[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]


 
H.R. 3636; H.R. 2972; H.R. 3036; H.R. 2798; H.R. 2645; H.R. 2681; H.R. 
3224; H.R. 2982; H.R. 2752; H.R. 2628; H.R. 2816; H.R. 1527; H.R. 1163; 
   H.R. 3798; H.R. 3867; H.R. 4096; DRAFT BILL, TO ESTABLISH IN THE 
 DEPARTMENT OF VETERANS AFFAIRS THE OFFICE OF WOMEN'S HEALTH, AND FOR 
                             OTHER PURPOSES

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

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

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                     WEDNESDAY, SEPTEMBER 11, 2019

                               __________

                           Serial No. 116-31

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]       


        Available via the World Wide Web: http://www.govinfo.gov
        
                               __________
                               

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
40-889                      WASHINGTON : 2021                     
          
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                     COMMITTEE ON VETERANS' AFFAIRS

                   MARK TAKANO, California, Chairman

JULIA BROWNLEY, California           DAVID P. ROE, Tenessee, Ranking 
KATHLEEN M. RICE, New York               Member
CONOR LAMB, Pennsylvania, Vice-      GUS M. BILIRAKIS, Florida
    Chairman                         AUMUA AMATA COLEMAN RADEWAGEN, 
MIKE LEVIN, California                   American Samoa
MAX ROSE, New York                   MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire          NEAL P. DUNN, Florida
ELAINE G. LURIA, Virginia            JACK BERGMAN, Michigan
SUSIE LEE, Nevada                    JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina       ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR.,           DANIEL MEUSER, Pennsylvania
    California                       STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota        CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN,      W. GREGORY STEUBE, Florida
    Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York
                 Ray Kelley, Democratic Staff Director
                 Jon Towers, Republican Staff Director

                         SUBCOMMITTEE ON HEALTH

                 JULIA BROWNLEY, California, Chairwoman

CONOR LAMB, Pennsylvania             NEAL P. DUNN, Florida, Ranking 
MIKE LEVIN, California                   Member
ANTHONY BRINDISI, New York           AUMUA AMATA COLEMAN RADEWAGEN, 
MAX ROSE, New York                       American Samoa
GILBERT RAY CISNEROS, Jr.            ANDY BARR, Kentucky
    California                       DANIEL MEUSER, Pennsylvania
GREGORIO KILILI CAMACHO SABLAN,      W. GREGORY STEUBE, Florida
    Northern Mariana Islands

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                            
                            
                            C O N T E N T S

                              ----------                              

                     Wednesday, September 11, 2019

                                                                   Page

H.R. 3636; H.R. 2972; H.R. 3036; H.R. 2798; H.R. 2645; H.R. 2681; 
  H.R. 3224; H.R. 2982; H.R. 2752; H.R. 2628; H.R. 2816; H.R. 
  1527; H.R. 1163; H.R. 3798; H.R. 3867; H.R. 4096; Draft Bill, 
  To Establish In The Department Of Veterans Affairs The Office 
  Of Women's Health, And For Other Purposes......................     1

                           OPENING STATEMENTS

Honorable Julia Brownley, Chairwoman.............................     1
Honorable Neal P. Dunn, Ranking Member...........................     3
Honorable Max Rose, Member U.S. House of Representatives.........     5
    Prepared Statement...........................................    71

Honorable Gus M. Bilirakis, Member, U.S House of Representatives.     6
    Prepared Statement...........................................    72

Honorable Anthony Brindisi, Member, U.S House of Representatives.     7

Honorable Lauren Underwood, Member, U.S. House of Representatives     8

                               WITNESSES

Dr. Teresa Boyd, DO, Assistant Deputy Under Secretary for Health 
  for Clinical Operations, U.S. Department of Veterans Affairs...    10
    Prepared Statement...........................................    39

        Accompanied by:

    Dr. Patricia Hayes, Chief Consultant, Office of Women's 
        Health Services

    Dr. David Carroll, Executive Director, Office of Mental 
        Health and Suicide Prevention
Mr. Jeremy Butler, CEO, Iraq and Afghanistan Veterans of America.    23
    Prepared Statement...........................................    56

Ms. Joy Ilem, National Legislative Director, Disabled American 
  Veterans.......................................................    24
    Prepared Statement...........................................    58

Mr. Roscoe Butler, Associate Legislative Director, Paralyzed 
  Veterans of America............................................    26
    Prepared Statement...........................................    67

                       STATEMENTS FOR THE RECORD

Honorable Lou Correa, Member, U.S House of Representatives.......    73
Honorable Vicky Hartzler, Member, U.S House of Representatives...    74
Honorable Susie Lee, Member, U.S House of Representatives........    75
Honorable Chris Pappas, Member, U.S House of Representatives.....    75
Honorable Elise Stefanik, Member, U.S House of Representatives...    76
Honorable Nydia Vel zquez, Member, U.S House of Representatives..    77
Minority Veterans of America.....................................    77
The Military Women's Coalition...................................    82
The Veterans of Foreign Wars of the United States (VFW)..........    83
National Association of State Women Veteran Coordinators.........    88
Service Women's Action Network...................................    90


 
H.R. 3636; H.R. 2972; H.R. 3036; H.R. 2798; H.R. 2645; H.R. 2681; H.R. 
3224; H.R. 2982; H.R. 2752; H.R. 2628; H.R. 2816; H.R. 1527; H.R. 1163; 
   H.R. 3798; H.R. 3867; H.R. 4096; DRAFT BILL, TO ESTABLISH IN THE 
 DEPARTMENT OF VETERANS AFFAIRS THE OFFICE OF WOMEN'S HEALTH, AND FOR 
                             OTHER PURPOSES

                              ----------                              


                     Wednesday, September 11, 2019

            Committee on Veterans' Affairs,
                    U. S. House of Representatives,
                                                   Washington, D.C.
    The Subcommittees met, pursuant to notice, at 10:08 a.m., 
in Room 210, House Visitors Center, Hon. Julia Brownley 
[chairwoman of the Subcommittee on Health] presiding.
    Present: Representatives Brownley, Lamb, Levin, Brindisi, 
Rose, Cisneros, Dunn, Radewagen, Barr, and Steube.
    Also Present: Representatives Sablan, Underwood, and 
Bilirakis.

        OPENING STATEMENT OF JULIA BROWNLEY, CHAIRWOMAN

    Ms. Brownley. Good morning, ladies and gentlemen. I call 
this legislative hearing to order. On this morning, we 
recognize the lives lost in the terrorist attacks that occurred 
on September 11. Since that time, upwards of 3 million 
servicemembers have been deployed on more than 5.4 million 
deployments. Seventeen percent of the servicemembers that have 
volunteered to defend this country in what has become the 
longest war in this Nation's history are women; they are 
mothers, daughters, sisters, soldiers, airmen, sailors and 
Marines, and those that were able to return home from the 
battlefield deserve the same access to timely, high-quality 
health care as their male counterparts. That is why during the 
116th Congress the Health Subcommittee's key focus has been 
ensuring equitable access to high-quality health care for our 
Nation's heroes.
    As chair of the Women Veterans Task Force, I am proud to 
lead 78 Members of Congress in identifying gaps and 
opportunities to achieve equity in access to health care 
benefits, economic opportunities, and other resources for women 
veterans. I am pleased that today's hearing includes 12 bills 
that will improve equity for the delivery of health care for 
women who have served in our Nation's Armed Forces.
    Also, this month is Suicide Prevention Month, and it is 
critical that we address the gender-specific mental health 
needs of women veterans. Women veterans are nearly twice as 
likely to die by suicide than women who have never served in 
the military. Experiencing military sexual trauma, isolation, 
and intimate partner violence increases the risk of suicide in 
women veterans.
    Suicide is preventable and several of the bills presented 
at today's hearing provide additional resources to programs and 
services known to decrease the risk of suicide in women 
veterans. My bill, H.R. 2798, the Building Supportive Networks 
for Women Veterans Act, provides reintegration counseling for 
women veterans in retreat settings.
    H.R. 3867, the Violence Against Women Veterans Act, 
introduced by Ms. Velazquez, improves programs and services for 
veterans who are survivors of intimate partner violence and 
sexual assault.
    Mr. Brindisi's bill, H.R. 2972, improves resources for the 
women veterans call center and VA websites, so that women 
veterans can easily obtain information about accessing benefits 
and health care.
    Research shows that these resources, and knowledge that 
those resources exist, significantly reduce the risk of suicide 
in women veterans.
    Ranking Member Dunn, I understand from yesterday's Member 
Day that Mr. Bergman has also introduced a bill related to 
suicide prevention, and I would like to reiterate Chairman 
Takano's commitment to work alongside you and Ranking Member 
Roe to support VA's ability to connect veterans to the upwards 
of 45,000 community-based organizations that seek to serve 
them.
    Women veterans are the fastest-growing demographic in the 
veteran population, and it is clear that VA facilities must be 
built, retrofitted, and staffed in accordance with that pace of 
growth.
    H.R. 3636, the Caring for Women Veterans Act, introduced by 
Ms. Underwood; H.R. 3036, the Breaking Barriers for Women 
Veterans Act, introduced by Mr. Rose; H.R. 4096, the Improving 
Oversight of Women Veterans Care Act of 2019; and my bill, H.R. 
3223, the Women Veterans Equal Access to Quality Care Act; all 
ensure that VA is providing sufficient staff, training, 
building, and retrofitting facilities, and maintaining an 
environment of care standards wherever women veterans receive 
taxpayer-funded care, whether at a VA facility or a community 
care provider.
    It is imperative that we eliminate all cultural and 
physical barriers to women veteran's health care. Mr. Pappas' 
bill, H.R. 2681, ensures VA is equipped to provide women 
veterans with life-transforming prosthetics that are 
specifically for their needs.
    Over the past decade, VA conducted two studies to identify 
barriers to care for women veterans. The most recent study, 
completely nearly 5 years ago, enabled VA to identify necessary 
changes to improve services for women veterans. More still must 
be done. And Mr. Cunningham's bill, H.R. 2982, renews the 
authorization for the barriers to care study to enable VA to 
best serve women veterans by 2030 and beyond.
    In the last 20 years, we have seen a significant shift in 
the demographics of the veteran population. Not only is the 
women veteran's population growing rapidly, but women veterans 
are on average 15 years younger than male veterans and more 
likely to be of reproductive age. That is why members of the 
Women Veterans Task Force introduced three bills to improve 
reproductive health care access for women veterans.
    My bill, H.R. 3798, Equal Access to Contraception for 
Veterans Act, eliminates co-payments for prescription 
contraceptives, so that women veterans have the same access to 
birth control as during their service.
    For veterans who choose to become mothers, two bills will 
give veterans peace of mind in the earliest days of their 
newborn's lives. H.R. 2645, the Newborn Care Improvement Act, 
introduced by Ms. Lee, doubles the number of days of newborn 
health care coverage for children of veterans.
    Mr. Allred's bill, H.R. 2752, the VA Newborn Emergency 
Treatment Act, further expands coverage for newborns when 
medically necessary and streamlines the billing process, so 
that veterans are not unnecessarily burdened with debt after 
the birth of a child.
    In addition to today's legislation focused on women 
veterans, we are also considering a number of bipartisan 
measures that have been introduced by my Republican colleagues.
    Last Congress, I was honored to join a number of Members of 
this Committee to cosponsor the Long-Term Care Veterans Choice 
Act, introduced by Congressman Clay Higgins. This measure is a 
first step towards right-sizing VA's long-term care options by 
offering veterans more opportunity to age at home.
    As women are generally expected to live nearly 5 years 
longer than men, ensuring VA is prepared to care for its aging 
population is important to women veterans and the community at 
large.
    In addition, the legislation introduced by Congresswoman 
Stefanik, H.R. 2816, the Vietnam Era Veterans Hepatitis C 
Testing Enhancement Act of 2019, would allow VA to partner with 
veterans service organizations to offer hepatitis C testing at 
outreach events is an important step towards ensuring VA is 
properly leveraging its existing partnerships to reach veterans 
where they are.
    As chair of this Health Subcommittee, I am truly proud of 
the work we are doing here today; I am especially proud of the 
way we are doing it in a bipartisan manner.
    In closing, I would like to thank our witnesses for 
appearing and I look forward to your testimony.
    Ms. Brownley. Before I recognize Dr. Dunn for his opening 
statement, I would like to note that I will not be asking 
Members to waive their opening statements today, as is 
tradition, so that the Members with legislation on today's 
agenda are afforded the opportunity to issue statements in 
support. While a few of the Members with legislation before us 
today are not Members of this Committee, please note that each 
has been given the opportunity to submit a statement for 
today's record, as well as the opportunity to deliver remarks 
in support of their legislation at yesterday's Member Day 
before the Full Committee.
    With that, I would like to recognize Ranking Member Dunn 
for 5 minutes for any opening remarks he may wish to make.

       OPENING STATEMENT OF NEAL P. DUNN, RANKING MEMBER

    Mr. Dunn. Thank you, Chairwoman Brownley. After several 
weeks away from Washington, it is good to be back with you, 
working to serve our Nation's veterans.
    Our agenda this morning is full, and I look forward to our 
discussion.
    Before yielding, I do say, I would like to say I have three 
areas of regret and a little disappointment here, and that is 
this is the second legislative hearing that this Subcommittee 
has held in Congress and both of the agendas of those hearings 
were set entirely by the majority without any input from the 
minority, either Members or staff.
    The witness list for this hearing did not include the 
Member panel, which you mentioned just a moment ago. Typically, 
Members who sponsor bills are invited to testify and contribute 
to our conversations about their bills.
    I note that the Committee Members with bills up for 
consideration today, Committee Members with bills up today, 
have been allowed to sit on the dais and testify on their 
bills. And while most of the Democrat bills are sponsored by 
the majority Members, only one of the Republican bills chosen 
by the majority is sponsored by a Committee Member. Now, that 
is probably unintentional, but it creates a perception of 
imbalance.
    By failing to provide the minority an opportunity to 
provide input about bills to be considered, and further failing 
to provide sponsors from both parties' equal opportunity to 
advocate for their legislation, I think it runs somewhat 
counter to the past practices of this Subcommittee. The VA and 
its Subcommittees have uniquely been very bipartisan, and I 
sincerely hope we will continue to conduct it that way.
    Finally, had the minority been consulted in advance about 
the agenda, there is one bill that we would have asked to be 
included that has not been, that is H.R. 3495, the Improve 
Well-Being for Veterans Act, which you referenced in your 
opening statement. The Improve Act is bipartisan legislation, 
it is sponsored by Congressman Bergman and Congresswoman 
Houlahan. I note for the record that Congressman Bergman is 
also Lieutenant General Bergman, the highest-ranking officer 
and veteran ever to serve in Congress in the history of our 
Nation. It is supported by many veterans service organizations 
and by the VA, and, most importantly, it addresses what 
Chairman Takano has stated repeatedly is this Committee's 
single highest priority, preventing veteran suicide, by 
creating a grant program to support entities that provide and 
coordinate suicide prevention services for veterans and their 
families in their local communities.
    The Improve Act alone would not solve the national suicide 
crisis that tragically takes the lives of 20 veterans a day, 
but it could certainly be part of that solution. It would save 
lives, and it is worthy of this Subcommittee's time and 
attention.
    When staff was first informed of today's hearing, after the 
majority had already set the agenda and informed the VA of the 
hearing, our staff requested to add the Improve Act to the 
agenda, and that request by staff was denied. Letters were 
subsequently sent to Chairman Takano by Secretary Wilkie and 
followed by Ranking Member Roe requesting the Improve Act be 
included. Chairwoman Brownley, I certainly hope that your staff 
provided you copies of those letters and, to my knowledge, we 
have had no response on those.
    September is National Suicide Prevention Month and Chairman 
Takano marked it on September 1st by calling for new solutions 
and fast actions. One concrete way for this Committee to follow 
that call would be debating the Improve Act without any 
unnecessary delay. I regret that we are not doing that.
    But, with that, I look forward to today's hearing and I 
yield back. Thank you.
    Ms. Brownley. Thank you, Dr. Dunn. I appreciate it.
    And just to follow up on your remarks with regards to 
Lieutenant General Bergman's bill, I assure you and the 
Committee that our staff and Chairman Takano are prepared to 
work through that bill to gain bipartisan support and, 
hopefully, that particular bill will come forward to us at 
another time. So I appreciate your comments there.
    So now I would like to recognize Congressman Rose for 5 
minutes for any opening remarks he may wish to make in support 
of his bill.

                 OPENING STATEMENT OF MAX ROSE

    Mr. Rose. Thank you, Chairwoman Brownley and Ranking Member 
Dunn, for having this forum to provide due attention to the 
pending legislation before us.
    With respect to legislation impacting women veterans before 
us, let me just say it is beyond clear that the women who 
served alongside me in Afghanistan, who also served in Iraq and 
who have generally put on our Nation's uniform in defense of 
all that we hold dear, they deserve our support and national 
investment now more than ever.
    When these heroes come home, they aren't necessarily 
greeted with a hero's welcome, although they are always thanked 
for their services. Instead, they face challenges severely 
disproportionate to their civilian and male counterparts, and 
it is unacceptable.
    Studies have shown women veterans have higher rates of 
interpersonal trauma than male veterans, and this includes 
military sexual trauma. There is little doubt that this plays a 
role in higher instances of medical challenges than other 
groups. And, tragically, women who served have a rate of 
suicide that is nearly double than that of civilian women age 
18 and over. It is Suicide Prevention Month and I want us to 
fully appreciate the scope of that. We cannot let this persist.
    And let me just say that, if you thank a female veteran for 
their service when they come home, but nonetheless do not do 
anything about the fact that they receive inadequate health 
care at our VA institutions, then beyond that just being 
hypocritical in nature, saying thank you for your service is a 
disgraceful thing to be doing if we are not fixing this. Our 
female veterans deserve so much better.
    That is why I am proud to have introduced H.R. 3036, a 
critical bipartisan piece of legislation to make sure 
facilities at the VA are as equipped as possible to serve a 
growing population of veterans. This bill would ensure funds to 
support the physical infrastructure of our VA hospitals and 
clinics for a woman veteran's care needs. It would require that 
there is at least one full-time or part-time woman's primary 
care provider within any given clinic or facility, and would 
expand the woman veteran's health care mini-residency program, 
which further protects against staffing concerns being a 
barrier to access.
    And, in addition to requiring the VA to produce relevant 
reports as care is provided, this bill would require the VA to 
establish a training module for community providers, because as 
we see time and again through these hearings, these issues do 
not end within the four walls of the VA.
    After seeing the VA's testimony to this Subcommittee, I am 
heartened the VA supports the intent of many provisions within 
this bill and, while the VA is working on many of these goals, 
we must ensure that our women veterans do not fall through the 
cracks; that is not an option.
    So, again, I urge all my colleagues to support this 
legislation. I thank many of those who have cosponsored. And, 
again, Madam Chairwoman, thank you again for the time.

    [The prepared statement of Congressman Rose appears in the 
Appendix]

    Ms. Brownley. Thank you. Mr. Bilirakis.

             OPENING STATEMENT OF GUS M. BILIRAKIS

    Mr. Bilirakis. Thank you, Madam Chair, I appreciate it. I 
would like to thank you again for--and the Ranking Member, of 
course--for allowing me to sit on this Subcommittee hearing and 
allowing me to speak on one of the bills being considered 
today, my legislation, which is H.R. 2628, the Vet Care Act.
    Many of my veteran constituents have come to me over the 
years expressing their desire to add dental care to the VA's 
medical benefits package. As you know, Madam Chair, the VA 
currently on provides outpatient dental services to a limited 
number of the disabled veteran population who have 100 percent 
service-connected ratings, and then a couple other categories 
as well, POWs and, again, anything that happened on the 
battlefield as far as if it is service-connected regarding the 
mouth area. But, again, some may be eligible, some veterans may 
be eligible for the VA dental insurance program, which provides 
a discount, a low-cost insurance plan provided by insurers, but 
I believe we can do more to move this issue forward.
    And I commend you, Madam Chair, for filing your bill as 
well and I am very supportive of your bill.
    Many small studies suggest that regular dental care equates 
to lower overall health care costs and better health outcomes. 
One such study published in the American Journal of Preventive 
Medicine conducted by the University of Pennsylvania professor 
Dr. Marjorie Jeffcoat, found that regular periodontal checkups 
lead to reduced hospitalizations and overall medical cost 
savings and care for chronic conditions such as heart disease, 
cerebral vascular disease, including stroke and diabetes. And, 
again, I think there are more chronic diseases that are 
affected as well.
    In light of these results, I worked directly with Dr. 
Jeffcoat and Dr. Zack Kalarickal, who is a constituent of mine 
from Wesley Chapel, Florida, we worked to develop the 
parameters and replicate this type of study at the VA by 
authorizing the Vet Care Act.
    H.R. 2628, my bill, expands on this research to help 
determine the potential health benefits to veterans and 
potential cost savings to the VA associated with periodontal 
care. The Vet Care Act would require the VA to create a 4-year 
pilot program to provide dental services to 1500 veterans 
diagnosed with type 2 diabetes. Each treated veteran will 
receive appropriate periodontal evaluation and treatment on an 
annual basis during the pilot. Throughout and at the conclusion 
of the pilot, the overall health of the treated veterans will 
be recorded.
    These results will be compared to veterans who did not 
receive treatment to determine if providing veterans with 
dental care equates to fewer complications of chronic ailments. 
If so, an analysis can be done to determine if the lower costs 
of the overall health care due to fewer chronic ailments saves 
the VA enough money to reallocate funds to provide more 
veterans with dental care. It makes sense, as far as I am 
concerned. The data recorded and collected by the VA would also 
be able to be distributed to the research community for further 
study.
    Finally, at the end of the pilot program, the 4-year pilot 
program, veterans who participate in the program will receive 
administrative support and information from the VA on how they 
may continue to obtain dental services and treatments in the 
community for low to no cost, including information about 
enrolling in the VA DIP program.
    Now, I want to thank the non-profits and the dental 
associations that offer care to our true heroes as well 
currently.
    In this way, we can ensure that we are providing continuity 
of care for veterans in need of further treatment.
    To conclude, if we are able to improve the VA health care 
system by providing preventive dental services that lead to 
fewer complications of chronic ailments, it not only shows that 
we are looking at the long-term outlook of our veterans' 
health, but it could also prove to be done in a cost-effective 
manner.
    The Vet Care Act is a practical, commonsense way to 
demonstrate this approach for dental services, replicating 
already established research in the community.
    Again, I thank the chair and I thank the Ranking Member for 
bringing this bill up for discussion at today's hearing, and I 
look forward to continuing the conversation further.
    Thank you and I yield back, Madam Chair.

    [The prepared statement of Bilirakis appears in the 
Appendix]

    Ms. Brownley. Thank you, Mr. Bilirakis, and thank you for 
your work on this important measure, and I am hopeful that we 
will be able to find a path forward on this very, very 
important issue. So, thank you for bringing this bill forward.
    Congressman Brindisi, you are now recognized for minutes to 
deliver any comments you may have in support of your bill, H.R. 
2972.

             OPENING STATEMENT OF ANTHONY BRINDISI

    Mr. Brindisi. Thank you, Chair Brownley and Ranking Member 
Dunn, for the opportunity to speak today about the importance 
of improving VA services tailored to the needs of women 
veterans. I would also like to thank the Committee for their 
continued efforts this year to make VA more accessible and 
equitable for our women veterans, and for Chairwoman Brownley, 
for your leadership of the new Women Veterans Task Force, which 
I am proudly a member of.
    Women veterans are the fastest-growing demographic in the 
veteran community. Women comprise nearly 10 percent of the 
veteran population and that figure is expected to rise to 18 
percent over the next 20 years. As a result, the number of 
women veterans seeking care at the VA will certainly increase 
and VA needs to be ready. However, 75 percent of women veterans 
do not use VA health care, and face a number of inequalities in 
a system that simply hasn't adjusted quickly enough to meet 
their specific needs. That is why I introduced H.R. 2972, which 
directs the VA Secretary to improve VA's communications 
regarding services available to women veterans.
    While VA has begun to offer text messaging as a way to 
connect the Women Veterans Call Center, and I commend VA for 
doing so, my bill would statutorily require VA to include a 
text messaging capability at the Women Veterans Call Center.
    The Women Veterans Call Center is staffed by female VA 
employees who can provide and link women veterans to 
information regarding resources available to them, and 
requiring text message capabilities at the call center will 
make it even more accessible.
    Additionally, this bill would make navigating VA websites 
easier by creating a central web page where women veterans can 
access various information regarding the extensive resources 
available to them within VA. This page would include the 
locations of each VA medical center and community-based 
outpatient center, as well as the name and contact information 
of each women's health coordinator, and contact information for 
staff from the Veterans Benefits Administration and the 
National Cemetery Administration.
    This bill would build on efforts by the VA and this 
Committee to ensure all women veterans are aware of the hard-
won resources and benefits available to them, and where to turn 
if they are struggling. I believe this bill is a positive step 
forward towards making VA more accessible to women veterans and 
I urge the Committee to support this legislation.
    I want to thank Chairwoman Brownley, and I yield back the 
balance of my time.

    [The prepared statement of Congressman Brindisi appears in 
the Appendix]

    Ms. Brownley. Thank you, Mr. Brindisi.
    [Audio malfunction in the hearing room.]

