[Senate Hearing 114-295]
[From the U.S. Government Publishing Office]




                                                        S. Hrg. 114-295

                FULFILLING THE PROMISE TO WOMEN VETERANS

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             APRIL 21, 2015

                               __________

       Printed for the use of the Committee on Veterans' Affairs



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                     COMMITTEE ON VETERANS' AFFAIRS

                   Johnny Isakson, Georgia, Chairman
Jerry Moran, Kansas                  Richard Blumenthal, Connecticut, 
John Boozman, Arkansas                   Ranking Member
Dean Heller, Nevada                  Patty Murray, Washington
Bill Cassidy, Louisiana              Bernard Sanders, (I) Vermont
Mike Rounds, South Dakota            Sherrod Brown, Ohio
Thom Tillis, North Carolina          Jon Tester, Montana
Dan Sullivan, Alaska                 Mazie K. Hirono, Hawaii
                                     Joe Manchin III, West Virginia
                       Tom Bowman, Staff Director
                 John Kruse, Democratic Staff Director
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                            C O N T E N T S

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                             April 21, 2015
                                SENATORS

                                                                   Page
Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........     1
Brown, Hon. Sherrod, U.S. Senator from Ohio......................     1
Blumenthal, Hon. Richard, Ranking Member, U.S. Senator from 
  Connecticut....................................................     2
    Prepared statement...........................................     3
Rounds, Hon. Mike, U.S. Senator from South Dakota................    22
Manchin, Hon. Joe, U.S. Senator from West Virginia...............    25
Heller, Hon. Dean, U.S. Senator from Nevada......................    27
Tillis, Hon. Thom, U.S. Senator from North Carolina..............    31
Hirono, Hon. Mazie, U.S. Senator from Hawaii.....................    68
Boozman, Hon. John, U.S. Senator from Arkansas...................    70

                               WITNESSES

Hayes, Patricia, Ph.D., Chief Consultant, Women's Health 
  Services, Office of Patient Care Services, Veterans Health 
  Administration, U.S. Department of Veterans Affairs; 
  accompanied by Susan McCutcheon, National Mental Health 
  Director for Family Services, Women's Mental Health and 
  Military Sexual Trauma, Veterans Health Administration; and 
  Rosye Cloud, Acting Director, Office of Transition, Employment 
  and Economic Impact, Veterans Benefits Administration..........     7
    Prepared statement...........................................     8
    Response to request arising during the hearing by:
      Hon. Richard Blumenthal....................................    22
      Hon. Mike Rounds 


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      Hon. Thom Tillis...........................................    32
    Response to posthearing questions submitted by:
      Hon. Richard Blumenthal....................................    34
      Hon. Sherrod Brown.........................................    38
Ilem, Joy J., Deputy National Legislative Director, Disabled 
  American Veterans..............................................    40
    Prepared statement...........................................    41
    Response to request arising during the hearing by 
      Hon. Johnny Isakson........................................    62
Davis, Anne L., Col., USA (Retired), Chairperson, Nevada's Women 
  Veterans Advisory Committee....................................    52
    Prepared statement...........................................    54
Mouradjian, CPT Christina L., U.S. Army (Ret.)...................    58
    Prepared statement...........................................    60

                                APPENDIX

Spillman, Monique, MD, PhD, FACOG, The American Congress of 
  Obstetricians and Gynecologists; prepared statement............    73
O'Hare-Palmer, Kate, Chair, Women Veterans Committee, Vietnam 
  Veterans of America; prepared statement........................    74

 
                FULFILLING THE PROMISE TO WOMEN VETERANS

                              ----------                              


                        TUESDAY, APRIL 21, 2015

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:32 p.m., in 
room 418, Russell Senate Office Building, Hon. Johnny Isakson, 
Chairman of the Committee, presiding.
    Present: Senators Isakson, Moran, Boozman, Heller, Rounds, 
Tillis, Sullivan, Blumenthal, Brown, Hirono, and Manchin.

      OPENING STATEMENT OF HON. JOHNNY ISAKSON, CHAIRMAN, 
                   U.S. SENATOR FROM GEORGIA

    Chairman Isakson. I call this meeting of the Veterans' 
Affairs Committee of the U.S. Senate to order. I am taking 
executive privilege to name the new Ranking Member Sherrod 
Brown from Ohio.
    Senator Brown. Permanently, I might add. [Laughter.]
    Chairman Isakson. When Senator Blumenthal comes in, he will 
assume his appropriate place next to the new Ranking Member and 
we will go forward accordingly.
    Seriously, your time is valuable and our time is valuable, 
so we want to get started. So, I will let Sherrod make an 
opening statement in just a second on behalf of the minority.
    Let me say two things before I start. Last night, or early 
this morning, America lost a great veteran. Pete Wheeler, the 
Commissioner of Veterans Services in the State of Georgia for 
61 years, appointed first in 1954, served under 11 Governors, 
has been given every award possible by a decorated veteran in 
the United States of America and has served for six decades, 
passed away in the Atlanta Veterans Hospital at Clairmont Road 
in Atlanta. I want to start this meeting by paying tribute to a 
personal friend of mine, a veteran for life, Pete Wheeler, the 
Commissioner of Veterans Affairs in Georgia, who passed away 
early this morning. I know that he will be remembered by all 
that he has helped and all that he has served for many, many 
years to come.
    Second, I had a great privilege on Sunday. I gave the 
Congressional Gold Medal to a Tuskegee Airman, Amelia Robinson 
Jones, who in 1943, when there were no African Americans in the 
United States military in an integrated position, nor were 
there any women--African American women--she volunteered for 
the Army Air Corps and flew with the Tuskegee Airmen in World 
War II, which broke the glass ceiling for women, broke the 
glass ceiling for African Americans. She is 95 years old and I 
was able to give her the award in a hospice facility where she 
is in Savannah, GA. I want to remember today Amelia Robinson 
Jones, a great United States veteran, a great lady, and one of 
the original Tuskegee Airmen. I want to throw both those two 
comments in.
    I want to welcome everybody to our hearing today, which is 
about fulfilling our promise to America's women veterans. You 
know, up to 9.2 percent of our military is made up of women. 
Soon, it will be 15 percent of our active duty services are 
women and 18 percent of our Guard and Reserve are women, so it 
is growing. By the year 2020, 10.5 percent of our veterans will 
be women. By the year 2040, 16 percent will be women. There are 
90,000 women veterans in the State of Georgia, the fifth 
largest women's population in the country.
    One in five women veterans who use VA health services have 
experienced military sexual trauma (MST). Women veterans are 
also three times more likely to experience homelessness than 
non-veterans, and when a woman experiences homelessness, her 
children experience it with her. It is important that we do 
everything we can to meet and fulfill the promise to women.
    In that weekend trip where I gave the Congressional Gold 
Medal and was able to visit the Savannah VA, I also saw 
firsthand what the VA is doing in its planning for women's 
services in their new community-based outpatient clinics 
(CBOCs). They are doing a good job of offering mental health 
services, gynecological services, OB/GYN services, and the 
services that are unique to women. We must ensure that our 
veterans of military service in America, when they leave the 
DOD and become active members of the veterans' society, they 
get the same services that a woman would expect in the private 
sector from the VA health services.
    This is an important hearing. Women play an important role 
in our United States military in the defense of our country. 
They fight in every capacity possible, they volunteer in every 
capacity possible, and they do a great job. We need to make 
sure we are doing the same.
    I see the Ranking Member is here. I took a little advantage 
of leadership and replaced you for a couple minutes so we could 
get started. Now it is my privilege to introduce our Ranking 
Member, Sen. Richard Blumenthal from Connecticut.

         OPENING STATEMENT OF HON. RICHARD BLUMENTHAL, 
         RANKING MEMBER, U.S. SENATOR FROM CONNECTICUT

    Senator Blumenthal. Thank you, Mr. Chairman, and I 
appreciate your leadership in calling this hearing which deals 
with perhaps one of the most critical and important issues 
facing this Committee, the Veterans Administration, and our 
Nation today.
    Women are, in fact, one of the fastest growing segments of 
the overall veterans' population. By 2020, they are expected to 
grow to 11 percent of the total veterans' population. Yet, for 
too long, the VA has essentially ignored many of the most 
pressing needs that our women veterans face.
    In Connecticut, for example, the facility serving women 
veterans has been in the basement of our West Haven VA 
Hospital. They have now upgraded that clinic, or at least are 
in the process of doing so, and I want to make sure that those 
improvements are completed.
    I have stories that are recounted in the full statement, 
which I would ask permission be entered into the record.
    Chairman Isakson. Without objection. Thank you.
    Senator Blumenthal. Since I am intent on hearing and 
listening more than talking during this session--which we have 
a very, very expert and competent panel--I am going to close at 
this point by saying there are too many homeless women 
veterans. There are too many women veterans in need of medical 
care that is simply inaccessible to them. There are too many 
veterans whose job needs have been disregarded, maybe not 
purposely, but in effect, negligently. There are too many 
veterans, women and men, who need better treatment from the VA. 
This hearing is a very, very important step toward meeting the 
needs of women veterans, the challenges that our Nation faces 
in keeping faith with all our veterans.
    Thank you, Mr. Chairman.
    [The prepared statement of Senator Blumenthal follows:]
   Prepared Statement of Senator Richard Blumenthal, Ranking Member, 
                     U.S. Senator from Connecticut
    Women veterans are one of the fastest growing segments of the 
overall veteran population and by 2020, they are expected to grow to 11 
percent of the total veteran population. Despite their prominent role 
in the wars being fought overseas, fewer than 30 percent of women 
veterans self-identify as veterans in their community and they are 
often unaware of the benefits and services that are available to them.
    For too long, VA has been thought of as somewhat of an old-boys 
club, and changing that culture requires making important 
infrastructure and staffing changes as well as shifting a long-
entrenched culture that has perceived veterans to be male.
    I do want to recognize the fact VA has made some progress toward 
addressing the under-recognition of women veterans and the lack of 
gender-specific services for women veterans, but VA is still far from 
where it needs to be. In 1994, VA established the Center for Women 
Veterans, to coordinate VA programs across the Federal Government and 
also to work with public and private partners to raise awareness of the 
services and benefits available to women veterans. VA has also worked 
to ensure there is a designated women's health provider at every VA 
Medical Center and at the vast majority of all Community-Based 
Outpatient Clinics. I look forward to hearing Dr. Hayes's testimony 
about other efforts to improve access to health care for women 
veterans.
    Part of improving that access is ensuring VA has an adequate number 
of trained medical professionals, but another equally important 
component of that access is ensuring that women feel comfortable 
utilizing the services that are available to them. I have visited the 
West Haven VA many times, and while I applaud their efforts to 
establish a women's clinic on-site, putting that clinic in the basement 
doesn't exactly create an environment in which women are likely to feel 
that they are welcome.
    There are obviously physical restrictions on the actual footprint 
of the building that require constructing more space to move the 
women's clinic elsewhere, and I am told that change will be completed 
later this year. However, the reality is we have to find a way to make 
sure that while we are improving services available to all veterans, 
that we are specifically ensuring we take into account the needs of 
women veterans in addition to male veterans.
    In advance of this hearing, my staff to reached out to some of the 
veterans networks in Connecticut to hear directly from constituents 
about their experiences accessing benefits and health services from VA. 
The experiences that constituents shared are invaluable in 
understanding the scope of reforms needed to truly ensure that VA is 
serving women veterans as well as they need to be. The veterans in 
Connecticut reached out to others across the country including female 
alumni from West Point and Annapolis. Excerpts from the stories they 
shared on their experiences utilizing VA services follow:

           When I was transitioning out of the Navy knowing 
        that I needed some mental health help I was lost and didn't 
        know what to do. I did what you are supposed to do when you are 
        getting out. I registered for school, before I left on my last 
        deployment I went to Navy TAP (transition assistance program), 
        which was great but not useful. I did not know about the VA nor 
        did anyone from the VA come and speak with us. Granted this was 
        in 2005 and things were a bit different. I would have used the 
        VA if I knew, but I didn't know and my family didn't know. I 
        was somewhat fortunate and I lived with my now husband when he 
        worked for a major insurance company who allowed for co-
        habitation partners to be covered under his insurance. When he 
        had to change jobs we lost my coverage. That was in 
        October 2005. I was a student and not working. I got one last 
        check up and finished up the 6 month supply of birth control 
        the Navy had given me prior to my discharged and then prayed 
        that I didn't get sick or pregnant. I went to Planned 
        Parenthood when I got a UTI and they helped. I never would have 
        gone to the VA. I would have never thought about going there. I 
        spent 2 years being harassed and other things by ``salty dogs'' 
        (read old Navy guys). That was not happening.
           Even though the women's clinic in West Haven is the 
        farthest possible location from the entrance and located in the 
        basement, it was nice to have all of my care go to one central 
        location and have a dedicated team [At a VA hospital in New 
        Jersey]. I had to get an x-ray one time. Because I am a woman 
        in her child bearing years, I am required to take a pregnancy 
        test before getting the x-ray. The hospital had no idea how to 
        do this. It became a several minute conversation about whether 
        to send me to the lab or to just hand me a pregnancy test or 
        some other option. There was no standard for how to get a pre-
        x-ray pregnancy test. I don't even remember what the final 
        decision was but I do remember thinking it was really odd that 
        they didn't know how to handle something so simple that is 
        specific to women.

          Until some of the areas got to know me, almost every time I 
        checked into an appointment, I was asked if I was the sponsor 
        or an employee. I thought this was a standard question that was 
        asked of everyone; I started listening to how the VA employees 
        interacted with other patients. As it turns out, that was NOT a 
        standard question. I had another female veteran friend who used 
        the facility often and had a similar experience. It was almost 
        as if they had never had a female veteran patient before and 
        assumed that I am either there with my father or a VA employee. 
        One nurse even commented one time that they ``don't get a lot 
        of young females in here.''

           I have extremely bad hirsutism due to hormonal 
        issues. I had one doctor who didn't believe that I grew a 
        beard. I mentioned my daily process to keep my face [clear]. 
        The doctor still didn't believe me and asked me to grow my 
        facial hair for two weeks and then come back in so she could 
        see if ``it is as bad as [I] claim.'' I asked if I could just 
        come in first thing in the morning and she could observe one 
        day's growth. When she said no, I got a little anxious and 
        teary eyed thinking about walking around town & graduate school 
        with a full beard for two weeks (which would have been the 
        case). How did she react to my reaction? She said, ``Oh come 
        on. There are worse things in the world.'' That is true; there 
        are worse things in life but at that moment, I was reacting to 
        a prospective situation which was highly uncomfortable for me. 
        Ultimately, I ignored her request and came in with only one-
        day's growth and she saw that I was, in fact, not making up my 
        hirsutism.
          I went to the VA's emergency clinic one time with a condition 
        related to my hormonal imbalance. The Doctor admitted to never 
        having dealt with women and being visibly nervous and 
        uncomfortable with the situation. Not his fault, but I felt the 
        need to try to calm his nerves. It was overall awkward.

           I left active duty in 1992 and was never told about 
        possible VA benefits. When I was mobilized and subsequently 
        demobilized, we were rushed through the process.
          My care has been pretty good overall. 2 exceptions:

          1) Women's health has an older male doctor. He isn't bad, but 
        it would be better if all the OB/GYNs were female. I had a less 
        than pleasant experience with him, but couldn't wait to get on 
        the female doctor's schedule (2 or 3 month wait to see her).
          2) Mental Health--I had been seeing a counselor/doctor for 
        sleep issues, stemming from my deployment and major depression. 
        Sleep doctor was wonderful and I felt cared for. The Mental 
        Health counselors are nice people, but I don't feel like CBT 
        (Cognitive Based Treatment) is the best for an issue that 
        occurred at 18 and I am still dealing with. I have asked for 
        help in putting it aside, but the counseling is focused on how 
        you interpret today, not exorcising demons. Also, I feel like 
        as soon as I agreed to go on an antidepressant, my counseling 
        was halted--I was considered finished. The Rx helps, but the 
        underlying issue is still there. The Psychiatrist who monitors 
        my Rx is awesome and helpful, but she can't take on patients 
        for counseling. I would like to see more small groups for women 
        only. I was put into a group initially before I could get into 
        the counseling and it consisted of 2 addicts and a gentleman 
        and I. I never really talked because I couldn't relate to their 
        issues.

           I want to share that I have had, thus far, nothing 
        but good experiences with the VA. I have many military-related 
        issues--to include a sexual assault--but my Compensation and 
        Disability assessment was extraordinarily thorough and swift.
          I will acknowledge that I approached my retirement physical 
        and the VA evaluation with great care in documenting my health 
        status. It took me several months to collect all the necessary 
        records and documentation for my various ailments and injuries, 
        since the period of service was over 30 years, military medical 
        records were incomplete, and some of my ``worse'' conditions 
        (such as cancer) had been diagnosed and treated at civilian 
        medical care facilities, with little shared documentation 
        between the referring military physicians and the civilian 
        ones. In some cases, there was simply no documentation at all--
        such as my sexual assault--because I had not reported to a 
        medical facility at the time (and my ``command'' did not 
        suggest it to me when I reported it to them).
          However, I carefully laid out a chronology of concerns (and 
        also grouped the concerns in terms of ``function'') and 
        carefully showed where there was documentation (by tabbing my 
        medical records appropriately) and indicated where 
        documentation was missing. I asked for and received a ``pre-
        filing'' face-to-face appointment with a VA representative and 
        got some tips on requesting the documentation from the non-
        military treatment facilities (due to privacy laws, the patient 
        has to ask for the documentation). By the time I was ready to 
        file, my packet (which was several inches thick) was ready as a 
        ``Fully Developed Claim.''
          My first appointments were scheduled within 60 days of my 
        filing. My disability determination was awarded within 90 days 
        of my appointments.
          Perhaps most importantly, when I went through the evaluation, 
        I was asked very pertinent questions about my obstetric/
        gynecological health--as well as my emotional health. This was 
        both ``in general'' as well as specific to my sexual assault 
        experience. Some of the questions related directly to my own 
        health history, but some were more generic. I certainly felt as 
        if I had the opportunity to address ANY female-specific issue--
        or issue relating to sexual harassment/assault/
        marginalization--with any of the doctors or staff that I met at 
        this VA.
          In fact, the only time I have been disconcerted with my 
        Lebanon VA is when I got letters addressed to me as ``Sir.'' 
        They also had me as ``male'' for my first appointment, but made 
        the change to their database on site and I have not had a 
        ``sir'' since then.
          Now, I already pointed out that I did A LOT of work on my own 
        behalf to make my medical records as complete as possible 
        beforehand. I will also point out that I have been comfortable 
        as my own advocate for many years, so nothing about the VA 
        process was difficult for me. Third, I made myself as 
        accommodating as I could to the process. Therefore, my 
        experience may not be the experience of others.

           A little history about myself, I am a West Point 
        graduate, and experienced several issues while at West Point 
        and in the Army. I was sexually assaulted and never reported it 
        because of the stigma at the time, I suffered numerous head 
        traumas while serving, and a severe concussion from a biking 
        accident while I was in graduate school after leaving the Army.
          I used the services of Vocational Rehab when I left the Army, 
        they were very helpful, kind, and advised me about education 
        options, and after graduation assisted my job search. They 
        provided me a whole new direction and new start for a career 
        when I was unable to continue in the job for which I was 
        trained and could no longer perform due to medical issues. I 
        have nothing but high praise for them.
          My VA hospital system experiences have been a mixed bag. They 
        have been changing over the years as I have aged and learned 
        more about the system and how to deal with everything. When I 
        visit the VA hospital in West Haven, in order to get to the 
        women's clinic, I have to go through what can only be described 
        as somewhat of a gauntlet of vets who are either there waiting 
        for an appointment or prescription, or just there to socialize. 
        If I look them in the eye this seems to give them permission to 
        hit on me or make some kind of harassing comment. Given my 
        traumas this is extremely stressful and I avoid eye contact 
        when I am even able to get myself to go to the hospital. When I 
        am able to get an appointment and deal with going there, the 
        staff is wonderful, and my psychologist is very kind and 
        helpful with my PTSD and anxiety with new doctors.

Other issues were raised by the veterans who responded to our outreach, 
but I wanted to highlight these particular stories because they are 
especially informative regarding the problems faced by women veterans. 
I hope their stories will help VA see exactly where the gaps in service 
are. They will certainly help me to exercise appropriate oversight of 
VA and push for reforms to address issues faced by women veterans. It 
should not be the case that veterans who have fought so valiantly for 
our country have to fight just to reaffirm their status as veterans and 
to get basic access to health care services.
    Additionally, VA needs to ensure that gender-specific health care 
for women covers more than reproductive and gynecological care. It 
means offering treatments across all specialties that is appropriate 
for that individual, taking into account factors like gender. As a part 
of gender-specific services, we need to ensure that specialty care, 
such as mental health care for PTS and TBI reflects the different care 
needs of women veterans.
    Finally, the unemployment rate is currently higher for women 
veterans than for male veterans and civilian women. Unemployment is 
strongly associated with adverse health and is highly correlated with 
homelessness. We need to determine whether the transition and 
employment services that are offered through the joint VA, DOD and DOL 
Veterans Employment Center are appropriately reaching women veterans in 
order to help them establish and meet career goals. In some cases, this 
might mean that child care is provided at locations where veterans must 
go to obtain job training and benefits. It might also mean that 
employees at the Veterans Employment Center have training in how to 
best prepare women veterans to enter the job market.
    There are a number of specific steps that VA must take to address 
the needs of women veterans. DAV has been particularly active on 
bringing outstanding issues to the attention of VA and of this 
Committee, and I thank them for their strong advocacy and service to 
this country. Ultimately, VA must ensure that it is bridging the 
existing cultural gap and fully including women veterans in the general 
veteran population the Department serves in order to ensure that women 
veterans and their children do not end up homeless.
    There are still too many homeless veterans period. However, we must 
address all of the services whether offered by VA alone or in 
partnership with other Federal agencies or private partners to ensure 
that women veterans truly have access to the services they may need.
    I look forward to the testimony today and to hear from VA about 
what they plan to do to ensure that the women separating from service 
feel comfortable proudly identifying as veterans and can safely use the 
benefits and services that they have earned. I especially look forward 
to hearing from the women veterans on the second panel about their 
individual experiences so that we can learn what will most make a 
difference to them and others who have served. Thank you in advance for 
your testimony today and for your service to this country.

    Chairman Isakson. As is our tradition, the other Members of 
the Committee can submit statements for the record or remain to 
make a closing statement if they wish, but we want to get 
straight to our witnesses, then questions and answers.
    For our first panel I will introduce Patricia Hayes, Ph.D., 
Chief Consultant, Women's Health Services, Veterans Health 
Administration, U.S. Department of Veterans Affairs; 
accompanied by Dr. Susan McCutcheon, National Mental Health 
Director for Family Services, Women's Mental Health and 
Military Sexual Trauma, Veterans Health Administration; and 
Rosye Cloud, Acting Director of the Office of Transition, 
Employment and Economic Impact, Veterans Benefits 
Administration.
    Dr. Hayes, welcome.

 STATEMENT OF PATRICIA HAYES, Ph.D., CHIEF CONSULTANT, WOMEN'S 
     HEALTH SERVICES, VETERANS HEALTH ADMINISTRATION, U.S. 
     DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY SUSAN 
    McCUTCHEON, NATIONAL MENTAL HEALTH DIRECTOR FOR FAMILY 
  SERVICES, WOMEN'S MENTAL HEALTH AND MILITARY SEXUAL TRAUMA, 
    VETERANS HEALTH ADMINISTRATION; AND ROSYE CLOUD, ACTING 
DIRECTOR, OFFICE OF TRANSITION, EMPLOYMENT AND ECONOMIC IMPACT, 
                VETERANS BENEFITS ADMINISTRATION

    Ms. Hayes. Thank you very much, Chairman Isakson, Ranking 
Member Blumenthal, and distinguished Members of the Senate 
Committee on Veterans' Affairs. Thank you for the opportunity 
to discuss the high-quality care and the support that VA is 
providing to our women veterans.
    I am accompanied today, as you mentioned, by Dr. Susan 
McCutcheon, the National Mental Health Director of Family 
Services, Women's Mental Health and Military Sexual Trauma, and 
Ms. Rosye Cloud, who is the Acting Director of Veterans 
Benefits Administration Office of Transition, Employment, and 
Economic Impact.
    The number of women veterans enrolling in VA health care 
has increased rapidly, placing new demands on the VA health 
care system that historically treated mainly men. In fiscal 
year 2014, there were more than two million women veterans in 
the United States. Of those women veterans, 635,000 are 
enrollees, to include more than 400,000 users of VA health care 
services.
    To address the growing number of women veterans who are 
eligible for health care, VA is strategically enhancing 
services and access for women veterans.
    In 2008, VA first identified the necessary actions for 
ensuring that every woman veteran has access to primary care. 
Since then, our plan of delivering care to women veterans has 
come to fruition. VHA Women's Health Services oversees program 
and policy development for women's health and provides 
strategic support to implement positive changes in the 
provision of health care to all women veterans. Women's Health 
Services works to ensure that timely, equitable, high quality, 
comprehensive health care services are provided in a safe and 
sensitive environment at VA facilities nationwide. Women's 
Health Services programs include comprehensive primary care, 
women's health education, reproductive health, communication, 
and our partnerships.
    To provide the highest quality of care to women veterans, 
VA offers women veterans trained and experienced designated 
women's health providers who can provide general primary care 
and gender-specific primary care in the context of a long-term 
patient and provider relationship. Today, designated women's 
health providers are available at all VA medical centers and 90 
percent of our community-based outpatient clinics.
    With the launch of such a large-scale change in services, 
Women's Health Services recognized the need to assess the 
progress toward implementation of these goals. We evaluated all 
the women's health programs throughout several mechanisms, and 
in addition, we use an independent contractor to conduct 
detailed site visits to objectively assess the implementation 
of services for women veterans nationwide. Also, recent 
analysis indicates that VHA outperforms private and public 
sector health care in many quality performance measures.
    As a recognized leader in the provision of high-quality 
health care, VHA initiated efforts to address the gender 
disparity, a problem that affects health care nationwide. Since 
2006, VHA's Office of Informatics and Analytics has analyzed 
all external peer reviewed program data by gender and published 
the quarterly Gender Report on its Web site.
    Over the years, we have been working very hard to close the 
gender disparities gap. In 2008, VHA launched a concerted 
Women's Health Improvement Effort, focusing the providers' 
attention on gender disparity data. From 2008 to 2011, VA saw a 
significant reduction in gender disparity for many measures. At 
the close of 2013, small gender gaps still existed in only a 
few measures, including cholesterol management in high-risk 
patients, diabetes care, and rates of influenza vaccination. VA 
continues to address such key clinical issues and others, 
including cardiac care, to improve women veterans' health.
    VA recognizes the importance of providing services to women 
veterans over their life span. VA provides a full continuum of 
mental health services to women veterans, including outpatient, 
inpatient, and residential treatment options. VA also 
recognizes the significance that support groups and 
partnerships with our local communities have in our transition 
and recovery for women veterans. A number of programs connect 
women veterans and veterans with families with health care, 
employment, financial counseling, and housing.
    In conclusion, our mission at VA is to care for those who 
shall have borne the battle, as well as their families and 
their survivors. We are providing the highest quality care for 
today's women veterans while actively working to meet the needs 
of those who will come to us in the future. We have made 
significant strides in recent years. However, we know we still 
have much to do as VA continues to focus on a nationwide effort 
to enhance the language, the practice, and the culture of VA to 
be more inclusive of women veterans. We will continue to 
improve our efforts to provide high quality, timely health care 
to our women veterans, and we appreciate this Committee's 
support in doing so.
    Mr. Chairman, this concludes my testimony. My colleagues 
and I are prepared to answer any questions you or other Members 
of the Committee may have.
    [The prepared statement of Ms. Hayes follows:]
Prepared Statement of Dr. Patricia Hayes, Chief Consultant For Women's 
  Health Services, Veterans Health Administration, U.S. Department of 
                            Veterans Affairs
    Chairman Isakson, Ranking Member Blumenthal, and Distinguished 
Members of the Senate Committee on Veterans' Affairs, Thank you for the 
opportunity to discuss the high quality care and support VA is 
providing to our women Veterans. I am accompanied today by Dr. Susan 
McCutcheon, National Mental Health Director for Family Services, 
Women's Mental Health and Military Sexual Trauma, as well as Ms. Rosye 
Cloud, Acting Director of the Veterans Benefits Administration (VBA) 
Office of Transition, Employment & Economic Impact (OTEEI).
                       overview of women's health
    The number of women Veterans enrolling in VA health care is 
increasing, placing new demands on a VA health care system that 
historically treated mostly men. There are more than 2.0 million women 
Veterans in the United States accounting for more than 400,000 users of 
VA health care services in fiscal year (FY) 2014. To address the 
growing number of women Veterans who are eligible for health care, VA 
is strategically enhancing services and access for women Veterans.
    VHA's Women's Health Services (WHS) oversees program and policy 
development for women's health and provides strategic support to 
implement positive changes in the provision of care for all women 
Veterans. WHS works to ensure that timely, equitable, high quality, 
comprehensive health care services are provided in a sensitive and safe 
environment at VA facilities nationwide. WHS programs include 
comprehensive primary care, women's health education, reproductive 
health, communication, and partnerships. WHS' goals are to:

