 
highest homeless population in the country, the Committee believed that 
these numbers might be similar throughout the country. While it wasn't 
clear what percent of these veterans were minority veterans.
    Question 10(a): Please update the Committee on what the VA is doing 
to stem the rising tide of homeless amongst our veterans?
    Response: Since 1987, VA has developed the largest integrated 
network of services and programs designed to address the treatment, 
rehabilitation, and residential needs of homeless veterans. VA 
specialized homeless programs include domiciliary care for homeless 
veterans (DCHV); compensated work therapy/transitional residence (CWT/
TR); health care for homeless veterans (HCHV), homeless providers grant 
and per diem [GPD], and supported housing [SH]. VA in partnership with 
Housing and Urban Development (HUD) provides HUD-VA supported housing 
program [HUD-VASH]).
    VA homeless programs are designed to provide a continuum of care 
for homeless veterans. Key elements of this continuum are:

      outreach to identify veterans among homeless persons 
encountered in communities
      clinical assessment to determine the needs of those 
veterans;
      rehabilitation in VA domiciliary, in community-based 
contracted residential treatment facilities, or in transitional 
residences;
      supportive transitional housing to facilitate community 
re-entry (such as those supported by the VA grant and per diem 
program);
      supportive case management to maintain independent jiving 
in the community (such as the supportive housing program provided by 
HUD-VA).

    For the past several years, VA specialized homeless programs have 
treated 70,000 to 75,000 homeless veterans. In fiscal year (FY) 2006, 
VA homeless programs provided services to approximately 72,000 homeless 
veterans. Approximately 4 percent of VA homeless program clients are 
female; about 46 percent are White; about 46 percent are Black; about 5 
percent are Hispanic; about 1 percent are Native American; and 1 
percent are Asian American and Pacific Islander American. Consistent 
with the missions of the programs, the vast majority of clients have 
serious psychiatric, substance abuse or medical problems.
    About two-thirds of clients in these programs are seen on an 
outpatient basis, receiving direct services and referral to other 
treatment as needed. About one-third are seen more intensively in the 
residential programs. A recent longitudinal study of clients discharged 
from VA residential treatment programs indicated that approximately 80 
percent are stably housed 1 year later. Similarly favorable housing 
outcomes have been observed in studies of VA's longer term supportive 
case management programs.
    Question 10(b): What is it doing for homeless Minority vets with 
dependents?
    Response: VA homeless programs provide outreach and assessment 
services to minority veterans with dependents. The programs provide 
referral to community resources for dependents of homeless patients 
requiring shelter, residential services, medical and psychiatric care, 
or other social services.
    Question 11: The ACMV was concerned that the early identification 
of PTSD and the accompanying services might not be readily available to 
minority veterans who have served in the Vietnam Conflict. What is the 
VA doing to ensure access to treatment and benefits, when warranted, 
are made available to this particular subset of veterans?
    Response: VA is successful in providing mental health services to 
minority veterans of the Vietnam era and other service eras. VA has had 
clinical practice guidelines (CPG) that include PTSD since the mid 
eighties with the current PTSD CPG released in 2004. Following the 
release of the 2004 PTSD CPG, all veterans have been screened for PTSD 
(as well as for depression and alcohol abuse) on an annual basis. 
Beginning in FY 2007, PTSD screen is completed once every 5 years for 
Vietnam era veterans.
    Data from the National Vietnam Veterans Readjustment Study, that 
sampled Black and Hispanic veterans, and the subsequent Matsunaga study 
that specifically targeted Native American and Pacific Islander 
American veterans, showed increased incidence of PTSD among minority 
veterans. As a result, in the 1990s, training videos were created by 
VA's National Center for PTSD directed at providers and veterans and 
their families on PTSD in these minority groups.
    Data on use of VA mental health services by minority Vietnam era 
veterans indicates that overall, minorities are no less likely than 
non-minorities to use VA services (Rosenheck & Fontana, Journal of 
Nervous & Mental Disease, 1994).
    VA's ongoing program evaluation of PTSD care, entitled the Long 
Journey Home, is produced annually by VHA's Northeast Program 
Evaluation Center (NEPEC). NEPEC data for FY 2000 indicated that 33 
percent of veterans using special outpatient PTSD services were members 
of minority groups. For FY 2006, the percentage was 35 percent. A 
special survey of the 10,131 new Vietnam era veterans, who received 
intake assessments for the specialized outpatient PTSD program in FY 
2006, showed that 37.5 percent were members of minority groups. This is 
about double the proportion of minorities in the general population of 
Vietnam era veterans.
    While VBA does not conduct specific outreach to veterans who may 
suffer from PTSD, all outreach coordinators and telephone 
representatives are knowledgeable about the condition. They can inform 
an inquirer what is needed to file a claim and how to request 
treatment. They are also trained in how to deal with callers with 
extreme mental conditions, including PTSD, who are threatening suicide. 
Additionally, VA's Web site has a wealth of information on PTSD for the 
veteran and his or her family.
    Question 12(a): Please provide a demographic breakdown of the 
number of Minority Veterans, African American, Hispanic, Samoan, Native 
American, and so forth.
    Response: The U.S. Census Bureau, Census Bureau 2006 American 
Community Survey data show the following veteran demographics:

------------------------------------------------------------------------
                       Race                                Number
------------------------------------------------------------------------
Blacks                                                       42,436,205
------------------------------------------------------------------------
Hispanic                                                      1,100,977
------------------------------------------------------------------------
American Indian/Alaskan Native                                  163,975
------------------------------------------------------------------------
Asian American                                                  281,100
------------------------------------------------------------------------
Native Hawaiian/Other Pacific Islander                           23,425
------------------------------------------------------------------------

    Question 12(b): How does the VA gather this information and make 
determinations for resources accordingly, please explain? For instance 
the Advisory Committee was very concerned about how the VA collects its 
data on ethnicity, especially as it seemed to disadvantage Native 
American veterans.
    Response: The VA Office of the Actuary within the Office of Policy 
and Planning develop estimates of veterans by race and ethnicity based 
on assumptions derived from analysis of U.S. Census Bureau data. Since 
1999, VHA has conducted comprehensive nationwide surveys designed to 
provide input into estimates of enrollees' demand for health care 
services. Surveys consist of telephone interviews with random 
stratified samples of enrolled veterans. Recognizing that good 
administrative data on race and ethnicity are lacking, the 2005 survey, 
for the first time, asked respondents their race and ethnicity.
    National estimates of enrollee demographics derived from responses 
to the 2005 Annual Survey of Veteran Enrollees, a telephone survey 
random stratified sample of approximately 42,000 enrollees. The 
estimated distributions from each source are as follows:

----------------------------------------------------------------------------------------------------------------
                                                      American                       Native
                                                       Indian              Black/   Hawaiian              More
                                            Hispanic     or       Asian    African  or Other    White   than one
                                                       Alaska             American   Pacific              race
                                                       Native                       Islander
----------------------------------------------------------------------------------------------------------------
Office of the Actuary (2007)                    5.6%      0.8%      1.2%     10.9%      0.1%     79.9%      1.4%
----------------------------------------------------------------------------------------------------------------
Survey of Veteran Enrollees (2005)*             4.5%      4.6%      0.7%     10.0%      0.5%     84.1%     2.8%
----------------------------------------------------------------------------------------------------------------
*Does not add to 100% because of non-responses