             OPENING STATEMENT OF LAUREN UNDERWOOD

    Ms. Underwood. Thank you, Chairwoman Brownley, for holding 
today's hearing, and thank you and Dr. Dunn for permitting me 
to join today's important panel. I appreciate you and Chairman 
Takano's willingness to focus on and fight for what our women 
veterans need.
    Women veterans face a number of unique needs and 
challenges, from access to clinically appropriate services at 
VA facilities to mental health care. We need to act now to 
address their needs, because the number of women veterans is 
going to increase dramatically in the next decade.
    I am proud to serve both on Chairwoman Brownley's Women 
Veterans Task Force and on the Servicewomen and Women Veterans 
Congressional Caucus, founded by my fellow freshman 
Congresswoman Houlahan.
    So I am thrilled that the Committee is moving forward today 
on my legislation, H.R. 3636, the Caring for Our Women Veterans 
Act. My bill directs the Secretary of Veterans Affairs to 
submit an annual report to Congress on gender-specific care 
available at VA facilities. This includes locations where women 
veterans can access VA care; the numbers of women's health care 
centers and women's health providers like OB/GYNs; and 
recommendations for improving those facilities to better serve 
women veterans.
    The bill will provide an informed and sustainable roadmap 
to providing high-quality, accessible care for women veterans.
    I also want to highlight two critical health care issues 
for women veterans that I have been working on this year. The 
first is eliminating co-pays for contraceptives, breast cancer 
screenings, and other preventative health care services for 
veterans. Right now, civilians and active duty servicemembers 
don't have to pay these co-pays, but veterans do. That is 
unacceptable and we need to fix it.
    Chairwoman Brownley has been a leader on this issue and I 
am looking forward to working with her to close this loophole 
and eliminate unfair health care costs for our veterans.
    Lastly, I am proud to be introducing the ACE Veterans Act 
today with Congressman Conor Lamb. This bill allows women 
veterans to get a full year's supply of birth control at a time 
at the VA. My focus is always on data-driven, evidence-based 
policymaking, and so this bill builds off research showing that 
a full year contraception dispensing improves health outcomes 
for women and saves the VA money.
    As this Committee moves forward on legislation to improve 
health care for women veterans, I am excited to work on these 
proposals and more.
    Thank you again for holding today's hearing and to our 
witnesses for being here. I yield back.
    [Audio malfunction in the hearing room.]

    [The prepared statement of Ms. Underwood appears in the 
Appendix]

    Ms. Brownley. --this Committee and a health care 
professional is really invaluable, so we really appreciate you 
being part of this and moving this important issue forward.
    So are there any other Members that would like to deliver 
any opening statements this morning?
    Hearing none, we will move on to two great panels before us 
today. I thank each of you for joining us today in what I hope 
to be a fruitful discussion on these 17 bills.
    For our first panel, we have Dr. Teresa Boyd, Assistant 
Deputy Under Secretary for Health for Clinical Operations at 
the Department of Veterans Affairs. Dr. Boyd is accompanied by 
Dr. Patricia Hayes, Chief Consultant, Office of Women's Health 
Services.
    We are also joined by Dr. David Carroll, Executive Director 
for the Office of Mental Health and Suicide Prevention at the 
Department of Veterans Affairs.
    I now recognize Dr. Boyd for 5 minutes for her opening 
comments.

                  STATEMENT OF TERESA BOYD, DO

    Dr. Boyd. Thank you and good morning. Good morning, Ms. 
Chairman Brownley, Ranking Member Dunn, and Members of the 
Subcommittee. Thank you for inviting us here today to present 
our views on numerous bills, including those that address the 
critical needs of women veterans, as well as other important 
areas.
    I also want to recognize the veterans service organizations 
represented on the next panel, as I have seen personally how 
much they contribute to our work on behalf of veterans and how 
dedicated they are in our common mission to serve veterans.
    I do need to thank you for your patience, as the submission 
of my written testimony was delayed. Because I need to keep 
this statement brief, I cannot address all 17 bills in my oral 
statement, but they all touch on important topics. Of course, 
the written testimony covers all the bills in detail, and we 
are prepared to field questions on them today.
    I would like to take a moment to briefly discuss a bill 
that is not on today's hearing. H.R. 3495, the Improve Well-
Being for Veterans Act would help VA build partnerships with 
community groups, who can offer direct help to veterans, who 
are at risk of harming themselves. VA believes this legislation 
will assist us in reaching the 14 of the 20 veterans dying each 
day by suicide, who are not under VA care at the time of their 
death.
    It would fulfill a critical legislative component of the 
administration's multi-faceted program to prevent veteran 
suicide, and we strongly urge its consideration. We appreciate 
that so many of the bills today are focused on meeting the 
special needs of our women veterans. That is a priority of the 
secretary, and a big focus of attention for VHA.
    The VA supports the following bills, at the very least in 
principle, relating the care of women veterans. Although for 
some, we do believe there are important technical changes that 
should be made, or we need to ensure that the initiatives are 
adequately funded. We support H.R. 2645, which would increase 
the period that VA is authorized to care for a newborn child. 
And we also support in principle, H.R. 2752 regarding 
transportation of those newborns when medically necessary.
    For the latter bill, however, there are some significant 
technical issues that would need to be worked through. H.R. 
2798 concerns special retreat programs for women veterans 
returning from long deployments. VA is enthusiastic about these 
retreats. We have received very positive feedback from 
participants who have said they now realize that they are not 
alone, and that they have learned to trust themselves, and feel 
that they are important.
    The response has been so positive, we would like to expand 
the scope of the bill for all veterans who are eligible for vet 
center services, as long as we can secure adequate funding to 
do so. We support H.R. 3798, which aims to further improve 
veterans' access to contraceptives. Although we do have some 
technical points to offer on this bill.
    There are other bills concerning women veterans on the 
agenda that we cannot offer our support today for the reasons 
explained in detail in my written statement, even though we are 
fully in line with the goals of the sponsors. In some 
instances, we believe they are duplicative of existing programs 
or initiatives, or are inconsistent with clinical practice. For 
example, on the key importance of making sure our clinical 
spaces are ideally configured for the needs of women veterans, 
the subject of H.R. 3036, many of the actions called for in 
that bill are already being undertaken. And for H.R. 2982, 
which requires a study of barriers that women veterans 
encounter in securing care from VA, we have in place an array 
of initiatives that recognize those barriers and aim to remedy 
them.
    Regarding the draft bill that would establish the Office of 
Women's Health, we believe that the current placement of the 
Office of Women's Health Services is strategically aligned to 
interact with all other clinical programs at the national level 
that provides a conduit for coordination and collaboration 
where services are similar.
    For H.R. 4086, we understand why the Committee wants to get 
a formal report on issues of concern to women veterans in the 
context of care with community providers. However, the data 
points required for the report would require the modification 
of contracts with community providers, which given the extent 
of care in the community would be disruptive. We would like to 
discuss how the Committee could exercise oversight in this area 
by other means.
    H.R. 3867 is focused on an area of intensive nationwide 
concern for veterans and non-veterans alike. The issue of 
domestic violence and sexual assault. VA is totally in accord 
with the goal of coordinating in the fullest way possible all 
VA services across the board for victims of domestic violence 
and sexual assault.
    There are other provisions, however, that may be 
duplicative of current programs and require technical changes. 
VA is very engaged in this issue, and we would welcome further 
discussion with the Committee. There are other bills on today's 
agenda that concern issues not directly tied to the special 
needs of women veterans, but which also touch on critical 
subjects. We support H.R. 1527, which would allow VA to pay for 
long-term care in what are known as our medical foster homes. 
This option is something we are enthusiastic about, as it will 
help reduce a barrier to the use of these homes.
    For some veterans, a more homelike setting has great 
advantages over traditional nursing home care. We look forward 
to discussing some of the technical issues identified in our 
written testimony.
    H.R. 2628 concerns dental care for veterans. We support the 
part of the bill regarding administrative support to those 
providing dental care to veterans, separate from VA's 
authority. Although we do have some technical comments. VA does 
not, however, support Section 3 for several reasons.
    We are concerned the bill would create disparities in the 
overall application of dental eligibility by expanding access 
to these benefits to veterans in participating locations, but 
not elsewhere. We also believe the bill is far too prescriptive 
in terms of its requirements, and that it is unnecessary 
because the dental literature already strongly supports the 
cost effectiveness of preventive dental care.
    Before I conclude my statement, I know we all want to 
acknowledge the veterans and servicemembers who were inspired 
to serve our country in response to the attacks that occurred 
18 years ago today on September 11th, 2001. We are eternally 
grateful to you and all veterans and servicemembers for the 
many sacrifices you and your families have made in order to 
preserve our freedom as a Nation.
    Thank you, again, for inviting us here today. My colleagues 
and I are prepared to answer any questions you may have.

    [The prepared statement of Dr. Teresa Boyd appears in the 
Appendix]

    Ms. Brownley. Thank you, Dr. Boyd. And I now recognize 
myself for 5 minutes for questions. And the first question that 
I wanted to ask is regarding Mr. Rose's bill, 3036. And in your 
written testimony, I understand with so many bills that you 
can't address each one in your opening comments today, and I 
understand that, but I did read your written testimony and I 
thank you for its thoroughness.
    And you noted that the turnover for women's health 
providers is 20 percent. And during the task force, we have 
been traveling across the country, and having lots of visits, 
both myself and staff, making these visits. And we have really 
learned that the high rate of trauma within the women veteran 
community that is taking place can cause secondary trauma 
actually to the health care providers, because they are 
listening to so many traumatic stories.
    And so staffing shortfalls have made it even more 
challenging for the providers because if there are less 
providers, they have more tragic stories to hear. And so I 
wanted to know really what the VA is learning--first, making 
sure that you are doing exit surveys of these providers who are 
leaving, and what you are learning from these exit surveys to 
help inform us in terms of how to hold on to our health care 
providers, particularly women health care providers and women 
health care providers who are serving our women veterans.
    Dr. Boyd. That is a great question. And I do believe that 
next week, there will be another hearing with some subject 
matter experts with regards to our hiring and our work force. I 
will briefly state a few things and then let Dr. Hayes jump in. 
One thing that we have started to do, and we don't have enough 
data yet on it, but is to not wait until the exit--I mean, to 
continue to go ahead and do that, but let's get in the habit of 
asking folks, and learning why folks stay. Why our providers 
stay? What keeps them here?
    With regards to burn out and exhaustion, workload, 
depersonalization, we pick that up more and more specifically 
now on our all employee survey as well. So in a nutshell, we 
have some tools that we are trying to connect the dots. But I 
do want to give Dr. Hayes a little bit of time, because she has 
specifics about the women's health providers.
    Ms. Hayes. Good morning. You have pointed out some really 
critical issues for us about the overburdened numbers of 
women's health primary care providers. In fact, we have been 
doing a deep dive on their burnout and on their retention 
issues, talking to them, those sort of left having interviews. 
What we are finding are a number of factors.
    One is that the population has grown so fast and we haven't 
gotten enough help, not enough providers in each site, and that 
is sort of a topic of a lot of other things. We have been 
talking about how to build that staff. One of the other factors 
is that they frequently don't have the appropriate nursing 
staff. So you can't take care of these women in a clinic 
without the nursing staff and the other staff, such as social 
work or pharmacy. So the staffing levels in the packed clinic 
is one of our targets. And then just the tremendous sense, as 
you were saying of the complexity of these patients with trauma 
histories, and also several--usually several physical 
comorbidities. These are very complex patients and it is too 
much. We need to reduce the panel sizes.
    What we are doing is attacking all of these issues. The 
undersecretary and principal deputy have charged me with a 
women's health modernization called an IPT. We have been 
meeting approximately three times a week since June. We are 
looking at these in a very deep dive way and coming up with 
action plans for management that is coming back up to the 
leadership, we are hoping within the next month or so. So we 
are going to be informing the field where the problems are, 
what are the things we know, and try and deal with the issue of 
hiring more providers. But we will be getting into that a bit 
more in this hearing, I imagine, because the primary care 
provider recruitment issue is beyond women's health as well. It 
is a problem nationally.
    Ms. Brownley. Thank you, Dr. Hayes. And this Committee and 
myself will be very interested to see what your deep dive 
reveals, and what some of the solutions and policies moving 
forward are. So I appreciate that. Well, I only have a few 
seconds left, so I will end my questioning and hopefully can 
get back to it. And so I will now yield to Dr. Dunn for 5 
minutes for questioning.
    Mr. Dunn. Thank you, Chairwoman Brownley. This question is 
for Doctors Boyd and Carroll. Do you have formal views--it is 
regarding, by the way, the Improve Wellbeing for Veterans Act. 
That is 3495. Do you have formal views and cost estimates 
regarding the Improve Act for the VA, and would you--are you 
able to provide those? Either, both?
    Mr. Carroll. Good morning, sir. Yes, we do. I know we have 
prepared them. We will make sure that the department gets them 
to you if you have not received them.
    Mr. Dunn. Yes. I appreciate that. Is it fair to say that 
you are supportive of that Act?
    Mr. Carroll. Yes.
    Mr. Dunn. And, Dr. Boyd?
    Dr. Boyd. Absolutely. We strongly support it.
    Mr. Dunn. Do you think it could be funded out of existing 
appropriations without impacting the department's internal 
mental health or suicide prevention programs?
    Mr. Carroll. Yes, a similar proposal was included in the 
president's fiscal year 2020 appropriations budget. And so the 
plan was to fund it out of current appropriations without any 
impact or jeopardy to current programs.
    Mr. Dunn. Thank you. You make me feel so much more 
comfortable. I appreciate that. Dr. Boyd, regarding H.R. 1163, 
do you know how many prospective hires each year are barred 
from VA employment due to non-compete agreements with other 
health care systems or private practices?
    Dr. Boyd. I do not have that information.
    Mr. Dunn. Is it something that is actually obtainable? I 
mean, do you think you--do you have a sense of it?
    Dr. Boyd. I have anecdotal after being in the field and 
being a chief of staff. I think it is anecdotal and I am not 
really--I wouldn't put a lot of credence in it. There will be a 
hearing next week where there will be the workforce H.R. folks 
involved, and they may have more, but I doubt at this point 
that they do.
    Mr. Dunn. Yeah. I would be interested to know that. 
Certainly in my private practice, we saw those non-competes 
crop up, even when I doctor was going into the VA, which I was 
sort of surprised that that--but people are people, right?
    Do you know, has your office--General Counsel Office 
reviewed this piece of legislation, 1163, and do they have any 
concerns regarding the potential legal challenges that could 
arise as a result of this bill impacting existing non-compete 
agreements?
    Dr. Boyd. Yes, sir. There may be an unintended consequence, 
especially for Section 2. It's possible that the former 
employer may actually litigate.
    Mr. Dunn. Yes.
    Dr. Boyd. And that is not something that we want. And back 
to your comment, if I just may. Really the VA is not in 
competition with private sector. And so--
    Mr. Dunn. And I perceive that just like you do.
    Dr. Boyd. Yes.
    Mr. Dunn. But nonetheless, I see these non-compete 
agreements become stumbling blocks to treatment for veterans 
and employment of doctors. You have an answer? Your general 
counsel maybe has an answer.
    Dr. Boyd. They do. Well, on that again, I can just go back 
to my own experience in the field. I come from the private 
sector. But then within the VA hiring physicians as a chief of 
staff. And most of the time, it was the former employer did not 
follow through on that non-compete, and that was just in my 
experience.
    Mr. Dunn. All right. Let's, I guess, since I am picking on 
Dr. Boyd. Actually, I am enjoying your testimony. I am not 
picking on you. On 2816, the Hepatitis Testing Enhancement Act, 
first let me say 100,000 veterans cured of Hepatitis C. Never 
did I think I would see that in my lifetime. That is such good 
news. So congratulations. I know you have worked the number 
down to 25,000. Keep going. How does the VA intend to continue 
the screening, and the awareness on Hepatitis C?
    Dr. Boyd. So it has been a multi-faceted approach. We are 
down to the more difficult veterans to bring in to test, and to 
not only test, but if they are positive, to actually treat. We 
are down to those that are difficult to find, difficult to 
locate, maybe some of the homeless veterans as well. And so we 
continue. It is a multi-faceted, inter-disciplinary approach, 
not only with the homeless programs but with our primary care, 
women's--I mean, it is with all of our clinical.
    We did send out a letter to all veterans that had not been 
screened within that cohort. And that letter is an order--
    Mr. Dunn. There is 100 percent screening on time of 
separation from the military, am I correct?
    Dr. Boyd. Now, that I am not sure. I would have to find out 
about that.
    Mr. Dunn. I think that is one good way to start the 
screening. Although, you can get Hepatitis C as a veteran too.
    Dr. Boyd. That is correct.
    Mr. Dunn. Well, with that, we are out of time. I appreciate 
your comments.
    Dr. Boyd. Sure.
    Mr. Dunn. Thank you. And I yield back, Madam Chair.
    Ms. Brownley. Thank you, Dr. Dunn. Congressman Rose, you 
are now recognized for 5 minutes.
    Mr. Rose. Thank you, Madam Chairwoman. I wanted to first 
off give you all an invitation to just speak to the issue of 
frequency of deployments, as well as the time between 
deployments, and any effect that you have seen this have on the 
post-9/11 female veteran population, and any lessons that we 
could potentially learn as we as a Nation conduct warfare in 
years ahead.
    Dr. Boyd. So I will pass that off to Dr. Carroll initially 
to see his input on that, and then of course, Dr. Hayes will 
have more specifics about the female deployments.
    Mr. Carroll. Thank you for your question, sir. We are very 
concerned about the impact of deployment on veterans. Male 
veterans, female veterans, anyone who is in a deployed 
situation. We know that deployment alone is not necessarily a 
risk factor. It depends upon what occurs during that 
deployment, the frequency of deployment. We have put into place 
special programs for units that we know had particularly 
difficult deployments. We are working with our partners to 
create reunion events for them and bring them back together.
    We know that the power of peer support and veteran to 
veteran support is critically important. We are looking for 
ways to extend that beyond the military life cycle itself, and 
to the veteran experience, making sure that all providers are 
aware of the impact of deployment, in making sure the community 
providers are also educated about the risks that veterans may 
have if they are seeing a community provider instead of one of 
ours. Dr. Hayes?
    Ms. Hayes. Thank you. I just want to bring up a couple of 
things, and I am very grateful to the veterans who have 
actually done a number of works published about this, as well 
as the Disabled American Veterans within their journey home, 
working on the issues for women veterans.
    I think that there is a sense that for many women, they 
have had to come home and deal with the family and children 
issues, sort of postponing some of their own needs as they have 
dealt with this. And also, that is one issue, and the 
psychological family needs it, family therapy, things like that 
that the vet centers can offer, but women sometimes postpone 
those needs, and then get a little bit lost to our systems. And 
some of the other challenges actually really are in the area of 
employment.
    And women have more difficult times getting into the right 
kind of employment, and the levels of employment for any number 
of reasons. But these are areas that then are very impactful in 
their lives and concern us in the transition, and particularly 
about the issues of self-harm and the risk during the 
transition time.
    Mr. Rose. And then did you have anything else in that 
regard?
    Dr. Boyd. Not at all. But it struck me when you asked the 
question, going back to Ms. Chairwoman Brownley's comment, the 
impact. I mean, it is just--it has kind of connected all the 
dots to me about the impact on our providers and our staff that 
meet these women veterans especially, whether at any point of 
care.
    Mr. Rose. So just lastly, I haven't heard much spoken 
about, and maybe I might have missed this, but care management 
programs and particularly efforts to meet patients, or future 
potential patients' veterans where they are, calls, text 
messages, knocking on their doors. This is the future of health 
care and it is particularly important for the veteran 
population because many of them are not seeking care. And they 
are certainly not seeking care at the VA, and sometimes we, 
based off our current systems, don't want them to.
    So where do we stand on this and what do you think we 
should be doing?
    Ms. Hayes. I think a really important part of this is the 
women veteran call center, which actually was set up to do 
outgoing calls to women veterans who don't use VA services, may 
not be connected and to inform veterans about eligibility, 
appointments, cemetery, BVA. And we have touched 1.6 million 
women through the outgoing call center.
    The other part of the call center is obviously all of the 
incoming calls and we wanted to make sure that calls and texts 
were available. That is a primary triaging and information 
service that we find very valuable to women. The other is care 
management in terms of local care management. And we have 
expanded the number of women's care managers, particularly in 
the rural areas, and that is another part of our ongoing effort 
right now to beef up that program to hire more women's care 
managers to do exactly what you are talking about: hook up with 
the veterans when they are in our clinics or in our facilities.
    Mr. Rose. Is there any further improvements you think we 
should be making to the care management program? Is it 
adequately resourced right now?
    Ms. Hayes. I think the resources are there within VA. I 
think we need to right size it so that we have the right kinds 
of services available.
    Mr. Rose. What would that look like?
    Ms. Hayes. It means moving people. You know, making sure we 
have more care managers. It means even more devotion to this 
hiring of primary care providers, social workers, nurses. It is 
taking the resources we have and putting a greater focus on the 
women veteran program within our own system.
    Mr. Rose. Okay. Thank you.
    Ms. Brownley. Thank you, Mr. Rose. I now recognize Mr. Barr 
for 5 minutes.
    Mr. Barr. Thank you, Madam Chairwoman. Thanks for holding 
this hearing. Thank you for our panel for discussing the 
legislative proposals before us. And first and foremost, let me 
echo the sentiments of those expressed today. In memory of 
those who sacrificed for our country, of course, the 3,000 
Americans who lost their lives in the attacks in 9/11, also the 
thousands of servicemen and women who were inspired to defend 
our country in the aftermath of that great tragedy.
    So many of these post-9/11 veterans now deserve and they 
have earned the support of this Congress and the Department of 
Veterans Affairs, and we appreciate all of your service in 
support of those heroes.
    Dr. Boyd, let me ask you a little bit about this Long Term 
Care Veterans Choice Act, which I have been proud to co-
sponsor. I want to thank, first of all, my colleague 
Representative Higgins, for introducing this legislation. And I 
like this bill because it gives our veterans who need long term 
care freedom and flexibility. They may not always want to go to 
a traditional institutional nursing home, and we think of the 
post-9/11 generation. These are young veterans, and especially 
if they are disabled, they don't want to go to what they 
consider a nursing home.
    So this is a really good alternative, I think. Allowing 
those veterans to live in a more intimate setting, like a 
medical foster home makes sense for the well-being of the 
veteran and can be facilitated at a fraction of the cost.
    And I noted, Dr. Boyd, your comment about the net savings 
estimate. So it is a win/win. Win for the taxpayer, win for the 
veteran, and I really think this is a great opportunity.
    The Lexington VA in my own district is proud to have a 
medical foster home program, and a former medical director had 
this to say about the program. ``The decision to leave the 
privacy and familiarity of your own home to live in a strange 
and unfamiliar environment is one of life's most difficult to 
make. Our program gives veterans a palatable middle option. 
Veterans live in the warmth and comfort of a medical foster 
home of their choice. And this is an encouraging option for our 
younger veterans injured in Iraq and Afghanistan who are too 
disabled to live alone, but they are too young to live in a 
nursing home.
    Dr. Boyd, in your testimony, you state that only 200 of the 
1,000 veterans living in MFHs currently would be eligible to be 
paid for by the VA under this program. Can you explain why that 
is?
    Dr. Boyd. That is taking into account that their priority 
1A veterans. But don't let this detour from this at all. We 
easily have capacity to accommodate up to the 900 average daily 
per year of veterans that would meet that criteria. This is a, 
as you said, a win/win. First of all, the quality and 
respecting the wishes and the preferences of our aging or our 
needy population. So it goes long in line.
    I visited with Ms. Chairman Brownley in a field hearing 
once where we talked about the choose home initiatives and long 
term care, and this coming up. And this is perfect. We strongly 
support this bill.
    Mr. Barr. Thank you. And I noted your technical suggestions 
as well. You mentioned the one year timeline that the bill 
gives you to get all the contracts in place. Would this work 
like the MISSION Act's community care network? Opt in is region 
2 in my area. They are going to take over for Tri-West, for 
example. Would they get the contract for Lexington--for the 
Lexington area if they are already operating in our region for 
community care? How will that work?
    Dr. Boyd. So the medical foster home is a separate entity. 
I am not aware of this being part of our CCN, our community 
care.
    Mr. Barr. Community care. Okay.
    Dr. Boyd. No, these are within the community.
    Mr. Barr. Okay.
    Dr. Boyd. Yes.
    Mr. Barr. So it would not--
    Dr. Boyd. Not to use it with community--
    Mr. Barr. Part of the VA, not in the community care 
network.
    Dr. Boyd. That's correct.
    Mr. Barr. Okay. MST really quickly. Can any of you all 
think of potential barriers to care that exist for MST 
survivors seeking care? And I want to ask that question in the 
context of the MISSION Act. Of course, eligibility criteria is 
whether or not it is in the veteran's best medical interest to 
qualify to seek care in the community.
    If an MST survivor were more comfortable with a provider in 
the community than at the VA, how would they interact with the 
community care criteria?
    Mr. Carroll. We screen all veterans for military sexual 
trauma that come into VA care. So it is a priority of focus for 
us. In terms of-- and they can receive care at VA at no cost, 
and we make sure that staff can refer people to our military 
sexual trauma coordinators across our facilities. And we would 
work with--if they are more comfortable in the community, we 
would want them to go to the most appropriate resource to take 
care of them.
    Mr. Barr. Well, I appreciate that. I think the VA is 
improving rapidly in addressing MST. And I know there is 
legislation here today that we are considering that addresses 
that as well for the VA. But a number of my, especially female 
veterans who I represent, are very interested in accessing 
community care for that specific issue. So we appreciate that, 
and my time has expired, and I yield back.
    Ms. Brownley. Thank you, Mr. Barr. And I just want to say I 
concur with your support on Mr. Higgins' bill. I think it is a 
great bill and hopefully we can move that forward.
    So, Mr. Cisneros, you are now recognized for 5 minutes.
    Mr. Cisneros. Thank you, Madam Chair. Thank you, everyone 
on the panel, for being here today. I want to address a couple 
things. Dr. Boyd, it has already been said, I think, like over 
75 percent of women don't use the VA. It takes them almost 
three years before they are connected to VA, if they do. I 
mean, do you acknowledge that that is true?
    Dr. Boyd. I would defer that overall to Dr. Hayes from her 
expertise.
    Ms. Hayes. Yes, those are accurate statistics. There is a 
delay in seeking care. And what I would say, though, is we have 
gone up from--where only 11 percent of women used our care when 
I was first working on this, and now we are up to 25 percent, 
but we are still way below the percentage of men who use VA.
    Mr. Cisneros. Correct. We still have a long way to go.
    Ms. Hayes. Right.
    Mr. Cisneros. I mean, it is good that there is improvement, 
but still a long way to go. We will acknowledge that. But, you 
know, on bills like 2982, where you oppose some research being 
done to find what are the barriers for women using VA care, and 
also in Section 4 of 3867. The VA doesn't--thinks that a task 
force that would help women expand--who will find out way 
expanding services are available to veterans at risk of 
pertaining to domestic violence, why that is necessary.
    I mean, you both reference, or you reference in your 
opening statement that both with the one in 3867 that there was 
a study done or a task force created back in 2012 and 2013, and 
this doesn't need to be done again. And also in 2982, you talk 
about a study that was done in 2015, took down the barriers to 
find out what are the barriers that keep women from seeking 
care.
    So if these studies have already been done, obviously, I 
mean, we both acknowledge, or everyone acknowledges that more 
needs to be done. Why would we not seek more data, more 
information? Why would we not want to do a task force that 
would provide us with the information to find out how women 
could find out more information, or really to seek in regard to 
domestic violence? Why won't the VA acknowledge that we need to 
find more data, and to do these studies, and to do these task 
force?
    Dr. Boyd. Well, I will start with this. With regards to the 
Violence Against Women Veterans Act that you referenced; I will 
pass that off to Dr. Carroll in just a bit. But we have, and 
thanking Congress for the 17 million back in fiscal year 2018 
and 2019, we have a very, very strong assistance program for 
the intimate partner violence assistant program.
    We would suggest that that be the lead to take this 
forward. We already have that in place, and I would like--if it 
is okay, I would like Dr. Carroll just to give a little snippet 
about that as well.
    Mr. Carroll. It is an important area, and we know that 
intimate partner violence is also a risk factor for suicide, 
and so those two things, and being a woman, those--the 
combination of factors is a great concern for us. With the help 
of Congress, as Dr. Boyd mentioned, we did stand up the 
intimate partner violence assistance program. There is a point 
of contact at every facility.
    We know that based upon evidence that if providers ask 
about this and veterans feel comfortable talking about it with 
their provider, that there is a significant chance, a 
significantly greater chase that they are going to get out of a 
dangerous situation and take action against that. And so I 
think we have many things in place already. We are very happy 
to move forward with it and to learn more from our experience, 
and to learn from women veterans as they participate in that.
    Mr. Cisneros. Your last task force was six years ago. There 
are still, obviously, barriers for women to seek out these 
services. Don't you think it is time to update and to kind of 
maybe get a new task force together to find out what can we do 
more to increase these numbers?
    Ms. Hayes. If I could, we are sort of bifurcating two 
different topics. One is about domestic violence, interpersonal 
violence, and sexual assault. The other part is the survey that 
you have recommended. We do, again. Now, I want to show you. 
This is the 2015 survey. It is no small report. It didn't--we 
took this. We have made recommendations. We have initiated 
actions. We have those actions moving forward. We have them 
going on. In addition, we have continued to talk to veterans in 
a very critical way through something that is called the 
veteran experience journey.
    We have been working individually with veterans in various 
parts of the country to have them describe what they need right 
now today, and those experiences are being acted on. So we have 
pain points for veterans, like getting into the system, finding 
out about their benefits, getting better relationships with 
their providers. Things that we would survey, but a survey just 
gives the answers across the country. It doesn't get us to the 
action.
    We have gone more directly to veterans right now in real 
time, and then we have design factors that are making them 
happen. So we can explain more to you about what that is, but 
frankly, the amount of money that it takes to do a study like 
this, I have a sense that we are going to find the same answers 
that we know about right now from the veterans. They have 
difficulty with information, how to access, distance, 
understanding the MISSION Act, all of these things that we can 
work on today.
    Mr. Cisneros. Yeah. Well, my time has expired, and the size 
of the report doesn't really suggest that it is better, but 
maybe we need to start asking different questions so we can get 
these numbers up. We need to figure out how we can get women to 
start using the VA benefits and to really seek treatment at the 
VA that they are entitled to. And I am glad that you are up to 
25 percent now, but that is still way below where it needs to 
be.
    So thank you very much for your time.
    Ms. Brownley. Thank you, Mr. Cisneros.
    Mr. Levin, you are just under the wire. You are now 
recognized for 5 minutes.
    Mr. Levin. Thank you, Chair Brownley.
    As a member of the Women Veterans Task Force I appreciate 
you holding this hearing on a number of bills addressing the 
women veterans' health care needs. It is critical that we 
tailor VA services to women veterans rather than asking them to 
just adjust to a male-centric system.
    One of the ways we can do this is by training our providers 
at the VA and those we partner with in the community to better 
understand the unique needs of women veterans.
    I want to thank my colleague, Mr. Rose, for introducing the 
Breaking Barriers for Women Veterans Act to work towards this 
important goal.
    Dr. Boyd, I would like to ask you about your testimony on 
this bill. You mentioned that some clinics do not treat enough 
women to justify a full-time women's health care provider and, 
instead, train existing providers to treat both men and women.
    Who trains these providers and how does the training 
specifically address the needs of women veterans?
    Dr. Boyd. Well, I will pass that on to Dr. Hayes. She can 
give you a much more fluid answer. We're very confident in that 
training. So, Dr. Hayes.
    Dr. Hayes. We have an extensive training process. The 
basis, it starts with a women self-mini residency. The 
providers go for a week. They train with what is called 
standardized patients to do pelvic exams. They also learn about 
deployment issues, chronic pain, and they learn about 
contraception and abnormal pregnancies, everything that they 
need to have their skills updated on.
    This year we trained over 700. We have trained over--it is 
our own staff that trains, and some of us have trained the 
trainer model, but it is our own highly proficient women's 
health providers that do the training.
    Mr. Levin. Thank you, Dr. Hayes.
    Dr. Boyd, you also stated that the $1 million increase for 
the women veteran's health care mini residency program would be 
unnecessary, but also stated that past mini residencies have 
had waiting lists because demand exceeds capacity.
    If this is the case, can you explain why the VA does not 
support a funding increase?
    Dr. Hayes. If I may, this is a technical issue. In the bill 
we were unclear whether this $1 million--first of all, whether 
that is a ceiling and would actually crimp our style. We have 
actually spent about $1 million right now.
    It is the staff capacity to go on and do more training that 
has left us with this problem of having people still on the 
waiting list. We have done a number of initiatives to work on 
that. One is our rural health initiative. We have started a new 
team and have people go out to the rural sites where our 
greatest need is and train them on site. So that is one of the 
things that we are doing.
    But we have just sort of reached the max of what we can do 
right now, and that is why we have waiting lists. We could 
expand it. We think the VA has within its resources to do this. 
It is always great to get additional appropriations, but we 
were concerned that you not limit us to $1 million--
    Dr. Boyd. Right.
    Mr. Levin. Okay.
    Dr. Hayes [continued].--because we are already spending at 
that level.
    Mr. Levin. So it sounds like there--
    Dr. Boyd. That is right.
    Mr. Levin [continued].--is an opportunity for some 
collaboration between yourselves and--
    Dr. Boyd. That is correct.
    Mr. Levin [continued].--staff to work out that language to 
clarify.
    Dr. Hayes. I would welcome that. Thank you.
    Mr. Levin. That is good.
    Dr. Boyd. Uh-huh.
    Mr. Levin. Dr. Boyd, I am glad also that another one of the 
bills we are reviewing today, the VA Hiring Enhancement Act, 
would provide additional tools to recruit staff.
    I hear from many veterans in my district in Southern 
California that understaffing affects their ability to receive 
health care in a timely manner. And as you noted in your 
testimony, the provision allowing VA to recruit physicians 
before they complete their residencies only applies to those 
that enter a specialty field.
    Could you explain why this authority is important in the 
recruitment of both primary and specialty care providers?
    Dr. Boyd. So a couple of things. In addition to the hiring 
authority that we have, we can offer a job, if we have a slot 
available, to a training resident within any facility, within 
my facility, say. But they have to meet the requirements by the 
time of employment.
    And that is part of what we want to do. We want to hire the 
ones that we train. They are there because they like the 
community. They are invested. And just to be clear as well, we 
have been afforded other hiring authorities and opportunities 
from congress as well. The education debt reduction is huge. 
That has been a huge success for us, as well as our retention 
and our incentives in relocation.
    So we can hire ahead of time and that is the best thing to 
do. If you see a good candidate who is training, we want to 
hire them. So we already had that authority. We don't think 
that we--that, in fact, would be a duplicative authority for 
us.
    And next week, I don't know if you were here earlier, but 
next week there will be a hearing and there will be specialists 
in that workforce area and HR area that we have been consulting 
with.
    Mr. Levin. Thank you.
    Dr. Boyd. You are welcome.
    Mr. Levin. And I am out of time, but I want to again 
commend the chair for her great work on the women veteran's 
task force, and all of my colleagues on both sides of the aisle 
for all their excellent work in service to our veterans.
    Thank you very much.
    Ms. Brownley. Thank you, Mr. Levin. And I don't see Mr. 
Steube. He was here earlier. And so I will just say before I 
excuse the panel that, Dr. Boyd, thank you for a pretty 
comprehensive written statement. I think that you have made 
some valid observations with some of these bills. There are 
some places where we may not agree completely, but I hope that 
over time we can work through these things and to see these 
bills through and sent to the president's desk for signature. 
So we will look forward to that work ahead of us.
    And having said that, thank you for being here. And we will 
excuse you and we will move onto our second panel.
    Dr. Boyd. Thank you very much.
    [Pause]
    Ms. Brownley. Welcome to our second panel. Thank you for 
being here. We have Mr. Jeremy Butler, Chief Executive Officer 
for Iraq and Afghanistan Veterans of America. Next, we have Ms. 
Joy Ilem, National Legislative Director of Disabled American 
Veterans, and finally we are also joined by Mr. Roscoe Butler, 
Associate Legislative Director for Paralyzed Veterans of 
America. Thank you, again, for being here.
    And I now recognize Mr. Butler for 5 minutes.