     Transform health care delivery for women Veterans using a 
personalized, proactive, patient-centered model of care;
     Develop, implement, and influence VA health policy as it 
relates to women Veterans;
     Ensure a proficient and agile clinical workforce through 
training and education;
     Develop, seamlessly integrate, and enhance VA reproductive 
health care; and
     Drive the focus and set the agenda to increase 
understanding of the effects of military service on women Veterans' 
lives.
implementing comprehensive primary health care model for women veterans
    To provide the highest quality of care to women Veterans, VA offers 
women Veterans assignments to trained and experienced Designated 
Women's Health Providers (DWHP) who can provide general primary care 
and gender-specific primary care in the context of a long-term patient/
provider relationship. In 2009, we had women's health providers at 33 
percent of medical centers. Today, DWHPs are available at 100 percent 
of VA medical centers (VAMC) and 90 percent of Community-Based 
Outpatient Clinics (CBOC). National VA satisfaction and quality data 
from 2014 indicate that women who are assigned to DWHPs have higher 
satisfaction and higher quality of gender-specific care than those 
assigned to other providers. VA's plan is that whenever a woman Veteran 
enters the health care system, she will have access to a DWHP. To meet 
this plan, VA must ensure that all new primary care hires are 
proficient in the care of women as well as men. VA is continuing to 
train and update skills of current VA primary care and emergency 
providers in the care of women. Since 2008, VA has provided intensive 
training to over 2,000 women's health providers and provided over 50 
different online, accredited women's health classes, which can be taken 
24/7 to enhance the flexibility of learning opportunities for 
employees. The combination of educational offerings provides not only 
basic training in women's health but advance courses so that providers 
and other staff can keep their skills and knowledge up-to-date.
                 assessing women's comprehensive health
    With the launch of such a large scale change in services, WHS 
recognized the need to assess the progress toward implementation of 
high quality programs focused on women Veterans. WHS evaluates all 
women Veterans' health programs through several mechanisms. Every VAMC 
completes an annual self-assessment of the implementation of 
comprehensive women Veterans' services through the Women's Assessment 
Tool for Comprehensive Health. This tool includes an assessment of the 
Enrollee Health Care Projection Model's current and future enrollment 
and utilization projections, strategic planning for women Veterans' 
services, and reports on the providers and capacity for clinical 
services, such as primary care, gynecology, and emergency services.
    In addition, VHA uses an independent contractor to conduct detailed 
site visits to objectively assess the implementation of services for 
women Veterans nationwide. Over the course of each year, the 
independent assessment team conducts a more intense review at 25 VAMCs. 
Each year, the independent contractor provides an evaluation of the 
state of implementation and a national roll-up report highlighting both 
areas where capacity has been built and areas that still need 
development. The annual reports have been provided to VHA Central 
Office and Veterans Integrated Service Network (VISN) leadership teams. 
This allows leadership to examine trends in implementation and to 
identify and address gaps in services available for women Veterans.
                      narrowing gender disparities
    Recent analysis indicates that VHA outperforms private and public 
sector health care in many quality performance measures.\1\ As a 
recognized leader in provision of high-quality health care, VHA 
initiated efforts to address gender disparity, a problem that affects 
health care nationwide.\2\ In an effort to measure the quality of care 
provided to women Veterans, since 2006 VA's Office of Informatics and 
Analytics (formerly Office of Quality and Performance) has analyzed all 
External Peer Review Program Data (EPRP)\3\ by gender and published the 
quarterly Gender Report on its Web site. Starting in 2006, a number of 
gaps were identified in the quality of care for men and women, 
including disparities in measures for screening, prevention, and 
chronic disease management.
---------------------------------------------------------------------------
    \1\ Gender Differences in Performance Measures VHA 2008-2011 Women 
Veterans Health Strategic Health Care Group, Patient Care Services, 
VHA, Washington DC, June 2012
    \2\ JGIM Vol 28 Supp 2 July 2013. Women's Health During Health Care 
Transformation, Clancy and Sharp
    \3\ EPRP is designed to provide medical centers and outpatient 
clinics with diagnosis and procedure-specific quality of care 
information. It provides a database for analysis and internal and 
external comparison of clinical care. Data used for these analyses are 
abstracted from a random sample of both paper and electronic medical 
records. EPRP data is primarily used for quality improvement, 
evaluation and benchmarking with external organizations. (VHA DIRECTIVE 
2008-032)
---------------------------------------------------------------------------
    In FY 2008, VHA launched a concerted Women's Health improvement 
effort, focusing providers' attention on gender disparity data. From 
2008 to 2011, VA saw a significant reduction in gender disparity for 
many measures, including hypertension, diabetes, pneumococcal vaccine, 
and influenza prevention. Improvements were also made in screening 
measures for colorectal cancer, depression, Post Traumatic Stress 
Disorder (PTSD), and alcohol misuse. In FY 2011, VA included Gender 
Disparity Improvement as a performance measure in the VISN Director 
Performance Plans, which concentrated management attention on systems 
to continuously reduce gender disparity. WHS has continued to publish 
reports on these efforts; the FY 2013 report illustrates that VA has 
made continued progress in closing the gap in gender disparities. At 
the close of FY 2013, small gender gaps existed in only a few measures 
including cholesterol management in high-risk patients, diabetes care, 
and rates of influenza vaccination.
                    women veterans economic outcomes
    In addition to addressing women Veterans' health care concerns, VA 
is committed to working with our partner Federal agencies to help 
transition female Servicemembers and Veterans achieve strong economic 
outcomes through meaningful employment and suitable housing.
    In January 2015, VA's Veterans Economic Opportunity Report examined 
how Veterans compare to their non-Veteran counterparts in obtaining 
meaningful employment, increasing their income, accessing education, 
and other indicators of success. VA reported that female Veterans are 
doing well compared to their non-Veteran female and Veteran male peers 
in both career earnings and education. Specifically, VA's Economic 
Opportunity Report\4\ cited that female Veterans attain 14 percent 
higher median earnings than the non-Veteran female population with 
similar demographic characteristics; and that female Veterans 
participating in the GI Bill had a 10 percent higher program completion 
rate compared to male Veterans for all ages combined, an 8 percent 
higher program completion rate across all individual age groups, and a 
5 percent higher program completion rate when compared to female 
students in the general population. This report provides valuable 
insight, and VA continues to work with our Federal partners to ensure 
all women Veterans, like their male counterparts, are empowered with 
the tools necessary to gain meaningful employment and career mobility.
---------------------------------------------------------------------------
    \4\ VA's Economic Opportunity report: http://www.benefits.va.gov/
benefits/docs/VeteranEconomic OpportunityReport2015.PDF
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    One program contributing to this effort is the interagency 
Transition Assistance Program (TAP), through which VA equips 
Servicemembers and their families with the tools they need to make a 
smooth, successful transition to civilian life. A key component of TAP 
is Transition Goals, Plans, Success (GPS), a curriculum jointly managed 
by VA, DOD, and DOL, designed to help transitioning Servicemembers 
connect with jobs, training, and other benefits prior to leaving 
service. To support TAP, VBA has more than 300 VA benefits advisors 
permanently located at more than 100 military locations worldwide. From 
beginning of FY 2014 to date, VBA has conducted 12, 342 briefings to an 
estimated 329,400 separating Servicemembers. As part of Transition GPS, 
VA benefits advisors not only provide a day long briefing on VA 
benefits and services but also provide the Career Technical Training 
Track, an optional 2-day workshop, which helps transitioning 
Servicemembers identify relevant civilian occupations, establish career 
goals, and begin applying for credentials and vocational training. 
Additionally, VA benefits advisors work to ensure Servicemembers are 
referred to appropriate services such as VA's Vocational Rehabilitation 
and Employment (VR&E) Program.
    The VR&E Program provides comprehensive services and assistance to 
enable Veterans with service-connected disabilities and an employment 
handicap prepare for, find, and maintain suitable employment. For 
Veterans with service-connected disabilities so severe that they cannot 
immediately consider work, VR&E offers services to improve their 
ability to live as independently as possible in their homes and 
communities. Vocational rehabilitation counselors and employment 
coordinators work closely with their DOL counterparts to help Women 
Veterans find meaningful, sustainable careers. Services provided 
include training and career assessment to help them reach their career 
goals, individual counseling and direct assistance to VA-specific 
services, homeless placement services, and referrals for VA medical 
services.
    VA, DOD, and DOL also partnered to launch the Veterans Employment 
Center (VEC) in April 2014. The VEC provides transitioning 
Servicemembers, Veterans, and their families with a single 
authoritative Internet source that connects them with job 
opportunities, and provides tools to translate their military skills 
into plain language and build a profile that can be shared--in real 
time--with employers. Over 1.7 million private and public-sector jobs 
are listed on the VEC. As of February 15, 2015, 844 employers made 
public hiring commitments to hire over 553,500 individuals. In 
addition, committed employers have reported hiring over 286,000 
Veterans and family members.
    VA has also initiated an aggressive rollout of innovative public-
private partnerships that are leveraging best practices and tools of 
premier companies in private industry to provide unique support to 
transitioning Servicemembers, Veterans, and their families and to help 
bridge the cultural gap. For example, VA has strategic partnerships 
with LinkedIn and Coursera. Most recently, VA partnered with TriWest 
Healthcare Alliance to connect women Veterans who are homeless or at 
risk of being homeless with meaningful and stable employment.
    VA is also exploring various learning opportunities as potential 
alternatives or supplements to traditional education that yield career 
competitive skills and employment opportunities for Veterans. VA will 
be opening accelerated learning opportunities this fiscal year to help 
bridge the gap between Veterans' separation from service and successful 
civilian employment outcomes. Additionally, VA is establishing 20 
learning hubs that will provide space and resources, such as computers 
for Veterans, transitioning Servicemembers, and military spouses to 
complete the online educational courses available in a classroom 
environment.
    VA's efforts to improve economic outcomes for women Veterans 
include providing greater access to suitable housing through VA's Home 
Loan Guaranty Program. The Home Loan Program assists eligible Veterans 
in obtaining, retaining, and adapting their homes. In each of the past 
10 fiscal years, the numbers of VA loans to women Veterans averaged 
between 10 and 12 percent of the VA guaranteed loan portfolio. Over the 
last decade, VA has guaranteed 3.5 million home loans, including loans 
for nearly 400,000 women Veterans. This figure does not include women 
Veterans who have entitlement, but elected to use their spouse's 
eligibility for the home loan benefit.
    Additionally, VA pursued, and Congress passed as Public Law 112-
154, legislation that affords more single, active-duty Veterans with 
children the opportunity to obtain a home using their VA home loan 
benefit. This law expanded the occupancy requirement attached to VA 
home loans to include not just the Veteran or a spouse but also a 
dependent child of an active duty Servicemember. A key impact of this 
legislative change is that single Veterans with children, many of whom 
are women, are not adversely impacted by their active duty service and 
can provide housing for their children, and as necessary, caretakers 
and guardians.
                   disability assistance and benefits
    Women Veterans are eligible for the wide variety of VA benefits 
available to all U.S. Military Veterans. These benefits include 
disability compensation, pension, education, vocational rehabilitation, 
home loan guaranty, and life insurance as well as monetary burial 
allowances.
    VA is committed to ensuring that all Veterans, Servicemembers and 
their families are aware of and know how to access the benefits they 
have earned and deserve. VA conducts targeted outreach to women, 
minorities, elderly, and homeless. VA also uses social media such as 
Twitter and Facebook and electronic communication through GovDelivery 
for targeted messaging. Of the 4.3 million registered eBenefits users, 
24 percent are women. Through these outreach efforts, VA has seen an 
increase in utilization of benefits by women Veterans. In 2014, 356,748 
women Veterans received compensation benefits; an 8 percent increase 
over 2013. In addition, 12,624 women Veterans received pension 
benefits, 128,800 used Post-9/11 GI Bill education benefits, and 46,714 
received VA guaranteed home loans totaling $10.5 billion in FY14.
    One of VA's outreach goals is to ensure the National Guard and 
Reserve population receive information about VA health care, benefits, 
and services. This is accomplished through consistent dialog with 
leadership within the Reserve Components and the Army and Air National 
Guard and participation in Yellow Ribbon Reintegration Programs (YRRP). 
VA participated in over 1,600 of these events throughout the United 
States and territories, providing more than 190,000 OEF/OIF/OND 
Servicemembers, Veterans and their families with vital information. 
Additionally, VA staff frequent demobilization events (post-deployment 
health reassessments), job fairs, stand down events for homeless 
Veterans, and activities on active duty bases as well as Reserve and 
National Guard Armories.
                  military sexual trauma (mst) claims
    VA is committed to serving Veterans by accurately adjudicating 
claims based on military sexual trauma (MST) in a thoughtful and caring 
manner, while fully recognizing the unique evidentiary considerations 
involved in such an event. The Under Secretary for Benefits has 
spearheaded the efforts of VBA to ensure that these claims are 
adjudicated compassionately and fairly, with sensitivity to the unique 
circumstances presented by each individual claim.
    VA is aware that, because of the personal and sensitive nature of 
MST stressors in these cases, it is often difficult for the victim to 
report or document the event when it occurs. To remedy this, VA 
developed a regulation (38 CFR Sec. 3.304(f)(5)) and procedures 
specific to MST claims that appropriately assist the claimant in 
developing evidence necessary to support the claim. As with other Post 
Traumatic Stress Disorder (PTSD) claims, VA initially reviews the 
Veteran's military service records for evidence of the claimed 
stressor. VA's regulation also provides that evidence from sources 
other than a Veteran's service records may corroborate the Veteran's 
account of the stressor incident, such as evidence from mental health 
counseling centers or statements from family members and fellow 
Servicemembers. Evidence of behavior changes, such as a request for 
transfer to another military duty assignment, deterioration in work 
performance, and unexplained economic and social behavior changes, is 
another type of relevant evidence that may indicate occurrence of an 
assault. VA notifies Veterans regarding the types of evidence that may 
corroborate occurrence of an in-service personal assault and asks them 
to submit or identify any such evidence. The actual stressor need not 
be documented in service records. If evidence of a stressor is 
obtained, VA will schedule an examination with an appropriate mental 
health professional and request an opinion as to whether the evidence 
indicates that an in-service stressor occurred.
    When a Veteran files a claim for mental or physical disabilities 
other than PTSD based on MST, VA will obtain a Veteran's service 
medical records, VA treatment records, relevant Federal records, and 
any other relevant records, including private records, identified by 
the Veteran that the Veteran authorizes VA to obtain. VA must also 
provide a medical examination or obtain a medical opinion when 
necessary to decide a disability claim. VA will request that the 
medical examiner provide an opinion as to whether it is at least as 
likely as not that the current symptoms or disability are related to 
the in-service event. This opinion will be considered as evidence in 
deciding whether the Veteran's disability is service-connected.
    VBA has placed a primary emphasis on informing VA regional office 
personnel of the issues related to MST and providing training in proper 
claims development and adjudication. Women Veterans Coordinators are 
located in every regional office to assist Veterans. In December 2014, 
MST Coordinators were assigned at each regional office to address MST-
specific concerns of both male and female Veterans. In addition, under 
VBA's new standardized organizational model that has been implemented 
at all of our regional offices, all MST-related claims are now 
processed in the special operations lane, ensuring that our most 
experienced and skilled employees are assigned to manage these complex 
claims.
                   gender-specific health screenings
    VA exceeds the private sector in gender-specific health screening 
rates including cervical cancer screening and mammography.\5\ 
Mammograms for women Veterans can be provided on-site at 52 VHA health 
care sites where digital mammography is available. When VA or other 
Government facilities cannot provide these services, VA may contract 
for non-VA medical care using applicable statutory authority, i.e., 38 
United States Code Sec. Sec. 1703, 8153, 8111. WHS has also convened a 
task force of subject matters experts from women's health, oncology, 
radiology, surgery, and radiation oncology to develop guidance to 
standardize and enhance breast cancer care in VA facilities nationally. 
Despite these accomplishments, VHA agrees with a recent VA Office of 
Inspector General (OIG) report that tracking the results of mammograms 
performed outside VA has been a challenge. Recently VA completed work 
on breast cancer treatment guidance which advises the field of optimal 
pathways and processes to ensure that mammography orders are 
standardized and that results are tracked and communicated to patients 
appropriately.
---------------------------------------------------------------------------
    \5\ http://www.womenshealth.va.gov/WOMENSHEALTH/docs/OIA-
BRCO_GenderHealthCareRe port.pdf
---------------------------------------------------------------------------
    VA has been working to ensure that test results from studies done 
outside of VA are documented in the Computerized Patient Record System 
and that patients are notified of normal and abnormal mammography 
results within an appropriate timeframe. VA has two information 
technology (IT) projects underway that will revolutionize tracking and 
results reporting for breast cancer screening and follow-up care: the 
Breast Care Registry and the System for Mammography Results Reporting. 
Both IT enhancement projects are scheduled for completion by the end of 
2015. These systems are designed to work together to identify, 
document, and track all breast cancer screening and diagnostic imaging 
(normal or abnormal), orders results, patient notification, and follow-
up to ensure that all women Veterans receive high-quality, timely 
breast care whether treatment is provided within or outside of VA.
   improving coordination and access: women veterans program managers
    In order to ensure improved advocacy for women Veterans at the 
facility level, VA has mandated all VAMCs appoint a full-time Women 
Veterans Program Manager (WVPM). These WVPMs increase 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. WVPMs also provide appropriate local outreach initiatives to 
women Veterans. Each of VA's 144 health care systems have appointed a 
full-time WVPM, and VHA carefully tracks this position with regard to 
orientation and training.
         improving access to women's health through technology
Women's Health Telehealth Programs and Mobile Applications
    Since 2011, WHS has awarded funding to 26 VHA facilities for 
projects that offer telehealth programs to female Veterans. Telehealth 
projects that received funding involve tele-mental health, tele-
gynecology, tele-pharmacy, and telephone maternity care coordination.
    VA is currently developing six mobile applications (apps) for women 
Veterans' use. Patient-facing apps will provide information on VA 
eligibility and services and health information for women Veterans. 
Provider-facing apps will provide information to enhance knowledge of 
both VA and non-VA medical care providers about special health issues 
of women Veterans.
Women Veterans Call Center
    The Women Veterans Call Center, 1-855-VA-WOMEN (1-855-829-6636), 
was created to increase women's knowledge of VA benefits and services, 
enrollment, and utilization of health care services. We are pleased to 
see that the Call Center is being utilized. In FY 2014, the Call Center 
received nearly 15,000 incoming calls and made over 190,000 outbound 
calls, successfully reaching over 100,000 women Veterans. The Call 
Center is staffed by trained operators who provide information on VA's 
benefits and services. Call Center staff make referrals to WVPMs, the 
VHA Health Eligibility Center, VBA, and suicide and homeless crisis 
lines as needed. The outbound, outreach Call Center was moved to the 
Canandaigua VAMC in October 2012, and the inbound Call Center launched 
in April 2013.
                      readjustment and integration
Vet Center Services
    Life is not always easy for women Veterans after a deployment, and 
Vet Centers have developed services to assist Veterans in re-
integration. Vet Centers across the country provide a broad range of 
counseling, outreach, and referral services to women combat Veterans, 
Servicemembers, and their families. Vet Centers guide women Veterans, 
Servicemembers, and their families through many of the major 
adjustments in life that often occur after they return from combat. 
Services for a woman Veteran or Servicemember may include individual 
and group counseling in areas such as the symptoms associated with 
PTSD, Military Sexual Trauma (MST), alcohol and drug assessment, and 
suicide prevention referrals. All services are free of cost and are 
strictly confidential.
    The Vet Center program was established by Congress in 1979 out of 
the recognition that a significant number of Vietnam-era Vets were 
still experiencing readjustment problems. Over time, Congress extended 
eligibility to all Veterans who served in a combat zone or area of 
hostility or who have experienced MST.
    Recent legislation now authorizes Vet Centers to provide 
readjustment counseling services to certain active duty Servicemembers 
and their families. Vet Centers are community-based and part of VA. Vet 
Center program staff welcome home war Veterans and Servicemembers with 
honor by providing quality readjustment counseling in a caring manner. 
Vet Centers understand and appreciate these individuals' war 
experiences while assisting them and their family members toward a 
successful post-war adjustment in or near their community. Recognizing 
the increased roles for women in the military, the Vet Centers provide 
an important place outside of the traditional sites of care for women 
Veterans to receive services related to those experiences.
                   women veterans reproductive health
    Reproductive health is a critical component of women's health. It 
encompasses gynecologic health throughout life such as pre-conception 
care, infertility care, maternity care, cancer care, and the 
interaction of these with other health conditions (e.g., mental 
health). VHA's Reproductive Health Program initiatives include 
enhancing VHA's reproductive health workforce; providing high quality 
maternity and mental health care; delivering high-quality emergency 
services for women; and ensuring safe prescribing, pre-conception care, 
and care for aging women Veterans. WHS has several key accomplishments 
specific to reproductive health including:

     Decreasing fragmentation of maternity care in VHA through 
the implementation of Maternity Health Care and Coordination policy and 
supporting the development of Maternity Care tele-health pilots at 11 
VA Healthcare Systems serving over 500 women Veterans.
     Developing a prototype maternity dashboard named 
``Maternity Tracker'' that will enhance the delivery of high-quality 
maternity care and facilitate care coordination between VA and non-VA 
medical care providers. The ``Maternity Tracker'' is set to pilot in a 
VHA facility during FY 2015.
     Awarding funds to VHA facilities to support the 
development of innovative tools and purchase of gynecologic equipment 
to enhance the quality of care delivered to women in VA emergency 
departments and launching and disseminating the VA Emergency Services 
for Women (ESW) Toolkit, an online database of searchable tools and 
resources for VA Emergency Medicine providers and staff.
Gynecological Care--Enhancing the Reproductive Health Workforce
    VA recognizes the availability of on-site gynecologists plays a 
critical role in providing comprehensive care to women Veterans. In 
collaboration with primary care, emergency medicine, mental health, and 
other subspecialty providers, obstetrics and gynecology providers 
strengthen the team of providers caring for women Veterans. VHA 
provides high-quality gynecologic care to all women Veterans, either in 
VHA facilities or locally through non-VA medical care mechanisms.
    However, gynecology specialty providers are not available on-site 
at all VA health care centers. Therefore, VA intends to address the 
hiring of gynecologists and improved access by expanding on-site 
gynecologic services and support as we implement the Veterans Access, 
Choice, and Accountability Act of 2014.
    Reproductive health also includes care related to infertility, 
menopause, and subspecialty gynecology care including female pelvic 
medicine (urogynecology) and reconstructive surgery, high-risk 
maternity care, and gynecologic oncology. We are planning to expand the 
scope of VA practice in reproductive health through additional 
resources and innovative technologies and partnerships with local 
experts and key stakeholders particularly in areas of urogynecology and 
infertility care. We also plan to address key issues in specialty 
gynecological care coordination for women with gynecologic cancers to 
improve delivery and coordination of care between VA and non-VA medical 
care settings.
    VHA is already enhancing gynecology care to women in rural areas 
through innovative technologies such as e-consults, tele-gynecology, 
and tele-maternity services. Expansion of these innovative technologies 
is being explored as a mechanism to ensure access to gynecology care in 
parts of the country where recruitment of gynecologists is a challenge.
                         military sexual trauma
    Military sexual trauma (MST) is a VA term that refers to sexual 
assault or repeated, threatening sexual harassment experienced during 
military service. In FY 201, 85,033 or 25.04 percent of female Veterans 
seen for VA health care had reported a history of MST when screened by 
a VA health care provider. Not all MST survivors have long-term 
difficulties, but some experience chronic physical and mental health 
problems, including PTSD, depression, and substance use disorders.
    All VA treatment for physical and mental health conditions related 
to MST is provided free of charge. Service connection is not required, 
and Veterans may be able to receive free MST-related care even if they 
are not eligible for other VA services. VA offers a wide range of 
treatment services: Outpatient MST-related mental health care is 
available at every VAMC, and residential and inpatient programs are 
available for Veterans who need more intense treatment and support. 
Community-Based Vet Centers also offer MST-related counseling and 
services. Among Veterans who screen positive for MST in VA, rates of 
engagement in care and amount of care provided continue to increase 
every year. In FY 2014, 64,696 or 76.1 percent of women who screened 
positive for MST received outpatient care for either a mental or 
physical health condition related to MST. This is an increase of nearly 
11 percent from FY 2013, where 58,061 or 74.7 percent of women who 
screened positive for MST received MST-related outpatient care. These 
women Veterans had a total of 735,608 MST-related visits in FY 2014, 
which represents an increase of 11.4 percent (from 660,398 visits) from 
FY 2013.
    Every VA health care system has a designated MST Coordinator who 
serves as the local point person for MST-related issues. In FY 2014, VA 
initiated a continuation and expansion of its successful National 
Review of the Accessibility of MST Coordinators. This program is an 
innovative ``secret shopper'' initiative to survey the experiences a 
Veteran would be likely to have in attempting to reach an MST 
Coordinator via telephone. This initiative was expanded in FY 2014 to 
include calls to one CBOC as well as one VAMC for each health care 
system. In early FY 2014, over 80 percent of VA health care systems 
received a satisfactory rating, a nearly 30 percentage point 
improvement since the review began.
    In order to ensure VA's capacity to provide MST-related care, VA 
annually evaluates the number of full-time equivalent employees 
required to meet the outpatient MST-related mental health treatment 
needs of Veterans. In the most recent analyses (based on FY 2013 data), 
all 140 VA health care systems were above the minimum threshold 
indicating adequate capacity to provide MST-related mental health care.
    The Veterans Access, Choice, and Accountability Act of 2014 (VACAA) 
contained several provisions relevant to VA MST services. VA now 
provides free treatment for conditions related to sexual assault or 
sexual harassment during inactive duty training (primarily drill 
weekends for Reservists and National Guard members). The new law also 
allows VA to provide MST services to active duty Servicemembers without 
a referral from DOD; VA is working with DOD on plans for 
implementation. Finally, VA will produce two new reports for Congress 
on its MST services. The first compares VA MST services available for 
male and female Veterans. The second describes processes for 
transitioning care for MST Survivors from DOD to VA and joint efforts 
to assist Veterans in filing a disability claim related to MST.
    VA is committed to ensuring that providers and key staff receive 
appropriate training to address the needs of Veterans who have 
experienced MST and may be at risk of suicide. VA's Veterans Crisis 
Line (VCL) is a hotline for Veterans experiencing suicidal thoughts. In 
FY 2014, specialized materials were developed to further enhance VCL 
staff's understanding of issues specific to MST and facilitate 
sensitive and effective handling of calls from Veterans who experienced 
MST. Additionally in FY 2014, an initiative was developed to strengthen 
collaboration between MST Coordinators and Suicide Prevention 
Coordinators, who serve as local points of contact and facilitators of 
MST and suicide prevention program efforts, respectively, at every 
VAMC. Finally, all VA mental health and primary care providers are 
required to complete a mandatory training on MST. The training includes 
clinically relevant topics such as working with Veterans who have 
experienced MST and may exhibit self-destructive behavior or are at 
risk of suicidal ideation. This training program will receive a major 
update in FY 2015 that will provide an opportunity to further 
strengthen and expand upon content on suicidal behavior and self-harm.
                         mental health services
    VA provides a full continuum of mental health services to women 
Veterans, including outpatient, inpatient, and residential treatment 
options. Evidence indicates that women differ from men in the 
prevalence and expression of certain mental health disorders, as well 
as in their responses to treatment. These differences may be due to 
biological sex differences, such as the impact of the female 
reproductive cycle on mental health, or social and cultural 
differences, such as the impact of gender-related violence. Awareness 
of these differences informs VA's Women's Mental Health Services. VA 
policy requires that mental health services be provided in a manner 
that recognizes that gender-specific issues are indeed important 
components of care.
Gender-Sensitive Mental Health Care
    In 2012, VHA surveyed mental health leadership within each VA 
health care system (N = 141) to determine the availability of gender-
sensitive mental health care for women Veterans. VA conceptualizes 
gender-sensitive mental health care as containing these key components:

     Comprehensiveness: Includes full continuum of service 
availability for women (e.g., general mental health, specialty mental 
health, residential/inpatient);
     Choice: Considers treatment modality (e.g., mixed-gender, 
women-only service options);
     Competency: Addresses women's unique treatment needs, and;
     Innovation: Provides creative options and settings for 
subgroups of women, especially when caseloads of women are small.

    Survey results indicate that women Veterans have access to general 
and specialty outpatient mental health treatment options at all VHA 
health care systems. Findings also indicate that mental health services 
for women Veterans are most commonly provided in mixed-gender settings. 
Individual therapy was the most frequently reported alternative, when 
clinically indicated, to mixed-gender group therapy. Other frequently 
reported alternatives to mixed-gender outpatient care included tele-
mental health, referrals to Vet Centers or community resources, and 
non-VA medical care. Overall, survey results indicated numerous and 
varied general and specialty outpatient options are offered to female 
Veterans seeking VA mental health services.
Mental Health Across the Life Span
    Life transitions and physiological hormonal changes that occur 
during a woman's life cycle may serve to increase her risk of 
developing a mental health disorder. For example, sex-specific hormonal 
differences and reproductive life-cycle stages, such as pregnancy and 
perimenopause, can have effects on mental health. These changes across 
the reproductive life-cycle are particularly relevant for VHA, as over 
40 percent of women Veterans seen in VHA are within their reproductive 
years (ages 18-44), and over 25 percent are aged consistent with 
perimenopause (ages 45-55).
    Physiological changes across the life cycle can complicate 
treatment decisions; for example, maternal and fetal benefits and risks 
must be considered in medication management among pregnant women. 
Because of this, it is critical that providers for women Veterans are 
aware of the impact of biology on mental health and knowledgeable about 
the implications and efficacy of pharmacologic and behavioral 
intervention choices.
    To ensure this, VHA has initiated collaborations between mental 
health, primary care, pharmacy, and women's health. We have assessed 
needs across VA for training about the impact of life cycle biological 
changes on women's mental health; over 600 providers were surveyed. 
Based on the results of this assessment, we have developed and 
disseminated educational tools for VA providers in the form of six 
module curricula. Currently, there are virtual pilots at two VA health 
care facilities and five VA virtual university trainings taking place.
Supporting Women's Transitions from Military to Civilian Life
    VA recognizes the importance of coordination with DOD to support 
Veterans' reintegration and transitions from military to civilian life. 
DOD and VA Integrated Mental Health Strategy (IMHS) Strategic Action 
#28 examined gender differences in delivery and effectiveness of mental 
health services for female Servicemembers and Veterans, and those who 
have experienced military sexual assault (MSA), military sexual 
harassment (MSH), or MST. Findings from the Strategic Action #28 Task 
Group informed the development of recommendations to address identified 
gaps, developed strategies for overcoming health care disparities and 
barriers to care, identified the need for further research, and 
improved quality of care for these populations. The final report (still 
in the review /concurrence process) presents recommendations to address 
key research, surveillance, prevention and treatment gaps, and proposes 
a structure and processes for the continuation of DOD and VA 
collaboration in support of this initiative.
                   women's transition support groups
    VA recognizes the significance that support groups have in the 
transition and recovery of Veterans and especially in the transition 
and recovery of women Veterans. VA is able to offer a broad range of 
resources and programs for women Veterans within the scope of current 
legal authority. VHA has implemented a number of services to address 
the unique needs of women Veterans. The graduated continuum of family 
member services include:

     Family Education
     Support and Family Education (SAFE)
     National Alliance on Mental Illness (NAMI) Family-to-
Family Education Program
     Family Consultation
     Family Psychoeducation
     Marriage and Family Counseling
     Coaching Into Care
     AboutFace
     Military Kids Connect
     Caregiver Support Program
     Operation Enduring Freedom/Operation Iraqi Freedom/
Operation New Dawn Care Management Teams
     The Federal Recovery Coordination Program (FRCP)
     VA's Fisher House and Temporary Lodging Program
     The Domestic Violence/Intimate Partner Violence (DV/IPV) 
Assistance Program
     Family Readjustment Counseling
           local partnerships and outreach for women veterans
    VA recognizes the importance of outreach and partnership with our 
local communities. Several VHA specialized homeless programs include 
efforts designed to connect Veterans. These include connecting women 
Veterans and Veterans with families with health care, employment, 
financial counseling, and housing. Initiatives within VHA's continuum 
of homeless programs and services include:

     The Health Care for Homeless Veterans (HCHV) program:
         - During FY 2014, the total number of unique homeless Veterans 
        served through HCHV outreach was over 158,000; of which 11 
        percent were females as compared to 10 percent of the total 
        from the previous fiscal year.