    In addition, to apply for enrollment in the VA health care system, 
or for nursing home, domiciliary or dental benefits, veterans (or their 
legal proxies) must complete the 1010 EZ form. The form includes 2 
questions, similar to those used in the 2000 Census, asking the 
applicant to self-identify Spanish, Hispanic or Latino ethnicity (yes 
or no) and to self-identify race (one or more). This information is 
self-reported, is strictly voluntary, and a disclaimer is offered that 
any information collected is used for statistical purposes only. 
Enrollment and benefit eligibility decisions are not influenced by the 
answer to one or both of these questions, including a non-response. 
Once a veteran is enrolled, information on ethnicity and race is not 
routinely collected, although it may be referenced in the enrollee's 
confidential electronic health record.
    Each administration is responsible for making resource 
determinations in order to serve this minority population. At the 
Department level the Secretary established minority veterans' program 
coordinators (MVPC) at each VA health care facility, regional office 
and national cemetery. The directors of the health care facility, 
regional office and national cemetery are responsible to ensure that 
MVPCs have the necessary resources to be effective and efficient to 
perform the functions needed (e.g., numbers of hours allocated to 
perform the duties, computer access/email, and funding for projects 
and/or special programs as required).
    Question 13(a): For the recommendations made by the Advisory 
Committee, and for those in which the VA concurs, who is responsible 
for ensuring implementation of the recommendations made by the Advisory 
Committee?
    Response: The administrations along with various staff offices are 
responsible for implementing the recommendations of ACMV. CMV tracks 
the status of recommendations to ensure implementation; and requests 
briefings on unresolved recommendations at ACMV bi-annual meetings.
    Question 13(b): How are these missives sent down throughout all of 
the VA?
    Response: CMV assigns each recommendation to the appropriate 
administration or staff office, and then monitors and follows up as 
needed.
Questions on the Backlog
    Question 1: During its visit, the Committee also noted that the LA 
VARD had a significant backlog in its appellate reviews. In fact, it 
was reported to the Advisory Committee that 4,000 appeals were pending 
but that only 8 percent of the VARO staffing was designated to work on 
those appeals. How does the VA determine the allocation of resources 
for these backlogged areas?
    Response: Under the claim process improvement (CPI) model, a 
regional office has established claims processing teams performing the 
functions of triage, pre-determination, rating, post-determination, 
appeals, and public contact.
    The claims processing taskforce recommends the following 
distribution of staffing:

------------------------------------------------------------------------

------------------------------------------------------------------------
Triage:                                                    20-25 percent
------------------------------------------------------------------------
Pre-determination:                                         15-20 percent
------------------------------------------------------------------------
Rating:                                                    20-25 percent
------------------------------------------------------------------------
Post-determination:                                        10-15 percent
------------------------------------------------------------------------
Appeals:                                                    5-10 percent
------------------------------------------------------------------------
Public contact:                                            15-18 percent
------------------------------------------------------------------------

    The Los Angeles RO allocates 12.4 percent of its Veterans Service 
Center decisionmakers, to the appeals process. Because of the 
complexity of the appeals process, these decisionmakers are highly 
skilled and more experienced.
    Since October 2006, the Los Angeles Regional Office has reduced its 
appeals workload by 15 percent, and improved the timeliness of the 
notice of disagreement process by 24 percent. There are currently 3,673 
appeals pending.
    Question 2: Has been omitted.
    Question 3: What percentage of the VA population is Native 
American?
    Response: Public Law 103-446 denotes that Native Americans include 
American Indians, Alaskan Natives, and Native Hawaiians. The U.S. 
Census 2006 reflects that there are 163,975 American Indian veterans 
and 23,425 Native Hawaiians and Pacific Islanders. U.S. Census data 
doesn't provide a separate breakdown for Native Hawaiians and Pacific 
Islanders.
    Question 4: What is being done in terms of outreach for this 
special set of Minority Veterans?
    Response: The Department of Health and Human Services (HHS) and the 
VA signed a memorandum of understanding (MOU) in February 2003 to 
encourage cooperation and resource sharing between the Indian Health 
Service (IHS) and VHA to deliver quality health care services and 
enhance the health status of American Indian and Alaska Native (AI/AN) 
veterans.
    Outreach. Most networks are engaged in a variety of outreach 
activities, including meetings and conferences with IHS program and 
tribal representatives, VA membership in the Native American Healthcare 
Network, VA participation in traditional Native American ceremonies, 
transportation support to AI/AN, and so forth.
    Education. VHA Employee Education Service (EES) provides training 
programs to IHS staff and the tribal community. In FY 2007, VHA has 
delivered 123 training programs to IHS staff and the tribal community 
of which 68 were made available using satellite technology and 55 using 
web based technology. These educational programs will be continued in 
2008, and VHA will also provide selected IHS staff an opportunity to 
attend regional EES workshops.
    Behavioral Health. The Behavioral Health workgroup developed a 
framework for AI/AN communities to assist returning OEF/OIF AI/AN 
servicemembers and veterans reintegrate with their families and 
communities and readjust to civilian life. The objective is to promote 
a community health model with tools that is provided to Tribal 
communities and families to help returning veterans address emerging 
adjustment reactions, traumatic stress, and PTSD, emphasizing recovery 
as the goal. The Joint Committee has developed a slide presentation to 
be used by outreach teams. There have been briefings using the slide 
presentation in Montana, with approximately 30 veterans now receiving 
services from VA.
    Expanded Health Care Services. At the local level, 10 VHA networks 
are engaged in targeted initiatives aimed at providing a full continuum 
of health care services, such as; health fairs, VA/IHS advisories, use 
of Health Buddy, and education and/or shared services in substance 
abuse, domestic violence programs, cardiac rehabilitation, dietetics, 
behavioral medicine, and so forth.
    Care Coordination. The VHA-IHS Shared Health Care workgroup is 
working on developing an Inter-Departmental coordinated care policy. 
The goals are to optimize the quality, appropriateness and efficacy of 
the health care services provided to eligible AI/AN veterans receiving 
care from both VHA and IHS or Tribes and to improve the patients' 
satisfaction with the coordination of care between the 2 Departments. A 
separate memorandum of understanding to facilitate electronic record 
sharing was signed in August 2007.
    Tribal Veteran Representatives. In July 2007 9 Tribal veteran 
representatives (TVRs) and a drum group participated in a Wounded 
Warriors program in Park City, Utah for returning OEF/OIF veterans. A 
similar program is being considered for women and then another for men. 
American Vet video filmed and will have a new film come out soon. TVRs 
are working on an outreach program to urban veterans in October 2007. 
Training to add TVRs continues.
    Telemedicine. Telemedicine has proven to be an extremely effective 
in the treatment of PTSD in Alaskan Native villages. VA and IHS are 
working to spread the use of telemedicine services by AI/AN veterans, 
which will allow VA to bring physical and mental health care to the 
tribes, especially those in remote areas of the country.
    Traditional Healing. Some VHA facilities and Vet Centers have 
incorporated traditional healing ceremonies along with modern methods 
of treatment and counseling. As a national initiative, VA has sent over 
500 letters to tribal leaders to ask them to provide information on 
appropriate providers of traditional practices so that they may be 
called upon for religious/spiritual care of AI/AN veterans.
    The majority of VBA's outreach to this group is in those States 
where there are concentrations of Native American veterans. Several 
regional offices have been very successful in establishing 
relationships with tribal councils to allow VBA to meet with Native 
American veterans in familiar settings. Currently, VBA works closely 
with TVRs a liaison between the Tribes and VBA in processing of claims.
    NCA has recently added a Native American member to its Advisory 
Committee on Cemeteries and Memorials. In addition to his regular 
duties as a Committee member he will assist in identifying and 
conducting outreach to Native American populations unaware of VA 
memorial benefits.
    Public Law 109-461, Veterans Benefits, Health Care, and Information 
Technology Act of 2006 amended section 2408 of title 38, United States 
Code, to allow the Secretary to make cemetery grants to tribal 
organizations in the same manner, and under the same conditions, as 
grants to States are made under the State cemetery grants program.
    Inclusion of tribal organizations into the State cemetery grants 
program will assist NCA in identifying groups of veterans interested in 
learning about VA memorial benefits when they initiate the grant 
process.
    Question 5: What metrics does the VA use to measure success in its 
outreach programs to Minority veterans?
    Response: The purpose of outreach is to make individuals aware of 
the benefits available from VA. Of course, awareness does not always 
translate into applying for benefits. Under section 805 of Public Law 
108-454, VA is charged with conducting a national survey to ascertain 
servicemembers' and veterans' and their family members' and survivors' 
levels of awareness of VA benefits and services. When this survey is 
completed we will have a better understanding of the effectiveness of 
the outreach initiatives.
    Question 6: What has the VA done to implement the establishment of 
full-time Minority Outreach Coordinators where warranted?
    Response: The Secretary's memorandum dated April 25, 1995, 
established MVPCs at each VA medical center, regional office, and 
national cemetery. VA Directive 0801, Minority Veterans Program 
Coordinator signed by the Secretary of Veterans Affairs on April 15, 
2007 States that each administration shall support facility MVPCs and 
ensure they are provided the necessary resources to be effective and 
efficient to perform the functions needed (e.g., numbers of hours 
allocated to perform the duties, computer access/email, and funding for 
projects and/or special programs as required).
    VHA has designated MVPCs at each medical center. The MVPC assist 
the medical center director and CMV with identifying the needs of 
minority veterans through outreach activity. The primary goal of this 
outreach initiative is to increase local awareness of minority veteran 
related issues and develop strategies for increasing their 
participation in existing VA benefit programs for eligible veterans. 
MVPC's are responsible for:

      Promoting the use of VA benefits, programs, and services 
by minority veterans.
      Supporting and initiating activities that educate and 
sensitize internal staff to the unique needs of minority veterans.
      Targeting outreach efforts to minority veterans through 
community networks.
      Advocating on behalf of minority veterans by identifying 
gaps in services and make recommendations to improve service delivery 
within their facilities.

    VBA has designated outreach coordinators at every regional office 
for several specific audiences of servicemembers and veterans including 
minority, OEF/OIF, women, the elderly, Native American, former 
prisoners of war, and homeless. Because of the overlap of groups, a few 
regional offices have consolidated their outreach activities with one 
coordinator. In 20 States, the homeless coordinator is a full-time 
position because of the size of the homeless veteran population in 
those States. In only a few other cases is there a substantial specific 
population to justify assigning a full-time coordinator to any specific 
targeted group.
    NCA now has an outreach coordinator staff position at the national 
level within the Communications Management Service. The position 
includes responsibilities for minority outreach as well as other 
program outreach on the national level.
Questions for Women Veterans
    Question 1: In its 2004 Report, the VA Advisory Committee on Women 
Veterans indicate that the VA perform a study to determine the 
prevalence of Military Sexual trauma among homeless women veterans and 
the psychosocial consequences of Military Sexual Trauma (MST) and 
whether a correlation exists between MST and homelessness. The VA 
concurred. Please update the Committee on the results of any follow-up 
studies that may have been conducted. (p. 36).
    Response: North East Program Evaluation Center (NEPEC) has 
conducted a follow-up study of homeless female veterans in the course 
of which we have collected data on military sexual trauma (MST). These 
data show that among female veterans being served at 1 of the 11 
specialized homeless women veterans programs throughout the country, 43 
percent reported being raped while in the military. This rate of MST 
can be compared to rates reported among VA ambulatory female 
outpatients of 23 percent (Skinner, 2000) and rates noted through 
mandatory VA screening procedures of 21 percent (external peer review 
package data). Skinner, Katherine M; Kressin, Nancy; Frayne, Susan; 
Tripp, Tara J; Hankin, Cheryl S; Miller, Donald R; Sullivan, Lisa M. 
The prevalence of military sexual assault among female Veterans' 
Administration outpatients. Journal of Interpersonal Violence. Vol. 
15(3) Mar 2000, 291-310.
    Question 2: Are there any correlations between MST and 
Homelessness?
    Response: NEPEC collected data on homeless female veterans. These 
data show that among female veterans being served at specialized 
homeless women veterans programs throughout the country, 43 percent 
reported being raped while in the military. This rate of MST can be 
compared to rates reported among VA ambulatory female outpatients of 23 
percent (Skinner, 2000) and rates noted through mandatory VA screening 
procedures of 21 percent (external peer review package data). This 
difference suggests that homeless female veterans under VA care may be 
more likely to have suffered MST than non-homeless female VA clients. 
However, without longitudinal data it is not possible to conclude that 
experiencing MST significantly increases the risk of homelessness among 
all female veterans. Skinner, Katherine M; Kressin, Nancy; Frayne, 
Susan; Tripp, Tara J; Hankin, Cheryl S; Miller, Donald R; Sullivan, 
Lisa M. The prevalence of military sexual assault among female 
Veterans' Administration outpatients. Journal of Interpersonal 
Violence. Vol. 15(3) Mar 2000, 291-310.
    Question 3(a): As women are increasingly prevalent on the 
frontlines of combat, what is the VA doing to prepare for and address 
the needs of the growing number of veterans who are minority?
    Response: VA is aware that the number of women serving on active 
duty and in combat area deployments has dramatically increased. Because 
of the numbers of new OEF/OIF veterans, VA is preparing for the 
population of women veterans to double in the next 2 to 5 years. To 
address the needs of these women veterans, including minority women, VA 
plans to:

      Enhance the skills of primary care providers treating 
women through primary care education initiatives;
      Increase the focus on comprehensive care, including those 
conditions that have high mortality for women, such as heart disease 
and obesity; and,
      Help new OEF/OIF women veterans stay fit and healthy for 
life, since we expect them to be receiving care from VA throughout 
their adult years. Special attention to issues for minority veterans, 
and veterans' perception of health care are being addressed in this 
program.