                   STATEMENT OF JEREMY BUTLER

    Mr. Jeremy Butler. Thank you, ma'am.
    Chairwoman Brownley, Ranking Member Dunn, and Members of 
the Subcommittee on behalf of IAVA, thank you for the 
opportunity to share our views on the pending legislation 
today.
    I would like to take a moment to say that I also appreciate 
the opportunity to testify today on the anniversary of the 
September 11th attacks. It was obviously a tragic day in our 
country's history, but it was also a day that inspired many of 
IAVA's members to join the military. And it is an honor to be 
here with you all to work together to ensure that we are 
getting them the best care that our veterans deserve.
    Support and recognition of women veterans is an incredibly 
part of IAVA's work. And as such, it is included in our 2019 
big 6 priorities. We launched our groundbreaking, She Who Borne 
the Battle campaign in 2017, focused on recognizing the service 
of women veterans and closing gaps in care provided by VA.
    IAVA chose to lead on this issue not only because it is 
important to the nearly 20 percent of our members who are 
women, but because it is important to our entire membership, 
and it will help ensure the future of America's health care and 
national security.
    Two years ago IAVA worked with congressional allies to 
introduce the bipartisan Deborah Sampson Act in the House and 
the Senate. It called on the VA to modernize facilities to fit 
the needs of a changing veteran population. Increased newborn 
care, established new legal services for women veterans, 
eliminate barriers faced by women seeking care, and increased 
data tracking and reporting to ensure that women veterans get 
care on par with their male counterparts.
    The Deborah Sampson Act was not passed last session, but 
IAVA recognized that some progress was made in support of women 
veterans with key provisions of that legislation passed or 
funded. With much more still to be done, though, IAVA strongly 
supports passage of all of the provisions of the Deborah 
Sampson Act. Many have been introduced by members of this 
Subcommittee and across congress, and IAVA emphatically 
supports the 6 Deborah Sampson Act bills being considered 
today: H.R. 2645; 2681; 2798; 2972; 3036; and 3636.
    IAVA also supports the VA Newborn Emergency Treatment Act. 
Coupled with provisions in the Deborah Sampson Act, this will 
finally allow the VA to adequately care for veteran mothers and 
their babies.
    To design precise policy solutions, we also need robust 
data collecting, sharing and analysis to know the extent to 
which women veterans are underserved. IAVA strongly supports 3 
bills to address these shortcomings: The Improving Oversight of 
Women Veterans Care Act; The Women's Veteran Health Care 
Accountability Act; and Improving Benefits for Underserved 
Veterans Act.
    For women veterans who choose to seek care at VA, finding 
quality providers who understand their needs can be difficult. 
Not surprisingly, women veterans are more likely than their 
male counterparts to seek care in the community, meaning they 
are often seen by private care providers that may not 
understand military service and its health impacts.
    Our 2019 member survey found that while 70 percent of 
respondents felt that VA clinicians understood the medical 
needs of veterans, only 44 percent felt that non-VA clinicians 
understood them. For these reasons IAVA supports the Women 
Veterans Equal Access to Quality Care Act and the draft 
legislation to establish the VA Office of Women's Health.
    Since 2001 the number of women using VA services has 
tripled. As more military women make the transition to civilian 
life, it is paramount that DoD and VA are ready to support 
them. That includes ensuring proper reproductive care for women 
veterans and their spouses. Currently, women veterans do not 
have the same access to contraceptives as their civilian 
counterparts. That is unacceptable and it is why IAVA supports 
the Equal Access to Contraception for Veterans Act.
    Ensuring that the VA is able to accommodate the millions of 
veterans who use it for access to medical care and benefits, it 
is paramount to ensuring the lasting success and health of the 
veteran population. About 48 percent of all veterans and about 
55 percent of post-9/11 veterans are enrolled in VA care. Among 
our survey respondents, 81 percent are enrolled in VA health 
care, and the vast majority have sought care from VA in the 
last year.
    The VA has made incredible strides in modernizing its 
operating systems, but VA also needs robust modern hiring 
practices in order to compete for talent to fill their 
overwhelming number of vacancies. To this end, IAVA supports 
the VA Hiring Enhancement Act.
    Members of the Subcommittee, thank you for your commitment 
to ensuring women veterans receive care that is on par with 
their male counterparts. And thank you for the opportunity to 
share IAVA's views on these issues. I look forward to answering 
any questions you have.

    [The prepared statement of Jeremy Butler appears in the 
Appendix]

    Ms. Brownley. Thank you, Mr. Butler. And I now recognize 
Ms. Ilem for 5 minutes.

                     STATEMENT OF JOY ILEM

    Ms. Ilem. Thank you, Chairwoman Brownley, Ranking Member 
Dunn, and Members of the Subcommittee.
    DAV appreciates the opportunity to provide testimony on the 
17 bills under consideration today. We thank the Subcommittee 
for its focus on improving VA health care services and programs 
for our Nation's women veterans.
    Ensuring women have equal access to high quality, 
comprehensive primary care and the specialized services VA 
offers is a critical legislative priority for DAV. We are 
pleased that many of the bills that we are providing comments 
on today reflect recommendations made in DAV's 2018 report, 
Women Veterans, The Journey Ahead, and comport with DAV 
Resolution Number 020.
    DAV offers our support for H.R. 2645 and H.R. 2752. These 
bills improve VA's maternity care package and ensure VA can 
secure appropriate contracts for VA sponsored community care 
for women veterans and their newborns.
    H.R. 2681 requires VA to submit a report on the 
availability of prosthetic items for women veterans in VA.
    While DAV supports the intent of this bill, under DAV 
Resolution Number 383, we ask the Subcommittee to consider 
broadening the scope of the study proposed to ensure the intent 
of the legislation is fully realized.
    Specifically, we want to ensure that women veterans have 
access to high quality prosthetic items and prosthesis that 
meet their expectations in fit, function and appearance.
    DAV is also pleased to support H.R. 2798, a bill that would 
establish a permanent counseling program in retreat settings. 
This pilot has shown consistent improvements in participants' 
ability to better manage PTSD symptoms and maintain learned 
coping strategies. It also garners high satisfaction rates 
among women who note peer interaction and networking is 
especially helpful for long-term recovery from post-deployment 
mental health challenges that many women veterans face.
    DAV supports H.R. 2972, 2982 and H.R. 3036, bills which 
focus on improving web-based resources and outreach to women 
veterans, information about availability of women's health 
services throughout the VA system, correcting environment of 
care and staffing deficiencies for women's health, and 
eliminating barriers to care.
    H.R. 3224 seeks to ensure women veterans have access to 
comprehensive gender specific care in all VA facilities, and 
calls for a study on using extended care hours to better serve 
veteran patients.
    While DAV supports what we believe to be the overall intent 
of this bill, we do ask that the definition of gender specific 
services be added to the bill prior to its advancement. In our 
formal statement, we express concern that without that 
definition there could be an expectation that services such as 
obstetrics and newborn care, which are generally provided in 
the community, would be required in VA facilities.
    H.R. 3636 and H.R. 4096 call for comprehensive reports that 
include data on the women veteran population using VA, models 
of care, access to care in the community, capital investment 
planning, environment of care standards, and staffing levels 
and provider training in women's health.
    DAV believes the collection and summary of this data in one 
report can be helpful for future planning to better meet the 
needs of this growing population, and we are happy to provide 
our support for these bills as well.
    DAV also supports H.R. 3798, a bill that would eliminate 
co-payments for contraceptive items and medication in 
accordance with DAV Resolution Number 365.
    H.R. 3867 seeks to create a national task force to 
integrate VA programs with existing community resources to 
better serve veterans who have experienced sexual assault and 
domestic violence. DAV does not have a specific resolution 
calling for such a task force or plan. However, we acknowledge 
the impact that these issues have on many veterans, and have no 
objection to a passage of this bill.
    The final draft bill, women veterans bill being considered 
today would establish an office of women's health within the 
VA. This measure would provide the director of the office 
control over all aspects of women veterans' health care, 
including distribution of resources. DAV believes this change 
is warranted and necessary for VA to address many long-standing 
issues and the enhancement of the provision of care for women 
veterans using VA and, therefore, supports the bill's passage.
    Finally, DAV supports the remaining bills on the agenda 
mentioned here today: H.R. 1163, the VA Hiring Enhancement Act; 
H.R. 1527, the Long-Term Care Veterans Choice Act; H.R. 2628, 
the Vets Care Center Act; and 2816, the Vietnam Era Veterans 
Hepatitis-C Enhancement Act.
    Chairman Brownley, that completes my testimony and I am 
happy to answer any questions the Subcommittee may have.

    [The prepared statement of Joy Ilem appears in the 
Appendix]

    Ms. Brownley. Thank you, Ms. Ilem.
    And I now recognize Mr. Butler for 5 minutes.

                   STATEMENT OF ROSCOE BUTLER

    Mr. Roscoe Butler. Thank you, Chairwoman Brownley.
    Ms. Brownley. Mr. Roscoe Butler.
    [Laughter]
    Mr. Roscoe Butler. Thank you, Chairwoman Brownley, Ranking 
Member Dunn, and Members of the Subcommittee.
    Paralyzed Veterans of America would like to thank you for 
the opportunity to submit our views on the important 
legislation pending before the Committee.
    The bills being reviewed today address a number of 
challenges veterans are facing and will provide vital 
assistance to help them overcome the pain and suffering from 
domestic violence while improving oversight of women veterans' 
health care and breaking down barriers for women veterans.
    For the sake of time, and since you have my full written 
statement, I would only discuss a few of the bills.
    H.R. 1163. PVA encourages many efforts to bolster staffing 
levels at VA facilities, particularly within the spinal cord 
injury system of care which historically, data shows, is one of 
the most difficult areas to recruit and retain physicians and 
nursing staff.
    We strongly support H.R. 1163, the VA Hiring Enhancement 
Act which seeks to release physicians from non-compete 
agreements for the purpose of serving at VA. Removing these 
barriers would help encourage more of the best and brightest 
doctors and nurse practitioners coming out of medical school to 
pursue a career in the VA.
    H.R. 2982. PVA also supports H.R. 2982, which directs the 
Secretary of Veterans Affairs to conduct a study of the 
barriers for women veterans to health care from the Department 
of Veterans Affairs. A major concern for PVA members is the 
accessibility of facilities.
    Here are a few recent examples of the barriers PVA members 
have experienced:
    Women veterans having to sit in their wheelchairs outside a 
Model 3 women veterans' clinic because the facility did not 
have a system in place to alert staff that someone was waiting 
to gain access into the clinic;
    Poorly designed facilities that limit VA's ability to 
provide medical care to people with severe or catastrophic 
disabilities and not having the appropriate diagnostic 
equipment on site to conduct mammography examinations on spinal 
cord injury women veterans.
    Identifying these and other kinds of barriers that women 
veterans face is an important first step toward improving the 
care they receive from VA.
    H.R. 3224. Without additional clarification, PVA cannot 
support H.R. 3224 as written. We are concerned that H.R. 3224 
does not define the type of gender specific services VA is 
required to provide. VHA Directive 1330.01(02), Health Care 
Services for Women Veterans break down gender specific care 
into several categories: Primary care and specialty care. 
Paragraph j provides a list of gender specific specialty 
services that must be available in-house to the greatest extent 
possible.
    Unless additional clarification is provided, VA could 
interpret Congress's intent with this legislation as a 
requirement to offer gender specific services in each VA 
medical center or community based outpatient clinic. There are 
a number of gender specific specialty services listed in VA's 
directive that VA medical centers and community based 
outpatient clinics are not capable of providing, particularly, 
when it comes to maternity and newborn care.
    In order to improve the bill and earn our support, this 
legislation would have to include language clearly defining the 
kind of gender specific services VA would be required to 
provide.
    Again, PVA appreciates this opportunity to express our 
views on some of the many important pieces of legislation being 
examined today, and I am available to answer any questions.

    [The prepared statement of Roscoe Butler appears in the 
Appendix]