     The Supportive Services for Veteran Families (SSVF) 
program:
         - SSVF continues to serve women in greater proportion than 
        they appear in the general homeless population (15 percent in 
        SSVF versus 10 percent in the general homeless population). 
        Also, as women are more commonly the custodians of dependent 
        children, SSVF serves many female Veterans and their dependent 
        children. Fifteen percent (11,702 of 79,449) of Veterans served 
        were female--the highest proportion of women Veterans served of 
        any VA homeless initiative. Nearly one quarter (29,884 of 
        127,829) of all those served were dependent children.

     Grant and Per Diem (GPD) funded outreach programs:
         - In FY 2014, more than 200 GPD projects had some capacity to 
        serve women Veterans. Of those projects, approximately 40 were 
        women-specific and 38 had the capacity to serve women with 
        dependent children; although per diem was only paid for the 
        women Veterans. In FY 2014, over 45,160 Veterans were served 
        through the GPD program; of these, approximately 7 percent were 
        women. In the first 4 months of FY 2015, over 24,000 unique 
        Veterans were provided services through GPD; the percentage of 
        homeless women Veterans has remained consistent at 
        approximately 7 percent.

     The Department of Housing and Urban Development--VA 
Supportive Housing (HUD-VASH) program:
         - During FY 2014, about 12 percent of those admitted to HUD-
        VASH were women. In FY 2014, there were 17,829 families served 
        by HUD-VASH an increase of 3,195 new families housed with the 
        Veteran by HUD-VASH. At the time of entry into the program, 
        approximately 36 percent of females and 13 percent of males 
        planned to live with their children and/or other family members 
        when housed.

     Veterans Justice Programs (VJO):
         - In FY 2014, HCRV provided services to over 16,700 Veterans 
        of which 2.2 percent were women. In FY 2014, VJO served to 
        nearly 41,700 justice-involved Veterans, of which 5.6 percent 
        were women.

     Community Employment Coordinators (CEC) for homeless 
Veterans program:
         - Of the 121 CECs who have been hired thus far, 10 percent are 
        women Veterans, and 7 percent are women Veterans who have 
        exited homelessness.
                               conclusion
    Our mission at VA is to care for those ``who shall have borne the 
battle'' and their families and Survivors. While we have made 
significant strides in recent years, we still have much to do as VA 
develops a nationwide effort to enhance the language, practice, and 
culture of VA to be more inclusive of women Veterans. We will continue 
to improve our efforts to provide high-quality, timely health care to 
our women Veterans and we appreciate this Committee's ongoing support 
in doing so.

    Mr. Chairman, this concludes my testimony. My colleagues and I are 
prepared to answer any questions you or the other Members of the 
Committee may have.

    Chairman Isakson. Thank you very much, Dr. Hayes, and thank 
you for your commitment to America's veterans and our women 
veterans.
    Let me begin the questioning. We will do 5-minute rounds 
for the Committee and we will operate under the early bird 
rule.
    Let me ask you this question, Dr. Hayes. Privacy is 
particularly an issue with women veterans, and I have toured a 
number of CBOCs and a number of hospitals that are obviously 
busting at the seams with our veteran population. How is 
privacy being provided for women and what have you done to make 
sure women have the privacy they deserve and need in the 
facilities?
    Ms. Hayes. I absolutely agree that privacy is very 
important. What privacy means is the ability to feel safe and 
secure in the environment and to feel that there is a place for 
women who do not feel like they are being stared at by men and 
that they have that kind of safety in their care.
    We, for a number of years, since 2009, have guidelines for 
privacy and we have actually done a paper and pencil checklist 
for a number of years detailing each and every privacy 
deficiency. However, we found that system really did not get at 
all of our space and deficiencies in an organized way. So, last 
year we launched what is basically a tablet-based system for 
rounds which detail every privacy deficiency, including missing 
locks, missing curtains, and has a deadline with a timeline on 
that electronic system saying how long until that particular 
deficiency is corrected.
    We are rolling it up nationally. We will not be able to 
have national reports until later this year, but we have local 
reports and we know how many have exceeded 14 days to 
correction of the deficiencies.
    Chairman Isakson. Dr. McCutcheon, given your expertise and 
your title, I am going to direct this question to you. What 
percentage of the mental health issues that women have are 
directly related to military sexual trauma, or to what extent 
is that a problem?
    Ms. McCutcheon. Certainly, in your opening statements you 
mentioned military sexual trauma, and when we look at this 
year's results, we find that it is closer to 25 percent of the 
women who utilize the VA health care system have experienced 
military sexual trauma. Military sexual trauma in itself is not 
a mental health diagnosis, and the most common mental health 
diagnosis associated with military sexual trauma is PTSD, 
second by depression. Certainly, with the numbers of 25 
percent, it is a significant issue for many of our women.
    The majority of care for those that do screen positive, 76 
percent of those women end up receiving either physical health 
or mental health treatment who have been screened positive, and 
a smaller amount do just mental health treatment. You do see 
there is a small percent of those individuals, those women who 
have experienced military sexual trauma also have physical 
health care needs.
    At 25 percent, yes, it is a significant number.
    Chairman Isakson. I know this would be probably a DOD 
question more than a Veterans Affairs question, but I have 
toured a number of warrior transition units where the 
warfighters come home. They are getting ready to sever from DOD 
and they go through a battery of questionnaires required, 
generally by computer, where they are asked whether they have 
ever been traumatized, have they ever had nightmares, or all 
kinds of things that lead toward mental health problems.
    Ms. McCutcheon. Mm-hmm.
    Chairman Isakson. What specific, or do you know if the DOD 
does anything specifically to try to early identify women who 
might have had military sexual trauma before they leave the 
military to go into VA?
    Ms. McCutcheon. You are correct. I cannot speak for what 
occurs in DOD, but certainly in transitioning, we make sure 
that that is an item. In the separation health exam, there is 
also an item on MST. You probably know that at every VA medical 
center, we screen every veteran who comes to us for experiences 
of military sexual trauma, and it is just two simple questions, 
one that addresses sexual assault and the other that addresses 
sexual harassment. By answering yes to either one of those 
questions, that veteran is entitled to free health care--mental 
health care, physical health care, and pharmaceuticals. There 
is no need to have proof that this experience happened to them.
    Chairman Isakson. Dr. Hayes, I was at Fort Stewart about 6 
months ago in a warrior transition unit, talking to some 
members of the Third ID who were female in the transition unit. 
I asked them what was the single biggest problem they thought 
they faced medically versus a man. Almost every person said it 
was musculoskeletal recovery after coming back from combat. Is 
that true?
    Ms. Hayes. Absolutely, sir. We find that for both men and 
women, that musculoskeletal injuries are the number 1 reason 
that they seek health care, either from VA or while they are 
still in the transition. I think when we think about the roles 
that women serve today, it is quite natural that they would 
have the same kind of injuries from jumping off of a truck or 
from carrying heavy packs and that chronic pain and 
musculoskeletal issues are number 1.
    Chairman Isakson. Just following up on that, since I have 
got 9 seconds to go, we had a hearing here on opiates a while 
back. Are you all paying attention to the prescription of 
opiates and pain killers to make sure we are not over-
prescribing them in cases where it is musculoskeletal injury 
and not something that should get opiates?
    Ms. Hayes. We are very much involved in the issues of 
chronic pain for women as well as for our male veterans and 
looking at the issues of opioids and also the alternative 
medication and non-medical ways, complementary therapies that 
are effective in treatment of chronic pain. It takes a very 
comprehensive look for the person so that we are not just 
somehow cutting off and worrying about substance use disorder, 
but also trying to find adequate solutions for their chronic 
pains.
    Chairman Isakson. Thank you very much.
    Ranking Member Blumenthal.
    Senator Blumenthal. Thanks, Mr. Chairman.
    Let me sort of try to focus a bit on numbers, on 
specialties that would affect women directly, and primarily OB/
GYN. What is your estimate as to the number that are needed now 
and in the future compared to the number available? In other 
words, what is the gap that has to be met?
    Ms. Hayes. First, I want to be clear that we have OB/GYN 
care--I should say, we have gynecology care at every VA medical 
center. What we do not have is a gynecologist actually on the 
staff at, right now, about 35 of our sites. The distinction is 
that some of those sites have access to gynecology from the 
community. The women are not going without care, but the care 
is available through VA Coordinated Care, sometimes on site, 
but not necessarily on staff.
    Senator Blumenthal. But, they are not available in 
sufficient number.
    Ms. Hayes. That is correct, sir. But, I think----
    Senator Blumenthal. You may say they are at the site, but 
they are not there when the veterans need them and they are not 
there in sufficient numbers to meet the volume of care. I am 
asking, essentially, how many do you need to hire or get on 
board somehow?
    Ms. Hayes. Right now about 35----
    Senator Blumenthal. Thirty-five----
    Ms. Hayes [continuing]. Full or part-time----
    Senator Blumenthal [continuing]. New doctors?
    Ms. Hayes. We need to have part-time gynecologists 
available on staff at about 35 sites. Now, what we are doing 
about that is we are talking to the leadership at each site and 
working on ways for that to happen. It is an individual 
conversation between my office, the Chief of Surgery, and the 
leadership at that site to see what are the barriers. 
Sometimes, it is a recruitment issue from the community. 
Sometimes it is just not actually having brought the person on 
staff.
    Senator Blumenthal. Do you regard Connecticut as one of 
those sites, the VA facility in West Haven?
    Ms. Hayes. The VA facility in West Haven currently has 
gynecologists on staff.
    Senator Blumenthal. But, my understanding is that it needs 
more.
    Ms. Hayes. That is part of----
    Senator Blumenthal. That is an example of the point I am 
trying to make. In other words, to say you have an OB/GYN on 
site may mean, well, she is there a half-day a week, or there 
is one and you need five. I am trying to drill down on how many 
you need--what the universe of need is compared to what you 
have and what it will be in the future----
    Ms. Hayes. Right.
    Senator Blumenthal [continuing]. As the number of women 
veterans increases.
    Ms. Hayes. What I can say is I would agree that we have not 
had an effective planning mechanism up until this time. As part 
of VACA Section 301 and the adoption of the Workforce Planning 
Model, we have been looking at every site and the workforce 
that is needed in gynecology, women's health, primary care, 
specialty care, and that project is underway. It is not yet at 
fruition in terms of exactly what is needed where.
    In the meantime, we have addressed that each site must 
strategically plan for the number of women who are there and 
start increasing the gynecology----
    Senator Blumenthal. Here is what I would suggest, and I do 
not mean to interrupt you, but for planning and management 
within the VA with regard to this specific specialty to be 
regarded as effective and competent. I would think you could 
give us numbers of doctors in this specialty that are available 
now to meet the need, what the unmet need would require in 
additional numbers, and what it will be in the future. You 
cannot really tell whether you are meeting the need unless you 
have that estimate of numbers. I think the same should be done 
in other specialties, as well. I hope that you will be able to 
provide those numbers to us.
    Since my time is limited, I am going to go to another 
topic, which is mental health care. This morning in the 
Commerce Committee, we had a hearing on telemedicine, including 
tele-mental health care, which often is very promising and 
effective because it provides for the kind of privacy and 
anonymity that people seeking mental health care need and 
deserve. What has been your experience, Dr. McCutcheon, in 
treating military sexual trauma, which is one area of mental 
health care that has to be addressed, with telemedical health 
care?
    Ms. McCutcheon. Thank you for that question. I do not have 
personal clinical experience, but I do know that, as I 
mentioned before, military sexual trauma is not a diagnosis in 
itself, but, let us say, Post Traumatic Stress Disorder. There 
have been some pilots with using tele-mental health in the 
delivery of prolonged exposure or cognitive processing therapy, 
which is the gold standard for treating Post Traumatic Stress 
Disorder, and I think for the reasons that you mentioned, some 
women, do not feel comfortable coming to the VA. There also may 
be an issue of distance. I think that is an alternative to 
treatment that we should embrace and we do embrace. Thank you.
    Senator Blumenthal. Thank you.
    My time has expired, but I want to just emphasize again, 
Dr. Hayes, that my feeling is that the VA should supply to the 
Committee numbers as to specialties in women's health care, 
numbers of doctors on board now, numbers that are needed now to 
meet women's health care needs, and numbers that will be needed 
5 and 10 years out. I cannot accept that the VA is unable to 
provide those kinds of numbers.
    Ms. Hayes. I agree, sir; I'll take that for the record.
    Senator Blumenthal. Thank you.
    [The information requested during the hearing follows:]
    Response to Request Arising During the Hearing by Hon. Richard 
 Blumenthal to Patricia Hayes, Ph.D., Chief Consultant, Women's Health 
      Services, Office of Patient Care Services, Veterans Health 
          Administration, U.S. Department of Veterans Affairs
    Response. The current number of Designated Women's Health Providers 
(DWHP) across VHA is 2,168 as of the end of FY 2014. DWHPs are 
specially trained and certified to provide primary care specific to 
women Veterans. Our target is for every VHA site of primary care to 
have a sufficient number of DWHPs to provide support for the local 
women Veteran population, to include redundancy when a given provider 
may be on leave or otherwise unavailable.
    To that end, VHA needs to immediately train and certify, or recruit 
an additional 675 DWHPs to meet the current demand. We will leverage 
all means at our disposal, to include training of existing providers 
and hiring of additional providers through our Medical Services 
appropriation and through VACAA funds. Within the next fiscal year, 
accounting for primary care provider turnover rate of 18 percent per 
year, and a projected 10 percent increase in the number of women 
Veterans, it is estimated that an additional 521 primary care providers 
will be needed; bringing the total near-term need to 1196 Primary care 
Designated Women's Health Providers.
    As for our requirements in the out-years, VHA is developing models 
to more precisely project both the number of women Veterans in need of 
care and the number of DWHPs required to support them. Women Veterans 
health care is more than just a subset of the overall health care 
infrastructure--and the future demographics of women Veterans will not 
mirror those of men. The models we craft will focus on understanding 
this distinction and deriving useful provider projections in turn.

    Chairman Isakson. Senator Rounds.

        HON. MIKE ROUNDS, U.S. SENATOR FROM SOUTH DAKOTA

    Senator Rounds. Thank you, Mr. Chairman.
    I would like to just begin by following up on Ranking 
Member Blumenthal's comments and thoughts in terms of the 
number of individuals available for providing care, and in 
particular, could you provide us the number of women 
gynecologists that you have available for our veterans?
    Ms. Hayes. We can provide that, sir.
    [The information requested during the hearing follows:]
 Response to Request Arising During the Hearing by Hon. Mike Rounds to 
   Patricia Hayes, Ph.D., Chief Consultant, Women's Health Services, 
 Office of Patient Care Services, Veterans Health Administration, U.S. 
                     Department of Veterans Affairs
    Response. Overall, women comprise 37 percent of VHA's physician 
workforce. Nearly half of providers in both gynecology and primary care 
are female (48% and 47% respectively).
    The table below shows the breakout in greater detail.

 
----------------------------------------------------------------------------------------------------------------
                                                                                 % by                    % by
                                                                    Primary   Gender All     % by       Gender
                                      Physicians   Gynecologists     Care       Medical     Gender      Primary
                                                                   Physician   Officers   Gynecology     Care
----------------------------------------------------------------------------------------------------------------
Male...............................     14,948           64          3,354       63.13%      52.03%      53.42%
Female.............................      8,732           59          2,925       36.88%      47.97%      46.58%
                                    ------------------------------------------
  Grand Total......................     23,680          123          6,279
----------------------------------------------------------------------------------------------------------------


Additional Background on Gynecology:
    The DAV and other VSO's continue to report that we don't have 
gynecologists at ``1/3'' of VA medical centers.'' However, we have 
increased significantly, from 60 sites a few years ago, to 118 VAMCs 
now (78%).
    That said, more work remains to be done: we need to add Gynecology 
surgical clinics and a minimum of one staff Gynecologist at five 
Intermediate Surgical Complexity sites.
    For the 26 remaining sites, VHA is working directly with VISN, 
facility, Surgery and other leaders to assess the population of women 
Veterans at each site, how offsite gynecology is managed, and coverage 
for emergency conditions. Many of the 26 sites do not have surgery in-
house; hence VHA needs to ensure coverage of Emergency needs/high risk 
conditions. The outcome of this work is a plan to appropriately manage 
gynecology staffing or coordination at each of the 26 VAMCs. We 
anticipate completion by Fall, 2015.

    Senator Rounds. Would you, please.
    Ms. Hayes. Yes. One of the things I want to make clear, 
though, is that we have the kind of women's health for basic 
gynecological procedures, meaning pap smears, mammograms, 
treating menopause, birth control. That is available 
everywhere, and that is why we went to the comprehensive 
women's health, designated women's health provider model. I 
think sometimes people confuse the need for gynecology--
gynecology is needed in our centers for specialty care, for 
surgery, for removal of fibroids, for hysterectomies, but for 
basic gynecological, what most people think of as basic 
gynecological care, that is treated everywhere by our 
designated women's health providers.
    Making that distinction, we have that available, the 
providers, and most of them, actually, 98 percent of those 
providers are female. Very few men have chosen to become 
designated women's health providers in our system. We want to 
make sure that we address both the basic gynecological needs, 
or women's health gender-specific needs, and the gynecology 
needs, which is a more scarce resource and sometimes harder to 
obtain in certain communities.
    Senator Rounds. I was pleased to hear that you had some 
very favorable reports in your opening comments with regard to 
the performance, or at least the analysis. Could you provide 
us, or have you provided the Committee with a copy of those 
most recent results, the data that was completed and how it was 
determined?
    Ms. Hayes. Absolutely, and I would like to just highlight 
that, for example, for many years, VA has exceeded the private 
sector, scoring 87 percent on getting mammograms, breast cancer 
screening. The comparable rate in 2011, which is the last time 
that gender was put out in HEDIS measures, the private 
insurance rate is between 60 and 70 percent, and the Medicare 
rate is 52 percent.
    [The information requested during the hearing follows:]
 Response to Request Arising During the Hearing by Hon. Mike Rounds to 
   Patricia Hayes, Ph.D., Chief Consultant, Women's Health Services, 
 Office of Patient Care Services, Veterans Health Administration, U.S. 
                     Department of Veterans Affairs
    Response. The National Committee for Quality Assurance (NCQA) 
produces the Healthcare Effectiveness Data and Information Set (HEDIS) 
tool used by more than 90 percent of America's health plans to measure 
performance on important dimensions of care and service. The NCQA State 
of Healthcare Quality Report 2014 shows breast cancer screening rates 
(women 50-74 years of age who had at least one mammogram to screen for 
breast cancer in the past two years) for 2013 were: Commercial Health 
Maintenance Organization (HMO) 74.3 percent Commercial Preferred 
Provider Organization (PPO) 69.5 percent; Medicaid 57.9 percent; 
Medicare HMO 71.3 percent; and Medicare PPO 69.1 percent. In 
comparison, VA screening rates for the same time period were 86 
percent.
    The NCQA State of Healthcare Quality Report 2013 shows cervical 
cancer screening rates (women 21-64 years of age who received one or 
more Pap tests to screen for cervical cancer in the past 3 years) for 
2012 were: Commercial HMO 75.5 percent); Commercial PPO 73.6 percent; 
and Medicaid 64.5 percent. In comparison, VA screening rates for the 
same time period were 93 percent.

    Senator Rounds. The numbers that you are talking about are 
basically the metrics of the numbers of specific tests and so 
forth that have been performed as opposed to an analysis of the 
satisfaction of the individuals that have been involved.
    Ms. Hayes. We actually also have satisfaction data, and we 
can show you data regarding, for example, our designated 
women's health providers. Those women patients who see those 
providers are much more satisfied than the women who see other 
providers.
    Senator Rounds. If you could. I would appreciate that, Mr. 
Chairman, if they could provide that to the Committee.
    Chairman Isakson. Absolutely.
    Senator Rounds. Thank you.
    [The information requested during the hearing follows:]
 Response to Request Arising During the Hearing by Hon. Mike Rounds to 
   Patricia Hayes, Ph.D., Chief Consultant, Women's Health Services, 
 Office of Patient Care Services, Veterans Health Administration, U.S. 
                     Department of Veterans Affairs
    Response. In 2010, the VA established policy requiring the 
provision of comprehensive women's health care by specially trained and 
designated women's health providers (DWHPs) who can provide both 
general primary care and gender specific care within the context of a 
longitudinal relationship.
    In an analysis of data from the VA Survey of Healthcare Experience 
of Patients (SHEP) using the Consumer Assessment of Healthcare 
Providers and Systems (CAHPS) patient-centered medical home (PCMH) 
survey from March 2012 through February 2013, a survey designed to 
measure patient experience with care, satisfaction with provider 
responses were measured for 8151 women, providing data on 3147 
providers, 1,267 of whom were DWHPs. Scores for six outpatient 
satisfaction composites were higher for women Veterans assigned to 
DWHPs than for women who were assigned to primary care providers who 
were not designated as Women's Health Providers.
    Scores for six outpatient satisfaction composites were higher for 
women Veterans assigned to DWHPs than non-DWHPs: Access 42.1 vs. 37.7, 
Communication 74.1 vs. 71.0, Shared Decision Making 61.6 vs. 58.8, 
Self-management Support 56.0 vs. 50.3, Comprehensiveness 67.4 vs. 62.0, 
and Office Staff 66.0 vs. 64.4. In a multivariable model, patients seen 
by DWHPs reported higher overall experiences with care compared to 
patients seen by non-DWHPs.

Reference: Bastian LA1, Trentalange M2, Murphy TE2, Brandt C2, Bean-
            Mayberry B3, Maisel NC4, Wright SM5, Gaetano VS2, Allore 
            H6, Skanderson M7, Reyes-Harvey E8, Yano EM9, Rose D3, 
            Haskell S10.Association between women veterans' experiences 
            with VA outpatient health care and designation as a women's 
            health provider in primary care clinics. Womens Health 
            Issues. 2014 Nov-Dec;24(6):605-12. doi: 10.1016/
            j.whi.2014.07.005. Epub 2014 Oct 28.

    Senator Rounds. When you indicated currently one-third of 
the VA medical centers do not have a gynecologist on staff and 
refer women to other VA facilities or community providers. Just 
thinking out loud with regard to the Choice Program and the 
opportunity, how far away are you from being able to provide 
the necessary services or the desired services at the level 
that you would like to within the facilities, and is there 
another alternative out there in terms of amending the existing 
Choice Act that we have got right now to allow women to be able 
to go outside of the VA if they want to for their services? Is 
that another option? Have you explored that?
    Ms. Hayes. I cannot speak specifically to the elements of 
the Choice Act. What I can tell you is that for many years, 
about 30 percent of our women needed to go outside of VA for 
various kinds of care, for mammograms, for breast cancer 
treatment, for gynecological cancers and such. We have been 
using non-VA care and the PC-3 contract, and absolutely where 
appropriate, the Choice Card eligibility, in order that we give 
the best opportunity for the veteran to access outside the VA.
    When we talk about gynecologists on staff, we are talking 
about bringing in the knowledge and skill level to up our level 
overall of providing appropriate health care to women. I am as 
concerned about risk, making sure that when someone comes into 
our emergency room, they get the appropriate gynecological 
care. We could always send people out, but that does not make 
sure that we have got the right kind of care in-house.
    Out of our 150 centers, we are down to about 30 that we do 
not have on staff, even though we may have available nearby. 
That is the number we are still working on. We have actually 
improved over the last 2 years from about 60 sites to over 90 
sites where we have gynecology on site. On the whole, they are 
smaller sites, less complex sites, and they are a challenge to 
bring that kind of expertise in-house.
    Senator Rounds. Thank you.
    Mr. Chairman, I will leave back my 4 seconds. Thank you.
    Chairman Isakson. Thank you, Senator Rounds.
    Senator Manchin.

       HON. JOE MANCHIN, U.S. SENATOR FROM WEST VIRGINIA

    Senator Manchin. Thank you, Mr. Chairman, and thank all of 
you for your service.
    The VA is committed top ending veteran homelessness by 
2015. We have all talked about that. While the nationwide 
veteran homeless rate has dropped by 33 percent since 2010, we 
still have nearly 50,000 veterans without a home. Of that 
number, 13,000 are women. Their rate of homelessness is twice 
as high as men's, and worse than that, many of them have 
dependent children with them. Forty-five percent suffer from 
mental health issues. Seventy percent are affected by substance 
abuse. Forty percent report experiences of sexual assault in 
the military.
    How do we best attack the problem, and do you believe you 
will achieve the VA's goal of ending homelessness for these 
women and their children? Are we able to really get a handle on 
this? This has been so elusive for so long. Can you give me an 
idea of where you might be on that issue.
    Ms. Hayes. Thank you very much. Certainly, the issues of 
homelessness for women are intense and they are multi-
factorial, as you have just pointed out. We want our women 
veterans to be successful and we certainly want to be able to 
have in place the programs that we need to meet each of those 
types of needs. Depending on where she comes into our system, 
in terms of whether it is needing counseling, whether it is 
poverty and she needs a job, whether it is additional just 
basic housing for her and her child, our homelessness programs 
are set up.
    Particularly the ones that are seeing the most use by women 
are the supportive services for veterans and their families, 
which is about 15 percent of their services go to women and 
children. Our HUD-VASH program, about 14 percent. That is in 
contrast to the fact that 7 percent of VA users are women. You 
see about double that proportion are being seen in our homeless 
programs.
    I also think we have quite a bit to offer in terms of that 
juxtaposition between those who need jobs and the jobs that are 
available, and I actually would like to call upon Ms. Cloud for 
a moment to talk about VA's efforts in this area.
    Ms. Cloud. Thank you, Senator Manchin. We have, in 
partnership with the Veterans Health Administration, worked 
hard to support our women veterans who many times suffer from 
rates of homelessness with children. We have entered into a 
public-private partnership in key cities where we have high 
rates of homelessness for women with children, and with the 
private sector and local community leaders are working together 
to fast track, if you will, the sponsorship and mentorship of 
the employment community.
    Our benefits advisors, who provide transition benefits 
briefings across the country to all of our active duty and 
Guard and Reserve personnel, are part of this pilot. They are 
bringing in the cutting edge tools that are being provided to 
our transitioning population to our veterans who are a part of 
this pilot, as well. We have kicked off in Seattle-Tacoma and 
are moving to five other locations this year.
    Senator Manchin. The other thing that I have a tremendous 
problem in the State of West Virginia is prescription drug 
abuse. In all honesty, I see so many of our veterans being 
diagnosed and given pain pills. We are addicting a generation 
of our veterans, I do not think intentionally. I do not think 
we really know what we are doing. There have to be 
alternatives, and I know you must see it with all of the women 
you are dealing with and all the patients that you deal with. 
Does the VA at the higher levels see what we are doing, and is 
there any other alternative to using just prescription drug 
medication for PTSD?
    Ms. Hayes. On two fronts, one is making sure that we have 
the right treatments for chronic pain, because when someone has 
become addicted, cutting them off is not the answer. We need to 
make sure we have the right comprehensive treatments available. 
This is where I think we have found that----
    Senator Manchin. I am so sorry, because my time is running, 
but it seems like the pathway of least resistance is, let me 
write you a prescription for that, and it starts us down a road 
that we cannot get off. The opiate road is horrific, not just 
in the VA, but all through society. Do you all have an 
alternative way of prescribing any other alternative method 
than just writing a prescription?
    Ms. Hayes. Yes, we do, and women appreciate and have more 
uptake of the complementary treatments such as: yoga, 
acupuncture, chiropractic, and meditation.
    Senator Manchin. You are pushing that in the VA?
    Ms. Hayes. We are pushing those in VA, and our women are 
asking for them. We know that in a complex addressing of this 
problem, all of those options need to be available to our 
veterans.
    Senator Manchin. Do you have drug treatment centers for----
    Ms. Hayes. Every veteran who comes in, we do assess 
substance use disorder----
    Senator Manchin. Can you help them get----
    Ms. Hayes. We have treatment centers, yes. I do not know if 
you wanted to add to that in terms of----
    Ms. McCutcheon. Just quickly, as far as West Virginia, as 
you mentioned, of your four VA medical centers, you have both 
our standard addiction outpatient treatments, you have two with 
intensive addition outpatient treatments, and you have two 
facilities that actually have residential programs that treat 
addiction. In the State of West Virginia, you do have great 
resources for addictions.
    Senator Manchin. I am looking for the effectiveness of 
those resources, because I can tell you, it is the number 1 
killer in my State. It comes out of the medicine cabinet. It 
does not come off the street corner. It is an epidemic and as a 
society, we have gotten to accept that everybody knows somebody 
that is addicted or has a drug problem. We are not talking 
about it. We are not doing anything about it. We are not trying 
to prevent it. I think it starts here and we can do something 
from the type of drugs that are coming on the market, the way 
they are prescribing it, and it really starts in the medical 
profession of how you look toward this as far as they are 
trained properly to be dispensing this. I am just happy to hear 
what you are doing. I would like to see some of the alternative 
programs and see them in West Virginia. I will do that.
    My time has expired, but I appreciate very much your 
efforts.
    Chairman Isakson. Thank you, Senator Manchin.
    Senator Heller.