    Question 3(b): Please inform the Committee what percentage of OIF/
OEF women veterans are minority?
    Response: As of August 31, 2006, of the 69,861 women veterans who 
had served in OEF/OIF 42 percent are minorities. Of this 42 percent, 26 
percent are Black, 9 percent are Hispanic, and 7 percent are members of 
other minority groups or multiple races.
    Question 4: Based on a recommendation by the Women's Advisory 
Committee, what has the VA done specifically to ensure that Veterans 
Benefits advisors at the Transition Assistance Program (TAP) briefings 
specifically address MST (military sexual trauma) information, Le. 
placing in packets?
    Response: The VA TAP benefits briefing presentation used by 
military services coordinators includes 5 slides on Military Sexual and 
Other Personal Trauma. These slides are mandatory at all VA benefits 
briefing presentations conducted for separating and retiring 
servicemembers. When VBA conducts site visits to evaluate TAP VA 
benefits presentations, this requirement is on our checklist to confirm 
it is included in the briefings.

                                 
                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                     August 2, 2007

Shirley Ann Quarles, R.N., Ed.D
Chairwoman, Advisory Committee on Women Veterans
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420

    Dear Shirley:

    In reference to our joint Subcommittee hearing on ``Issues Facing 
Women and Minority Veterans'' held on July 12, 2007, I would appreciate 
it if you could answer the enclosed hearing questions by the close of 
business on October 2, 2007.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full and 
Subcommittee hearings. Therefore, we would appreciate it if you would 
provide your answers consecutively and single-spaced. In addition, 
please restate the question in its entirety before the answer.
    Please provide your response to Cathy Wiblemo. If you have any 
questions, please call 202-225-9154.

            Sincerely,
                                         MICHAEL H. MICHAUD
                                                           Chairman

                                 ______
                                 

                    Dr. Shirley Quarles, R.N., Ed.D.
             Response to Follow-Up Questions for the Record
                    From Joint Subcommittee Hearing
     U. S. House of Representatives Committee on Veterans' Affairs
                    Subcommittees on Health and the
       Subcommittee on Disability Assistance and Memorial Affair
    Question 1--
    I was pleased to see that there is a national Survey of Women 
Veterans being implemented with the results expected in December 2008.

      In your estimation, what are the 3 most prevalent and 
urgent issues facing women veterans today?

    As stated in earlier testimony in July 2007, 1) access to care for 
women veterans in rural areas, 2) primary care in community-based 
outpatient clinics that offer the same services that are provided at VA 
medical centers, and 3) that women veterans receive health care on par 
as male veterans.

    Question 2--
    To my knowledge, VA has not yet held any type of summit or 
conference on OEF/OIF female veterans and the unique needs that are 
arising as a result of women in combat.

      Has the Advisory Committee looked at this, and if so, 
what have you found?

    In April 2007, VA held a national conference in Las Vegas, Nevada 
called ``Evolving Paradigms: Providing Health Care to Transitioning 
Combat Veterans''. The main attendees to the conference were VA and DoD 
primary care givers and related health care professionals from all 
disciplines who work with new combat veterans returning from Iraq and 
Afghanistan to include: physicians, nurses, pharmacists, psychologists, 
social workers, rehabilitation and mental health staff. The primary 
purpose of the conference was to disseminate information to VA and DoD 
health care providers on unique and challenging health care needs for 
transitioning veterans with war wounds. Veterans transition to VA with 
multiple and complex war wounds and the environment of care is critical 
to the healing process. VA health care providers need to understand all 
of these complex health care needs in a variety of settings, as these 
new veterans transition from DoD to VA for their immediate and long-
term health care needs. Sessions focused toward women included: Health 
Issues of Female Soldiers in Garrison, Combat and VA; Sexual Trauma; 
and Gender Differences: What the Data Shows.
    More recently, on February 19, 2008, the Department of Veterans 
Affairs held a 1-day conference entitled Update on Health Care: 
Responding to the Needs of VA's Newest Generation of Combat Veterans, 
in the Sonny Montgomery Conference Center. Speakers from VA and the 
Department of Defense covered such topics as traumatic brain injury and 
polytrauma; mental health, post-traumatic stress disorder, and 
readjustment issues; DoD/VA data sharing, changes in VA and DoD 
disability evaluation; an individual veteran's experience, case 
management: role of the Federal recovery coordinators, transition 
patient advocates, and VA social workers; pay and compensation; and 
special issues for national guard and reserve.
    Veterans Health Administration is scheduled to participate in the 
6th Annual Battlefield Healthcare Combat Casualty Care from the Front 
Line to CONUS on March 31-April 2, 2008 at Georgetown University 
Conference Center (and Hotel), Washington, DC. The conference will 
discuss the continued operations in Iraq and Afghanistan and addressing 
new challenges in care for combat veterans who serve in theater.
    Also, The Department of Veterans Affairs, Center for Women Veterans 
is planning the 2008 National Summit on Women Veterans Issues scheduled 
for June 20-22, 2008 in Washington, DC. This is the 4th such Summit, 
the prior Summits having been held in 1996, 2000, and 2004. Summit 2008 
will look at the issues and recommendations from the 2004 Summit, 
review VA's progress on these issues, provide information on current 
issues, and develop recommendations and a plan for continuous progress 
on women veterans' issues. A special focus of this Summit is on updates 
for the Reserve and Guard. Breakout sessions have been designed for our 
returning OEF/OIF service members and veterans, however, there will be 
breakout sessions that are relevant for women veterans of all eras as 
well. A townhall meeting and health expo are also planned.
    Question 3--
    Could you tell me what the biggest barriers to care for women 
veterans are?
    Access to care continues to be a barrier for women veterans. We 
continue to outreach to the women veterans' community with increased 
emphasis, working with our partnerships with Federal, state, and county 
agencies, national veterans service organizations and community 
organizations. HVAC, Subcommittees on Health and DAMA, 7-12-07, 
Questions for the Record, Malebranche

                                 

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                     August 2, 2007

Colonel Reginald Malebranche, USA (Ret.)
4919 Donovan Dr.
Alexandria, VA 22304

    Dear Reginald:

    In reference to our joint Subcommittee hearing on ``Issues Facing 
Women and Minority Veterans'' held on July 12, 2007, I would appreciate 
it if you could answer the enclosed hearing questions by the close of 
business on October 2, 2007.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full and 
Subcommittee hearings. Therefore, we would appreciate it if you would 
provide your answers consecutively and single-spaced. In addition, 
please restate the question in its entirety before the answer.
    Please provide your response to Cathy Wiblemo. If you have any 
questions, please call 202-225-9154.