    Ms. Brownley. Thank you, Mr. Butler. And I want to thank 
all of the witnesses today for your testimony, and even more 
importantly thank you for your engagement on all of these very 
important bills.
    So I will now recognize myself for 5 minutes for 
questioning.
    And the first thing, the first question I wanted to ask 
really is to Ms. Ilem since you referenced this around my bill, 
the Office of Women's Health.
    So, you know, what I am trying to get at here, basically 
with a bill, is, you know, when we are looking for equity and 
parity in terms of health services to women, you know, one 
quick thing one would look at is if women veterans make up 10 
percent of the veteran population and then you look at the 
health care budget, roughly you should see, you know, 10 
percent of the resources being spent on women's health. I mean, 
that makes sense.
    Medical directors across the country have a lot of 
flexibility and authority in terms of how those resources and 
spent. And in some cases, they may spend way beyond 10 percent 
in their facility. In other cases, they won't.
    So, you know, the intent here is to try to provide some 
accountability and some oversight with regards to how resources 
are being spent because reality, at the end of the day all of 
these issues that we are raising comes down to money to be able 
to provide the services, the staffing that we need to properly 
address veterans' needs, and in this case women veterans' 
needs.
    So do you have any other ideas of how we go about that? Do 
you think this is headed in the--you mentioned that it was 
headed in the right direction, and I appreciate that, or if you 
had any other sort of ideas?
    Ms. Ilem. I think this proposal would be key to really 
addressing what the congressional task force of women veterans 
is really seeking to do, which is to take care of these long-
standing issues that have been around for some time. I mean, I 
can just remember testifying on these same, many of these same 
issues for, you know, more than a decade now.
    I think the women's health services program office in VA 
has the direction, has the data, has much of what they need. 
They just need to be able to execute it. And I don't see that 
they really have that authority at the level of where that 
office is now.
    I know in VA's testimony they indicate that, you know, they 
feel it is positioned appropriately for them to carry out, but 
we would respectfully disagree. I think this will be key. They 
have got a plan. They just need to execute it. And they have 
the support of the leadership in the secretary in VA to really 
address these problems and take care of the staffing issues, 
the deficiencies, the cultural issues that they want to 
address. They have noted all of these things and they have a 
provision of services that they want to provide.
    So I hope that this will be--this bill will be considered 
and move forward because I see it is key in overall work that 
you and the Committee and the Subcommittee are trying to do.
    Ms. Brownley. Great. Thank you very much.
    Do the Mr. Butlers have any comments?
    [Laughter]
    Mr. Jeremy Butler. I don't have anything to add.
    Ms. Brownley. Okay. Very good.
    You know, and this question is really to anyone and all of 
you on the panel. You know, three of today's bills address 
improving reproductive health care access for women veterans. 
Can you add any additional services that the VA should be 
providing that would improve reproductive health for women?
    Mr. Jeremy Butler. I am happy to jump in.
    Yeah. I think a number of important issues are discussed in 
the legislation that is being discussed today. But beyond that, 
one of the recommendations that we have that IAVA has in our 
policy agenda is around expanding access to and funding for in 
vitro fertilization. I think IVF is another one of those areas 
where you have a disconnect between services available to 
active duty servicemembers and then what is available to 
veterans.
    And this is an especially important question for our 
membership because we do have a younger cohort, many of whom 
have deferred parenthood perhaps until their time in service 
was over because those demands in service were so great. And so 
increasing these accesses to things around fertility and 
childcare is very important to our membership.
    Ms. Brownley. Thank you.
    Mr. Butler.
    Mr. Roscoe Butler. I don't have anything additional to add, 
but I would like to bring to your attention the issue of 
mammography exams for women veterans in wheelchairs.
    VA facilities, most VA facilities, while they may have a 
mammography machine to do the exam, they don't have the 
appropriate equipment. So most of the time women have to sit in 
their wheelchairs. If they are a large woman, it is difficult 
to raise.
    There are certain equipment that they can purchase that 
will make it much easier for them to do their exams. And if 
they complete the exam without the woman getting out of the 
wheelchair, it is not going to be the appropriate type of 
examination that really should be done.
    So I would ask that they really look at that and expand 
upon the type of equipment that they purchase and procure for 
women particularly who are in wheelchairs.
    Thank you. Thank you for adding that and bringing that up. 
And I will say that you have an extraordinary representative 
who came to my office, a woman in a wheelchair talking about 
this issue, and she was quite persuasive.
    So thank you very, very much.
    And with that I recognize Dr. Dunn for 5 minutes.
    Mr. Dunn. Thank you, Chairwoman Brownley.
    I want to start with saying that we fully expect that some 
of the items that are coming through in these bills suggest 
like they have cost implications to the VA. And what we would 
like to do is secure, you know, the VSS, all of them, you being 
lead dogs as it were on the VSS, to work with us here in 
congress and with the VA specifically, that what we can do in 
our jurisdictions to get offsets for some of these costs 
because hopefully we can find some of the money right there.
    You know, so please address that.
    Mr. Jeremy Butler. I think we often caution about this 
discussion where the pay come from other veteran benefits. I 
don't necessarily have the answer as to where the money should 
come from, but what I can say is our membership is adamant that 
it should not come by reducing other benefits that go to 
veterans. We fought this battle just last year I think it was 
around the GI Bill, when there was an attempt to maybe make 
some cuts on the GI Bill payments to have money go to another 
veterans' benefit.
    We always want to ensure that our veterans are getting the 
care that they deserve and the support they deserve and the 
benefits that they deserve, but we should not be cannibalizing 
one program to fund another one, especially when both of those 
programs are equally necessary and important.
    Mr. Roscoe Butler. PVA echoes Jeremy's concerns and would 
not support taking away funding from one program to support 
another program. We have to find a common way to support all of 
the bills being presented today. And we, the PVA, supported all 
of the bills today with one exception.
    So whatever the common ground that we can reach, but we 
echo Jeremy's concern.
    Ms. Ilem. I think my colleagues have addressed our same 
concerns; that certainly we want to be able to work with the--
with you and your staff on this agenda because we think it is 
so critical and so important.
    But, you know, we do have those considerations in mind when 
it comes to taking away from one veteran to serve another 
veteran. And we want to make sure that services that are being 
provided to women veterans have--we have equal access to care 
which has been a problem--
    Mr. Dunn. My thought was actually more about programs that 
are either no longer viable or they are replaced with newer 
programs, or there are some programs that overfunded. There is 
extra money sitting in some parts of the VA. And I think we can 
all identify efficiencies in offices. Certainly, I identified a 
lot of efficiencies in my offices over time.
    Next question, Ms. Ilem, I read your testimony. I liked it. 
But there was one jarring, I kind of kept coming back to it. 
You said you thought that the--well, let me get the paragraph 
here. ``We believe the VA health has different responsibilities 
than the health care industry in general.''
    I have worked in both VA and, you know, civilian health 
care and active duty health care. What do you think is 
different about it? I mean, other than you have a unique 
population.
    Ms. Ilem. Well, definitely I think in that reference for 
the--that was on Bill 1163 we were talking about the 
responsibility of VA to train, the training responsibility that 
they have had for training our Nation's clinicians. So--
    Mr. Dunn. So training, you think that is the unique part of 
it, that they have to do training?
    Ms. Ilem. Well, not just the training of clinicians, but 
that has been one of their major functions within the 
department.
    Mr. Dunn. I remember.
    [Laughter]
    Ms. Ilem. Yes. You know, so many clinicians are trained 
through VA and they do have some additional responsibilities 
that, you know, we don't see so much in the general sector, and 
a very specialized mission and some very specialized programs.
    So I think we were just trying to make the point that VA is 
a unique health care system in itself, you know.
    Mr. Dunn. All right. So I thought I traveled pretty fluidly 
between the different programs and, you know, it is about 
taking care of people. Certainly, you know, I like taking care 
of military people especially, but that is why I did it for a 
long time. But I just--it kind of kept coming back like what is 
different, what is different. All right.
    So the last thing is I want to ask you to help, again, as 
advocates for services in the VA for the Hepatitis-C program. 
We talked earlier with the first panel. You know, we have cured 
100,000 veterans of Hepatitis-C. That is amazing. That is just 
amazing.
    When I was practicing 20 percent of surgeons would 
terminate their career because they caught Hepatitis from a 
patient during surgery, you know, accidentally, needle pricks.
    So this is a big, big deal. It is close to my heart. I want 
you to get the word out to the veterans.
    Thank you very much.
    Ms. Brownley. Thank you, Dr. Dunn.
    Mr. Lamb, you are recognized for 5 minutes.
    Mr. Lamb. Thank you, Madam Chairwoman, and thank you for 
holding this important hearing and advancing all these bills. 
We have a lot of work to do in this area, and I think those of 
us who served in uniform more recently know that there is just 
absolutely no excuse for any veteran, man or woman, feeling 
that when they leave the service the VA services are not for 
them.
    So I think we are starting to make a big impact on that 
now. But one of my concerns that we see across problems faced 
by the VA is difficulty in connecting with the people who we 
are intending these new services and reforms to reach.
    And so I am sure you have addressed it a little bit 
already. I apologize for coming in late. But I just wanted to 
throw it open to any of the three of you about whether you can 
advise us on what we can do to better reach into the wider 
veteran population that is not enrolled in VA services or that 
are enrolled once and didn't like the experience and has never 
used it again, to advertise some of these new things that we 
are passing, to invite people back in.
    And I guess kind of a subset of that, if you have had any 
experience with it already is what are the implications for 
community care. Obviously, community care has been expanded. A 
lot of new services and new patients will be eligible for all 
of that. Are you seeing excitement or interest in community 
care among women veterans, particularly those maybe who haven't 
used the VA much before? Anyone who can weigh in on that.
    Ms. Islam. Sure. I would love to take the opportunity to 
talk about that.
    While we support community care and we want women veterans 
who feel they need access to care in the community or may need 
because VA can't provide certain services, obviously we want 
that to happen. We think it is really critical, though, during 
this implementation phase of the MISSION Act that VA is really 
instrumental in being the coordinator of that care as those 
women veterans go to the community.
    As you heard from the first panel today, so many women 
veterans have complex--the women who are being seen in VA have 
complex medical health histories and challenges. Their veteran 
experience is really important and VA can help train those 
providers that are going to be in their network to make sure if 
they are seeing a woman veteran, here are the things that we 
know about this women veteran population and to be sensitive 
about and the gender sensitivities and cultural sensitivities 
around military sexual trauma especially.
    So I think that is going to be critical, and for VA to be a 
real partner because we know some women veterans have had a 
really negative experience in VA. But at VA we do want them to 
reach out. So many changes have been made. Just over the past, 
you know, 10 years we have seen incredible changes.
    I am a woman veteran. I use VA. I have for 20 plus years. I 
have seen those changes firsthand and I think they would really 
benefit for coming to VA, especially those who have service 
connected disabilities, obviously those who have catastrophic 
injuries, our OEF/OIF population, so key. You know, they have 
had several deployments and, you know, over time there is 
really so many benefits in VA with their specialized programs.
    So I hope that VA will be able to do some additional 
outreach to those, come back, try the VA, we are there for you, 
and improve services.
    Mr. Lamb. I think that is an excellent point.
    Mr. Butler, did you want to--
    Mr. Jeremy Butler. Yeah. I was just going to echo Joy's 
statements about MISSION Act and community care. And then just 
add maybe around your question on getting word out and 
everything. You know, I was in a similar case. When I 
transitioned off of active duty in 2005, I didn't really 
understand the VA. It wasn't really something that was talked 
about when you are on active duty. I think once you start to 
hear about it when you are out of active duty, you generally 
hear the more negative things rather than the positive things.
    So I think as VA care continues to improve and there are 
more positive stories coming out, 1, I think you're going to 
have a more understood idea in the veteran community that it is 
a positive place to go. But then there also just needs to be 
better interaction, I think, with the non-profit organizations, 
with community care organizations to understand how to access 
the VA.
    I have been in this business for 4 years now and it still 
is incredibly complex to me to understand how one accesses the 
VA to begin with.
    Mr. Lamb. No, it is, and that seems to be the most 
important hurdle. What I always hear, at least, is that once 
people finally get enrolled and are in and they know that they 
are in, at least in Western Pennsylvania they are happy. They 
think the VAs are great. But we have a hard time getting people 
over that initial obstacle.
    So I think that is what we can all work on. And I think 
your groups play a really important role in that. So please 
continue to challenge us as to how we can support you to 
recruit new people and get better information to those that are 
there.
    And with that, Madam Chairwoman, I yield back.
    Ms. Brownley. Thank you, Mr. Lamb.
    Mr. Barr, you are recognized.
    Mr. Barr. Thank you, again, Madam Chairwoman, for holding 
this hearing and thank you for considering legislation that 
supports and recognizes our women veterans and newborns and 
their kids, and looking at ways to eliminate barriers for women 
veterans to access the VA.
    I would note, Chairwoman Brownley, that I was happy to 
support your bill, H.R. 840, earlier in this congress, the 
Veterans Access to Child Care Act. One of those barriers is 
needing to provide women veterans with childcare so that they 
can have the time to go seek veterans care.
    I would urge you and Chairman Takano to consider the VA 
Child Care Protection Act, which we offered as a motion to 
recommit and then we also offered it as an amendment in the 
last mark up to the Cisneros bill.
    And then in July we introduced a separate bill because I 
think there was some commentary that it needed to be separate 
from the Cisneros bill, the VA Child Care Protection Act, to 
make sure that employees of the VA are not a threat to our 
children, so that that wouldn't be an additional barrier for 
women veterans seeking access to care.
    And just to remind the Committee, we did send a letter on 
July 19th with 10 republican Members of this Committee to the 
Chairman asking for a hearing. We have not yet heard a 
response. I just bring that to your attention, Chairwoman 
Brownley, because we would like to work with you on that issue.
    Mr. Butler, in your testimony you point out that while the 
VA provides care team support to the medical foster homes, it 
does not have the authority to pay for the costs of those 
medical foster homes. As a result, veterans must use personal 
or other funding sources should they choose this alternative 
rather than nursing homes.
    And I appreciate your association, support and endorsement 
of the Long Term Care Veterans Choice Act to support more of 
your members having access to these MFHs.
    Can you or any of the other colleagues on the panel 
describe what funding sources veterans do use to pay for this 
care and obviously the hardship that that creates?
    Mr. Jeremy Butler. I can't necessarily speak specifically 
to that, but what I do know is that financial hardships are one 
of the main reasons that veterans come to our organization 
seeking support. And a lot of those financial hardship cases 
are underpinned by trying to pay for medical care that they 
need.
    We have a rapid response referral program that veterans and 
family members can reach out and work with social service 
professionals that are employed by IAVA. And this is one of the 
most frequent things that they hear about. It is financial 
hardship, and then when they start to dig into what the cause 
of the financial hardship, it is paying for medical care.
    So that is kind of a high level--
    Mr. Barr. Yeah.
    Mr. Jeremy Butler [continued].--answer to your question. It 
is not exactly specific.
    Mr. Barr. Can you speak to the quality difference or the 
quality of life differences that veterans may experience, those 
who live in these medical foster homes versus traditional 
nursing homes? Any of your members of any organizations can 
speak to that.
    Ms. Ilem. We just have heard that, and I think some members 
on the Committee today have mentioned, especially for younger 
veterans who maybe have experienced a TBI, can't live 
independently, but could really benefit from living in a 
medical foster home environment versus a long-term perhaps 
nursing home, one of the community living centers.
    So I think it really adds to their dignity, to their 
quality of life, what they want to achieve even though they 
have undergone, you know, a serious injury or disability.
    So I think the medical foster home is just an excellent 
program and I really hope that we can make sure there is no 
disincentive for any service disabled veteran to choose that 
access or that option.
    Mr. Roscoe Butler. And I would just add, it adds to their 
independence, being able to live outside of a nursing home 
facility. And then overall, as Ms. Ilem mentioned, their 
quality of life dramatically improves living in a medical 
foster home versus being in a--
    Mr. Barr. Thank you, Mr. Butler.
    Mr. Roscoe Butler [continued].--community nursing home.
    Mr. Barr. And, Ms. Ilem, one last question for you. With 
regard to your testimony on H.R. 3867, the Violence Against 
Women Veterans Act, I was interested in your testimony that 
there was a study that women are re-traumatized when they are 
attempting to obtain care in the VA, and that those occurrences 
are all too common.
    Are we seeing the setup of nationwide community care under 
MISSION Act in a way that would get women veterans, or men 
veterans, who are uncomfortable in the VA because of re-trauma, 
being re-traumatized, are we seeing the MISSION Act give an 
alternative to those veterans who don't feel comfortable in a 
VA and want to choose community care to deal with MST?
    Ms. Islam. Well, VAs recent harassment study, I think, is 
just really alarming for a lot of us. We know that some women 
veterans coming to VA reporting, you know, being harassed while 
seeking care, and that has been a disincentive for them to go. 
And these are generally probably the ones who most need that 
care.
    So I think here in the community for some women veterans it 
may be the answer, but I hope that that is a temporary thing. I 
really hope VA, which they have talked about today, that they 
are addressing these issues full force, full on. Their culture 
has to change, making sure that every veteran feels welcome at 
VA. And obviously no veteran should be harassed, male or 
female, coming to VA.
    And we don't want it to--we don't want that to remain. I 
mean, we know that is a problem, and I grant it to VA for 
actually bringing that research forward. And we have been 
hearing that for some time. And, you know, if that is 
prohibiting somebody from going, we want them to get care then. 
That might be something that they could consider in the 
community.
    But we certainly don't want that to just be the only 
place--
    Mr. Barr. Right.
    Ms. Islam [continued].--they can go. We want it to be fixed 
within VA.
    Mr. Barr. Absolutely.
    Thank you. Thank you. And I yield back.
    Ms. Brownley. Thank you, Mr. Barr. You can never say I 
never gave you extra time.
    [Laughter]
    Ms. Brownley. Mr. Bilirakis, you are recognized for 5 
minutes.
    Mr. Bilirakis. Thank you. Thank you, Madam Chair. I 
appreciate it very much.
    Yeah. My questioning will be regarding H.R. 2628, the Vet 
Care Act, which I introduced.
    The VA has expressed concerns--this is for the entire 
panel. We will start with, is it--well, whoever wants to go 
first. The VA has expressed concerns about apparent disparities 
created in H.R. 2628, the Vet Care Act, pilot programs, 
eligibility standards.
    Given the logic of the VA, it seems to me that every pilot 
program VA has ever operated could also be viewed as creating 
disparities in care for veterans. Indeed, this argument could 
be applied across the board to all valid controlled clinical 
research done in science and in medicine. There will always be 
limitations and exclusions.
    Considering the current eligibility criteria for dental 
care in the first place, can you explain why you agree that 
this pilot program is a reasonable way to take a first step 
into assessing the specific benefits of preventive dental 
medicine at VA such as the one in H.R. 2628? Whoever would like 
to go first, please.
    Mr. Roscoe Butler. I will try and address it.
    But as we said in our written testimony, oral health has a 
major impact on their physical health, and gum disease is often 
associated with diabetes, heart disease and many other serious 
medical conditions.
    So a large number of veterans who receive care from the VA 
are not getting the appropriate dental care needed, and which 
could later add to other complications of health complications.
    Mr. Bilirakis. Thank you.
    Anyone else, please?
    Ms. Ilem. DAV has been a longtime advocate of dental care 
for all veterans, being within a comprehensive care package. As 
we know, anybody who has health insurance, I mean, dental 
insurance is an important part of that complete package of 
care. And we have long wanted to make sure that veterans have 
access to that.
    So I think your bill is very reasonable in terms of a start 
to look at the conditions, as Mr. Butler indicated, that are 
prevalent in the veteran population and to kind of mirror the 
study as a first step of really offering that benefit.
    Mr. Bilirakis. Anyone else?
    Mr. Jeremy Butler. Just to agree. I never understood the 
disconnect between dental care and medical care. I think, you 
know, we all, I think, are in agreement here that it is the 
whole health that is the important part here and they should be 
seen as one thing. So we are very much in agreement.
    Mr. Bilirakis. Thank you very much.
    And I want to reemphasize that Dr. Jeffcoat from the 
University of Pennsylvania, who is the former dean of the 
dental school there, actually helped me craft this bill. She 
actually conducted the study and I worked with a dentist in my 
community as well, Dr. Zack Kalarickal, who is a good friend.
    But let me go ahead and ask one more question. The VA has 
expressed some concerns that the pilot in the vet care program 
would lead to veteran dissatisfaction if the pilot disqualifies 
certain veterans who receive examinations for dental care and 
are deemed to need surgery.
    H.R. 2621, however, specifically authorizes the VA to 
provide administrative support to ensure those veterans can 
receive the treatment that they may need.
    My thought is that the patient is better off than before 
because they have been alerted to a treatable problem having 
received a free examination compared to previously which must 
be seen as a significant benefit to the veteran with diabetes.
    To the panel, do you think your members would be 
dissatisfied with the pilot program outlined in this bill, 
especially considering the end goal? And we know what the end 
goal is, and I appreciate the chairwoman working with me on 
this particular issue because we all want veterans who qualify 
for health care under the VA ultimately to get dental care.
    So whoever would like to go first, please respond to that.
    Ms. Islam. I think veterans would understand your 
explanation and, certainly sometimes just even having that 
first opportunity to really identify, I have a problem and 
there is an issue here, and hopefully the assistance to, you 
know, get that care, that they wouldn't be dissatisfied. They 
may want to make--you know, they would love to be able to have 
that access to a full treatment.
    But I think it is a first good step and it is something. So 
certainly we would be supportive of that. And I think most 
veterans would agree with your logic.
    Mr. Bilirakis. Thank you.
    Mr. Roscoe Butler. I agree with Ms. Ilem. And an informed 
veteran is a happy veteran to the most part. Knowing that they 
have a condition that they didn't know they had, and then 
what's the recourse for taking care of that condition then 
becomes the issue for the veteran if they can't get it in the 
VA. But not knowing you have a condition is of really not a 
good thing which could lead to other complications.
    Mr. Jeremy Butler. Yeah. Agreed. I am still in the Navy 
Reserves and I have to get a dental checkup from a Navy dentist 
every couple of years. And it simply is to make sure that you 
have a proper level of dental care. If they find something 
wrong with you, the Navy, the Department of Defense isn't going 
to pay to cover it for you. They alert you that you need to go 
out and get that taken care of on the private side.
    If that is the way we are handling our reservists, then I 
think veterans would understand that it is the same thing; that 
you are getting access to a determination that you need some 
support and then you can go from there. So I think they would 
be okay with it and understand it.
    Mr. Bilirakis. Yeah. And under the legislation we 
authorize, after the pilot program, the caregiver, the dentist 
will refer them possibly to a non-profit or the insurance 
program. And that will be very helpful as well. But I think it 
is dangerous not to get the examination.
    So thank you very much, Madam Chair. I appreciate it. I 
yield back. I guess I am over time. I apologize.
    Ms. Brownley. Yes. You, too, can never say--
    [Laughter]
    Ms. Brownley [continued]. --that you have never had extra 
time on this Committee.
    Well, this concludes our questioning. And, you know, before 
I close, I wanted to just thank the VA staff for saying through 
the second panel. That doesn't happen every time when the VA 
comes to our hearing. So we appreciate that very, very much.
    And I just want to conclude with just a few remarks, and to 
say first that we have--I think this has been a good hearing. I 
am very excited about these proposed bills. But, first, we have 
a long way to go until we uphold the promise that we have made 
to our veterans, and this includes achieving equity for our 
women veterans.
    And, second, the VA must plan ahead for rapid growth of the 
women's veteran population. And I think many of these bills 
sort of address that. And the bills discussed today gives VA 
the tools to identify gaps and opportunities to plan for that 
growth and allocate resources accordingly.
    So, again, before I conclude I just want to reemphasize my 
hope for this Subcommittee and that we continue to work in a 
bipartisan manner. I look forward to continuing to work closely 
with Ranking Member Dunn as we have already done and will 
continue to do. And bipartisanship in this Committee, that is 
the only way we are going to get to good results for our 
veterans.
    So I thank all of our witnesses for their expertise and my 
colleagues for their interest.
    And with that, Dr. Dunn, would you like to make any closing 
comments?
    Mr. Dunn. Thank you very much, Chairwoman Brownley. I just 
want to say thank you as well to both panels. I think, you 
know, it has been a good exchange. I think you see the interest 
level in veterans' affairs, you know, throughout the congress 
and the administration. It is reflected in the budget as well.
    So I would--VA continues to be the single largest source of 
my constituent services' problems, I guess. The people come. 
They run afoul of the system. So anything we can do to help 
that system, you know, we are doing it on a one by one basis 
back home, but you guys could do the whole thing at once. So we 
appreciate everything that you do up here in helping us with 
that.
    And I agree. Working with Ms. Brownley on a bipartisan 
basis, we should be able to get something accomplished. In the 
last session it was the single most productive Committee, I 
believe, wasn't it? Yeah. The VA Committee was the single most 
productive bill-wise Committee in the congress, in the last 
session of congress. Let's see if we can do that.
    Thank you.
    Ms. Brownley. Hear. Hear.
    So with that, all Members will have 5 legislative days to 
revise and extend their remarks, and include extraneous 
material.
    Without objection, the Subcommittee stands adjourned.

    [Whereupon, at 12:05 p.m., the Subcommittee was adjourned.]



                            A P P E N D I X

                              ----------                              

                 Prepared Statement of Teresa Boyd, DO
    Chairwoman Brownley, Ranking Member Dunn, and Members of the 
Subcommittee. Thank you for inviting us here today to present our views 
on several bills that would affect VA health programs and services. 
Joining me today are Dr. Patricia Hayes, Chief Consultant, Office of 
Women's Health Services, and Dr. David Carroll, Executive Director, 
Office of Mental Health and Suicide Prevention.
    Madame Chairwoman, while it is not on today's agenda, we have taken 
the opportunity to include in this testimony VA's views on H.R. 3495, 
the Improve Well-Being for Veterans Act, because of the urgency of 
addressing the issue of Veteran suicide. H.R. 3495 would fulfill a 
critical legislative component of the Administration's multi-faceted 
program to prevent Veteran suicide.

H.R. 1163 VA Hiring Enhancement Act

    Section 2 of this bill would amend title 38, United States Code 
(U.S.C.), by adding a new section 7414 to restrict the applicability of 
non-VA covenants not to compete to the appointment of certain VHA 
personnel, specifically those appointed under 38 U.S.C. section 7401. 
Section 2 would further require an individual appointed to such a 
position to agree to provide clinical services at VA for a duration 
beginning from the date of their appointment and ending on the latter 
of either 1 year after the date of appointment, or the termination date 
of any covenant not to compete that was entered into between the 
individual and the non-VA facility. The Secretary would have the 
authority to waive this particular requirement.
    VA has concerns with section 2 of this proposed bill and requests 
the opportunity to discuss the bill further with the Committee.
    Section 3 of the bill would amend section 7402 to permit VHA to 
make a contingent appointment as a VHA physician on the basis of the 
physician completing their residency training.
    VA also has concerns with this section and requests an opportunity 
to further discuss. With regard to section 3, VA recommends removing 
the language regarding the completion of a residency leading to board 
eligibility, subsection (b)(1)(B)(i), since the requirement for 
residency training is provided in the published VA physician 
qualification standard (VA Handbook 5005, Part II, Appendix G2). 
Physicians must have completed residency training or its equivalent, 
approved by the Secretary in an accredited core specialty training 
program leading to eligibility for board certification. Approved 
residencies are as follows:

      Those approved by the accrediting bodies for graduate 
medical education, the Accreditation Council for Graduate Medical 
Education (ACGME) or American Osteopathic Association (AOA), in the 
list published for the year the residency was completed; or
      Other residencies or their equivalents which the local 
Professional Standards Board determines to have provided an applicant 
with appropriate professional training. The qualification standard also 
allows for facilities to require VA physicians involved in academic 
training programs to be board certified for faculty status.

    VA also recommends removing the language regarding an offer for an 
appointment on a contingent basis, subsection (b)(1)(B)(ii), since VA 
may currently provide job offers to physicians pending completion of 
residency training. There are no restrictions in statute or VA policy 
on making job offers contingent upon completing residency training and 
meeting other requirements for appointments as physicians within VHA. 
If this needs to be clarified in statute, VA suggests including the 
information in a new subsection (h) as follows: Section 7402 of title 
38, U.S.C., is amended by adding at the end the following subsection 
(h): ``(h) The Secretary may provide job offers to physicians pending 
completion of residency training programs and completing the 
requirements for appointments under subsection (b) by not later than 2 
years after the date of the job offer.''

H.R. 1527 Long-Term Choice Veterans Care Act

    H.R. 1527, the Long-Term Care Veterans Choice Act, would amend 
section 1720 to add a new subsection (h) providing authority for the 
Secretary to pay for long-term care for certain Veterans in Medical 
Foster Homes (MFH) that meet Department standards. Specifically, the 
bill would allow Veterans, for whom VA is required by law to offer to 
purchase or provide nursing home care, to be offered placement in homes 
designed to provide non-institutional long-term supportive care for 
Veterans who are unable to live independently and prefer to live in a 
family setting. VA would pay MFH expenses by a contract or agreement 
with the home. VA would be limited to furnishing care and services, and 
paying for MFH care, to no more than a daily average of 900 Veterans in 
any year. One condition of providing support for care in an MFH would 
be the Veteran's agreement to accept Home Based Primary Care or Spinal 
Cord Injury Home Care program furnished by VA. These amendments would 
take effect October 1, 2020, and VA would be authorized to carry out 
this program for a period of 3 years.
    VA endorses the concept of using MFHs for Veterans who meet the 
appropriateness criteria to receive such care in a more personal home 
setting. VA endorsed this idea in its Fiscal Year (FY) 2018, 2019, and 
2020 budget submissions and appreciates the Committee's consideration 
of this concept. Our experience has shown that VA-approved MFHs can 
offer safe, highly Veteran-centric care that is preferred by many 
Veterans at a lower cost than traditional nursing home care. VA 
currently manages the MFH program at over two-thirds of our medical 
centers, partnering with homes in the community to provide care to 
nearly 1,000 Veterans every day. However, Veterans are solely 
responsible for the expenses associated with MFH care today. Of the 
1,000 Veterans in MFHs currently, 200 would be eligible for care at the 
MFH at VA expense under this bill. Our experience also shows that MFHs 
can be used to increase access and promote Veteran choice-of-care 
options. We appreciate that the bill would provide VA more than 1 year 
to implement this new benefit, as this would provide VA sufficient time 
to ensure contracts or agreements are in place, and that policies and 
regulations, if needed, are in effect.
    While VA fully supports the MFH concept, we would look forward to 
working with you to resolve a few technical issues in this bill. For 
example, the limitation in proposed subsection (h)(2), regarding a 
limit ``in any year'' of a ``daily average'' of 900 or fewer Veterans 
receiving care, is ambiguous; it is unclear how the limitation to a 
given year qualifies the daily average and how VA could operationalize 
this effectively. VA would like to work with the Committee to ensure VA 
can effectively incorporate MFHs into the continuum of authorized long-
term services and support available to Veterans. We are happy to 
provide the Committee with technical assistance on this matter and are 
available for further discussion.
    VA estimates that, if enacted, this bill would cost approximately 
$6.2 million each year for administrative expenses associated with the 
program, with total administrative expenses reaching $18.72 million. 
However, we estimate that the resulting savings from paying for MFH 
care in lieu of nursing home care would result in net savings of $16.10 
million in FY 2021, $29.21 million in FY 2022, and $43.03 million in FY 
2023 for a total net savings of $88.34 million over the 3-year program.