                STATEMENT OF HON. DEAN HELLER, 
                    U.S. SENATOR FROM NEVADA

    Senator Heller. Mr. Chairman, thank you for holding today's 
hearing. I also want to thank the Ranking Member. I also 
appreciate the fact that we are holding this so early in the 
session. This is an important issue, I think, for everybody 
that is here in this room and an issue that, I think, is very 
important.
    We raised the question early on about when was the last 
time we actually had a hearing on women's health care issues 
facing our veteran women and it had been quite some time. 
Again, I am very appreciative. This hearing does not happen 
unless the Chairman decides that it is a priority to him, so I 
am just grateful that we are having this discussion. I also 
want to thank those witnesses here that are with us today and 
for taking time and sharing your expertise.
    Chairman Isakson. The record should reflect that the 
Senator from Nevada was the first person to ask for this 
hearing and we are happy to respond to him. Thank you.
    Senator Heller. Thank you.
    I am looking at some statistics--we will shift from West 
Virginia, I guess, over to Nevada a little bit--and looking at 
the new hospital that was built down there in Las Vegas. It is 
a great facility. It really is. The problem was is that they 
failed to recognize or realize how much use that facility would 
have, and because of that, after only being 2 years old, they 
are back to construction and other add-ons to meet the demands.
    I think women veterans may have part of the reason that we 
are seeing these add-ons and this extra construction. I am just 
looking at some statistics here. In the past 10 years--I think 
you alluded to this, Dr. Hayes--the number of women veterans 
using the VA clinic or health care system has increased by 80 
percent.
    Ms. Hayes. Yes.
    Senator Heller. Last year, the Las Vegas VA Hospital served 
a total of 4,500-plus women veterans. This year, in the first 6 
months of the fiscal year, we have exceeded that number. You 
can see that it is growing and growing quickly.
    Are there any statistics out there of what you anticipate 
the statistics to be for women veterans using our health 
clinics and hospitals over the next 5 years, 10 years, 15 years 
so we can prepare?
    Ms. Hayes. Absolutely. Our enrollment projection model was 
adjusted, actually, when I came on board to include gender 
projections, so that we work very closely with the group in 
OPP, Policy and Planning in the VA, to go very carefully over 
those projections. We expect the near term, 6 to 9 percent, 
basically kind of what you were seeing, year over year. That 
has been borne out in the last couple of years, so we have had 
a 29 percent increase in the last 3 years.
    We know, however, that when you think about the number 
inside is 7 percent today, but 11 percent in Gulf War I, which 
some people remember--I certainly remember--and 15 percent 
active duty, that we are just getting to the point where we are 
going to have lots and lots of women on our doorstep and we 
have to ramp this up even more quickly than we have been.
    I agree that we can give you the enrollment projection 
model and the numbers at each site and what we project. We are 
looking at things like space. We now have new design guides for 
women and space because we know that we are going to be 
bursting at the seams with women. We do not have the capacity 
and resources in place for what is coming in the door tomorrow.
    Senator Heller. Let me go back to the Las Vegas Hospital. 
Like you said, it has a great women's health clinic in that 
particular hospital. But, if you go up to Reno, that hospital 
was built in 1939 and older facilities are finding quite a 
challenge to meet some of these health care needs. What is the 
VA doing to meet some of these challenges?
    Ms. Hayes. Each site is obligated to do a strategic plan 
for women. What is important about that is we have a town hall 
method and we have input from the women veterans at that site 
so that what type of women's clinic or other type of facilities 
that are going to be built have the input of the local women 
veterans. In some sites, we do integrate care with women and 
men in the same type of clinics, and in other sites, women 
prefer that we have a stand-alone women's clinic.
    I have been to Reno. I know that they have been trying to 
expand the space that they had for women's clinic. It is 
bursting at the seams. In each site, it has to be based on the 
local needs, and we are supporting that through an oversight of 
the strategic planning nationally.
    Senator Heller. I would anticipate that you would 
incorporate into any new building, new hospital, a women's 
clinic?
    Ms. Hayes. Absolutely.
    Senator Heller. Would you anticipate in the next 10 years 
that there would be a women's clinic in every hospital across 
the country?
    Ms. Hayes. Within 10 years? That would be my guess, but I 
think what I can tell you is we have been very involved in the 
SCIP process, where they put in their bids to do more 
construction. We have been looking at every project, because it 
is not just building a women's clinic that is important. It is, 
as was mentioned before, it is every site in the hospital, 
wherever women may go, whether it is the cardiac stress test 
area, where there has to be the appropriate accommodations for 
both women and men in each and every one of those sites.
    While it is looking at if they have enough of the right 
primary care space for women or gynecological procedure rooms 
for women, it is also do they have the right bedrooms for women 
and inpatient facilities for women and every other possible 
kind of space is adjusted to the needs of the women coming in.
    Senator Heller. Dr. Hayes, thank you.
    Ms. Hayes. Thank you.
    Senator Heller. Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Heller.
    Senator Sullivan.

          HON. DAN SULLIVAN, U.S. SENATOR FROM ALASKA

    Senator Sullivan. Thank you, Mr. Chairman, and I also want 
to echo Senator Heller's comments about you and Ranking Member 
Blumenthal, and this hearing is a very important topic.
    I would like to drill down a little bit more on Senator 
Manchin's focus on homelessness. I saw a recent fact sheet from 
the Office of the First Lady on the strategy of ending 
homelessness within 5 years. I think that is a great goal. I 
think that is something we should all be rallying around. I 
commend the VA and the White House for doing that.
    With regard to women's homelessness there was a recent GAO 
study that mentioned that women veterans were three times as 
likely to be homeless than non-veterans. What do you think the 
factors are? What is driving that? That is a startling 
statistic to me.
    Ms. Hayes. I think that the issues for women are different 
than they are for men. Women veterans coming out of the 
military, particularly those deployed, have a tremendous 
challenge in the reintegration period, and it is about 
reintegrating with their family. It is about the emotional 
issues, many of the physical issues we just talked about, and 
the overall societal issues, as well, and not being recognized 
as veterans, not necessarily seeking out the care that is 
helpful to them. Put on top of that that they have children in 
tow. We also know that there is a challenge in terms of 
divorces and disruption in marriages.
    If we do not get to them early in that process through our 
Vet Centers or through our other outreach programs, we do not 
identify their needs and help them soon enough, then they 
spiral down pretty quickly. I think we have kind of lost some 
of the ground at that point.
    Senator Sullivan. If we are looking at the core top 
principles that we would want to be implementing, either as 
part of the VA or as part of Congressional action, on this 
issue of women veterans' homelessness, what would the top three 
be?
    Ms. Hayes. I think one of them is transition, and I want 
Ms. Cloud to talk a little bit about getting them before they 
are out.
    Senator Sullivan. Good. That is my next question.
    Ms. Hayes. That is it. The other, I think, is an early 
assessment of what help do they need. We have got to get them 
in so we can assess what they need, and we have lots of things 
to give them. We have things to prevent homelessness.
    Senator Sullivan. Does the VA have the authority to do 
these things, to focus on these things? Do you need that from 
the Congress, or do you have that right now?
    Ms. Hayes. We have the ability to provide almost everything 
in order to prevent homelessness if we get them at a point 
where we are assessing them in our health care system or 
elsewhere to figure out if they need these things.
    Senator Sullivan. Ms. Cloud, I am glad that Dr. Hayes 
raised the issue of the TAP program. You know, as somebody who 
has been through that a couple times in my own career, as 
somebody who is the father of three teenage daughters, I would 
be very proud if one of them chose or all of them chose to be 
in the military. I certainly would want, when they left the 
service that they would have more opportunities than when they 
started.
    When I went through the TAP programs in the Marine Corps, 
it was pretty much standardized. Are there any things that we 
are doing right now that are more tailored to the issues of 
women veterans with regard to transition assistance, and if so, 
what?
    Ms. Cloud. In addition to the benefits advisors, who are 90 
percent of them are veterans who provide that service of 
transition----
    Senator Sullivan. Are they women advisors, for the women?
    Ms. Cloud. Thirty-five percent of them are female----
    Senator Sullivan. Good.
    Ms. Cloud [continuing]. We are able to provide in a high-
intensity rate that one-on-one connection point for that warm 
handover, not only to VA services, but also to Department of 
Labor American Job Center services. Our regional offices also 
have women veteran coordinators, MST coordinators, and 
dedicated resources. Those warm handovers are a lot cleaner 
than they were in the past.
    To your previous point, in many cases, our women veterans 
as they enter and reintegrate, the private sector many times 
does not have visibility, not only of their service, but will 
automatically look for their skills translation as a veteran.
    Senator Sullivan. Yes.
    Ms. Cloud. Helping the private sector truly understand that 
not only are we transitioning male veterans, but we have a high 
percentage of women veterans who are also coming out the door 
and oftentimes are more hesitant to recognize their own----
    Senator Sullivan. These veterans should be viewed as some 
of the top candidates for jobs, as you well know--motivation, 
discipline, they have it all, right? This is a win-win for 
corporate America, for anyone who hires a veteran. Do you think 
that there is an issue that women are not being recognized as 
veterans that have these great skill sets that all of our 
veterans, men or women, have?
    Ms. Cloud. I think we have taken on the challenge to speak 
to the private sector. We looked at a million records--many of 
them are women--and found that the story of women veterans who 
graduate at a higher rate than their male counterparts by 10 
percent, who outperform when they connect to competitive 
employment the general population of women, we need to tell 
that story. We are working in community-based efforts, in 
partnership with not only homelessness teams but employment 
teams and our Federal partners, to tell that story, why they 
are a good bet.
    Senator Sullivan. Great. Thank you.
    Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Sullivan.
    Senator Tillis.

       HON. THOM TILLIS, U.S. SENATOR FROM NORTH CAROLINA

    Senator Tillis. Thank you, Mr. Chair, and thank you for 
having this meeting on a very important topic.
    Mr. Chair, over the past 10 days, I have gone to three 
different VA facilities down in North Carolina, Fayetteville, 
Durham, and Salisbury. I saw some good things there. I saw some 
challenges in terms of facilities and other things, but a 
number of really good and promising things, in Salisbury, in 
particular, some things particularly focused on women veterans. 
While we hold you all to a high standard for the things we want 
fixed, I also want to recognize some good work that is going on 
there that, hopefully, will be replicated over time.
    To go back to the questions that Senator Blumenthal asked 
about getting information on providers specifically for women, 
I think it would be also helpful to get information on 
facilities and how we would grade the current facilities in 
terms of serving the needs of women. Some of the new health 
care centers that are coming online in North Carolina are far 
better equipped, I mean, physically better configured to be 
able to provide segregated service when needed, and I think 
probably a better setting.
    I would like to know how we are looking, and it really gets 
back to Senator Heller's question about what can we look at 
over the next 10 years. I would like to see what is already in 
the pipeline, things that are going to happen versus things 
that are subject to future funding and other constraints so 
that we can get a better feel for what we can reasonably 
expect. Is that information readily available? Is that 
something we can get follow-up?
    Ms. Hayes. We can follow up with that. We do have each 
facility do what we call a WATCH, Women's Assessment Tool for 
Comprehensive Health, each year and report on a number of 
things, including the number of providers, the number of women 
that they see, how many women they project, and what their 
strategic plan is.
    [The information requested during the hearing follows:]
 Response to Request Arising During the Hearing by Hon. Thom Tillis to 
   Patricia Hayes, Ph.D., Chief Consultant, Women's Health Services, 
 Office of Patient Care Services, Veterans Health Administration, U.S. 
                     Department of Veterans Affairs
    Response. The Women's Health (WH) Dashboard monitors elements from 
the Women's Assessment Tool for Comprehensive Health. Each quarter, 
Network Lead Women Veteran Program Managers upload facility data on the 
requested data. The WH Dashboard includes strategic planning; market 
penetration; the implementation of women's health care and extended 
hours; privacy and security corrections; and gender specific rural and 
telehealth initiatives. Attached are the most recent results submitted 
for 4th quarter FY 2014.
    In regards to facility settings, in accordance with VHA Handbook 
1330.01, ``Health Care Services for Women Veterans,'' (2010) a VHA 
facility may choose one or more of the following Comprehensive Primary 
Care Clinic Models to best meet the needs of women Veterans and the 
achieve the standards for Comprehensive Primary Care for Women 
Veterans:

          ``a. Model 1. General Primary Care Clinics. Comprehensive 
        primary care for the women Veteran is delivered by a designated 
        WH PCP who is interested and proficient in women's health. 
        Women Veterans are incorporated into the WH PCP panel and seen 
        within a general gender-neutral Primary Care clinic. Mental 
        health services for women should be co-located in the general 
        gender-neutral Primary Care Clinic in accordance with the 
        Primary Care-Mental Health Integration. Efficient referral to 
        specialty gynecology service must be available either on-site 
        or through fee-basis, contractual or sharing agreements, or 
        referral to other VA facilities within a reasonable traveling 
        distance (less than 50 miles).
          b. Model 2. Separate but Shared Space. Comprehensive primary 
        care services for women Veterans are offered by designated WH 
        PCP(s) in a separate but shared space that may be located 
        within or adjacent to Primary Care clinic areas. Gynecological 
        care and mental health services should be co-located in this 
        space and readily available.
          c. Model 3. Women's Health Center (WHC). VHA facilities with 
        larger women Veterans populations are encouraged to create 
        Women's Health Centers (WHC) that provide the highest level of 
        coordinated, high quality comprehensive care to women Veterans.

                  (1) WHC offers comprehensive primary care services by 
                a designated WH PCP(s) in an exclusive separate space. 
                Whenever possible, a WHC needs to have a separate 
                entrance into the clinical area and a separate waiting 
                room with attention to privacy, sensitivity and 
                physical comfort.
                  (2) Specialty gynecological care, mental health and 
                social work services must be co-located in this space.
                  (3) Other sub-specialty services such as breast care, 
                endocrinology, rheumatology, neurology, cardiology, 
                nutrition, etc., may also be provided in the same 
                physical location.
                  (4) Women Veterans receiving comprehensive primary 
                care through general primary care clinics in sites with 
                WHC need to be referred to the WHC for gynecological 
                care, mental health treatment, and other sub-specialty 
                care.''

    To summarize, Model 3 clinics are Comprehensive Women's Centers 
that have dedicated separate space, Model 2 are women's clinics that 
also have a separate space, but the space may be shared with other 
services when the women's clinic is not in session. Model 1 clinics 
provide women's health primary care in integrated settings. All three 
models should have Designated Women's Health Primary Care Providers 
(DWHP) and can be available at either medical centers or CBOCs. From 
the definitions it can be determined that all Model 2 and Model 3 are 
``women's clinics.''
    Women's Health Models of Care as of September 30, 2014 are: Model 
1-841; Model 2-99; and Model 3-77.

    Senator Tillis. Yes. Part of the reason why I am interested 
in getting that, it probably dovetails with a question or 
comment that Senator Rounds made as to figure out what more we 
may need to do based on the short, intermediate, and long-term 
plans for providing care to women veterans. Are there other 
things that we should look at that would be a safety valve 
through Choice, and then any other things that we do with our 
non-VA care? I know you are actively leveraging them, and I 
think for women's health care service. I would like to kind of 
get those two things together so we can match it up and see if 
there is any short-term relief we can provide.
    I am going to try and cover a few things and not re-cover 
ground that some of the other members discussed. With the 
transition assistance, are the advisors particularly trained to 
identify a potential risk situation for people who are going 
through transition? Are we just providing them a road map for 
transitioning, or are they trained in a way that could identify 
people that may be at risk for one form of transition problems 
or another?
    Ms. Cloud. Both Department of Defense with their in-
transition program is focused on supporting the identification 
and the warm handover for individuals that are needing mental 
health or more direct engagement from mental health 
practitioners. In the TAP program, we also provide specific 
training for all of our benefits advisors on the identification 
and the referral of resources available for things such as 
military sexual trauma, but also for very specific employment 
efforts. That is part of the core curriculum for our benefits 
advisors.
    Ms. Hayes. I would like to add that we also, our primary 
care providers, have developed a tool which gets at the risk 
for problems and for homelessness, and they administer this 
tool for women in the primary care setting. We also put the 
same tool online in a site called Unidas so that veterans can 
actually take the tool themselves and see some of their own 
risks for having problems in employment or homelessness.
    Senator Tillis. One other thing I wanted to mention in my 
visits to the VA was the good news that I got from Fayetteville 
in terms of their dealing with pain medication, very positive 
results that they have down there. It is in contrast to some of 
the stories we have heard in other facilities, but I am very 
happy about that. Hopefully, it is something that we are, to 
the extent we can, replicating elsewhere.
    The last question I have in my time remaining relates to 
suicide rates among female veterans versus the male population. 
Is there anything there that we should be concerned with? I 
mean, aside from the horrible reality that we have 22 veterans 
dying every day.
    Ms. Hayes. We are concerned for women veterans. Some of the 
other problems are duplicated also in the rates of suicide 
attempts and suicides. We know that women veterans are at 
higher risk than their non-veteran counterparts. We are 
examining that in terms of our mental health approach. We also 
know that some of our most vulnerable women veterans are at 
risk for higher possibilities of suicide attempts.
    Senator Tillis. Are there, within the suicide data that we 
have today, is there a disproportionate number of men or women, 
or is it roughly proportionate to the veterans' population? Is 
there a disproportionate number of women potentially at risk of 
suicide over male veterans?
    Ms. Hayes. Male veterans are at higher risk, but women are 
at higher risk than their non-veteran counterparts. It is hard 
to measure those kind of things.
    Senator Tillis. Yes.
    Ms. Hayes. It is tragic. We are looking at those issues in 
general in primary care and in every place in which we connect 
with our veterans so that we do not look at it as data later, 
but it is, rather, an issue that we are very concerned about.
    Senator Tillis. If we can, just back on the first question, 
that when we get the information, or if you can get the 
information on facilities, I assume that some of the other 
members may be interested, but I am particularly interested in 
getting some of that long-term information for the Southeastern 
States, where we have one of the fastest growing veterans' 
populations. I would like to see that data. Thank you.
    Chairman Isakson. Thank you, Senator Tillis.
    Senator Moran, did you want to ask a question or go ahead 
to the second panel?
    Senator Moran. Go ahead, Mr. Chairman. Thank you.
    Chairman Isakson. Let me thank the first panel for being 
here. Dr. Hayes, thank you for your service, Dr. McCutcheon, 
Ms. Cloud. Please understand, this focus today is not a passing 
focus. This Committee has a supreme interest in women's health, 
our veterans' health, and continuing services to our women 
veterans. Consider us a resource and consider us a sounding 
board as you have issues that come up that we need to know 
about. Please volunteer them to us. Do not make us have to come 
look for them.
    Ms. Hayes. Thank you, Mr. Chairman. We appreciate the 
opportunity to be here today.
    Chairman Isakson. Thank you very much.
Response to Posthearing Questions Submitted by Hon. Richard Blumenthal 
 to Patricia Hayes, Ph.D., Chief Consultant, Women's Health Services, 
 Office of Patient Care Services, Veterans Health Administration, U.S. 
                     Department of Veterans Affairs
                        military sexual assault
    Question 1. VA's written testimony mentions it is working on 
implementing a provision from the Veterans Access, Choice, and 
Accountability Act that allows VA to provide MST services to active 
duty Servicemembers without a referral from DOD. I highly suspect that 
much like in the general population, there are many survivors of sexual 
assault who have not reported their assault that could be eligible for 
services through VA. A reluctance to report, particularly in 
environments like the military or on a college campus where reports 
were not historically taken seriously, does not in any way indicate 
that the survivor does not need assistance and services related to his 
or her assault. In many cases, the survivor may be unwilling to even 
access services through VA because using VA may remind them of the 
trauma that happened while serving. We must do all we can to make 
services available to survivors, including providing services to all 
who need them, even if there is no formal referral from DOD.

    Can you please provide an update for when those services for active 
duty Servicemembers will be available?
    Response. Section 402 of the Veterans Access, Choice and 
Accountability Act authorizes VA, in consultation with DOD, to provide 
Military Sexual Trauma (MST)-related healthcare to Active Duty 
Servicemembers (ADSMs) without the need for a referral from DOD. VA and 
DOD are proposing a phased approach starting at as of yet to be 
identified VA site(s) that will provide MST-related confidential 
healthcare services for ADSMs without requiring a referral. VA and DOD 
are currently working toward identifying the pilot site(s) and reaching 
a clinical consensus on any restrictions to confidentiality such as 
duty limitations as part of the treatment plan. The phased 
implementation of Section 402 is scheduled to begin August 2015.
                     women health provider training
    Question 2. As the Fiscal Year (FY) 2016 budget submission noted, 
the number of women using VA's health care system has doubled since 
2001. This number is projected to continue to grow. By FY 2023, women 
will represent over 10 percent of the enrollee population at VA. As a 
result it is essential VA ensures it is equipped to serve the diverse 
needs of this group of Veterans. VA's testimony discussed intensive 
training for over 2,000 women's health providers as well as online, 
accredited women's health classes.

    a. Can you please provide a summary of the material covered in 
these trainings?
    Response. The intensive Women's Health update for primary care 
providers includes lectures and facilitated small group case 
discussions with expert facilitators on topics such as contraception, 
vaginitis and sexually transmitted infections, cervical cancer 
screening, menopause, abnormal uterine bleeding, breast health and 
breast cancer screening. In addition, there is a post-deployment 
session that includes a demonstration of military equipment used by 
women during deployment and a discussion about deployment issues 
specific to women Veterans. Training on performing breast and pelvic 
examination is done using simulation equipment, training videos, and 
trained, live actors. Participants have access to a women's health 
pharmacist on-site for medication questions.

    b. How much of the current workforce is represented by the 2,000 
providers who have received the intensive training and how many have 
taken the online training?
    Response. As of September 30, 2014, there were 2,168 primary care 
providers specifically designated to care for women Veterans. Of the 
2,168 providers 55 percent (1193) have taken the comprehensive VHA 
training and an additional 21 percent (455) have taken women's health 
training of similar scope (roughly 20 credit hours). The remainder of 
these individuals are designated to care for women Veterans because 
they have recent prior experience (ex: in a non-VA practice with 
substantial numbers of female patients) or professional residency or 
fellowship (ex: Family Medicine residency or Women's Health fellowship) 
but they still may benefit from attending the Women's Health Mini-
Residency.
    It is estimated that at a minimum an additional 675 providers need 
to be trained, or recruited and designated, so that there are at least 
two designated women's health providers (DWHPs) at each site to ensure 
continuity related to leave and turnover. Sites with larger numbers of 
enrolled women Veterans need at least one additional DWHP per 1000 
women Veterans.
    Given that, and accounting for provider turnover and the continued 
increasing numbers of women Veterans anticipated to use VA for health 
care, it is estimated that up to 900- 1,200 additional providers are in 
need of the VHA intensive training in the near future.
    Of note, roughly 800 providers have taken the mini-residency 
training program in the past six years who currently are not in this 
group of designated providers because they are: no longer employed by 
VA; no longer care for women in VA; have not yet received an official 
designation; or have taken the training for their own professional 
development.
    In addition to face-to-face courses for primary care providers, 
nurses, and emergency care staff, VHA has launched more than 50 online 
courses and awarded more than 20,000 hours of professional continuing 
education credits to clinicians in women's health topics in the past 
four years.
                        access to contraceptives
    Question 3. Given VA is witnessing an influx of young female 
Veterans who are of child bearing age, interest in reproductive 
contraception is no doubt growing. According to VA data, over 40 
percent of women Veterans seen in VHA are within their reproductive 
years. Requirements that private insurers provide free preventive care 
services do not apply to VA.

    a. What is VA doing to ensure it is offering this group of Veterans 
access to a wide range of contraceptive options?
    Response. VA provides the full continuum of health care for women 
Veterans including a wide range of contraceptive services including 
availability of: intrauterine devices (IUDs); hormonal methods 
(implant, injection, oral pills, ring, and patch); barrier methods; 
emergency contraception and tubal ligations; and occlusion procedures.

    b. If a Veteran seeks a method of contraception that is not on VA's 
national formulary, what options do they have?
    Response. The Veteran's provider can place a non-formulary request 
that indicates a clinical reason the method is preferred over what is 
on the national formulary.

    c. Has VA done any outreach to determine whether women Veterans are 
satisfied with the contraceptive options available through VA?
    Response. Women's Health Services sponsored a project involving 
pilot implementation of a reproductive life planning counseling 
intervention in a Women's Clinic, followed by qualitative interviews to 
assess women Veterans' perceptions of this counseling. As a part of 
this project, primary care providers (PCPs) and women Veterans engaged 
in a patient-centered conversation to (1) identify their reproductive 
goals, (2) identify preconception health risks and develop strategies 
to address these risks, and (3) choose a contraceptive method that 
aligns with their reproductive goals. The results demonstrated that 
women Veterans generally perceived reproductive life planning 
discussions with their PCPs as important opportunities to obtain new 
and relevant information about contraception and planning healthy 
pregnancies. Available data do not suggest that women Veterans are 
dissatisfied with the VA's contraceptive options.
                           mental health care
    Question 4. Given VA's desire to offer women Veterans access to 
high-quality comprehensive health care that includes reproductive 
health care and focused mental health care:

    a. Please provide a summary of the specific training that providers 
and other clinical staff at VA are receiving to achieve this goal.
    Response. Beginning in FY 2012, the Reproductive Mental Health 
(RMH) Steering Committee has worked to enhance the care of women 
Veterans with mental health conditions. A Needs Assessment was 
developed and implemented across the VA system that assessed VA mental 
health providers' need for Reproductive Mental Health education, 
resources, and tools. VA has launched a new online RMH curriculum which 
supports VA providers' knowledge of reproductive mental health and 
their ability to best meet the reproductive mental health needs of 
women Veterans. Six modules are available online through VA's Talent 
Management System (TMS) addressing the following topics:

     Overview and History of Reproductive Mental Health
     Course and Treatment of Psychiatric Illness during 
Pregnancy
     Course and Treatment of Psychiatric Illness during 
Postpartum and Lactation
     Treatment of Psychiatric Disorders and Menopausal Symptoms 
in Midlife Women
     Special Topics in Reproductive Mental Health: Focus on 
Treatment Emergent Side Effects
     Gender based Differences in Presentation and Treatment of 
Posttraumatic Stress Disorder

    Additionally in fiscal year (FY) 2013 and 2014, VA launched a total 
of five MyVEHU (www.MyVeHUcampus.com) learning sessions on reproductive 
mental health. During the live viewing, over 300 learners participated 
in each session.

    b. Please describe any research efforts in specialized areas like 
mental health, including PTS and TBI, that VA is pursuing that relate 
specifically to women Veterans. Further, how does VA anticipate those 
efforts will translate into improvements for clinical care?
    Response. The mental health of women Veterans has long been an 
important priority in VA women Veterans' research, and over time has 
often been the most important focus of women's health research at VA. 
This has been evident in five VA Health Services Research and 
Development Service systematic reviews of published women Veteran's 
research since 2006, and in particular, in an additional systematic 
review in 2014, by VA Mental Health services specifically focused on 
women Veterans' mental health. These studies have examined the full 
spectrum of women Veterans' mental health for different military era 
cohorts and ages (including women from the Vietnam era and Iraq and 
Afghanistan). The studies also assessed gender differences between male 
and female Veterans. Research addressed: the prevalence of various 
mental health conditions among women Veterans; screening for these 
conditions; risk factors; the prevalence and association of medical or 
physical health conditions and functional impairment with mental health 
care.
    In 2010, VA's Health Services Research and Development Service 
funded the Women's Health Research Network (WHRN) in order to build 
women's health research capacity, expand research, and also expand the 
recruitment of women Veterans nationwide in VA research. The primary 
goals of the WHRN are to: examine VA's research portfolio; identify 
gaps in research; accelerate the development, testing and dissemination 
of interventions, implementation and high-impact research to improve 
women Veterans' health and healthcare. Among the initial WHRN strategic 
research portfolio areas was mental health. A dedicated Mental Health 
Work Group of both researchers and VA program and policy managers was 
organized to develop a strategic research agenda for mental health. 
More recently, additional work groups have been developed for 
depression and for trauma (sexual trauma, Post Traumatic Stress 
Disorder and intimate partner violence). In addition to identifying 
research gaps and new research areas, the WHRN plays a major role in 
testing new innovations in mental health care and facilitating 
implementation of improvements in care into practice.
    The emphasis on mental health within the WHRN and VA research has 
been demonstrated in recent research findings. Two special VA journal 
supplements have included extensive research on mental health issues. 
Research has addressed: the relationship of military sexual trauma and 
homelessness among women Veterans; gender differences in prescribing 
among Veterans with PTSD; gender differences in mental health 
conditions and stressors associated with military deployment; gender 
differences in mental health and substance use disorders and treatment 
entry among Veterans in the criminal justice system; the relationship 
between the experience of intimate partner violence and presence of 
Traumatic Brain Injury among women Veterans; and the effect of medical 
comorbidities on male and female Veterans' use of psychotherapy for 
PTSD. Findings that Operation Enduring Freedom/Operation Iraqi Freedom 
(OEF/OIF) women Veterans had a greater number of healthcare visits than 
women from other military eras, and also higher rates of mental health 
disorders, suggest a need for better integration and coordination of 
primary, reproductive health and mental health care.
    Numerous other studies highlight the need for improved screening 
and attention to mental health issues in multiple healthcare delivery 
settings. The first such study involving reproductive health indicated 
a higher prevalence of mental health conditions among pregnant Veterans 
enrolled in VA healthcare than among non-pregnant women Veterans; this 
finding helped shape national policy requiring coordination of 
maternity care, and informed development of a national initiative on 
reproductive mental health. Recent research confirms the importance of 
addressing mental health issues for reproductive care and health:

     Mothers with active PTSD are significantly more likely to 
suffer spontaneous preterm birth;endometriosis among those 18-44, or 
menopausal disorders) were more likely to have concomitant medical and 
mental health diagnoses and also more VA outpatient encounters; and
     Pregnant women Veterans who use VA prenatal benefits (vs. 
those who do not use these benefits) are a high risk group: they were 
more likely to have self-reported depression, and current depression or 
PTSD symptoms or PTSD.

    The importance of VA mental health services to women Veterans has 
been demonstrated by a recent nationwide survey of over 6,000 women 
Veteran VA primary care users. This survey, which focused on gender-
sensitive access to mental health care, showed that almost all women 
who used mental health services in the past year used VA care for at 
least some of their mental health care; however, only about half of 
these women indicated their mental health care met their needs 
completely or very well, suggesting gaps in perceived access. Higher 
levels of patient activation were associated with better ratings of 
mental health experiences and gender-related or--sensitive care 
experiences contributed to greater perceived access. In a related 
analysis, researchers examined women Veterans' needs, priorities and 
preferences for behavioral services, which included: treatment for 
depression; pain management; coping with chronic conditions; sleep 
problems; weight management; and Post Traumatic Stress Disorder (PTSD). 
This relatively new area of research is focused on understanding women 
Veterans' experiences with care and preferences (e.g., co-located 
primary care and mental health services, and designated women's health 
services and providers)--both for behavioral and physical health. These 
findings will inform development of models of care (e.g., integrated 
primary care and mental health care) that are more in line with women 
Veteran preferences, and support development of tools for enhanced 
patient activation and health management that ln turn will improve 
perceived access and guide implementation of more patient-centered 
behavioral health services.
    Other current and past research will also guide development and 
implementation of more patient-centered mental health services for 
women Veterans. Important areas of research include: examination of the 
impacts of sexual and combat trauma, as well as PTSD, on seeking care 
and patient experiences; examining the impacts of trauma, PTSD and 
depression in lesbian, bisexual and heterosexual women; determining 
other barriers to mental health care use such as stigma (particularly 
self-stigma), personal mental health beliefs, and perceptions of VA 
care; further analysis of the impacts of deployment and military 
related risk factors on mental health, physical health and Veteran 
functioning; longitudinal study of an OEF/OIF/OND cohort regarding 
predictors and psychiatric and psychosocial modifiers of treatment 
patterns, use of services and health outcomes associated with mental 
health conditions, musculoskeletal pain and cardiovascular disease; and 
development and assessment of web-based and shared decisionmaking 
interventions to improve evidence-based mental health and PTSD care for 
Reserve/National Guard women Veterans with PTSD.
                                 ______
                                 
 Response to Posthearing Questions Submitted by Hon. Sherrod Brown to 
   Patricia Hayes, Ph.D., Chief Consultant, Women's Health Services, 
 Office of Patient Care Services, Veterans Health Administration, U.S. 
                     Department of Veterans Affairs
    Every piece of testimony-from both panels-reflects the changing 
demographics of today's Veterans and recognizes the need for the VHA to 
adapt to serve all Veterans, especially the growing female Veteran 
population. I was pleased to join Senator Murray and Senator Heller on 
their bill, Women' Veterans Access to Quality Care Act, to ensure that 
all female Veterans have access to a full-time obstetrician or 
gynecologist at every VA medical center. This seems to be a common 
sense approach to properly care of our women Veterans, in addition to 
steps to update training for primary care professionals.