            Sincerely,
                                         MICHAEL H. MICHAUD
                                                           Chairman

                                 ______
                                 

                        Follow-Up Questions for
                 Col. Reginald Malebranche, USA (Ret.)
    Question:
    In your testimony you stress the absence of diversity at the senior 
staff level.
      When the Committee presented their concern to the VA 
about this issue, how did they respond?
    Answer:
    VA's answer has been to ``concur in principle.'' The Committee did 
note that VHA planned on adding a 2007 work force performance measure 
for diversity management for all Senior Managers that includes the 
following:
        ``a. VISNs will take action to remove any barriers to full 
        participation of the local work force.
        ``b. Based on the analysis of the results from the Diversity 
        Acceptance factors from the 2006 All Employee Survey (AES), 
        VISNs will develop goals for improvement and implement the 
        resulting action plan.''
    The absence of diversity at the senior staff level is a systemic 
issue, which has been addressed and discussed in the majority of ACMV 
reports. Yet, diversity at the senior staff level continues to be a 
major problem at and within VA.
    VA perceives its problem to be the lack of white and Hispanic 
females at its senior staff level, even though the supportive data is 
inconclusive. It stands to reason that VA's targets will be white and 
Hispanic females, although analysis of VA data would suggest that 
minorities, excluding white and Hispanic females, were significantly 
absent from senior staff level positions at and in VA settings.
    The Committee has been on record to recommend that VA exercise all 
leverage available, including performance bonuses to bring required 
changes, including the establishment of goals or floors, and hold all 
leaders and managers personally accountable to meet established or 
required goals, for the hiring of minority staff. The Committee 
believes that these actions would result in a work force population 
which would be more representative of the veteran population being 
served.
    Question:
      To your knowledge, has the VA put forth a strategic plan 
that would target recruitment and retention of minority veterans among 
the senior staff level?
    Answer:
    I am unaware of a specific strategic plan, which would remedy the 
issue. During the Committee's meeting in Washington, DC, April 16-19, 
2007, the Office of Diversity Management and EEO Administration, VA, 
presented data in the Executive Summary, EEOC Form 715-01 Part E, for 
Fiscal Year 2007, which may be construed as VA's strategic plan. The 
Executive Summary, EEOC Form 715-01, offered the following:
    ``WORKFORCE PROFILE: VA has a workforce of approximately 238,580 
employees. During Fiscal Year (FY) 2006, total VA staffing increased by 
more than 4,700 employees, including about 600 temporary appointments. 
White women are 35.7% of the permanent positions, significantly below 
their 47.5% in the Relevant Civilian Labor Force (RCLF) for VA 
occupations, and declining slightly. Hispanic women are 3.6% of the 
permanent positions, well below their 4.4% in the RCLF, and not making 
meaningful progress toward RCLF parity. Hispanic men and American 
Indian women are slightly underrepresented, but at the current rate of 
gains should reach parity within 2 years. No other groups are 
underrepresented in national total. Black men are represented at almost 
3 times the RCLF and Black women are represented at almost double the 
RCLF.''
    This would suggest that VA's strategic plan is to focus on the 
recruitment, hiring, and training of white and Hispanic females, only. 
This would also suggest that VA does not consider having problem with 
minorities hiring, promotion, and so forth., except for White and 
Hispanic females. Data available at VA does not support this 
conclusion.
    There have been indications that VA had developed strategic 
initiatives targeting the recruitment and retention of minority 
veterans at the senior staff level. The plan and/or programs have not, 
to my knowledge, been presented to the Committee, which will ask for a 
comprehensive brief during its fall 2007 meeting in Washington, DC.
    Question 2:
    A big concern regarding the provision of care to the minority 
veteran population is sensitivity to the cultural differences of 
minority veterans--for instance, the differences in how to approach the 
Alaska Native veteran community as opposed to the Hispanic veteran 
community.
      Does VA provide education to its many employees on 
cultural competencies and sensitivity, particularly to the frontline 
medical personnel?
    Answer:
    Indications are that the Veterans Health Administration (VHA) is 
developing a 3-year phased cultural competency plan, targeting Alaska 
Natives, Native Americans and Hispanic Americans veterans. The 
Committee will endeavor to seek a comprehensive brief on the plan, 
during its fall 2007 meeting in Washington, DC.
    The Center for Minority Veterans does conduct a biennial training 
conference for its Minority Veterans Program Coordinators (MPVC). 
Included in that format is a cultural and sensitivity competency 
module.
    Question 3:
    Outreach is a major challenge for the VA. In your testimony you 
mention transportation to VA centers, in major metropolitan, rural, and 
isolated areas, is a major impediment for minority veterans.
      What kinds of recommendations concerning outreach has the 
committee made to VA to be more effective?
    Answer:
    In its July 1, 2006 report, the Committee recommended:
        Outreach Program
          ``The Secretary mandates that an outreach program be 
        established by all Veterans Affairs Administrations and 
        appropriate staff offices to reach out and support all 
        veterans. As a minimum, the program must incorporate the 
        following goals/activities:
                  a. ``Inclusion of and coordination with local, 
                Federal and state veteran serving organizations in VA 
                facilities' outreach activities. These entities should 
                include, as a minimum, state and county Veterans 
                Affairs Agencies, Veteran Service Organizations (VSOs), 
                veteran serving organizations (i.e. minority veterans' 
                organizations that have not been granted VSO status), 
                agencies and organizations that serve the minority 
                community in the local area, faith-based organizations 
                that serve veterans, etc.;
                  b. ``Establishment of periodic Veteran Town Hall 
                meetings with veterans and their families to determine 
                needs and issues; meetings/processes must ensure that 
                minority veterans and communities are targeted in 
                culturally appropriate venues;
                  c. ``Allow facilities to advertise veteran benefits 
                and health care services and consult Marketing experts 
                to help VA facilities conduct effective communication 
                of VA offerings with particular attention to marketing 
                to minority communities;
                  d. ``Expand and improve the use of Internet based 
                access to VA benefits and health care, with particular 
                attention given to cultural and linguistic diversity;
                  e. ``Establish Minority Outreach Coordinators that 
                are full time, where warranted. Further recommend that 
                these be additional billets that are fully resourced 
                for those facilities, rather than requiring facility 
                directors to give up other billets to fill those 
                positions;
                  f. ``Mandate enhanced outreach communication and 
                coordination between VHA, VBA, NCA and appropriate 
                staff offices;
                  g. ``Identify Federal grants for states to conduct 
                grassroots outreach programs.''
    The Committee also recommended that That VA's Outreach program is 
extended and/or modified to include all means and processes to advise 
minority veterans of their entitlements.

                                 

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                     August 2, 2007

Saul Rosenberg, Ph.D.
Associate Clinical Professor of Medical Psychology
University of California, San Francisco
401 Parnassus Avenue
San Francisco, CA 94143

    Dear Dr. Rosenberg:

    In reference to our joint Subcommittee hearing on ``Issues Facing 
Women and Minority Veterans'' held on July 12, 2007, I would appreciate 
it if you could answer the enclosed hearing questions by the close of 
business on October 2, 2007.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full and 
Subcommittee hearings. Therefore, we would appreciate it if you would 
provide your answers consecutively and single-spaced. In addition, 
please restate the question in its entirety before the answer.
    Please provide your response to Cathy Wiblemo. If you have any 
questions, please call 202-225-9154.

