[Senate Hearing 111-205]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 111-205

 VA HEALTH CARE SERVICES FOR WOMEN VETERANS: BRIDGING THE GAPS IN CARE

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                             JULY 14, 2009

                               __________

       Printed for the use of the Committee on Veterans' Affairs


 Available via the World Wide Web: http://www.access.gpo.gov/congress/
                                 senate


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                     COMMITTEE ON VETERANS' AFFAIRS

                   Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West         Richard Burr, North Carolina, 
    Virginia                             Ranking Member
Patty Murray, Washington             Lindsey O. Graham, South Carolina
Bernard Sanders, (I) Vermont         Johnny Isakson, Georgia
Sherrod Brown, Ohio                  Roger F. Wicker, Mississippi
Jim Webb, Virginia                   Mike Johanns, Nebraska
Jon Tester, Montana
Mark Begich, Alaska
Roland W. Burris, Illinois
Arlen Specter, Pennsylvania
                    William E. Brew, Staff Director
                 Lupe Wissel, Republican Staff Director










                            C O N T E N T S

                              ----------                              

                             July 14, 2009
                                SENATORS

                                                                   Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........     1
Burr, Hon. Richard, Ranking Member, U.S. Senator from North 
  Carolina.......................................................     2
Burris, Hon. Roland W., U.S. Senator from Illinois...............     3
Murray, Hon. Patty, U.S. Senator from Washington.................     4
Brown, Hon. Sherrod, U.S. Senator from Ohio......................     5
Begich, Hon. Mark, U.S. Senator from Alaska......................    53

                               WITNESSES

Hayes, Patricia M., Ph.D., Chief Consultant, Women Veterans 
  Health Strategic Health Care Group, U.S. Department of Veterans 
  Affairs; accompanied by Irene Trowell-Harris, M.Ed, Ed.D, 
  Director, Center for Women Veterans, U.S. Department of 
  Veterans Affairs...............................................     6
    Prepared statement...........................................     7
    Response to requests arising during the hearing by:
        Hon. Daniel K. Akaka.....................................    44
        Hon. Patty Murray........................................    51
        Hon. Mark Begich.....................................54, 58, 64
    Response to post-hearing questions submitted by:
        Hon. Daniel K. Akaka.....................................    65
        Hon. Richard Burr........................................    68
Williamson, Randall B., Director, Health Care Issues, Government 
  Accountability Office..........................................    12
    Prepared statement...........................................    14
Ilem, Joy, Deputy National Legislative Director, Disabled 
  American Veterans..............................................    70
    Prepared statement...........................................    71
Christopher, Tia, U.S. Navy Veteran; Women Veterans Coordinator, 
  Iraq Veteran, Project Associate, Swords to Plowshares..........    78
    Prepared statement...........................................    79
Chase, Genevieve, U.S. Army Reserve Veteran, Operation Enduring 
  Freedom, Afghanistan; Founder and Executive Director, American 
  Women Veterans.................................................    82
    Prepared statement...........................................    84
Williams, Kayla M., U.S. Army Veteran; Board of Directors, Grace 
  After Fire; Senior Adviser, VoteVets.org.......................    85
    Prepared statement...........................................    87
Olds, Jennifer, U.S. Army Veteran on behalf of Veterans of 
  Foreign Wars...................................................    89
    Prepared statement...........................................    91

                                APPENDIX

Veterans Health Administration, U.S. Department of Veterans 
  Affairs, Patient Satisfaction Scores by Gender Using CAHPS; 
  report.........................................................   103
Four, Marsha (Tansey), RN, Chair, Woman Veterans Committee, 
  Vietnam Veterans of America; prepared statement................   109
Bhagwati, Anuradha K., MPP, Executive Director, Service Women's 
  Action Network (SWAN); prepared statement......................   113

 
 VA HEALTH CARE SERVICES FOR WOMEN VETERANS: BRIDGING THE GAPS IN CARE

                              ----------                              


                         TUESDAY, JULY 14, 2009

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 9:33 A.M., in 
room 418, Russell Senate Office Building, Hon. Daniel K. Akaka, 
Chairman of the Committee, presiding.
    Present: Senators Akaka, Murray, Brown, Begich, Burris, and 
Burr.

     OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN, 
                    U.S. SENATOR FROM HAWAII

    Chairman Akaka. This hearing of the Senate Veterans' 
Affairs Committee will come to order.
    Aloha and good morning to all of you. Welcome to this 
important hearing on VA's Health Care Services for Women 
Veterans. We will be looking at programs already in the works 
to improve access to and the quality of care and other unique 
issues facing women veterans.
    Women veterans are the fastest-growing segment of veterans. 
In 1988, when VA first began providing care to women, they were 
only 4 percent of the veteran population. Today, the percentage 
of women veterans is nearing 8 percent and expected to rise 
substantially over the next two decades. So, it is appropriate 
that we ask now, ``Is VA meeting the needs of women veterans?''
    Many women veterans in need of services fall through the 
cracks because VA does not have a thoroughly gender-focused 
range of care set up to catch them. There are many obstacles 
that veterans face. Access to health care and homelessness are 
two, and many veterans--women veterans in particular--are 
struggling to get the services they deserve. For too long, the 
approach to helping veterans avoid obstacles through veteran 
benefits and services has been predominantly focused on men. 
Today, the Committee will review these issues and how they 
affect women veterans.
    While I applaud VA for the progress it has made in recent 
years to ramp up services for the rapidly growing number of 
women veterans, there is much still to be done to bridge the 
gaps in access to care that women veterans face compared to 
their male counterparts.
    I am pleased that the Committee, with the leadership of 
Senator Murray, recently approved legislation designed to 
enhance the understanding of women veterans' need for health 
care and to improve the delivery of that care. I hope to bring 
this legislation before the full Senate during this work 
period.
    Today's hearing gives us a chance to better understand the 
current situation with an eye toward fixing what is not working 
and expanding what is.
    And now I'd like to call on our Ranking Member for his 
opening statement.

        STATEMENT OF HON. RICHARD BURR, RANKING MEMBER, 
                U.S. SENATOR FROM NORTH CAROLINA

    Senator Burr. Mr. Chairman, thank you. I hope you're doing 
well this morning. Aloha.
    Chairman Akaka. Aloha.
    Senator Burr. Welcome to our witnesses.
    We're here to look at the advocacy of health care services 
VA provides to a growing number of individuals who have proudly 
worn the Nation's uniform: women veterans. The statistics do 
not lie. In 1990, there were 1.2 million women veterans. Today, 
there are 1.8 million, a number that continues to grow. In 
1990, women represented 4 percent of the veterans' population. 
Today, they represent 8 percent.
    North Carolina is no stranger to this growth. My State 
ranks sixth in the total number of women veterans, with just 
over 67,000 residing there. Fourteen percent of the active duty 
force is comprised of women, many of whom have served in combat 
or war zones. They fly combat aircraft, man missile placements, 
serve on ships in dangerous waters, drive convoys in areas at 
risk of ambush.
    In short, our military and our country are heavily 
dependent on the service of women. We must honor their service 
by ensuring VA health care systems meet their unique needs.
    As we move forward to do that, there is one more statistic 
that I would like to call to the attention of everyone--one 
that suggests we have some work to do. According to the VA 
budget submissions, in 2007, just over 146,000 women veterans 
used gender-specific health care services at the Veterans 
Administration.
    In 2008, despite the growing number of women veterans that 
I talked about, there were over 141,000 users of the system, a 
decline of 3 percent from just 1 year ago.
    The question this Committee must ask is why? Why do women 
veterans feel uncomfortable coming to a hospital system largely 
comprised of male patients, or do they? Does the VA provide the 
unique services required by women veterans? Does it provide 
these services in enough locations to make travel convenient?
    When VA cannot provide quality care, does it use services 
that already exist in the community that are specific to the 
needs of women? These are all questions that I am hopeful our 
panelists will help us find the answers to.
    Mr. Chairman, just across the Potomac River stands the 
Women in Military Service for America Memorial. The memorial 
serves as the ceremonial entrance of Arlington National 
Cemetery. I think its placement at the front gate of American's 
most hallowed military cemetery is symbolic.
    For many years, the service of military women often went 
overlooked and unheralded. We now know better. As Former 
Senator Bob Dole said at its dedication 12 years ago, the 
memorial serves as ``a lens through which we can better see and 
appreciate the dedication and sacrifice of American service 
women.''
    I look forward to hearing from our witnesses today, and I 
hope that this will serve as a lens through which this 
Committee can see where improvements need to be made for women 
who have served their country and their military.
    I thank you, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Burr.
    Now I'd like to call on Senator Burris for his opening 
statement.

              STATEMENT OF HON. ROLAND W. BURRIS, 
                   U.S. SENATOR FROM ILLINOIS

    Senator Burris. Thank you very much, Mr. Chairman, Ranking 
Member Burr.
    Unfortunately, Members, I am scheduled to preside over the 
Senate in just a few moments. But, before I go, I would like to 
recognize the importance of this hearing.
    As someone who has fought for the quality and diversity 
throughout my career, I believe this hearing is long overdue. 
Too often the role of women in military has been misunderstood; 
their accomplishments and needs overlooked.
    In the VA health system, women's status as a minority has 
lead to disjointed, gender-specific care that can be difficult 
to access and hard to navigate. There is no reason why a woman 
seeking basic, primary care should have to go to two or three 
different providers in order to meet their needs.
    Women make up the largest-growing segment of the veterans' 
population, which is all the more reason for us to move forward 
toward integrated services, including mental health providers 
that recognize the unique needs of women, such as military 
sexual trauma.
    I commend the work of the VA thus far at addressing these 
issues. Tremendous progress has been made, but I am concerned 
that only one-third of the Veterans' health facilities provide 
for the one-stop shop approach, an approach which shows the 
highest level of patient satisfaction. All of our female 
veterans deserve the highest quality of care, and we must work 
toward that day when every VA facility is fully equipped to 
address these needs.
    Mr. Chairman, I recall a presentation on the floor by 
Senator Kay Bailey Hutchison from Texas about these women who 
were in the Air Force in World War II--and there are a few of 
them still around--and what the trauma was from Senator 
Hutchison's presentation, which she was trying to get 
resolution.
    I became a cosponsor, so I really want to know just where 
that is because women flew those missions while the men were 
fighting the wars. They flew the supply missions on those 
airplanes, and they paid their way to Texas. Then, when they 
were discharged--unbelievably, as Senator Hutchison said--they 
had to pay their way back home. Some of these women are still 
alive. And after hearing that speech, I told her to put me on 
that bill as a cosponsor, because we have to recognize those 
women, the same way we recognize the Tuskegee Airmen for their 
dedicated service to this country.
    So, I am going to still try to follow-up on that, Mr. 
Chairman, find out what is really happening to that resolution 
that Senator Hutchison presented to the Senate because we need 
to recognize those women that are still alive and give respect 
to those who passed on for their service to this country.
    Thank you, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Burris.
    And now we'll hear from Senator Murray with an opening 
statement.

                STATEMENT OF HON. PATTY MURRAY, 
                  U.S. SENATOR FROM WASHINGTON

    Senator Murray. Thank you very much, Chairman Akaka and 
Senator Burr for holding today's hearing to have a chance to 
really examine the status of the VA's health care services to 
women veterans. I want to thank today's witnesses for all of 
their hard work to both improve the level of care provided to 
women veterans and to increase the public awareness of this 
important issue, as well.
    As has been said very well by my colleagues here, since the 
founding of our Nation, women have always played a role in our 
military, and that role, of course, has changed over time. In 
today's conflicts, women are playing a far different and far 
greater role. And, while they have historically remained as a 
very small portion of the veteran population and a small 
minority at the VA, women veterans now total about 1.8 million, 
and they make up nearly 8 percent of the total veteran 
population in the United States.
    That percentage, we all know, is expected to increase more 
than 14 percent by 2033, and the number of women veterans 
enrolled in the VA System is expected to double in the next 2 
to 4 years. That makes female veterans one of the fastest 
growing demographics of the veterans today, and I think it is 
really important at this hearing and always that we remember 
that behind those statistics are real women. These are women 
who sacrificed for their country, they have borne the burden of 
battle, and they now deserve the respect and the benefits that 
their service has earned.
    Earlier this year, as has been referenced, the Committee 
passed my bill, the Women Veterans Health Care Improvements Act 
of 2009. More recently, the full House has passed similar 
legislation. I think this is very important progress. I hope we 
can pass this out of the Senate soon because that bill will 
encourage women to access the VA, increase the VA's 
understanding of the needs of women veterans and, really, the 
practices that helped them get the best kind of care.
    But we cannot stop there and we are not stopping there. I 
know that the VA is recognizing the need to improve services to 
women veterans and are taking steps to ensure equal access to 
benefits and health care for them.
    So, I look forward to today's hearing for the steps the VA 
is taking and what else we need to be doing to achieve that 
goal.
    I would say to Senator Burris, I believe that the bill that 
Senator Hutchison was talking about was a Congressional Gold 
Medal that has been sent to committee. I appreciate you 
bringing that up and hope that it can move forward.
    Senator Burris. Mr. Chairman, my staff said the resolution 
was approved, but we need to get the Gold Medal part for the 
women. So, that is what is pending. That is correct, for the 
record.
    Thank you very much, Senator Murray. We must do that.
    Chairman Akaka. Thank you very much, Senator Murray.
    I want to welcome our principal witness from VA, Dr. 
Patricia Hayes, Chief Consultant of the Women Veterans Health 
Strategic Health Care Group. She is accompanied by Dr. Irene 
Trowell-Harris, Director of the VA Center for Woman Veterans.
    Following Dr. Hayes, we have GAO's Director of Health Care 
Issues, Mr. Randall Williamson.
    Thank you, all, for being here this morning. Both VA and 
GAO's full testimony will appear in the record.
    Before I call on Dr. Hayes for her testimony, I call on 
Senator Brown for an opening statement.

               STATEMENT OF HON. SHERROD BROWN, 
                     U.S. SENATOR FROM OHIO

    Senator Brown. Yes. Thank you, Mr. Chairman. I appreciate 
that. I appreciate the work that Senator Murray has done in the 
Women Veterans Health Care Improvement Act of 2009; and thank 
you, Mr. Chairman, for holding this meeting.
    I wanted to mentioned briefly, we know what the issue is, 
we know how important it is that there be more parity--if that 
is the right word--more equality in everything from the big VA 
Centers to the CBOCs to veterans' health care generally, but I 
wanted to tell a real quick story.
    A woman by the name of Loretta Schimmoler of Crawford 
County, Ohio--a rural county halfway between Columbus and 
Cleveland--was one of the first woman to be inducted in the 
Ohio Veterans Hall of Fame, helped to lead the way in what was 
to become the Flight Nurses Corps. Her story mirrors in many 
ways what women have faced in the military dealing with VA 
care.
    She was a dedicated patriot, intent on making our Nation 
and our military better. Despite the hurdles she faced, she was 
able to change the way our military did business to the 
betterment of all those who served. She began flying in 1932 
for her service. At that time, nurses, of course, were almost 
exclusively women, and would serve on planes and helicopters 
that provided care and evacuation to wounded servicemembers. It 
was not until World War II that the program became a reality, 
due in large part to her persistence and her vision.
    The VA of her day, of Loretta Schimmoler's day, looked a 
lot different from the Department of Veterans Affairs today in 
meeting the needs of our women veterans, but much more needs to 
be done.
    This hearing is a major step in doing that.
    I thank the Chairman and thank Senator Murray for her work.
    Chairman Akaka. Thank you very much, Senator Brown.
    Again, let me call on Dr. Hayes and ask for your testimony.

  STATEMENT OF PATRICIA HAYES, PH.D., CHIEF CONSULTANT, WOMEN 
  VETERANS HEALTH STRATEGIC HEALTH CARE GROUP; ACCOMPANIED BY 
 IRENE TROWELL-HARRIS, M.ED, ED.D, DIRECTOR, CENTER FOR WOMEN 
         VETERANS, U.S. DEPARTMENT OF VETERANS AFFAIRS

    Ms. Hayes. Good morning, Mr. Chairman and Ranking Member. 
Thank you very much for the opportunity to discuss how VA has 
provided and will continue to improve the health care for women 
veterans.
    As you mentioned, I am accompanied by Dr. Irene Trowell-
Harris, the Director of the Center for Women Veterans. Thank 
you for submitting my written testimony into the record.
    I also want to thank you, Chairman Akaka and Senator Murray 
specifically, again for your interest in working with VA to 
ensure that the quality of care for women veterans is improved 
and that they do get what they deserve for service to their 
country.
    Secretary Shinseki recently testified before this Committee 
that enhancing the primary care for women veterans is one of 
VA's top priorities. Women who were deployed and served in the 
recent conflicts in Afghanistan and Iraq are enrolling in VA at 
record numbers.
    Of all the women veterans who are deployed and served in 
Afghanistan or Iraq, VA knows that 44 percent have enrolled in 
VA health care, which suggests that many of these newly-
enrolled women veterans really rely on VA for their health care 
needs.
    Women veterans are entering VA's health care system 
younger, and they have health care needs distinct from their 
male counterparts. The average age of women veterans is 48-
years-old compared to 61-years-old among men. Nearly all newly-
enrolled women veterans are under age 40 and they are of 
childbearing age. This obviously means a trend that will create 
a shift in how we provide their care.
    This shift will move primary care and gender-specific care 
needs of women veterans from the multi-visit, multi-provider 
model that has been mentioned here--which does not achieve the 
continuity of care that we desire--to a more comprehensive, 
primary care delivery model. VA recognizes many current 
challenges and has initiated new programs, including the 
implementation of comprehensive primary care, enhancing the 
health care environment for women veterans, creating a mini 
residency education program among women's health, staffing 
every VA Medical Center with a Women Veterans Program Manager, 
and improving communication and outreach to women veterans.
    Most importantly, VA is implementing an innovative approach 
to women's health care that will address the concerns about 
fragmented care, quality disparities, and lack of provider 
proficiency in women's health by fundamentally changing the 
experience for women veterans in VA.
    To achieve the goal of providing comprehensive primary 
care, we have designed three models to promote the delivery of 
optimal primary care, and we recognize that more than one model 
might be needed even within various facilities in order to meet 
the needs to deliver comprehensive care to women veterans.
    All three models ensure that every women veteran, wherever 
she comes to VA, has access to a VA primary care provider who 
is capable of meeting all of her primary care needs in the one-
stop shop model that we have described. A site-level evaluation 
will also begin so that we can be certain that this program is 
effective. We are going to start that in fiscal year 2010.
    All women veterans need to feel welcomed in their VA 
setting. The health care environment directly and indirectly 
affects the quality of the care that is provided to women 
veterans, and a part of redefining our comprehensive care to be 
delivered means that we have to have improvements in the health 
care environment which are being made in order to support 
dignity, privacy, and sense of security.
    VA recognizes many primary care providers need to update 
their women-specific clinical experience. VA is offering many 
residencies in women's health across the country. Early results 
from this program indicate success in increasing competencies 
in 12 areas of women's health care.
    As of June 2009, 216 participants from 90 VA medical 
centers and 28 community-based outpatient clinics have 
completed the program. In order to ensure improved advocacy at 
the facility level, VA has mandated that all medical centers 
appoint a full-time Women Veterans Program Manager. These 
managers support increased outreach to women veterans, improve 
the quality of care, and develop best practices in the 
organizational delivery of women's health care.
    Effective internal and external communication is also 
important in terms of outreach and our success of implementing 
comprehensive care. VA Center for Women Veterans will continue 
to expand its ongoing outreach and communications plan to 
ensure not only public awareness of women veterans' service to 
our country, but making sure that women veterans are aware of 
their eligibilities and access to VA health care.
    Mr. Chairman, VA's commitment to women veterans is 
unwavering, and while significant efforts are underway, we know 
that we have to do a lot more to improve the care. A lot more 
needs to be done. We stand at a really unique moment in time 
where our actions and plans today will build this system that 
will provide equal care for all of American veterans regardless 
of gender.
    Thank you once again for this opportunity to testify, and 
we now are very prepared to answer any addition questions that 
you may have of us.
    [The prepared statement of Ms. Hayes follows:]
 Prepared Statement of Patricia Hayes, Ph.D., Chief Consultant, Women 
     Veterans Health Strategic Health Care Group, Veterans Health 
             Administration, Department of Veterans Affairs
    Good morning, Mr. Chairman and Ranking Member. Thank you for the 
opportunity to discuss how the Department of Veterans Affairs (VA) has 
provided, and will continue to improve, health care availability for 
women Veterans. I would like to thank the Chair, this Committee and 
Senator Murray specifically for your interest in working with VA to 
ensure women Veterans receive the care they have earned through service 
to their country.
    The Secretary has recently testified before this Committee that 
enhancing primary care for women Veterans is one of VA's top 
priorities. VA recognizes that the number of women Veterans is growing 
with women becoming increasingly dependent on VA for their health care. 
Of the 1.8 million women Veterans in the United States more than 
450,000 have enrolled for care. This number is expected to grow by 30 
percent in the next 5 years. Women currently comprise approximately 14 
percent of the active duty military, 17.6 percent of Guard and Reserves 
and 5.9 percent of VA health care users.
    Women who were deployed and served in the recent conflicts in 
Afghanistan and Iraq are enrolling in VA at historical rates. Of all 
women who were deployed and served in Afghanistan or Iraq, 44 percent 
have enrolled and 43 percent have used VA between 2 and 11 times. This 
suggests that many of our newer women Veterans rely more heavily on VA 
to meet their health care needs.
    My testimony will describe how VA plans to continue to enhance the 
delivery of high quality health care to this fastest growing cohort of 
Veterans and ensure today's heroes and tomorrow's Veterans receive the 
care they need. Women Veterans served; they deserve the best care 
anywhere.
                           current challenges
    Women Veterans entering VA's system are younger and have health 
care needs distinct from their male counterparts. The average age of 
women Veterans is 48 years old, compared to 61 years old among men. 
Nearly all newly enrolled women Veterans accessing VA care are under 40 
and of childbearing age. This trend creates a need to shift how we 
provide health care.
    General primary care and gender-specific care needs of women 
Veterans are currently provided through a multi-visit, multi-provider 
model that may not achieve the continuity of care desired. 
Additionally, some VA facilities rely on outside providers for gender- 
specific primary care and specialty gynecological care through the use 
of fee-basis care. This approach to women's health delivery can provide 
challenges in providing continuity of care.
    Moving to a more comprehensive primary care delivery model could 
challenge VA clinicians, who may have dealt predominately with male 
Veterans and sometimes have little or no exposure to female patients. 
VA facilities may also need to increase both focus and resources on 
women's health (e.g., space, staffing, appropriately equipped exam 
rooms) to ensure adequate privacy for women during examinations. 
Initiatives are underway and under development to address these and 
other changes brought on by the increasing number of women Veterans 
seeking care from VA.
    The quality of health care VA provides to women Veteran's exceeds 
the care many would receive in other settings (including commercially 
managed care systems, Medicare and Medicaid). For example, VA's system 
of quality management and preventive patient care, supported by 
technology like our electronic health record and clinical reminders, 
ensures women are screened for unique health concerns like cervical 
cancer or breast cancer at higher rates than non-VA health care 
programs. On the other hand, VA is aware of existing disparities 
between male and female Veterans in our system. The Department is 
particularly concerned with performance measures related to 
cardiovascular disease, the leading cause of death in women. 
Performance scores for several quality measures, including high blood 
pressure, high cholesterol and diabetes, all of which contribute to 
cardiovascular disease risk, show a consistent difference between men 
and women Veterans. Gender-neutral prevention measures such as colon 
cancer screening, depression screening and immunizations show a 
disparity between men and women Veterans as well. For example, although 
VA significantly outperforms Medicare on colorectal cancer screening, 
only 75 percent of women Veterans are screened compared with 83 percent 
of male Veterans. These issues and other quality issues are being 
addressed.
    Some women report that lack of newborn care and child care forces 
them to seek care elsewhere. VA recently supported section 309 of 
S. 252, which would authorize VA to furnish health care services up to 
7 days after birth to a newborn child of a female Veteran who is 
receiving maternity care furnished by VA if the Veteran delivered the 
child in a VA health care facility or in another facility pursuant to a 
contract for service related to such delivery. We similarly supported a 
companion measure in the House. We believe benefits such as these will 
help improve women Veterans' perception that VA welcomes them and will 
provide complete, effective and compassionate care.
                          current initiatives
    VA recognizes the need to continually improve our services to women 
Veterans, and has initiated new programs including the implementation 
of comprehensive primary care throughout the Nation, enhancing mental 
health for women Veterans, staffing every VA medical center with a 
women Veterans program manager, creating a mini-residency education 
program on women's health for primary care physicians, supporting a 
multifaceted research program on women's health, improving 
communication and outreach to women Veterans, and continuing the 
operation of organizations like the Center for Women Veterans and the 
Women Veterans Health Strategic Healthcare Group.
Comprehensive Primary Care for Women Veterans
    VA is implementing an innovative approach to women's health care 
that seeks to reduce the possibilities of fragmented care, quality 
disparities, and lack of provider proficiency in women's health by 
fundamentally changing the experience of women Veterans in VA.
    In March 2008, the former Under Secretary for Health charged a 
workgroup to define necessary actions for ensuring every woman Veteran 
has access to a VA primary care provider capable of meeting all her 
primary care needs, including gender-specific and mental health care, 
in the context of a continuous patient-clinician relationship. This new 
definition places a strong emphasis on improved coordination of care 
for women Veterans, continuity, and patient-centeredness. In November 
2008, the workgroup released its final report identifying 
recommendations for delivering comprehensive primary care. These 
recommendations included: (1) delivering coordinated, comprehensive 
primary women's health care at every VA health care facility by 
recognizing best practices and developing systems and structure for 
care delivery appropriate to women Veterans; (2) integrating women's 
mental health care as part of primary care, including co-locating 
mental health providers; (3) promoting and incentivizing innovation in 
care delivery by supporting local best practices; (4) cultivating and 
enhancing capabilities of all VA staff to meet the comprehensive health 
care needs of women Veterans; and (5) achieving gender equity in the 
provision of clinical care.
    To implement these goals and recommendations, the Women Veterans 
Health Strategic Health Care Group developed a women's comprehensive 
health implementation planning (WCHIP) tool to assist facilities in 
analyzing its own current health care delivery for women Veterans and 
plans for primary care delivery enhancement. Every VA health care 
facility was requested to convene a multidisciplinary planning and 
implementation team to address comprehensive primary care for women 
Veterans. The WCHIP tool outlines an analysis of current services and 
projected use, a market analysis and a needs assessment, which 
facilitated the development of a business plan. This plan includes 
resource needs, goals, timelines, budgets, training needs and program 
evaluation metrics to deliver comprehensive health care to women 
Veterans. No later than August 1, 2009, facilities will finalize their 
analyses and action plans based on the WCHIP tool. These plans will be 
instrumental in decisions for directing resources for fiscal 2010 and 
2011.
    To achieve the goal of providing comprehensive primary care for 
women Veterans, VA has designed three models to promote the delivery of 
optimal primary care. Under the first model, women Veterans are seen 
within a gender neutral primary care clinic. Under the second model, 
women Veterans are seen in a separate but shared space that may be 
located within or adjacent to a primary care clinic. Under the third 
model, women Veterans are seen in an exclusive separate space with a 
separate entrance into the clinical area and a distinct waiting room. 
In this scenario, gynecological, mental health and social work services 
are co-located in this space. Each of these models can be tailored to 
local needs and conditions to systemize the coordination, continuity, 
and integration of women Veterans' care. One-third of VA facilities 
have already adopted the third model of comprehensive primary care 
delivery and found it to be very effective. Access and wait times are 
better at sites where gender-specific services are available in an 
integrated women's primary care setting, regardless of whether the care 
was delivered in a separate space (such as a women's clinic) or 
incorporated within general primary care clinics. VA facilities that 
have established a ``one-stop'' approach to primary care delivery have 
already reported higher patient satisfaction on care coordination for 
contraception, sexually transmitted disease screening, and menopausal 
management.
    In addition to improving the primary care infrastructure for women 
Veterans, VA is committed to advancing the entire range of emergency, 
acute, and chronic health care services needed by women Veterans to 
develop an optimal continuum of health care. Such a continuum of health 
care includes: enhancing and integrating mental health care, medical 
and surgical specialty care, health promotion and disease prevention, 
diagnostic services and rehabilitation for catastrophic injuries.
Enhancing Mental Health
    VA has identified that 37 percent of women Veterans who use VA 
health care have a mental health diagnosis; these rates are higher than 
those of male Veterans. Women Veterans also present with complex mental 
health needs, including depression, post- traumatic stress disorder 
(PTSD), military sexual trauma (MST), and parenting and family issues.
    In response, VA has instituted policy requirements, such as that 
outlined in its Handbook on Uniform Mental Health Services in VA 
medical centers and Clinics, to emphasize the importance of being aware 
of gender-specific issues when providing mental health care. In 
particular, the Handbook identifies services every health care facility 
must have available for women Veterans to ensure integrated mental 
health services as a part of comprehensive primary care for women 
Veterans. For example, the services provided optimally involve a 
designated, co-located, collaborative provider (psychologist, social 
worker, or psychiatrist) and care management with an emphasis on the 
need for safety, privacy, dignity, and respect to characterize all 
gender-specific services provided. Facilities are strongly encouraged 
to give patients treated for other mental health conditions the option 
of a consultation from a same-sex provider regarding gender-specific 
issues. All inpatient and residential care facilities must provide 
separate and secured sleeping accommodations for women. Every VA 
facility has a designated MST coordinator who serves as a contact 
person for related issues. VA is ensuring a concerted effort to provide 
quality mental health care appropriate to the needs of women Veterans.
Women Veterans Program Managers
    In order to ensure improved advocacy for women Veterans at the 
facility level, VA has mandated all VA medical centers appoint a full-
time Women Veterans Program Manager. These Women Veterans Program 
Managers support increased outreach to women Veterans, improve quality 
of care provision, and develop best practices in organizational 
delivery of women's health care. They serve as advisors to facility 
directors in identifying and expanding the availability and access of 
inpatient and outpatient services for women Veterans and provide 
counseling on a range of gender- specific care issues. Women Veterans 
Program Managers also coordinate and provide appropriate local outreach 
initiatives to women Veterans. As of June 2009, each of VA's 144 health 
care systems has appointed a full-time Women Veterans Program Manager.
Mini-Residency Training in Women's Health
    As the number of women Veterans continues to grow, particularly 
women of childbearing age, VA recognizes many primary care providers 
need to update their women-specific clinical experience. VA is offering 
waves of mini-residencies in women's health across the country in 
strategic geographic locations. Each mini- residency lasts two and a 
half days and is taught by national women's health experts. Clinical 
staff receive presentations on contraception, cervical cancer screening 
and sexually transmitted infections, abnormal uterine bleeding, chronic 
abdominal and pelvic pain, post-deployment readjustment issues for 
women Veterans, and other womens' health topics. Early results from 
this program indicate its success in increasing competencies in 12 
areas of women's health care. As of June 2009, 216 participants (119 
physicians, 77 nurse practitioners, 10 physician assistants, 9 
registered nurses and 1 therapist) from 90 VA medical centers and 28 
community-based outpatient clinics have either scheduled or completed 
this program.
Research on Women Veteran's Health Issues
    VA has clearly established women's health as a research priority 
and intensified its efforts in the last decade. Currently, VA's Office 
of Research and Development supports a broad research portfolio focused 
on women's health issues, including studies on diseases prevalent 
solely or predominantly in women, hormonal effects on diseases in post-
menopausal women, and health needs and health care of women Veterans. 
VA's Office of Health Services Research and Development is funding 27 
research projects in this area. VA is also conducting a study that will 
survey 3,500 women Veterans (both those who use VA health care and 
those who do not) to identify the changing health care needs of women 
Veterans and to understand the barriers they face in using VA health 
care. We anticipate receiving the results of this study within the next 
several months, and we will share these findings with the Committee. VA 
is also conducting risk assessments to track the effects of deployments 
on women Veterans and improve our epidemiological data on Operation 
Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) women Veterans 
through the National Health Study for a New Generation of U.S. Veterans 
(an OEF/OIF cohort study). We are enrolling 60,000 Veterans for this 
study--of these 12,000 are women.
Outreach Initiatives
    Effective internal and external communication and outreach to women 
Veterans is critical to the success of implementing comprehensive care. 
Surveys and research show that women Veterans are often not aware of 
the services and benefits available to them. VA is engaging in multiple 
efforts to correct this. For example, VA's Center for Women Veterans 
and the Women Veterans Health Strategic Health Care Group will continue 
to expand its ongoing outreach and communications plan to ensure 
increased public awareness of women Veterans and their service to our 
country and increased awareness by women Veterans of VA health care.
Center for Women Veterans
    The Center's mission is to ensure that women Veterans have access 
to VA benefits and services on par with male Veterans; that VA programs 
are responsive to the gender- specific needs of women Veterans; that 
joint outreach is performed to improve women Veterans' awareness of VA 
services, benefits, and eligibility criteria; and that women Veterans 
are treated with dignity and respect. The Center coordinates and 
collaborates with Federal, State and local agencies, Veterans service 
organizations and community- based organizations.
Women Veterans Health Strategic Healthcare Group
    VA has developed a women Veterans health care ``brand'' within VA 
and among women Veterans. VA has made available upgraded communication 
resources, processes, and tools to Veterans Integrated Service Networks 
(VISN) and facilities. VA is building on the OEF/OIF call center to 
reach out to women Veterans. New scripts, new outreach materials and 
training are being developed to ensure women Veterans are aware of VA's 
services and benefits. While these efforts have created an important 
foundation upon which to build, it will take sustained and coordinated 
planning to successfully reach out to women Veterans.
                              future plans
    While significant efforts are underway, we recognize that more must 
be done. VA must provide recurring funds to build adequate 
infrastructure for primary care and expand services to provide a full 
continuum of care for women Veterans at its secondary and tertiary care 
facilities. This investment of resources will contribute to the 
continuing goal of delivering quality health care focused on privacy, 
safety, sensitivity, dignity and continuity.
Expanding Access to Gynecology
    Gynecologists are indispensable in providing care for women with 
abnormal findings on pelvic exams, such as abnormal pap smears, 
complicated cases of pelvic pain and abnormal vaginal bleeding in 
addition to specialized services in urology-gynecology, gynecology-
oncology and obstetrics care. As VA primary care physicians increase 
their proficiency in women's health care to meet the needs of the 
growing numbers of women Veterans, primary care physicians will need to 
have on-site gynecologists available to act as experts, consultants and 
teachers. VA plans to have a gynecologist available at each of VA's 144 
health care systems by 2012.
Expanding Innovative Technology
    In the area of innovative technologies, VA is expanding its efforts 
to dramatically transform and improve care for women Veterans by 
enhancing its electronic health records system to provide more 
functionality related to women's health, including clinical reminders, 
pharmacy alerts for teratogenic drugs, improved decision support, 
gender-specific health history and screening questionnaires, e-videos 
and other tools for shared decisionmaking, particularly with regard to 
preference-sensitive health care choices (e.g., breast cancer surgery 
and treatments).
                               conclusion
    Mr. Chairman, VA's commitment to women Veterans is unwavering. We 
stand now at a unique moment in time where our actions and plans today 
will build the system that will provide care equal to the health care 
needs of all of America's Veterans, regardless of gender. Thank you 
once again for the opportunity to testify. My colleagues and I are 
prepared to address any additional questions you might have.