    Question 1.  My question for Dr. Hayes is this, why, when the VHA 
is aware of military's changing force structure, would it take an act 
of Congress to make access to a full time obstetrician or gynecologist 
possible? Why did the VHA not take proactive steps to address critical 
gaps in medical coverage for the rising number of female Veterans?
    Response. VA has been taking proactive steps to enhance access to 
medical care for women Veterans. VA has enhanced access to Designated 
Women's Health Primary Care Providers and developed training to enhance 
a provider's ability to care for women Veterans. A Gynecology Health 
Care Delivery Workgroup has been assembled to develop guidance on 
enhancement of gynecology services across VA and is actively contacting 
health care systems with no gynecologist on site to collaboratively 
determine plans for future enhancements in this area.

    Question 2.  In your testimony Dr. Hayes, you mention the yearly 
assessments conducted by an independent contractor regarding the 
implementation of services for women Veterans. What was the result of 
the most recent report, and what, if any, gaps were detailed in the 
report? How is VHA working to address those gaps, and what is the 
timeline to fix them?
    Response. In FY 2014, the independent contractor conducted 24 
comprehensive evaluations, to bring the total completed to 94 site 
evaluations (67 percent of Women's Health Programs). The primary 
purpose of this program evaluation was to gauge progress toward the 
full implementation of comprehensive health care for women Veterans as 
delineated in VHA Handbook 1330.01: ``Health Care Services for Women 
Veterans'' (May 2010). The assessment teams used a Capability Review 
Tool that addressed five essential Women's Health Program domains or 
``components:'' 1) Program features; 2) Health Care Services; 3) 
Outreach, Communication, and Collaboration; 4) Patient Centered Care 
(PCC)/Patient Aligned Care Teams (PACTs); and 5) Education and 
Training. Within these components there are 33 capabilities comprising 
more than 300 evaluation criteria.
    Each capability was scored on a four-point Likert scale:

          1 = ``Needs Development''--No ongoing plans to meet critical 
        success factors
          2 = ``Being Developed''--At least one critical success factor 
        not met
          3 = ``Developed''--All critical success factors met
          4 = ``Highly Developed''--All criteria met

    Data for this report were analyzed by examining ``High 
Performance'' versus ``Less than Developed'' across components and 
capabilities. Recommendations were based on capabilities that emerged 
as ``Less than Developed,'' where critical success factors were not met 
at the majority of sites. As a result of the analysis, Component 2 
(Health Care Services), Component 3 (Outreach, Communication, and 
Collaboration) and Component 4 (Patient Centered Care/Patient Aligned 
Care Team (PCC/PACT)) emerged as High Performance components. Component 
1 (Program) emerged as a Less than Developed component reflecting 
opportunities for further improvement.
    Below are summary charts of the 2014 report results:

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    VHA has developed tools and trainings to assist Women Veteran 
Program Managers (WVPMs) to address opportunities for improvement in 
the programmatic functions of the Women's Health Program (WHP) such as 
strategic planning, organizational structure, human resources planning 
and cross coverage. In FY 2013, Women's Health Services developed a 
strategic planning tool kit specific to women's health as a resource 
for the field. The ultimate goal was for each local WHP to have a 
usable, sustainable strategic planning process. The toolkit materials 
are meant to assist the WVPM lead a planning process that assesses the 
current status of its WHP, identifies areas for growth and improvement 
in order to meet future needs, and implements target objectives. In 
2014, VHA held a large national training for all WVPMs and Women's 
Health Medical Directors in topics that included: strategic planning, 
leadership skills, finance and budget issues, enhancing maternity and 
breast care coordination, and addressing gender gaps in quality 
measures. In addition, through the implementation of a Women's Health 
Dashboard, VHA is able to monitor facility implementation of the WHP.

    Chairman Isakson. We invite the second panel to come 
forward at this time. [Pause.]
    I would like to welcome our second panel. We look forward 
to your testimony, and I will introduce two of the members and 
then turn it over to Senator Heller for a third introduction.
    First is Joy Ilem, Deputy National Legislative Director of 
the Disabled American Veterans. We are glad to have you with us 
today, Joy.
    Christina Mouradjian, U.S. Army veteran. Thank you for your 
service to the country and thank you for being here.
    Senator Heller will introduce our third guest.
    Senator Heller. Thank you very much, Mr. Chairman. I want 
to welcome Dr. Davis being with us here today. She is the 
Chairwoman of the Nevada Women Veterans Advisory Committee, 
which Nevada Governor Brian Sandoval established so that the 
Committee could provide recommendations to how to improve care 
for women veterans in our State. I am thrilled to have you 
here. She is a graduate from the U.S. Military Academy, served 
in the Army for 29 years. Thank you very much for being with us 
today.
    Chairman Isakson. We welcome all of you here to the hearing 
and we will hear first from Ms. Ilem. Everybody will have up to 
5 minutes for your testimony.

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

    Ms. Ilem. Thank you, Mr. Chairman. We appreciate your 
invitation for DAV to testify at this important hearing.
    Over the past decade of war, women have been a rapidly 
increasing and important component of the military services. 
Women now routinely serve in occupations that put them in 
harm's way in combat, often resulting in trauma, injury, and 
environmental exposures associated with modern warfare.
    Following military service, as you have heard, women are 
turning to VA in record numbers. In fact, the number of women 
seeking VA care has more than doubled over the past decade and 
continues to rise.
    The experiences of current wartime deployments have 
contributed to the number of new transition and reintegration 
challenges for these servicemembers. As a result, DAV 
commissioned a study in 2014 to look at women transitioning 
from the military and the existing Federal programs and 
services available to aid them in that transition. Our report, 
``Women Veterans: The Long Journey Home,'' represents a 
comprehensive assessment of the existing programs and policies 
serving women across the Federal landscape.
    One of DAV's key legislative priorities has been to ensure 
that women veterans are properly recognized for their military 
service and receive equal benefits and high-quality health care 
in the VA health care system. DAV's report highlights that 
despite a government that provides a generous array of benefits 
to assist veterans with transition and readjustment following 
military service, gaps do exist, are evident for women in 
existing programs, and these gaps can impede a successful 
transition and negatively impact their health outcomes. The 
majority of these deficiencies result from a disregard for the 
differing needs of women veterans and a historic focus on 
developing programs for men who are prominent in numbers and 
the public consciousness.
    Research demonstrates that when compared to men, women 
veterans returning home from current wartime deployments are 
more likely to be divorced, a single parent, and unemployed 
after their service, have higher rates of homelessness, at 
least twice as high as women non-veterans, limited access to 
safe housing options in certain cases, especially for 
homelessness women veterans with minor children, high rates of 
military sexual assault, and higher use of VA mental health 
services. Women also continue to report limited access to child 
care services as a barrier to needed health care.
    Despite the fact that VA has made tremendous progress to 
improve services for women, they still lack consistent access 
to a full range of gender-sensitive health care benefits and 
services. To correct these deficiencies, DAV makes a number of 
key recommendations, including requiring every VA medical 
center to hire a gynecologist and address more appropriate 
staffing levels to meet current demand; implementation of 
gender-specific clinical IT tools; improving access to gender-
sensitive mental health programs; tailored transition 
assistance, education, and career guidance programs; increased 
access to safe transitional beds and housing for homelessness 
women with children; improved access to specialized prosthetic 
items and treatment for military sexual trauma; permanent 
authorization for child care service and women-focused post-
deployment readjustment retreats; and an effective plan overall 
for systemic culture change to ensure women experience a 
welcoming, safe, and private environment of care at all VA 
facilities.
    Over the history of our country, millions of women have 
answered the call to duty and put themselves at risk to 
preserve our Nation's security. They have kept their promise 
and served this country faithfully, many with distinction. Now, 
it is time we keep our promise to them. We can do that by 
acknowledging their dedicated military service and serving them 
with greater respect, consideration, and care. Given the fact 
that more than half of the women veterans under VA care are 
service-disabled, the Department must step up its efforts to 
address their unique health maintenance needs, reallocate 
resources, and ramp up clinical training for these high-
priority VA beneficiaries with age-appropriate lifelong 
specialized care.
    This is a transformative moment for the VA. Secretary 
McDonald is leading an ambitious effort to change the 
Department's overall culture and to direct resources where they 
will ensure that VA health care services meet the needs of 
every veteran. That cannot happen without a strong focus on 
women veterans and a detailed plan of action.
    For these reasons, we call on Congress to legislate and set 
a firm deadline of Memorial Day 2016 for action by the 
Department to complete the steps outlined in DAV's testimony. 
This will ensure that women veterans have equal access to high-
quality gender-sensitive health care and benefits.
    Again, DAV appreciates the opportunity to testify before 
the Committee today on this important topic and I am pleased to 
answer any questions that you may have. 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 
DAV (Disabled American Veterans) to testify at this hearing examining 
access to, and quality of care and services for women veterans at the 
Department of Veterans Affairs (VA). Ensuring that women veterans gain 
equal access to benefits and high quality health care services is a top 
legislative priority for DAV. We have a long-standing resolution from 
our membership of 1.2 million service-disabled wartime veterans that 
seeks to ensure VA health care services for women veterans, including 
gender-specific care, are equitable and provided to the same degree and 
extent that VA services are provided to male veterans.
    As a service-disabled veteran, I know first-hand the challenges 
women face during military service and when they return home. I, like 
many women who served, did not understand on leaving military service 
the benefits and services to which I was entitled, despite the fact 
that I suffered an injury during my service as an Army medic while 
stationed at the Army 67th evacuation hospital in Wurzburg, Germany. It 
was not until nearly a decade after I had discharged from the military 
that a fellow veteran contacted me and told me about DAV. He urged me 
to file a VA disability claim and seek VA treatment. I resisted for 
months and remember asking him, ``are you sure I can use the VA health 
care system?'' I didn't think of myself as a veteran, and knew next to 
nothing about filing a disability claim or for which benefits I might 
be eligible. Today, many women who have served still do not readily 
self-identity as veterans. The good news is a concerted effort is being 
made to change this trend and ensure that women veterans are recognized 
for their military service and gain information about their earned 
benefits.
    The number of women serving in the military, their roles, and their 
exposure to combat has dramatically changed during our war years in 
Iraq and Afghanistan. Likewise, over the past decade we have seen a 
dramatic rise in the number of women seeking health care and other 
benefits from VA with expectations that this trend will continue. 
According to VA, the number of women veterans using Veterans Health 
Administration (VHA) services increased by 80 percent between fiscal 
year (FY) 2003 and FY 2012.\1\ Currently, over 635,000 women veterans 
are enrolled in the VA health care system, and over 400,000 actively 
use VA health care; more than double the number of women who used VA 
health care in the year 2000 (160,000).\2\
---------------------------------------------------------------------------
    \1\ U.S. Dept. of Veterans Affairs, VHA, Office of Patient Care 
Services, Women's Health Services, ``Sourcebook: Women Veterans in the 
VHA, Vol. 3: Sociodemographics, Utilization, Costs of Care, and Health 
Profile.'' Feb 2014.
    \2\ United States. Cong. House. Committee on Veterans Affairs. U.S. 
Dept. of Veterans Affairs Budget Request for FY 2016. Hearings, Feb. 
11, 2015. 114th Congress. 1st Sess. Washington (Statement of Robert 
McDonald, Secretary, U.S. Dept. of Veterans Affairs.)
---------------------------------------------------------------------------
    Along with this significantly increased demand, VA experienced a 
shifting age demographic and inclusion of younger women veterans 
enrolling in VA health care, which required significant changes in both 
policies and clinical practice. According to VA, the number of women 
veteran patients under 35 years of age has increased by 120 percent 
between FY 2003 and FY 2013.\3\ New providers with expertise in women's 
health were needed; clinical space in many locations was insufficient 
to meet rising demand; and privacy and safety concerns were prevalent. 
VA providers suddenly needed to be knowledgeable about reproductive 
health services, conducting breast and gynecological examinations and 
becoming aware of the possibility of pregnancy when treating younger 
women of child-bearing age to ensure medications and recommended 
treatments did not pose a risk of birth defects. Many VA providers were 
not seeing enough women patients to be proficient in women's health, 
necessitating VA to institute a mini-residency program to help 
clinicians refresh their knowledge and skills. All prenatal and 
obstetric care is referred to private providers, and mammography 
services are provided by non-VA providers for about 75 percent of 
enrolled patients through VA's fee basis medical care program, 
complicating coordination of care for women veterans.\4\ Other trends 
in this population that impact health policy and planning became 
evident as well.
---------------------------------------------------------------------------
    \3\ U.S. Dept. of Veterans Affairs, ``Sourcebook: Women Veterans in 
the VHA, Vol. 3.'' Feb 2014.
    \4\ Elizabeth Yano, Ph.D., MSPH. VA Women's Health Research 
Network, Center for the Study of Healthcare Innovation, Implementation 
& Policy, Spotlight on Women's Health Cyberseminar ``Women's Health 
CREATE Overview.'' January 27, 2014. PowerPoint presentation.
---------------------------------------------------------------------------
    According to VA, more than half (57 percent) of women veterans 
under VA care are service-disabled, some of whom are very young.\5\ 
These women will be eligible for lifelong VA care for their service-
connected conditions. Women veterans were also presenting with unique 
post-deployment health care and mental health needs. More than half (57 
percent) of the women who served in the wars in Iraq and Afghanistan 
(OEF/OIF/OND) have sought VA care following military service and have 
targeted health care needs, including chronic musculoskeletal pain; 
mental health conditions including Post Traumatic Stress Disorder 
(PTSD), anxiety, depression, and substance-use disorders (SUD); 
genitourinary system, endocrine and metabolic disorders; and 
respiratory conditions.\6\ Given the greater exposure of service women 
to combat, the specific medical profile of this group, and women who 
have sustained traumatic war-related injuries, it became clear there 
was a need for adjustments to not only primary care services but 
specialized care, transition services including supportive counseling, 
and psychological services.
---------------------------------------------------------------------------
    \5\ U.S. Dept. of Veterans Affairs, ``Sourcebook: Women Veterans in 
the VHA, Vol. 3.'' Feb 2014.
    \6\ Dept. of Veterans Affairs, VHA, Office of Public Health, 
Epidemiology Program, ``Analysis of VA Health Care Utilization Among 
OEF, OIF and OND Veterans.'' 4th Qtr FY 2014. Released Jan. 2015.
---------------------------------------------------------------------------
    To address these challenges, in 2008, VA launched a five-year plan 
to redesign the women's health care delivery system with a goal of 
reducing fragmentation of care and ensuring women receive comprehensive 
primary care services, including gender-specific care, by competent 
clinicians. To date, significant progress has been made to implement 
comprehensive primary care and patient-centered medical home programs 
(patient aligned care teams, or PACTS, to include integrated mental 
health, clinical, pharmacy, and social work support) for women, to 
increase capacity in women's clinical services, and to ensure that VA 
health professionals are properly trained and skilled in women's health 
through its mini-residencies in women's health programs. Nevertheless, 
VA is still working to ensure that women gain access to comprehensive 
primary care services throughout its health care system as evidenced by 
the absence of gynecologists at one-third of VA health care sites, as 
well as continuing deficits in safety, privacy and related physical 
space.\7\ Even though gaps in services still exist, we applaud VA's 
efforts to date and the exceptional work done by the Women's Health 
Services (WHS) program office in collaboration with VA's women's health 
researchers, to improve access and quality. Measurable progress has 
been made and we now urge the new leadership in VA to develop a 
specific timeline and include targeted resources to complete the goals 
set out by the WHS.
---------------------------------------------------------------------------
    \7\ DAV Special Report, ``Women Veterans: The Long Journey Home.'' 
September 2014.
---------------------------------------------------------------------------
    Despite all of the changes over the past decade, women are still 
frequently under-recognized for their military service. Transitions can 
be more complex for women who served in a combat theater as they 
process what they experienced while deployed, and return home to deal 
with societal assumptions that women are not exposed to direct combat. 
Today women serve on female engagement teams; as military police; truck 
drivers; fighter pilots; combat medics; trauma nurses and physicians; 
and a variety of other occupations that expose them to the same dangers 
as male servicemembers. It became clear to DAV, that if we wanted women 
to be valued and recognized for their military service, and have VA 
meet their unique needs, it was essential for VA staff and care 
providers to be aware of the diverse range of modern military 
experiences of women.
    For these reasons, over the past decade-plus of war DAV made it a 
priority to highlight and celebrate the stories and experiences of 
women serving in the military and to address the distinctive issues and 
barriers they face when they return home. We have sponsored three 
Congressional screenings of documentaries focused on women veterans--
followed by panel discussions with the women featured in the films to 
spark dialog among policymakers. DAV sponsored a ``Stand up for Women 
Veterans'' campaign and produced two special edition magazines 
highlighting service-disabled women veterans. DAV's efforts are aimed 
at ensuring that women are treated with the same dignity and respect 
provided to male veterans and that they receive equitable benefits and 
services. Women veterans consistently tell us they do not want or need 
special treatment--but simply access to the same treatment and 
consideration afforded to male veterans.
    In 2014, with the wars in Iraq and Afghanistan winding down and 
women turning to VA in record numbers, DAV commissioned a special 
report on women transitioning from military to veteran status. Women 
Veterans: The Long Journey Home (hereafter, ``Report'') presents a 
comprehensive assessment of the existing programs and services women 
veterans are provided by the VA, and the Departments of Defense, Labor 
and Housing and Urban Development (HUD).
    The Report highlights that despite a generous array of government 
provided benefits to assist veterans with transition and readjustment, 
serious gaps are evident for women in nearly every aspect of current 
Federal programs. Although DAV's Report addresses programs across the 
Federal landscape, I will focus my testimony and recommendations today 
primarily on the services that involve VA.
    Since the release of our Report, we have been repeatedly asked why 
so many identifiable gaps exist in services for women. The answer is 
simple--the vast majority of these deficiencies result from a disregard 
for the differing needs of women veterans and a historic focus on 
developing programs to meet the health care needs of men, who are 
prominent as veterans in both numbers and public consciousness. 
Although there has been dramatic growth in the number of women coming 
to VA, they will always be a statistical minority within the system. VA 
has an estimated 6.6 million users; of these, women represent only 
about 6.8 percent of the patient population.\8\ This reality poses a 
number of specific and ongoing challenges for VA--but the challenges 
can and must be resolved.
---------------------------------------------------------------------------
    \8\ U.S. Dept. of Veterans Affairs, ``Sourcebook: Women Veterans in 
the VHA, Vol. 3.'' Feb 2014.
---------------------------------------------------------------------------
    DAV's Report identifies 27 key policy and programmatic 
recommendations necessary to overhaul the culture and various services 
provided by the Federal agencies mandated to assist veterans. I urge 
the Committee to review our Report in its entirety; however, for the 
sake of brevity in my statement I will highlight only three key areas 
of main concern: access to gender-specific care, women veteran-centered 
care, and the government's culture:

     Today, women veterans lack consistent access to a full 
range of primary care and gender-sensitive benefits and services.
     Many specialized transition programs developed to assist 
veterans have not been tailored to meet the unique needs of women 
veterans--especially those returning from war-time military service.
     The Federal Government has not ensured that the staffs of 
each agency responsible to serve veterans, and the elements within 
them, are promoting a culture that fully supports women veterans.
                access to equitable quality health care
    We recognize that some VA health care facilities serve only a small 
number of women, or have experienced difficulty in recruiting or 
retaining specialty providers in certain locations; however, these 
services are essential to providing comprehensive health care. We urge 
the Department to reallocate the necessary resources to ensure women 
veterans gain access to a full continuum of gender-specific, age-
appropriate, high quality health care at all VA facilities.

     VA needs to ensure access to gender-specific health care 
services for women veterans by requiring every VA medical center to 
employ a part-time or full-time gynecologist or obstetrician and ensure 
24/7 access to such services for emergencies. VA should explore the 
wider use of e-consults and tele-gynecology to address existing 
limitations to access of these gender-specific services in certain 
locations.
    The last Government Accountability Office (GAO) report on women 
veterans programs, in 2009, reported on the extent to which VA 
personnel were following existing health care delivery policies, and 
identified key challenges that VA facilities were experiencing in 
providing care to women. GAO conducted a series of site visits at VA 
medical centers, community-based outpatient clinics (CBOCs) and Vet 
Centers, and identified variability in delivery of gender-specific 
services as well as a number of related challenges including space 
constraints that impacted patient privacy; difficulty in hiring 
providers with specific training and expertise in women's health care; 
and, a need for specialized mental health providers for survivors of 
sexual assault.\9\
---------------------------------------------------------------------------
    \9\ U.S. Govt. Accountability Office, ``VA Health Care: Preliminary 
Findings on VA's Provision of Health Care Services to Women Veterans.'' 
GAO 09-899T. Released July 16, 2009.

     DAV urges the Committee to request that GAO conduct a 
follow-on study and comparative review from its work in 2009 to 
evaluate VA's current ability to meet the needs of all eras of women 
veterans across the array of VA services, including current findings on 
compliance with privacy and safety policies.
                    va's specialized health services
    The Committee should also request that GAO assess VA's specialized 
services for women with amputations, PTSD, SUD, blindness, spinal cord 
injury, Traumatic Brain Injury (TBI), and burns to determine whether 
these programs meet the needs of women veterans who use them. With the 
wars in Iraq and Afghanistan, we saw for the first time a number of 
women with war-related blast injuries resulting in TBI, single and 
bilateral traumatic amputations, and other life-altering injuries. 
Although the number of women who have suffered war-related amputations 
is small compared to men (23 vs. 1,626 respectively \10\), according to 
VA, women veteran amputees use more health care and rehabilitation 
services, and are seen more frequently than men. Research also 
indicates women are more likely to be unsuccessful in fitting of their 
prostheses and present other distinct needs. Women veterans with 
traumatic war injuries note that the social dialog about combat 
experiences and the impact of these injuries often omits them from the 
discussion. Women veterans with limb loss also stressed the 
psychosocial differences in how war-related amputations are viewed by 
the public for women versus men, and the resultant impact on self-
esteem, mental health and intimate relationships.
---------------------------------------------------------------------------
    \10\ DOD/VA Extremity Trauma and Amputation Center of Excellence 
Registry (EACE-R), excludes finger(s), thumb(s); includes partial foot 
and hand amputations. Aug. 1, 2014.
---------------------------------------------------------------------------
    While there are a relatively small number of war-related 
amputations noted for women veterans, there is a much larger population 
of women who have non-war-related medical conditions that required 
amputations, such as diabetes. DAV has received numerous calls from 
women veterans complaining about the quality of VA prosthetic care; the 
apparent lack of knowledge about specialized prosthetic appliances for 
women; various challenges related to properly fitting prosthetic items 
and VA's unwillingness in certain cases to order special gender-
specific prosthetic hardware, such as knee replacements. Special 
prosthetics needs occur in women, especially during pregnancy. Weight 
fluctuation directly impacts the fitting of prostheses--providers must 
be aware when women become pregnant that they will likely need more 
frequent prosthetic modifications and adjustments during and after 
pregnancy. Women with above-the-knee leg amputations who require 
delivery by caesarian section need a higher abdominal incision than 
would normally be expected to avoid irritation of the socket brim.\11\ 
Women veterans needing prosthetic items would be better served by VA if 
it appointed a clinical advisor that has special expertise in 
prosthetics and women's health, who would be available for consultation 
and develop a guide on various vendors and options for items needed by 
women.
---------------------------------------------------------------------------
    \11\ DAV Special Report, ``Women Veterans: The Long Journey Home.'' 
September 2014.
---------------------------------------------------------------------------
    Women veterans with poly-traumatic injuries, including spinal cord 
injury, also present special challenges. Modernized medical equipment 
for gynecological examinations is necessary for VA to provide 
comprehensive care and to ensure safety. Women with spinal cord injury 
and dysfunction, and those with other severe wartime injuries, also 
express concern about the impact of their injuries related to the aging 
process such as out-living their spouses, the ability to conceive 
children, and to gain access to comprehensive reproductive and long-
term care services. Despite the type or level of injury, it is 
important for women, like men, to have peers provide a source of 
support and experience post-injury and during the rehabilitation phase, 
and for individualized treatment plans to be developed for women by 
providers who have an understanding of these factors.

     VA should assess the specialized services it offers to 
ensure all existing programs meet the unique needs of women veterans 
and consider appointing clinical advisors with expertise to act as a 
resource and consultant for other providers related to the special 
needs of women patients seeking care for amputations, PTSD, burns, 
blindness, spinal cord injury or TBI.
      the impact of information technology and infrastructure on 
                             women's health
    The VA's Office of Public Health and Environmental Hazards and the 
Women Veterans Health Strategic Health Care Group developed a roadmap 
in November 2008, entitled Provision of Primary Care to Women Veterans, 
to correct many of the gaps identified. However, it appears that 
competing budgetary priorities in many locations stalled the full 
implementation of necessary changes and modernization that were 
recommended. Two prime examples are: the aging infrastructure of VA has 
made it difficult to ensure privacy, safety and appropriate clinic 
space for women at many locations; and, competing information 
technology (IT) priorities have delayed full implementation of an 
electronic clinical reminder about prescribing certain medications to 
women of childbearing age at risk of potential birth defects. We 
understand the addition of this clinical tool is part of the upgrade 
being made to VA's electronic clinical patient records system (CPRS) 
later this year. Likewise, the IT smart system for breast and cervical 
cancer screening and tracking abnormalities and a registry for breast 
cancer are still pending. IT tools such as breast health registries 
that help track mammography results, cervical screening results and 
other critical preventative gender-specific information should be a 
priority for VA as delays have the potential to negatively impact 
direct patient care and can result in poor health outcomes for women 
patients. For example, the majority of mammograms (75 percent) are done 
in the private sector \12\ and although VA pays for those services and 
is provided a copy of the test results, there are a number of steps 
that must occur to have those results scanned into VA's computerized 
records system. These health care tools would allow for more timely 
tracking of testing and appropriate follow-up of abnormal results.
---------------------------------------------------------------------------
    \12\ Elizabeth Yano, Ph.D., MSPH. Cyberseminar ``Women's Health 
CREATE Overview.'' January 27, 2014. PowerPoint presentation.

     Increased attention should be given to requesting and 
appropriating funds needed for IT clinical updates, and in both major 
and minor construction projects, correct identified environment-of-care 
deficiencies that directly impact the care of women veterans.
                        need for culture change
    One of the most perplexing problems is a culture in VA that is not 
perceived by women as welcoming to them, and does not afford them or 
their needs equal consideration. VA's own Women Veterans' Task Force 
noted the, ``need for culture change across VA to reverse the enduring 
perception that a woman who comes to VA for services is not a veteran 
herself, but a male veteran's wife, mother, or daughter.''
    While VA deserves praise for its excellent targeted communications 
initiatives such as ``She Wore These'' [combat boots], ``Please Don't 
Call Me Mister,'' ``She Was There,'' and ``She Earned These'' [military 
medals]. While these public service announcements and poster campaigns 
are effective, it does not appear that a full assessment by all service 
lines of VA has been made to assure that women veterans' needs are 
incorporated into overarching strategic plans and policies at all 
levels of the organization. We fully concur with VA's Advisory 
Committee on Women Veterans 2014 Report findings and recommendations 
that Women Veterans Program Managers (WVPMs) located at each VA medical 
center are instrumental in coordinating services for women veterans, 
and the Lead WVPM should be part of the strategic planning process to 
ensure each Veterans Integrated Service Network (VISN) is involved in 
addressing the gender-specific gaps and needs of women and how they 
will be met and resourced. While VA reports that 96 percent of 
facilities now have a Women's Health Strategic Plan, it notes that only 
50 percent of WVPMs are involved in strategic planning at the health 
care system level. Likewise, VA notes that in 2012, as VISNs 
reorganized, Lead WVPMs were decreased to a part-time position and 
subsequently six of the 11 that did have full-time positions (in the 21 
VISNs) either retired or left the position.\13\ We want VA to be the 
health care system of choice for women veterans so they too can benefit 
from the specialized services and care VA provides. Therefore, it is 
essential that the system fully recognizes and can meet the primary and 
specialized health care needs of women veterans, has sufficient 
staffing levels, is focused on women's health needs, and undergoes a 
culture change that is more sensitive of women's needs.
---------------------------------------------------------------------------
    \13\ U.S. Dept. of Veterans Affairs, Advisory Committee on Women 
Veterans, 2014 Report, ``Women Veterans--Proudly Breaking Barriers.'' 
Sept. 2014 (9, 16).