            Sincerely,
                                         MICHAEL H. MICHAUD
                                                           Chairman

                                 ______
                                 

                        Questions for the Record
                       Joint Subcommittee Hearing
             ``Issues Facing Women and Minority Veterans''
                   held on July 12, 2007, 10:00 a.m.
                 Room 334, Cannon House Office Building
             Follow-Up Questions for Saul Rosenberg, Ph.D.
    I was particularly interested in the part of your testimony that 
comments on the fact that African American veterans were about half as 
likely as other veterans to receive service connected disability for 
PTSD.

      Was there an explanation as to why this was so?

    You also mention in your testimony an idea promoted by the DoD Task 
Force on Mental Health regarding Centers of Excellence for the Study of 
Resilience.

      Would you elaborate on that for the Subcommittee?

[DR. ROSENBERG DID NOT RESPOND TO THESE QUESTIONS SUBMITTED BY THE 
SUBCOMMITTEE.]

                                 

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                     August 2, 2007

Joy J. Ilem
Assistant National Legislative Director
Disabled American Veterans
807 Maine Ave. SW
Washington, DC 20024

    Dear Joy:

    In reference to our joint Subcommittee hearing on ``Issues Facing 
Women and Minority Veterans'' held on July 12, 2007, I would appreciate 
it if you could answer the enclosed hearing questions by the close of 
business on October 2, 2007.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full and 
Subcommittee hearings. Therefore, we would appreciate it if you would 
provide your answers consecutively and single-spaced. In addition, 
please restate the question in its entirety before the answer.
    Please provide your response to Cathy Wiblemo. If you have any 
questions, please call 202-225-9154.

            Sincerely,
                                         MICHAEL H. MICHAUD
                                                           Chairman

                                 ______
                                 

                       POST-HEARING QUESTIONS FOR
                              JOY J. ILEM
                                 OF THE
                       DISABLED AMERICAN VETERAN
    Question 1:
    In testimony provided, DAV gives 8 recommendations to better serve 
women veterans from combat theaters. The first recommendation concerns 
barriers to seeking health care through VA.

      In your estimation, what are the 3 biggest barriers 
female veteran encounter when trying to access health care through VA?

    Response: DAV believes women veterans face many barriers, some very 
tangible and others that are seemingly invisible. As for the top 3 I 
offer the following remarks.
    Women's programs are small. When a new VA initiative or program is 
created, for mental health, homeless veterans, or residential care, for 
example, women typically constitute the smallest fraction of veterans 
to be served. Sometimes this causes VA planners and managers 
significant difficulty in program design and management. Additionally, 
women's care is often complicated by a history of military sexual 
assault, or they have minor children. Program planners typically design 
these programs for the majority of patients who will use them, and the 
majority of VA's patients are males. Fitting in women with their 
special needs is often problematic, or women are required to accept the 
program designed ``as is,'' without special consideration for their 
circumstances. This is a barrier to care.
    Second, there are no ``best models'' of care for women in VA. VA is 
becoming recognized as a system that bases its services on evidence and 
efficacy. We believe evidence-based care is the best care because VA 
has tested its methods and has measured its outcomes for certain health 
issues versus other health care techniques and practices that have not 
been subjected to rigorous review. DAV supports this policy because it 
produces higher quality of care for veterans. In respect to women, 
however, until 2006 VA had no systematic research agenda for women's 
health. While now underway, the results of this research agenda will 
not be known or implemented for some time. In the interim, VA 
clinicians are treating women without best-practices guidance. This is 
a barrier to care.
    Third, privacy and security for women remains a problem in VA 
facilities. DAV continues to hear from women veterans that their 
personal security and privacy are regularly compromised in VA 
facilities that lack adequate space, secured rooms, private restrooms, 
dressing rooms and sufficient privacy curtains in some VA clinics. 
Women are frequently integrated into VA primary care teams, often 
without regard to these gender and privacy issues. DAV and the 
Independent Budget veterans service organizations have raised these 
issues in the past, but progress in improving privacy and security for 
women patients has been slow. This is a barrier to care.
    Today's military will soon be comprised of 20 percent women. 
Additionally women veterans are the fastest growing segment of the VA-
enrolled population. VA Central Office has established an Office of 
Women's Health and a Center for Women Veterans, and VA has a Women's 
Advisory Committee. Field facilities of the VA have designated women's 
coordinators to help women move more smoothly through VA's various 
processes. We hope that some of these developments and efforts will 
help VA better address the needs of women who need VA health care as 
urgently as their male counterparts who do not face these barriers to 
care.
    Question 2:
    Women and minority OEF/OIF veterans returning from theater face, 
what I believe, are additional challenges than their returning peers, 
due, in part, to the lack of cultural education, lack of adequate 
research on meeting their unmet needs and other issues.

      What has your organization done to help in the outreach 
effort?
    Response: While outreach is a statutory responsibility of the 
Department of Veterans Affairs, to ensure veterans are fully aware of 
the benefits and services for which they may be eligible, DAV has a 
fully trained corps of 260 National Service Officers (NSOs) who work in 
both VA regional offices and VA medical centers, to ensure veterans 
have full access to their rights and benefits. Also, DAV has stationed 
NSOs and special Transition Service Officers (TSOs) in or near major 
military treatment facilities to aid active duty members and veterans 
who are under care in those facilities. The primary purpose of our out-
stationing the NSOs and TSOs in military facilities is to ensure that 
claims for benefits are filed early and that we at DAV are able to help 
get those claims processed in an expedited fashion. The TSO corps of 
over 30 specially trained individuals plays an additional key role, of 
providing VA benefits presentations, reviewing service medical records, 
and assisting transitioning servicemembers with filing original VA 
claims for benefits at nearly 100 military separation sites in the U.S. 
These TSOs also participate in Department of Labor programs in 
transition assistance.
    Question 3:
    Does your organization have any recommendations as to how to 
address the growing need for specialized services for both women and 
minority veterans?
    Response: DAV believes that these matters are improved when they 
are not concealed within VA but are properly brought out and to the 
attention of the veterans service organization community and to 
Congress. The more oversight the Committee is able to provide helps 
keep these important issues surfaced. If the Department sees that the 
Committee places a high priority on them, they will draw necessary 
resources (in whatever form) so that progress can be made.

                                 

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                     August 2, 2007

Betty Moseley Brown, Ed.D.
Associate Director, Center for Women Veterans
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420

    Dear Betty:

    In reference to our joint Subcommittee hearing on ``Issues Facing 
Women and Minority Veterans'' held on July 12, 2007, I would appreciate 
it if you could answer the enclosed hearing questions by the close of 
business on October 2, 2007.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full and 
Subcommittee hearings. Therefore, we would appreciate it if you would 
provide your answers consecutively and single-spaced. In addition, 
please restate the question in its entirety before the answer.
    Please provide your response to Cathy Wiblemo. If you have any 
questions, please call 202-225-9154.
            Sincerely,
                                         MICHAEL H. MICHAUD
                                                           Chairman