    Chairman Akaka. Thank you very much, Dr. Hayes.
    Mr. Williamson, we will now begin with your testimony.

  STATEMENT OF RANDALL B. WILLIAMSON, DIRECTOR OF HEALTH CARE 
            ISSUES, GOVERNMENT ACCOUNTABILITY OFFICE

    Mr. Williamson. Good morning, Mr. Chairman and Members of 
the Committee. I am pleased to be here today as the Committee 
considers issues related to VA's health delivery of service to 
women veterans.
    VA provided health services to over 281,000 women veterans 
in fiscal year 2008, an increase of 12 percent in just 2 years. 
Looking ahead, VA estimates that, while a total number of 
veterans will decline by 37 percent by the year 2033, the 
number of women veterans will increase by more than 17 percent 
over that period; thereby putting greater demands on VA's 
health care system to meet the physical and mental health care 
needs of women veterans.
    Women veterans seeking care at VA medical facilities need 
access to a full range of physical health care services 
including: basic gender-specific services, such as cervical 
cancer screening and clinical breast examinations; specialized 
gender-specific services such as obstetric care and treatment 
of reproductive cancers; and mental health care services, such 
as care for depression and anxiety.
    In addition, women veterans from conflicts in Iraq and 
Afghanistan present new challenges for VA's health care system. 
These women have experienced a greater exposure to combat than 
women participating in previous conflicts. VA data showed that 
as many as 20 percent of women veterans of Iraq and Afghanistan 
have been diagnosed with Post Traumatic Stress Disorder. An 
alarming number have also experienced sexual trauma while in 
the military. As a result, many have complex physical and 
mental health care needs.
    In my testimony today, which is based on ongoing work for 
the Committee, I will discuss three aspects based largely on 
the work we did at 19 VA medical facilities.
    First, the onsite availability of health care services for 
women veterans at VA facilities. Second, the extent to which VA 
facilities are following VA policies for delivering health care 
service for women veterans. And, third, some key challenges 
that VA facilities face in providing women's health care.
    Dr. Hayes has outlined a number of steps VA is undertaking 
to fulfill its commitment to provide high-quality health care 
services for women veterans. VA has taken some bold steps in 
this regard. However, much remains to be done in some areas to 
fully implement the new initiatives.
    Regarding the availability of services, we found that basic 
gender-specific services, including pelvic and clinic breast 
examinations, were available onsite at all 9 VAMCs and 8 of the 
10 CBOCs we visited. All of the VAMCs that we visited offered 
at least some other specialized gender-specific services, such 
as treatment for abnormal cervical screening test and breast 
cancer.
    Among the CBOCs, the two largest facilities we visited 
offered an array of specialized, gender-specific care onsite. 
The other eight referred women to other VA and non-VA 
facilities for most of these services. Outpatient mental health 
care services for women varied widely among the VAMCs and the 
eight Vet Centers we visits, but were more limited at some of 
the CBOCs.
    Four CBOCs offered women-only counseling groups, and only 
the two larger CBOCs offered specific programs for women who 
had experienced sexual trauma in the military. Also, only two 
VAMCs offered residential treatment programs for women who 
experienced sexual trauma. None had dedicated inpatient 
psychiatric units for women.
    Regarding the extent to which VA facilities are following 
VA policies for delivering health care services for women 
veterans, we found that none of the VAMCs and CBOCs we visited 
was fully compliant with VA policy requirements related to 
privacy for women veterans in all clinical settings where those 
requirements applied.
    For example, many of the outpatient clinics we visited did 
not have adequate visual and auditory privacy in their check-in 
areas. Further, the facilities we visited were in various 
stages of implementing VA's new initiative to provide 
comprehensive primary care for women veterans.
    Finally, officials at facilities that we visited identified 
challenges they face in providing health care services to the 
increasing numbers of women seeking VA health care. One 
challenge involves space constraints.
    For example, the number, size, and configuration of exam 
rooms, as well as limited space for women's bathrooms, 
sometimes made it difficult for facilities to comply with VA's 
privacy requirements.
    Officials also reported challenges in hiring providers with 
specific training and experience in women's health care issues, 
including treatment for women veterans with Post Traumatic 
Stress Disorder and those who had experienced military sexual 
trauma.
    So, overall, Mr. Chairman, while VA has taken important 
steps in many areas to improve health care services for women 
veterans, some areas still require attention.
    Mr. Chairman, that concludes my remarks.
    [The prepared statement of Mr. Williamson follows:] 
    
    
    

    Chairman Akaka. Thank you very much, Mr. Williamson.
    Dr. Hayes, thank you for your testimony.
    VA is poised to make some important changes to how care is 
delivered to women, but, in fairness, we seem to have a bit of 
a disconnect between mandates and what is actually happening. I 
am going to ask you a series of questions about this.
    First, VA has mandated that all VA medical centers appoint 
a full-time Women Veterans Program Manager.
    Does every VA medical center have one in place?
    Ms. Hayes. VA has reported, as you know, that there are 144 
out of the 144 sites that have a full-time Women Veterans 
Program Manager. I am actively now in the process of verifying 
that.
    What we do know is that my office, over the last 3 months, 
has held three different trainings. We trained 142 Women 
Veterans Program Managers over the last 3 months. We think it 
is very important to train folks--to take these brand-new folks 
and make sure that they know what they are doing--in terms of 
this plan to develop health care for women.
    Chairman Akaka. Dr. Hayes, hopefully, you have read the 
testimony of the second panel.
    Jennifer Olds details her battle with PTSD and specifically 
makes a case for cognitive therapy. Congress passed a law last 
year requiring that these state-of-the-art therapies be 
available to all veterans.
    I suppose this is something you need to take for the 
record, but are all veterans with PTSD able to receive this 
kind of treatment?
    Ms. Hayes. You're right, Mr. Chairman, I will have to take 
that specifically for the record in terms of the issues about 
access to PTSD treatment. But I think that one of the things 
that was pointed out in the GAO report about where there is 
access, it is very important that we first ask veterans what 
they need, and that is why it is important to hear from 
veterans about what their struggles are and, I think, to make 
sure that we are addressing what that veteran needs in terms of 
her care.
    So, for example, there has been a lot of question about 
residential treatment. I think when we look at women veterans, 
we have to be aware that, for example, women with children are 
not necessarily interested in going off, leaving their 
children, and going to a residential site. So that every time 
we look at what we have available, we have to make sure we have 
available for each veteran what she might need, whether it is 
intensive outpatient, residential, or telehealth-telemedicine. 
Some of our veterans have rated that as very highly successful 
for them to be in that type of treatment.
    So, we will take the question for the record in terms of 
the exact issue of where PTSD treatment is available, but I 
think that it needs to be a constant issue of asking the 
veteran what they need, and that particular issue for Ms. Olds, 
I think, is very important.
    Chairman Akaka. Thank you.
    [The response to additional information requested during 
the hearing follows:]
Response to Request Arising During the Hearing by Hon. Daniel K. Akaka 
   to Patricia Hayes, Ph.D., Chief Consultant, Women Veterans Health 
    Strategic Health Care Group, U.S. Department of Veterans Affairs
    The Department of Veterans Affairs (VA) is strongly committed to 
making evidence-based psychotherapies for Post Traumatic Stress 
Disorder (PTSD) widely available to Veterans. VA is in the process of 
actively disseminating Cognitive Processing Therapy (CPT) and Prolonged 
Exposure Therapy (PE), two specialized forms of Cognitive-Behavioral 
Therapy for PTSD. CPT and PE are recommended in the VA/Department of 
Defense (DOD) Clinical Practice Guidelines for PTSD stating that the 
intervention is always indicated and acceptable. Moreover, in 2008, the 
Institute of Medicine conducted a review of the literature of 
pharmacological and psychological treatments for PTSD and concluded in 
its report, Treatment of Post Traumatic Stress Disorder: An Assessment 
of the Evidence, that the evidence was greater for these treatments 
than for all other currently available treatments for PTSD.
    To date, 1,908 Veterans Health Administration staff have received 
training in CPT. The majority of these clinicians were trained as part 
of the national CPT rollout, with some staff also receiving training 
through similar, locally arranged training. In addition, 722 DOD 
clinicians have received CPT training through the national rollout or 
locally arranged VA training. Seven hundred and twenty-eight VHA 
providers have received training in PE, with the majority of staff 
being trained as part of the national PE rollout. One hundred and 
twenty-nine DOD clinicians have received PE training through the 
national rollout or other similar VA training. Additionally, VA is 
planning training in CPT and PE for the remainder of this Fiscal Year 
and beyond. Currently, 94 percent of VA medical centers provide CPT or 
PE; remaining sites are implementing plans to provide at least one of 
these therapies. Moreover, to promote the implementation and ongoing 
delivery of evidence-based psychotherapies for PTSD and other mental 
disorders, VA has designated a Local Evidence-Based Psychotherapy 
Coordinator at each medical center.

    Chairman Akaka. Mr. Williamson, your testimony lays out 
that none of the facilities reviewed fully implemented VA's 
policies for women's health care.
    Could you determine the reasons behind this noncompliance? 
Was it funding, lack of training, or anything else?
    Mr. Williamson. Thank you, Mr. Chairman.
    It is very difficult sometimes to understand the reason.
    The area you referred, for example, in assuring privacy of 
women veterans, part of it is due to facilities in terms of the 
layout that currently exists and is trying to convert and 
modify that. But, also, I think part of it comes down to 
commitment at the local level.
    There is no doubt that the Secretary, Dr. Hayes, and others 
at the top are very committed to implementing VA policies and 
improving overall health care for women. Yet, as we visited the 
facilities, simple things that are easy to do like placing exam 
tables so the foot is away from the door, putting sanitary 
products in bathrooms for women--those things are easy--and if 
they're not being done, part of that reason may come back to is 
there a commitment at the local level to make sure these 
policies are done?
    Chairman Akaka. Several witnesses on the second panel are 
quite critical of VA care for women. Let us take these one by 
one.
    DAV is most concerned that some service-connected women 
veterans are without access to VA health care.
    Ms. Williams detailed a lack of understanding on the part 
of VA providers.
    Ms. Christopher found that community care is easier to 
access than VA care.
    And Ms. Chase finds that, generally, VA is playing catch-up 
to meet the needs of women veterans.
    Dr. Hayes, what is at the root of all these issues, and how 
can we rectify them?
    Ms. Hayes. I think that what is at the root of these issues 
really is a system that has not been responsive to the needs of 
women veterans.
    I came a year ago and launched an initiative specifically 
to make VA more inclusive of women veterans: to establish 
primary care that meets their needs so they do not have to come 
for multiple visits; and to make sure that we reach out to 
those who do not have health care.
    One of the things that research has shown us over and over 
again is that women do not know that they have VA services 
available. And it is not good enough if we reach them yet we do 
not have the right care when they get in our front door.
    And, so, we have a very intensive effort going on, which 
started, as you saw last year, but is rolling up August 1 with 
every facility giving us an implementation plan for: how to fix 
primary care for women veterans; how to make the facilities 
respond to the environment of care issues; and to develop 
services going forward that will meet women veterans' needs. I 
think that until we do that--until we make sure that it is 
right--then we should begin to reach out to our women veterans 
and welcome them back. We will have a specific initiative which 
we identified the need for service-connected women veterans to 
get their health care, and that is the first on our list. When 
we can be assured that there is primary care available for them 
when they walk in the door.
    Chairman Akaka. Thank you.
    Senator Burr, your questions?
    Senator Burr. Thank you, Mr. Chairman.
    Dr. Hayes, I want to give you an opportunity to clarify 
something for me from a statement.
    In your testimony on page 7, you state, ``As of June 2009, 
each of the VA's 144 health care systems has appointed a full-
time Women Veterans Program Manager,'' but I thought I heard 
you say in the response to Senator Akaka that you were in the 
process of confirming if you had 144 Women Veterans Program 
Managers. Which one is accurate? Do we have them or are you in 
the process of verifying that we----
    Ms. Hayes. I am personally in the process of verifying, and 
because I want to make sure that I can tell you that is 
accurate when we say that we have 144 in place.
    Senator Burr. How long does that take?
    Ms. Hayes. We have a list out now. It is really a question 
sometimes of are they in place or not. The 144 was----
    Senator Burr. But your testimony says, ``As of June 2009, 
each of the VA's 144 health care systems has appointed a full-
time Women Veterans Program Manager.''
    Is that a correct statement or an incorrect statement?
    Ms. Hayes. That is a correct statement in terms of a person 
appointed to be in that job. We want to make sure that person 
is full-time, they are able to do the job, they have been 
trained, and they are the person in place to do the work that 
we need them to do to advance this program.
    Senator Burr. But what----
    Ms. Hayes. Some of them had just been hired----
    Senator Burr. This is under an architecture put out by VA 
leadership that you are going to have 144 individuals in 144 
facilities, and I would take for granted that listed in the 
dictate is permanent and full-time. It spells out exactly what 
these program managers are going to do.
    Ms. Hayes. That is correct.
    Senator Burr. So, I guess what I am having difficulty 
clarifying is if you say they are ``in place,'' but you have to 
verify they are in place because you want to make sure that 
they are full-time folks, et cetera. Does that mean that you 
have had individual facility managers who have hired somebody 
different than what the leaderships dictate was?
    Ms. Hayes. No, sir. I do not want to indicate that.
    For example, we had sites where a Women Veteran Program 
Manager was half-time, and----
    Senator Burr. But is that allowable under----
    Ms. Hayes. No, excuse me. I do not mean new, I meant that 
she was doing it half-time. She was performing duties serving 
women veterans in a clinic setting, and she has been appointed 
as a full-time person. We want to make sure that veterans have 
been transferred appropriately to other people so that her 
full-time can be devoted to the Women Veteran Program Manager 
job.
    We are still in a transition phase. I'm making sure that we 
are fulfilling what we said we're fulfilling, which is making 
sure those folks are available to do this work for us.
    Senator Burr. OK. You said on page 9, ``The VA plans to 
have gynecologists available at each of the VA's 144 health 
care systems by 2012.''
    Why is it 2012 and not 2009?
    Ms. Hayes. Maybe I should explain. We have gynecologists 
onsite in approximately 70 locations. And, again, I do not have 
an exact number for the record on that. At the other sites, we 
have gynecology services available largely by fee-basis.
    As we develop and the number of women veterans increases, 
we anticipate that we will need to bring those services in-
house; and we want to move toward that by fiscal year 2012.
    Senator Burr. Well, do you agree with the statement that I 
made that we've actually had a decrease in the number of women 
seeking gender-specific health care services at the VA from 
last year to this year?
    Ms. Hayes. I do not actually think that we have had a 
decrease. I think that the way that we were accounting for the 
numbers for gender-specific health care has changed, and that, 
in fact, masked some of the gender-specific care. We've changed 
from having women go just to pap clinics to having women go to 
comprehensive primary care clinics, and the costs of that were 
all rolled in together so that we actually, on paper, look like 
we decreased our gender-specific care, when, in fact, we 
believe that it has increased.
    Senator Burr. What percentage of gender-specific care does 
the VA purchase in the community? Has it increased or 
decreased?
    Ms. Hayes. I do not know the answer to that.
    Senator Burr. OK. In your testimony, you mentioned the 
disparity in quality between male and female veterans in the VA 
System. You specifically noted the disparity in prevention 
measures such as colon cancer screening, depression screening, 
and the immunizations.
    What are you doing to address these issues?
    Ms. Hayes. We are quite aware that there have been quality 
differences for women. The quality for performance measures for 
women has been significantly lower than that for men, and we 
have data now consistently showing that trend from 2006 
forward.
    We have launched, with the Office of Quality and 
Performance, efforts which are identifying the quality measures 
at each site. That data was not available to facility directors 
until very recently, so, we knew there was a national problem, 
but we did not know exactly how people were doing. So, we have 
asked the facilities now--as we rolled out this data just this 
last week--to address specific areas at their facility where 
the gender performance scores are lower for women than men; and 
we are helping them as we develop mechanisms to look at patient 
factors, provider factors, and system factors.
    And, again, it goes back to the issues about are we 
providing care that women can access in a way that once we say, 
for example, come back for your fasting lipid test, that that 
is even possible for a woman to conveniently do. So, we need to 
look at all of it. We need to look at it from a facility-
specific level, and we need to address these gender disparities 
very actively, and we are doing that.
    Senator Burr. You noted the recently-released report 
``Provisions of Primary Care to Women Veterans,'' and you point 
to it as a roadmap for improving service to women veterans. The 
report's recommendations, I think, have been well-received 
throughout the veterans' community.
    Let me ask you, does the VA have a timetable for 
implementing the report's recommendations?
    Ms. Hayes. We have a timetable for implementing 
comprehensive primary care to women veterans. The first part--
the comprehensive plans--are due by the facilities in August, 
and that is a 5-year plan. Not to say they have 5 years to get 
it done, but they must take immediate actions, interim actions, 
and mid-term actions.
    Senator Burr. Does that plan encompass all of the 
recommendations in that report?
    Ms. Hayes. That plan does not encompass all the 
recommendations in the report. There are many recommendations 
that are still being developed in terms of a timeline.
    Senator Burr. Whose responsibility will it be for 
implementing the recommendations in the report?
    Ms. Hayes. It is ultimately the responsibility of the Under 
Secretary for Health. The workgroup was set up by the Under 
Secretary for Health, but I consider the responsibility largely 
on my shoulders and my office.
    Senator Burr. Great. I thank you and thank you, Mr. 
Chairman.
    Chairman Akaka. Thank you, Senator Burr.
    Senator Murray?
    Senator Murray. Thank you, Mr. Chairman.
    Let me follow-up on Senator Burr's question on the report 
called ``Provision of Primary Care for Women Veterans.''
    I thought it was a good report, and it did a good job of 
detailing some of the most pressing challenges, but it was sent 
out as not mandatory. It was just sent out to the VA 
facilities.
    If it did not include any mandatory requirements or any 
accountability, how do we expect it to be implemented?
    Ms. Hayes. There are two factors that actually help us move 
forward immediately with the recommendations of the report. As 
I mentioned, there were these mandatory implementation plans 
which started in January; and there was a gap analysis that was 
mandatory and required in March; and a resource request that 
was submitted in May, which was also required.
    The other part of the policy, though, is that we have the 
policy for Women Veterans Program Health Services Handbook, 
formally known as handbook 1330.01, which has been revised and 
is now in the concurrence process. It details mandated policy 
changes, including the one-stop type model for Provision of 
Women's Health Care and Primary Care. It also continues to 
mandate the privacy standards and the other environment issues 
that are required.
    Senator Murray. OK. Well, sometimes when things are sent 
out, it is informational; they're not implemented. So, I am 
concerned that there is not any mandatory requirements, but we 
will continue to follow that.
    Dr. Hayes, as you know, the military currently bars women 
from serving in combat. We all know, however, in today's wars 
that there is no frontline on the battlefield. We know that 
women are serving right alongside their male colleagues and 
they are engaging in combat with the enemy. Unfortunately, the 
new reality of this modern warfare is not well understood here 
at home, including by some in the VA. This knowledge gap 
obviously impacts the ability of women veterans to receive 
health care and disability benefits from the VA.
    What are you doing, Dr. Hayes, to ensure that all VA 
staff--both in the VHA and in the VBA--are aware that women are 
serving in combat and that they are getting the health care and 
benefits that they have earned?
    Ms. Hayes. We have initiated a number of efforts. In 
addition to training providers--we know that it is not enough 
just to train the providers in terms of women's health--we need 
to train all of the staff. We have a staff module--a 
sensitivity module, which is under development--in order to get 
across and make sure that everyone who comes into contact with 
women veterans appreciates the extensiveness of her service and 
some of the complex issues that she may face.
    As you know and are well aware that many of our women 
veterans have the effects of combat and are serving--there is 
not, I do not think, anyone who is serving today who is not 
under significant stress.
    Senator Murray. Right. But we have people who say well, you 
were not in combat. You are a woman.
    Ms. Hayes. I am distressed that those reports have come 
forward, and we are educating our mental health people and our 
other staff about the significance of women's service.
    Senator Murray. Are you working with the Defense Department 
to make sure that the experience of women veterans is properly 
documented in their DD-214s?
    Ms. Hayes. Dr. Trowell-Harris?
    Ms. Trowell-Harris. I serve as an ex-officio on the Defense 
Advisory Committee on Women in the Services, and the director 
for that committee also is an ex-officio on the VA Advisory 
Committee on Women Veterans.
    This issue does come up frequently, and we are attempting 
to educate everybody within DOD and VA; and currently we are 
exploring an option of working with DOD and VA through the 
White House Project called the Interagency Council on Women and 
Girls. But, in this case, we are looking at women veterans and 
servicemembers.
    We are interested in an outreach communications model for 
exploring that and which could help educate because the 
education is not just to women veterans, the women 
servicemembers----
    Senator Murray. But you are talking about outreach in 
general. I am talking about the problem which women are finding 
on their DD-214s. It's not that nobody wrote ``combat'' because 
nobody wanted to say they are in combat, but they come home and 
then they cannot get service.
    And Mr. Chairman and Members of the Committee should know 
that we do have the Defense Bill on the floor right now. I am 
going to be offering an amendment to make sure that the Defense 
Department properly notes the combat experience on the DD-214s 
so that when women come home, they are not fighting somebody 
when saying ``but I was in combat.'' And they reply, ``Well, 
you can't be.''
    Ms. Trowell-Harris. Right.
    Senator Murray. So, I hope that I get the support of this 
Committee to do that.
    Ms. Trowell-Harris. And that issue was raised in a 
roundtable we had recently, which we were told during that 
session that the military documents the location and they do 
not use the word of combat. So, we did take that back to the 
DACOWITS Committee, and they had somebody who is going to be 
looking at that.
    But this is probably an area where you all could really 
help us with that, because the documentation needs to be there. 
That would make it really easy for VA to deal with those 
particular cases.
    Senator Murray. OK. Well, I plan on offering that. I will 
have more on the second round, but, for this round, I hear so 
often from women veterans that you can provide all the service 
you want, but I have got to take care of my kids. There is no 
childcare available.
    Are we looking at the issue of making sure women have 
childcare so that is not the obstacle to them getting the 
treatment they need?
    Ms. Hayes. As you mentioned, we are very much aware that 
women and men with children and grandparents with children need 
childcare in order to access VA services. The Secretary has us 
actively examining the issues, and we also are looking at the 
opinion of General Counsel.
    We may need Congress's support on this in terms of 
authority to provide childcare, but we are actively exploring 
it with the task force. We do have some pilots----
    Senator Murray. You need authority from Congress to be able 
to provide childcare? Did I hear----
    Ms. Hayes. General Counsel may advise us. We will have to 
get back with you for the record because there is concern about 
the authority to provide childcare by VA.
    Senator Murray. Well, do you expect to have that soon?
    Ms. Hayes. Yes. Yes, ma'am, we do.
    [The response to additional information requested during 
the hearing follows:]
Response to Question Arising During the Hearing by Hon. Patty Murray to 
   Patricia M. Hayes, Ph.D., Chief Consultant, Women Veterans Health 
    Strategic Health Care Group, U.S. Department of Veterans Affairs




    Senator Murray. OK.
    Thank you, Mr. Chairman.
    Chairman Akaka. Thank you, Senator Murray.
    Senator Begich?