     We recommend that VA examine the role, responsibility and 
impact of the Lead Women Veterans Program Manager on the Women's Health 
Program and aggressively pursue staffing, culture and organizational 
changes to ensure that experiences of women in the military are 
understood by health care providers and staff, that women veterans are 
treated with respect, and that they encounter a safe, welcoming 
environment as they seek VA services.
                               employment
    The Department of Labor (DoL) has conducted research on how to best 
serve the employment needs of women veterans and provide them with many 
customized programs, communications and supports; however, despite 
these targeted efforts, the unemployment and under-employment rates for 
women veterans are slightly higher than their male counterparts.\14\ 
While DoL found no employment challenges that are exclusive to women 
veterans, it indicated that the demographics of this group make it more 
likely they are in subpopulations that have higher unemployment 
rates.\15\ Innovative outreach efforts to ensure women are aware of 
these services are necessary. Additionally, employment assistance will 
become even more pressing as DOD executes its current downsizing plan. 
Some servicemembers who may have expected to complete full military 
careers will be thrust, with little preparation, into civilian 
communities and job markets.
---------------------------------------------------------------------------
    \14\ U.S. Dept. of Labor, Economic News Release, ``Employment 
Situation of Veterans--2014.'' Mar. 18, 2015.
    \15\ U.S. Dept. of Labor, Fact Sheet, ``Women Veterans: Equally 
Valued. Equally Qualified. Equally Served.'' Retrieved Apr. 2015.
---------------------------------------------------------------------------
    With an estimated 200,000 women expected to leave the military over 
the next four to five years, it is imperative that we improve our 
efforts and support for women veterans' employment. We are pleased that 
organizations such as the Business and Professional Women Foundation 
and the VA's Center for Women Veterans have focused on helping women 
veterans better prepare for the civilian workforce, utilize their 
military experience, and refine skills to improve their competitiveness 
in the civilian work force so they have optimal employment 
opportunities and can obtain and sustain rewarding careers.
                              homelessness
    Another troubling trend that has emerged is women veterans 
experience higher rates of homelessness--at least twice as high as 
women who have not served. Most women who return from deployments are 
stronger from their military experience, but some have difficulty in 
their transitions and are not fully supported by existing programs. VA 
research shows that unemployment, disability and unmarried status are 
among the strongest predictors of homelessness for women. Women without 
strong support systems, those who have a service-connected disability 
and chronic health issues, or experienced sexual or physical trauma in 
the military or who have significant mental health or substance-use 
challenges can easily spiral downward losing connection with family, 
friends and community--resulting in homelessness.
    VA's efforts to eliminate veterans' homelessness have been 
impressive and are showing significant success. However, women 
veterans, especially single women with children, are often not able to 
take full advantage of VA's comprehensive array of services to regain 
health, improve work skills, and secure stable employment--or housing 
opportunities are not suitable to women veterans with children. GAO's 
2011, report on Homeless Women Veterans noted that women veterans face 
barriers to accessing and using veterans housing, including lack of 
awareness about existing programs, lack of referrals for temporary 
housing while awaiting placement in a HUD-VASH arrangement, limited 
housing for women with dependent children and continuing concerns about 
personal safety and security.\16\ In 2010, nearly 40 percent of women 
veterans served by HUD-VASH entered the program with their dependent 
children.\17\
---------------------------------------------------------------------------
    \16\ U.S. Govt. Accountability Office, ``Homeless Women Veterans: 
Actions Needed to Ensure Safe and Appropriate Housing.'' GAO 12-182. 
Published Dec. 23, 2011. Released Jan. 23, 2012.
    \17\ Syracuse Univ. Inst. for Veterans and Military Families, Natl. 
Veterans Tech. Asst. Center. ``Lessons learned from the U.S. DOL 
grantees: Homeless female veterans and homeless veterans with 
families.'' Syracuse, NY. 2013.
---------------------------------------------------------------------------
    While women veterans continue to report access to child-care 
services as a key barrier to needed health care, mental health care, 
and other supportive services, we were pleased to see VA's March 
announcement awarding nearly $93 million to the Supportive Services for 
Veteran Families (SSVF) program in the form of three-year grants to 
help at-risk veterans and their families stay in their homes.

     Based on the success of the VA's congressionally mandated 
child-care pilot program, authorized by Public Law 111-163, DAV urges 
the Committee to establish child-care services as a permanent program 
to support better access to health care, vocational rehabilitation, 
education, and supported employment services. Also, VA and HUD should 
invest in additional safe transitional and supportive beds designated 
for women veterans. Finally, VA should work with community partners to 
provide housing programs to accommodate women veterans with dependent 
family members, and especially targeted on those with minor children.
                         mental health services
    VA offers a comprehensive array of mental health and specialized 
post-deployment mental health services. VA's Uniform Mental Health 
Services Handbook requires that mental health services be provided as 
needed to women veterans at an equivalent level to that of their male 
counterparts system-wide, and that providers be capable and competent 
to meet the unique needs of women.
    Women's military and wartime deployment experiences and 
reintegration processes are inherently different from those of their 
male peers. Research indicates that men and women may develop PTSD as a 
response to combat exposure, and women are more likely to manifest 
depression as a co-occurring disorder, but are less likely to display 
anger and resort to substance use. Women are also more likely than men 
to experience depression or develop an eating or anxiety disorder 
without a diagnosis of PTSD. Findings also show that when women return 
from deployment, the camaraderie and support from their male peers is 
often curtailed--resulting in isolation for many. Studies have shown 
that peer support is important to a successful transition, but women 
report they often experience difficulty finding a network of women who 
relate to their military or wartime experience. While VA is recognized 
for its long-standing expertise in specialized mental health and post-
deployment mental health services, it continues to lag in establishing 
system-wide access to gender-specific group counseling, residential 
treatment, and specialty inpatient programs that serve women. Improved 
access to these programs is essential for recovery and effective 
reintegration. Existing programs should be re-evaluated to ensure they 
are appropriately tailored to meet the unique mental health care and 
post-deployment transition challenges women experience related to 
wartime service and trauma.
    DAV recognizes the challenges VA faces in establishing and 
maintaining specialized programs in every treatment location for a 
highly variable population cohort; therefore, we recommend that VA and 
DOD work collaboratively to:

     Explore innovative programs such as telehealth for 
providing gender-sensitive mental health programs for women. An 
interagency work group should be tasked to review options, develop a 
plan, fund pilots, and track outcomes.
     Coordinate structured women transition support groups to 
address unique issues of deployment, post-deployment readjustment, 
marriage, reintegration with children and spouses, child care and 
living as a dual military family.
     Establish joint group therapy options, peer-support 
networks, and inpatient programs for women.
     Develop a standardized approach to transition women with 
serious mental health issues and those who have experienced sexual 
assault from DOD to VA care.

    While the VA's women veterans' mental health retreat pilot program, 
established under Public Law 111-163, has been a resounding success in 
reducing stress, improving coping skills, and improving women's sense 
of psychological well-being, it is only a small pilot effort and has 
served a limited number of women. In its report to Congress, VA noted 
that 85 percent of participants showed improvement in psychological 
well-being, 81 percent showed significant reduction in stress symptoms, 
and 82 percent showed an improvement in positive coping skills. These 
findings warrant permanent reauthorization of the program, and justify 
a research study of long-term outcomes of participants.

     Congress should make permanent and expand the authority 
for the VA Readjustment Counseling Service's women veterans retreat 
program. The VA Office of Research and Development should study the 
program to determine its key success factors, its effectiveness as an 
alternative treatment regimen, and whether it can be replicated in 
other settings.
                         military sexual trauma
    Military sexual trauma (MST), while not exclusively a women's 
issue, is also of special concern to DAV. Sexual assault and rape are 
crimes. In order to successfully eliminate rape, other forms of sexual 
assault, and sexual harassment in the Armed Forces, DOD must address 
organizational, cultural, and preventive solutions.
    VA testified in February 2014 that in FY 2013, 93,439 veterans 
received MST-related care in the veterans health care system--a 9.3 
percent increase from FY 2012. There was also a 14.6 percent increase 
in the total number of MST-related visits during the same period--an 
increase from 896,947 visits to 1,027,810 respectively. Research has 
found that both men and women are at increased risk of developing PTSD 
after a sexual assault. MST screening and related services are mandated 
to be available at all VA medical centers, and that VA provides 
specialized MST-related PTSD care in a variety of settings. According 
to VA, in FY 2013, among the 77,681 female veterans who screened 
positive for MST, 58.7 percent received outpatient MST-related services 
compared to 57,856 male veterans who screened positive, and 44.3 
percent received outpatient treatment.\18\
---------------------------------------------------------------------------
    \18\ United States. Cong. Senate. Committee on Armed Services. 
Subcommittee on Personnel. The Relationships Between MST, PTSD and 
Suicide, and on DOD and VA Medical Treatment and Management of Victims 
of Sexual Trauma. Hearings, Feb. 26, 2014. 113th Congress. 1st Sess. 
Washington (Dr. Susan J. McCutcheon, Natl. Mental Health Dir., Family 
Services, Women's Mental Health and MST, Dept. Of Veterans Affairs)
---------------------------------------------------------------------------
    There is also an indication that MST is significantly associated 
with risk of suicide for both men and women. DAV's Report noted that 
while 10 percent of all patients in VA's specialized outpatient PTSD 
Treatment programs are women, VA has only three women's stress disorder 
treatment teams for the entire VA system. They are similar in structure 
to specialized PTSD clinical teams and provide individual and group 
treatment to women veterans. VA also has two women's trauma recovery 
programs; these are 50-day live-in rehabilitation programs that include 
PTSD treatment and coping skills for re-entering the community. In 
2012, the two programs served only 73 women.\19\ Given the high rates 
of PTSD and other mental health conditions in women, and the number of 
men and women seeking care for MST-related conditions, the current 
number of specialized programs that serve them is inadequate.
---------------------------------------------------------------------------
    \19\ Institute of Medicine. Treatment for PTSD in Military and 
Veteran Populations: Final Assessment. National Academies Press. 
June 20, 2014.
---------------------------------------------------------------------------
    Additionally, although VA has excellent evidence-based treatments 
for MST survivors, preliminary information suggests VA needs more 
qualified providers with specific training and expertise in treating 
the consequences of MST and helping veterans recover. In 2013, VHA 
reported that 31 percent of VAMCs and CBOCs are challenged to provide 
adequate care for MST, often because of staffing shortages.\20\ Experts 
note that MST-related cases are frequently complex, with high rates of 
comorbidity including alcohol misuse, depression, suicidal ideation and 
other mental health problems requiring intensive case management, 
frequent clinic visits, and comprehensive treatment.
---------------------------------------------------------------------------
    \20\ Ibid.

     VA should evaluate and publicly report the number of 
providers system-wide who are trained to deliver specialized care for 
MST-related PTSD, and develop a staffing model that ensures a 
sufficient number of staff are available to meet demand for these 
specialized services.
     We recommend that DOD redouble its efforts to eliminate 
rape, sexual assault, and sexual harassment in every part of its 
organization and take action to establish a culture that does not 
tolerate sexual assault and sexual harassment.
                     transition assistance program
    No comprehensive studies have been completed that evaluate the 
effectiveness of the long-standing Transition Assistance Program (TAP). 
The hallmark of learning is that individuals seek out and absorb 
information when they perceive they need it, not necessarily when it is 
made available. Some transitioning servicemembers may not be prepared 
to absorb TAP training during their pre-separation periods but would be 
more receptive once they are actively seeking help and assistance 
several months or more after their discharge.\21\
---------------------------------------------------------------------------
    \21\ DAV Special Report, ``Women Veterans: The Long Journey Home.'' 
September 2014.

     To judge the success of TAP, data on participation, 
satisfaction, effectiveness, employment outcomes and educational 
attainment should be tracked and reported on a rolling basis, 
stratified by gender, ethnicity, and race, for all separated 
servicemembers.
     TAP partners should conduct an assessment to determine 
unique needs of women veterans and incorporate specific breakout 
sessions during the employment workshops, or add a specific track for 
women in the three-day sessions to address identified needs.
     VA should evaluate the effectiveness of transition support 
groups that address issues with marriage, deployment, changing roles, 
child care, and life for dual military families, and determine whether 
these efforts help achieve more successful outcomes for women.
     VA and DoL should provide gender-sensitive follow up with 
all servicemembers six to 12 months after separation to offer 
additional support and services, if needed.
                        disability compensation
    The burden of wounds, illness and injury in post-9/11 veterans is 
high, and nearly half who served have applied to VA for disability 
compensation. Regarding MST-related PTSD claims, VA confirmed that 
approval rates for service connection were lower for women veterans 
than for men who made PTSD claims based on combat exposure. The 
Veterans Benefits Administration (VBA) took action to educate and 
retrain staff on existing policy and proper adjudication of these 
specific claims. We are pleased that VBA acknowledges the need to do 
further data collection and analysis in this regard, and we encourage 
additional analysis to assure that women are receiving fair and 
equitable adjudication of all their claims, for whatever disability is 
being claimed.

     The VBA should track, analyze, and report all its rating 
decisions separated by gender to ensure accurate, timely, and equitable 
decisions on claims filed by women veterans.
                 the need for data collection by gender
    In order to better understand the experience of women in the 
military, data needs to be routinely collected, analyzed and reported 
by gender and minority status. DAV recommends improved data collection 
on women and minorities for health care, disability compensation, 
justice involvement, education, transition assistance, sexual trauma, 
employment, and housing programs. Congress, policymakers, program 
directors, and researchers need this information in order to monitor 
and appropriately enhance services for women veterans.

     The Federal Government should collect, analyze, and 
publish data by gender and minority status for every program that 
serves veterans, to improve understanding, monitoring, and oversight of 
programs that serve women veterans.
                        women's health research
    VA's Health Services Research and Development (HSR&D) function 
continues to contribute to a growing body of women's health research 
that is aimed at improving the health and health care of women 
veterans. This research effort focused on women's health became a 
priority in the early 1990s and has increased dramatically over the 
past two decades. Early on, a VA Women's Health Research Planning Group 
was established and worked to develop a comprehensive research agenda 
for women veterans. Key research priorities were identified in 
November 2004, and a special supplement on VA research on women's 
health was published in the Journal of General Internal Medicine with 
several contributions from VA HSR&D investigators.
    VA researchers began to focus on chronic illnesses and mental 
health conditions in women and in 2010 sponsored a conference titled, 
``Using Research to Build the Evidence Base for Improving the Quality 
of Care for Women Veterans.'' In 2014, VA hosted a Women's Health 
Research Conference, bringing together investigators interested in 
pursuing research on women veterans and women in the military, with a 
goal to advance the state of and potential impact on VA women's health 
research. VA recently published a second women veterans' research 
journal supplement in Medical Care and announced that Phase 2 of the 
Women Veterans Cohort Study has begun. VA researchers have been 
studying women and the impact of exposure to combat during the wars in 
Iraq and Afghanistan--specifically the impact of military service on 
women's physical health, unique health care needs, and subsequent 
utilization of VA services. In addition to ongoing research in women's 
health and health care, HSR&D is funding a women veterans Practice-
Based Research Network and established the Women's Health Collaborative 
Research to Enhance and Advance Transformation and Excellence (CREATE) 
initiative to focus on accelerating implementation of research findings 
into practice.
    All of these targeted research efforts and studies to date have 
provided a solid foundation on which to shape national policy and 
improve the overall health of women veterans.

     We urge Congress to provide sufficient resources to 
support VA research efforts.
                                closing
    Millions of women have answered the call of duty and put themselves 
at risk to preserve our Nation's security and our way of life. They 
served this country faithfully and many with distinction. Acknowledging 
their dedication and resilience and serving women veterans with greater 
respect, consideration, and care must become a priority.
    This is a transformative moment for the VA--Secretary Robert 
McDonald is leading an ambitious effort to change the culture at the VA 
and to direct resources where they will ensure that VA health care can 
meet the needs of every veteran. That cannot happen without a strong 
focus on women veterans and a detailed, action-orientated plan. For 
these reasons, we call on Congress to set a firm deadline for action by 
the Department to ensure that women veterans have equal access to high-
quality health care services and benefits.
    While DAV's report makes a number of key recommendations, today, we 
call on Congress to authorize or exercise its oversight authority and 
responsibility and require that, by Memorial Day, 2016, at a minimum, 
the following steps are completed by VA:

     Every VA medical center must employ a part-time or full-
time gynecologist.
     VA must complete implementation of IT solutions that 
directly impact women's health including clinical reminders in its 
electronic medical record system on prescribing teratogenic medications 
to younger women and capturing vital gender-specific information, such 
as breast and cervical cancer screening results and abnormalities.
     VA must develop standards to ensure VA health care 
facility infrastructure meets the specific needs of women veterans. 
These standards should be integrated into prioritization for VA 
construction projects under VA's Strategic Capital Investment Plan.
     Authorize child-care services as a permanent program to 
support better access to VA health care, mental health programs, 
vocational rehabilitation, education, supported employment and other 
specialized services.
     Create a VA/DOD interdisciplinary work group to develop 
gender-sensitive mental health programs for women veterans, including 
peer-to peer support and services for post-deployment transition 
challenges. A full report, including recommendations of the work group, 
must be provided to Congress by the deadline.
     Increase the number of safe transitional and supportive 
beds designated for women veterans to meet demand and the number of 
housing programs available to women veterans with dependent family 
members, especially minor children.
     Conduct a GAO study on VA's ability to meet the health 
care needs of women veterans including an assessment of specialized 
programs for women seeking care for amputations, PTSD, burns, 
blindness, spinal cord injury and TBI.

    DAV is pleased to support S. 471, the Women Veterans Access to 
Quality Care Act introduced by Senators Heller and Murray. This measure 
seeks to ensure VA adapts programs and services to meet the needs of 
women veterans, and that women veterans can access safe, comfortable 
and high quality care at all VA health facilities. We also support 
S. 469, the Women Veterans and Families Health Services Act of 2015, a 
bill introduced by Senator Murray to expand VA's current reproductive 
health and fertility treatment options to assist injured veterans who 
want to start families. The measure also includes a provision to make 
permanent the highly successful child care pilot program in VA. Both of 
these bills are in line with recommendations put forth in DAV's Report 
and DAV Resolution Number 040, which supports enhanced medical services 
and benefits for women veterans.

    Again, DAV appreciates the opportunity to testify before the 
Committee today on this important topic and will be happy to address 
any questions the Committee may have.

    Chairman Isakson. Well, thank you, Ms. Ilem, very much for 
your testimony.
    I want to acknowledge to the Members of the Committee that 
are here and to the audience, there is a book at each Member's 
seat called ``The Long Journey Home,'' which is the Disabled 
American Veterans report on women's transitional issues from 
service to veterans services, and your report is the foundation 
of this hearing. We intend to follow through on your deadline 
for Memorial Day weekend and see if we cannot foster good 
response to you for the work that you have done. Thank you for 
your testimony.
    Dr. Davis.

STATEMENT OF ANNE DAVIS, CHAIR, NEVADA WOMEN VETERANS ADVISORY 
                           COMMITTEE

    Ms. Davis. Chairman Isakson, Ranking Member Blumenthal, 
members of the Senate Veterans' Affairs Committee, it is my 
honor to be here today. As Senator Heller mentioned, I am 
serving as the Chairperson of Nevada's Women Veterans Advisory 
Committee and our charter is to support and assist the State 
Women's Veterans Coordinator in locating, educating, and 
advocating for all women veterans in the State.
    One of the central issues we encounter is the 
identification of women veterans. As of September 30 of 2014, 
the U.S. Department of Veterans Affairs estimated the total 
veteran population within the State of Nevada at 228,027, with 
21,362 of those being female veterans. But, these are just 
numbers and do not translate to the actual women within the 
State. To date, the Nevada Department of Veterans Services has 
identified by name approximately 2,500 female veterans, or only 
11.7 percent of the estimated total number of women veterans in 
the State.
    To help connect veterans with service providers, Nevada has 
implemented a Statewide effort called the Green Zone Initiative 
which aligns operations under three pillars: The policy 
development pillar, the service provider coordination pillar, 
and the connecting to veterans pillar.
    According to the Nevada Department of Veterans Services, 
the connecting to veterans pillar presents the single most 
difficult challenge, especially for our women veterans. Meeting 
the needs of the individual women veterans requires a 
connection with them, and this cannot occur unless we know 
where our women veterans are.
    While the Department of Defense and Department of Veterans 
Affairs have taken some initial steps to create a handoff 
system, much more needs to be done. How can you connect a woman 
veteran to benefits and opportunities their service to our 
Nation has earned them if you cannot find the veterans? To 
truly identify our veterans, better collaboration between the 
Department of Defense and the VA and timely and in-depth 
information sharing with State governments is critically 
needed.
    Anecdotal evidence indicates that women are less likely to 
identify themselves as veterans than are men. We recommended 
that the State of Nevada agencies who collect veteran data 
replace the question, ``Are you a veteran?'' with the question, 
``Have you ever served in the United States military?'' on 
their forms and applications during their next program update. 
Studies have shown that women veterans do not self-identify as 
a veteran, and so asking if they have served in the military 
may ensure their status as a veteran is identified.
    Many women veterans are taking advantage of their education 
benefits within the State, and most, if not all, of the college 
campuses throughout the State have someone on their staff who 
deals with veterans issues. While women will always be in the 
minority within the veteran population, women feel more 
comfortable attending veteran events when other women veterans 
attend. Women do not seem to be participating in large numbers 
at the University of Nevada-Reno as compared to the University 
of Nevada-Las Vegas campus due to the smaller number of women 
if they also are the sole women attending veterans' events and 
meetings. Other reasons women do not attend include the timing 
of these events and meetings and the lack of child care.
    At a recent committee meeting, the UNR Director of Veterans 
Services noted women are hesitant to join campus veterans 
groups because they see the military part of their life as 
being behind them and women veterans would rather move forward 
through their education toward a new career. The UNR Director 
of Veterans Services is looking at ways to collaborate with the 
colleges and groups on campus to bring integrated services to 
our women veterans rather than stovepiping services solely 
within veteran organizations.
    Another initiative is a collaboration between the Sierra 
Nevada Health Care System and the University of Nevada at Reno, 
where they are putting a social worker on both the UNR and the 
Truckee Meadows Community College campuses through a program 
called VITAL, Veterans Integration to Academic Leadership. The 
goal of this veteran-centered, results-oriented collaboration 
is to enhance academic retention and success. The social worker 
noted that her workload was low initially as veterans seemed 
reluctant to seek out the services of the social worker, but 
trust has grown and she is now quite busy serving veterans on 
both campuses. It is important to note, however, that not a 
single woman veteran has contacted her for assistance.
    Women veterans have unique challenges in gaining 
employment. For example, they are twice as likely to be 
divorced or more often single parents, and their earnings 
average $6,000 per year less than male veterans. Women veterans 
also have higher military disability in general.
    Helping women veterans translate their military skills for 
use in the civilian workforce and emphasizing mentoring 
programs designed specifically to assist women veterans should 
be continued areas of emphasis.
    The VA has instituted an extensive initiative to eliminate 
homelessness by the end of 2015, which means finding homes for 
approximately 50,000 veterans. But, how can we eliminate 
homelessness if we are not properly identifying our women 
veterans? Due to the small numbers of homeless women veterans 
in any given location, the VA must encourage and support the 
partnering of Federal, State, and local agencies to find space 
for these homeless women veterans.
    With respect to health care and the health needs of women 
veterans, our committee believes telehealth initiatives need to 
be further expanded to better serve women veterans in rural and 
frontier communities outside of the large urban areas to reduce 
the need for travel and to access medical care and advice.
    I would also like to touch on military sexual trauma just 
briefly. Although our committee has not spoken to any women who 
have experienced military sexual trauma, I did reach out to a 
group of women veterans to try to understand their experiences. 
One woman shared her personal story with me, noting that the 
children of those suffering from military sexual trauma with a 
subsequent Post Traumatic Stress Disorder diagnosis may be the 
unseen victims of military sexual trauma.
    If approved, the PTSD-MST diagnosis may result in a 
disability rating below 100 percent, but often these veterans 
are unable to work and, therefore, rely solely on the VA 
benefits, and this may leave them operating below the Federal 
poverty level. Because the veterans may be unable to work, they 
often do not have health insurance for their children. Many of 
the MST victims are single parents. When their claims are 
denied, they are forced to rely on the generosity of county and 
State children's health and mental health insurance programs 
rather than on the VA dependent health care benefits. These 
children of PTSD-MST veterans also need to receive mental 
health care due to their parent's disability. Furthermore, 
parents with PTSD-MST tell us the VA claims process can 
actually exacerbate their condition.
    College-age children of these PTSD and MST veterans have 
limited access to affordable higher education, and a 100 
percent permanent and total disability rating would allow 
veterans to take advantage of the VA's dependent education 
benefits. A lack of education benefits may contribute to a 
continued cycle of poverty for affected children.
    The title of this hearing is ``Fulfilling the Promise to 
Women Veterans.'' I believe the way to do this is to push to 
identify our women veterans and to understand their needs. 
Committees such as Nevada's Women Veterans Advisory Committee 
are a good start and I would encourage other States to 
institute similar committees to better understand and support 
the needs of our women veterans. Our goal is not to find fault, 
but rather to support our women veterans who have served and 
sacrificed.
    Again, thank you for this opportunity to speak with you 
today.
    [The prepared statement of Ms. Davis follows:]
Prepared Statement of Anne L. Davis, Col., USA (Retired), Chairperson, 
               Nevada's Women Veterans Advisory Committee
    Chairman Isakson, Ranking Member Blumenthal, and Members of the 
Senate Veterans' Affairs Committee, it is my honor to appear here 
today. My name is Dr. Anne Davis. I am a retired Army Colonel who 
served 29 years on active duty. In June 2014, Nevada's Governor, Brian 
Sandoval, appointed me to serve on his Women Veterans Advisory 
Committee. I serve as Chairperson of that committee and our charter is 
to support and assist the State Women Veterans Program Coordinator in 
locating, educating, and advocating for all women veterans in the 
state. Our goal is not to find fault, but rather to understand the 
issues women veterans are facing and work toward finding solutions.
                              introduction
    Nevada's Women Veterans Advisory Committee currently consists of 
four members from throughout the state. Our initial members included 
women who are veterans of the Army, Air Force and Marine Corps, and 
represent both officer and enlisted ranks. Our meetings are open to the 
public and we welcome all who want to participate. We have two 
additional advisory members to our committee. These advisors represent 
the Veterans Health Administration organizations in Reno and Las Vegas. 
To date we have submitted an interim report with ten recommendations to 
Governor Sandoval and have a final report due by June 1, 2015.
    We use information from surveys, face-to-face conversations with 
women veterans, presentations from the Nevada Department of Veterans 
Services (NDVS) and the U.S. Department of Veterans Affairs, and our 
own personal knowledge and experiences to develop our recommendations. 
To assist us in our efforts, we also seek information from experts and 
from others who are in positions that allow them to interact with women 
veterans.
    One of the central issues we encountered is the identification of 
women veterans. As of September 30, 2014, the U.S. Department of 
Veterans Affairs (VA) estimated the total veteran population within the 
state of Nevada at 228,027 with 21,362 of those being female veterans. 
But these are just numbers and do not translate to the actual veterans 
within the state. To date, the Nevada Department of Veterans Services 
has identified (by name) approximately 2,500 female veterans or only 
11.7% of the estimated total of women veterans in the state. This 
indicates that the state could do a better job of identifying and 
recognizing our female veteran population. It is difficult to support 
and advocate for women veterans without having contact with a larger 
number of them.
    To help connect veterans with service providers, Nevada has 
implemented a statewide effort, the Green Zone Initiative, which aligns 
operations under three pillars: The Policy Development Pillar, the 
Service Provider Coordination Pillar, and the Connecting to Veterans 
Pillar. According to the Nevada Department of Veterans Services, the 
``Connecting to Veterans Pillar'' presents the single-most difficult 
challenge, especially for our women veterans. Meeting the needs of the 
individual woman servicemember, veteran, or family member requires a 
connection with them, and this cannot occur unless we know where our 
women veterans are. While the Department of Defense and the U.S. 
Department of Veterans Affairs have taken some initial steps to create 
a ``hand-off'' system that helps states know when servicemembers return 
home, much more needs to be done. How can you connect a woman veteran 
to benefits and opportunities their service to our Nation has earned 
them, if you cannot find the veteran? Nevada has undertaken local 
initiatives to learn where our women veterans live, such as the 
identification of veterans' status on driver's licenses, but to truly 
identify our returning servicemembers, better collaboration between the 
Department of Defense and the VA and timely, in-depth information 
sharing with state governments is critically needed.
    Anecdotal evidence indicates that women are less likely to identify 
themselves as veterans than are men. Our committee has made several 
recommendations to try to remedy this situation. First, we endorsed the 
Nevada Department of Veterans Services continuing efforts to develop a 
Veterans Information System to identify veterans throughout the state 
so that all veterans are informed about their available benefits and 
opportunities. Furthermore, we recommended that the State of Nevada 
agencies who collect veteran data add a data collection question asking 
``Have you ever served in the United States Military?'' to their forms/
applications during their next programmed update. This question would 
replace the question ``Are you a veteran?'' Studies have shown that 
many women veterans do not self-identify as a veteran, so asking if 
they have served in the military may ensure their status as a veteran 
is identified.
    Our committee also recommended that Governor Sandoval direct the 
Nevada Department of Veterans Services develop a Strategic 
Communications Plan that includes how to reach women veterans 
throughout the state. One additional recommendation was for the Nevada 
Department of Veterans Services to develop a white paper in 
collaboration with our committee that would inform our legislators and 
state agencies of facts regarding Nevada's women veterans. Such facts 
would include demographics, contributions to national and state 
security, and unique needs of the women veteran population. This white 
paper may help reduce misinformation and improve programming support 
for women veterans.
                               education
    Many women veterans are taking advantage of their education 
benefits within the state. Most, if not all, of the college campuses 
throughout the state have someone on their staff dealing with veterans 
issues. Many of the colleges also have veterans groups on campus. While 
women will always be in the minority within the veteran population, 
women feel more comfortable attending veterans' events when other women 
veterans attend. As there are more women veterans in the Las Vegas area 
than in other parts of the state, a greater percentage of the available 
women veterans participate in veterans' events and clubs at the 
University of Nevada, Las Vegas (UNLV) than participate in other parts 
of the state. Women do not seem to be participating in large numbers at 
the University of Nevada, Reno (UNR) campus due to the smaller number 
of women, as they often are the sole woman attending veterans' events 
and meetings.
    At a recent committee meeting, the UNR Director of Veterans 
Services noted that women are hesitant to join these groups because 
they see the military part of their life as being behind them and women 
veterans would rather move forward with their education toward a new 
career. Some women veterans feel they are better served joining groups 
and attending events that meet their needs. The UNR Director of 
Veterans Services is looking at ways to collaborate with other colleges 
and groups on campus to bring integrated services to women veterans 
rather than stovepiping services solely within veterans' organizations.
    Another UNR initiative is a collaboration with the VA Sierra Nevada 
Health Care System. Through this collaboration, the VA Sierra Nevada 
Health Care System has been able to put a social worker on the UNR and 
Truckee Meadows Community College campuses on a regular basis. The 
enabling mechanism is a program called Veterans Integration to Academic 
Leadership (VITAL). This is a Veteran-centered, results oriented 
collaboration between the VA Medical Center and state higher education, 
whose goal is to enhance academic retention and success. The social 
worker noted that her workload was low initially as veterans seemed 
reluctant to seek out the services of a social worker, but trust has 
grown and she is now quite busy serving veterans on both campuses. It 
is important to note, however, that not a single woman veteran has 
contacted her for assistance.
                               employment
    Unemployment for women veterans is over 8%, which is 20% above 
their male counterparts. Women veterans have unique challenges in 
gaining employment. For example, they are twice as likely to be 
divorced, are more often single parents, and their earnings average 
$6,000 per year less than male veterans. Women veterans also have 
higher military disability ratings in general.
    Women veterans face some of the same challenges as do men in 
translating their military skills into the civilian workforce. This 
will continue to be an issue as the services downsize. State and 
Federal VA agencies, as well as other organizations, continue to assist 
veterans in this area. Helping veterans translate their military skills 
for use in the civilian workforce should be a continued area of 
emphasis.
    As noted earlier, women do not identify themselves as veterans and 
therefore some will not take advantage of career fairs directed toward 
the hiring of veterans. Some women veterans feel uncomfortable in this 
setting, as the majority of the job seekers will be men and many of 
those hiring will expect the veterans they hire to be men.
    Several organizations offer mentoring programs for veterans. 
Mentoring is designed to be a helping relationship where a mentor and 
protege work closely together. Having men mentoring women can be a 
challenge when either the man or the woman feels uncomfortable in this 
relationship. Fewer female mentors are available to assist our women 
veterans although several professional women's' groups do offer 
mentoring services. Mentoring programs should also be a continued area 
of emphasis.
                              homelessness
    Women are the fastest growing segment of the homeless veterans 
population and are more likely to be homeless with children. One in 
five women homeless veterans is typically diagnosed with Post Traumatic 
Stress Disorder (PTSD). There is a link between homelessness and 
military sexual trauma for women veterans.
    The VA has instituted an extensive initiative to eliminate 
homelessness by the end of 2015, which means finding homes for 
approximately 50,000 veterans. But how can we eliminate homelessness if 
we are not properly identifying our women veterans? A 2014 research 
article published in Public Health Reports noted that women and younger 
veterans are at a higher risk of not being identified as veterans among 
the homeless population.
    Homeless women veterans do have unique needs, however, in that they 
often have children. Homeless shelters often do not mix males and 
females. Some shelters place restrictions on the ages of children 
within their facilities. These restrictions place an additional burden 
on homeless women to keep their families together.
    Due to the small number of homeless women veterans in any given 
location, the VA must encourage and support the partnering of Federal, 
state, and local agencies to find space for these homeless women 
veterans.
                              health care
    Overall, the health needs of women veterans are being met within 
the state of Nevada. We have access to Obstetrician/Gynecologist care 
but our committee has recommended that Governor Sandoval communicate 
the need for a full time Obstetrician/Gynecologist at Southern Nevada 
Veterans Medical Center to serve women veterans in the Las Vegas area. 
Within the state of Nevada, most of our veterans are clustered in the 
urban areas of Las Vegas and Reno. We believe tele-health initiatives 
need to be further expanded to better serve women veterans in rural and 
frontier communities outside of these urban areas to reduce the need 
for travel to access medical care and advice.
    Nevada is unique in that we have three VA Veterans Integrated 
Service Networks (known as VISNs) operating within the state boundaries 
while all other states only have one or two VISNs. VISN 19 serves 
Northeastern Nevada, Utah, Colorado, Wyoming, and Montana. VISN 21 
serves Northern California and Northwestern Nevada. VISN 22 serves 
Southern California and Southern Nevada. Having different parts of our 
state belonging to different VISNs has allowed our committee to see 
that each VISN operates differently. The three VISNs serving Nevada's 
veterans conduct business differently, particularly in regard to 
support, events, and celebrations of and for women. While I see a need 
for some flexibility to adapt to the needs of local veterans, some 
services should be standardized across all VISNs. The Women Veterans 
Access to Quality Care Act introduced by U.S. Senator Heller (R-NV) and 
U.S. Senator Murray (D-WA) may go a large way toward accomplishing this 
goal. I thank you for sponsoring this important legislation.
    To date, our committee has not come across any issues with regard 
to mental health care for women veterans. Does this mean that we are 
taking good care of our women veterans or does this mean women veterans 
are not seeking assistance within the VA or not seeking assistance at 
all? Without being able to identify more women veterans and their 
needs, it is difficult to answer this question. Some women who have 
experienced military sexual trauma find it difficult to walk into a VA 
health care facility to seek assistance. This is an area requiring 
further exploration.
                      military sexual trauma (mst)
    Our committee has not spoken to any women who have experienced 
military sexual trauma. Remember that our meetings are open to the 
public and some women veterans who have experienced MST report a 
reluctance to speak in such a forum. Although our committee has not 
spoken to any women who have experienced MST, I did reach out to a 
group of women veterans to try to understand their experiences. One 
woman shared her personal story with me, noting that the children of 
those suffering from Military Sexual Trauma with a subsequent Post 
Traumatic Stress Disorder (PTSD) diagnosis may be the unseen victims of 
military sexual trauma. A PTSD/MST diagnosis allows a veteran a 70% 
disability rating. Often, however, these veterans are unable to work 
and therefore rely solely on this VA benefit. This 70% rating puts a 
family of three below the Federal poverty level. A 100% disability 
rating would enable food, shelter, and heating oil security. Because 
the veteran may be unable to work, they often do not have health 
insurance for their children. Many of these MST victims are single 
parents. When their claims are denied, they are forced to rely on the 
generosity of county and state children's health and mental health 
insurance programs rather than on VA dependent health care benefits. 
These children of PTSD/MST veterans often need to receive mental health 
care due to their parent's disability. Furthermore, these parents with 
PTSD/MST have noted that difficulties with the VA claims process can 
exacerbate their condition. College-age children of these PTSD/MST 
veterans have limited access to affordable higher education. A 100% 
permanent and total disability rating would allow these veterans to 
take advantage of the VA's dependent education benefits. A lack of 
education benefits may contribute to a continuing cycle of poverty for 
these children.
    Based on my discussion with women veterans, I offer the following 
recommendations regarding MST:

          1. Congress should mandate the release, publication, and 
        monitoring of disaggregated data to include the number, age, 
        background, and treatment by geographic VA location and 
        regional office of those women and men being treated for PTSD/
        MST. The data should also include the number of single parents 
        with young children and grandchildren within this population. 
        These children are at risk. When PTSD/MST women veterans are 
        denied access to care, a generation of children bear the brunt 
        of poverty, disability, and lack of access to medical and 
        mental health care. The VA should also look at the population 
        most likely to be outside the system in need of treatment given 
        the rate of MST prevalence within the ranks. The VA should 
        report on grants versus denials in PTSD/MST disability claims. 
        This data may expose critical systemic issues and force 
        accountability. These actions will enable the Veterans 
        Administration to have a complete view of this issue.
          2. Congress should order an immediate review of all PTSD/MST 
        claims currently in the appeals process. In particular, the VA 
        should be directed to review those claims impacted by the 
        backlog (>120 days) and specifically those claims which have 
        undergone more than one review at the Board of Veterans Appeals 
        level. Congress should direct the VA to resolve all cases 
        involving single parents of minor children within the next 6 
        months. The VA should track this review and report progress 
        weekly on the resolution of these PTSD/MST cases.
                               conclusion
    The title of this hearing is ``Fulfilling the Promise to Women 
Veterans.'' I believe the way to do this is to push to identify our 
women veterans and to understand their needs. Committees, such as 
Nevada's Women Veterans Advisory Committee, are a good start and I 
would encourage other states to institute similar committees to better 
understand and support the needs of our women veterans. Our goal is not 
to find fault, but rather to support our women veterans who have served 
and sacrificed.

    Again, thank you for this opportunity to speak with you today.

    Chairman Isakson. Thank you, Dr. Davis.
    Ms. Mouradjian.

             STATEMENT OF CHRISTINA L. MOURADJIAN, 
                       U.S. ARMY VETERAN

    Ms. Mouradjian. Chairman Isakson, Ranking Member 
Blumenthal, Members of the Committee on Veterans' Affairs, it 
is a distinct honor to appear before you today as a military 
retiree and a female combat veteran.
    As a woman veteran, I have a personal stake in seeing that 
the unique issues we face are addressed and addressed properly 
so that future servicewomen do not face the same obstacles that 
this Committee is assembled here to address today. While there 
are many concerns to tackle, I would like to take this 
opportunity to concentrate on the one that has proved most 
difficult in my own life, access to and the quality of care at 
the VA.
    As a patient at the VA, I have received some of the best 
care and from some of the best doctors. However, that 
experience is tempered by the fact that I have also received 
some of the worst care, not only by doctors and care providers, 
but by the system itself.
    For years, I complained to my doctors at the VA of numerous 
symptoms that were summarily dismissed. I was told I was too 
young to have any issues. I was told the basic blood work came 
back normal. The ultimate betrayal, I was told I was not really 
being honest.
    These symptoms worsened and worsened until finally I was 
forced to pursue medical advice out of the VA and on my own. 
Once my blood work and MRIs proved positive for Cushing's 
disease and the brain tumor that caused it, the VA started to 
take me seriously. It is hard to argue when you are staring at 
an MRI with a big white mass in the middle of someone's head. 
But, the years of suffering, both physically, mentally, and 
emotionally, that I had to endure in order to get someone just 
to listen is not something I would wish on anyone and something 
that should not happen to any veteran.
    The road to recovery for Cushing's patients is not easy. 
There are countless tests and months of observation and the 
inevitable brain surgery. There are the frequent visits to 
endocrinology, neurology, the ENT. The list is very long. But, 
what complicates this is that at the VA, you may never see the 
same doctor twice. Not only do you have to repeat your story to 
every specialist under the sun, you have to repeat it to a 
revolving door of white coats who are hearing it for the very 
first time, or even worse, the specialist you may need to see 
may have left and it may be months before a new one is found 
and you can even get an appointment. I know this because I have 
lived it.
    While I was stated at New York City, I had to travel to 
three separate VA facilities in three separate boroughs because 
no one facility had all the specialists I needed. For allergy 
treatments alone, I had to travel from Brooklyn to the Bronx, 
sit through what could easily be hours in traffic and $30 in 
tolls for a 15-minute appointment.
    Coordination of care is essential in any system that aims 
to treat the whole person, and at the VA, the system is 
counterproductive to enabling this process. Prior to my brain 
surgery, which the VA only did on the second Tuesday of every 
month, my surgery date was canceled three separate times. Three 
separate times, I prepped. I had family travel down from Rhode 
Island and take off work, as I could not be left alone for the 
first few days of recovery. Three separate times, I was told 
another case was more important, they could not get all the 
required doctors in the same room together, or that the doctors 
did not have a chance to review my case. They would have 
canceled the fourth time had I and my family not contacted the 
patient advocate and voiced our complaints boisterously.
    After brain surgery, there were other nightmares. There was 
the MRI in which the attendant, rushing because I was the last 
patient before she could leave for the day, did not remove the 
metal nodes from my body, and too weak to squeeze the panic 
button because my arm was sewn to a stabilizer in order to keep 
the PIC line in, I could do nothing but weep silently while the 
metal nodes burned welts into my skin.
    There was the resident doctor who had not researched my 
disease before morning rounds, and not knowing the main 
symptoms of Cushing's is weight gain could not tell if I was 
presenting because, quote-unquote, ``I was too heavy.'' It is 
hard to have faith in a system when you know more about your 
condition than the doctors who are supposed to be treating you.
    Navigating the VA can be daunting, and even more so as a 
female veteran. The women's clinic is often well segregated 
from the rest of the facility. Oftentimes, you have to traverse 
to the basement of the hospital, next to the lab, to find it. 
And, once you get there, it is obvious that it is an 
afterthought. As a resident of Ranking Member Blumenthal's 
district in Connecticut, he knows well of what I speak.
    Perception is part of the issue. For women veterans to feel 
like they belong, they need to know that their care is just as 
important as their male counterparts. They need to trust that 
their care providers, and they need to know that their care is 
a priority.
    In the past few years, I have seen with my own eyes the 
VA's renewed commitment to women's health, and while I am 
heartened to see these changes, I know that more needs to be 
done. Female veterans need quality health care now and they 
need to be confident in that care so they are not afraid to 
access it.
    I thank you for your time this afternoon and the 
opportunity to appear before the Committee. I thank you for 
allowing me to share my story, but remind you that my story is 
not unique. There are countless women veterans that have 
endured far worse than me, and it is for them that I am here 
today. Thank you.
    [The prepared statement of Ms. Mouradjian follows:]
   Prepared Statement of CPT Christina L. Mouradjian, U.S. Army (Ret)
    Chairman Isakson, Chairman Blumenthal, Members of the Committee on 
Veterans' Affairs, It is a distinct honor to appear before you today as 
a military retiree and a female combat veteran.
    As a woman veteran, I have a personal stake in seeing that the 
unique issues we face are addressed, and addressed properly, so that 
future service women do not face the same obstacles. And while there 
are many concerns to tackle, I would like to take this opportunity to 
concentrate on one of the obstacles that has proved most difficult in 
my own life--access to and the quality of care at the VA.
    As a patient at the VA, I have received some of the best care, from 
some of the best doctors, however that experience is tempered by the 
fact that I have also received some of the worst care not only by 
doctors and care providers but by the system itself.
    For years I complained to my doctors at the VA of numerous symptoms 
that were summarily dismissed; I was told I was too young to have any 
issues, I was told the basic blood work came back normal, and the 
ultimate betrayal, I was told I was not really being honest. These 
symptoms worsened and worsened, until finally I was forced to pursue 
medical advice out of the VA on my own.
    Once my bloodwork and MRIs proved positive for Cushing's disease 
and the brain tumor that caused it, the VA started to take me 
seriously, it's hard to argue when you're staring at an MRI with a big 
white mass in the middle of someone's head. But the years of suffering 
both physically, mentally and emotionally that I had to endure in order 
to get someone to listen is not something I would wish on anyone, and 
something that should not be happening to any veteran.
    The road to recovery for Cushing's patients is not easy, there are 
countless tests and months of observation and then the inevitable brain 
surgery. There are the frequent visits to Endocrinology, neurology, the 
ENT, the list is long. But what complicates this, is that at the VA you 
may never see the same doctor twice. So not only do you have to repeat 
your story to every specialist under the sun, you have to repeat it to 
a revolving door of white coats who are hearing it for the first time. 
Or even worse, the specialist you may need to see may have left and it 
may be months before a new one is found and you can get an appointment. 
I know this because I have lived it.
    While I was stationed in NYC, I had to travel to three separate VA 
facilities in three separate boroughs because no one facility had all 
the specialists I needed. For allergy treatment alone I had to travel 
from Brooklyn to the Bronx, sit through what could easily be over an 
hour in traffic and $30 in tolls, for a fifteen minute appointment.
    Coordination of care is essential in any system that aims to treat 
the whole person, and at the VA the system is counterproductive to 
enabling this process. Prior to my brain surgery, which the VA only did 
on the second Tuesday of every month, my surgery date was canceled 
three separate times. So three separate times I prepped, I had family 
come down and take off work as I could not be left alone for the first 
few days of recovery, and three separate times I was told another case 
was more important or that they could not get all the required doctors 
in the same room together, or that the doctors did not have a chance to 
review my case yet. They would have canceled the fourth date also had I 
and my family not called the patient advocate and voiced our 
complaints.
    After brain surgery there were other nightmares. The was the MRI in 
which the attendant, rushing because I was the last patient before she 
could leave for the day, did not remove the metal nodes from my body, 
and too weak to squeeze the panic button, because my arm was sewn to a 
stabilizer in order to keep the pic line in, I could do nothing but 
weep silently while the metal burned welts into my skin. There was the 
resident doctor who had not researched my disease before mourning 
rounds and not knowing the main symptom of Cushing's is weight gain 
said he could not tell if I was presenting because I was so heavy. It's 
hard to have faith in a system when you have read more on your 
condition then the doctors who are supposed to be treating you.
    Navigating the VA can be daunting, and even more so as a female 
veteran. The women's clinic is often well segregated from the rest of 
the facility. Often times you have to traverse to the basement of the 
hospital next to the lab to find it, and once you get there it is 
obvious that it is an afterthought. Perception is part of the issue. 
For women veterans to feel like they belong, they need to know that 
their care is just as important as their male counterparts. They need 
to trust their care providers and they need to know that their care is 
a priority.
    In the past few years, I have seen with my own eyes the VA's 
renewed commitment to women's health, and while I am heartened to see 
these changes, I know that more needs to be done. Female veterans need 
quality health care now and they need to be confident in that care so 
they are not afraid to access it.
    I thank you for your time this afternoon and the opportunity to 
appear before the Committee. I thank you for allowing me to share my 
story but remind you that my story is not unique, there are countless 
women veteran's that have endured far worse than me, and it is for them 
that I am here today.

    Chairman Isakson. Well, thank you, Ms. Mouradjian. Your 
story is compelling, and I want to follow up on your last 
sentence as my first question.
    You said you are not an isolated case and you referred to 
many, many women who had similar cases, obviously not with 
Cushing's, necessarily, but with other complications. Would you 
elaborate on that for just a minute?
    Ms. Mouradjian. That is correct. I know myself and several 
of my friends in the service have had a hard time just either 
accessing care or getting doctors to listen to the particular 
issues that are unique to them. Particularly with mental health 
issues, there is oftentimes lack of a response to women, just 
one of the big issues is getting a female provider.
    I know a lot of the female veterans that I have served with 
do not necessarily feel comfortable telling their story to a 
male, who might not be able to sympathize with what they have 
gone through just as a woman in general. The physical issues 
aside, some of the very delicate issues that we face as women, 
we are just not comfortable sharing those with a male.
    One of the biggest hurdles is just being able to get access 
to a provider and feeling comfortable enough to get the help 
they need.
    Chairman Isakson. That actually is the point I was going to 
lead up to. One of the things we are looking at in the Veterans 
Choice bill, we had two issues. One was the 40-mile rule, which 
we have dealt with; and the other was the nearest to care the 
veteran needs. In your particular case, you had a very 
specialized need. Cushing's is a rare condition, is that not 
correct?
    Ms. Mouradjian. It is very rare.
    Chairman Isakson. Obviously, the VA was not prepared 
initially either to diagnose or recognize it. Is that correct?
    Ms. Mouradjian. That is correct.
    Chairman Isakson. Yet, you had enough symptoms to know 
something was still wrong and you needed care. Was that the 
case?
    Ms. Mouradjian. Yes.
    Chairman Isakson. Did you ever consider going anywhere for 
a second opinion outside of the VA, or were you limited and not 
able to do that on your own?
    Ms. Mouradjian. No, I am fortunate enough that my mother is 
in the medical field, so I did have an advocate in my corner 
who had enough background to guide me. So, I had personal 
resources in my life that could verify that the treatment I was 
getting at the VA was actually, after I was diagnosed, 
sufficient to deal with it.
    Chairman Isakson. But, without the advocate, you may have 
never gotten to that care. Is that correct?
    Ms. Mouradjian. Absolutely.
    Chairman Isakson. That is my point. I see the VA folks are 
staying for the rest of the hearing, which I appreciate you all 
staying for. There is a message in this story to us. Obviously, 
there are things we can do to help make sure that you go from 
lack of diagnosis or misdiagnosis to appropriate diagnosis and 
there is an ombudsman to help you along the way. You were 
fortunate enough to have a mother to do that, but a lot of our 
women veterans are not. I think it is important we recognize 
there ought to be some way for communication or ombudsmanship 
to be available to the veteran who thinks they need the service 
and the care.
    Ms. Ilem.
    Ms. Ilem. I would just like to follow up. I think that is a 
great idea. I think with the cultural transformation that 
Secretary McDonald is trying to implement throughout the 
system, there needs to be a specific line for women veterans, 
you know, to take on this role. I know VA has lost some of 
their lead Women Veteran Program managers throughout the 
system. I mean, they have been critical over the years when I 
have had a problem. When a woman veteran calls and I call the 
Women's Veterans Health Service, they are right on it. They 
want to know. They want to help. But, they have to have the 
staff out there of somebody leading that understands these 
particular issues.
    Chairman Isakson. I would like for you to consider this an 
order from the Committee, for you to submit to us some ideas 
that you think might help facilitate exactly that.

    [The information requested during the hearing follows:]
 Response to Request Arising During the Hearing by Hon. Johnny Isakson 
       to Joy J. Ilem, Deputy National Legislative Director, DAV
    In testimony before the Senate Veterans' Affairs Committee on 
April 21, 2015, DAV recommended that the Committee and the Department 
of Veterans Affairs (VA) take legislative and policy actions, 
respectively, based on dozens of recommendations contained in our 2014 
report, Women Veterans: the Long Journey Home. After acknowledging the 
importance of our report, the Chairman indicated the Committee would 
appreciate receiving further information about DAV's priorities for 
specific legislation or other actions that would aid women veterans. 
While the report speaks for itself, and all of the recommendations are 
important, at the request of the Chairman, we outline some associated 
topics that need to be addressed by Congress and the VA.
    Given that women veterans are turning to VA in record numbers, 
especially young women veterans, now is not the time to retrench VACO 
positions in this crucial program. At times of retrenchment, VACO 
generally tends to fall back on the inevitability of random attrition 
to meet its personnel reduction goals. In our view, and especially 
because this technique dramatically affects the women's health program 
across the VA system, this is unwise policy. If personnel restructuring 
is required, VHA should develop its plans in a more strategic manner. 
At a time of unprecedented growth in the number of women veterans 
enrolling in VA health care, we believe the women's health program 
should be enhanced with additional personnel, not be allowed to shrink 
along with other VACO programs as if no negative outcomes would occur.
    The women veterans health program at VA is led by a capable but 
very small staff. One key position, that of Deputy Director for 
Reproductive Health, is now vacant. Also, one of three authorized 
Deputy Field Director positions in women's health is now vacant. 
Because these positions are journalized to VA Central Office (VACO), 
they are caught in the ongoing hiring freeze affecting all VACO 
personnel.
    Also in VA Central Office, we believe the Center for Women Veterans 
is in need of a program analyst to collect and analyze relevant data on 
women veterans. VA should take action immediately to identify suitable 
candidates for this important program management position. Without the 
ability to collect and analyze data (among the functions of this 
position), the Center is challenged to know whether VA's numerous 
programs for women veterans are meeting their responsibilities and 
intended outcomes.
    Secretary McDonald announced the VA system is reorganizing through 
the advent of five new entities he has described as ``districts.'' 
These districts when formed will integrate all VA missions, whether in 
health, benefits, memorial affairs or other VA activities. Given the 
growth rates of women seeking VA services of all kinds, DAV believes 
each district, each Veterans Integrated Service Network, and each VBA 
equivalent office should be staffed with full time women's coordinators 
or program managers. Also, at the local medical center level, DAV 
believes VA should deploy one or more women's peer support specialists 
in an expansion of the existing peer support and counseling concepts VA 
has advanced in recent years. These peers could serve women veterans as 
guides and coaches to introduce them to VA health care and key women's 
health staff, help them navigate the system and to pave the way for new 
women veterans to have a more positive experience in their contacts 
with VA.
    Most if not all of these essential actions to improve services for 
women veterans could be taken by VA without enactment of new 
legislation. With the strong support and determined oversight of the 
Committee, however, we believe VA might be encouraged to address these 
unmet needs as a higher priority.

    Chairman Isakson. Ms. Mouradjian, anything you might have 
to give this Committee information-wise to help us understand 
how we could avoid having the situation that happened to you. I 
am just going on here, and I ask the Committee to pardon me for 
going over a little bit. It seems to me that you had a 
different doctor every time you went to the VA, plus you 
mentioned coordinated care. I am a big advocate for seniors, 
which I fall into that category. You are a woman, I am a 
senior. We need coordinated care, too, because we have unique 
needs, just as women do. I think the fact that you had to see a 
different physician each time, or a different specialist each 
time, you lacked the continuity that you really need to care 
for something, particularly something as dangerous as 
Cushing's. Would that be correct?
    Ms. Mouradjian. That is correct, and one of the issues was 
the doctors would often communicate very hastily through e-mail 
or try to get each other on the phone. There was not 
necessarily a chance for them to consult each other on a more 
thorough basis. Obviously, the system has constraints, but when 
you are dealing with brain surgery and something that serious, 
you would hope that your doctors would have had an ample 
opportunity to actually get together and consult your case.
    Chairman Isakson. That actually magnifies the point I was 
going to close with. You said at the outset of your testimony 
that you really had no issue with the quality of care that you 
had received, that you had, in fact, received excellent quality 
of care, except for the fact you were never really believed or 
accepted. You continued to tell them that you felt you had 
problems, even though they said the blood work they had done 
did not indicate it. The frustration, the lack of seeing the 
same doctor twice, three times, or four times to follow your 
case probably led to some of that misunderstanding between the 
VA and yourself.
    I would think there is a lesson to be learned, not that it 
is an indictment of the quality of care, but it may be an 
indictment of the system of care and the continuity of 
information that you, the patient, and the VA have over your 
particular case.
    Ms. Mouradjian. I am sorry. I would agree with you. I think 
one of the issues is, oftentimes, I was not seen as a veteran. 
I know in the ICU after brain surgery, several times, a care 
provider would be surprised that I was in the bed and I would 
hear the comment, ``Oh, we were expecting a vet.'' To them, I 
think the perception is a veteran is an older male. Because 
they had that perception, sometimes you are just not taken 
seriously.
    Chairman Isakson. We appreciate your service to the country 
and we appreciate your testimony today. Thank you very much.
    Ranking Member Blumenthal.
    Senator Blumenthal. Thanks, Mr. Chairman, and thanks for 
giving me the opportunity to invite Ms. Mouradjian to be here 
today.
    I am familiar with your story, but I want to make sure that 
as much as possible of it is in the record, because my other 
colleagues who were not here today or who may be unfamiliar 
with that very impressive story should also learn about it, and 
I appreciate the Chairman's questions to you.
    I just want to clarify that you actually had to seek help 
outside the VA simply to get a diagnosis of a problem that was 
bothering you for some time, is that correct?
    Ms. Mouradjian. That is correct. I went to a doctor that I 
knew back home and described the symptoms to him, and he did 
some blood work and it really only took one test. It was pretty 
immediate after the blood work was ordered.
    Senator Blumenthal. If I were your mom or your parent, or 
if you were one of my two sons who has served in our military, 
one in the Marine Corps Reserve, the other in the Navy, my 
opinion would be--and I would be angry about it--that the VA 
failed you.
    Ms. Mouradjian. My mother was very irate, yes.
    Senator Blumenthal. It was more than just the revolving 
door of white coats. It was the delay of the surgery, by my 
calculation, at least 3 months, because they only do the 
surgery on the Tuesday of 1 month; hence, your surgery for a 
very dire, potentially dangerous condition was delayed month 
after month after month. Is that correct?
    Ms. Mouradjian. That was one of the complications--because 
it is so rare, it is seen as an opportunity, I think, by the 
specialists in the community to observe. For the patient, 
obviously, the only cure is surgery, so you want to have that 
immediately. But, I do realize that doctors, because of the 
rarity, wanted to sort of just test me and collect some data. 
Unfortunately, at the VA, one of the other complications is 
oftentimes there is a protocol. You are not necessarily allowed 
to be involved in your own care and make the choices that you 
think is appropriate for your own care.
    Senator Blumenthal. When, in fact, involvement of patients 
in care, listening to the patient, is one of the preeminent 
principles of modern health care. I am not asking you as an 
expert, because you are not a doctor, but I will say it for the 
record that most good doctors will tell you, listen to the 
patient and heed what he or she has to say.
    You seem fine now, is that correct?
    Ms. Mouradjian. I am, thank you.
    Senator Blumenthal. Tell us what you are doing at this 
point.
    Ms. Mouradjian. Currently, I work at Sikorsky Aircraft 
Corporation in the legal department. I actually received my law 
degree right after commissioning and I am a productive member 
of the workforce. I think I would like to be an example that 
you can be a veteran, you can be a disabled veteran, but you 
can still be productive and contribute.
    Senator Blumenthal. I can tell you, my impression is from 
what I have heard about your work that you are more than just 
productive. You are very exceptional, an expert at what you do. 
I thank you for your service to our Nation in the military, and 
I thank you for your service now.
    Dr. Davis and Ms. Ilem, what is your reaction to this 
story?
    Ms. Davis. It is obviously disappointing, sir, to hear 
stories like that.
    Senator Blumenthal. Let me be a little more precise, in 
fairness to you, rather than just asking you such an open-ended 
question. Do you know of similar stories?
    Ms. Davis. I have heard some women's stories where they 
have not felt comfortable with the diagnosis they have received 
and they have sought help elsewhere. But, I would say that for 
the most part, the women that I know that are receiving medical 
care through the VA system are fairly happy with that care. 
But, I would also say they have not experienced what Captain 
Mouradjian has experienced, as well.
    Senator Blumenthal. Similar delays?
    Ms. Davis. There have been some delays. I have heard of 
surgeries being delayed on a couple of occasions. Again, I 
believe they are isolated incidents, but it does occur.
    Senator Blumenthal. Thank you, and thanks for your work in 
Nevada as a member of the Advisory Committee.
    Ms. Ilem, thank you for your work on behalf of disabled 
veterans. What is your reaction? Do you know of similar 
stories, delays, seeking treatment outside the VA system, and 
so on?
    Ms. Ilem. Well, I would like to say first that I have been 
a patient of the VA health care system for over 20 years and I 
have seen tremendous progress and a reinvigoration of--real 
hope there that we are going to be getting the best care 
anywhere. That is, I think, from DAV's point, we really want to 
make sure that women veterans can take advantage of the VA 
health care system and all that it has to offer.
    Dr. Hayes and her staff have done an outstanding job over 
the past 6, 7, 8 years that I have known her. I have seen them 
using the research and really making progress for the first 
time. That is so essential. For the patient care coordination, 
making sure that what has happened does not happen to anyone 
else and making sure VA recognizes our women veterans.
    I would say specific to women, I have heard a number of 
things from DAV members that have called with regard to 
prosthetic items. One of our members talked about needing a 
knee replacement and was told they were not going to order the 
prosthetic hardware that would be used in the surgery. They 
would not use one for women. They would just use the same that 
they do for men, when there was a specific opportunity for them 
to do that. You know, things like that just should not be 
happening. They need to have that sensitivity to women. They 
need to know the products, the items, whatever is needed for 
women needs to be there, even if they are in small numbers.
    Senator Blumenthal. Thank you very much.
    Chairman Isakson. Senator Heller.