                                 ______
                                 

                        Questions for the Record
                   Hon. Michael H. Michaud, Chairman
      Subcommittee on Health, House Committee on Veterans' Affairs
                             July 12, 2007
             ``Issues Facing Women and Minority Veterans''
    Question 1: Your testimony indicates that there are 22 VA health 
care facilities that have dedicated comprehensive women's center space. 
I have 3 questions on that:
    Are you saying that 22 of the 154 VA Medical Centers have space for 
women? That isn't a very good percentage if that is what you are 
saying. Why don't all of the V AMC's have dedicated space for women? Is 
the space proportionate to the number of female veterans provided 
services at those locations?
    Response: The Veterans Health Administration (VHA) provides high 
quality primary and specialty health care to women veterans at its 
facilities and clinics throughout the country. At 22 of these 
facilities, VHA has comprehensive women's primary care clinics that 
provide coordinated care such as mental health treatment, and 
gynecological and breast services at the same visit and within the same 
physical space.
    Any specialty care that is needed but not available at a specific 
facility can be provided by another Department of Veterans Affairs (VA) 
facility in the same geographic area, or fee-for-service arrangements 
with a community provider.
    The women veterans' strategic health care group monitors services 
provided to women veterans through an annual, Web-based survey, Plan of 
Care/Clinical Inventory (POC/CI). The fiscal year (FY) 2006 Annual 
Report of 153 VA medical facilities found that 41 percent of VA medical 
facilities have designated women's primary care clinics and teams. An 
additional 43 percent of VA medical facilities provide separate gender-
specific care in a women's health clinic, with the woman veteran 
receiving her primary care in a mixed gender primary care clinic. Only 
16 percent of VA facilities have no separate women's health clinic to 
provide care to women veterans. The Under Secretary for Health has 
asked for program proposals to address gender gaps during FY 2008. 
Decisions on those proposals will occur in the next 60 days.
    With regard to space, the women's comprehensive health clinic 
spaces are designed locally to meet the needs of the women veterans in 
that geographic area. Most commonly the development has been in 
response to the increasing numbers of women presenting for care and 
using the medical facility. In addition, VA research has shown that 
having strong physician leadership in women's health has been a key 
factor in development of comprehensive women's clinics.
    Question 2: Are the Military Sexual Trauma (MST) Coordinators that 
are designated in every VA facility full time?
    Response: Every VA facility is required to appoint an MST 
coordinator to serve as a point person for staff and veterans regarding 
MST issues. This position is currently a collateral one, such that 
coordinators are usually performing their MST coordinator duties along 
with other clinical and/or administrative duties related to their 
primary position. Many MST coordinators provide clinical care to 
veterans with experiences of MST as part of their primary position. 
However, clinical care is not a required component of the MST 
coordinator position itself.
    Question 3: The MST Support Team that was established in FY 2007 in 
VA's Office of Mental Health Services help to ensure that VA is in 
compliance with mandated monitoring of MST screening and treatment. 
When in FY 2007 was this team established? How are they monitoring 
compliance of MST screening and treatment? What have been the findings 
so far?
    Response: The MST support team was established in October, 2006. 
The MST support team uses data from VHA electronic medical records to 
monitor MST screening and treatment. The team submits annual screening 
reports that describe the proportion of all veteran patients who have 
been screened for MST in the past fiscal year. A screening rate is 
provided for VHA nationally and for each VHA facility. The information 
is also aggregated by gender, as is mandated by public law.
    The team also submits annual treatment reports, which contain the 
proportion of all veterans with positive MST screens that have received 
free MST-related treatment, and the amount of treatment provided. These 
reports also provide both national treatment rates and treatment rates 
for each VHA facility, and provide data aggregated by gender.
    During FY 2007 the MST support team accomplished the following:

      Produced and distributed MST screening reports for FY 
2005 and FY 2006. These reports improved upon existing MST monitoring 
by aggregating data by VA facility, and for the first time enabled VA 
facilities to monitor the proportion of all patients screened for MST. 
Prior to this time, only national MST Screening rates were reported.
      Created benchmarks for MST screening performance and 
identified facilities functioning below the benchmark. VA's Office of 
Mental Health Services (OMHS) set the target MST screening rate at 90 
percent and above. The target was met by 96 out of 127 VA facilities. 
There were 13 facilities with rates below 90 percent but greater than 
or equal to 80 percent and 18 facilities with rates below 80 percent.
      Provided consultation to sites regarding issues of 
monitoring and performance benchmarking, with special attention to 
sites not meeting the 90 percent criterion.
      Identified that MST-related treatment is provided at all 
VA facilities. These data also provide key feedback to VA clinicians 
regarding the proportion of MST patients they are able to engage in 
treatment.
      Identified facility-based information resources 
management (IRM) errors in clinical reminder implementation and 
provided technical assistance for these facilities to correct 
implementation and effectively screen for MST.
      Identified the need to develop a more refined screening 
tool that provides more specific data about the range of MST.

    Question 4: What do you believe is the biggest challenge facing 
women veterans today?
    Response: The biggest challenge facing women veterans today is 
gaining awareness of the benefits and services for which they are 
entitled. According to a VA study, titled Women Veterans' Perceptions 
and Decision-Making about Veterans Affairs Health Care (Washington et 
al 2007), in spite of efforts to make women veterans knowledgeable 
about available gender-specific services, there is an information gap 
regarding women veterans' VA eligibility and advances in care. A second 
article, titled To Use or Not to Use: What Influences Why Women 
Veterans Choose VA Health Care (Washington et al 2006), cited that'' . 
. . non-VA users had substantial knowledge deficits of VA benefits, 
eligibility, and availability of women's health care service.'' The 
study notes that 48.5 percent of non-VA users cite lack of knowledge of 
VA eligibility and benefits as the reason for not using them.
    VA is tenaciously addressing this information deficit. Not only are 
we aggressively informing women veterans of their benefits, we have 
women veterans program managers at each VA medical center and women 
veteran coordinators at each VA regional office to assist women 
veterans.
    The number of women using VA health care continues to rise, and is 
projected to be 8.11 percent of all veteran users by FY 2011. VA is 
committed to meeting the needs of returning deployed women veterans as 
well as those of our aging women's population, and to create an 
environment that serves the woman veteran by providing excellent 
comprehensive health care services.
    In order to increase focus on quality of care issues and 
comprehensive longitudinal care for women veterans, additional 
initiatives in FY 2008 are focused on comprehensive care of women, 
including those conditions which have high mortality for women, such as 
heart disease, obesity, and cancers such as lung cancer and colorectal 
cancer. HVAC, Subcommittees on Health and DAMA, 7-12-07, Questions for 
the Record, McClenney

                                 
                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                     August 2, 2007

Lucretia McClenney
Director, Center for Minority Veterans
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420

    Dear Lucretia:

    In reference to our joint Subcommittee hearing on ``Issues Facing 
Women and Minority Veterans'' held on July 12, 2007, I would appreciate 
it if you could answer the enclosed hearing questions by the close of 
business on October 2, 2007.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full and 
Subcommittee hearings. Therefore, we would appreciate it if you would 
provide your answers consecutively and single-spaced. In addition, 
please restate the question in its entirety before the answer.
    Please provide your response to Cathy Wiblemo. If you have any 
questions, please call 202-225-9154.