H.R. 2628 VET CARE Act of 2019

    H.R. 2628 contains two substantive sections affecting VA's 
provision of dental care benefits. Section 2 of the bill would amend 
section 1712 to include a new subsection (d) that would authorize VA to 
furnish administrative support (including information for the provider 
to share with Veterans regarding the VA Dental Insurance Program) to 
persons providing dental care to Veterans separate from VA's authority.
    VA strongly supports this section, if amended. We sought similar 
authority for a community partnered collaboration to expand dental care 
for Veterans in the FY 2020 budget request. VA has limited statutory 
authority to furnish dental care to Veterans. This section would 
authorize VA to provide administrative support for the provision of 
needed dental care in the community to Veterans who are not eligible to 
receive that dental care from VA. The section would authorize VA staff, 
in the scope of their normal duties, to work with community dental 
providers approved by the Secretary to coordinate and schedule dental 
appointments for these Veterans in the community.
    We believe the bill should be amended, however, to not limit the 
provision of administrative support to providers of dental care; we 
anticipate that in many cases, VA medical support assistants or 
providers would be offering administrative support directly to 
Veterans, advising them of the availability of pro bono or other 
services from community providers furnishing care independently from 
VA. We would be happy to work with the Committee to provide the 
necessary amendments for this purpose. We also recommend a technical 
amendment to replace the ``; and'' with a period at the end of 
subsection (d)(2)(B), as that subparagraph is not followed by a 
subparagraph (C) and subsection (e), as redesignated, would not 
logically be connected to or qualify the rest of subsection (d)(2).
    We estimate this section would have no cost to the Department.
    Section 3 would require VA to carry out a pilot program to provide 
outpatient dental services and treatment, and related dental 
appliances, to participating Veterans at no cost to these Veterans. The 
purpose of the pilot program would be to determine whether there is a 
correlation between Veterans receiving such services and treatment, and 
the Veterans suffering fewer complications of chronic ailments, thereby 
yielding a lower cost of care. To be eligible to participate in the 
pilot program, a Veteran would have to be: (1) enrolled in VA health 
care; (2) ineligible for dental care under section 1712; (3) not 
receiving regular periodontal care; (4) between 40 and 70 years of age; 
and (5) diagnosed with type 2 diabetes. Eligible Veterans would have to 
elect to apply for the program, and any eligible Veteran who applies 
for the pilot program would receive an initial periodontal evaluation, 
including vertical bitewing radiographs. If an eligible Veteran 
diagnosed with periodontal disease required surgery, the Veteran would 
be disqualified from participating in the pilot program. Subsection (c) 
would require VA to enroll at least 1,500 eligible Veterans for the 
pilot program, giving preference to Veterans with service-connected 
disabilities that increases in accordance with the Veterans' disability 
ratings in a manner that ensures one-third of eligible Veterans 
enrolled in the pilot program have been diagnosed with no or mild 
periodontitis, and two-thirds of eligible Veterans enrolled in the 
pilot program have been diagnosed with moderate to severe 
periodontitis. VA would have to begin the pilot program within 180 days 
of the date of the enactment of this Act and carry out the pilot 
program for a 4-year period. VA would have to carry out the pilot 
program in five VA facilities, with one such facility in each of five 
Veterans Integrated Service Networks (VISN) the Secretary considers 
appropriate for the pilot program. Each facility would have to serve 
not more than one-fourth and not fewer than one-sixth of the Veterans 
enrolled in the pilot program, in approximately even proportions of 
Veterans categorized under subsection (c). VA would be required to make 
timely and appropriate periodontal therapy available to Veterans with 
moderate to severe periodontitis. Each eligible Veteran who elected to 
receive treatment would receive an annual dental evaluation, during 
which the periodontal health of the Veteran would be reassessed and 
recorded for purposes of determining the severity of the Veteran's 
periodontitis. VA would have to collect and record data regarding the 
health of treated Veterans, including events, treatments, and outcomes; 
these data would have to be made available for analysis by qualified 
researchers. VA would have to provide standardized instructions to all 
physicians and dentists who work in facilities selected for the pilot 
program to ensure consistent evaluation and care for Veterans enrolled 
in the pilot program. VA would also have to provide each Veteran 
enrolled in the pilot program with an orientation and information 
before any care was provided under the pilot program, as well as an 
exit interview that includes information regarding how such Veterans 
may obtain dental services and treatment after the pilot program ends. 
VA would have to notify institutions of higher education that offer 
degrees in periodontology about the pilot program so that such 
institutions may engage in similar studies regarding private 
periodontal care for Veterans. VA would have to submit a report of 
findings to Congress within 18 months of the conclusion of the pilot 
program. Finally, VA would be required to administer the pilot program 
under such regulations as the Secretary would prescribe, including best 
practices regarding informed consent and study registration.
    VA does not support section 3 of the bill. We are concerned the 
bill would create disparities in the overall application of dental 
eligibility under section 1712 by expanding access to these benefits to 
Veterans in participating locations but not elsewhere. We believe this 
could have the unintended consequence of Veteran dissatisfaction. We 
have serious concerns about the provision in the bill that would 
disqualify from treatment a Veteran who has been comprehensively 
examined and for whom surgery has been deemed necessary. This would be 
unethical and against VA's core values and professional standards of 
care. Dis-enrolling Veterans who have advanced periodontal disease 
after examination could be a stressor on Veterans who believed VA had 
their best interests in mind in treating their conditions. Also, as a 
time-limited program, VA is concerned about how it would manage care 
authorized near the end of the pilot program, as some Veterans may 
actually be worse off if they received only a portion of a fuller 
episode of care.
    We also believe the bill is far too prescriptive in terms of its 
requirements. For example, the bill provides that an eligible Veteran 
is one between 40 and 70 years of age. This could result in a situation 
where a Veteran is eligible at the beginning of the pilot program but 
becomes ineligible during the course of the pilot program (e.g., the 
Veteran is 68 years old at the start of the pilot but turns 70 during 
the pilot program). As written, the Veteran would no longer be eligible 
and could no longer receive benefits under this program, which could 
result in fragmentation of care. The requirements concerning enrollment 
and prioritization in subsection (c) are ambiguous and appear to 
conflate two different decision criteria: level of service-connected 
disability and severity of periodontitis. It is also unclear what VA 
would be required to do if there was insufficient interest among 
Veterans meeting the specific eligibility criteria such that VA could 
not enroll 1,500 Veterans in the pilot program. The criteria for 
selecting facilities are similarly ambiguous and could result in 
unintended consequences, if, for example, one facility (particularly a 
smaller or rural facility) simply could not keep up with demand at 
larger (particularly urban) facilities and fell below the one-sixth 
threshold. The preceding is not an exhaustive list of our technical 
concerns with the bill, but it is demonstrative that the bill is too 
prescriptive to be implemented effectively.
    Finally, we believe Section 3 of the bill is unnecessary because 
the dental literature already strongly supports the cost-effectiveness 
of preventive dental care. There is a large volume of scientific 
evidence supporting preventive dental care for individuals with 
conditions such as Type II diabetes to reduce the morbidity of tooth 
loss associated with periodontal disease. It is unclear how this 
proposed pilot program would further advance science and reduce overall 
health care costs. A controlled, well-defined, and sanctioned research 
project would be a more appropriate vehicle. The proposed legislation 
would not provide scientifically rigorous and valid findings because it 
does not adopt the structure and methodology of a controlled research 
project. The purpose of the legislation is to ``determine'' if there is 
a correlation based on treatment, but we do not believe VA could make 
such a determination given the parameters of the pilot program in the 
bill.
    VA estimates that section 3 would cost $3.72 million in the first 
year, $3.83 million in the second year, and $15.56 million over 4 
years.

H.R. 2645 Newborn Care Improvement Act of 2019

    H.R. 2645 would amend section 1786 to increase from 7 to 14 the 
number of days after the birth of a child for which VA may furnish 
covered health care services to the newborn child of a woman Veteran 
who is receiving maternity care furnished by the Department and who 
delivered the child in a facility of the Department or another facility 
pursuant to a Department contract for services related to such 
delivery. Not later than 31 days after the start of each fiscal year, 
VA would be required to submit a report to Congress on such services 
provided during the preceding fiscal year, including the number of 
newborn children who received such services during that fiscal year.
    VA supports H.R. 2645, subject to the availability of 
appropriations. A newborn needing care for a medical condition may 
require treatment extending beyond the current 7 days that are 
authorized by law. Additionally, the standard of care is to have 
further evaluations during the first 2 weeks of life to check infant 
weight, feeding, and newborn screening results. Pending these results, 
there may be a need for additional testing and follow-up. There are 
also important psychosocial needs that may apply, including monitoring 
stability of the home environment or providing clinical and other 
support if the newborn requires monitoring for a medical condition. 
Extending care to 14 days would provide time for further evaluations 
appropriate for the standard of care, as well as sufficient time to 
identify other health care coverage for the newborn.
    We estimate the bill would cost $12.9 million in FY 2020, $13.9 
million in
    FY 2021, $69.6 million over 5 years, and $142.3 million over 10 
years. The FY 2020 President's Budget did not include any funding for 
H.R. 2645 in FY 2020 or FY 2021.

H.R. 2681 Report on Prosthetic Items for Women Veterans

    H.R. 2681 would require VA, not later than 1 year after the date of 
the enactment of this Act, to submit to Congress a report on the 
availability from VA of prosthetic items made for women Veterans, 
including an assessment of the availability of such prosthetic items at 
each VA medical facility.
    VA provides comprehensive prosthetic and sensory aids and services 
that support and optimize the health and independence of all Veterans, 
regardless of gender. VA defines the term ``prosthetic'' as an item 
that replaces a missing or defective body part. For women Veterans, 
specifically, prosthetic items include: post-mastectomy items; wigs for 
alopecia; long-acting reversible contraception (e.g., intrauterine 
devices); maternity support belts items; and vaginal dilators.
    While VA supports providing Congress clear information at the end 
of each fiscal year on the types of prosthetic items, quantities of 
such items, and the amount expended on women Veterans, VA does not 
support providing an assessment of the availability from VA of 
prosthetics made for women Veterans because the report required by this 
bill would be incongruent with current clinical practice and 
procurement processes. The provision of a prosthetic item begins with 
the Veteran's appointment with a VA or community provider, who assesses 
the Veteran's prosthetic needs and submits a prescription or consult 
for a prosthetic item to the local VA medical center (VAMC) Prosthetic 
and Sensory Aid Service (PSAS). The type and variety of prosthetic 
items that a local facility maintains onsite will vary based upon their 
patient population, patients' needs, and the uniqueness of prosthetic 
items. Most prosthetic items are purchased from commercial sources. As 
a result, the report would not provide meaningful information as to the 
availability of these items for women Veterans.

H.R. 2752 VA Newborn Emergency Treatment Act

    H.R. 2752 would expand the scope of benefits for newborn children 
of women Veterans by authorizing VA to furnish transportation necessary 
to receive covered health care services. The bill also would allow VA 
to furnish more than 7 days of health care services to a newborn child 
and to provide transportation necessary to receive such services, if 
such care is based on medical necessity, including cases of 
readmission.
    VA supports, in principle, providing medically necessary 
transportation benefits for newborns. The bill presents, however, a few 
technical concerns, such that we do not support the bill in its current 
form. For example, it would allow VA to ``waive'' a debt that a 
beneficiary owes for medically necessary transportation provided for a 
newborn that was incurred prior to enactment of this Act. VA would 
generally have no ability to waive such a debt because the debt would 
not be owed to VA; further, VA would not have been a party to the 
transportation agreement or arrangement entered into by the beneficiary 
and a third party. In addition, the bill's exception to the otherwise 
applicable 7-day limitation on the duration of services is sweeping in 
scope. We would welcome the opportunity to discuss this to better 
understand the Committee's intent.
    We further note that if the Committee intends to advance both H.R. 
2645 and H.R. 2752, steps should be taken to ensure that the changes 
proposed are consistent with each other. VA would be happy to work with 
the Committee to ensure the amendments made by the two bills are 
complementary and not contradictory.

H.R. 2798 Building Supportive Networks for Women Veterans Act

    H.R. 2798 would direct VA to provide reintegration and readjustment 
counseling services, in a retreat setting, to women Veterans who are 
recently separated from service in the Armed Forces after prolonged 
deployments.
    VA agrees that providing these retreats is beneficial to women 
Veterans; however, other Veteran and Servicemember cohorts could also 
benefit from this treatment modality. While VA appreciates the intent 
of this bill, we request that the bill language be amended to allow VA 
the ability to conduct these retreats for all Veteran or Servicemember 
cohorts eligible for Vet Center services and that appropriate resources 
be provided through the appropriations process. Examples include those 
who have experienced military sexual trauma, Veterans and their 
families, and families that experience the death of a loved one while 
on active duty. Also, rather than creating a separate biennial report, 
as would be required by the bill, VA recommends that this bill amend 
section 7309 to include a report on this program as part of the annual 
report to Congress on the activities of the Readjustment Counseling 
Service.
    We estimate the bill would cost approximately $483,000 in FY 2020, 
approximately $500,000 in FY 2021, $2.59 million over 5 years, and 
$5.67 million over 10 years. The FY 2020 President's Budget did not 
include any funding for H.R. 2798 in FY 2020 or FY 2021.

H.R. 2816 Vietnam-Era Veterans Hepatitis C Testing Enhancement Act of 
    2019

    H.R. 2816 would require VA, not later than 180 days after the date 
of the enactment of this Act, to carry out a 1-year pilot program to 
make Hepatitis C testing available to covered Veterans at certain 
outreach events organized by Veterans Service Organizations (VSO). 
Covered Veterans would mean a person who served in the active military, 
naval, or air service between February 28, 1961, and May 7, 1975, and 
was discharged or released therefrom under conditions other than 
dishonorable, regardless of whether such person is enrolled in VA 
health care. VA would have to select five VISNs in which to carry out 
the pilot program, with two such networks predominantly serving rural 
areas and three predominantly serving urban areas. If at least 350,000 
Veterans were tested for Hepatitis C by the termination of the pilot 
program, VA would be required to expand the program to all VISNs not 
later than 1 year after the date on which the pilot program ends. Not 
later than 180 days after the date on which the pilot program ends, VA 
would have to submit a report to Congress on the number of covered 
Veterans tested for Hepatitis C under the pilot program and a list of 
resources needed to expand the pilot program to all VISNs for the 
length of time necessary to test all covered Veterans for Hepatitis C. 
No additional funds would be authorized to carry out the requirements 
of this Act; VA would have to implement this authority using amounts 
otherwise authorized to be appropriated to VA for the express purpose 
of providing Hepatitis C-related care.
    VA does not support this bill. Testing Vietnam Era Veterans and 
other Veterans at risk for chronic infection by the Hepatitis C virus 
(HCV), as well as Veterans who are not at increased risk but simply 
wish to be tested, remains a high priority for VA. The most recent HCV 
testing data for the general U.S. population show that as of 2016, only 
14.1 percent of individuals born between 1945 and 1965 had been tested 
for HCV. By comparison, in 2016, 75.1 percent of Veterans in VA care 
had been tested for HCV.
    We are concerned that VA would face significant legal, ethical, and 
practical barriers to implementation of this bill. As currently 
constructed, this bill raises a very serious ethical issue because it 
authorizes VA to test Veterans for HCV but not to provide anti-viral 
treatment, follow-up laboratory testing, or diagnosis and treatment of 
comorbidities (such as substance use and alcohol use disorders) that 
can interfere with anti-viral treatment. On a practical level, VA would 
need to have a mechanism to be notified by a VSO about when and where 
HCV testing outreach events would be held, with sufficient time to 
prepare for participation (e.g., ordering rapid test kits, logistics, 
etc.) and to provide for VA employees to attend these events outside of 
official duty hours and locations (e.g., clinician time/overtime pay, 
liability for use of a personal car/access to a VA car, etc.). The HCV 
testing model on which this bill is based involves holding HCV testing 
events at local VSO offices (e.g., an American Legion post). VA 
clinical staff and eligibility officers have attended such events, but 
the actual testing has been done by non-VA personnel because the 
individuals who come to the event are not known to be eligible for or 
enrolled in VA care. This bill uses a different model in which VA would 
perform the testing. This introduces the following very significant 
challenges:

      The VA laboratory would be using a rapid initial 
screening test that requires follow-up confirmatory testing for any 
positive results. There would not be any mechanism for logging, 
accessioning, and testing blood specimens for follow-up testing.
      Results from confirmatory testing are generally not 
available for several days. Again, because these individuals are not 
enrolled in VA care, there would not be a mechanism for contacting the 
Veteran to provide results.
      VA does not currently have authority to provide 
individualized follow-up assessments and counseling to individuals who 
test positive. This could create immediate and serious ethical 
conflicts for VA clinical staff. For example, if a Veteran who tests 
positive wants advice on informing his or her spouse, VA clinicians 
would have very limited (if any) ability to respond in detail.
      Performing the specified test requires oversight by a 
laboratory possessing a current, valid Clinical Laboratory Improvement 
Amendments (CLIA) certificate. It is not clear how willing VA 
laboratory directors would be to perform such testing outside of a VA 
facility because of legitimate concerns about jeopardizing the 
laboratory's CLIA certificate.

    The automatic trigger provision in section 2(d) raises legal 
concerns as well. It states that if at least 350,000 Veterans are 
tested for Hepatitis C by the termination date, the Secretary shall 
expand the program to all VISNs not later than 1 year after the date on 
which the pilot program ends. However, this would create an uncertain 
legal authority for such expansion. By its terms, subsection (c) 
directs VA to act to expand the program not later than 1 year after the 
pilot program ends; however, subsection (a) would be VA's only 
authority to make Hepatitis C testing available to Veterans who were 
not enrolled in VA health care, and this authority is limited to the 1-
year pilot program. Also, subsection (c) clearly provides that the 
program terminates 1 year after the program begins. Consequently, it 
does not appear the bill would provide VA an adequate statutory basis 
to furnish testing to Veterans who were not enrolled in VA health care 
after completion of the pilot program. This subsection also has 
technical issues that create further ambiguity, namely its failure to 
use the term ``covered Veteran'' and its failure to specify whether the 
350,000 Veterans tested must be tested under the pilot program (rather 
than generally). As of December 31, 2018, VA had screened 78.2 percent 
of the approximately 2.4 million Vietnam Era Veterans currently in VA 
health care, and across the system, there are approximately 527,000 
Vietnam Era Veterans remaining to be tested.
    We further note that the reporting requirement in section 2(e)(2) 
would require VA to report to Congress a list of the resources needed 
to expand the pilot program to all VISNs for the length of time 
necessary to test all covered Veterans for HCV. However, not all 
Veterans who are eligible for testing are willing to be or interested 
in being tested. While VA can offer Hepatitis C testing to these 
individuals, it is a personal decision on the part of the Veteran to 
agree to testing; thus, VA cannot guarantee that all Veterans with HCV 
will be tested.
    Finally, we note that the bill appears to be overly inclusive, as 
it applies to all Veterans who served on active duty during the Vietnam 
era, whether or not the Veteran served in the Republic of Vietnam. 
Under 38 U.S.C. 101(29)(B), the Vietnam era for Veterans who did not 
serve in the Republic of Vietnam began August 5, 1964, and ended May 7, 
1975. The bill would create an inequity in terms of Vietnam era 
Veterans' access to benefits by using the earlier date of February 28, 
1961, for all Vietnam era Veterans, regardless of their service in the 
Republic of Vietnam.

H.R. 2972 Improving Communications Related to Services for Women 
    Veterans

    H.R. 2972 contains two sections. Section 1 would require VA to 
expand the capabilities of the Women Veterans Call Center to include a 
text messaging capability.
    VA supports the intent of section 1 but does not believe this 
section is necessary because VA already implemented text messaging 
capabilities at the Women Veterans Call Center in April 2019. Similar 
to the existing call line and online chat, women Veterans who text 1 
(855) 829-6636 will be connected with Women Veterans Call Center 
representatives, who are all women, and who can answer general 
questions about benefits, eligibility, and services specifically for 
women Veterans. Text messaging is available Monday through Friday 8 
a.m. to 10 p.m. EST, and on Saturdays from 8 a.m. to 6:30 p.m. EST.
    Section 2 would require VA to survey VA Internet Web sites and 
information resources in effect on the day before the date of the 
enactment of this Act and publish an Internet Web site that serves as a 
centralized source for the provision to women Veterans of information 
about the benefits and services available to them from VA. The Web site 
would have to provide to women Veterans information regarding all 
services available in the district in which that Veteran is seeking 
services, including with respect to each VAMC and Community-Based 
Outpatient Clinic (CBOC) in the applicable VISN, the name and contact 
information of each women's health coordinator; a list of appropriate 
staff for other benefits available from the Veterans Benefits 
Administration (VBA), the National Cemetery Administration (NCA), and 
such other information as VA considers appropriate. VA would be 
required to ensure the information published on the Web site is updated 
not less frequently than once every 90 days. In carrying out this 
section, VA would have to ensure that the outreach conducted under VA's 
suicide prevention program (outreach and education for Veterans and 
families) includes information regarding the Web site required by this 
bill. VA would be authorized to use only funds made available to it to 
publish information on VA Web sites to implement this requirement.
    VA supports this section. VA has over 75 programs across VBA, VHA, 
and other business lines that offer transition benefits and services to 
transitioning Servicemembers. Transition programs that address the 
needs of women include the Women Veterans Health Care program in VHA; 
the Center for Women Veterans program within VA's Central Office; and 
the VA Transition Assistance Program (TAP) within VBA. VBA includes on 
its Web page, https://www.benefits.va.gov/persona/veteran-women.asp, 
information on VA benefits available to all Veterans (including women), 
links to women's health coordinators, links to health resources, and 
instructions on how to apply for VA benefits. VA TAP, which is offered 
through the Office of Transition and Economic Development (TED), 
recognizes the importance of providing programs and initiatives that 
support women Veterans. VA TAP Benefits and Services curriculum, for 
example, covers gender-specific health care to address the particular 
needs of female Veterans. The Participant Guide, which Servicemembers 
have as a reference as they continue their transition, includes more 
details on available services and programs for women Veterans. Should 
this section of the bill be enacted, TED would include directions for 
transitioning women Servicemembers to access the Web site in its TAP 
briefings. Also, VA has in place at each VAMC a Web site specific to 
women Veterans that highlights the services available and provides 
information for a point of contact at the facility. In addition, VA 
offers two national Web sites that offer facility location information.
    VA does not believe this section would result in any additional 
costs.

H.R. 2982 Women Veterans Health Care Accountability Act

    H.R. 2982 would require VA to enter into a contract with a 
qualified independent entity or organization to conduct a comprehensive 
study of the barriers to the provision of comprehensive health care by 
VA encountered by women Veterans. In conducting this study, VA, through 
the contractor, would have to survey women Veterans who seek or receive 
care from VA, as well as women Veterans who do not seek or receive such 
care or services; administer the survey to a representative sample of 
women Veterans from each VISN; and ensure that the sample of women 
Veterans surveyed is of sufficient size for the study results to be 
statistically significant and a larger sample size than the National 
Survey of Women Veterans in FY 2007-2008. In conducting the study, VA 
would be required to build on the work of this survey from 2007-2008, 
as well as the Study of Barriers for Women Veterans to VA Health Care 
2015. VA would be required to conduct research on the effects of the 
following on the women Veterans surveyed in the study: the perceived 
stigma associated with seeking mental health care services; the effect 
of driving distance or availability of other forms of transportation to 
the nearest medical facility on access to care; the availability of 
child care; the acceptability of integrated primary care, women's 
health clinics, or both; the comprehension of eligibility requirements 
for, and the scope of services available under, hospital care and 
medical services; the perception of personal safety and comfort in 
inpatient, outpatient, and behavioral health care facilities; the 
gender sensitivity of health care providers and staff to issues that 
particularly affect women; the effectiveness of outreach for health 
care services available to women Veterans; the location and operating 
hours of health care facilities that provide services to women 
Veterans; and such other significant barriers as VA considers 
appropriate. VA would be required to ensure that the head of the Center 
for Women Veterans and the Advisory Committee on Women Veterans reviews 
the results of the study, and that the head of each of these entities 
submits findings with respect to the study to the Under Secretary for 
Health. Not later than 30 months after the date of the enactment of 
this Act, VA would be required to submit to Congress a report on the 
study required by this bill. The report would have to include 
recommendations for such administrative and legislative actions as VA 
considers appropriate, including the findings of the Center for Women 
Veterans, the Advisory Committee on Women Veterans, and the Under 
Secretary for Health.
    VA does not support this bill. VA conducted an extensive study of 
the barriers to health care for women Veterans in 2013 and released the 
results of the report to Congress in 2015. The scope of this proposed 
legislation is a study identical to that 2013 study. VA is already 
implementing initiatives that address the identified barriers.
    VA offers comprehensive primary care for women Veterans and ensures 
that any woman Veteran seeking VA care receives complete primary care 
from one primary care provider at her preferred site. VA has enhanced 
provision of care to women Veterans by focusing on the goal of 
developing Women's Health Primary Care Providers (WH-PCP) at every site 
where women access VA. VA has at least two WH-PCP at all of VA health 
care systems. In addition, 90 percent of CBOCs have a WH-PCP in place. 
VA is in the process of training additional providers to ensure that 
every woman Veteran has an opportunity to receive her primary care from 
a WH-PCP.
    VA has responded to the growing number of women Veterans by 
offering a wide range of mental health services to meet their unique 
needs. Such services include psychological assessment and evaluation, 
outpatient individual and group psychotherapy, acute inpatient care, 
and residential-based psychosocial rehabilitation. Specialty services 
are offered to target problems such as PTSD, substance use problems, 
depression, sexual trauma, and homelessness.
    VA launched an End Harassment program at every VAMC in the summer 
of 2017. Through increased awareness, education, reporting, and 
accountability, VA is working to address this issue. VA's efforts hinge 
on awareness and education, followed by accountability. We have 
launched messaging, including ``it's not a compliment, it's 
harassment'' directed primarily at educating male Veterans that these 
actions are harmful and unacceptable. Employees have been trained on 
these cultural change efforts, including an awareness of the 
experiences of women Veterans and ways to intervene and respond. 
Cultural change efforts continue as we develop updated resources, 
training, and associated messaging; accountability through the local 
VAMC Director is a critical element.
    The End Harassment training was developed at the VA Central Office 
level as a tool for VA sites to use to create an awareness of and 
educate staff on the issue of women Veterans being harassed by male 
Veterans, as well as to introduce intervention strategies. Necessary 
variation exists at VA sites related to processes for staff training, 
as well as reporting and tracking of various types of Veteran 
complaints. As such, leadership at the local level is responsible for 
identifying and communicating these processes and actions.
    In 2019, in collaboration with research subject matter experts from 
the Women's Health Practice Based Research Network (PBRN), VA will 
conduct a more detailed care study in which PBRN sites will be asked to 
respond to questions about whether their facility delivered End 
Harassment training, which types of staff were trained, and how women 
Veterans can report incidents of harassment at their facilities.