                STATEMENT OF HON. MARK BEGICH, 
                    U.S. SENATOR FROM ALASKA

    Senator Begich. Thank you, Mr. Chairman. Thank you very 
much for your testimony.
    I apologize I was not here when you gave your verbal 
testimony, but I have a few questions. I do want to follow-up 
on several of the questions by the Chairman and the Ranking 
Member in regards to the Women Veterans Program Managers.
    I have a friend in Alaska, Joelle Hall, who's a female 
veteran with two kids and a husband in the Guard. She has given 
me kind of a shopping list the minute I told her that you all 
were coming in front of me. She quickly gave me a list of 
questions to ask and this is one of them.
    I know there is a lot of discussion of what the 144 is or 
is not, and I am going to ask you this question, then ask for a 
timeline.
    Can you provide the list of the positions that will be 
occupied and by whome full-time, part-time, and when they will 
actually be working full-time?
    Ms. Hayes. We can provide that for the record.
    Senator Begich. And your timetable to do that?
    Ms. Hayes. We can provide that very soon for the record.
    [The response to additional information requested during 
the hearing follows:]




    Senator Begich. OK, I think that will specifically answer 
the questions that we are all asking around this topic and, in 
that process, make sure that we know where they are going to be 
assigned, which would help us understand the 144, and what they 
mean, and what they are going to be doing.
    Also, in regards to the Women Veterans Program Manager, is 
there discussion of expanding this requirement to the CBOCs?
    Ms. Hayes. We currently require that there be a liaison 
named at each CBOC--a VA employee who is the liaison to the 
Women Veterans Program Manager. We are not requiring that at 
the CBOCs. They are facilities that we are looking at, 
particularly at the very large CBOCs, as to whether that would 
be an appropriate placement. But, no, we do not have a 
requirement for that at the CBOCs.
    Senator Begich. Let me ask you personally. Do you think 
that is something that we should strive to do? I mean, it is 
easy to have a task force and a group, but what do you think? 
You are running the program.
    Ms. Hayes. I think that if the person is full-time at the 
facility and they are doing their job to involve everyone in 
taking care of women veterans, then we do not necessarily need 
one at a CBOC. I think the person has the ability to go out to 
that CBOC, to make sure what is going there, and to provide 
active coordination through other means--telephone and other 
means--with that site.
    So, I think if we make it so they are able to do their job, 
then the CBOCs do not necessarily have to have one onsite.
    Senator Begich. OK. Let me ask, and I do not know who would 
answer this--Dr. Hayes or Dr. Harris. In regards to the design 
of the facilities, we know--based on some of the other 
facilities--the design is not there really to take into account 
women veterans.
    What is the process now to expand the facilities for that 
purpose? And then I have a couple of additional questions.
    Ms. Hayes. In part of the implementation plan, which, as I 
said, could expand as far as 5 years, we have asked facilities 
to name where they need space, where they need construction 
monies to be able to fix the situation in terms of women 
veterans. And, so, they are able to submit those longer-term 
requests right now.
    Also, my office is working with the Office of Construction 
and Design so that new construction appropriately has designs 
for women veterans' exam rooms, appropriately has requirements 
for bathrooms, et cetera, in the new design process.
    Senator Begich. In the Office of Construction Design, other 
than your office, do they actually have clients that sit down 
with them on a regular basis reviewing the designs? Do people 
actually use the facilities?
    Ms. Hayes. I do not know. We would have to get back with 
you on that.
    [The response to additional information requested during 
the hearing follows:]
                Women Veterans Facility Design Guidance
    VA's Office of Construction & Facilities Management's (CFM) guiding 
principles for the development of design and construction standards for 
state-of-the-art 21st century VA facilities include a variety of 
approaches to ensure they address the needs of Veterans, their 
families, and VA health care providers in the most efficient and cost-
effective manner.
     Advocating evidence-based design, with involvement and 
awareness of latest issues in healing environment forums including 
Planetree, Greenhouse, AIA Academy of Architecture for Health, American 
Society of Healthcare Engineers, Center for Health Environments 
Research, and others. Example: VAMC Martinsburg '07 Patient Single 
Rooms Mock-up Study with results published in Health Environments 
Research and Design (HERD) Journal, a leading peer reviewed evidence-
based design publication.
     Basing Space Planning Criteria and Design Guide programs 
on applicable evidence-based design research, active participation of 
VA healthcare providers, administrators, and staff. Surveying best-
practice in private sector and other agencies, with Veterans' input. 
All CFM efforts are focused on providing Veteran- and family-centric 
healing environments supporting world class health care. Design Guides 
depict functional relationships and design considerations in addition 
to space planning criteria for heath care functions. They include 
comprehensive information including an overview of design principles 
and concepts, narrative text descriptions, and guide plates for 
reference.
     Extensively involving state-of-the-art experienced 
national health care consultants together with field input in regular 
VA Design and Construction Standards upgrades. CFM also follows the 
principles in 2010 Guidelines for the Design and Construction of 
Healthcare Facilities used by HHS, most state and local Authorities 
Having Jurisdiction, and the Joint Commission for Accreditation of 
Health Care Facilities as codes, regulations, or guidelines for design 
and inspection. This process provides the experience of a wide range of 
technical consultants and users.
     Coordinating with over 70 VA advisory groups who 
collaborate in the development and updating of VA Design Guides, Space 
Planning Criteria, and Construction Standards and Specifications for 
life-cycle operations. Examples: VA Community Living Centers; VA Mental 
Health Facilities; Polytrauma Rehabilitation Centers; etc.
    Many of the Veteran- and family-centric environments included in 
our updated criteria reflect women's needs; these include the privacy 
afforded by single bedrooms with bathrooms in hospitals and VA's 
patient-centered design for Community Living Centers, replacing older 
design concepts of traditional nursing home care facilities, again with 
single bedrooms with bathrooms, organized in small community family-
like living units.
    The Space Planning Criteria and Design Guides, completed in the 
recent past, have addressed numerous specific changes reflecting 
women's issues. These include Design Guides for Ambulatory Care, 
Outpatient Clinic, and Leased-Based Clinic Design Guide, MRI, 
Radiology, Nuclear Medicine, Radiation Therapy, etc. Changes include 
increased importance of Mammography spaces, adjustment of workload 
criteria to ensure the appropriate generation of women's health spaces, 
larger more private dressing rooms areas, women's specialty exam/
procedure rooms larger than standard spaces, more bathrooms in targeted 
treatment and diagnostic areas, separate male and female bathrooms in 
small pubic areas and waiting rooms where one unisex bathroom would 
technically suffice. On going recent efforts include:

     February 5, 2010 finalization of interim space criteria 
for Women's clinic, working with CFM staff and the Chief, Consultant 
Women's Health Office. This interim space criteria will be utilized 
either as part of a larger ambulatory care clinic or a stand alone 
women's clinic.
     Chief, Consultant Women's Health Office and members of her 
staff have been regular members of advisory committee reviewing CFM 
Standard updates.
     00CFM has been meeting regularly with Women's Health 
Office since early 2009 to review standards and discuss comments
     Ongoing updates of Mental Health Design Guide, Community 
Living Center Design Guide, Inpatient Units--Medical, Surgical Patient 
Care Units Design Guide, and Procedure Suites Design Guides will 
include updated criteria specifically addressing women's issues, 
related to waiting rooms, privacy, check in areas, bathroom facilities 
etc. These will be completed later this year.
     Current IDQA/E task order is complete and soon to be 
contracted for the updating or development of 6 priority Design Guides, 
one of which is the Women's Clinic Design Guide which will include the 
interim space criteria for women's clinic noted above and additional 
guidance, to be completed later this year.
Project Examples:

     VAMC Las Vegas New Hospital--Under Construction:

        Women's Ambulatory Care Clinic located at the 3rd floor level 
        of the tower. The clinic area is 5600 sq. ft. and includes 9 
        exams rooms, 2 procedure rooms, a reception/waiting area, a 
        nurse station, utility rooms (clean and soiled), patient 
        toilet, staff lounge, staff toilet and offices.

     VAMC Walla Walla OPC:

        Women's Exam Rooms and physician offices grouped in a ``mini'' 
        pod type arrangement (800 sq. ft.) along a dedicated clinic 
        corridor affording privacy, two dedicated exam rooms with 
        dedicated women's toilet provided between the exam rooms, 
        private dressing cubicle within the room and exam table out of 
        the line-of-sight from the door, and separate family waiting 
        and toilet rooms room to accommodate women and families.

08 February 2010

    Senator Begich. I would suggest, as a former mayor who 
dealt with many designs of buildings, that the users need to be 
part of the equation. If they are not involved, they should be, 
to be very frank with you, because--no offense to your office 
and anyone else--but I know construction people; I used to be 
in the business. They build to facilitate, they work off of 
budget, and then they are done. I highly recommend that you 
establish your work with the Office of Construction including 
an advisory of actual clients who utilize those facilities 
currently or have utilized their facilities to give advice on 
how those should be constructed.
    Some of the issues that you brought up, Mr. Williamson, are 
small, yet they are significant. And design is part of it 
because I can tell you if you do not design the bathroom the 
right size, those extra items that you want in there are not 
going to fit. Just if you would take that under at least some 
advisement, I would appreciate that.
    Mr. Williamson. If I may add also----
    Senator Begich. Sure.
    Mr. Williamson. We have heard the same thing in terms of 
needing to have good communication between Dr. Hayes' office 
and others with the construction people because, again, we are 
dealing with a cultural change here. And it is really important 
that the design people and the people who do specifications 
have incorporated the needs of women veterans in terms of the 
facilities.
    Senator Begich. Well, thank you very much for echoing that. 
Again, if you could report back to the Committee what your 
plans are. I cannot stress enough, I have seen projects turn 
from good projects to excellent projects because of the client 
involvement. It does not matter if it is health care facilities 
or anything, but, in this case, health care.
    I will just end on this one question.
    To follow-up on Senator Murray's comments in regards to how 
women veterans understand what care is available, you had 
mentioned there were veterans that are not necessarily aware of 
the benefits.
    How big would you say that universe is if you could measure 
it in volume of people? Is it a few thousand? Is it tens of 
thousands?
    Ms. Hayes. I think it might be on the level of about 1 
million women veterans.
    Senator Begich. One million women.
    Ms. Hayes. We have an active plan now to utilize the VA 
call centers to reach out to women veterans and advise women 
veterans about the benefits and the access. Again, that is 
going to be phased in. We will start with the service-connected 
women veterans, but we want to make sure that that does not 
start until at least this fall because we want to make sure the 
clinics are available.
    Senator Begich. OK.
    Ms. Hayes. And we have been told that there may be in the 
neighborhood of 1.5 million women veterans altogether, 
including those who use us.
    There are about 450,000 enrolled women veterans right now. 
So, there are about 1 million women veterans who have not 
enrolled in VA. To the extent that they do not know about us, 
we can only hope that we can reach out and tell them.
    Senator Begich. And where do you think they get health care 
coverage now?
    Ms. Hayes. We don't know that.
    Senator Begich. Or do they?
    Ms. Hayes. We do have a study underway by Dr. Donna 
Washington, and the results of that study will be available 
approximately September. She has done research on this for us--
a stratified random sample of women--women who use VA, women 
who do not use VA who are veterans, and those who use this and 
don't come back. That study is going to help us understand how 
women veterans who do not use VA access health care.
    Senator Begich. Great. If you could share that with us, 
that would be great.
    [Note: This study was not completed in the anticipated 
timeframe and the target for completion and release is spring 
of 2010.]
    Senator Begich. Mr. Chairman, I apologize for going over, 
and thank you very much.
    Chairman Akaka. Thank you very much, Senator Begich.
    I have one remaining question for you, Dr. Hayes.
    As part of my oversight responsibility, I learned that some 
veterans at the Austin, Texas, clinic were inappropriately 
being charged for services related to military sexual trauma. 
As you well know, such care is provided at no charge. It is 
quite difficult for women to seek such care to begin with, let 
alone to be presented with a bill for it. One woman told me she 
found this emotionally draining and an insult to all women who 
served.
    Is it your belief that this situation at Austin is an 
isolated incident or are veterans nationwide being charged for 
care for military sexual trauma?
    Ms. Hayes. I can only let you know that personally having 
been in the field for 25 years, I was actually involved in the 
initial attempts to roll out the eligibility for military 
sexual trauma for free counseling. It should not be ``free;'' 
it is without-charge counseling for veterans who have undergone 
such trauma. So, it is personally distressing when I see all 
these years later that there are veterans who have, I think, 
inadvertently been charged, but, nevertheless, been charged for 
their counseling services.
    After the incident in Austin, a mental health group that 
oversees the Military Sexual Trauma Program not only educated 
the persons there at Austin regarding eligibility, but have 
done a nationwide search and should have a report very soon 
about any other cases that were uncovered. But we believe it is 
an isolated type of occurrence.
    They made an effort to retrain the eligibility clerks 
through some online information that has gone out, and they 
will have a report as to whether they discovered any other 
sites where veterans were being charged for these services.
    Chairman Akaka. Thank you very much.
    Let me call on Senator Murray for any second round 
questions.
    Senator Murray. Thank you, Senator Akaka. I just have two 
additional questions.
    One is about homeless female veterans. The number of women 
veterans who are ending up homeless has nearly doubled over the 
last decade. One out of every 10 homeless veterans under the 
age of 45 is now a woman. Many of these homeless female 
veterans have kids.
    According to Pete Dougherty, who is the Director of VA's 
Homeless Veteran Programs, he said, ``While the overall numbers 
of homeless vets have been going down, the number of women 
veterans who are homeless is going up.''
    I have introduced legislation to expand and improve the 
services and care for homeless female veterans and their 
children through the VA Grant and Per Diem Program in the Labor 
Department's Homeless Veteran's Reintegration Program.
    Dr. Hayes, tell me what else you think we should be doing 
currently; and are you aware of this challenge that we have?
    Ms. Hayes. Yes, I am very aware of the challenge. And I 
think it is in part an unfortunate side effect of what is going 
on in terms of the number of new women veterans, but it is a 
particular challenge in a system that we have not done what I 
think we need to do with screening for the things that underlie 
the problems of homelessness.
    I think--again, women veterans are largely invisible, so we 
need to do more to screen for risks of homelessness in our 
primary care setting. We need to do a better job of screening 
women for substance use, asking women about whether they have 
enough to get by, and having earlier interventions to avoid the 
final decline into homelessness.
    So, that is what I think we need to do in our system; and, 
again, when we organize the primary care better to 
comprehensively serve women and not just say, well, we will 
take care of your pap smear and we will take care of your 
mammogram, but to say instead, we will take care of you as a 
whole person. Part of our goal is to make sure that we have 
adequate mental health and social work in our primary care 
setting for women.
    I applaud and thank you for your efforts to put more into 
the Grant and Per Diem Program. As you know, there have been 
barriers because of the issues of children, and women with 
children have been the most difficult group to place--whether 
they are veterans or non-veterans--and, so, I certainly applaud 
that effort because that is clearly what we need in expanding 
the services that are available to women.
    And I think it is another area where we have to continue to 
provide education to our homeless outreach workers and our 
homeless placement folks in areas where we may underserve the 
women homeless so that they clearly ask a homeless person 
whether they are a veteran and ask a homeless women whether she 
is a veteran to make sure she gets in the VA services.
    Senator Murray. Which goes to my last question. When a man 
tells you they are a veteran, folks immediately say yes. Women 
do not perceive themselves to be veterans. The general public 
does not perceive women to be veterans, even if the woman says 
she served in the military.
    How are we going to overcome that sentiment and make the VA 
and the general public really respect the service of women and 
for women to perceive themselves as veterans? I mean, may we 
should not call them ``veterans.'' I do not know. It is just a 
real problem.
    Have you thought about that? Do you have any advice for us? 
What can we do to change that?
    Ms. Hayes. I may turn to Dr. Trowell-Harris. A major effort 
of her office is to tackle this problem.
    I, myself, believe that the kind of effort that you are 
putting in to raise the awareness goes very far in helping to 
identify that women proudly served, and women have always 
served as volunteers. I think we have to continue to get that 
message out in the media, in the Internet, any way that we can, 
and turn to our partners who are here--the veterans who are 
here--to help us with that message.
    But Dr. Trowell-Harris' office is dedicated also to this 
outreach effort.
    Ms. Trowell-Harris. We participate in all of the major 
women's policy groups, the Veteran Service Organizations 
Convention, minority groups, roundtable groups, hearings, and 
we work with DOD. So, we try to get the education out there. 
But my opinion is it is a matter of changing the culture, 
getting everybody to understand that women are veterans.
    So, you may recall that, years ago, the census used to ask 
women are you a veteran? They would say, ``no.'' But the census 
question changed to ask, ``Have they ever served in the Armed 
Forces?'' Then women would say, ``yes.''
    But, still, the education is needed for everybody, as Dr. 
Hayes, said: the media, the women veterans, VA staff, and 
Congressional members. It takes all of us. And, again, this is 
one way that you can help us.
    We are doing extensive outreach with the State Departments 
of Veterans Affairs. Each State Department of Veterans Affairs 
has a designated female assigned to work with women veterans, 
and we do have conferences and send them tons of educational 
material. Again, we work with various committees, such as the 
Homeless Committee, the Minorities Affairs Committee, and the 
Research Committee.
    I have a report which some of you have seen. I had 20 
recommendations for women veterans, and, as part of that, the 
program managers who were part of that committee got Dr. Hayes' 
office raised on the VA organizational chart, which was one of 
the recommendations, and that has been done.
    So, all of these things we are trying to do to improve 
outreach. We are also working with the Honorable Tammy 
Duckworth, who was just employed with VA. She heads a major 
outreach effort, so we are meeting with her staff, looking at 
some creative ways of getting the message out--not just to the 
women veterans, but to everybody.
    Senator Murray. I appreciate that. I think we really have 
to focus on that as communities, as the media, as everybody so 
that we, as a country, recognize that women who serve in the 
military are veterans, deserve the benefits that they have 
earned, and the respect of this country.
    Ms. Trowell-Harris. Thank you.
    Chairman Akaka. Thank you very much, Senator Murray.
    Senator Begich?
    Senator Begich. Mr. Chairman, if I can just ask a couple 
more quick questions. I know I went over time last time.
    Can you give me a sense of--making people aware as women 
who are getting into the military--what kind of relationship 
does the VA have with the DOD in ensuring that knowledge of 
what is available specifically for women is available once they 
become a veteran?
    Who could answer that? Just what kind of relationship is 
there?
    Ms. Trowell-Harris. Our Secretary works with the Secretary 
of Defense, and, also, there is a designated person at DOD that 
works on benefit issues and also on health care issues. And I 
did mention before about being on the DACOWITS Committee.
    We do have some printed material that we use at all major 
conventions and forums for women veterans. We have open forums. 
Women do site visits to the field with our Advisory Committee. 
So, we're trying multiple ways of getting the word out.
    We have numerous media interviews, also; and we really 
appreciate those because they help us get the word out to the 
veterans nationally.
    Senator Begich. And recruitment centers? Is there 
information available at the recruitment centers?
    Ms. Trowell-Harris. You mean military?
    Senator Begich. Yes.
    Ms. Trowell-Harris. I am not sure about that. We can get 
back to you on that.
    Senator Begich. I mean, the recruitment centers are the 
first opportunity to educate on what the benefits are on the 
back-end. So, if you could let me know how the recruitment 
centers are operating and people are doing the recruitment, 
what is there also? Is there any special effort, especially for 
women on what is available and what could be available to them?
    So, whichever of you could answer that, that would be 
great.
    Ms. Trowell-Harris. Sure, we will get back to you on that.
    Senator Begich. And please, whoever would be the right 
person to answer this, please do so.
    From a funding level, is there enough resources for what 
you need in some of the leasing of the space that is occurring 
as well as future construction, and what will be necessary to 
expand these facilities to meet the women veterans' needs? And, 
if not, is that part of the 5-year plan, and tell me how that 
all works.
    Ms. Hayes. We have been working very closely with the 
Office of Budget and with the Secretary's office to help define 
the resource needs for this infusion of infrastructure, and we 
understand that with the support of the Secretary, VA will have 
the resources needed to enhance the care to women veterans.
    Senator Begich. That is good. Very good.
    At what point will you have kind of the strategic plan of 
expansion of facilities that this Committee could at least see? 
In other words, a plan that would kind of say, here is our game 
plan for the next five or so years and here are the highest 
priorities based on demand, based on facility structure, and so 
forth.
    Ms. Hayes. OK, that will not be my office specifically, 
although, the plans are coming back through the VISN level 
office and the Offices of Construction, but we can get back to 
you regarding the Secretary's response on how the Secretary's 
office would see these priorities.
    [The response to additional information requested during 
the hearing follows:]
 Responses to Questions Arising During the Hearing by Hon. Mark Begich 
                 to the Department of Veterans Affairs
    Question. Please provide a priority list of VA's plans to have the 
facilities identified in the GAO's preliminary findings on VA's 
Provision of Health Care Services to Women Veterans.
    Response. VHA has identified the following as top privacy and 
security priorities based on the preliminary findings of the GAO's 
Report on VA's Provision of Health Care Services to Women Veterans:

     Adequate visual and auditory privacy at check-in;
     Adequate visual and auditory privacy in the interview 
area;
     Exam rooms located so they do not open into a public 
waiting room or a high-traffic public corridor;
     Privacy curtains present in exam rooms;
     Exam tables placed with the foot facing away from the door 
(if not possible, placed so they are fully shielded by privacy 
curtains);
     Changing area provided behind privacy curtain;
     Toilet facilities immediately adjacent to examination 
rooms where gynecological exams and procedures are performed;
     Sanitary napkin and/or tampon dispensers and disposal bins 
in at least one women's public restroom;
     Privacy curtains in inpatient rooms (with exception of 
psychiatry and/or mental health units);
     Access to a private bathroom facility (with toilet and 
shower) in close proximity to the patient's room (inpatient and 
residential units).