            Sincerely,
                                         MICHAEL H. MICHAUD
                                                           Chairman

                                 ______
                                 

                        Questions for the Record
                   Hon. Michael H. Michaud, Chairman
      Subcommittee on Health, House Committee on Veterans' Affairs
                             July 12, 2007
             ``Issues Facing Women and Minority Veterans''
    Question 1: In your testimony you indicate that the Minority 
Veterans Program Coordinators' annual report has been converted to a 
quarterly web based report.
    Question 1(a): Could you elaborate on what measures are taken once 
your Center identifies opportunities for improvement?
    Response: The Center for Minority Veterans (CMV) meets on a monthly 
basis with senior Department of Veterans Affairs (VA) officials and 
program offices to identify opportunities for improvement, to develop 
strategies, and to track progress. The Director of CMV meets monthly 
with the Deputy Secretary and provides updates on the status of these 
opportunities.
    Question 1(b): What type of support do the coordinators get at the 
local level from the director's of the facilities?
    Response: The directors of the health care facility, regional 
office and national cemetery are responsible to ensure that MVPCs have 
the necessary resources to be effective and efficient to perform the 
functions needed (e.g., numbers of hours allocated to perform the 
duties, computer access/email, and funding for projects and/or special 
programs as required). In addition, each administration has a 
designated MVPC liaison at VA central office. CMV staff meets monthly 
with these liaisons and quarterly with the senior leadership of each 
administration to discuss outreach activities, issues and concerns that 
impact minority veterans.
    Question 1(c): Are these full time positions?
    Response: As of September 2007, 5 minority veterans program 
coordinators are full time positions. The majority are part time or 
collateral duties.
    Question 2: You mention that the Center provides cultural 
competency training to the field.
    Question 2(a): How comprehensive is the training and is it hands on 
or remote training as in web based?
    Response: CMV provides training to the minority veterans program 
coordinators by 2 primary means:

      Biennial Training Conference--Every 2 years, CMV sponsors 
a minority veterans program coordinator training conference. During 
these conferences attendees are provided instruction on various topics 
of interest to support their local programs. Cultural competencies are 
one of the subject areas covered. After the recent 2007 conference, 
slides from the cultural competencies presentation were posted on the 
VA Employee Education Service (EES) website for use by minority veteran 
program coordinators who were not able to attend the conference.
      Monthly Conference Calls--Cultural competencies have been 
a training topic during monthly conference calls with minority veterans 
program coordinators.

    Question 3: Outreach to minority veterans can be particularly 
challenging given the differences in cultures. There are many ways to 
conduct outreach, but to conduct effective outreach is critical. How 
does the center measure its success in reaching minority veterans 
through the various partnerships and programs that you have?
    Response: CMV measures its success in reaching minority veterans by 
tracking the number of veterans calling or writing directly for 
assistance, participation at outreach activities, and partnerships that 
have been established with external stakeholders.
    Question 4: What do you believe is the biggest challenge facing 
minority veterans today?
    Response: Minority veterans experience many of the same challenges 
that all veterans experience. However, minority veterans have 
experienced and often experience racial/ethnic discrimination or lack 
of cultural sensitivity more often than non-minority veterans. Minority 
veterans are more likely to be effected by chronic diseases, 
disparities in health care, homelessness, and unemployment. HVAC, 
Subcommittees on Health and DAMA, 7-12-07, Questions for the Record, 
Middleton

                                 
                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                     August 2, 2007

Shannon L. Middleton
Deputy Director, Veterans Affairs and Rehabilitation Division
The American Legion
1608 K Street, NW
Washington, DC 20006

    Dear Shannon:

    In reference to our Subcommittee on Health hearing on ``Vet 
Centers'' held on July 19, 2007, and our joint Subcommittee hearing on 
``Issues Facing Women and Minority Veterans'' held on July 12, 2007, I 
would appreciate it if you could answer the enclosed hearing questions 
by the close of business on October 2, 2007.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full and 
Subcommittee hearings. Therefore, we would appreciate it if you would 
provide your answers consecutively and single-spaced. In addition, 
please restate the question in its entirety before the answer.
    Please provide your response to Cathy Wiblemo. If you have any 
questions, please call 202-225-9154.

            Sincerely,
                                         MICHAEL H. MICHAUD
                                                           Chairman

                                 ______
                                 

                        Questions for the Record
                       Joint Subcommittee Hearing
               Issues Facing Women and Minority Veterans
                                Held on
                       July 12, 2007, 10:00 a. m.
              Follow-Up Questions for Shannon L. Middleton
    1. In testimony provided, DAV gives 8 recommendations to better 
serve women veterans from combat theaters. The first recommendation 
concerns barriers to seeking health care through VA.

      In your estimation, what are the 3 biggest barriers 
female veterans encounter when trying to access health care through VA?

    The 3 biggest barriers female veterans encounter when trying to 
access health care through VA are: lack of knowledge about VHA 
services, not knowing that they may be eligible for health care 
benefits, and the perception that VA only caters to male veterans.

    2. Women and minority OEF/OIF veterans returning from theater face, 
what I believe, are additional challenges than their returning peers, 
due, in part, to the lack of cultural education, lack of adequate 
research on meeting their unmet needs and other issues.

      What has your organization done to help in the outreach 
efforts?

    The American Legion publishes a booklet entitled Guide for Women 
Veterans that provides information about VA health care, services 
provided by The American Legion, information about health issues (like 
breast cancer, PTSD, sexual trauma, heart disease, drug and alcohol 
addiction) and a list of resources to enable them to find information 
about various issues. We disseminate them through our department 
service officers, outreach events, on our website and make them 
available upon request to the public.
    In the past, The American Legion has participated in a homeless 
female veteran workgroup for the Southeast Veterans Service Center and 
served on Subcommittees for the 2004 Women Veterans Summit hosted by 
the Department of Veterans Affairs.
    The American Legion is currently planning to collaborate with the 
Center for Women Veterans to organize a Women Veterans' Forum to be 
held in conjunction with the organization's mid-winter conference. The 
American Legion is also participating in the 2008 Women Veteran's 
Summit.
    We are constantly seeking new ways to bring information to 
veterans, all veterans.

      Does your organization have any recommendations as to how 
to address the growing need for specialized services for both women and 
minority veterans?

    One effective way to ascertain the need for specialized services is 
to find various ways to ask women and minority veterans what needs they 
have that are not being met by current services. This can be patient 
survey, or an outreach initiative that includes a survey that VA 
disseminates by mail or via web. The information gathered would be 
useful in determining system-wide need for specific programs or 
services and may be useful in depicting geographical or population 
trends for needed services.
    Once these needs are identified, The American Legion recommends 
that VA develop and implement policy to address these deficiencies in a 
timely manner and conduct an extensive outreach campaign to make these 
special populations--and those who serve them--aware of the 
enhancements. The organization also recommends that Congress 
appropriate adequate funding to maintain these enhancements, once they 
are in place.
    Finally, DAV's recommendations that VA and DoD collaborate to 
conduct surveys of recently discharged active duty women and recently 
demobilized female Reserve component members to assess the barriers 
that they perceive or have experienced in seeking health care through 
VA and that VA Medical Centers establish a consumer council that 
includes veterans' service organizations, family members, and 
veterans--especially OEF/OIF veterans--would be excellent approaches as 
well.

                                  
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