H.R. 3036 Breaking Barriers for Women Veterans Act

    H.R. 3036 contains five substantive sections. Section 2 would 
require VA to retrofit existing VA medical facilities with fixtures, 
materials, and other outfitting measures to support the provision of 
care to women Veterans. Not later than 180 days from the date of the 
enactment of this Act, VA would have to submit to Congress a plan to 
address deficiencies in the Environment of Care (EOC) for women 
Veterans at VA medical facilities. Subsection (c) would authorize the 
appropriation of $20 million to carry out this section, in addition to 
amounts otherwise made available for these purposes.
    VA does not support section 2. VA has already recognized the 
importance of meeting the health care needs of our women Veterans. We 
recently updated VHA Directive 1330.01 to clarify definitions and 
provide objective privacy and dignity requirements that have been 
incorporated into updated facility design requirements through issuance 
of a design alert. Facilities are on course to fully address the health 
care needs and EOC privacy and dignity issues, regardless of the type 
of service or setting, through operational and non-recurring 
maintenance (NRM) funding sources, as appropriate. The NRM program is 
being used to make corrections for significant deficiencies. Also, 
physical facility compliance with privacy and dignity standards have 
been incorporated into VHA's EOC survey tool, which is used by all VA 
medical facilities to assess patient care spaces and identify any 
needed corrections or alterations. EOC survey tool results are tracked 
by both local facility and Network leadership, as well as oversight at 
the national level; existing survey tool reports can be used as a basis 
for informing Congress on compliance without the need for an additional 
report, as this bill would require. The specific reporting requirements 
in subsection (b) would unnecessarily redirect resources needed for the 
delivery of care and maintenance of the patient EOC.
    We estimate the one-time report required by section 2 would cost 
$450,000.
    Section 3 would require VA to ensure that each VA medical facility 
has not fewer than one full-time or part-time WH-PCP whose duties 
include, to the extent possible, providing training to other VA health 
care providers on the needs of women Veterans.
    While VA supports the intent of this section, we do not support 
enactment because it is unnecessary. VA already has the authority to 
employ WH-PCP at all of our health care systems, and in addition, 90 
percent of CBOCs have a WH-PCP in place. For many community sites, 
though, there is no justification to hire a full-time designated WH-PCP 
due to the small number of women Veterans assigned to the clinic. In 
these cases, VA trains an existing provider who will treat both men and 
women Veterans instead. There is approximately a 20-percent turnover 
each year for women's health providers, so training new providers is a 
constant need.
    Section 4 would authorize to be appropriated $1 million for each 
fiscal year for the Women Veterans Health Care Mini-Residency Program 
to provide opportunities for participation in such program for primary 
care and emergency care clinicians. These amounts would be in addition 
to amounts otherwise made available for such training.
    VA supports the concept of mini-residencies but does not believe 
this is necessary. VA's efforts to train clinicians to meet the needs 
of an ever-increasing number of women Veterans seeking care has 
included large scale initiatives to deploy core curricula covering the 
highest priority topics in women's health care through mini-
residencies. VA has developed four mini-residency programs in recent 
years and trained more than 5,800 clinical providers since 2008. .The 
four programs are Women's Health Mini- Residency for Primary Care 
Providers (Physicians, NPs, PAs); Women's Health Mini- Residency for 
Primary Care Nurses (RNs/LPNs/LVNs); Women's Health Mini-Residency for 
Primary Care Providers and Nurses (Interprofessional curriculum 
designed for providers and RNs); and Women's Health Mini- Residency for 
Emergency Care Providers and Nurses (Interprofessional). VA offers 
mini-residency programs as large, national training conferences each 
year. Current mini-residencies held to date have had waiting lists as 
demand has exceeded capacity. VA is also providing contract training to 
VA facilities through computer-based women's health modules completed 
in advance of the contract training team arriving at the clinic to 
deliver a 1-day training for interactive, hands-on activities, and 
breast and pelvic exam instruction. This training delivery will enhance 
the opportunity for clinicians to attend trainings and reduce the 
amount of time they need to be away from clinical care.
    We estimate section 4 would result in additional costs of $1 
million each year.
    Section 5 would require, not later than 1 year after the date of 
the enactment of this Act, VA to establish a training module that is 
specific to women Veterans and make it available to community providers 
who furnish care on VA's behalf.
    VA supports the intent of this section but does not believe it 
necessary. VA recognizes that women Veterans are more likely than their 
male counterparts to obtain care in the community, and VA is developing 
a training module for community providers who care for women Veterans 
to be attuned to their unique needs. Key competencies in the module 
will cover military history, caring for Veterans with complex medical 
conditions, coordinating care between VA and community providers, and 
identifying VA resources for help. This learning module will reside on 
a virtual platform available for providers furnishing care on behalf of 
VA.
    Section 6 would require VA to conduct a study on the use of the 
Women Veteran Program Manager program at VA to determine if the program 
is appropriately staffed at each VAMC, whether each VAMC is staffed 
with a Women Veteran Program Manager, and whether it would be feasible 
and advisable to have a Women Veteran Program Ombudsman at each VAMC. 
Not later than 270 days after the date of the enactment of this Act, VA 
would have to submit to Congress a report on the study conducted under 
this section. Subsection (c) would require VA to ensure that all Women 
Veteran Program Managers and Women Veteran Program Ombudsmen receive 
the proper training to carry out their duties.
    VA agrees that the information required by section 6 would be 
useful but does not support this legislation because it is unnecessary. 
VA has self-reported data on the Women Veteran Program at each VAMC. 
The Women's Assessment Tool for Comprehensive Health (WATCH) is an 
annual report that assesses the Women's Health Program in VA medical 
facilities. The self-assessment enhances national and local strategic 
planning for the development of women's health programs. In addition, 
VA recently developed a women Veterans integrated project team (IPT) 
charged with focusing efforts on improving the experience of women 
Veterans by addressing capabilities impacting critical focus areas. The 
IPT is charged with transforming the culture and operation of VA by 
developing innovative solutions to create access to high quality health 
care with a respectful, safe, and welcoming environment for women 
Veterans by ending harassment and addressing capacity gaps, gender 
disparities, variation in women's health program implementation, and 
care coordination.

H.R. 3224 To Provide Increased Access to VA Medical Care for Women 
    Veterans

    H.R. 3224 would create a new section 1720J regarding medical 
services for women Veterans. Subsection (a) of this new section would 
require VA ensure that gender-specific services are continuously 
available at every VAMC and CBOC. Subsection (b) would direct the 
Secretary to conduct a study to assess the use of extended hours as a 
means of reducing barriers to care, the need for extended hours based 
on interviews with women Veterans and employees, and the best practices 
and resources required to implement the use of extended hours. Finally, 
subsection (c) would require VA submit to Congress by September 30 of 
each year a report on VA's compliance with subsection (a).
    We agree with the aims of the legislation but do not support it as 
written. We fully agree with the intent of the legislation, to ensure 
that women Veterans are able to receive timely, high-quality care, but 
we are concerned that, as drafted, it is unworkable. Specifically, 
concerning the proposed section 1720J(a), we are concerned about the 
phrase ``continuously available'' and what it is intended to mean. Very 
few health care services within VA or any health care system are 
available around the clock, every day; even if the phrase was only 
meant to convey continuous availability during business hours, there is 
still no guarantee that providers would be constantly available, as 
there may be periods of time when a provider is on leave or when a 
vacancy has occurred that takes some time to fill. This could 
potentially have significant resource implications depending upon the 
intended effect. We also note that the term ``gender specific 
services'' is unclear; this could apply to both men and women Veterans. 
It is also unclear if this is intended to refer to gender-specific 
primary care services for women or more advanced services such as 
obstetrics and gynecology (for women) or urology (for men). We note 
that VA recently implemented two provisions of the VA Maintaining 
Internal Systems and Strengthening Integrated Outside Networks 
(MISSION) Act of 2018, the Veterans Community Care Program under 
section 1703 and the urgent care benefit under section 1725A, that 
expand access to timely care, particularly urgent or emergent 
conditions. These new initiatives may relieve some of the need for VA 
facilities to have extended hours of operation.
    We believe section 1720J(b) is unnecessary in part because VA has 
already established extended hours of care to reduce barriers to access 
and has promoted new modalities, such as telehealth, to make it easier 
for Veterans to obtain care. We can provide data, both quantitative and 
qualitative, regarding some of the elements of the study required by 
subsection (b), and we would be pleased to discuss our findings with 
the Committee.
    We would greatly appreciate the opportunity to meet with the 
Committee further to discuss these and other issues to improve this 
legislation. Given the unclear scope of the legislation, we are unable 
to provide a cost estimate for this bill at this time but note that it 
could have significant resource implications depending on the intended 
effect.

H.R. 3495 Improve Well-Being for Veterans Act

    H.R. 3495 would require VA to provide financial assistance to 
eligible entities approved under this section through the award of 
grants to provide and coordinate the provision of services to Veterans 
and Veteran families to reduce the risk of suicide. VA would award a 
grant to each eligible entity whose application was approved by VA. VA 
could establish a maximum amount to be awarded under the grant, 
intervals of payment for the administration of the grant, and a 
requirement for the recipient of the grant to provide matching funds in 
a specified percentage. VA would ensure, to the extent practicable, 
that financial assistance is equitably distributed across geographic 
regions, including rural communities and Tribal land. VA also, to the 
extent practicable, would need to ensure that financial assistance is 
distributed to provide services in areas of the country that have 
experienced high rates or a high burden of Veteran suicide and to 
eligible entities that can assist Veterans at risk of suicide that are 
not currently receiving health care furnished by VA.
    VA would have to give preference in the provision of financial 
assistance to eligible entities providing or coordinating (or who have 
demonstrated the ability to provide or coordinate) suicide prevention 
services or other services that improve the quality of life of Veterans 
and their families and reduce the factors that contribute to Veteran 
suicide. Each grant recipient would have to notify Veterans and Veteran 
families that services they provide are being paid for, in whole or in 
part, by VA. If a grant recipient provided temporary cash assistance to 
Veterans or Veteran families, the recipient would have to develop a 
plan, in consultation with the beneficiary, to ensure that any 
beneficiary receiving such temporary cash assistance is self-sustaining 
at the end of the period of eligibility for such assistance.
    VA would require each grant recipient to submit an annual report 
describing the projects carried out with VA's financial assistance; VA 
would also specify to each recipient the evaluation criteria and data 
and information to be included in the report, and VA could require 
entities to submit additional reports as necessary. An eligible entity 
seeking a grant would submit a form to VA containing such commitments 
and information as VA considers necessary to carry out this section. 
Each application would have to include a description of the suicide 
prevention services to be provided, a detailed plan describing how the 
entity proposes to coordinate and deliver suicide prevention services 
to Veterans not currently receiving care furnished by VA (including an 
identification of community partners, a description of arrangements 
currently in place with such partners, and identification of how long 
those arrangements have been in place), a description of the types of 
Veterans at risk of suicide and Veteran families proposed to be 
provided suicide prevention services, an estimate of the number of 
Veterans at risk of suicide and Veteran families that would be provided 
services (including the basis for the estimate and the percentage of 
those Veterans not currently receiving VA care), evidence of the 
experience of the applicant (and the proposed partners) in providing 
suicide prevention services (particularly to Veterans at risk of 
suicide and Veteran families), a description of the managerial and 
technological capacities of the entity, and other application criteria 
VA considers appropriate.
    VA would be required to provide training and technical assistance 
to eligible entities under this section regarding the data that must be 
collected and shared with VA, the means of data collection and sharing, 
familiarization with and appropriate use of any tool to measure the 
effectiveness of the financial assistance VA provided, and how to 
comply with VA's reporting requirements. VA would have to establish 
criteria for the selection of eligible entities that have submitted 
applications. In establishing these criteria, VA would have to consult 
with Veterans Service Organizations (VSO), national organizations 
representing potential community partners of eligible grant recipients, 
organizations with which VA has a current memoranda of agreement or 
understanding related to mental health or suicide prevention, State 
Departments of Veterans Affairs, national organizations representing 
members of the reserve components of the Armed Forces, Vet Centers, 
organizations with experience in creating measurement tools for 
purposes of determining programmatic effectiveness, and other 
organizations VA considers appropriate.
    VA would have to develop measures and metrics for grant recipients 
in consultation with the same group of entities or organizations. 
Before issuing a Notice of Funding Availability under this section, VA 
would have to submit to Congress a report containing the criteria for 
the award of a grant under this section, the tool to be used by VA to 
measure the effectiveness of the use of financial assistance provided 
under this section, and a framework for the sharing of information 
about entities in receipt of financial assistance under this section. 
VA could make available to grant recipients certain information 
regarding potential beneficiaries of services, including confirmation 
of the status of a potential beneficiary as a Veteran and confirmation 
of whether a potential beneficiary is currently receiving or has 
recently received VA care.
    VA's authority to provide financial assistance would end on the 
date that is 3 years after the date on which the first grant is 
awarded. Not later than 18 months after the date on which the first 
grant is awarded, VA would have to submit a detailed report on the 
provision of financial assistance under this section. Not later than 3 
years after the date on which the first grant is awarded, VA would have 
to submit to Congress a follow up on the interim report containing the 
same elements and a final report on the effectiveness of the financial 
assistance provided through this authority, an assessment of the 
increased capacity of VA to provide services to Veterans at risk of 
suicide and Veteran families as a result of this financial assistance, 
and the feasibility and advisability of extending or expanding the 
provision of financial assistance.
    Eligible entities would be: (1) an incorporated private institution 
or foundation that is approved by VA as to financial responsibility and 
no part of the net earnings of which incurs to the benefit of any 
member, founder, contributor, or individual and that has a governing 
board that would be responsible for the operation of the suicide 
prevention services provided under this section; (2) a corporation 
wholly owned and controlled by an organization meeting the same 
requirements; (3) a tribally designated housing entity (as defined in 
section 4 of the Native American Housing Assistance and Self-
Determination Act of 1996 (25 U.S.C. 4103)); or a community-based 
organization that is physically based in the targeted community and 
that can effectively network with local civic organizations, regional 
health systems, and other settings where Veterans at risk of suicide 
and the families of such Veterans are likely to have contact. Suicide 
prevention services would be services to address the needs of Veterans 
at risk of suicide and Veteran families and includes outreach; a 
baseline mental health assessment; education on suicide risk and 
prevention; direct treatment; medication management; individual and 
group therapy; case management services; peer support services; 
assistance in obtaining any VA benefits for which the Veteran or 
Veteran family may be eligible; assistance in obtaining and 
coordinating the provision of other benefits provided by the Federal 
Government, a State or local government, or an eligible entity; 
temporary cash assistance (not to exceed 6 months) to assist with 
certain emergent needs; and such other services necessary for improving 
the resiliency of Veterans at risk of suicide and Veteran families as 
VA considers appropriate. Veteran family would mean, with respect to a 
Veteran at risk of suicide, a parent, a spouse, a child, a sibling, a 
step-family member, an extended family member, or any other individual 
who lives with the Veteran. VSOs would be those organizations 
recognized by VA for the representation of Veterans included as part of 
an annually updated list available online.
    VA strongly supports this bill. VA's efforts to reduce the 
incidence of suicidal ideations and behavior (and suicide completions) 
among all Veterans could be complemented by partnering with community-
based providers who are able to replicate VA's suicide prevention 
programs in the community and to connect with Veterans that are 
currently beyond VA's reach. This novel approach would assist VA in 
reaching more of the 14 of the 20 Veterans dying each day by suicide 
who are not under VA care at the time of their deaths; effective 
partnering with eligible grantees would be key to our being able to 
reduce, if not prevent, the number of these tragic occurrences. 
Additionally, the legislation aligns with VA's proposal submitted with 
the President's FY 2020 budget. This proposal has been identified as 
the Secretary's top legislative priority and the legislation provides 
the necessary authorities clinicians believe will help the Department 
combat suicide among Veterans. Lastly, we note that the legislation is 
aligned with the President's strategic taskforce to combat suicides in 
the Nation. The taskforce will assist in planning and providing 
strategic guidance with our stakeholders allowing VA to operate and 
implement the grant program. The need for this legislation is evident 
and will enhance and increase the suicide prevention measures the 
Department is currently taking to combat and reduce suicides in the 
Nation.
    We offer one comment for the Committee's consideration, but we 
emphasize that this is not an issue that would alter VA's position on 
the bill. The definition of ``risk of suicide'' in section 2(k)(4) 
would include exposure to or the existence of any of the specified 
conditions. We believe this definition is overly broad and recommend 
instead allowing the Secretary to implement this definition by 
regulation to include the addition of a process for determining degrees 
of risk of suicide based on consideration of the factors set forth in 
section 2(k)(4). Risk is obviously variable, ranging from no risk to 
high risk. Even without this recommended change, the bill would give VA 
sufficient authority to prefer applicants that ensure their services go 
to those Veterans who have the highest risk of suicide.
    We estimate the bill would cost $19.10 million in FY 2021, $28.36 
million in FY 2022, and $37.70 million in FY 2023, for a total cost of 
approximately $85.16 million over the 3-year period of the program.

H.R. 3636 Caring for Our Women Veterans Act

    H.R. 3636 contains three substantive sections.
    Section 2 of the bill would require VA to submit to Congress a 
report on the use by women Veterans of health care from VA. The first 
report would be required not later than 90 days after the date of the 
enactment of this Act, and VA would be required to submit annual 
reports thereafter. Each report would need to include the number of 
women Veterans who reside in each state; the number of women Veterans 
in each state who are enrolled in VA health care; the number of 
enrolled women Veterans who received VA health care at least one time 
in the previous year; the number of women Veterans who have been seen 
at each VA medical facility in the previous year; the number of 
appointments that women Veterans had at each VA medical facility; an 
identification of the medical facility in each VISN with the largest 
rate of increase in patient population of women Veterans (if known); 
and an identification of the medical facility in each VISN with the 
largest rate of decrease in patient population of women Veterans (if 
known).
    We have no objection to this section; the data requested by 
Congress are currently collected by VA, and we believe producing the 
report would result in no additional cost.
    Section 3 of the bill would require VA to submit to Congress a 
report on the use by VA of general primary care clinics, separate but 
shared spaces, and women's health centers as models of providing health 
care to women Veterans. The first report would be required not later 
than 90 days after the date of the enactment of this Act, and VA would 
be required to submit annual reports thereafter. Each report would need 
to include the number of VA facilities that fall into each model 
described disaggregated by VISN and state; a description of the 
criteria VA used to determine which model is most appropriate for each 
VA facility; an assessment of how VA decides to make investments to 
upgrade facilities to the next higher-level model; a description of any 
plans VA has to upgrade facilities from the lowest-level model (general 
primary care clinics) to another model; an assessment of whether any 
facilities could be upgraded to the next higher-level model within 
planned investments under the strategic capital investment planning 
process (SCIP); an assessment of whether any facilities could be 
upgraded to the next higher-level model with minor modifications to 
existing plans under SCIP; and an assessment of whether VA has a goal 
for how many facilities should fall into each such model.
    VA does not support this section. VA has empowered local facilities 
to determine the appropriate model of care with input from the women 
Veterans they serve. We emphasize that the same services are provided 
at all facilities, regardless of the model they use. We disagree with 
the assumption in this section that these models are inherently 
hierarchical with some better than others. The intent behind having 
three different models of care is to allow VA facilities to be flexible 
and responsive to local needs. Many factors, such as the patient 
population and available space, influence these decisions.
    Section 4 would require VA to submit a report to Congress on VA 
staffing relating to the treatment of women. The first report would be 
required not later than 90 days after the date of the enactment of this 
Act, and VA would be required to submit annual reports thereafter. Each 
report would need to include the number of women's health centers; the 
number of patient aligned care teams relating to women's health; the 
number of full- and part-time gynecologists; the number of designated 
women's health care providers; the number of health care providers who 
have completed a mini-residency for women's health during the previous 
year and the number that plan to participate in such a mini-residency 
in the following year; and the number of designated women's health care 
providers who have sufficient female patients to retain their 
competencies and proficiencies. Data for all of these would need to be 
disaggregated by VISN and state, except for the number of women's 
health care providers, which would be disaggregated by facility.
    We do not support this section because we do not believe it is 
necessary. VA has already implemented these requirements through WATCH.

H.R. 3798 Equal Access to Contraception for Veterans Act

    H.R. 3798 would amend section 1722A to prohibit VA from requiring a 
Veteran to pay an amount for any contraceptive item or service for 
which coverage under health insurance coverage is required without 
imposition of any cost-sharing requirement pursuant to section 
2713(a)(4) of the Public Health Service Act (42 U.S.C. 300gg-13(a)(4)).
    VA supports this bill, subject to the availability of 
appropriations and technical amendments. We believe this bill would 
help further improve the access of contraceptives to Veterans, 
particularly those who have lower incomes.
    We believe the bill language would exempt from copayment liability 
the provision of contraceptives. We are unsure, though, of the intended 
meaning of the phrase ``or service,'' and whether this is meant to 
exempt from copayments the medical appointments related to the 
provision of contraception. The bill clearly exempts the medications 
from copayments by amending section 1722A. However, copayments for 
appointments related to the furnishing of medications, including 
contraceptives, are established for certain Veterans in a different 
statutory provision, section 1710, which is unamended by the bill. We 
note there may be significant administrative and technical difficulties 
in identifying and exempting only certain appointments from copayments, 
so if the Committee had this intent, we would appreciate the 
opportunity to discuss this further. We recommend the phrase ``or 
service'' be removed, as well as the cross-reference to section 
2713(a)(4) of the Public Health Service Act (42 U.S.C. 300gg-13(a)(4)).
    VA estimates the lost revenue for medication copayments would be 
approximately $396,000 in FY 2020, approximately $414,000 in FY 2021, 
$2.07 million over 5 years, and $4.18 million over 10 years. The bill 
would result in much greater losses of revenue if it exempted from 
copayment liability appointments related to contraceptive care. The FY 
2020 President's Budget did not include the potential lost revenue for 
H.R. 3798 in FY 2020 or FY 2021.