    Senator Begich. That would be great. And that is just so I 
can get a sense of where and what in preparation priorities. 
You see, when I sat on the Armed Services Committee we 
sometimes focused just on the year. The problem with that is 
one year will have ramifications for the next and following 
years. So, it just kind of helps.
    Ms. Hayes. Yes.
    Senator Begich. I know there is a big commitment from the 
president in regards to dollars for the Veterans 
Administration, which is great. I just want to make sure we are 
in the right tow here.
    Ms. Hayes. I also want to clarify, a lot of the issues, as 
Mr. Williamson said, are really issues of being able to put 
some renovation costs and would be on the priority list for 
construction, but rather needing the ability to plan and put 
together a space that would really involve renovation costs and 
local costs.
    Senator Begich. If I can ask, so, will the renovation costs 
then not be in the long-term capital improvement?
    Ms. Hayes. Oh, no, I did not mean to confuse that.
    Senator Begich. Oh, OK.
    Ms. Hayes. I am just telling you that the process is one in 
which we are looking at both short-terms in terms of some 
renovation where places are putting in new projects. That is 
already part of other processes that you would be aware of.
    Senator Begich. OK. Very good.
    Mr. Chairman, I am going to end there. I do have some 
additional questions, but I know I exceeded my time the last 
time and I have a feeling with about 30 seconds left, I'll burn 
that up very quickly. So, let me end here.
    Thank you.
    Chairman Akaka. Thank you very much, Senator Begich.
    I want to thank the first panel for your testimony and your 
responses.
    As we know, we are facing a huge surge of an issue here 
that has been important to our country, and some of the 
problems have been noted. We want to work together as closely 
as we can to move it and provide the health care services that 
our women veterans expect and will have.
    So, we look forward to working with you. Thank you very 
much.
    Ms. Trowell-Harris. Thank you.
    Ms. Hayes. Thank you.
Response to Post-Hearing Questions Submitted by Hon. Daniel K. Akaka to 
    Patricia Hayes, Ph.D., Chief Consultant, Women Veterans Health 
    Strategic Health Care Group, U.S. Department of Veterans Affairs
    Question 1. VA's written testimony discusses how the ``women's 
comprehensive health implementation planning (WCHIP) tool'' is used to 
``assist facilities in analyzing its own current health care deliver 
for women veterans.'' After the initial analysis is completed by each 
facility, is there a process to repeat the analysis periodically to 
account for the expected growth in the women veteran population and how 
that may affect the model a facility uses to provide care for its women 

veterans?
    Response. The Veterans Health Administration (VHA) continues to 
incorporate WCHIP to assess the current status of primary care delivery 
to women Veterans across VHA, and recommend enhancements as required.
    For every VA health care facility, VHA will create a benchmarking 
tool to evaluate WCHIP. The tool will help define and develop 
recommendations regarding the essential components and critical 
capabilities of comprehensive primary care delivery models. In 
addition, metrics will be developed that evaluate the implementation of 
comprehensive care for women Veterans. The tool is currently being 
developed with an expected completion of February 2010. A plan to pilot 
the tool is expected in March 2010, and validation is expected May-
August 2010. Once the tool has been validated, an annual reporting 
process will be established for ongoing evaluation and resource 
monitoring and tracking so that facilities can plan for the expected 
growth in the women Veteran population in their areas.

    Question 2. During the hearing, there was discussion regarding VA's 
plans for expanding and remodeling clinical areas that provide women's 
health care and the need to maintain close coordination with VA's 
Office of Construction and Facilities Management when implementing 
these plans. In addition to evaluating the space used to provide 
women's health care, is VA evaluating the equipment, such as exam 
tables, used in these spaces to ensure it is appropriate for all women 
veterans, particularly those with catastrophic disabilities?
    Response. VA's design criteria moved aggressively to improve space 
and logistics issues related to women's health this past year. The 
design criteria incorporated many women-specific requirements, such as 
ensuring adequate space for women specific equipment, ensuring 100% 
private patient rooms and ensuring adequate space for dependents 
accompanying the women Veterans. These design criteria have been 
incorporated into both, our existing facilities, as well as new Women's 
Centers.
    More specifically for high-tech/high-cost equipment, equipment 
needs are assessed and evaluated for performance continually. Prior to 
a new acquisition, an intensive review occurs to optimize the selection 
to best suit VA's needs. This new equipment then becomes the basis for 
designing the room to ensure adequate space and 
privacy.
    Regarding the space designs for women's areas in general, VA's 
standards development efforts have increased addressing the physical 
and mental health care needs of the growing number of women Veterans. 
Most efforts related to updating VA's Space Planning Criteria and 
Design Guides for specific functional areas. Space Planning Criteria 
provides space requirements and guidance for development of space 
programs for specific VA Facility Project development and leasing 
agreements. It contains functional relationships and design 
considerations in addition to space planning criteria for heath care 
functions. Design Guides provide comprehensive information, including 
an overview of design principles and concepts, narrative text 
descriptions, and guide plates for reference.
    These Space Planning Criteria and Design Guides, particularly over 
the recent past, have addressed numerous specific changes reflecting 
women's issues. In the most recent Design Guides for Ambulatory Care, 
Outpatient Clinic, MRI, Radiology, Nuclear Medicine, Radiation Therapy, 
etc., changes include increased importance of Mammography spaces, 
adjustment of workload criteria to ensure the appropriate generation of 
women's health spaces, larger more private dressing room areas, women's 
specialty exam/procedure rooms (10% larger than standard spaces), more 
bathrooms in targeted treatment and diagnostic areas, separate male and 
female bathrooms in small public areas, and waiting rooms where one 
unisex bathroom would technically suffice.
    The Office of Construction and Facility Management (CFM) is 
partnering with and including the Chief Consultant Women's Health 
Office, on the Advisory Teams established to update Space Planning 
Criteria and Design Guides along with consultants and other VHA health 
care providers. Design Guide and Space Planning Criteria recently 
completed or major updates are underway: Mental Health; Inpatient 
Units--Medical, Surgical, and Neurological Patient Care Units; 
Intensive Care Units; Procedure Suites; and Leased-Based Clinic Design 
Guide.

    Question 3. Much attention is given to providing gender-specific 
care to women Veterans from OIF/OEF. Besides the research mentioned in 
written testimony regarding hormonal effects on diseases in post-
menopausal women, what is VA doing to ensure there are adequate gender-
specific services for our older generations of women veterans?
    Response. The gender-specific services VA provides takes into 
account the changing needs of women at each stage of their lives. VA's 
comprehensive health services for older women Veterans include:

     Continued access to gender-specific screening for breast 
and cervical cancer to detect early malignancies and improve survival. 
VA also notes that postmenopausal women are at increased risk of having 
cardiovascular disease, the number one killer of women. Thus our 
comprehensive primary care initiatives take into account the needs of 
our aging women Veterans and focus on breast health and heart health, 
diabetes and weight management, and smoking and lung cancer.
     Education initiatives for women's health providers include 
modules on prevention and management of osteoporosis in addition to 
evaluation and basic assessment of reproductive issues in older women. 
In addition to hormonal replacement therapy, these issues include 
urinary incontinence, pelvic floor disorders, and reproductive cancers. 
Women Veterans with are appropriately and expeditiously referred to 
subspecialty care services as needed.

    Question 4. VA's testimony referred to the mini-residency training 
in women's health which is taught by national women's health experts. 
During the hearing it was suggested numerous times that it would be 
beneficial for someone to learn about women veterans' experiences in 
the military from actual women veterans. What is your view about having 
women veterans provide education and insight to VA health care 
providers in order to help them understand their patients better?
    Response. VA understands and agrees that it is essential to have 
women Veterans participate in providing insight to VA health care 
providers. In September 2009, VA held a conference entitled, ``OEF/OIF 
Evolving Paradigms II: The Journey Home,'' that was aimed at preparing 
approximately 3,000 VA providers of care to Veterans returning from the 
current conflicts. This conference included several plenary sessions 
featuring men and women Veteran patients sharing their stories.
    VHA also created a staff training CD-Rom which includes numerous 
images of women Veterans, aimed at increasing awareness and sensitivity 
about women Veterans. This presentation also includes a video of a 
woman Veteran describing her military experiences, and her perspectives 
on care in a VA primary care women's clinic. VA will include women 
Veterans in person and videos when possible in future educational 
events. In addition, future educational programs will include 
techniques and tools for providers such as the military service history 
pocket card (http://vaww.va.gov/oaa/pocketcard/default.asp) to help 
providers discuss a better military history and to begin to engage 
their own patients in the dialog to better understand the experiences 
of their patients.
    All of these things are essential as VA moves toward providing 
health care that is more patient-centered.

    Question 5. What can this Committee do to assist the CWV in its 
efforts to increase awareness about the women veterans' programs?
    Response. The Center for Women Veterans continues to encounter 
women Veterans who do not self-identify as Veterans, or who are unsure 
of their entitlement to VA benefits and services. The Senate Committee 
on Veterans' Affairs could complement the Center's efforts to educate 
women Veterans about VA's programs for women Veterans as it interacts 
with constituents, especially those who are women Veterans. Examples of 
actions the Committee and its members can consider include:

     Including information about women Veterans programs in 
outreach literature targeting Veterans in general.
     Noting the contributions of women in the military and 
women Veterans in remarks and speeches, as appropriate.
     Establishing forums for women Veterans in their respective 
states that would provide opportunities to learn about these programs 
and how to access them.
     Sharing initiatives and ideas with non-Committee lawmakers 
regarding VA's programs and efforts for women Veterans in order to 
expand opportunities for 
outreach.

    Question 6. What happens if a female veteran asks for a female 
provider and one is not available?
    Response. It is VHA's goal that women Veterans be given the option 
to designate their preference for a female provider. Overall, 62% of 
VHA providers are female. More than 80% of all nurse practitioners are 
women and up to one third of all VA physicians are women. Facilities 
are strongly encouraged to make the necessary accommodations for a 
female provider (if one is requested) so that services are provided in-
house to the greatest extent possible. If a female provider is not 
available in-house, services are to be provided through fee-basis 
arrangements or sharing contracts to the extent the Veteran is 
eligible.

    Question 7. When will the new handbook for VHA services for women 
veterans be issued?
    Response. The revised handbook for VHA services for women Veterans 
incorporates the new standard requirements and delineates the essential 
components necessary to ensure that all enrolled women Veterans have 
access to appropriate services, regardless of their VHA site of care. 
The handbook has recently been revised to reflect comments made in the 
review process and is going back through internal concurrence. The 
handbook is expected to be issued during the second quarter of FY 2010.
                                 ______
                                 
    Response to Post-Hearing Questions Submitted by Senator Burr to 
    Patricia Hayes, Ph.D., Chief Consultant, Women Veterans Health 
    Strategic Health Care Group, U.S. Department of Veterans Affairs
    Question 1.a. As we discussed at the hearing, on page 7 of your 
written testimony there is a statement that ``As of June 2009, each of 
VA's 144 health care systems has appointed a full-time Women Veterans 
Program Manager.'' On page 9 of GAO's testimony there is a statement 
that ``In July 2008, VA required VAMCs to establish the WVPM as a full-
time position (no longer a collateral duty) no later than December 1, 
2008. So, it appears that according to both VA's internal directives 
and your own testimony that each health care system should have 
appointed a full-time WVPM long ago.
    In response to questions from the Chairman, however, you stated 
that you were ``actively in the process of verifying'' whether that is, 
in fact, the case. In response to my questions you stated, in essence, 
that just because each system has appointed a full time WVPM that it 
doesn't necessarily mean that it's happening, and that you wanted to 
make sure it was because VA was in a ``transition phase'' on this 
matter. For the record:

    Please clarify these statements. Is there a distinction between the 
``appointment'' of a WVPM and the actual placement of an individual to 
fill that job?
    Response. Occasionally during the hiring process, when bringing on 
board a new person to fill a vacant slot, there may be a lag from 
appointment to actual on-site placement. In those cases, the Department 
of Veterans Affairs (VA) names an acting women Veterans program manager 
(WVPM) until the appointed individual is officially on board. 
Additionally, many of the WVPMs who held the position prior to its 
becoming a full-time position have had to greatly reduce their clinical 
time to fill the role of a full-time WVPM. For some, the transition 
from clinical duties had taken longer than expected. This process is 
still underway. VA currently employs 137 full-time WVPMs; 7 sites have 
individuals acting in these roles with recruitment for full-time 
employees underway.

    Question 1.b. Is it typical for VA to appoint someone to a position 
who is unable to perform the job to which they are appointed?
    Response. VA does not appoint anyone to a position who is unable to 
perform that position. Mandatory training of new hires does not suggest 
they are unqualified or unable to perform the job to which they are 
appointed. The role of the WVPM is quite complex with regard to 
understanding the population of women Veteran and their unique needs. 
Therefore, significant training of new WVPMs and ongoing training for 
all existing WVPMs is required.
    Every new WVPM is required to complete a Web-based, 40-hour 
certificate training course, which is monitored through the employee 
education system. In addition, VA women Veterans health strategic 
health care group (SHG) has provided training for all WVPMs. The 
eastern region 1 training was held in Baltimore, MD, in April 2009; the 
mid-western/south region 2 in Chicago, IL, in May 2009l and the western 
region 3 in San Francisco, CA, in June 2009. Through the course of 
these three sessions, VA trained all existing, acting and new WVPMs in 
additional program-specific skills areas. A follow-on training meeting 
for all current WVPMs was held on September 20, 2009. This training 
focused on a variety of relevant topics including:

     Follow-up on the Women's Comprehensive Health Care 
Implementation Plan (WCHIP)
     Issues related to the newly developing Veteran-centered 
patient care model
     Building a successful women's health center with full 
backing of leadership
     Writing successful request for proposal responses
     Issues associated with military sexual trauma

    Question 1.c. How long before you have verified that each of the 
144 WVPMs is in place, trained, and performing the duties for which 
they were appointed? Please report that to me as soon as possible.
    Response. Attached is a comprehensive list of the 144 WVPMs, where 
they are posted and when they began working full time in that position; 
2 WVPMs are currently part-time, and 3 sites have acting WVPMs, while 
recruitment for the 5 permanent positions are being advertised. All 
have received the WVPM training referred to in response to question 1b.

    Question 2.a. At the hearing I noted that VA budget submissions 
show a decline, from 2007 to 2008, in the number of unique users 
seeking gender-specific care at VA. In response you stated that ``on 
paper it looks like we've decreased our gender specific care when, in 
fact, we believe that it's increased.'' Please clarify this for me If 
from one year to the next the number of unique users seeking gender-
specific care has declined, doesn't that indicate that those who were 
once users of the system for gender-specific purposes are seeking that 
care elsewhere?
    Response. In the fiscal year (FY) 2010 President's Budget 
submission the reported number of the female Veterans being treated for 
gender specific conditions (FY 2008 actual) was lower than the number 
that was reported in the FY 2009 President's Budget (FY 2007 actual). 
The reason the FY 2007 (actual) number was higher is because non- 
Veteran women were mistakenly counted in the FY 2007 number; that 
cohort should have been deleted from the equation before the budget 
submission was finalized.
    In addition to identifying the non-Veteran inconsistency, the VA 
review process produced insight on what is identified as gender-
specific care for women. In that review, 172 additional diagnosis codes 
that represent gender specific were added to the former list of 441 
codes to more accurately identify care that is gender-specific. These 
additional codes were applied to historical data for use in the FY 2011 
budget process.

    Question 2.b. If you believe that the number of women seeking 
gender-specific care has actually gone up instead of down, then, what 
are the true numbers? What do the numbers look like for 2009 and do 
they track what was estimated for 2009?
    Response. The table below shows the revised historical data for 
female Veterans who come to VA for gender-specific care using the 
expanded list of diagnosis and clinics.
    In FY 2008, actual data through mid-year reflected 61 percent of 
the annual total unique female Veteran patients in FY 2008 had already 
received care and 43 percent of the annual total costs had been 
expended by mid-year FY 2008. At mid-year FY 2009, actual unique 
patients are 68 percent of the estimated annual total and actual costs 
are 50 percent of the estimated annual total, so actual experience thus 
far indicates that the estimate may have been low if second half 
expenditures occur at the same pace as happened in FY 2008. As compared 
to mid-year FY 2008, FY 2009 actual data shows a 14 percent increase in 
female Veteran patients and a 26 percent increase in cost.
    The following table shows historical data for female Veterans who 
come to VA for gender-specific care using the expanded list of 
diagnosis and clinics. The response to question 2a discusses the 
expansion of the scope of gender-specific care.


----------------------------------------------------------------------------------------------------------------
                                                             FY 2008       FY 2009    FY 2008  Mid- FY 2009  Mid-
                                                             Actual        Budget         Year          Year
----------------------------------------------------------------------------------------------------------------
Female Veteran Patients.................................       141,698       145,647        87,128        99,500
Obligations (000s)......................................      $153,315      $167,330       $65,758       $82,860
----------------------------------------------------------------------------------------------------------------


    Question 3. What percentage of the gender-specific care (as a 
percentage of obligations) VA provides was purchased from a non-VA 
provider? Has this number increased or decreased in the last decade?
    Response. The data below shows the percentage spent in VA and the 
percentage spent on non-VA providers. Data are not available prior to 
FY 2005. Since FY 2005 the percent spent on gender-specific care 
increased between 12.18 percent in FY 2005 to 14.2 percent in FY 2009. 
The data over this short period is narrow in variance and does not 
allow for reliable trending.


----------------------------------------------------------------------------------------------------------------
                    Fiscal Year                                    VA                          Non-VA
----------------------------------------------------------------------------------------------------------------
2009, 2nd quarter..................................                 85.80 percent                 14.20 percent
2008...............................................                 86.90 percent                 13.10 percent
2007...............................................                 87.92 percent                 12.08 percent
2006...............................................                 88.49 percent                 11.51 percent
2005...............................................                 87.82 percent                 12.18 percent
----------------------------------------------------------------------------------------------------------------


    Chairman Akaka. I welcome now a second panel this morning. 
Members of this panel are five women veterans, each working in 
the field of advocacy in its various forms.
    First, I welcome Joy Ilem, Deputy National Legislative 
Director for Disabled American Veterans.
    Next, we have Tia Christopher, who is an Iraq Veteran and 
Project Associate and Women Veteran Coordinator for Swords to 
Plowshares.
    Next, welcome to Genevieve Chase, Executive Director for 
American Women Veterans.
    We will hear testimony also from Kayla Williams, a veteran 
of the U.S. Army.
    And, finally, we have Jennifer Olds, also a U.S. Army 
veteran. I am grateful to VFW for making it possible for Ms. 
Olds to join us today.
    Ms. Ilem, we will begin with you and then move down the 
table in order.
    Ms. Ilem?

 STATEMENT OF JOY ILEM, DEPUTY NATIONAL LEGISLATIVE DIRECTOR, 
                   DISABLED AMERICAN VETERANS

    Ms. Ilem. Thank you, Mr. Chairman and Ranking Member Burr. 
Thank you for inviting the Disabled American Veterans to 
participate in this timely hearing on women veterans.
    The changing roles of women in the military, increasing 
numbers of women coming to VA for care, and the impact of war 
on women's health present a number of new challenges for VA in 
meeting the unique needs of women veterans today.
    Ensuring equal access to benefits and high-quality health 
care services for women veterans is a top priority for DAV. We 
have a longstanding resolution that calls for review of VA's 
health program for women to ensure they have access to the same 
high-quality health care and specialized services that male 
veterans receive.
    It is apparent from the recently-released Report of the 
Under Secretary for Health Workgroup on Women Veterans that VA 
is aware of the shortcomings in its women's health program and 
is making a concerted effort to systematically address the 
significant challenges it faces to bring care provided to women 
veterans on par with male veterans.
    The report outlines the most critical challenges VA faces 
in caring for women veterans, and, more importantly, provides a 
roadmap for change. Some of the most critical issues identified 
in the report include: significantly increasing utilization 
rates of younger women accessing VA care; the systemic 
fragmentation of primary care delivery for women; too few 
proficient, knowledgeable providers with expertise in women's 
health; and a number of identified outpatient quality 
disparities for women veterans.
    Additionally, VA researchers report a number of access 
barriers for women veterans, including lack of childcare 
services, privacy, safety, and comfort concerns, and unique 
post-deployment mental health reintegration issues for newly-
discharged women veterans who have served in Operations Iraqi 
and Enduring Freedom.
    The workgroup states its primary objective is to ensure 
every woman veteran has access to a qualified health care 
provider who can deliver coordinated, comprehensive, primary, 
women's health care inclusive of gender-specific care, 
preventive, and mental health services.
    It plans to achieve these goals through a number of key 
policy recommendations to reform and enhance women's health 
delivery in VA. These recommendations thoroughly address 
quality, efficiency, access, and equity of care for women who 
use VA services.
    And we congratulate the Women Veterans Health Strategic 
Health Care Group for an extraordinarily forthcoming report in 
a highly-detailed series of goal-orientated recommendations and 
action items. These recommendations are fully consistent with a 
series of recommendations that have been made in recent years 
by VA researchers, experts in women health, VA's Advisory 
Committee on Women Veterans, and the Independent Budget.
    If implemented, these reforms will change the face of 
health care delivery for women veterans in the VA health care 
system, and, in turn, improve the health of women veterans.
    Without question, VA has a lot of hard work ahead to 
achieve these goals it has set out for itself, but we are 
hopeful with the attention, oversight, and collaboration of 
this Committee, that an implementation plan can be 
expeditiously carried out.
    A number of events focused on women veterans have been held 
in recent months and all are essential to process of change. 
However, nothing is more important than taking action. For 
these reasons, DAV urges the Committee to carefully consider 
the recommendations outlined in the report on women's health 
and to support VA's efforts for change.
    Although this groundbreaking report represents progress, we 
question if the women's health program directors have the 
resources to build adequate infrastructure and program capacity 
and the internal support necessary at the very highest levels 
to make the reforms it says are necessary.
    One final concern we bring to the Committee's attention, 
although it appears VA has been making a good faith effort to 
move forward on its plans for improving women's health care 
services and implement the principles outlined in the report, 
it does not appear VA has issued a formal policy or directive 
to the field to address the gaps identified in the report. 
Therefore, we seek assurance from VA that its implementation 
will be, in fact, faithfully executed.
    Mr. Chairman, again, we thank you and other Members of the 
Committee for your leadership and continued support on women 
veteran's issues, and we appreciate the opportunity to 
participate in this important hearing.
    Thank you.
    [The prepared statement of Ms. Ilem follows:]
    Prepared Statement of Joy J. Ilem, Deputy National Legislative 
                  Director, Disabled American Veterans
    Mr. Chairman and Members of the Committee: Thank you for inviting 
the Disabled American Veterans (DAV) to testify at this hearing that is 
focused on women veterans, entitled ``Bridging the Gaps in Care.'' This 
hearing is extremely timely given the changing roles of women serving 
in our Armed Forces today, the 1.7 million women veterans who served 
previously, and the dramatically growing number of women seeking health 
care and other benefits from the Department of Veterans Affairs (VA).
    Ensuring equal access to benefits and high quality health care 
services for women veterans is a top priority for DAV. We have a long-
standing resolution from our membership of 1.2 million disabled war 
veterans that seeks to ensure VA health care services for women 
veterans, including gender-specific care, are provided to the same 
degree and extent that services are provided to male veterans. Also, 
given the undoubted greater exposure of servicewomen to combat, we 
believe they should have equal access to supportive counseling and 
psychological services incident to combat exposure. Military sexual 
trauma, while not exclusively a women's issue, is also of special 
concern to DAV. Additionally, we urge VA to strictly adhere to their 
stated policies regarding privacy and safety issues related to the 
treatment of women veterans and to proactively conduct research and 
health studies as appropriate, periodically review its women's health 
programs, and seek innovative methods to address women's barriers to VA 
health care and services, thereby better ensuring women veterans 
receive the treatment and specialized services they rightly earned 
through military service to America.
    Likewise, for many years, the organizations that make up the 
Independent Budget (IB)--AMVETS, DAV, Paralyzed Veterans of America 
(PVA) and Veterans of Foreign Wars of the United States (VFW)--have 
included a special section in the IB emphasizing women veterans, in an 
effort to call attention to the need to address many of the challenges 
VA faces in providing high quality health services to women veterans in 
a predominantly male-oriented health care system. We are pleased to see 
that many of the recommendations made in this section of the fiscal 
year 2010 IB have been addressed by VA in a recent ground-breaking 
publication--Report of the Under Secretary for Health Workgroup: 
Provision of Primary Care to Women Veterans (Report), published in 
November 2008 but released only very recently. Additionally, DAV 
included a special focus on women veterans as part of our ongoing Stand 
Up For Veterans campaign--focusing public attention on the unique needs 
of women veterans--with a special emphasis on women who became disabled 
during their wartime service.
    VA's 2008 Report \1\ reflects the most pressing challenges VA 
faces: specifically, developing the appropriate health care model for 
women in a system that is disproportionately male focused, the 
increasing numbers of women coming to VA for care, the impact of 
changing demographics in the women veteran population, and impact on VA 
health care delivery as well as the already-identified gender 
disparities in quality of care for women veterans.
---------------------------------------------------------------------------
    \1\ U.S. Dept of Veterans Affairs, Office of Public Health and 
Environmental Hazards, Women Veterans Health Strategic Health Care 
Group; Report of the Under Secretary for Health Workgroup: Provision of 
Primary Care to Women Veterans. Washington, DC: November 2008.
---------------------------------------------------------------------------
    Women veterans are the fastest growing segment of the veteran 
population--and according to the Veterans Health Administration (VHA), 
women are projected to account for one in every seven enrollees within 
the next fifteen years, compared to the one in every sixteen enrollees 
today. Because of the large and growing number of women serving in the 
military today, the percentage of women veterans is projected to rise 
proportionately from 7.7 percent of the total veteran population in 
2008, to 10 percent in 2018. Additionally, VA notes that women who 
served in Operations Iraqi and Enduring Freedom (OIF/OEF) utilize VA 
services at a higher rate than other veterans, including other women 
veterans and male OIF/OEF veterans--with 42.5 percent of the 102,000 
OIF/OEF women veterans having enrolled in VA, and nearly 43.8 percent 
who are consuming between two and ten VHA visits per year on average. 
Earlier generations of women veterans enrolled in VA health care at a 
15 percent average rate.\2\
---------------------------------------------------------------------------
    \2\ Patty Hayes, Ph.D., Chief Consultant, Women Veterans Health, 
Strategic Health Care Group, Department of Veterans Affairs; Women 
Veterans Health Care, Evolution of Women's Health Care in the Veterans 
Administration, Page 1. June 2009. www.amsus.org/sm/presentations/
Jun09-B.ppt
---------------------------------------------------------------------------
    As reported by VA, historically, women have underutilized VA health 
in comparison to male veterans. In the past five years, on average, 22 
percent of men versus 15 percent of women have accessed VA health care. 
Women veterans using VA health care are also younger--with an average 
age of 48 compared to male veterans' average age of 61. Among women 
users from OIF/OEF, more than 85 percent are under age 40 and of child-
bearing age, and nearly 60 percent are between the ages of 20-29.\3\ In 
addition, women veterans have been shown to have unique and more 
complex health needs with a higher rate of comorbid physical health and 
mental health conditions, i.e., 31 percent of women have such 
comorbidities versus 24 percent of men. Even with this high rate of 
comorbidity, women veterans receive their primary and mental health 
care in a fragmented model of VA health care delivery that complicates 
continuity of care. In fact, according to the VHA Plan of Care Survey 
for fiscal year 2007, 67 percent of sites provide primary care in a 
multi-site/multi-provider model (i.e., with primary care at one visit 
and gender-specific primary care at another visit), with only 33 
percent of facilities offering care to women in a one-visit model. The 
Under Secretary's workgroup concluded given these facts that there are 
now sufficient numbers of women veterans to support coordinated models 
of service delivery to meet their needs, and that while women will 
always comprise a minority of veterans in the VA system, they represent 
a critical mass as a group and should therefore be factored into plans 
for focused service delivery and improved quality of care.
---------------------------------------------------------------------------
    \3\ Ibid.
---------------------------------------------------------------------------
    As indicated above, we have read with great interest a recently 
released VA publication titled: Report of the Under Secretary for 
Health Workgroup: Provision of Primary Care to Women Veterans, dated 
November 2008. We are impressed with the thoroughness of the review of 
women's care in VHA, and also with the optimism of its recommendations 
to improve women's health. If implemented nationally its 
recommendations could assure that women veterans receive coordinated, 
comprehensive, primary care at every VA facility from clinical 
providers who are trained to meet their needs; an integration of 
women's mental health with primary care in each clinic treating women 
veterans; the promotion of innovation in women's health delivery; 
enhanced capabilities of all staff interacting with women veterans in 
VA health care facilities; and an achievement of gender equity in the 
provision of clinical care within VA facilities.
    As directed by the VA Under Secretary for Health, the workgroup was 
charged with defining the actions necessary to ensure that every woman 
veteran has access to a VA primary care provider who can meet all her 
primary care needs. The workgroup reviewed the current organizational 
structure of VHA's women's health care delivery system, addressed 
impediments to delivering their care in VHA, identified current and 
projected future needs, and proposed a series of recommendations and 
actions for the most appropriate organizational initiatives to achieve 
the Under Secretary's goals.
                           current challenges
    VA noted in its Report that only recently had it begun to address 
development of the most appropriate health care services for women 
veterans at each VA facility. The workgroup identified seven challenges 
that VA must overcome in order to deliver quality, comprehensive 
primary care to women veterans.
    Challenge 1: VA recognizes that women have been under-served in the 
veterans health care system. Utilization rates for men have held at 
approximately 22 percent for many years--while utilization rates for 
women range between 11-19 percent. Research shows that women veterans 
do not self-identify as bona fide veterans, and are more unlikely to be 
unaware of their enrollment eligibility. Of special note to DAV--and 
greatest concern is that among women veterans in this study who had not 
had access to health care in the past 12 months, 18.7 percent of this 
group is service-connected for disability incurred in the line of 
duty.\4\ This finding--that service-connected women veterans are 
without access to health care, are not enrolled in nor using VHA 
services--is especially distressing to DAV.
---------------------------------------------------------------------------
    \4\ Patty Hayes, Ph.D., Chief Consultant, Women Veterans Health, 
Strategic Health Care Group, Department of Veterans Affairs; Women 
Veterans Health Care, Evolution of Women's Health Care in the Veterans 
Administration, Page 15. June 2009. www.amsus.org/sm/presentations/
Jun09-B.ppt
---------------------------------------------------------------------------
    Challenge 2: VA acknowledged there is a clear and growing need for 
improved service delivery to women veterans in VHA. Given the 
significantly higher VA utilization rates among women returning from 
OIF/OEF as indicated above, VA expects the number of women veterans 
coming to VA for care will likely double within the next four years. 
The workgroup noted there are now sufficient numbers of women to 
justify a VA effort to produce coordinated models of service delivery 
to meet their needs--and that as a group women veterans should be 
factored in as a special population cohort in any new strategic plans 
for service delivery.\5\
---------------------------------------------------------------------------
    \5\ Ibid.
---------------------------------------------------------------------------
    Challenge 3: In recent years, VA reports have shown a significant 
demographic shift related to women VA-users and notes the impact of 
age-related health concerns. Given the fact that almost all new users 
of the system are under age 40--and of child-bearing age--there is a 
need for a focused shift in the provision of health care services. The 
Under Secretary's workgroup also noted VA must continue to be sensitive 
to the needs of older women veterans as well, since women over 55 years 
of age face high risks for cardiac disease, cancers and the 
consequences of obesity (such as Type 2 diabetes).
    Challenge 4: The workgroup identified and acknowledged gender 
disparities in quality of care in VHA. Despite positive results on 
gender-specific measures such as screening for cervical and breast 
cancer, significant differences are recorded in VHA performance scores 
between men and women on certain outpatient quality measures that are 
common to both men and women. Specifically, depression and PTSD 
screening, colorectal cancer screening and vaccinations were reported 
as less favorable for women.
    Challenge 5: The workgroup identified routine fragmentation of 
health care delivery to women veterans that poses possible negative 
health outcomes. According to the report, to a large extent, health 
care services offered to women veterans have evolved in a patchwork 
fashion. Some facilities have strong champions with expertise in 
women's health and offer comprehensive services in one location; other 
facilities, however, require women to see several providers for basic 
primary care services, and some VA facilities rely heavily on fee-basis 
providers to care for enrolled women veterans.
    Challenge 6: One of the most significant challenges VHA faces 
according to this workgroup report is an insufficient number of 
clinicians with specific training and experience in women's health. The 
report acknowledges that the historical predominance of male veterans 
in the VA setting has resulted in many providers lacking or having 
limited exposure to women patients.\6\ According to the workgroup, 
women veterans' numerical minority in VHA has created logistical 
challenges in creating and sustaining delivery systems that assure VA's 
goal of equitable access to high quality comprehensive services that 
include gender-specific care.
---------------------------------------------------------------------------
    \6\ Patty Hayes, Ph.D., Chief Consultant, Women Veterans Health, 
Strategic Health Care Group, Department of Veterans Affairs; Women 
Veterans Health Care, Evolution of Women's Health Care in the Veterans 
Administration, Page 16. June 2009. www.amsus.org/sm/presentations/
Jun09-B.ppt
---------------------------------------------------------------------------
    Challenge 7: Finally, the workgroup identified that there is 
inconsistent policy in place for women's health in VHA. The group noted 
that, in previous directives issued by VA Central Office, VA clinical 
staff were required to provide gender-specific care on-site in VA 
facilities, but, that more recent versions of the directives shifted 
the emphasis to ``preferred'' rather than ``required.'' As a result, a 
decline in on-site gynecological services occurred with an increase in 
fee-basis referral for those key women's health care services. The 
workgroup noted that in contrast, gender-related care always has been 
recognized as an integral part of primary care delivery for men in VA 
health care.
    To aid in the implementation of comprehensive health care for women 
veterans at every VA facility, the Women Veterans Health Strategic 
Health Care Group developed a Women's Comprehensive Health 
Implementation Planning (WCHIP) tool. The tool, which outlines a care 
gap analysis, market analysis and needs assessment, was designed to 
help VA facilities and VISNs assess and make decisions about which 
services need to be developed and what resources were necessary to 
carry out those plans. The stated goal was to then have Women Veterans 
Program Managers (WVPM) work directly with strategic planners at their 
VA facilities to incorporate the results of the WCHIP into the health 
care planning model for those facilities. We are pleased the WVPM 
position was made full time in July 2008, since these managers are 
clearly integral to providing increased outreach to women veterans, 
improving quality of care and developing best practices in the delivery 
of care to women veterans throughout the VA health care system.
                    workgroup report recommendations
    The workgroup made a series of key recommendations with 
accompanying action items, as follows:

          Recommendation 1 focuses on the delivery of coordinated, 
        comprehensive primary women's health care at all VA facilities, 
        including the development of systems and structures for care 
        delivery that ensure every woman veteran has access to a 
        qualified primary care physician who can provide care for acute 
        and chronic illnesses, gender specific care, and preventative 
        and mental health services.
          Actions items necessary to achieve this goal include using 
        the WCHIP tool to provide an assessment of the current status 
        of care delivery and resources at each facility; identify steps 
        needed to achieve coordinated comprehensive primary women's 
        health care and implement a practice plan for each facility and 
        women's population in a particular catchment area; provide 
        appropriate funding to build adequate infrastructure and 
        program capacity; increase utilization rates for women and 
        provide staff and resources to conduct outreach and education 
        to women veterans; collect, analyze and report on data related 
        to access, staffing flexibility, and cost to carry out plan; 
        and, coordinate with VA academic affiliates for delivery of 
        comprehensive primary care services to women.
          The workgroup noted that current research evidence, clinical 
        data and the adoption of models of patient-centered care 
        support the advancement of comprehensive primary women's health 
        care and are further supported by existing policies in VHA 
        Handbook 1330.1 and Standards of Primary Care Directive 2006-
        031. These directives state that primary care includes gender-
        specific care services.
          Recommendation 2 seeks to ensure integration of women's 
        mental health care as a part of primary care. The workgroup 
        identified that women veterans using the VA health care system 
        carry a heavy burden of mental illness diagnosis--with 
        depression being the most frequent condition in women seeking 
        care in 2007. PTSD was the fourth most frequent diagnosis 
        reported, above diabetes and hypertension. (page 52 Rec. 2) The 
        workgroup concluded the adoption of the combined provision of 
        primary and mental health care services would help women 
        veterans overcome barriers to access needed mental health care.
          Action items for Recommendation 2 include: assignment of 
        mental health providers in primary care clinics who can provide 
        assessment and psychosocial treatment for a variety of mental 
        health problems, including depression and problem drinking with 
        associated sexual behavior risk factors; facilitating 
        collaboration of behavioral health with primary care to provide 
        ancillary services such as pain management, weight management, 
        and smoking cessation programs designed to meet the needs of 
        women veterans.
          Recommendation 3 focuses on promoting new ways of providing 
        care delivery for women through support of best practices 
        fitted to a particular facility or VISN configuration and the 
        women veteran population in that location or region. The 
        workgroup opined that individual VA facilities are best 
        positioned to develop innovative programs to meet the needs of 
        women veterans, especially sub-populations of minority groups 
        and women veterans from rural areas. We concur with VA that 
        best practices can help address variation in geographic and 
        demographic challenges across the system, and that innovative 
        technologies should be utilized to enhance delivery of care for 
        this population.
          Action items to achieve this goal include: sharing best 
        practice models for comprehensive women's health care through 
        an improved web portal, conferences and other appropriate 
        information transfer methods; developing requests for proposals 
        from VA field facilities for pilot project initiatives using 
        new technology; collaboration between the Offices of Care 
        Coordination and Information to explore new opportunities in 
        telehealth, inclusive of women veterans; recognize and promote 
        local achievements in creating environments of care that 
        support privacy, safety and comfort for women veterans who seek 
        VA care.
          Recognizing that VHA has a longstanding history and focus on 
        male patients, Recommendation 4 addresses the need to cultivate 
        and enhance the capabilities of all VHA staff--including 
        medical providers, clinical support, non-clinical, and 
        administrative staff, to meet the comprehensive health care 
        needs of women veterans. The workgroup acknowledged that 
        despite increasing numbers of women enrolling for VA care, 
        women users of the system continue to be relatively 
        ``invisible.'' We fully concur that a paradigm shift is 
        necessary and that a coordinated training and cultural 
        sensitivity program will be essential to creating an atmosphere 
        of equity and welcome for women veterans in VA health care 
        facilities.
          According to the workgroup, many VA clinical providers have 
        acquired skills during health professions internships or 
        residencies but have subsequently lost those proficiencies in 
        their intervening years working in VA facilities therefore, a 
        concerted effort must be made to cultivate and enhance the 
        capabilities of all VA staff to meet the needs of women 
        veterans. Action items to achieve this goal include: 
        recruitment and training of practitioners to be proficient, 
        knowledgeable, and engaged providers in women's health; funding 
        mini-residency programs in women's primary care programs for 
        current VA providers; continue to strengthen VA-based women's 
        health fellowships; develop recruitment and retention 
        strategies to increase the number of trained staff in women's 
        health; train and sensitize all VA staff on issues specific to 
        women's health care.
          Recommendation 5 seeks to achieve parity in clinical 
        performance measures and gender equity in clinical quality of 
        care issues by addressing the systemic reasons for the 
        identified disparities in outcomes for women using VA in order 
        to effect change in clinical practice.
          Although overall quality of care is high compared to the 
        private sector and despite positive results on gender-specific 
        measures such as screening for cervical and breast cancer, VA 
        acknowledges that clinical quality performance disparities 
        exist in the provision of care to women for certain prevention 
        measures. We are pleased the workgroup states its goal is to be 
        a ``national model for women's health care'' and challenges VA 
        to stand by its principles of providing the highest quality of 
        care--the best care anywhere--and to ensure gender parity in 
        the delivery of VA health care.
          Actions necessary to achieve this goal include: assuring 
        continual measurement of women veterans' health outcomes for 
        gender-specific and gender-neutral care; continuing research 
        that addresses best practice models for delivery of care to 
        women veterans; working closely with the VA Office of Research 
        and Development to better understand the unique health concerns 
        of post-deployed women veterans; developing and implementing a 
        validated tool for routine clinical assessment of sexual 
        activity, risk behaviors, and anticipation of pregnancy.

    These recommendations thoroughly address quality, efficiency, 
access and equity of VA care for women who use VA services. The 
workgroup found the need to improve all these areas in today's VA 
health care programs for women veterans, and to better prepare these 
programs for tomorrow's women veterans. We commend the members of the 
workgroup who contributed so much to what appears to us to be a 
comprehensive roadmap that could lead VA to make great strides in 
improving health programs and services for women veterans.
                                research
    Research plays an integral role in developing the most appropriate 
health care delivery model for women veterans and providing access to 
high quality health care services.
    Over the years, VA researchers have brought to light a number of 
important facts that, if acted upon, would greatly improve the care 
that women veterans receive at VA health care facilities. Among these 
facts, it was shown that access and waiting time scores were better at 
sites where primary care and gender-specific services were available in 
a one-stop setting. VA facilities that have established this type of 
primary care delivery, whether in women's clinics or in general primary 
care, have better patient satisfaction scores on care coordination for 
contraception, sexually transmitted disease screening and menopausal 
management than facilities that separate these services across multiple 
clinics.
    DAV is pleased that VA's Office of Research and Development (ORD) 
supports a comprehensive women's health research agenda, and VA has 
intensified its research on women's health in the last decade. The 
first comprehensive VA women's health research agenda, which covered 
biomedical, clinical, rehabilitative and health services research, was 
directed by ORD in 2004 with the goal of positioning VA as a national 
leader in women's health research. ORD successfully mapped research 
priorities based on the needs of women veterans and capitalized on VA's 
significant and productive research enterprise while using evidence-
based data on the health status and health care needs of women veterans 
to include a systemic literature review on health care research related 
to women veterans and women in the military. Within ORD, VA's Health 
Services Research and Development Service (HSR&D) is at the forefront 
of research focused on understanding and improving the health and 
health care of women veterans.
    ORD currently supports a broad research portfolio that includes: 
studies on diseases prevalent solely or primarily in women; hormonal 
effects on diseases in post-menopausal women; PTSD and other post-
deployment mental health concerns among women; and, osteoporosis and 
multiple sclerosis in women. Gender disparities have also been analyzed 
and highlighted in addition to the disparities in some types of 
preventative care among spinal cord injured women veterans that include 
the need of special equipment and body adjustments required to perform 
care. HSR&D is also currently funding 27 research projects that examine 
the health and health care of women veterans; the consequences of 
military sexual trauma and other military traumas; PTSD treatment in 
women; screening and utilization as well as post-deployment access and 
reintegration issues; utilization; outcomes and quality of care for 
women veterans related to ambulatory care; chronic mental and physical 
illness, alcohol misuse, breast cancer and pregnancy outcomes. HSR&D is 
also in Phase II of a study examining VA's approaches for delivering 
care to women veterans while another is assessing the implementation 
and sustainability of VA women's mental health clinics. These studies 
include OIF/OEF populations.
    We look forward to the results of these 27 research projects, and 
applaud VA for standing in the forefront and leading the way in 
assuring our women veterans that they will secure the same access to 
and quality of care that their male counterparts receive in the VA 
health care system.
                                summary
    We congratulate the Women Veterans Health Strategic Health Care 
Group for an extraordinarily forthcoming report and highly relevant 
series of goal-oriented recommendations and action items. These 
recommendations are fully consistent with a series of recommendations 
that have been made in recent years by VA researchers, experts in 
women's health, VA's Advisory Committee on Women Veterans, the 
Independent Budget, and DAV. DAV Resolution 238 seeks to ensure high 
quality comprehensive VA health services for all women veterans, with a 
special focus on the unique post-deployment needs of women veterans 
returning from OIF/OEF. DAV's resolution notes that VA needs to 
undertake a comprehensive review of its women's health programs, and to 
seek innovative methods to address barriers to care for women veterans 
to ensure they receive the treatment and specialized services they need 
and deserve. Therefore, we fully support the recommendations made in 
the Report and urge their speedy implementation.
    We are pleased that VA Secretary Shinseki has testified previously 
that the delivery of enhanced primary care for women veterans is one of 
VA's top priorities. Likewise, the Women Veterans Health Strategic 
Health Care Group's commitment to assuring all eligible women veterans 
will receive gender-specific primary care by proficient and interested 
primary care providers; privacy, dignity, and sensitivity to gender-
specific needs; state-of-the-art health equipment and technology; 
gender parity in performance measures; and, the right care in the right 
place and time are all laudable goals. We fully concur with the 
workgroup's conclusion that ``the debt owed to all our veterans and to 
women in particular demands nothing less than our full attention.''
    However, making these goals a reality will require VA's building 
the proper resources and adequate infrastructure and program capacity 
and developing the internal support necessary at the highest levels to 
make the changes it says are needed. Without question, this is a 
significant undertaking by VA and there is a lot of hard work ahead to 
achieve the goals it has set out for itself, but we are hopeful with 
the attention, oversight and collaboration of this Committee that VA 
can achieve implementation of the recommendations in this report.
    Mr. Chairman, a number of public events focused on women veterans 
have been held in recent months. All are essential to the process of 
change; however, nothing is more important than taking action. For 
these reasons DAV urges the Committee to carefully consider the 
recommendations outlined in the Provision of Primary Care to Women 
Veterans Report and to support VA's efforts to achieve these reforms.
    We would like to point out, Mr. Chairman, that as of March 11, 
2009, this landmark report on women veterans was distributed to VA 
field facilities and to regional network management offices within VHA. 
However, its transmittal to the field by VA Central Office did not take 
the form of a VHA directive; nor did it convey any mandatory 
implementation requirements or accountability on the part of local or 
regional officials. It was simply transmitted to VA field elements as 
an informational device, apparently for their discretionary use in 
planning. We recognize that VA has been making a good faith effort to 
move forward on its plans for improving women veterans' health 
services, and it is clear from VA correspondence included at the end of 
the workgroup report that at multiple levels work is underway to assess 
and implement principles outlined in the report. However, we note there 
is no formal expression of policy or directive to fill the gaps that 
this report identified.
    For these reasons we ask the Committee to oversee and seek VA's 
commitment to issue instructions to all VA health care personnel who 
will be held accountable for implementation of this comprehensive 
policy. The implementation phase should include establishing 
performance measures for facility and network executive staffs, 
submission of appropriate reports and provision of other oversight to 
ensure these reforms are implemented and sustained at every VA facility 
caring for women veterans. Additionally, we ask that Congress ensure VA 
is provided sufficient resources to accomplish these essential reforms.
    As you know, women are a growing population within the ranks of the 
active, Guard and Reserve forces of our Armed Services, and women 
veterans are streaming into VA health care by the thousands. Soon women 
veterans will share ranks nearly two million strong and will constitute 
one of every seven veterans enrolled in VA health care. Expectations 
for VA to step up to this challenge are high, and this report by VHA's 
own workgroup clearly reveals the necessity for VA to make significant 
changes in the short term to begin better addressing women's needs in 
the long term. This workgroup report is an excellent beacon to show 
them the way, but we must have, and seek assurance that its 
implementation will be faithfully executed.

    Mr. Chairman, again we thank you for the opportunity to share our 
views at this important hearing focused on women veterans--and bridging 
the gaps in their care. We will appreciate your consideration of our 
views on this pressing and important matter to America's women 
veterans. I would be pleased to address your questions, or those of 
other Committee Members.

    Chairman Akaka. Thank you very much for your testimony. I 
want you to know that your prepared remarks will be, of course, 
made part of the hearing record.
    So, now, let me call on Ms. Christopher.

 STATEMENT OF TIA CHRISTOPHER, U.S. NAVY VETERAN; IRAQ VETERAN 
PROJECT PROGRAM ASSOCIATE, WOMEN VETERAN COORDINATOR FOR SWORDS 
                         TO PLOWSHARES

    Ms. Christopher. Thank you, Mr. Chairman and Members of the 
Committee for allowing me to speak.
    My name is Tia Christopher. I'm a U.S. Navy veteran, and 
Woman Veterans Coordinator for the veteran non-profit Swords to 
Plowshares. I speak before you today both in my professional 
capacity and from my personal experience as a woman veteran.
    I am 70 percent VA-rated disabled veteran for PTSD and 
military sexual trauma. My experiences have given me the 
passion and perseverance to do advocacy work on behalf of 
Swords to Plowshares. I mention this to illustrate that I am a 
VA consumer, as well as a community avenue for my peers to seek 
and access care.
    The VA has made notable strides in the care of our Nation's 
women veterans. I would not be the person I am today without 
the young woman veteran PTSD groups established at some VA 
medical centers.
    Even as we acknowledge the amazing strides that have been 
made, it must be noted that services and support for women 
remain insufficient both in quality and accessibility. More 
women are serving in the military than ever before.
    No one entity should be expected to provide the breadth of 
services and support needed for female veterans. There needs to 
be a coordination and collaboration between the DOD, VA, and 
community providers in order to delivery adequate care.
    Community providers, such as Swords to Plowshares, are on 
the frontlines everyday serving veterans from all our Nation's 
conflicts. Because of the historical lack of gender-appropriate 
services, it is critical that no door be the wrong door to 
accessing care.
    Resources are stretched--we all know that--both for the 
government and non-profits. Women veterans may seek assistance 
in the community, which do not address their underlying health 
issues, but address their pragmatic needs in the moment.
    For example, I had a young woman Air Force veteran come in 
initially asking for help finding a job, but, at the end of our 
conversation, it became evident she was homeless. This young 
women who honorably served her country divulged that she was 
now selling her body just to get by. It broke my heart that 
this sister veteran of mine had been reduced to this.
    Because of the specific employment and training services 
that Swords provides and the fact that she was able to speak 
with a fellow female veteran, she felt comfortable asking for 
help. In this case, she needed mental health attention, as 
well. Services need to reflect the myriad, co-occurring issues 
surrounding our female veterans and care providers need to be 
versed in how to appropriately and comprehensively address 
these issues.
    This veteran is not unique in her experience. Female 
veterans frequently access community care rather than VA care, 
which is often times less of a hurdle to navigate, as well as 
less intimidating. Swords to Plowshares conducted focus groups 
of female veterans in San Francisco, during which many 
participants noted barriers to VA services.
    One stated, ``If you do have benefits available through the 
VA, you have to be very persistent, you have to want to get 
your benefits, and you have to fight for them. If the benefits 
are there, you're entitled to them, and you just have to find 
the right person in the office that's going to help you fight 
for them.''
    Women need not only more gender-specific care, but also 
care that is appropriate for their needs. The gender of a 
mental health provider does not necessarily qualify them to 
treat that woman veteran. It is essential that women who do 
need inpatient treatment for PTSD, whether combat or sexual 
assault-related, receive care in a safe treatment space. A coed 
environment can truly be the worst thing for a woman suffering 
from military sexual trauma and PTSD. We need more woman-
veteran-only inpatient VA programs.
    Just having the resources is not enough. Again, the 
quality, quantity, and accessibility of that care is vital. For 
those who are uncomfortable receiving treatment at a VA 
facility for whatever reason, funding needs to be allotted for 
culturally-competent care within the community.
    Both government and community entities need to be educated 
on the specific needs of women veterans. I regularly speak 
during the community panel portion of the National Center for 
PTSD's Clinical Training Program. Sharing my story and 
experience navigating the VA system and receiving treatment has 
helped these clinicians better understand their patients.
    The Iraq Veteran Project of Swords to Plowshares is 
primarily composed of staff who are veterans. We provide 
foundation-funded free panel representations for VA clinicians 
and community behavioral health providers on issues such as 
prevalence of PTSD, TBI, MST, military terminology 
clarification, triggers, cultural obstacles to care, and 
effective outreach approaches. This has led to greater dialog 
and collaboration among community and government entities 
treating veterans, as well as help the veterans themselves feel 
that they are understood by their caregivers.
    Thank you very much for your time.
    [The prepared statement of Ms. Christopher follows:]
  Prepared Statement of Tia Christopher, U.S. Navy Veteran and Women 
    Veteran Coordinator--Iraq Veteran Project, Swords to Plowshares
    Good morning. Thank you, Senators, for allowing me to speak. My 
name is Tia Christopher. I am a U.S. Navy veteran and Women Veterans 
Coordinator for the veteran nonprofit Swords to Plowshares. Our 
organization has been helping veterans since 1974.
    In response to the wars in Iraq and Afghanistan, we established the 
Iraq Veteran Project to specifically address the needs of the newest 
generation of veterans. Following the formation of the Iraq Veteran 
Project, Swords created my position to respond to the specific needs of 
the fastest growing cohort of the U.S. veteran population: Women. I 
speak before you today both in my professional capacity and from my 
personal experience as a woman veteran. I am a 70% VA-rated, disabled 
veteran for PTSD and Military Sexual Trauma. My experiences have given 
me the passion and perseverance to do advocacy work on behalf of Swords 
to Plowshares. I mention this to illustrate that I am a VA consumer as 
well as a community avenue for my peers to seek and access care.
    The Department of Defense has made considerable progress in the 
eight years since I served. Significant steps have been made in the 
area of sexual assault prevention; (i.e.: the establishment of the SAPR 
program). In the same spirit, the VA has made notable strides in the 
care of our Nation's women veterans. I would not be the person I am 
today without the young women veteran PTSD groups established at some 
VA medical centers. Even as we acknowledge the amazing strides that 
have been made, it must be acknowledged that services and support for 
women remain insufficient both in quality and accessibility. More women 
are serving in the military than ever before. No one entity should be 
expected to provide the breadth of services and support needed for 
female veterans. There needs to be coordination and collaboration 
between the DOD, VA, and community providers in order to deliver 
adequate care.
    Community providers such as Swords to Plowshares are on the front 
lines every day serving veterans from all our Nation's conflicts. 
Because of the historical lack of gender appropriate services it is 
critical that no door be the wrong door to accessing care. Resources 
are stretched; we all know that, both for the government and 
nonprofits. I am scrambling every day to find resources for the women 
veterans who come through our door.
    Whether it is housing, inpatient programs, or resources for their 
families, services are insufficient for women veterans. Women veterans 
may seek out services in the community which don't address their 
underlying health needs but address their pragmatic needs in the 
moment. For example, I had a young woman Air Force veteran come in 
initially asking for help finding a job, but at the end of our 
conversation it became evident she was homeless. This young woman who 
honorably served her country divulged that she was now selling her body 
just to get by. It broke my heart that this sister veteran of mine had 
been reduced to this.
    Because of the specific employment and training services that 
Swords provides, and the fact that she was able to speak with a fellow 
woman veteran, she felt comfortable asking for help. In this case, she 
needed mental health attention as well. Services need to reflect the 
myriad co-occurring issues surrounding our female veterans; and care 
providers need to be versed in how to appropriately and comprehensively 
address these issues.
    This veteran is not unique in her experience; female veterans 
frequently access community care rather than VA care, which is 
oftentimes less of a hurdle to navigate, as well as less intimidating. 
Swords to Plowshares conducted focus groups with female veterans in San 
Francisco, during which many participants noted barriers to VA 
services. One participant stated, ``If you do have benefits available 
through the VA, you have to be very persistent. You have to want to get 
your benefits, and you have to fight them for it. The benefits are 
there, you're entitled to them, and you just have to find the right 
person in the office that's going to help you fight for them.''
    Women need not only more gender specific care, but also care that 
is appropriate for their needs. It is essential that women who do need 
inpatient treatment for PTSD, whether combat or sexual assault related, 
receive care in a safe treatment space. A coed environment can truly be 
the worst thing for a woman suffering from Military Sexual Trauma (MST) 
and PTSD. Just having the resources is not enough, again, the quality, 
quantity, and accessibility of that care is vital. For those who are 
uncomfortable receiving treatment at a VA facility, for whatever 
reason, funding needs to be allotted for culturally competent care 
within the community.
    Both government and community entities need to be educated on the 
specific needs of women veterans. I regularly speak during the 
community panel portion of the National Center for PTSD's clinical 
training program. Sharing my story and experience navigating the VA 
system and receiving treatment has helped these clinicians better 
understand their patients. The Iraq Veteran Project is primarily 
composed of staff who are veterans. We provide free panel presentations 
for clinicians and community behavioral health providers on issues such 
as prevalence of PTSD, TBI and MST, military terminology clarification, 
triggers, language, cultural obstacles to care, and effective outreach 
and treatment approaches. Sessions such as these are a foundation-
funded free service provided by our nonprofit to government and 
community entities. This has led to greater dialog and collaboration 
among the various entities treating veterans, as well as helping the 
veterans themselves feel that they are understood by their caregivers.
    Another area of great concern is an understanding of the resources 
available to them, and an understanding of what to expect during 
transition. I encountered dry, outdated materials that were difficult 
to digest and did not speak to me as a young veteran. As a result, 
Swords to Plowshares published our OIF/OEF transition manual written in 
familiar language from one veteran to another. The concept behind this 
manual is not profound- however- it is unique in its approach and has 
been met with extremely positive feedback from DOD, VA, and community 
entities, as well as from the veterans themselves. Materials such as 
this could considerably augment and aid accessibility to VA services on 
a nationwide scale. This is one example of how the community and the VA 
can work together. Based on the success of this manual written for both 
genders, it is my dream to write one specifically for women veterans, 
working in partnership with the DOD and VA.
    Finally, women veterans have expressed their need for resources 
strictly for them. During the focus groups with Swords to Plowshares 
many expressed the need for peer-based emotional support. One 
participant stated, ``Getting support from other military veterans 
definitely helps. We have something in common.'' One answer to this has 
been weekend retreats. In October 2008 several veteran nonprofits came 
together with the support of several VAs, Vet Centers, and active duty 
bases. This retreat was attended by OIF/OEF women veterans, reservists, 
and active duty. The overwhelming response from the 25 participants was 
how important it was for them to have a space to call their own. Being 
surrounded by their peers was integral for their healing; they heard 
and saw that they were not alone. This experience not only aided in 
their healing and transition process into the civilian world, but also 
functioned as a successful augmentation to the post-deployment process. 
In the words of one participant, ``Thank you for recognizing this 
aching need for women veterans to meet and bond with other women 
veterans. Military service as a female . . . has been a very lonely and 
isolated experience, and I wish that I had been able to attend a 
workshop/retreat like this much earlier in my military career. Perhaps 
if such a support group/network had been established for me early on, I 
would not have struggled so much (or at least, not alone) through the 
dark valleys of depression and self-doubt that I traversed as a young 
female in the military.''
    The following are a list of recommendations for greater access to 
care for women veterans:

     Mandatory and routine training for VA clinicians on the 
specific issues facing women veterans.
     Resources available for VA providers to include: issues 
facing female combat veterans; military era specific information (i.e., 
OIF/OEF versus the Vietnam era); military terminology; the differences 
between Military Sexual Trauma and sexual trauma in a civilian setting; 
co-occurring combat and sexual trauma based PTSD, sometimes referred to 
as ``The Double Whammy;'' etc.
     Escorts at VA facilities for women veterans not 
comfortable going alone. This ``battle buddy'' system could be 
implemented at no cost to the VA through use of volunteers, the 
Chaplain Service, and veteran peers. This simple gesture could 
eliminate a huge barrier to care.
     Development of permanent women-only clinics at VA 
facilities, and improved signage at all VA facilities designating where 
the women's clinic is.
     Separate entrances or waiting areas that are safe and 
monitored.
     Childcare and extended clinic hours, at least for mental 
health. Some VA facilities do have extended hours, however this option 
needs to be universal regardless which community women veterans return 
to.
     More female only inpatient PTSD and MST programs. For 
veteran nonprofits providing these programs, greater collaboration 
between the VA and these entities needs to occur.
     Greater outreach concerning the eligibility for veterans 
with MST.
     Utilization of peer based approaches and the retreat model 
to supplement care received at the VA.
     More collaboration with community entities and the DOD to 
truly make transition seamless.
     VA to track rates of MST and subsequent early discharge 
from military service to provide evidence that rates of MST are a 
retention issue for the DOD.
                       about swords to plowshares
    War causes wounds and suffering that last beyond the battlefield. 
Swords to Plowshares mission is to heal the wounds, to restore dignity, 
hope and self-sufficiency to all veterans in need, and to significantly 
reduce homelessness and poverty among veterans.
    Founded in 1974, Swords to Plowshares is a community-based not-for-
profit organization that provides counseling and case management, 
employment and training, housing and legal assistance to homeless and 
low-income veterans in the San Francisco Bay Area.
    We promote and protect the rights of veterans through advocacy, 
public education, and partnerships with local, state and national 
entities. Over the years the name Swords to Plowshares has become 
synonymous with excellence in serving veterans in need, a highly 
visible yet dramatically underserved population. We developed a model 
of coordinated care based on the philosophy that the many obstacles 
veterans face-including homelessness, unemployment and disability-are 
interrelated and require an integrated network of support.
Frontline Drop-In Center
    Provides mental health services, including counseling for drug and 
alcohol problems and PTSD, as well as case management, income advocacy 
and referrals.
Supportive Housing
    We offer permanent supportive housing combined with options for 
counseling, academic instruction and vocational training for 102 
formerly homeless disabled veterans. Additionally, we provide 
transitional housing for 75 veterans at a time for intensive 
individual, group and peer counseling and a variety of recreational, 
cultural and community-building activities. Both housing programs 
provide daily hot meals to residents.
Employment Support
    Swords to Plowshares helps veterans make the transition to gainful 
employment by offering vocational counseling, life-skills training, 
resume preparation and job referrals.
Legal Services
    Many of our country's veterans never apply for or receive the 
benefits they deserve. Swords to Plowshares is one of the few 
organizations in the country that provides free attorney 
representation, case management and advocacy to indigent veterans 
seeking benefits.
The Iraq Veteran Project
    Launched in 2005 to make sure systems of care are appropriate, 
sufficient and accessible to meet the needs of veterans returning from 
the wars in Iraq and Afghanistan, and the needs of their families as 
well.

    Chairman Akaka. Thank you, Ms. Christopher.
    Now Ms. Chase.

   STATEMENT OF GENEVIEVE CHASE, U.S. ARMY RESERVE VETERAN; 
          EXECUTIVE DIRECTOR, AMERICAN WOMEN VETERANS

    Ms. Chase. Mr. Chairman and Members of the Subcommittee, 
thank you for inviting us to testify today.
    My name is Genevieve Chase, and I am a Founder and 
Executive Director of American Women Veterans. On behalf of my 
peers, I would like to thank you for your commitment and 
dedication to serving the growing number of women veterans.
    I am a veteran of combat operations in Afghanistan. While 
serving in the Army Reserve, I volunteered for a 32-month 
active-duty tour, which included deployment in support of 
Operation Enduring Freedom.
    On April 7, 2006, our vehicle was attacked by a suicide 
vehicle-borne, improvised explosive device. The car that hit 
our truck nearly disintegrated. Although I suffered minor 
external injuries, the impact of that explosion has continued 
to this day, and I now know that we were not adequately 
informed of the services available to us after our service.
    The Reserve soldiers I served with were discharged from 
active service with a 5-minute out-briefing. A single sheet of 
paper listing Web sites to access for VA health care and 
services. What I recall from that time was that being focused 
on overwhelming issues, like finding a job and figuring out how 
I was going to make it in a civilian world that had become 
somewhat foreign to me, not on service-related health issues I 
would face in the months to come or how I would seek care for 
those issues. I was not and am not alone in this.
    Weeks after returning home, I began to experience 
additional symptoms that I now know to be characteristic of 
Post Traumatic Stress and mild Traumatic Brain Injury, such as 
extreme guilt, anxiety, panic attacks, memory loss, 
hyperactivity, and bouts of deep depression, in addition to 
periods of consecutive days where I suffered exhaustion from 
insomnia and lacked the energy to leave my apartment or speak 
to anyone.
    During the past 2 years, I have gone to the VA Web site 
repeatedly and called the VA to pursue an assessment and 
screening for TBI and other related issues. After attempting to 
navigate through the bureaucracy, I gave up, frustrated by an 
unclear Web site and unfriendly service on the other end of the 
phone.
    I looked to the VA for help when I most needed it, but 
never succeeded in completing my enrollment, let alone actually 
receiving the care that I needed. In communicating with other 
veterans, I have found that I am hardly alone in this, as well.
    While the VA struggles to catch up and provide adequate, 
gender-specific care to previous generations of women veterans, 
the total number of women veterans is projected to double in 
the next 10 years. It is vital that this Nation proactively and 
immediately address the broad spectrum of treatment needs for 
this significant increase in the women veteran population.
    VA resources for women must expand to meet the growing 
number of combat-experienced women; and women dealing with PTS, 
military sexual trauma, and TBI must be able to find easily-
accessible and concise information and guidance about these 
vital services when needed. Veterans should not need a third 
party to help them navigate the VA system.
    AWV believes that women veterans of all generations are 
entitled to VA services that include women-only clinics, women 
providers, holistic care, extended service hours, offsite care, 
PTSD and MST peer support groups, and the availability of 
childcare during clinic visits. But even with all of these 
services, women must know they are eligible, they must be 
enrolled, and they must have access to the VA.
    Despite the VA's efforts and claims of educating and 
reaching out to today's veterans, the message is not getting 
through. Even minor changes in the delivery of this message can 
have a huge impact.
    As just one example, women veterans from all eras have 
expressed to me that they would prefer to receive immediate e-
mail updates on VA benefits and services rather than periodic, 
automatic mailings, which do not always get forwarded through 
the postal system. AWV believes the best way to improve access 
to the VA is for servicemembers to be educated and enrolled 
into VA services while they are still on active-duty.
    Briefings, workshops, and enrollment for VA benefits must 
be mandatory and should be conducted by knowledgeable 
representatives from the VA. Reaching out to all veterans prior 
to their discharge from active-duty would address several 
issues to include raising awareness and knowledge of 
eligibility for benefits and care; allowing continuity of care 
and eligibility from hospital to hospital; and offering 
immediate availability of physical and mental health care when 
needed rather than after lengthy and unknown waiting periods.
    Veterans getting the care they need when they need it can 
help prevent a number of extended issues which includes extreme 
depression, which contributes significantly to the risk of 
homelessness, substance abuse, and suicide.
    In closing, our Nation's veterans from all eras answer this 
country's call to service, and the VA has the unique and 
rapidly-growing challenge of ensuring easily-accessible, 
quality services for women veterans across the spectrum from 
childbearing years to well beyond retirement.
    On behalf of American Women Veterans, thank you for working 
to honor and repay the service of all veterans through this 
inclusive dialog, and we thank you for your commitment to 
ensure the quality and scope of physical and mental health care 
that today's American women veterans have earned by their 
service.
    Ladies, gentlemen, and Mr. Chairman, I thank you for your 
time and consideration and welcome your questions.
    [The prepared statement of Ms. Chase follows:]
   Prepared Statement of Genevieve Chase, U.S. Army Reserve Veteran, 
 Operation Enduring Freedom; Founder and Executive Director, American 
                             Women Veterans
    Mr. Chairman and members of the Subcommittee, Thank you for 
inviting us to testify today. My name is Genevieve Chase and I am the 
Founder and Executive Director of American Women Veterans (AWV). On 
behalf of my peers, I would like to thank you for your commitment and 
dedication to serving the growing number of women veterans.
    I am a veteran of combat operations in Afghanistan. While serving 
in the Army Reserve, I volunteered for a 32-month active duty tour, 
which included a deployment in support of Operation Enduring Freedom. 
On April 7, 2006, our vehicle was attacked by a suicide vehicle-borne, 
improvised explosive device. The car that hit our truck nearly 
disintegrated. Although I suffered minor external injuries, the impact 
of that explosion has continued to this day and I now know that we were 
not adequately informed of the services available to us.
    The reserve soldiers I served with were discharged from active 
service with a five-minute out-briefing and a single sheet of paper 
listing Web sites to access for VA services. What I recall from that 
time was being focused on overwhelming issues like finding a job and 
figuring out how I was going to make it in a civilian world that had 
become somewhat foreign to me--not on the service related health issues 
I would face in the months to come or how I would seek care for those 
issues.
    Weeks after returning home, I began to experience additional 
symptoms that I now know to be characteristic of Post Traumatic Stress 
(PTS) and mild Traumatic Brain Injury (TBI), such as: extreme guilt, 
anxiety, panic attacks, and bouts of deep depression--in addition to 
periods of consecutive days where I suffered exhaustion from insomnia 
and lacked the energy to leave my apartment or speak to anyone.
    During the past two years, I have gone to the VA Web site 
repeatedly and called the VA to pursue an assessment and screening for 
TBI and other related issues. After attempting to navigate through the 
bureaucracy, I gave up, frustrated by an unclear Web site and 
unfriendly service on the other end of the phone. I looked to the VA 
for help when I most needed it, but never succeeded in completing my 
enrollment, let alone actually receiving the care I needed. In 
communicating with other veterans, I have found that I am hardly alone 
in this.
    While the VA struggles to catch up and provide adequate, gender 
specific care to previous generations of women veterans, the total 
number of women veterans is projected to double in the next 10 years. 
It is vital that this Nation proactively address--immediately--the 
broad spectrum of treatment needs for this significant increase in the 
women veterans population. VA resources for women must expand to meet 
the growing number of combat-experienced women; and women dealing with 
PTS, Military Sexual Trauma (MST) and TBI must be able to find easily-
accessible and concise information and guidance about these vital 
services when needed. Veterans should not need a third party to help 
them navigate the VA system.
    AWV believes that women veterans of all generations are entitled to 
VA services that include women-only clinics, women providers, holistic 
care, extended service hours, offsite care, PTSD and MST peer support 
groups, and availability of childcare during clinic visits. But even 
with all of these services; women must know they are eligible, must be 
enrolled and must have access to the VA.
    Despite the VA's efforts and claims of educating and reaching out 
to today's new veterans, the message is not getting through. Even minor 
changes in the delivery of this message can have a huge impact. As just 
one example, many women veterans have expressed to me that they would 
prefer to receive immediate email updates on VA benefits and services 
rather than periodic automatic mailings which don't always get 
forwarded through the postal system.
    AWV beleives the best way to improve access to the VA is for 
servicemembers to be educated and enrolled into VA services while they 
are still on active duty.
    Briefings, workshops and enrollment for VA benefits must be 
mandatory, and should be conducted by knowledgeable representatives 
from the VA. Reaching out to all veterans prior to their discharge 
would address several issues to include:

     Raising awareness and knowledge of eligibility of benefits 
and care,
     Allowing continuity of care and eligibility from hospital 
to hospital, and
     Offering immediate availability of physical and mental 
health care when needed, rather than after lengthy and unknown waiting 
periods.
    Veterans getting the care they need, when they need it, can help to 
prevent a number of extended issues to include extreme depression which 
contributes significantly to the risk of homelessness, substance abuse 
and suicide.
    In closing, our Nation's veterans from all eras answered this 
country's call to service and the VA has the unique and rapidly growing 
challenge of ensuring easily accessible, quality services for women 
veterans across the spectrum, from child-bearing years to those well 
beyond retirement. On behalf of American Women Veterans, thank you for 
working to honor and repay the service of all veterans through this 
inclusive dialog, and we thank you for your commitment to ensure the 
quality and scope of physical and mental healthcare that today's women 
veterans have earned by their service.

    Ladies, gentlemen and Mr. Chairman, I thank you for your time and 
consideration and welcome your questions.

    Chairman Akaka. Thank you very much, Ms. Chase.
    Now we'll hear from Ms. Williams.

   STATEMENT OF KAYLA M. WILLIAMS, U.S. ARMY VETERAN; BOARD 
                    MEMBER, GRACE AFTER FIRE

    Ms. Williams. Mr. Chairman and Members of the Committee, 
thank you for hearing me speak today. On behalf of women 
veterans, I would like to thank you all for your commitment to 
meeting the changing needs of our Nation's veterans.
    My name is Kayla Williams. I sit on the Board of Directors 
of Grace After Fire, a non-profit dedicated to helping women 
veterans.
    As a soldier with the 101st Airborne Division, Air Assault, 
I took part in the initial invasion of Iraq in 2003, and was 
there for approximately 1 year. As an Arabic linguist, I went 
out on combat foot patrols with the infantry in Baghdad.
    During the initial invasion, my team came under small arms 
fire. Later, in Mosul, we were mortared regularly. I served 
right alongside my male peers. With our flak vests on during 
missions, we were all truly Soldiers first.
    However, it became clear upon our return that, as Senator 
Murray noted, most people do not understand what women in 
today's military experience. I was asked whether, as a woman, I 
was even allowed to carry a gun; and I was also asked whether I 
was in the infantry. This confusion about what role women play 
in war today extends beyond the general public. Even VA 
employees are still sometimes unclear on the nature of modern 
warfare, which presents challenges for women seeking care.
    For example, since women are supposedly barred from combat, 
they may face challenges proving that their PTSD is service-
connected. It is vital that all VA employees, particularly 
health care providers, fully understand that women do see 
combat in Operations Iraqi Freedom and Enduring Freedom, so 
that they can better serve women veterans.
    Many of the other problems that women face when seeking 
health care through the VA are by no means exclusive to women. 
The transition from DOD to VA remains imperfect, despite 
efforts to improve the process--lost records and missing 
paperwork are frequent complaints. Despite a growing number of 
community clinics and Vet Centers, many veterans face lengthy 
travel times to reach a VA facility, which is a particular 
burden during these tough, economic times. Often, other 
barriers may disproportionately affect women.
    For example, since women are more likely to be the primary 
caregivers of small children, they may require help in getting 
childcare to attend appointments at the VA. Currently, many VA 
facilities are not prepared to accommodate the presence of 
small children. Several friends have described having to change 
babies' diapers on the floors of VA facilities because the 
restrooms lacked even the most basic changing tables.
    Another friend, whose babysitter canceled at the last 
minute, brought her infant and toddler to a VA appointment. The 
provider told her that it was not appropriate, and that if she 
could not find childcare, she should not even bother to come 
in.
    Facilities in which to nurse and change babies, increased 
availability of telehealth or telemedicine, and/or childcare 
assistance, or at least patience with the presence of small 
children, would ease the burdens on all veterans with small 
children, especially women.
    Women in the military are also far more likely to be 
married to other servicemembers. These women veterans must 
worry not only about their own readjustments to civilian life, 
but also the challenges their husbands may be facing. The VA 
must consider the dual role that women veterans may be 
balancing as both givers and seekers of care.
    My husband, for example, sustained a penetrating Traumatic 
Brain Injury in Iraq, and was medically retired from the 
military. This impacted my decision not to reenlist because he 
needed assistance that he simply was not getting. It was years 
before I realized that, as both a caregiver and a veteran, I 
needed to not simply suck it up and drive on as the military 
taught, but rather had to reach out for help and support.
    When struggling to cope with invisible wounds of war, such 
as PTSD or in simply facing challenges readjusting post-combat, 
peer support can be vital. However, there are things about 
women's experiences in war zones that our male peers simply do 
not understand.
    They cannot truly know what it is like to fear not only the 
enemy, but also sexual assault from your brothers in arms. They 
may be aware of, but not fully able to empathize with the 
challenges of facing regular sexual harassment, and they 
certainly do not understand what it is like to feel invisible 
as a veteran, as many women veterans do. It is, therefore, 
vital that the VA provide times and/or places where women 
veterans--especially those who may have experienced military 
sexual trauma--can feel safe and comfortable in seeking help in 
a community of their peers. These are all challenges that I am 
confident every VA hospital can meet and overcome.
    In 2006, I went to the VA Medical Center in Washington, DC. 
My visit was uncoordinated, stressful, and confusing. The 
facility did not smell clean and was crowded with veterans who 
seemed to have poorly-managed mental health concerns. I was not 
given clear information about what services were available to 
me.
    My husband also went to that VA in 2006. He was regularly 
told that he was at the wrong clinic and sent from one office 
to the other. Doctors gave him the impression that he and his 
issues were an inconvenience at best. My husband's inability to 
schedule timely, well-coordinated appointments eventually made 
him give up on getting care from the VA at all.
    We both began relying exclusively on TRICARE for all of our 
medical and mental health needs, even though civilian providers 
we see are less familiar with combat injuries and Post 
Traumatic Stress.
    My visit to the VA Medical Center in Martinsburg, West 
Virginia, last month, however, was a stark contrast to both my 
previous experience and the experiences that I have heard about 
from other women veterans at some facilities.
    There was a women's restroom clearly visible in the lobby. 
It was clean. There was a changing table available. I was 
treated as a veteran at all times, asked about my combat 
experiences, and sensitively asked if I had experienced sexual 
harassment or assault in the military. Providers carefully 
coordinated my visit, ensured that I was aware of all available 
resources, and followed-up promptly and thoroughly.
    Their OEF/OIF integrated care clinic and newly-opened 
women's clinic are models worthy of emulation, and I truly 
believe that with continued advocacy and oversight, all VA 
facilities can provide that same standard of care.
    In order to best meet the needs of all veterans, I also 
urge the development of enhanced relationships not only between 
the DOD and VA, but also with those community organizations 
that are ready and willing to fill gaps in services. Public-
private partnerships can allow all of us to come together to 
meet the needs of our veterans in innovative and exciting ways. 
I strongly urge that all legislators support S. 597, which will 
help better meet the needs of women veterans.
    Thank you all so much for working to assess VA's health 
care services for women veterans and for your efforts to 
improve care for all of our Nation's veterans.
    [The prepared statement of Ms. Williams follows:]
  Prepared Statement of Kayla M. Williams, Author: Love My Rifle More 
Than You: Young and Female in the U.S. Army; Board of Directors, Grace 
                After Fire; Senior Adviser, VoteVets.org
    Mr. Chairman and Members of the Committee, thank you for hearing me 
speak today. On behalf of women veterans, I would like to thank you all 
for your commitment to meeting the changing needs of our Nation's 
veterans.
    My name is Kayla Williams. As a Soldier with the 101st Airborne 
Division (Air Assault), I took part in the initial invasion of Iraq in 
2003, and was there for approximately one year. As an Arabic linguist, 
I went on combat foot patrols with the Infantry in Baghdad. During the 
initial invasion, my team came under small arms fire. Later, in Mosul, 
we were mortared regularly. I served right alongside my male peers: 
with our flak vests on during missions, we were all truly Soldiers 
first.
    However, it became was clear upon our return that most people did 
not understand what women in today's military experience. I was asked 
whether as a woman I was allowed to carry a gun, and was also asked if 
I was in the Infantry. This confusion about what role women play in war 
today extends beyond the general public; even Veterans Affairs (VA) 
employees are still sometimes unclear on the nature of modern warfare, 
which presents challenges for women seeking care. For example, being in 
combat is linked to Post Traumatic Stress Disorder (PTSD), but since 
women are supposedly barred from combat, they may face challenges 
proving that their PTSD is service-connected. One of my closest friends 
was told by a VA doctor that she could not possibly have PTSD for just 
this reason: he did not believe that she, as a woman, could have been 
in combat. It is vital that all VA employees, particularly health care 
providers, fully understand that women do see combat in Operations 
Iraqi Freedom and Enduring Freedom so that they can better serve women 
veterans.
    Many of the other problems that women face when seeking to get 
health care through the VA are by no means exclusive to women: the 
transition from DOD to VA remains imperfect, despite efforts to improve 
the process. Lost records and missing paperwork are frequent 
complaints. A woman I know who spent over twenty years in the Army 
Reserves was turned away from her local VA hospital because she never 
deployed to a combat zone; her paperwork was never even examined to 
determine if she is indeed eligible for care. Despite a growing number 
of community clinics and Vet Centers, many veterans face lengthy travel 
times to reach a VA facility--a particular burden during tough economic 
times.
    Other barriers may disproportionately affect women. For example, 
since women are more likely to be the primary caregivers of small 
children, they may require help getting childcare in order to attend 
appointments at the VA. Currently, many VA facilities are not prepared 
to accommodate the presence of children; several friends have described 
having to change babies' diapers on the floors of VA hospitals because 
the restrooms lacked changing facilities. Another friend, whose 
babysitter canceled at the last minute, brought her infant and toddler 
to a VA appointment; the provider told her that was ``not appropriate'' 
and that she should not come in if she could not find childcare. 
Facilities in which to nurse and change babies, as well as childcare 
assistance or at least patience with the presence of small children, 
would ease burdens on all veterans with small children.
    Women in the military are also far more likely to be married to 
other servicemembers; throughout the Department of Defense (DOD), 51.3% 
of married female enlisted active duty personnel reported being in 
dual-service marriages, compared to only 8.1% of their male 
counterparts.\1\ These women veterans must worry not only about their 
own readjustments, but also their husbands' challenges. The VA must 
consider the dual role women veterans may be balancing as both givers 
and seekers of care. My husband sustained a penetrating Traumatic Brain 
Injury (TBI) in Iraq and was medically retired from the military. This 
impacted my decision not to reenlist, because he needed assistance that 
he simply was not getting. In addition, I was so focused on his 
recovery that I barely considered my own needs. It was years before I 
realized that as both a caregiver and a veteran I needed to not simply 
``suck it up and drive on,'' as the Army taught, but rather had to 
reach out for help and support.
---------------------------------------------------------------------------
    \1\ ``Population Representation in the Military Services,'' Table 
3.7, FY2004, available at: http://www.defenselink.mil/prhome/
poprep2004/enlisted--force/marital--status.html
---------------------------------------------------------------------------
    When struggling to cope with invisible wounds of war such as PTSD, 
or when simply facing challenges readjusting post-combat, peer support 
can be vital. However, there are things about my experience as a woman 
in a war zone that my male peers do not understand. They cannot truly 
know what it is like to fear not only the enemy, but also sexual 
assault from your brothers in arms. They may be aware of, but not be 
able to fully empathize with, the challenges of facing regular sexual 
harassment. And they certainly do not understand what it is like to 
feel invisible as a veteran, as many women veterans do. It is therefore 
vital that the VA provide times or places where women veterans, 
especially those who may have experienced military sexual trauma, can 
feel safe and comfortable seeking help in a community of their peers.
    These are all challenges that I am confident every VA hospital can 
meet and overcome. In 2006, I went to the VA Medical Center in 
Washington, DC. My visit was uncoordinated, stressful, and confusing. 
The facility did not smell clean and was crowded with veterans who 
seemed to have poorly managed mental health concerns. I was not given 
clear information about what services were available to me. My husband 
also went to that VA in 2006; he was regularly told that he was in the 
``wrong clinic'' and sent back and forth between multiple offices. 
Doctors gave him the impression that he and his issues were an 
inconvenience at best. My husband's inability to schedule timely 
appointments that fit in with his schedule eventually made him give up 
on getting care from the VA at all. We both began relying exclusively 
on TRICARE for all our medical and mental health needs, even though the 
civilian providers we saw were less familiar with combat injuries and 
post-traumatic stress.
    My visit to the VA medical center in Martinsburg, West Virginia in 
June 2008, however, was a stark contrast to my own previous experience 
and the stories I have heard from veterans about some other facilities. 
There was a women's restroom clearly visible in the lobby; it had a 
changing table. I was treated as a veteran at all times, asked about my 
combat experiences, and sensitively asked if I had experienced sexual 
harassment or assault in the military. Providers carefully coordinated 
my visit, ensured that I was aware of all available resources, and 
followed up both promptly and thoroughly. Their OEF/OIF Integrated Care 
Clinic and newly-opened Women's Clinic are models worthy of emulation, 
and I truly believe that with continued advocacy and oversight, all 
facilities can provide the same standard of care.
    In order to best meet the needs of all veterans, I also urge the 
development of enhanced relationships not only between the DOD and VA 
but also with those community organizations that are ready and willing 
to fill gaps in services. Public-private partnerships can allow all of 
us to come together to meet the needs of our veterans in innovative and 
exciting ways.