    Senator Heller. Thank you, Mr. Chairman. Again, thanks to 
the witnesses for being here today.
    Dr. Davis, I have, of course, traveled throughout the State 
and recently had a roundtable. Numerous VSOs were present 
representing men and women veterans. But, I think there are a 
couple of themes in today's hearing, and one of them being, in 
fact, that a lot of combat veterans do not consider themselves 
to be veterans. I never got a specific number. Somewhere 
between 14,000 and 27,000 female veterans in the State of 
Nevada, and you gave a specific number. I am wondering why the 
VSOs do not know these numbers but you do.
    Ms. Davis. Sir, I am getting the information from the VA 
Web site, and so I do not know how accurate that information 
is, as well. I guess it is an estimate. It is a moving target. 
Veterans come into the State every day. Veterans leave the 
State every day. It is a snapshot in time. Those were the best 
numbers that I had available to me. I think they are 
illustrative, if nothing else. They might not be exactly 
accurate.
    Senator Heller. I am assuming you talk about outreach all 
the time. What more can the VA be doing to try to identify who 
and where these veterans are?
    Ms. Davis. It is a great point, sir. I think one of our key 
issues is identifying who these women veterans are, and one of 
the things that we have heard, and I think you heard down in 
Las Vegas, as well, is that women do not often call themselves 
a veteran. And, when you ask them if they have served in the 
military, they will say, yes, I have served.
    Senator Heller. Right. You mentioned that in your opening 
statement.
    Ms. Davis. Yes, sir. Maybe we are asking the wrong 
question. If we can understand who has served in the military, 
then we can connect them to their veterans' benefits, even if 
they do not personally self-identify themselves as veterans.
    Senator Heller. So, instead of asking them if they are a 
veteran, ask them if they have served in the military.
    Ms. Davis. Yes, sir. I think it would go a long way toward 
identifying more of our women veterans.
    Senator Heller. Thank you.
    Captain Mouradjian, do you feel that the VA failed you?
    Ms. Mouradjian. I feel at a certain moment in time, yes, 
they did. Right now, I am receiving excellent care. I cannot be 
more pleased with the care I am receiving in Connecticut. My 
doctors are very responsive. They are available to me. I can 
contact them when I need to. That is why I state in my 
statement I recognize that there has been a shift in the care 
and the VA's responsiveness to women's issues.
    Senator Heller. Do you think your experience was an 
aberration, or do you think it was a common occurrence?
    Ms. Mouradjian. I think it was a culmination of several 
factors, the rarity of my condition. You know, I was in my late 
20s at the time, so I necessarily was not seen as someone who 
would get sick. I do not think it is endemic of the system as a 
whole. I think it was more of an isolated case, but at the same 
time, still a failure.
    Senator Heller. Captain, in your day-to-day work, you 
probably meet up with other women veterans. Do they share 
similar stories with you?
    Ms. Mouradjian. They do. One of the biggest issues is they 
do not even know what is available at the VA. I like to share 
what is available because I think it is important that they 
have access to the services. I think the major complaint is 
they just do not know what is there.
    Senator Heller. Do you believe that services for women 
veterans are inferior to services to male veterans?
    Ms. Mouradjian. I believe they are getting better, sir. I 
do not believe they are at the same level yet. I do believe 
that there is a concentrated effort. I know that every time I 
go to the VA--I just went last week--the women's coordinator, 
when I checked into my appointment, made it a point to come out 
and introduce herself to me and tell me she was available 
should I need anything. I realize that I am more vocal an 
advocate for my own health than maybe most veterans, but I do 
know that in the time that I have been receiving VA care, there 
has been a marked increase just in the VA's involvement.
    I completed the survey when they called me 2 weeks ago 
because I think it is important to give my feedback. Before 3 
weeks ago, I do not think I have ever gotten a call for a 
survey before. I do believe that the response is increasing.
    Senator Heller. Captain, thank you for sharing your story 
with us and thank you also for your service.
    Ms. Mouradjian. Thank you, sir.
    Senator Heller. Ms. Ilem, when was the last time the VA 
conducted a comprehensive study on hospitals to determine 
whether or not they are meeting the needs of women veterans?
    Ms. Ilem. There was a GAO study in 2009 that did sort of an 
overlook of VA services and programs, but I know the VA itself 
in the Women's Health Service uses a private vendor to do some 
evaluation, and I think that would be important for the 
Committee to see the results of those visits that they are 
doing to really look for deficiencies. They have laid out a 
great plan. Their policies are where they should be, but----
    Senator Heller. Is that current? Are you saying this is 
current?
    Ms. Ilem. Yes. They have been doing that the last several 
years.
    Senator Heller. OK.
    Ms. Ilem. But, 2009 is the last GAO study that has been 
done, and I think it would be warranted to see where VA has 
come in terms of that last evaluation they did.
    Senator Heller. Do we know when that will be readily 
available? When will that report be available?
    Ms. Ilem. I am recommending that they do a follow-on study 
from 2009. But, VA has some internal data that may be of 
interest to the Committee.
    Senator Heller. OK. Mr. Chairman, if we can get access to 
any of that data or information, I think it would be very 
helpful for this Committee. Ms. Ilem, thank you.
    Chairman Isakson. My Staff Director will follow up on that 
request.
    Senator Heller. Thank you.
    Chairman Isakson. Thank you very much.
    Senator Hirono.

          HON. MAZIE HIRONO, U.S. SENATOR FROM HAWAII

    Senator Hirono. Thank you, Mr. Chairman. I particularly 
want to thank you for focusing on whether we are keeping our 
promises, as indicated in the hearing notice, to our women 
veterans. I think that we should look at the particular issues 
as they confront women veterans, and I want to thank our 
witnesses for being here.
    One of the issues that confronts our work with veterans is 
that it is not easy to find them, whether they are women 
veterans or men veterans. I am finding that to be the case in 
Hawaii and I would think that that is an issue elsewhere.
    I think Ms. Davis or Ms. Ilem, you mentioned that there 
should be better collaboration between the DOD and the VA, and 
perhaps the right questions should be asked. I was wondering, 
since there is an entire process for the active duty people to 
get the information that they need regarding VA regarding the 
G.I. Bill and all of that before they muster out, why can they 
not get a tamper-proof card, for example, that indicates or 
that attests to their service that can just be then taken to 
the VA?
    Ms. Ilem. I think one of the things that they are doing is 
trying to enroll people right at the sites when they are coming 
off active duty, especially for Guard and Reserve, as far as we 
have understood. They try to really make available, and I am 
sure, you know, pamphlets and information. You are saying a 
specific card for them to just be able to----
    Senator Hirono. Yes, so that we do not have to find them 
after they have already gotten out.
    Ms. Ilem. Mm-hmm. Yes, I think the Transition Assistance 
Programs are trying to educate them. One of the things the DAV 
found in the report is that, oftentimes, veterans are not ready 
to intake information at the time of their out-processing----
    Senator Hirono. Oh, I know.
    Ms. Ilem [continuing]. So, they leave----
    Senator Hirono. I have heard those.
    Ms. Ilem. So, there needs to be follow-on.
    Senator Hirono. But, something like an ID card, something 
that is akin to an ID card is not something that you would 
normally just toss aside----
    Ms. Ilem. I see.
    Senator Hirono [continuing]. I would think. That may be 
another way for us to locate the veterans. I really think that 
once they are out of the system, out of the active duty system, 
it is really a challenge to find them.
    Ms. Ilem. I know with the OEF/OIF population, they have had 
a high rate of those, especially women veterans, about 57 
percent of women veterans who served and separated from OEF/OIF 
have come to the VA system for care or enrolled and users of 
the system. That is a pretty high rate, and they might look at 
that for these follow-ons that they are doing----
    Senator Hirono. A model.
    Ms. Ilem [continuing]. To make sure they locate them. I 
believe they went through DOD to get Social Security numbers or 
tracking of where to send them a letter.
    Senator Hirono. I think we should make it as simple as 
possible for people who are transitioning from active duty to 
veteran status to be able to access the information. I realize 
that the TAP program is there, but there are some concerns 
about whether or not all of that information in the last month 
or so is really being taken in. That is also an issue.
    Now, Secretary McDonald has said that he would like to 
eliminate homelessness in veterans by 2015 and I am wondering 
whether any of you are familiar with how the homelessness issue 
is being addressed with regard to women veterans, since I 
believe you testified that there is a higher chance of women 
being homelessness than men. Are they doing anything special to 
deal with homelessness among women veterans?
    Ms. Ilem. I think just within VA, because of the small 
percent and the statistical minority of women, only about 7 
percent out of the six million veterans that VA treats, it is 
always difficult and a challenge with women veterans. That is 
one of the things that is so important, is for each program 
office, including the Homeless Program Office, to be working in 
coordination with the community, with their Women Veteran 
Program managers, with the State agencies, all trying to circle 
around women veterans to make sure prevention, if possible, 
obviously, first, but when they do have a woman veteran that 
shows up, that they are going to have some sort of services for 
that person and get them immediate intake and housing.
    Senator Hirono. Especially if there is a higher percentage 
of them, one, being homeless, two, having employment issues, 
and three, having children.
    Ms. Ilem. The risk factors, right.
    Senator Hirono. Yes. Ms. Davis, you noted that Nevada has a 
Women's Veterans Advisory Committee. That sounds like a really 
great idea, that there is an advocacy group, people coming 
together to focus on specific issues. Do you know if other 
States have similar----
    Ms. Davis. We have been talking to some other States and we 
have heard about other groups similar to that, but I would 
certainly encourage other States to institute such committees. 
I think it has been very helpful. It has been enlightening to 
us to hear from women throughout the State and learn about the 
issues.
    Senator Hirono. Good. I am going to check to see if Hawaii 
has one like that.
    Regarding military sexual trauma, do you know what 
percentage of women who serve in the military have experienced 
MST, anybody?
    Ms. Davis. I know VA just testified, maybe before you came 
in, I think it was at the 25 percent rate of women in VA who 
have screened positive for MST.
    Senator Hirono. Those are the women who are actually 
accessing the system. I have a feeling it might be a higher 
percentage. Are any of you familiar with the VA special lane to 
process MST claims?
    Ms. Ilem. I am aware of that.
    Senator Hirono. Do you know if it is working?
    Ms. Ilem. I have heard that it has been. We were very 
pleased that Under Secretary Hickey instituted it; really went 
back and looked and saw that those claims for MST-related 
conditions were being processed at a lower rate for PTSD. They 
went back and did training, re-education of their adjudication 
officers, and then developed these fast track or lanes for 
people who really specialize and look at those cases 
frequently. We have heard good reports from that.
    Senator Hirono. Good. Thank you.
    Thank you, Mr. Chairman. My time is up.
    Chairman Isakson. Thank you, Senator Hirono.
    Senator Boozman.

         HON. JOHN BOOZMAN, U.S. SENATOR FROM ARKANSAS

    Senator Boozman. Thank you, Mr. Chairman, and thank you all 
so much for being here. It is so important for you to come and 
share your real-life stories.
    I am working with Senator Tester on the Homeless Vets 
Reintegration Reauthorization Program, and that includes 
homeless women veterans with children, trying to get those 
programs reauthorized. One of the problems that we have is that 
if you are homeless and then we provide shelter for you, 
provide a home for you, then you lose benefits that would make 
it such that it would break the cycle, in other words, getting 
you the skills that you need to actually be able to make a 
living wage.
    Can you all comment about that, the importance of trying to 
get, like I say, getting people not homeless, but again, at the 
same time, when they are in that shelter, in that home, 
providing the resources that they need so that they can get 
themselves in a situation where they can provide for themselves 
and their families. Yes, either one or all.
    Ms. Davis. I think that is critically important, because 
you have to have that coordinated effort, because between 
getting them a home so that they have some stability in the 
short term, but you need that longer-term stability that the 
employment is going to provide, and that may require the skills 
and training needed in order to find that right job for that 
person in that particular situation. Then, again, it is 
exacerbated by the fact that many homeless women are also with 
children with them and child care seems to be a critical issue 
for these women.
    Senator Boozman. That is a good point.
    Ms. Ilem. I think the awareness, as has been mentioned, 
making sure that women are aware of what services VA has to 
offer them. Their homeless programs are second to none. They 
have an array of benefits and services, especially for 
employment, sustained employment, and to really support them 
through the process, that transitional process, if they are 
suffering with because of their disability, mental health 
issues, substance use disorder, and they have those wrap-around 
services.
    We really want to make sure that women do not get 
discouraged. If they show up and for some reason they do not 
have an opportunity with the community to have a place for them 
and their children to stay together, we have often heard they 
walk away and they look elsewhere, and that is a disadvantage 
to them.
    Senator Boozman. Very good. That is very helpful. Again, 
thank you all so much for being here and we appreciate your 
service to your country.
    Thank you, Mr. Chairman.
    Chairman Isakson. I would like to thank the Members for 
their attendance and their participation. Thanks, Senator 
Heller, for bringing this to our attention early on.
    I thank our witnesses for being here. Again, Ms. Mouradjian 
and all the others here, thank you for your service to the 
United States of America and we appreciate your service to 
veterans today. We want to be a conduit and an asset for all of 
you to come back to us as we improve the plight of women in 
veterans health care and we look forward to hearing from each 
of you whenever you have something for us.
    Thanks to the members of the VA who came and testified. I 
will report that you all did a great job. Thank you for being 
here.
    This meeting stands adjourned.
    [Whereupon, at 4:14 p.m., the Committee was adjourned.]

                            A P P E N D I X

                              ----------                              


    Prepared Statement of Monique Spillman, M.D., Ph.D., FACOG, The 
          American Congress of Obstetricians and Gynecologists
    Chairman Isakson, Ranking Member Blumenthal, and distinguished 
Members of the Senate Veterans' Affairs Committee, Thank you for giving 
the American Congress of Obstetricians and Gynecologists (ACOG), 
representing more than 58,000 physicians and partners in women's 
health, the opportunity to submit our written testimony for your 
hearing on Fulfilling the Promise to Women Veterans.
    I am a Fellow of ACOG, subspecializing in gynecologic oncology, and 
am the former Chair of ACOG's Committee on Ethics. Prior to my current 
position as a gynecologic oncologist with Texas Oncology, I was an 
Associate Professor at a large academic hospital in Colorado. While in 
Colorado, I received regular referrals from the VA in Denver as well as 
other Western Mountain States.
    Military service is associated with unique risks to women's 
reproductive health. As increasing numbers of women are serving in the 
military, and a greater proportion of United States Veterans are women, 
it is essential that ob-gyns are aware of and well prepared to address 
the unique health care needs of this demographic group. At the same 
time, it is equally essential that women Veterans have access to 
quality primary and specialty care provided by ob-gyns.
    Many Veterans Health Administration (VHA) sites have specialized 
women's health clinics and services available to provide care for women 
Veterans either on site or through referrals to non-VA health care 
providers. While I applaud the VHA's Women's Health Services efforts to 
expand access to and improve the quality of care available to women 
Veterans, there is still room for improvement.
    During my eight years in Colorado receiving referrals for 
gynecologic oncology from VAs in several states, it was not uncommon 
for women Veterans to have been delayed in being referred to specialty 
care. The women I saw described experiences of having to ask repeatedly 
to be referred to a specialist, and in multiple cases, by the time I 
saw these patients, it was clear that their delayed access to specialty 
care had a negative impact on their long-term health. Additionally, 
women Veterans whom I had identified as ideal candidates for enrollment 
in clinical trials would either not be permitted to enroll by the VA, 
or would face significant delays, in some instances missing a key 
window for certain treatment.
    Research regarding women Veterans has increased significantly over 
the past two decades. And, though limited in scope, we have learned 
some valuable information about this population, particularly the 
greater physical and psychiatric morbidity and diminished social 
support of these women compared with their civilian counterparts. We 
need to do better by our women Veterans, and a good first step is to 
improve access and seamless referral to women's health providers--both 
general ob-gyns and subspecialists like gynecologic oncologists and 
urogynecologists.
    One area where the VA excels is in screening for military sexual 
trauma. This screening is mandated by the VA for all Veterans seen by 
VA health care providers and involves brief questions that employ 
descriptive, nonjudgmental language. ACOG applauds this mandate by the 
VA and the efforts by the US Department of Defense and encourages the 
continuation of prioritization of efforts for primary prevention of 
military sexual trauma.
    Thank you for the opportunity provide written testimony. In 
general, while we have identified some areas needing improvement, ACOG 
recognizes and appreciates the good work of the VHA in attempting to 
meet the complex health care needs of women Veterans. We look forward 
to partnering with the VHA in meeting those needs and stand ready to 
assist the Committee on Veterans Affairs as you continue to look into 
this issue.
References: ACOG Committee Opinion 547, Health Care for Women in the 
            Military and Women Veterans, December 2012.
                                 ______
                                 
   Prepared Statement from Kate O'Hare-Palmer, Chair, Women Veterans 
                 Committee, Vietnam Veterans of America
    Good afternoon Mr. Chairman, Ranking Member Blumenthal, 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 Fulfilling the Promise to Women 
Veterans
    Since 1982, Vietnam Veterans of America has been a leader in 
advocacy and championing appropriate and quality health care for all 
women veterans. The Department of Veterans Affairs (DVA) has made many 
innovations, improvements and advancements over the past thirty years. 
However, some concerns remain respective of its policies, care, 
treatment, delivery mode, and monitoring of services to women veterans.
 medical treatment of women veterans by department of veterans affairs
    Department of Veterans Affairs (DVA) eligible women veterans are 
entitled to complete health care including care for gender specific 
illnesses, injuries and diseases. The DVA has become increasingly more 
sensitive and responsive to the needs of women veterans and many 
improvements have been made. Unfortunately, these changes and 
improvements have not been completely implemented throughout the entire 
system. In some locations, women veterans experience barriers to 
adequate health care and oversight with accountability is lacking. 
Primary care is fragmented for women veterans. What would be routine 
primary care in the community is referred out to specialty clinics in 
the VA. Over the last five years the per cent of women veterans using 
the VA has grown from 11% to 17%, with 56% of OEF/OIF women Veterans 
having enrolled in the VA. Their average age of women Veterans using 
the VA is 48.
    Vietnam Veterans of America will continue its advocacy to secure 
appropriate facilities and resources for the diagnosis, care and 
treatment of women veterans at all DVA hospitals, clinics, and Vet 
Centers and we ask the Secretary of Veterans Affairs ensure senior 
leadership at all facilities and Regional Directors be held accountable 
for ensuring women veterans receive appropriate care in an appropriate 
environment. Further, we seek that the Secretary ensures:

     The competency of staff who work with women in providing 
gender-specific health care.
     That VA provides reproductive health care.
     That appropriate training regarding issues pertinent to 
women veterans is provided.
     That there is the creation of an environment in which 
staff are sensitive to the needs of women veterans; that this 
environment meets the women's needs for privacy, safety, and emotional 
and physical comfort in all venues.
     Those privacy policy standards are met for all patients at 
all VHA locations and the security of all Veterans is ensured.
     That the anticipated growth of the number of women 
Veterans should be considered in all strategic plans, facility 
construction/utilization and human capital needs.
     That patient satisfaction assessments and all clinical 
performance measures and monitors that are not gender-specific, be 
examined and reported by gender to detect any differences in the 
quality of care.
     That the Assistant Deputy Under Secretary for Health for 
Quality, Safety, and Value report any significant differences and 
forward the findings to the Under Secretary for Health, Under Secretary 
for Operations and Management, the Regional Directors, facility 
directors and chiefs of staff, and the Women's Health Services Office.
     That every woman veteran has access to a VA primary care 
provider who meets all her primary care needs, including gender-
specific and mental health care in the context of an ongoing patient-
clinician relationship.
     That general mental health care providers are located 
within the women's and primary care clinics in order to facilitate the 
delivery of mental health services.
     That sexual trauma care is readily available to all 
veterans who need it and that VA ensure those providing this care and 
treatment have appropriate qualifications obtained through course work, 
training and/or clinical experience specific to MST or sexual trauma.
     That an evaluation of all gender specific sexual trauma 
intensive treatment residential programs be made to determine if this 
level is adequate as related to level of need for each gender, 
admission wait times, and geographically responsive to the need.
     That Vet Centers are able to adequately provide services 
to women veterans.
     That a plan is developed for the identification, 
development and dissemination of evidence-based treatments for PTSD and 
other co-occurring conditions attributed to combat exposure or sexual 
trauma.
     That women veterans, upon their request, have access to 
female mental health professionals, and if necessary, use VA outsource 
to meet the women veteran's needs.
     That all Community Based Outpatient Clinics (CBOC) which 
do not provide gender-specific care arrange for such care through VA 
outsource or contract in compliance with established access standards.
     Evidence-based holistic programs for women's health, 
mental health, and rehabilitation are available to ensure the full 
continuum of care.
     That the Women's Health Service aggressively seek to 
determine root causes for any differences in quality measures and 
report these to the Under Secretary for Health, Under Secretary for 
Operations and Management, the Regional Directors, facility directors 
and COS, and providers.
     That legislation be enacted to ensure neonatal care is 
provided for up to 30 days as needed for the newborn children of women 
veterans receiving maternity/delivery care through DVA.

    Senator Dean Heller (NV) (for himself and Ms. Murray) has 
introduced S. 471 the Women Veterans Access to Quality Care Act, when 
enacted d into law would improve the provision of health care for women 
veterans by the Department of Veterans Affairs, and for other purposes 
and based on our recommendations above VVA fully supports the bill.
                        homeless women veterans
    Over the past two decades we have become increasingly more vested 
in the recognition and address of the situation of homelessness among 
Veterans. In looking back VVA well remembers the time when the VA 
acknowledged that as many as 275,000 Veterans filled these roles. With 
the legislative creation of the VA Homeless Grant and Per Diem HGPD 
program and its program growth, the VA and community Veteran service 
providers have been able to chip away at this deplorable situation of 
life that existed for so many who served this county in its Armed 
Forces. Startling is the fact that the percentage of homeless women 
Veterans has raised from 2% to 6% of the homeless Veteran population 
and that over the past four years the actual number has doubled.
    Currently the VA sites that the number of homeless Veterans has 
been reduced to 49,933 as reported by the most recent Point in Time 
count. VVA recognizes this as a useful tool but doubts that this number 
is necessarily a solid number. It is a snap shot because it is 
impossible to have on record all the Veterans who are homeless. 
Nonetheless it is a true indicator that all the energy surrounding the 
above mentioned programs has made a difference. It is undeniable that 
the number of Homeless women veterans has been climbing; however, 
collection data on homeless women Veterans is not reliable as indicated 
in the Government Accounting Office's (GAO) 2011 report ``Homeless 
Women Veterans: Actions Needed to Ensure Safe and Appropriate Housing. 
The report also cited some significant barriers to access of housing 
for homeless women Veterans are:

     They are not aware of the opportunities available
     They don't know how or where to obtain housing services.
     They are not easily found/identified in the community. 
They often ``couch surf.''
     They have children and avoid shelters because of the 
safety factor;
     They avoid social service agencies for fear of losing 
their children to the system.
     24 percent of VA Medical Center homeless coordinators 
indicated they have no referral plans or processes in place for 
temporarily housing homeless women veterans while they await placement 
in HUD-VASH and GPD programs.
     Nearly 2/3 of VA HGPD programs are not capable of housing 
women with children.
     The program expense of housing women with children is a 
disincentive for providers.

    VVA believes that it is a very ambiguous plan of the Ending 
Homeless among Veterans by 2015, but asks the questions? Are women 
Veterans and their needs truly being met by the programs that exist for 
them today? ``What will be done to reach them, to know them, to meet 
their needs and provide them a safe environment in which to address 
them?'' VVA believes that a coordinated plan needs to be developed at 
the local level by the leadership of the respective VA medical center 
within its homeless Veteran program to address these needs. The influx 
of women in the military and one of every ten soldiers serving in Iraq 
a woman, the female homeless population will only grow and or 
facilities dedicated to women are vital.
                        women veterans research
    Because women veterans have historically been a small percentage of 
the veteran population, many issues specific to women veterans have not 
been researched. General studies of veterans often had insufficient 
numbers of women veterans to detect differences between male and female 
veterans and/or results were not reported by gender. Today, however, 
women are projected to be more than 11 % of the veteran population by 
2020 and 12% by 2025.
    Vietnam Veterans of America asks the Secretary to conduct several 
studies specific to women veterans and that Congress pass legislation 
to mandate such studies if the Secretary does not act:

     A comprehensive assessment of the barriers to and root 
causes of disparities in the provision of comprehensive medical and 
mental health care by DVA for women veterans.
     A comprehensive assessment of the capacity and ability of 
women veterans' health programs in VA, including Compensation and 
Pension examinations, to meet the needs of women veterans. (GAO: 
March 2010: VHA).
     A comprehensive study of the relationship of toxic 
exposures during military training and service, and the infertility 
rates of veterans.
     A comprehensive evaluation of suicide among women 
veterans, including rates of both attempted and completed suicides, and 
risk factors, including co-morbid diagnoses, history of sexual trauma, 
unemployment, deployments, and homelessness.
     VA evaluation of the integration of services to support 
veterans.
  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.
                  women veterans and veterans benefits
    The Veterans Benefits Administration (VBA), and to a lesser extent, 
the National Cemetery Administration (NCA), have been less proactive 
than the Veterans Health Administration in targeting outreach to women 
veterans and in ensuring competency in managing claims filed by women 
veterans.
    Vietnam Veterans of America will continue its advocacy to secure 
benefits for all eligible veterans. VVA asks the Secretary to ensure:

     That leadership in all VA Regional Offices (VARO) is 
cognizant of and kept current on women veterans' issues; that they 
provide and conduct aggressive and pro-active outreach activities to 
women veterans and; that VBA leadership ensures oversight of these 
activities.
     That a national structure be developed within VBA for the 
Women Veteran Coordinator (WVC) positions, located at each VARO.
     That VBA establish consistent standards for the time 
allocated to the position of Women Veteran Coordinator (WVC) based on 
the number of women veterans in the area the VARO serves.
     That VBA develop a clear definition to the job description 
of the WVC and implement it as a full time position with defined 
performance measures.
     That VBA identify a subject matter expert on gender 
specific claims as a resource person in each regional office location.
     That the WVC is utilized to identify training needs and 
coordinate workshops.
     That the WVC have a presence in the local VHA system.
     That VBA ensure that all Regional Offices display 
information on the services and assistance provided by the Women 
Veteran Coordinator with clear designation of her contact information 
and office location.
     That VBA establish a method to identify and track outcomes 
for all claims involving personal assault trauma, regardless of the 
resulting disability, such as PTSD, depression, or anxiety disorder.
     That VBA perform an analysis and publish the data on 
Military Sexual Trauma (MST) claims volume, the disparity in the claim 
ratings by gender, assess the consistency of how these claims are 
adjudicated, and determine if increased training and testing is needed 
in this regard.
     That all claim adjudicators who process claims for gender-
specific conditions and claims involving personal assault trauma 
receive mandatory initial and regular on-going training necessary to be 
competent to evaluate such claims.
     That the VARO create an environment in which staff are 
sensitive to the needs of women veterans, and the environment meets the 
women's needs for privacy, safety, and emotional and physical comfort.
     That National Cemetery Administration enhances its 
targeted outreach efforts in those areas where burial benefits usage by 
women veterans does not reflect the women veterans' population. This 
may include collaboration with VBA and VHA in seeking means to 
proactively provide burial benefits information to women veterans, 
their spouses and children, and to funeral directors.
                 women veteran program managers (wvpm)
    Women Veteran advocates call for Congressional oversight and 
accountability during this Congress. We are weary of hearing that the 
position of facility Women Veteran Program Managers would be full time 
positions, while in reality, after all this time, this isn't 
necessarily true. As a system wide directive the VA 2010, Handbook 
1330.01, Health Care Services for Women Veterans defines the 
responsibilities of both the VA Veterans Integrated Service Network 
(Regional) Director and the Medical Center (VAMC) Director and its 
enforcement demands this attention. Additionally, both WVPM positions 
are further defined in the VA 2012, Handbook 1330.02 Women Veteran 
Program Managers.
                      military sexual trauma (mst)
    Currently, instances of sexual assault in the military must be 
reported through the chain of command. The creation of a separate and 
independent office to address such crimes would remove barriers to 
reporting and provide additional protection and safety for the victims.
    According to DOD Sexual Assault Prevention and Response Office 
(SAPRO), the majority of survivors of MST (71%) are under 24 years old 
and of lower ranks; whereas the majority of assailants (59.5%) are 
between 20 and 34 years old and of a higher rank than the survivor. 
Military groups are extremely small communities and when reports of 
assault must proceed through the chain of command, it is impossible to 
guarantee that confidential information will stay with those who have a 
`need-to-know'. Additionally, survivors may fear that their own actions 
may be cause for punishment. The threat of retaliation or fear of being 
reprimanded is enough to silence many survivors or have them recant 
their stories. A defined system of checks and balances is needed to 
level the playing field. This office should also have a legal advisor 
on the team.
    VVA will pursue legislation that reassigns complaints of military 
sexual trauma by servicemembers and all alleged perpetrators outside of 
their immediate chain of command.
                        travel for vha treatment
    The Beneficiary Travel policy indicates that only selected 
categories of veterans are eligible for travel benefits and payment is 
only authorized to the closest facility providing a comparable service. 
This Directive is not aligned with the military sexual trauma (MST) 
policy, which states that patients with MST should be referred to 
programs that are clinically indicated regardless of geographic 
location.
    In light of the limited intensive residential treatment programs 
within the VA that are both MST specific and gender specific, many 
women veterans, especially those who are homeless and/or have limited 
income have difficulty seeking and accessing programs that meet their 
clinical needs.
    Vietnam Veterans of America calls on the Under Secretary for Health 
to review and reexamine existing VHA policy pertaining to the 
authorization of travel for veterans, who have been referred by their 
mental health clinician, to a MST-related specialized inpatient 
intensive residential treatment programs outside the facilities/Regions 
where they are enrolled. Additionally, VVA calls for the provision of 
these travel funds whether the Veteran is an in-patient or an 
outpatient also that all medical center clinical staff are advised and 
fully understand the implementation of this policy.
                     women veterans strategic plan
    The strategic plan FY 2010-2014 and Addendum FY 2011-2015 stated 
that the goals and integrated objectives were to be implemented and 
analyzed with published outcomes of performance measures. However, not 
all programs that serve women veterans have specific performance 
measures that track the outcome of programs initiated to respond to the 
needs of women veterans.
    Originally, in the Department of Veterans Affairs (VA) Strategic 
Plan for FY 2010-2014, the only objective that dealt with the women 
veterans directly was the Integrated Objective 2: Empower Women 
Veterans. The purpose of the objective is: Promote recognition of 
contributions of women, ensure VA programs are responsive to the needs 
of women veterans, and educate women about VA benefits and services.
    The Vietnam Veterans of America will continue its advocacy for 
women veterans. We recommend the VA should collect, analyze and publish 
data by gender and minority status for every program that serves 
veterans to improve understanding, monitoring and oversight of programs 
that serve women veterans. The data collected must be measured and 
reported to ensure that the needs of women veterans are met.
                               in closing
    Vietnam Veterans of America has as its' number one legislative 
priority the issue of accountability; accountability at every level of 
any agency, Federal, state, or local, that impacts Veterans and their 
families. It is through this accountability that Vietnam Veterans of 
America hopes to improve the quality of care and life for all of our 
Nation's Veterans.