H.R. 3867 Violence Against Women Veterans Act

    H.R. 3867 contains five substantive sections.
    Section 2 of the bill would state the purpose of this Act is to 
better integrate the medical, housing, mental health, and other 
benefits provided by VA with existing community-based domestic violence 
and sexual assault services to provide a more efficient and coordinated 
network of support for Veterans experiencing domestic violence or 
sexual assault and to better understand the impact of domestic violence 
and sexual assault on Veterans, particularly female Veterans.
    VA has no comments on this section.
    Section 3 of the bill would require VA to carry out a program to 
assist Veterans who have experienced or are experiencing domestic 
violence or sexual assault in accessing VA benefits, including 
coordinating access to medical treatment centers, housing assistance, 
and other VA benefits. VA would be required to carry out this program 
in partnership with domestic violence shelters and programs, rape 
crisis centers, state domestic violence and sexual assault coalitions, 
and such other health care or other service providers who serve 
domestic violence or sexual assault victims as determined by VA, 
particularly those providing emergency services or housing assistance. 
In carrying out this program, VA could conduct training for community-
based domestic violence or sexual assault providers on identifying 
Veterans; coordinating with VA health care providers; and connecting 
Veterans with appropriate housing, mental health, medical, and other VA 
financial assistance or benefits. VA could also conduct assistance to 
service providers to ensure access of Veterans to domestic violence and 
sexual assault emergency services, particularly in underserved areas 
(including services for members of Indian tribes), as well as such 
other outreach and assistance as VA determines necessary. VA would be 
authorized to establish local coordinators to provide local outreach 
under this program; each coordinator would have to be knowledgeable 
about: (1) the dynamics of domestic violence and sexual assault, 
including safety concerns, legal protections, and the need for the 
provision of confidential services; (2) the eligibility of Veterans for 
VA benefits and services that are relevant to recovery from domestic 
violence and sexual assault, particularly emergency housing assistance, 
mental and other health care, and disability benefits; and (3) local 
community resources addressing domestic violence and sexual assault. 
Each coordinator would be required to assist domestic violence shelters 
and rape crisis centers in providing services to Veterans.
    VA does not oppose section 3 subject to the availability of 
appropriations, but we believe technical edits could improve the bill, 
and we would appreciate the opportunity to work with the Committee in 
this regard. VA is committed to serving Veterans whose health and 
safety may be at risk as a result of experiencing domestic or intimate 
partner violence. VA developed a plan for implementation of a domestic 
violence and intimate partner violence assistance program in 2013, 
before launching the program in 2014. We appreciate Congress' support 
of these efforts through the inclusion of $17 million in the FY 2018 
and FY 2019 appropriations acts. Earlier this year, VA published a 
policy, VHA Directive 1198, Intimate Partner Violence Assistance 
Program, that mandates every VAMC identify a program coordinator and 
implement the full array of intimate partner violence-related 
programming in collaboration with internal and external stakeholders. 
This policy requires that every VA medical facility implement and 
maintain an Intimate Partner Violence Assistance Program (IPVAP), and 
that Veterans, their intimate partners, and employees impacted by 
intimate partner violence have access to services including resources, 
assessment intervention, and referrals to VA or community agencies as 
deemed appropriate and clinically indicated. During the VA Benefits and 
Services briefing of the Transition Assistance Program (TAP), all 
transitioning Servicemembers are provided information on VA's IPVAP and 
its available resources. The TAP briefing also explains gender-specific 
health care services available for women Veterans that address their 
unique health care needs; information on mental health care and 
emergency care services for women with actionable information is also 
provided. Central to the IPVAP is the need to provide screening for 
intimate partner violence to identify Veterans who are at risk, 
consistent with the U.S. Preventive Services Task Force recommendations 
to, at a minimum, screen all women of childbearing age. Screening 
allows our trained staff and providers to offer education, promote 
prevention, and identify those at risk to provide immediate crisis 
management and safety planning and intervention. The IPVAP works with 
the National Domestic Violence Hotline to offer outreach, resources, 
and safety planning for Veterans and their intimate partners, including 
hotline advocates who are available to chat every day. VA's Women 
Veterans Call Center is also available to provide additional guidance 
on benefits and resources.
    VA estimates section 3 would cost $21.1 million in FY 2020, $21.9 
million in FY 2021, $113.85 million over 5 years, and $258.18 million 
over 10 years. The FY 2020 President's Budget did not include any 
funding for H.R. 3867 in FY 2020 or FY 2021.
    Section 4 would require VA, in consultation with the Attorney 
General and the Secretary of Health and Human Services, to establish a 
national Task Force to develop a comprehensive national program, that 
includes integrating VA facilities, services, and benefits into 
existing networks of community-based domestic violence and sexual 
assault services, to address domestic violence and sexual assault among 
Veterans. The Task Force would be required to consult with 
representatives from not fewer than three national organizations or 
state coalitions with demonstrated expertise in domestic violence 
prevention, response, or advocacy, as well as such organizations or 
coalitions representing underserved or ethnic minority communities with 
such demonstrated expertise.
    The Task Force would be required to review existing VA services and 
policies and develop a comprehensive national program to address 
domestic violence and sexual assault prevention, response, and 
treatment. It would also have to review the feasibility and 
advisability of establishing an expedited process to secure emergency, 
temporary benefits including housing or other benefits for Veterans who 
are experiencing domestic violence and sexual assault. It would also 
have to review and make recommendations regarding the feasibility and 
advisability of establishing dedicated, temporary housing assistance 
for Veterans experiencing domestic violence or sexual assault and 
identify any requirements regarding domestic violence assistance or 
sexual assault response and services that are not being met by VA, as 
well as make recommendations on how VA can meet such requirements. In 
addition, the Task Force would have to review and make recommendations 
regarding the feasibility and advisability of providing direct 
services, or contracting for community-based services, for Veterans in 
response to a sexual assault, including through the use of sexual 
assault nurse examiners, particularly in underserved or remote areas 
(including services for members of Indian tribes). The Task Force would 
also be responsible for reviewing the availability of counseling 
services provided by VA and through peer network support and providing 
recommendations for the enhancement of such services to address the 
perpetration of domestic violence and sexual assault and the recovery 
of Veterans, particularly female Veterans, from domestic violence and 
sexual assault. Finally, the Task Force would have to review and make 
recommendations to expand services available to Veterans at risk of 
perpetrating domestic violence. The Task Force would be required to 
report annually to the VA Secretary and to Congress on its activities, 
including any recommendations for legislative or administrative action.
    VA does not support this section because it is unnecessary given 
that VA convened a similar Task Force in 2012 and 2013. This earlier 
Task Force provided a very thorough review of the needs of Veterans and 
their partners, relevant research, and a review of resources leading to 
14 recommendations for the implementation of a comprehensive, 
enterprise-wide program of integrated services for Veterans who 
experience or use intimate partner violence, their intimate partners, 
and VA employees impacted by such violence. VA's Intimate Partner 
Assistance Program has a national level leadership council that has 
many members from the original Task Force. Assembling a new Task Force 
would be duplicative, result in unnecessary costs, and could 
potentially deter the progress already being made. We also note that 
this section, as drafted, would appear to subject the Task Force to the 
Federal Advisory Committee Act (5 U.S.C. Appendix 2) in one or more 
ways. It is unclear if the drafters intended this result or not, but we 
would be happy to work with the Committee on this issue if needed.
    Section 5 would require VA, in consultation with the Attorney 
General, to conduct a national baseline study to examine the scope of 
the problem of domestic violence and sexual assault among Veterans and 
spouses of Veterans.
    We do not believe this section is necessary, but we do not oppose 
it. VA recognizes the value of proceeding with data-driven decisions 
for program expansion. VA investigators are already conducting research 
in this area and have been doing screening, although such work has not 
surveyed spouses of Veterans. We would appreciate the opportunity to 
discuss this work with the Committee to determine if any additional 
action is needed. Research to gather metrics around the various 
elements to be addressed, including intimate partner violence use and 
experience for men and women Veterans, domestic violence experience, 
and types and prevalence of sexual assault inside and outside the 
context of intimate partner relationships is important, but there are 
many inherent challenges in conducting a Veteran-specific study on 
these sensitive issues. Such a project would require a well-funded 
research team to design and conduct the study, with specific costs 
contingent upon the scope, design, and length of the study.
    Section 6 would amend the authorizing statute for VA's Advisory 
Committee on Women Veterans, 38 U.S.C. 542, by requiring the Advisory 
Committee on Women Veterans to include in its biennial report an 
assessment of the effects of intimate partner violence on women 
Veterans.
    We do not support this section. We are concerned that an assessment 
of the effects of intimate partner violence would require identifying 
resulting issues, medical conditions, and other effects (such as 
homelessness, criminal behavior, or divorce) that could require 
judgments based on partial or incomplete information. This could result 
in data being skewed or statistically insignificant. These concerns 
would be further amplified through underuse of VA health care by women 
Veterans, such that the population analyzed is not representative of 
women Veterans as a whole.

H.R. 4096 Improving Oversight of Women Veterans' Care Act of 2019

    Section 2 of H.R. 4096 would create a new section 1730D that 
requires VA to submit to Congress an annual report on the access of 
women Veterans to gender-specific services under contracts, agreements, 
or other arrangements with non-VA medical providers. The report would 
have to include data and performance measures for the availability of 
gender specific services, including the average wait time between the 
Veteran's preferred appointment date and the date on which the 
appointment is completed; the average driving time required for 
Veterans to attend appointments; and the reasons why appointments could 
not be scheduled with non-VA medical providers. Gender-specific 
services would be defined to mean mammography, obstetric care, 
gynecological care, and other services as considered appropriate.
    VA does not support section 2. Many of the specific data points 
identified are not currently included in VA's contracts, agreements, or 
other arrangements for obtaining community care; as a result, VA would 
have to renegotiate or modify these contracts, agreements, and other 
arrangements, which could be costly and would impose additional 
administrative burdens. Some providers may choose to drop out of 
network, rather than comply with these burdens, which would diminish 
Veterans' access to care. While VA does collect some of the data 
elements, other requirements, such as gender specific services 
(Mammography, obstetric care, and gynecological) are not specifically 
tracked or identifiable. Moreover, some Veterans eligible to receive 
community care choose to see providers who are farther away from their 
home; this could complicate any meaningful analysis of the reported 
data.
    We estimate the costs of this section would exceed $1.5 million in 
FY 2020.
    Section 3 of this bill would require VA establish a policy under 
which the EOC standards and inspections at VA medical facilities 
include an alignment of the requirements for such standards and 
inspections with the VHA women's health handbook; a requirement for the 
frequency of such inspections; a delineation of the roles and 
responsibilities of staff at the VAMC who are responsible for 
compliance; and the requirement that each VAMC submit to the Secretary 
a report on the compliance of the VAMC with the standards. The policy 
also would have to provide that, for the purposes of the End of Year 
Hospital Star Rating, no VAMC is eligible for a five-star rating unless 
it meets the EOC standards. Not later than 180 days after the date of 
the enactment of this Act, VA would have to submit a written 
certification to Congress that the required policy has been finalized 
and disseminated to all VAMCs.
    VA does not support this section as written. VA believes amendments 
could be made such that VA would not oppose it. Specifically, we 
recommend amending section 3(a)(1)(C) to clearly assign responsibility 
to the VAMC Director and VISN Director for EOC compliance. VA further 
recommends section 3(a)(1)(D) be amended to have the Directors of each 
medical facility report to the Under Secretary for Health, rather than 
to the Secretary. The Under Secretary for Health is directly 
responsible to the Secretary for VHA operations. VA does not support 
section 3(a)(2) and recommends its omission. Compliance with EOC 
standards should not be determinative of whether a facility otherwise 
furnishes high-quality care that would earn a five-star rating under 
the Strategic Analytics for Improvement and Learning Value Model. 
Regarding section 3(b) and the reporting requirement, we do not believe 
180 days would be a sufficient amount of time to prepare this report. 
We recommend this be revised to provide VA 270 days.

Draft Bill Establishing the Office of Women's Health

    The draft bill would create a new section 7310 that would require 
the Under Secretary for Health to establish and operate in VHA the 
Office of Women's Health, which would be located in VA Central Office. 
The Office would be led by the Director of Women's Health, who would 
report to the Under Secretary for Health. The Office would have to be 
provided the staff and support as necessary to carry out effectively 
its functions, including providing a central office for monitoring and 
encouraging VHA activities with respect to the provision, evaluation, 
and improvement of women Veterans' health care services; developing and 
implementing standards for care for the provision of health care for 
women Veterans; monitoring and identifying deficiencies in standards of 
care for the provision of health care to women Veterans, providing 
technical assistance to medical facilities to address and remedy 
deficiencies, and performing oversight of implementation of standards 
of care for women Veterans; monitoring and identifying deficiencies in 
standards of care for the provision of health care for women Veterans 
through the Veterans Community Care Program and providing 
recommendations to the Office of Community Care to address and remedy 
any deficiencies; overseeing distribution of resources and information 
related to women Veterans' health programs; promoting the expansion and 
improvement of clinical, research, and educational activities with 
respect to women's health care; providing recommendations with respect 
to the amount of funds to be requested for women Veterans, including, 
at a minimum, recommendations to ensure that such amount of funds 
either reflect or exceed the proportion of enrolled women Veterans; 
providing recommendations to the Secretary with respect to modifying 
the Veterans Equitable Resource Allocation (VERA) system to ensure that 
resource allocations reflect the health care needs of women Veterans; 
and carrying out other duties as the Under Secretary for Health may 
require.
    VA would be required to implement each recommendation made by the 
Director with respect to modifying the VERA system; however, if the 
Secretary chose not to implement such a recommendation, the Secretary 
would be required to notify Congress within 30 days of such a 
determination and provide the reasoning for the determination and an 
alternative to such recommendation. The bill would also establish the 
standards of care for the provision of health care for women Veterans 
in VA to include a requirement for at least one designated women's 
health primary care provider at each VA medical center and CBOC, 
training for all personnel at each VA medical facility on preventing 
and addressing harassment at VA medical facilities, and other 
requirements as determined by the Under Secretary for Health. The 
Director would have to provide to Congress an annual report on the 
actions taken by the Office, any identified deficiencies related to 
VA's provision of care to women Veterans and the standards of care 
established in this section, a description of the funding and personnel 
provided to the Office and whether additional funding or personnel are 
needed, and other information that would be of interest to Congress.
    VA does not support the draft bill. VHA currently has an Office of 
Women's Health Services that reports to the Office of Patient Care 
Services under the Deputy Under Secretary for Health for Policy and 
Services. The Chief Consultant in charge of the Office of Women's 
Health Services is a member of the Senior Executive Service; creating a 
new Office and Director would merely be renaming a position that is 
currently encumbered, as the duties and functions would be the same. 
The current placement of the Office of Women's Health Services is 
strategically aligned to interact with all other clinical programs at 
the national level, and this alignment provides a conduit for 
coordination and collaboration where services are similar. This 
arrangement also supports the alignment of patient needs when primary 
care or specialty services are identified.

Conclusion

    We note, as a general matter, that given the overlapping nature of 
some of the bills on the agenda today that the Committee proceed 
carefully in advancing legislation to ensure that any bills reported by 
the Committee make complementary changes to VA's authorities, rather 
than conflicting ones. We would be pleased to work with the Committee 
in this effort.
    This concludes my statement. Thank you for the opportunity to 
appear before you today. We would be pleased to respond to questions 
you or other Members may have.

                                 
                  Prepared Statement of Jeremy Butler
    Chairwoman Brownley, Ranking Member Dunn, and Members of the 
Subcommittee, on behalf of Iraq and Afghanistan Veterans of America 
(IAVA) and our more than 425,000 members worldwide, thank you for the 
opportunity to share our views, data, and experiences on the pending 
legislation today.
    I took over as CEO of the organization in February following the 
transition of our Founder, Paul Rieckhoff, to our Board of Directors, 
and I have been proud to take the helm of this incredible organization.
    I joined the Navy in 1999 and was commissioned as a Surface Warfare 
Officer. I served on active duty for 6 years to include deploying in 
2003 on the USS Gary (FFG-51) in support of the initial invasion of 
Iraq. I transitioned into the Navy Reserve in 2006, and I continue to 
serve today.

Support and Recognition of Women Veterans

    As the leading Veterans Empowerment Organization for the post-9/11 
generation of veterans, IAVA has the distinct honor of representing the 
cohort of veterans with the largest female population. We are also very 
proud that, though women represent 11% of all veterans, our membership 
is roughly 20% female.
    Support and Recognition of women veterans is an incredibly 
important part of our work; it is why it is included in our Big Six 
priorities for 2019, along with Combating Suicide, Defending Veterans 
Education Benefits, Reforming Government, Support for Injuries from 
Burn Pits and Toxic Exposures, and Support for Veteran Medicinal 
Cannabis Use.
    Over the past few years, we have fought to attain support for women 
veterans' issues. From health care access to reproductive health 
services to a seismic culture change within the veteran community, 
women veterans are now finally being elevated on Capitol Hill, inside 
the VA, and nationally. In 2017, IAVA launched our groundbreaking 
campaign, #SheWhoBorneTheBattle, focused on recognizing the service of 
women veterans and closing gaps in care provided to us by VA. 
Nevertheless, there is still a lot of work to be done.
    IAVA made the bold choice to lead on an issue that was important to 
not just the nearly 20% of our members who are women, but to our entire 
membership and that will help ensure the future of America's health 
care and national security. We continue to fight hard for top-down 
culture change in VA for the more than 700,000 women who have served 
since 9/11, including 345,000 who have deployed to Iraq or Afghanistan 
in support of the most recent wars.
    This is why in 2017, IAVA worked with Congressional allies on both 
sides of the aisle and in both chambers to introduce the Deborah 
Sampson Act. This bill called on the VA to modernize facilities to fit 
the needs of a changing veteran population, increasing newborn care, 
establishing new legal services for women veterans, and eliminating 
barriers faced by women who seek care at VA. This bill would have also 
increased data tracking and reporting to ensure that women veterans are 
getting care on par with their male counterparts.
    Although the Deborah Sampson Act, the centerpiece of IAVA's She Who 
Borne The Battle campaign, was not passed in the 115th Congress, IAVA 
recognizes that some progress has been made in support of women 
veterans, with key provisions of that legislation passed or funded in 
the last two years. These hard-fought victories included funding to 
improve services for women veterans, such as research on and 
acquisition of prosthetics for female veterans, increased funds for 
gender-specific health care, women veterans' expanded access and use of 
VA benefits and services, improved access for mental health services, 
and for supportive services for low income veterans and families to 
address homelessness.
    While we have seen greater awareness and progress toward improving 
services for women veterans, there is so much more we can do. Toward 
this goal, IAVA strongly supports passage of all of the provisions of 
the Deborah Sampson Act. Many of those provisions have been introduced 
by members of this Subcommittee and across Congress. To this end IAVA 
emphatically supports the six Deborah Sampson Act bills being 
considered today, H.R. 2645, H.R 2681, H.R. 2798, H.R. 2972, H.R. 3036, 
and H.R. 3636. Collectively these bills would expand newborn care, 
ensure VA facilities have a women's health care provider and gender 
specific services for veterans, allow women to receive counseling in 
retreat settings, increase reporting on women who use VA services, and 
increase the availability of female prosthetics. IAVA thanks the 
Subcommittee for their commitment to ensuring women veterans receive 
care that is on par with their male counterparts.
    In addition to the increase in newborn care under several Deborah 
Sampson Act provisions, IAVA supports another bill in front of the 
Subcommittee today, the VA Newborn Emergency Treatment Act (H.R. 2752). 
This legislation would allow VA to reimburse the cost of emergency 
transportation related to newborn care. Coupled with provisions in the 
Deborah Sampson Act this will finally allow VA to adequately care for 
veteran mothers and their babies.
    Without quality data collection and analysis, there is no way to 
know the extent to which women veterans are underserved. To date, 
limited useful and timely data exists. To design precise policy 
solutions and to hold accountable every agency in the continuum of 
care, we need robust data collection, sharing, analysis, and 
publication. It is for these reasons that IAVA strongly supports three 
bills to address this issue, Improving Oversight of Women Veterans' 
Care Act (H.R. 4096), the Women Veterans Health Care Accountability Act 
(H.R. 2982), and Improving Benefits for Underserved Veterans Act (H.R. 
4165). These bills will increase reporting and allow all of us to find 
and fill gaps in care for women veterans.
    For women veterans who choose to seek care at VA, finding quality 
providers who understand the needs of women veterans can be difficult. 
While VA has made some progress improving female-specific care for 
women veterans, including expanding the services and care available 
within VA, there is still much progress needed. Women veterans are more 
likely than their male counterparts to seek care in the community, 
meaning they are often seen by private care providers that may or may 
not understand military service and its health impacts. IAVA's 2019 
member survey underscores this as it found that while 70% of 
respondents felt that VA clinicians understand the medical needs of 
veterans, only 44% felt that non-VA clinicians understood them 
personally. For these reasons IAVA supports the Women Veterans Equal 
Access to Quality Care Act (H.R. 3224) to ensure women veterans have 
access to health care providers who are well qualified and with whom 
they feel comfortable and understood. In addition to the Draft 
Legislation to Establish the VA Office of Women's Health, in order to 
create a new office that will not only monitor VA's women-specific 
services, but create recommendations on how VA can improve their 
services to ensure that women veterans receive the health care that 
they have earned.
    Since 2001, the number of women using VA services has tripled. As 
more military women make the transition to civilian life, it is 
paramount that DoD and VA are able and ready to support them. Part of 
that care means ensuring proper reproductive care and support for women 
veterans and their spouses. Currently, women veterans do not have the 
same access to contraceptives as their civilian counterparts. That is 
unacceptable. It is for these reasons that IAVA supports the Equal 
Access to Contraception for Veterans Act (H.R. 3798).

Modernize Government to Support Today's Veterans

    According to a 2017 DoD report, more than 5,200 servicemembers, men 
and women, reported being sexually assaulted in 2017. Since only a 
fraction of sexual assaults are ever reported, this number is only the 
tip of the iceberg, and it is an increase of 10% from the previous 
year. Additionally, VA reports that about 29% of women veterans and 1% 
of male veterans report experiencing military sexual trauma (MST). The 
Violence Against Women Veterans Act (H.R. 3867) seeks to improve the 
services provided by VA for veterans who are victims of sexual assault 
and domestic violence by requiring an integration of those services 
with proven, existing community-based programs that serve domestic 
violence or sexual assault victims. In addition, this legislation would 
create a task force to review existing policies as well as develop a 
national program to address both domestic violence and sexual assault 
in the veteran community. IAVA insists on continuing efforts to help 
survivors of sexual assault and domestic violence come forward, so they 
can seek the care they need, bring the perpetrator to justice, and 
prevent future assaults by that perpetrator, and is supportive of this 
legislation.
    Millions of veterans rely on VA for both health care and benefits. 
Ensuring that the system is able and agile enough to accommodate the 
millions of veterans who use its services is paramount to ensuring the 
lasting success and health of the veteran population. About 48% of all 
veterans and about 55% of post-9/11 veterans are enrolled in VA care. 
Among IAVA member survey respondents, 81% are enrolled in VA health 
care, and the vast majority have sought care from VA in the last year. 
Over the past few years, VA has made incredible strides in modernizing 
its operating systems both internally and externally. This needs to 
continue outside of just infrastructure, but also with their hiring 
practices. VA needs robust, modern hiring practices in order to compete 
for talent to fill their overwhelming number of vacancies. To this end, 
IAVA supports the VA Hiring Enhancement Act (H.R. 1163), which will 
allow VA to better compete with the private health care industry and 
update the hiring practices within VHA.
    The Veteran Early Treatment for Chronic Ailment Resurgence through 
Examinations (VET CARE) Act (H.R. 2628) would create a pilot program to 
expand dental care to veterans that have certain chronic conditions. 
This type of care has been proven to increase overall health, and 
reduce health care costs. It is for these reasons that IAVA supports 
this legislation.
    VHA's Medical Foster Home program (MFH), provides a non-
institutional long-term care alternative for eligible veterans. 
However, while VA provides care team support to MFHs, it does not have 
the authority to pay for the cost of MFHs. As a result, veterans must 
use personal or other funding sources should they choose this 
alternative rather than nursing homes. The Long Term Care Veterans 
Choice Act (H.R. 1527) would change this and allow veterans to have 
more options when choosing their long-term care by authorizing VA to 
cover the cost of MFHs, during a three year period, up to 900 eligible 
veterans. IAVA supports the passage of this legislation.
    The Vietnam Era Veterans Hepatitis C (HCV) Testing Enhancement Act 
(H.R. 2816) would provide for a pilot project to study the benefits of 
implementing enhanced eligibility for all Vietnam and Vietnam Era 
veterans access to existing Hepatitis C testing through VA. Many 
Vietnam Era veterans were unknowingly exposed to HCV during their 
service and may still go undiagnosed. Without treatment, HCV can lead 
to a multitude of long term health problems including liver cancer and 
other serious health problems. Many Vietnam era veterans that are not 
connected to VA are unable to receive free HCV testing, and for those 
reasons IAVA supports the expansion of free HCV testing for Vietnam era 
veterans.
    Members of the Subcommittee, thank you again for the opportunity to 
share IAVA's views on these issues today. I look forward to answering 
any questions you may have and working with the Subcommittee in the 
future.