    Thank you for working to assess the VA's health care services for 
women veterans, and for your efforts to improve care for all our 
Nation's veterans.

    Chairman Akaka. Thank you very much, Ms. Williams.
    Ms. Olds?

  STATEMENT OF JENNIFER OLDS, U.S. ARMY VETERAN ON BEHALF OF 
                    VETERANS OF FOREIGN WARS

    Ms. Olds. Mr. Chairman and Members of the Committee, I 
would like to thank you and the VFW for the opportunity to 
testify today.
    My name is Jennifer Olds, and I served in the U.S. Army 
during the first Gulf War from 1990 to 1992.
    During my time in the military, I experienced multiple 
incidences of military sexual trauma. As a result of my 
experiences in the military, I suffer from severe and chronic 
PTSD.
    Some of the health conditions that resulted from that 
severe and chronic PTSD involved both physiological and 
psychological effects. Some common psychological effects that 
have been stated before are flashbacks, nightmares, insomnia, 
distrust of society, constant fear, depression, and becoming 
suicidal. I also suffered from physical ailments because of the 
PTSD, which include things like nervous issues, anxiety 
attacks, panic disorders, dizzy spells, ulcers, and I had 
shingles twice in my 20s.
    As I look back over the treatment that I have received from 
the VA, I find a list of things that I think has 
comprehensively helped me to recover to the place that I am 
today, which is significantly much better than I was 15 years 
ago. Among this list include the availability of counseling 
from the Vet Centers in the Portland, Oregon, VA; and, also, 
being assigned a psychiatric nurse practitioner who tried to 
provide medications to help me with sleeping because getting 
sleep can help improve your ability to handle all the other 
effects of PTSD.
    Eventually, about 10 years after my initial start in the VA 
system, I finally allowed them to provide anti-anxiety 
medications, which, in combination with other things, seemed to 
help me improve quite a bit.
    One of the things I believe that had a severe impact on 
turning my life around was my admittance into the vocational 
rehabilitation program. That gave me a reason to stop being 
suicidal or at least to start fighting my suicidal ideations 
and allowed me to look forward to my future.
    Not long after, a few years later, I was given the 
opportunity to participate in some PTSD research. It was a 
research study at the VA comparing cognitive studies--cognitive 
therapy--against exposure therapy. I was randomized into the 
exposure therapy program and participated in it. It was a 10-
week, intense, grueling program that asked me to recollect and 
discuss a traumatic event.
    So, it is not a program that is easy for people to get 
through, but, if you can, and you are like me, you benefit 
significantly.
    As I also look back, I realize the importance of having 
holistic care. Because I suffered not only psychological 
issues, but physical issues, being able to get the support from 
both sides of the coin was very helpful, as well.
    Finally, and I think most importantly, as we look at 
providing care for vets or women vets in particular--with the 
kinds of backgrounds that we tend to have, I think with PTSD 
and military sexual trauma--having very patient, understanding, 
good-fit providers is key. If we have someone that we are 
unhappy with or we feel does not understand us, we are not 
going to go. So, finding people that have the patience and 
endurance to stick with us until we are able to sort of work 
for ourselves, I think, is very important.
    As I look forward to the future for things that I think 
would be helpful for the VA system to implement, the first 
thing that comes to my mind is location.
    I spent an hour-and-one-half driving each way to my 
counseling appointments, not to mention the amount of time I 
spent in my counseling appointments, and those combined ended 
up being at least 4 hours per day, 3-5 days per week. That does 
not bode well for working.
    Also, as I think back on my original discharge, I, again, 
was not given any information. I had no idea that there was 
stuff available for me; and really, there was not, as I look 
back for PTSD and women specifically.
    But I had gotten so suicidal that I sought my own care from 
a private institution where I utilized my own private 
insurance. That only covered 2 weeks at the most. It only 
covers a portion of that amount, so, my family had to take on 
the burden of the additional costs. So, my point of this is: 
getting acceptance right into the VA system immediately is 
important.
    I also think that we need to think about women veterans as 
individuals. I do not think there is a one-size-fits-all. I 
have listed a number of things that I felt were extremely 
beneficial to me, but there were other options that came up 
that were available to me that I did not take advantage of 
because they were not good fits for me.
    An example of this is a counselor that tried to provide 
EMDR, another type of therapy for PTSD. While it has been 
proven to be very effective, it was not a type of therapy that 
I felt was fitting for me at the time.
    So, being able to look at the individual and examine what 
they themself need, then providing a variety of options to pick 
from, I think, is important, as well.
    One of the other things I think that we need to provide is 
education for everyone--for providers, for women vets, and for 
the public--on what the VA can offer and how the VA provides 
care for the women, sort of an around the world picture for 
everyone.
    As I have looked at the care that has been offered for 
women vets, I have come up with a conclusion like what some of 
the other people have said. I believe that if we have some of 
what I call ``information sessions'' for women or ``for vets by 
vets'' sessions in helping them understand how to navigate the 
system and to move forward with the different kinds of options, 
which is important, as well. If I had had that, I may have 
started some things earlier in my treatment plan. And I would 
be one to volunteer to do that for other vets because I feel it 
is important to help others get their life back sooner than 
some of us have.
    And, finally, I think we need to reduce the stigma that the 
VA has in the system in general. While I go out and speak 
positively about my experiences from the VA--because I have had 
numerous, wonderful experiences from the Portland, Oregon, VA--
there are other people who do not, and we need to reduce the 
amount of incidences like this that prevent the VA system from 
getting the good reputation that it can deserve.
    I understand there are differences from VA to VA, but, in 
general, reducing that stigma, I think, will help encourage 
vets to use the system.
    So, Mr. Chairman, this concludes my statement. I would be 
happy to answer any questions you or the other Members of the 
Committee may have. Thank you for your time.
    [The prepared statement of Ms. Olds follows:]
Prepared Statement of Jennifer Olds, B.S., M.B.A., U.S. Army Veteran on 
        Behalf of Veterans of Foreign Wars of the United States
    Mr. Chairman and Members of the Committee: I would like to thank 
you and the Veterans of Foreign Wars of the United States (VFW) for the 
opportunity to testify today.
    My name is Jennifer Olds, B.S., M.B.A., and I am from Forest Grove, 
Oregon. When I enlisted at 18 years old, I was voraciously positive 
about what life could offer and had much to look forward to. I was 
college oriented in high school taking college prep classes like 
physics, chemistry, college writing, etc., as well as athletic, engaged 
to be married and strong in my faith. I served on active duty in the 
U.S. Army during the first Gulf War, from 1990-1992. While in the Army 
I was exposed to Military Sexual Assault situations numerous times, 
either trying to protect myself, or the other female soldiers around 
me. This was my own ``battle field.'' Once discharged, I became 
increasingly aware of my new symptoms of PTSD.
    Some examples of my PTSD involved the following:

    1) While I was driving, I was constantly in belief that someone was 
out to harm me, constantly watching to see who was following me home, 
driving out of the way to make sure no one was following me, thus 
experienced intense fear and anxiety attacks while driving,
    2) While at restaurants I needed to sit in the corner, or against 
the wall and would be on constant guard evaluating who was out to harm 
me or my family. If one of them needed to run to the bathroom I would 
be extremely on edge until their return. If anyone asked me what was 
discussed during dinner at the restaurant, I couldn't tell you since I 
was so busy paying attention to the potential bad guys around us.
    3) I was no longer engaged upon my return from the military and had 
not dated for over 10-years since my discharge. Finally, When in my 
home I had to have every curtain closed, window and door locked, and 
was constantly freaked out about who was driving by or walking by 
because I truly believed they were scouting me out and would eventually 
be back to harm me.

    After a year of continued daily battles with insomnia, nightmares, 
flashbacks, anxiety attacks, depression, with situations described in 
the previous paragraph, it became clear to me that this way of living 
was something I no longer wished to deal with. I no longer felt that 
life would be worth living if that is all I had to look forward to. I 
became extremely depressed and suicidal, and had no knowledge of how to 
help myself.
    When I became suicidal I met with my family and asked them for 
help, since I had no idea what needed to be done and frankly was in no 
position to help myself. They suggested I enter a program at a hospital 
facility where I was admitted but the insurance coverage ran out within 
two weeks and I was discharged owing thousands of dollars to them, 
which my family had to take on. Within a week or so, I was desperate 
for help, as I knew I was still suicidal and finally was admitted to 
the Portland VAMC where again I was discharged within two weeks. I was 
told I didn't belong there and that staying any longer would force them 
to send me to the Salem ``crazy ward,'' a place I was sure would ruin 
my future. Again I was sent home with nowhere to go or seemingly any 
help.
    Fortunately I was assigned a psychiatric NP who patiently saw me 
over the next several years with little improvement from me. You see, 
our visits went something like this, I would be unable to continue a 
stream of thought, as the anxiety increased and I would become blank 
and unable to figure out my thoughts or feelings. This made the process 
very difficult, but so did making the appointments given the stigma. I 
didn't want others to know about, or me to actually realize about 
myself.
    I met with a representative of Paralyzed Veterans of America (PVA) 
who asked the right questions and helped me realize and seek help from 
the VA for the treatment of PTSD. Initially, I was sent to the Vet 
Center that was located over an hour drive away from my home. 
Eventually that therapist moved on, and I was assigned a new one who 
wanted to do EMDR. I was in no position to do EMDR and told the new 
therapist this many times and it seemed an endless conversation so I 
stopped going altogether. At this point I only maintained a working 
relationship with my Psychiatric NP who had the strength of a horse 
with enduring patience with my slow progress.
    Over the course of my treatment with the VA, I was given the 
opportunity to go to college under the VOC REHAB program, which was a 
turning point for me. This opportunity inspired me to want to live, and 
to fight the constant suicidal ideations. Getting over this hurdle took 
time, but college was certainly one of the many steps that have 
eventually given me some solace on life. By the time I was finishing up 
my undergraduate degree, a serious life event forced me to begin 
looking at old trauma wounds and I began to focus efforts with my NP. 
Eventually, after a few more years in treatment, my fabulous NP 
suggested I participate in the research study comparing cognitive 
therapy with exposure-based therapy. I said I would, because I wanted 
my life back, that is, the voracity and charge to live life and be 
happy.
    I participated in this grueling 10-week program that asked me to 
repeatedly discuss one of my traumatic events. I had intense anxiety 
attacks, dizzy spells, nausea, etc., while I was undergoing this 
therapy. It was not long after the completion of this treatment, that 
my family and friends became aware of the changes I was making, little 
known to me at the time. Eventually I came to see that I now could 
partake in conversations with others and actually hear what they were 
talking about and know what was going on in their lives. Within a few 
years I was dating again after quite some time. I have decreased 
nightmares, no longer watch who's following or walking by my house, and 
even enjoy a night full of sleep more often. I am extremely delighted 
with the caregivers at the Portland VA and think if not for them, I 
would not be where I am today.
    To say I had PTSD should not be summarized by mental capacities 
only. I made several visits to the doctors for dizzy spells, chest 
pains, skin issues, nervous ticks, ulcers, stomach/bowel issues and the 
shingles x2, all while in my 20's. Most of the time these things were 
``undiagnosable,'' but I have come to realize over the last 15 years 
that much of these were stress related. That is, I believe PTSD caused 
not only mental issues, but numerous physical issues as well. A person, 
like me, can become overwhelmed with the array of issues one can 
experience simply from PTSD, and become quite discouraged on how to 
tackle it all.
    I have a few suggestions on how I think we can encourage others to 
get help and improve their PTSD symptoms:

    1) encourage support groups and speakers from others like 
themselves who have actually improved from PTSD.
    2) Provide them with names of providers who have enormous patience.
    3) Provide holistic approaches, and specific focused treatment: I 
truly believe that one size does not fit all.

For example, Eye Movement Desensitization and Reprocessing Therapy 
(EMDR) is a comprehensive, integrative psychotherapy approach often 
used for MST. Although I did not feel comfortable with this type of 
treatment, it may work for some and exposure-based therapy may work for 
others, or perhaps medications in addition or on their own may also be 
the best way.
    Today I am able to do things that I have not been able to do in a 
long time, and I also find myself void of other previous behaviors, 
which were not positively affecting my life. All these changes are not 
only very encouraging, but seem to continue to yield way to yet more 
and more ``platforms'' on which to continue with more positive changes. 
I have seen these abilities and actions of change as extremely exciting 
and very positive, and so have my family and friends who have known the 
struggles I have had to deal with since my time in the Army. My life is 
continuing to improve.
    I have watched PVA make significant changes that have improved the 
care to all veterans and am extremely pleased with my care. This 
process of dealing with PTSD has been a learning experience for me as 
well as many at the VA.

    Mr. Chairman this concludes my statement, I would be happy to 
answer any questions you or the other Members of the Committee may 
have.

    Chairman Akaka. Thank you very much, Ms. Olds, for your 
testimony, and all of you here.
    Several of you mentioned the importance of VA providers to 
understand and acknowledge that women can experience combat 
while serving in the military.
    How would you recommend VA and women veterans educate their 
providers about this in order to help them provide better care 
for women veterans?
    Ms. Chase. Senator, I think----
    Chairman Akaka. Ms. Chase?
    Ms. Chase [continuing]. In terms of recognizing combat and 
raising awareness about that, there are several military 
occupational specialties within the Army and across the 
services that have women who are engaging in activities outside 
of the wire. Some of these include our intelligence teams, our 
medics, our truck drivers, our civil affair soldiers, our 
military police, and even sometimes our finance and supply 
sergeants and NCOs, and officers.
    I think the best way to get people to understand and to pay 
attention is to connect the two. I think if we could provide or 
somehow get together statements and maybe even personal 
testimony or a team of people that address the Veterans Affairs 
directly--to some of these service providers and some of these 
clinics in their local areas--and say, ``I am a real person and 
I am standing in front of you to tell you that I served in 
combat, and I need you to hear me.'' I think that would be more 
impactful than anything else that we could give them on a memo 
or an e-mail.
    Chairman Akaka. Yes, Ms. Williams?
    Ms. Williams. Another option that may help people 
understand a little more viscerally would be to have viewings 
of the Lioness documentary about women serving in combat 
available at VA facilities perhaps over lunch hour or in some 
way that providers would have a chance to watch it.
    Chairman Akaka. Ms. Ilem?
    Ms. Ilem. I would just note that I think the Lioness 
documentary probably most exemplifies a great opportunity for 
them to really see and hear female veterans in their own 
voices. Either that or other short videos that VA has done on a 
number of issues related to TBI and OEF/OIF population and 
mental heath issues--reintegration issues. A video on women 
veterans specifically would be an excellent opportunity for 
providers to see something short, and told in women veterans' 
own words for them to be able to connect.
    Ms. Chase. And, Senator, I would like----
    Chairman Akaka. Ms. Chase?
    Ms. Chase [continuing]. To caveat that. Sorry.
    The Lioness documentary is a phenomenal and fantastic 
documentary. However, it is specifically about a particular 
team of women called the Lionesses who were embedded with 
combat teams and infantry teams. We also need to recognize and 
make sure that they are aware that there are very many jobs out 
there--there are a lot of women every day on different jobs in 
different capacities, in different branches of service--that 
are serving outside the wire in combat every day, and not just 
that one specific team specific to that movie or documentary.
    Ms. Christopher. Mr. Chairman?
    Chairman Akaka. Ms. Christopher?
    Ms. Christopher. I agree with the fellow panelists on what 
they're suggesting. The one thing that I would like to note 
though, to be quite frank, is trainings can be very boring. I 
mean, whether you are watching a PowerPoint or a video or 
listening to someone talk, I mean, I think that in order for it 
to be truly effective, there needs to be dialog, and it needs 
to be interactive.
    And I think there should be a Q and A portion. When we do 
our trainings through Swords to Plowshares, we open ourselves 
up for questions. We actually refer to it as ``an uncomfortable 
questions panel,'' and we encourage the clinicians to ask us--
to clarify MOSs and military terminology--and to ask us our 
opinion on treatment that has worked for us and that has not; 
and we make it extremely candid, and I think that it has helped 
immensely. The feedback has been so positive.
    So, I just definitely stress the interactive component for 
a successful training.
    Chairman Akaka. Thank you.
    We will have a second round of questions. So, let me call 
on Senator Murray for her questions.
    Senator Murray. Thank you very much, Mr. Chairman.
    First of all, thank you all for your service to the 
country. I really appreciate what all of you have done, and 
going beyond the service now to come and talk with us about the 
important issue that we are discussing today. I just want to 
reiterate that I really do appreciate that.
    While it is the official policy of the military that women 
can not serve in combat, many of you talked about your 
experiences, whether it is Traumatic Stress Syndrome, being 
close to IED explosions, or being injured.
    Given the fact that women are serving in combat roles, have 
you found that this combat experience is reflected in DD-214ss?
    Ms. Williams. My own certainly was reflected on my DD-214s. 
It shows that I was awarded the service medal for my time in 
Operation Iraqi Freedom; and, also, if it ever were to become a 
question, I also received Army medals and the paperwork that 
support those details of what experiences they were earned for, 
which is another way people can show their experience. But I 
know that is not universally the case. I was just lucky enough 
that that was true for me.
    Senator Murray. How about others of you?
    Ms. Chase?
    Ms. Chase. When we get our DD-214ss, it states in there 
whether or not you served and in what theater, and it also 
states your job. I was also awarded the combat action badge. 
However, that is not an automatic award. It's not an automatic 
entitlement. It is something that is submitted by your chain of 
command, and if it is not submitted or the paperwork gets lost 
or it does not go through, then you do not have that, as well.
    And it also is not a qualifier. A lot of people do not 
perceive it to mean that you were actually in combat or 
directly engaging the enemy. So, that policy needs to be 
changed or reworded to reflect that women are, in fact, serving 
in combat and they are, in fact, on missions outside of the 
wire. Regardless of whether or not they are going outside the 
wire and they are inside an FOB or a PRT, when you have mortars 
that are incoming daily and you have no idea where they are 
coming from, that is combat; and the perception, I think, needs 
to be changed. I think the perception would be helped if the 
wording in the policy was changed, as well.
    Senator Murray. Ms. Williams, you mentioned that you were 
both a caregiver and a care seeker. Your husband was in the 
military. I assume that it is fairly common for a woman to be 
married to a fellow military officer and be in the same 
position.
    What can be done to help us better care for women veterans 
who are not only dealing with their own readjustment issues, 
but are dealing with spouse or children, as well?
    Ms. Williams. You are right, the percentages are very high. 
I think that it is important that care be more comprehensive. 
Among active-duty, enlisted, married, female servicemembers, 
over 50 percent are married to other servicemembers, compared 
to only 8 percent of their male peers. My husband and I were 
both enlisted.
    I know the VA is trying very hard to do outreach. I once 
got a call, for example, asking if I had sustained a Traumatic 
Brain Injury as part of their outreach effort to make sure that 
they are catching everybody. And I said, no, I did not; but I 
am glad you called because my husband did and our family is in 
shambles right now. I do not know how to hold myself together 
and my family together and keep my job, and I am struggling 
really hard here. And he said, well, I cannot really help you 
with that; I am calling to ask if you have suffered a brain 
injury.
    And that is the way that I think we can try to make sure 
that we are addressing entire family needs. If you have a 
servicemember who has sustained an injury making sure that 
their family is being taken care of both while they are in the 
DOD and once they have transitioned to VA care, is an important 
step.
    I know the VA does not cover care for family members, but 
if they learn that the spouse is also a veteran, it is 
important that they take an extra step, reach out and contact 
them proactively, and ask if they need help as a caregiver. Of 
course, this does apply to both male and female spouses; its 
just that the number of female spouses giving care is much 
higher.
    Senator Murray. I hear a lot from women about the access of 
childcare being a barrier to go to the VA. Several of you 
mentioned this in your testimony, and I do not think a lot of 
people realize that if you tell a woman that there is no 
childcare, they just simply do not go. That is it. They do not 
get their health care.
    For all of the panelists, do you think that the VA 
providing childcare services would increase the number of women 
who go to the VA and get the care that they need?
    Ms. Ilem. I would say definitely. I think researchers have 
repeatedly shown this as a barrier for women veterans, and that 
is the frustration. How many research surveys do you have to do 
when women keep repeatedly saying this is a barrier for them to 
access care? And I think it was Kayla who mentioned an 
experience of someone who was told it is inappropriate for them 
to bring their child with them. At some of these very 
personalized appointments for mental health or other things, it 
may be very difficult, but they have no other choice.
    So, I think it would definitely be a benefit and we would 
see an increase in the number of women veterans who would 
probably come to VA.
    Senator Murray. Ms. Williams?
    Ms. Williams. I definitely think that user traits of the VA 
would increase if women knew that they had childcare available. 
There are a variety of innovative ways that we could try to 
address the problem of women having to balance their needs for 
childcare with their needs to get services. Among them would be 
increasing the availability of telehealth or telemedicine, 
where women do not have to necessarily go all the way to a 
remote facility, spending 4 hours trying to get to and from and 
then be in care.
    There are also opportunities for innovative programs.
    For example, the VA has small business loans available. If 
they could provide loans to women veterans who want to provide 
childcare at facilities near VA facilities, that would be a 
great way to try to marry these two needs.
    There are also a lot of community organizations that stand 
ready and waiting to help that would be happy just given a 
small office to staff it with volunteers and be able to help 
provide that care for the time that a women has to be in an 
appointment.
    And I think as many others have said, the specific 
solutions may vary by location, but there are a lot of 
innovative ways that we could forge public-private partnerships 
to try to meet these needs.
    Senator Murray. OK. Excellent.
    Mr. Chairman, I have gone way over my time. I need to get 
to another committee for mark-up, but I love the video idea of 
showing the Lioness documentary at VA facilities. I think it, 
at the very least, opens peoples' eyes to the fact that women 
have served in very important roles and will maybe open that 
little door in their head to think oh, wow, women really have 
served our country in amazing ways and they do need the care 
and the respect and the services that they have earned.
    I would love to see another documentary about all the other 
things that women have done and start helping people everywhere 
really recognize the important service that women are 
providing.
    So, I thank all of you. And, Mr. Chairman, thank you so 
much for having this hearing today.
    Chairman Akaka. Thank you very much, Senator Murray.
    Senator Begich?
    Senator Begich. Thank you very much, Mr. Chairman.
    Like Senator Murray, at around 11:30, I am going to have to 
depart for a meeting. This is a very interesting panel, and I 
want to thank you for your service, and also for your insight 
in the day-to-day utilization of the VA services and what can 
be done. I have a couple of questions.
    I am going to look through my notes here and try to reread 
my handwriting, as each one of you were speaking, and I am 
going to make a couple of comments. It is not necessary for you 
to respond.
    I am kind of looking to Dr. Hayes. If you could follow-up 
with at least me and if the Committee so desires on a couple of 
things--one being the childcare issue.
    I remember a circumstance in Anchorage, Alaska. My wife and 
I had our first child, who was 1 year old when I got elected. 
In my office we had at least a crib in there at any given time 
and there were probably toys scattered throughout. I can 
remember a colonel from the Army coming over and introducing 
himself to me with his spouse and their 2-year-old, who also 
came into my office; and I think because I created an 
environment that showed it was OK, it made a big difference. I 
would not ever imagine that 5 years ago a colonel from the Army 
would bring his 2-year-old to the mayor of the city where they 
were being stationed. That would never probably have happened, 
but we created an environment for that.
    So, you had mentioned the childcare, each one of you, as 
critical.
    The question I would have, Dr. Hayes, you had mentioned 
legal counsel may have some issues with this. I would like to 
get whatever they write up, if they do, on childcare. I would 
like to see that because the one thing I know about attorneys--
and, no offense, I am not one--but they will always tell you 
why something cannot happen versus why something should happen. 
And, so, if you approach them in a way that when they give you 
the answer why it cannot happen, which is probably the 
likelihood, can you ask them what can change to make it happen?
    That is what I think many of us are talking about or are 
going to be interested in because I agree with you, if the 
facility does not have childcare--facilities for both women and 
men--it is a problem. And, so, if you could do that, that would 
be fantastic.
    A couple of you mentioned training and successful training, 
and I agree with you, it is ``boring.'' The trainings I have 
had to go to when they are not interactive are boring.
    I'll look to you first, Ms. Christopher.
    In your interactions, how do the clinic folks come to you? 
In other words, do they volunteer to come to your training? 
What happens? How does that work? Does the VA require it? I 
would say no to that, but it is a set up question. But how does 
it work? How do you get folks to participate from the clinical 
side, the professionals?
    Ms. Christopher. Honestly, we have been very lucky. 
Actually, the DOD liaison to the Palo Alto Polytrauma Center 
actually invited me and my colleagues to join the National 
Center PTSD Clinical Training Program. He actually cut his time 
in half to develop a community panel because he thought it was 
important. And, honestly, I found that the DOD liaisons have 
been extremely instrumental in bridging the gap between the VA 
and the community, which I think is fantastic.
    When it comes to the VA clinician trainings that we have 
done, honestly, we have approached them and we have gotten 
really good feedback, and I think in the Bay Area, there is 
some really good dialog. But, no, we----
    Senator Begich. No outcome yet?
    Ms. Christopher. To suggest it.
    Senator Begich. OK. Do you have something, again, you could 
share at least with me in any written document that is 
specifying what you would like to propose to the VA?
    For example, we did this with community police training in 
Anchorage when we saw an opportunity because we had a lack of 
understanding within our police department in regards to the 
cultural diversity of our city. We have 90-plus languages 
spoken in our school district--a very diverse community--so, we 
integrated that into our training. We kind of forced it at 
first because it was a structure, and police are paramilitary, 
so they have similar structures, procedures, and processes; and 
change is not necessarily high on the list.
    I would be interested in, Ms. Christopher--and I think it 
was Ms. Williams who also talked about training--any of you 
that have some suggestions of how to then have a discussion 
with the VA on how they can make that a little better. I would 
be very interested in that, if you could.
    Ms. Christopher. Yes, Senator.
    Senator Begich. And whoever else would be willing to do 
that.
    In connection to that, again, I am going to kind of veer 
through you to Dr. Hayes.
    I would be very interested if the VA actually surveys their 
clients for results of VA clinics because--I am just guessing--
even though in theory they are all same, they operate 
differently.
    The example you gave, Ms. Williams, was your positive 
experience in the last clinic you had gone to. It was very 
positive and there are some good things that occurred there. 
But that varies clinic to clinic. I would be curious if, Dr. 
Hayes, you could provide that. Ms. Williams, if you could tell 
me again where that was. I did not write it down quick enough. 
The one you had a very good experience in.
    Ms. Williams. Yes, sir. I have had negative experiences at 
the DC VA. And, just on my way here this morning, I shared with 
a woman in uniform that I was coming here, and she said she is 
in the process of retiring. She just went to the DC VA, and had 
the same experience that I did. She said that it seemed unclean 
to her and very disorganized, and there were people there 
clearly struggling to cope. It can be nerve-racking when you 
are seeking care to worry that that is your future. So I said, 
go to the one in Martinsburg, West Virginia.
    We live out near Dulles airport, and from there, it takes 
just as long to get into D.C. as it does to go all the way out 
to West Virginia based on the lovely traffic we all face. And 
the Martinsburg facility is doing great.
    There are obviously areas that they could improve on, as 
well. They are undergoing construction. So, currently, the OEF/
OIF clinic is collocated with the mental health outpatient 
clinic, which at first I found a little off-putting, but when 
they said that was because of the ongoing construction to 
improve the facility, I thought that was great and it is really 
a wonderful model.
    Senator Begich. That is great. Thanks for telling me which 
clinic that was which helps me get a little better 
understanding.
    The last think I will just mention, triggered by the 
discussion of telemedicine, that Alaska, because of our 
ruralness and remoteness, telemedicine is a very powerful tool, 
and it is very valuable in a lot of ways. So, I know we have 
had very positive comments and conversations with the VA about 
telemedicine and their interest in expanding that.
    I know from my State, it is a critical path to delivery 
because we do not have a VA hospital, for one. We have clinics. 
And then, in remote areas, we have nothing. And it is very 
difficult because there are no roads to get from one place to 
the next. So, I appreciate your comments on telemedicine from 
another perspective. You know, I see it from a rural 
perspective. I appreciate your comments from women veterans' 
perspective, is another access point that is a positive one. So 
thank you for that.
    Mr. Chairman, I will end there. It is a very enlightening 
panel in a lot of ways because of your direct contact, 
utilization, and work with other folks. So, thank you very much 
for this insight.
    Chairman Akaka. Thank you very much, Senator Begich.
    Hearing what has gone on here, I just want to inform 
everyone that the Committee's legislation S. 252 has provisions 
making childcare more available by using an existing childcare 
program and providing reimbursement to those getting care. So, 
that is in that bill and this is something, of course, as we 
have discussed, that certainly can be used here with helping 
all women.
    One of my major goals is to create a seamless transition 
for servicemembers as they leave the military and become 
veterans.
    As women veterans, what do you perceive as a major gap in 
this transition process, and how would you recommend we fix it?
    Ms. Williams?
    Ms. Williams. Sir, I think one thing that will go a long 
way toward fixing some of the problems--and it is my 
understanding it is at least in the trial process now in some 
locations--would be electronic medical records.
    Having to hand-carry your own medical records when you 
leave the DOD system and take them to the VA system, and the 
fear that some piece of paper will get lost--a vital piece of 
paper proving what has happened to you in the past--is very 
difficult and stressful, and may be even more of a challenge 
for veterans who may have sustained a Traumatic Brain Injury or 
be struggling with mental health concerns. So, I think that the 
implementation of universal electronic medical records will go 
a long way toward fixing that problem.
    Also, there can be big challenges in terms of benefits.
    When my husband was medically retired from the military, 
there was a gap between that time and when he started getting 
his VA benefits. During that time, we were so financially 
insecure that both of us ended up going on unemployment, which 
was a deeply humiliating experience for two proud and honorable 
combat veterans--to be reduced to that while we were waiting 
for his VA benefits to start coming in, and I was waiting for 
my job to get started.
    So, trying anything that can help smooth and ease that 
transition would help. I think efforts to get VA exams done for 
those servicemembers who have been injured in the military so 
that they can have a more seamless transition in terms of 
benefits is another step in the right direction.
    Chairman Akaka. Thank you.
    Ms. Chase?
    Ms. Chase. Senator, as a Reservist, when you come off of 
active-duty, which can be multiple times during your military 
career--especially if you have been activated several times--
one of the biggest issues is that we are handed our records, 
and then it comes on you to keep and maintain those records 
throughout the duration for however long you will need them.
    Once you are handed your medical records, that is it. That 
documentation does not flow from what is or may have been put 
into a computer system at a care facility that you were at even 
to another care facility while on active-duty orders from base 
to base, much less from when you are on DOD and then into the 
VA System.
    So, that enrollment period where the records directly 
transfer from your active military service and they follow you 
throughout your VA service or throughout your VA eligibility 
time, it is important, it is significant, and I cannot stress 
and say enough about how vital it is to have that to also prove 
combat service. If a woman or any veteran has served in combat 
and has been seen or treated by a physician or a physician's 
assistant while on active-duty, then it would flow right into 
their VA eligibility and into the computer system. So, it will 
alleviate so many of the other issues that we are seeing.
    Chairman Akaka. Thank you very much.
    Are there any other--Ms. Olds?
    Ms. Olds. Mr. Chairman, thank you.
    I want to follow-up with the medical records topic.
    That was one of the biggest problems with me getting care 
when I first got out back in 1992. To this day, no one has 
found my records, and, of course, that caused a significant 
delay in getting benefits from the VA. It took almost 3 years 
and Councilwoman Furse to get involved. So, having access to 
our medical records, having them transferred without anyone 
having an opportunity to lose them, I think, is significantly 
important.
    And, also, giving information to people about what benefits 
they can get, I was not given any. I had no idea I had benefits 
coming until I met with someone at the PVA and they asked the 
right questions.
    So, information and medical record availability, I think, 
are probably the two big ones as far as us getting our access 
into the VA system when we get out.
    So, thank you.
    Chairman Akaka. Thank you.
    Ms. Christopher?
    Ms. Christopher. Mr. Chairman, when I got out of the 
military, I did not think that I had any benefits. It was due 
to a volunteer writing an op-ed in the Seattle Times that I 
found out about the Military Sexual Trauma Program, and that I 
might be eligible.
    Needless to say, when I arrived, I had to fight for my 
eligibility. I have an honorable discharge, but the 
circumstances are a bit more complicated, so, it was the clerks 
that I really had to fight with to get seen to get treatment.
    Once I did finally prove that I was a veteran and that I 
was entitled to treatment for MST, I got great care by the 
doctors that I got there. But it was an uphill battle, and 
having to prove again and again my trauma and that I am a 
veteran has definitely affected me. And, let me tell you, it 
was very validating to finally be rated by the VA.
    I have witnessed having OEF/OIF advocates and case managers 
nowadays since the process is so much easier for new veterans, 
and I am so glad that the VA has those. However, most 
veterans--newly-separated servicemembers--are not always aware 
that these positions exist.
    So, again, referring back to the community: when veterans 
come into my clinic or when we are doing briefings, I ask them, 
hey, do you know about this office in the VA; or I hand out a 
business card and personally introduce them to my VA 
counterparts. So, my point is that the community is still a 
really integral tool in accessing VA health care.
    Chairman Akaka. Ms. Ilem?
    Ms. Ilem. I would say that things have changed a lot since 
I got out of the military in the mid-80s when there was little-
to-know information. I definitely did not recognize myself as a 
veteran; did not know that I had access to the VA; and did not 
even recognize that I was entitled to service-connected 
benefits for disabilities incurred during service until I met 
DAV folks.
    So, I think VA is on the right track now in terms of a 
number of outreach efforts when people are coming back from 
deployments--trying to outreach with them then, get them 
enrolled in VA care at that point, and giving them 
information--but also then doing follow-up letters and follow-
up phone calls.
    The unfortunate thing is, as we heard from Ms. Williams, 
when somebody from VA does call, if they would have the ability 
to just adapt a little bit and take into account that, yes, 
they were calling on this particular veteran, but others need 
help--to be able to refer them and simply go ahead and take 
care of these people. That is going to be key in terms of 
continued follow-up until the time when that veteran is ready; 
and maybe catch them at a point when they realize they have 
access to these benefits and are in need of them.
    Chairman Akaka. Thank you very much, Ms. Ilem.
    First, I want to thank you for the sacrifice you have made 
for our country; and for the kind of help you are giving us in 
trying to support our women veterans, I want to thank all of 
you for being here today.
    We have heard about a lot of good initiatives VA is 
undertaking to increase the quality and access to care for 
women veterans. However, we also heard that there is much more 
that could be done, especially in the areas of outreach and 
education about these services; and you mentioned medical 
records and also the electronic shift that needs to come.
    All our Nation's veterans, both men and women, deserve the 
best quality of health care, and I will continue to work to 
make sure that they receive it.
    I look forward to working with VA and others to find 
solutions to the gaps in care for our women veterans.
    Thank you all, again, for being here today. You have been 
very helpful.
    This hearing is now adjourned.
    [Whereupon, at 11:10 a.m., the hearing was adjourned.]
                            A P P E N D I X

                              ----------                              


 Patient Satisfaction Scores by Gender Using CAHPS Report Provided by 
  Veterans Health Administration, U.S. Department of Veterans Affairs



                                 ______
                                 
        Prepared Statement of Marsha (Tansey) Four, RN, Chair, 
         Woman Veterans Committee, Vietnam Veterans of America
    Good morning Mr. Chairman, Ranking Member Burr, and distinguished 
Members of the Senate Veterans' Affairs Committee. Thank you for giving 
Vietnam Veterans of America (VVA) the opportunity to submit our 
statement for the record regarding VA Health Care Services for Woman 
Veterans. VVA supports swift passage of S. 252, ``The Veterans Health 
Care Authorization Act of 2009;'' however, we would like for additional 
language to be included in Section III, regarding woman veterans health 
care which was missing from H.R. 1211, the Women Veterans Health Care 
Improvement Act that was passed by the House.
    It is indisputable that the number of women in the military has 
risen consistently since the 2 percent cap on their enlistment in the 
Armed Forces was removed in the early 1970s. This has resulted in an 
increased number of women we can now call ``veterans'', and most 
assuredly, will have a direct bearing on the number of women who will 
be knocking on the door of the VA in the very near future. A focus on 
the capacity and capability of the VA to equitably and effectively 
provide care and services must be a priority today. Planning and 
readiness is essential for the future. These responsibilities also 
require oversight and accountability in order to meet VA and veteran 
goals, objectives, requirements, standards, and satisfaction, along 
with agency advancement.
    While much has been done over the past few years to advance and 
ensure greater equity, safety, and provision of services for the 
growing number of women veterans in the VA system, these changes and 
improvements have not been completely implemented throughout the entire 
VA system. In some locations, women veterans still experience 
significant barriers to adequate health care. Thus, VVA asks Secretary 
Shinseki to ensure senior leadership at all VA facilities and in each 
VISN to be held accountable for ensuring that women veterans receive 
appropriate care in an appropriate environment by appropriate staff.
    There is much to learn about women veterans as a separate patient 
cohort within the VA. Women's Health is now studied as a specialty in 
every medical school in the country. It has moved far beyond that of 
obstetrics and gynecology. Gender has an impact on nearly every system 
of the body and mind. This has great significance in the ability of any 
health care system to provide the most appropriate, comprehensive, and 
evidence-based scientific treatment and care. This also has a direct 
effect on the delivery system along with staff requirements to meet the 
needs of women now utilizing the VA health care system, as well as for 
those new women veterans who will soon be accessing the system in the 
days and years to come.
    The VA has already identified that our country's new women veterans 
are younger and that they expect to use the system more consistently. 
For example, in December 2008, the VA reported that of the total 
102,126 female OIF-OEF veterans, 42.2 percent of them have already 
enrolled in the VA system, with 43.8 percent using the system for 2-10 
visits. Among these returning veterans, 85.9 percent are below the age 
of 40 and 58.9 percent are between 20 and 29. In fact, the average age 
of female veterans using the VA system is 48 compared with 61 for men. 
The needs of women veterans have yet to be fully identified or 
recognized * * * these needs are growing and already taxing the VA 
system, which historically has focused on an older male population.
    As time, social environments, and veterans' population demographics 
change, there are also cultural expectations based on scientific 
advancements in health care that elicit a re-definition of women 
veterans' needs in the VA system. Knowing the needs is vital to 
understanding and meeting them. The VA has recognized many of the needs 
of women veterans by actually creating interest groups comprised of not 
only VA staff, but veterans as well. For example, there is recognition 
that younger women veterans are also working women who need flexible 
clinic and appointment hours in order to also meet their employment and 
child-care obligations. They also need to have sexual health and family 
planning issues addressed, along with the needs of infertility and pre-
natal maternity. And there are unanswered questions and concerns about 
the role of exposures to toxic substances and women's reproductive 
health.
    VVA requests that this Committee continue to focus on treating 
women veterans who are homeless with children, victims of sexual 
trauma, and provide funding for additional caseworkers and mental 
health counselors, a women's mental health treatment program, and a 
comprehensive mental health study of returning female soldiers.
Studies and Assessments of Department of Veterans Affairs Health 
        Services for Women Veterans
    VVA believes that this study is vital to understanding today's 
women veterans and that building on the ``National Survey of Women 
Veterans in Fiscal Year 2007-2008'' is a referenced starting point and 
this study should be included as language in the bill as similar to 
H.R. 1211 to expand a survey of sufficient size and diversity to be 
statistically significant for women of all ethnic groups and service 
periods.
    VVA believes that this study should identify the ``best practices'' 
that facilities utilize to overcome identified barriers.
    VVA believes that with the fragmentation of women's health care 
services there needs to be consideration for driving time/
transportation to medical facilities that offer specialty care as well 
as primary care.
    While VVA holds great respect for and recognizes the important work 
of both the Office of the Center for Women Veterans and that of the 
Advisory Committee on Women Veterans, this section as written would 
limit the initial review, creating unnecessary delays. Rather, VVA 
believes that this study should also go immediately to these two 
entities, plus the VA Undersecretary for Health, the Deputy 
Undersecretary for Quality and Performance, the Deputy Undersecretary 
for Operations, the Office of Patient Care Services, and the Chief 
Consultant for the Women Veterans Health Program for review and 
recommendations, which in turn are then forwarded to the Deputy 
Undersecretary for action to remove or ameliorate the identified 
barriers.
    VVA recognizes that this requires 30 months after the VA publishes 
the 2007-08 National Survey of Women Veterans that the VA Secretary in 
turn is required to report to Congress on the barriers study and what 
actions the VA is planning. However, in reality, this means that the 
information/directions contained in the 1907-08 report is/are put ``on 
hold'' for two and a half years. Therefore VVA believes that the 
Secretary's report to Congress should also include what actions--if 
any--have transpired both during the survey and the 30 month hiatus.
Independent Study on Health Consequences of Women Veterans of Military 
        Service in Operation Iraqi Freedom and Operation Enduring 
        Freedom
    VVA believes this section should include appropriate language 
directing the study format to include the use of evidence-based ``best 
practices in care delivery.''
    During the 110th Congress, VVA was heartened to see that the 
S. 2799 legislation included a ``Long Term Study of Health of Women 
Veterans of the Armed Forces Serving Operation Iraq Freedom and 
Operation Enduring Freedom.'' However, VVA is extremely disappointed to 
see that while calling for ``a study on health consequences for women 
veterans of service on active duty in the Armed Forces in deployment in 
Operation Iraqi Freedom and Operation Enduring Freedom;'' it eliminates 
the longitudinal aspect contained in S. 2799 of the 110th Congress.
    As you know, the second round of the National Vietnam Veterans 
Readjustment Study was never completed by the VA, even though it was 
mandated by Congress to do so. VVA urges you not to let this 
opportunity be lost again on a statistically significant and diverse 
population of veterans. It is an important element to a study that will 
bring long term identification and understanding and of the long term 
implication of military service during this period of history when the 
role and duties of women veterans has far expanding the service of 
women in the past.
Report on Full-Time Program Managers for Women Veterans Programs at 
        Medical Centers
    VVA applauds the VA for recognizing the need and importance of the 
requirement for a full time Woman Veteran Program Manager at all VA 
medical center. However, VVA feels this action falls short of providing 
these managers with the reporting process that is commensurate with 
their full duties and responsibilities. Consistency is vital in 
recognizing the true tracking of the work they perform and in 
evaluating the issues of their mission. VVA believes this position is 
most significant and demands that this position's reporting line should 
also be significant and not determined by individual medical centers. 
It is known that reporting lines are varied from medical center to 
medical center. In some instances the reporting of identified items of 
the Woman Veteran Program Manager is moved forward through the medical 
center hierarchy based, not on the desire of the Woman Veteran Program 
Manager, but of other staff who are selective on what is actually 
``moved up the chain of command'' at the medical centers. VVA calls for 
the Undersecretary of Health to define the reporting line for the Woman 
Veteran Program Managers as that of the Chief of Staff at each medical 
center. This action backs up the initial significance that the VA 
recognized when elevating the position to full time. It brings 
significant investment in the importance of meting the needs of women 
veterans in its vast health system. If not, a true reporting of the 
work of the Woman Veteran Program Managers and the issues of women 
veterans could fall into the vast dark pit of the unknown. The work of 
the Woman Veteran Program Managers is vital to recognizing not only the 
needs but also providing clear information for program and process 
formation but also on establishing even possible research 
opportunities.
Improvement of Health Care Programs of the Department of Veterans 
        Affairs for Women Veterans
    VVA asks that particular reflective consideration be given to the 
following--VVA seeks a change in this section of the proposed 
legislation that would increase the time for the provision of neonatal 
care from 14 to 30 days, as needed for the newborn children of women 
veterans receiving maternity/delivery care through the VA. Certainly, 
only newborns with extreme medical conditions would require this time 
extension. VVA believes that there may be extraordinary circumstances 
wherein it would be detrimental to the proper care and treatment of the 
newborn if this provision of service was limited to solely 14 days. If 
the infant must have extended hospitalization, it would allow time for 
the case manager to make the necessary arrangements to arrange 
necessary medical and social services assistance for the women veteran 
and her child. This has important implications for our rural woman 
veterans in particular. And this is not to mention cases where there 
needs to be consideration of a woman veteran's service-connected 
disabilities, including toxic exposures and mental health issues, 
especially during the pre-natal period.
Training and Certification for Mental Health Care Providers on Care for 
        Veterans Suffering from Sexual Trauma
    VVA has concerns about the VA establishing a ``certification'' 
program. In order to be valid, VVA believes that such a certification 
program be based upon and modeled after those already utilized by many 
professional organizations. Such a certification program would lend 
itself well to oversight and accountability. Too many VA certification 
programs now consist of only a 1-hour training class or reading 
materials.
    Although this section calls for reporting the number of women 
veterans who have received counseling, care and services under 
subsection (a) from ``professionals and providers who received training 
under subsection (4)'', VVA asks ``Who in the VA is already trained and 
holds professional qualifications under these subsections''?
Care for Newborn Children of Women Veterans Receiving Maternity Care
    VVA asks that particular reflective consideration be given to the 
following--VVA seeks a change in this section of the proposed 
legislation that would increase the time for the provision of neonatal 
care to 30 days, as needed for the newborn children of women veterans 
receiving maternity/delivery care through the VA. Certainly, only 
newborns with extreme medical conditions would require this time 
extension. VVA believes that there may be extraordinary circumstances 
wherein it would be detrimental to the proper care and treatment of the 
newborn if this provision of service was limited to less than 30 days. 
The decision for extended would require professional justification. If 
the infant must have extended hospitalization, it would allow time for 
the case manager to make the necessary arrangements to arrange 
necessary medical and social services assistance for the women veteran 
and her child. This has important implications for our rural woman 
veterans in particular. And this is not to mention cases where there 
needs to be consideration of a woman veteran's service-connected 
disabilities, including toxic exposures and mental health issues, 
especially during the pre-natal period, multiple births and pre-mature 
births. Prenatal and neonatal birthrate demographics (including 
miscarriage and stillborn data) would seem to be an important element 
herein.
Delivery of Services
    Considering the ever increasing percentage of women veterans in the 
homeless veteran population and the extraordinary occurrence of this in 
the OEF/OIF homeless veteran population, one can see that their 
presence in the VA system will affect all levels of service, delivery, 
treatment, and care. Advocacy for them within the VA will be paramount.
    Vietnam Veterans of America 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.
    The new woman veterans also need increased mental health services 
related to re-adjustment, depression, and re-integration, along with 
recognition of differences among active duty, Guard, and reserve women. 
The VA already acknowledges the issue of fragmented primary care, 
noting that in 67 percent of VA sites, primary care is delivered 
separately from gender specific health care--in other words, two 
different services at two different times, and in some cases, two 
different services, two different times, and two different delivery 
sites. The VA also notes that there are too few primary care physicians 
trained in women's health, and at a time when medicine recognizes the 
link between mental and medical health, most mental health is separate 
from primary care. VVA seeks to ensure that every woman veteran has 
access to a primary care provider who meets all her primary care needs, 
including gender specific and mental health care in the context of an 
on-going patient-clinician relationship; and that general mental health 
providers are located within the women's and primary care clinics in 
order to facilitate the delivery of mental health services.
    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.  
Research
    Vietnam Veterans of America applauds the VA for elevating its 
Office of Women's Health to the Strategic Health Care Group level. With 
this action, the VA has ``pumped up'' the volume on the attention and 
direction of the VA regarding woman veterans. But there remains much to 
be learned about women veterans as a health care cohort. Data 
collection and analytical studies will provide increased opportunities 
for research and health care advancement in the field of women's 
health, as well as offer evidence-based ``best practices'' models and 
innovative treatments.
    As discussed by Phyllis Greenberger, President and CEO of the 
Society for Women's Health Research, at a recent Roundtable on Women 
Veterans before the House Committee on Veterans' Affairs, Ms. 
Greenberger stated that the focus of The Society clearly demonstrated 
that sex and gender differences exist throughout all conditions that 
affect women differently, disproportionately or exclusively and 
research needs to be done to identify those differences and understand 
their implications for diagnosis and treatment. She discussed the 
unknown in regard to the influence of hormones on not only the bodily 
process of the women's medical and mental care but also its influence 
on the regime of medication prescribed by the care providers and 
utilized by women veterans. This is especially true with medications in 
the mental health arena.
    It is well recognized that biological differences related to 
hormones affect mental health risks, rates of disorders and course of 
those disorders. Research had indicated that estrogen and progesterone 
influence brain function and stress response. Some women experience 
increased vulnerability to depression during times of reproductive 
endocrine changes such as premenstrual, postpartum and perimenopausal 
periods. VVA believes more funding needs to be available for research 
into sex differences and better coordination is needed among VA centers 
throughout the country to increase the number of women in clinical 
trials to understand the differences and their implication for 
treatment.
Suicide Risk
    Last, but just as important, VVA is deeply concerned about the high 
suicide risk among women veterans as reported at the American 
Psychiatric Association's May 2009 meetings in San Francisco. A 2007 
longitudinal study of women veterans, which followed individuals for a 
period of 12 years, suggests that women who have been in the military 
have a 3fold increased risk for suicide compared with nonmilitary 
women. Furthermore, female veterans are more likely to be young and use 
firearms to commit suicide compared with their civilian counterparts, 
who tend to choose other methods--commonly drug overdose. Data for this 
study came from the National Health Interview Study and was then linked 
with data from the National Death Index. It is important to note that 
this study was population-based and therefore, the findings are 
applicable to all military personnel and not just those in the Veterans 
Affairs (VA) health system.
    The VA is a massive health care system that possesses challenges 
for woman veterans, who are encouraged to seek treatment at VA 
facilities; but not many do. Treatment of women veterans at various 
facilities throughout the country are not ``women'' friendly. We are 
hopeful that any shortfalls can be turned into positive action for our 
so woman veterans who deserve the same care and treatment because of 
their service and sacrifice to this country.

    In closing, VVA would like to personally thank Senator Patty 
Murray, for her hard work and dedication to our woman veterans, for 
without Senator Murray, VVA believes that this hearing today would not 
be possible. We thank this Committee for the opportunity to submit 
testimony for the record.
                                 ______
                                 
Prepared Statement from Anuradha K. Bhagwati, MPP, Executive Director, 
                 Service Women's Action Network (SWAN)
    My name is Anuradha Bhagwati. I am a former Captain in the U.S. 
Marine Corps. I currently serve as Executive Director of the Service 
Women's Action Network (SWAN), a non-partisan, non-profit organization 
founded by female veterans, based out of New York City. SWAN 
specializes in policy analysis, advocacy, and legal services for all 
servicewomen, women veterans, and their families.
    Despite the progress the Veterans' Health Administration has made 
in addressing the recent influx of women veterans into the VA system, 
the challenges in delivering adequate health care services to women 
veterans remain numerous and daunting.
    Every day, SWAN receives calls from frustrated, disappointed, and 
traumatized women veterans looking for legal assistance or personal 
support due to inadequate health care, or mistreatment and harassment 
by staff or male patients at VA hospitals. Many women justifiably give 
up on the VA, as their traumas and conditions rapidly deteriorate into 
drug and alcohol abuse, homelessness, or suicide.
    The epidemic of Military Sexual Trauma (MST)--sexual harassment, 
assault and rape--which has yet to be fully recognized by the Armed 
Forces, has also yet to be adequately integrated into the daily 
operations of VA hospitals.
    MST screening at hospitals around the Nation appears to be 
inconsistent, at best. A shortage of female physicians and counselors, 
a rapid turn-over of inexperienced residents, a preponderance of 
culturally conservative administrative staff, and poorly trained or 
unprofessional medical staff contributes to a lack of understanding 
about how to treat veterans who suffer from symptoms related to MST.
    However, I must emphasize that regardless of medical condition, 
women veterans, when compared to their male counterparts, are largely 
subjected to unequal treatment at VA facilities nationwide. The 
following anecdotes illustrate just a few of the VA's institutional 
failures to deliver proper health care to women veterans:

     One Iraq veteran who checked herself into inpatient 
psychiatric care during a particularly bad PTSD episode, was forced to 
share a bathroom with male veterans, including a peeping tom. When she 
told her nurse she felt uncomfortable eating her meals with male 
veterans, the nurse threatened that she would not be fed at all.
     An Afghanistan veteran--a single mother--who was raped in 
theater by a fellow servicemember, cannot bear to enter a VA facility 
out of sheer terror of re-triggering the trauma from her assault. Like 
many other women veterans, she pays for counseling out of pocket so as 
not to subject herself to further trauma.
     One veteran recently received her annual pap smear with a 
male gynecologist who did not enforce the requirement to have a female 
staff member present during the examination. When this veteran 
mentioned to the gynecologist that she had experienced MST, he left the 
room and barked down the hall, ``We've got another one!''

    Many of these examples illustrate a larger point: that the VA 
requires an enormous cultural shift recognizing the sacrifices and 
specific needs of women veterans.
     recommendations to bridge the gaps in care for women veterans
    1. Require that the VA remedy the shortage of female physicians, 
female mental health providers and MST counselors at VA hospitals 
nationwide. Also require that the VA provide the option of female-only 
counseling groups for female combat veterans, and female- as well as 
male-only counseling groups for female and male survivors of MST.
    2. Require the VA to implement a program to train, educate, and 
certify all staff, including administrative and medical, in Federal 
Equal Opportunity regulations and MST, to reduce a discriminatory and 
unwelcoming atmosphere toward women veterans.
    3. Require the VA to increase accessibility of fee-based care for 
veterans (both male and female) who have been diagnosed with Military 
Sexual Trauma.
    4. Require day-care facilities for veterans who are parents, as 
well as more flexible evening hours for working veterans, at every VA 
hospital.
      

                                  
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