                                 
                   Prepared Statement of Joy J. Ilem
    Chairwoman Brownley and Members of the Subcommittee:
    Thank you for inviting DAV (Disabled American Veterans) to testify 
at this legislative hearing of the Subcommittee on Health. As you know, 
DAV is a non-profit veterans service organization comprised of more 
than one million wartime service-disabled veterans that is dedicated to 
a single purpose: empowering veterans to lead high-quality lives with 
respect and dignity. DAV is pleased to offer our views on the bills 
under consideration by the Subcommittee today.
                H.R. 1163, the VA Hiring Enhancement Act
    DAV believes the Veterans Health Administration's (VHA) employee 
vacancy number of over 43,000, which includes 39,500 health-related 
positions across all VHA medical facilities, is a problem that should 
be mitigated by Congress.\1\ While VHA is experiencing challenges 
similar to the private health care industry that is facing a national 
shortage of health care professionals, we believe VHA has different 
responsibilities than the health care industry in general.
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    \1\ https://catalog.data.gov/dataset/va-mission-act-section-505-
data
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    Title 38 of the United States Code mandates VA assist in the 
training of health professionals for its own needs and those of the 
nation. For over 70 years, in accordance with VA's 1946 Policy 
Memorandum No. 2, VA works in partnership with this country's medical 
and associated health profession schools to provide high quality health 
care to America's veterans and to train new health professionals to 
meet the patient care needs within VA and the nation. This partnership 
has grown into the most comprehensive academic health system 
partnership in history.
    VHA conducts the largest education and training effort for health 
professionals in the United States. In 2018, nearly 121,000 medical 
trainees received some or all of their clinical training in VA. VA's 
physician education program is conducted in collaboration with 144 of 
the152 Liaison Committee on Medical Education accredited medical 
schools and 34 Doctor of Osteopathic Medicine granting schools (AOA-
accredited medical schools). In addition, more than 40 other health 
professions are represented by affiliations with over 1,800 unique 
colleges and universities. Among these institutions are Minority 
Serving Institutions including Hispanic Serving Institutions and 
Historically Black Colleges and Universities.
    Congress should do all that it can to fully leverage this 
``upstream'' access to the pipeline of health care professionals. DAV 
fully supports efforts to recruit, retain and develop a skilled VHA 
clinical workforce to meet the needs of veterans, which H.R. 1163, the 
VA Hiring Enhancement Act, is proposing to do.
    This bill would allow VA, on a contingent basis, to begin both 
recruiting and hiring physicians up to two years before they complete 
their residency, as well as physicians who have completed their 
residencies leading to board certification. These contingent appointed 
physicians would be required to satisfy VHA's requirements to receive a 
permanent appointment.
    In addition, an applicant for VA employment would be released from 
any ``non-compete'' agreements between that applicant and their 
previous employer. Employees appointed with this understanding would be 
required to serve out the length of their non-compete agreement within 
their VA position or serve in that position for at least one year 
(whichever is longer).
    We applaud the goal of this legislation aimed at creating a larger 
applicant pool for qualified medical professionals to treat our 
service-disabled veterans without sacrificing the high quality of care 
VA provides. DAV Resolution No. 089 calls for effective recruitment, 
retention and development of the VA health care workforce. Because this 
measure attempts to reduce barriers for employment at VA for 
physicians, we are pleased to support the bill's passage.
           H.R. 1527, the Long-Term Care Veterans Choice Act
    Currently, subject to available appropriations, VA is required to 
provide nursing home care to enrolled veterans who are in need of 
nursing home care due to a service-connected disability or who are in 
need of nursing home care and have a service-connected disability rated 
at 70 percent or more.\2\
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    \2\ 38 U.S.C. Sec.  1710, 1710A
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    VA provides such institutional long-term service and support 
through VA owned and operated Community Living Centers (CLC), Community 
Nursing Homes (CNH) and State Veterans Homes (SVH) spending over $6 
billion in fiscal year 2018. In addition, VA spent over $4 billion 
across these three settings for service-connected veterans with an 
average daily census of over 23,000.
    H.R. 1527 would help VA better spend these funds and serve more 
veterans while providing high quality care in a setting service-
connected veterans prefer-a Medical Foster Home (MFH). MFHs are a safe 
and proven alternative to nursing homes by which veterans with serious 
chronic disabling conditions requiring nursing home level of care are 
able to receive these services through VA's Home-Based Primary Care 
program, and the MFH attendant.
    Veteran participation in the MFH program is voluntary and veteran 
residents report very high satisfaction ratings. Moreover, VA indicates 
it pays more than twice as much for the long-term nursing home care for 
many veterans than it would if VA was granted the proposed authority to 
pay for VA MFHs.\3\
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    \3\ VA Fiscal Year 2020 Budget Submission, Volume II--Medical 
Programs and Information Technology Programs, VHA-269.
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    Currently, the administrative costs for VA per veteran in the MFH 
program, including the cost of Home Based Primary Care, medications and 
supplies average less than $65 per day. However, service-connected 
veterans who qualify for nursing home care fully paid for by the 
government, must pay the full cost for room, board, and personal 
assistance to live in a MFH. These veterans who would otherwise choose 
to reside in a Medical Foster Home but are unable to pay approximately 
$1,500 to $3,000 per month are not able to avail themselves of this 
benefit, so many are placed in nursing homes at a cost to VA of about 
$7,000 a month.
    This measure would address this inequity by giving VA a three-year 
authority to pay for a limited number of service-disabled veterans to 
reside in a VA-approved MFH and save taxpayers from having to shoulder 
the higher cost of nursing home care-a reasonable approach when 
providing VA new authority.
    Chairwoman Brownley, as the veteran population continues to age, 
the need for more cost-effective long-term care services will continue 
to grow. Home-based community programs like MFHs will enable VA to meet 
the needs of aging service-connected veterans in a manner closer to 
independent living than institutionalized care. With the passage of 
this bill, service-disabled veterans would have the option of care that 
more closely aligns with their independence, protects their dignity and 
helps maintain their quality of life.
    DAV is pleased to support H.R. 1527, the Long Term Care Veterans 
Choice Act, in accordance with DAV Resolution No. 372, which calls for 
legislation to improve the comprehensive program of long-term services 
and supports for service-connected disabled veterans regardless of 
their disability ratings.
                  H.R. 2628, the VET CARE Act of 2019
    H.R. 2628, the Veterans Early Treatment for Chronic Ailment 
Resurgence through Examinations Act, or the ``VET CARE Act of 2019, 
would establish a four-year pilot program for at least 1,500 veterans 
to receive dental care in one VA medical center within five different 
Veterans Integrated Service Networks (VISNs). The program would 
prioritize enrollment of service-disabled veterans and would enroll 
mostly veterans with moderate to severe periodontal conditions. The 
bill also requires VA to assess the health outcomes of veterans who 
participate in the program in order to explore the effect of 
periodontal care on chronic health care conditions. The bill further 
requires VA to work with appropriate dental schools to further 
investigate any potential such correlation.
    The link between oral health and disability has been clearly 
established in medical literature. Patients who are medically 
compromised are more prone to oral disease, including periodontitis. If 
untreated, advanced periodontitis may lead to tooth loss and destroy 
tissue, bone and ligaments within the mouth. These outcomes can result 
in impaired functionality, productivity and quality of life for those 
with the condition.
    We understand this bill seeks to replicate studies in the veteran 
patient population that is different than the civilian patient 
population in that veterans who use VA for health care are typically 
older and more likely to be diagnosed with several health conditions. 
Equally important, the prevalence of costly medical conditions in this 
veteran patient population is projected to increase.
    DAV strongly supports this legislation in accordance with DAV 
Resolution No. 185, which calls on VA to offer comprehensive dental 
care to all service-connected veterans. We believe a pilot program such 
as this is a measured and reasonable way to assess the full costs and 
benefits associated with regular and preventive dental care for 
service-connected veterans and help policy makers in improving VA's 
current arcane and limited eligibility criteria for dental care.
            H.R. 2645, Newborn Care Improvement Act of 2019
    This legislation seeks to improve the care VA provided to women 
veterans by extending VA's authority to reimburse fees for newborn care 
from seven to 14 days. Women veterans using VA health care have high 
burdens of service-connected disabilities and many have delayed 
childbirth to accommodate their military careers. Both of these factors 
can affect women veterans' pregnancies and put them at greater risk of 
adverse outcomes, including premature labor and delivery of low-birth 
weight newborns.
    According to VA, younger women in childbearing years who use VA are 
particularly likely to be service-connected-noting that in fiscal year 
2015, almost three-quarters (73%) of its younger women veterans (18-44 
years old) had service-connected disabilities.\4\ Additionally, 
pregnant veterans with mental health conditions and injuries affecting 
their ability to procreate are liable to experience problematic 
pregnancies, including problems with labor and delivery that may 
threaten the life of the veteran and her newborn. VA must continue 
using its comprehensive maternity health coordination protocol and 
provide additional time for veterans and their newborns to recover from 
birth problems that are often related to their service-connected 
conditions.
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    \4\ Sourcebook: Women Veterans in the Veterans Health 
Administration. 2015, p. 35.
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    DAV is pleased to support H.R. 2645 based on recommendations in our 
2018 publication, Women Veterans: The Journey Ahead, which calls for 
legislative remedies to extend authority to reimburse care for newborns 
and DAV Resolution 020, which calls on VA to enhance health services 
for service-disabled women veterans.
H.R. 2681, a bill to direct the Secretary of Veterans Affairs to submit 
to Congress a report on the availability of prosthetic items for women 
           veterans from the Department of Veterans Affairs.
    H.R. 2681 would require the VA Secretary to report on the 
availability of prosthetic items made for women veterans at all VA 
medical facilities.
    Although the number of women with limb amputations who use VA is 
small (2%)\5\, across the lifespan, more than half of women (and men) 
in VHA care rely on VA prosthetic and sensory aids services for 
important devices and services. In fiscal year 2016, this encompassed 
233,005 women veterans.\6\ VA provides a wide variety of medical 
devices to support or replace a body part or function, from hearing 
aids and glasses to walkers, wheelchairs, home oxygen and other durable 
medical equipment.\7\ Services also cover specialized needs for women, 
such as maternity items, including maternity support belts; breast 
pumps and nursing bras; post-mastectomy items such as a breast 
prosthesis; swimsuits and bras; and intrauterine devices or pelvic 
floor strengtheners.
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    \5\ Meeting Minutes of the Advisory Committee on Women Veterans. 
2017
    \6\ Meeting Minutes of the Advisory Committee on Women Veterans. 
2017
    \7\ https://www.va.gov/budget/docs/summary/
fy2020VAbudgetVolumeIImedicalProgramsAndInformationTechnology.pdf p. 
65.
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    Despite this progress, VA is still having difficulty sourcing 
prostheses that fit women due to a lack of prosthetic options for women 
in the wider marketplace. One avenue for alleviating this issue, 3D 
printing, is something both VA and DoD are actively researching through 
an interagency work group and ongoing collaboration with the Food and 
Drug Administration, and DoD at the Walter Reed National Medical Center 
Printing Lab. Walter Reed's 3D Medical Application Center uses 
computer-aided design and manufacturing technologies to fabricate 
custom medical models, implants, prostheses and prosthetic parts. They 
have helped print custom prostheses for holding a fishing rod, wearing 
ice skates or getting around without strapping on full prosthetic legs.
    The technology and lab has obvious applications for women veterans, 
who often have issues with prosthetic fit, function and appearance. At 
a VA Innovation Creation Challenge in 2015, a team worked on an idea 
from a veterans advocate for a socket that would allow veterans to use 
a single lower-leg prosthesis while swapping attachments for different 
uses. VA funding has also been received for a 2018 research project to 
develop a new system to 3D print custom energy-absorbing feet to fit 
any shoe size that would incorporate a quick disconnect system to 
change foot and shoe combinations. Until 3D printers are more widely 
available, women veterans with prosthetic needs should be made aware 
that the 3D Medical Application Center accepts referrals for custom 
prostheses or attachments from any VA or DoD provider.
    VA also has plans to collect data on women who use a prosthesis, 
including funding prosthetic research that will help optimize women's 
upper-limb prostheses. However, because VA has a very small population 
of women prostheses users, VA and DoD research communities would 
benefit from collaborating with industry and academia to expand the 
number of women in the eligible research population who can be 
recruited to participate in comprehensive research studies to advance 
prosthetic science for women. VHA established the Amputee Veterans 
Registry to help target care and has plans for a second phase to add 
outcome measures to help researchers identify best practices. In 2017, 
VA established the Prosthetic Women Emphasis Group to also determine 
best practices and appropriate prosthetic needs of women veterans. 
Additionally, VA's Rehabilitation and Research Development Service was 
selected for and received funding for three studies focused on the 
needs of women veterans with limb loss.
    Madam Chair, we believe that some of the initiatives we describe 
above will help women obtain more appropriate prosthetic items, but we 
also believe Congress could fulfill its oversight duties more 
successfully by broadening the approach of information collected. We 
believe every VA medical center will report that it makes prosthetics 
available to women and may also provide data on the number of women 
veterans the prosthetic service has served. Unfortunately, that 
information is not enough to answer questions about the delivery of 
high-quality prosthetic items that are satisfactory to veterans.
    Instead, DAV recommends surveying a representative sample of the 
50,000 veterans in the Amputee Care program to assess their 
satisfaction with prosthetics furnished or procured by VA that replace 
appendages (or their functions) to ensure that the approach each 
medical facility uses to fit, customize and train veterans in the use 
of their prosthetic device is satisfactory and results in a product 
that meets veterans' expectations in terms of appearance and usability. 
Because they are a small portion of the user population, women veterans 
should be oversampled to ensure their representation in the results. A 
broader representative survey would allow VA to identify specific 
problems within subpopulations such as women, service-connected 
veterans or combat-injured veterans. It might also allow VA to target 
specific medical centers or points within the process that are less 
satisfactory to veterans. We believe these findings would allow for 
better remedies to address any challenges within the system.
    DAV supports the intent of H.R. 2681, but hopes that Representative 
Pappas and the Subcommittee would be amenable to broadening the scope 
of the survey and information collected about the availability of 
prosthetic items for women veterans in VA.
    H.R. 2752, a bill authorizing VA to furnish medically necessary 
     transportation for newborn children of certain women veterans
    H.R. 2752 would authorize VA to reimburse expenses for medically 
necessary transportation for newborns of women veterans and allow the 
Secretary to waive a debt or reimburse a veteran previously billed for 
such service.
    As we discussed in our justification for supporting H.R. 2645, 
women veterans in their childbearing years have many risk factors, 
including a high burden of service-connected conditions, which can 
endanger their pregnancies and negatively impact birth outcomes. This 
makes it more likely their newborn children might require more advanced 
care and require medical transport to a specialized pediatric medical 
facility. For these reasons, we strongly support this measure and urge 
its swift passage.
    DAV supports H.R 2752 as an important measure to enhance women 
veterans' health care as called for by DAV Resolution No. 020 by 
ensuring a robust maternity health care benefit.
     H.R. 2798, Building Supportive Networks for Women Veterans Act
    Madam Chair, this bill would establish a permanent counseling 
program in retreat settings for women veterans newly separated from 
military service. We believe these programs can offer women veterans 
important opportunities to network with other women with shared 
experiences in an environment conducive to healing and recovery-based 
care.
    DAV has supported the Boulder Crest program and stated our strong 
support for it and similar programs in our 2018 publication, Women 
Veterans: The Journey Ahead. These programs are born of the concept 
that post-traumatic stress can create opportunities for growth and a 
learning environment for veterans with similar experiences. The bill 
also requires that VA conduct an assessment to determine outcomes of 
these retreats and a biennial report. Preliminary data on these 
retreats thus far has shown significant improvements in participants' 
ability to better manage post-traumatic stress symptoms and maintain 
learned coping strategies.
    DAV Resolution No. 020 supports improvements in programs and 
services for women veterans and allows us to strongly support H.R. 
2798, the Building Supportive Networks for Women Veterans Act.
H.R. 2816, Vietnam-Era Veterans Hepatitis C Testing Enhancement Act of 
                                  2019
    H.R. 2816, the Vietnam-Era Veterans Hepatitis C Testing Enhancement 
Act of 2019, would increase access to testing for Hepatitis C for 
Vietnam-era veterans. Specifically, the bill would establish a one-year 
pilot within five Veterans Integrated Service Networks to conduct such 
testing at outreach events coordinated by veterans service 
organizations such as national or regional conventions or other 
community events.
    DAV recognizes the importance of spreading awareness of hepatitis C 
to this cohort of veterans, in addition to assuring that more veterans 
are aware of their status relative to this viral infection and their 
treatment options if they screen positive for the disease.
    DAV has no specific resolution on this matter, but it is in line 
with providing comprehensive health care services to all eras of 
veterans; therefore, we have no objection to the bill's favorable 
consideration.
   H.R. 2972, a bill to direct the Secretary of Veterans Affairs to 
   improve the communications of the Department of Veterans Affairs 
   relating to services available for women veterans, and for other 
                               purposes.
    H.R. 2972 would ensure that the VA Women Veterans Call Center has 
text messaging capability. While we understand that the Women Veterans 
Call Center already has the capability of receiving and sending text 
messages through its central call number, 1-855-VAWOMEN or 1-855-829-
6636, we appreciate the legislative assurance that the texting capacity 
will remain in place. The bill would also require VA to maintain a 
webpage with up-to-date listings of women veterans' coordinators and 
contact information for representatives assisting women in the Veterans 
Benefits, Health and National Cemetery Administrations. This resource 
would also list important health services provided within the network 
at each medical facility and community-based outpatient clinic to 
ensure women know what services are available in the location they are 
seeking care.
    Madam Chairwoman, in accordance with DAV Resolution No. 020, we 
support having these resources available for women veterans to enhance 
VA's outreach efforts, and, thus we are pleased to support H.R 2972.
        H.R. 2982, Women Veterans Health Care Accountability Act
    The Women Veterans Health Care Accountability Act seeks to identify 
and remedy barriers women veterans encounter in accessing VA health 
care. The legislation would require the VA Secretary to survey women 
veterans-both those who use VA health care as well as those who do not-
to better understand their reasons for not using VA services. The 
survey will question women veterans about their perceptions of safety 
in VHA facilities, access to services, and stigmas or barriers they may 
express about seeking treatment for sensitive issues such as military 
sexual trauma, mental health conditions or substance abuse disorders. 
The legislation also requires VA to identify strategies and make 
recommendation for addressing any issues identified by the survey.
    According to the VA, while there was a 175% increase in the number 
of women veterans using VA health care from 2000 to 2015, only 22% of 
women veterans, compared with 28% of men who are veterans, use VA 
health care.\8\ Over the past decade, VA has made many improvements in 
the way it manages the care of women using the system and launched 
several campaigns to increase awareness about women veterans' 
eligibility for VA benefits and services. VA has also sought to address 
long-standing cultural issues, including sexual harassment of women 
veterans seeking care at VA facilities by male veterans that prevent 
some women veterans from seeking the care they need, yet these problems 
persist.\9\
---------------------------------------------------------------------------
    \8\ Sourcebook: Women Veterans in the Veterans Health 
Administration, Volume 4, p.18.
    \9\ Dyer KE, Potter SJ, Hamilton AB, Luger TM, Bergman AA, Yano EM, 
Klap R. Gender Differences in Veterans' Perceptions of Harassment on 
Veterans Health Administration Grounds. Women's health issues : 
official publication of the Jacobs Institute of Women's Health. 2019 
Jun 25; 29 Suppl 1:S83-S93.
---------------------------------------------------------------------------
    Findings from an independent detailed survey as proposed in the 
bill, that build upon barrier to care studies conducted in 2008 and 
2015 may assist the VA in developing strategies to tackle some of the 
ongoing concerns and issues that prevent women veterans from accessing 
VA health care. Conducting research to examine women veterans 
perception of personal safety, gender sensitivity, comfort, sense of 
welcome, effectiveness of outreach efforts, access to child care and 
operating hours for VA services may also add value in better 
understanding the overall women veterans patient experience and help to 
improve services for this population.
    DAV supports H.R 2982 in accordance with DAV Resolution No. 020, 
calling for VA to enhance women veterans' health care programs and 
assist them in overcoming barriers that may affect their ability to 
obtain necessary medical care.
          H.R. 3036, Breaking Barriers for Women Veterans Act
    H.R. 3036, the Breaking Barriers for Women Veterans Act would 
correct environmental, structural, and staff deficiencies to ensure 
VA's delivery of high-quality health care to women veterans. The bill 
would authorize $20 million to assist VA in addressing deficiencies it 
identifies in annual environment of care surveys to assure that the 
privacy, security and dignity of women patients is upheld at each VA 
medical center. It would also require VA to ensure it had at least one 
full-time or part-time women's health primary care provider at each 
facility and authorize $1 million to develop more in-house expertise by 
offering mini-residency training to VA primary care and emergency 
physicians and other independent practitioners. The bill would also 
require VA to develop a training curriculum for community care 
providers treating women veterans and conduct a study to determine the 
staffing and training needs for Women Veterans' Program Managers and 
whether an ombudsman for women veterans at each VA facility is 
warranted.
    By authorizing the resources necessary, the legislation will better 
ensure that women veterans have expert care for gender-related issues 
wherever they seek such care within the VA or in sponsored settings.
    We strongly support H.R. 3036 in accordance with DAV Resolution No. 
020, which supports enhancing women's health care programs to ensure 
equity for women veterans seeking VA health care.
 H.R. 3224, to provide for increased access to Department of Veterans 
                Affairs medical care for women veterans.
    This measure seeks to ensure women veterans have access to 
comprehensive gender-specific VA medical services at all its clinical 
points of care. While we appreciate and concur with the general intent 
of this bill-the definition of gender-specific care and services is not 
included in the bill text. While current VHA directives (1330.01,02), 
outline what gender-specific services must be available in VA to the 
greatest extent possible-when such services are not available, VA is 
authorized to contract for such services in the community. Certain 
types of care, such as maternity and obstetric care (and newborn), is 
generally provided to women veterans in the community due to lack of 
volume and VA's lack of expertise in providing such care. Likewise, 
mammography services are not available at all VA locations due to low 
volume and frequently provided in the community. Without the gender-
specific services definition, the bill's overall intent is unclear.
    Additionally, H.R. 3224 calls for a study on extended care hours 
and the best practices and resources required to implement the use of 
extended hours at VA medical clinics and facilities.
    Women veterans are, on average, younger than their male peers (48.4 
v. 63 years old) and face a number of barriers when seeking care. Many 
women veterans struggle to maintain single-parent households, full-time 
employment or education track, or provide caregiving to an aging 
parent. Extended clinical hours at VA points of care may be an 
additional means of making services available to these women and we 
would be interested in the Committee's findings and recommendations 
based upon such a study.
    While DAV is able to support the provisions in the bill related to 
a study on extended hours and best practices, we request the 
Subcommittee amend the bill to clarify the definition of gender-
specific services prior to advancing H.R 3224.
              H.R. 3636, Caring for Our Women Veterans Act
    The Caring for Our Women Veterans Act would require the VA 
Secretary to submit a report on the number of women veterans who reside 
in each state; the number of women veterans who are enrolled in VA care 
and have received care in the past year; the number of women veterans 
seen at each VA medical facility over the past year; VISNs with the 
largest increase of women veteran users; models of care used by VA to 
treat women veterans and how VA makes such determinations about the 
appropriate use of such models in each facility; and VA staffing 
available for the care and treatment of women veterans.
    The measure also requires an assessment on strategic capital 
investment planning, including modifications and upgrades for women 
veterans and information on staffing levels, including the number of 
full and part-time gynecologists within the Department, the number of 
patient-aligned care teams in women's clinics, and the number of 
providers who have completed a mini-residency and serve as a women's 
health provider.
    DAV believes this information is essential to the development of 
Veterans Integrated Service Network marketing plans and any future 
modernization and capital restructuring efforts. While DAV believes 
much of this information is currently available through the Department, 
we agree a comprehensive assessment that provides all the required 
information in one report would be useful information for Congress and 
interested stakeholders. We therefore suggest the Subcommittee work 
closely with the Women's Health Program Office to determine any 
potential amendments to the bill regarding the collection of 
information needed to ensure the intent of the measure is fully 
realized. Fully understanding the impact of increasing use of VA 
services by women veterans and what resources and future plans are 
needed is essential to better serving this population.
    DAV is pleased to support H.R. 3636, which comports with 
recommendations made in our report Women Veterans: The Journey Ahead 
and DAV Resolution No. 091, which calls upon VA to modernize its health 
care infrastructure.
       H.R. 3798, Equal Access to Contraception for Veterans Act
    H.R. 3798, the Equal Access to Contraception for Veterans Act, 
would limit charging veterans copayments for contraceptive items/
medications furnished by the VA.
    Access to contraception is part of providing comprehensive health 
services. However, cost sharing can be a barrier for some veterans who 
need health care services or treatment. Many private health plans have 
eliminated copayments for beneficiaries for preventative care, in part 
because it is often significantly less expensive than having to treat 
various health conditions or stabilize chronic diseases.
    We are able to offer our support for H.R. 3798, as the measure is 
in accordance with DAV Resolution No. 365, which calls for the 
reduction or elimination of all copayments for health care for service-
connected veterans obtaining care within VA and DoD medical facilities.
             H.R. 3867, Violence Against Women Veterans Act
    H.R. 3867, the Violence Against Women Veterans Act, would create a 
comprehensive new program to improve supportive services for women 
veterans who have experienced domestic violence or sexual abuse.
    The measure calls for the establishment of a national task force 
(Task Force) on veterans experiencing domestic violence or sexual 
assault for the purpose integrating VA programs with community agencies 
and resources such as housing and benefit programs, rape crisis 
centers, shelters for women who are fleeing abusive partners, and other 
appropriate state and community programs meeting the needs of these 
individuals. The Task Force would include the VA Secretary working in 
consultation with the Attorney General and the Secretary of Health and 
Human Services. In addition, the bill requires VA to conduct a baseline 
study of domestic violence and sexual assault among veterans and 
spouses of veterans and an assessment of effects of intimate partner 
violence and the Secretary could assist with establishing VA 
coordinators who would help train community providers to identify and 
connect veterans with needed VA services, care and benefits.
    The DoD and VA continue to confront the worsening epidemic of 
military sexual trauma and its consequences. There are high rates of 
women who experience sexual trauma within the military (according to 
DoD's most recent survey of personnel, 6.2% of service women reported 
experiencing unwanted touching and many more (24.2%) report having 
experienced some form of harassment within the past 12 months.) A 
significant number of these women (1/5 of those assaulted) report 
having experienced both.\10\
---------------------------------------------------------------------------
    \10\ Department of Defense Annual Report on Sexual Assault in the 
Military Fiscal Year 2018. P. 9
---------------------------------------------------------------------------
    VA does not have the authority to change the policy and culture 
within the military services, but it can and should make changes in its 
own culture to ensure that women are not re-traumatized in the process 
of obtaining care for the mental health challenges these all-too common 
occurrences bring. According to a recent study, VA found that many 
women veterans (about 20%) are experiencing sexual harassment from male 
patients while seeking care within its facilities.\11\
---------------------------------------------------------------------------
    \11\ Dyer KE, Potter SJ, Hamilton AB, Luger TM, Bergman AA, Yano 
EM, Klap R. Gender Differences in Veterans' Perceptions of Harassment 
on Veterans Health Administration Grounds. Women's health issues : 
official publication of the Jacobs Institute of Women's Health. 2019 
Jun 25; 29 Suppl 1:S83-S93.
---------------------------------------------------------------------------
    VA reports also indicate a high burden of intimate partner violence 
experienced by women veterans using VA services that exceed those of 
civilian women. Specifically, about one-third of women veterans 
compared to one-fourth of civilian women experience intimate partner 
violence.\12\
---------------------------------------------------------------------------
    \12\ Dichter, M.E, et al. (2011). Intimate partner violence 
victimization among women veterans and associated heart health risks. 
Womens health Issues. 21 (suppl 4): S190-S194.
---------------------------------------------------------------------------
    Sexual trauma and domestic violence can lead to post-traumatic 
stress disorder, depression, anxiety, substance use disorders and other 
mental health conditions. Violent domestic attacks on women veterans 
have also been associated with traumatic brain injury (TBI) (about 25% 
of veterans experiencing intimate partner violence have a history of 
TBI and 12.5% have current symptoms).\13\ Any of these conditions can 
affect a survivors ability to live healthy, productive and economically 
stable lives.
---------------------------------------------------------------------------
    \13\ Iverson, KM, et al. (2017). Traumatic brain injury and PTSD 
symptoms as a consequence of intimate partner violence. Comprehensive 
psychiatry 74: 80-7.
---------------------------------------------------------------------------
    These findings indicate a compelling need for a comprehensive 
program for women veterans experiencing these types of violence. VA 
prescribes to a whole-health model of care that integrates supportive 
services and care coordination that allow them to address the array of 
issues that often accompany trauma, and require income assistance, 
housing, legal services and specialized medical and mental health care 
and substance-use treatment. VA's program for homeless veterans 
provides an excellent example of a successful collaborative model of VA 
and community providers.
    While we support the provisions in this measure focused on ensuring 
veterans using VA services who have experienced sexual trauma or 
domestic violence have access to supportive services aimed at recovery, 
DAV does not have a resolution calling for formation of a National Task 
Force that would integrate VA assets into community-based networks of 
care for survivors of sexual and domestic abuse. We note however, that 
VA does not have the breadth and scope of services provided in the 
community for these veterans who would likely benefit from VA 
leveraging community resources from agencies and programs with 
expertise in these area therefore, we have no objection to passage of 
the bill.
   H.R. 4096, Improving Oversight of Women Veterans' Care Act of 2019
    H.R. 4096, the Improving Oversight of Women Veterans' Care Act of 
2019, requires an annual report to determine veteran access to gender-
specific services such as mammograms, obstetric and gynecological care 
through VA's community care program.
    As VA implements the Veterans Community Care Program (VCCP) as 
required under the VA MISSION Act of 2018, it is increasingly important 
that VA identify means of assuring that VA network community care 
providers are required to meet the same quality standards as VA 
providers are required to meet and that community care is commensurate 
with VA's whole health model of care. H.R. 4096 requires information on 
average wait times, drive times, and reasons why appointments could not 
be scheduled with a community provider.
    H.R. 4096 would also require VA to standardize environment of care 
and VA's inspections and reporting procedures to align with VHA's 
women's health handbook. It would further disqualify high-performing VA 
medical centers (based upon Strategic Analytics for Improvement and 
Learning (SAIL) quality measures from being awarded a 5-star rating if 
they are not in compliance with environment of care standards for women 
veterans clinics outlined in the handbook.
    Ensuring the appropriate facility design and staff composition is 
critical to easing women veterans concerns about their safety, privacy 
and dignity and will help to ensure comprehensive high quality care at 
all VA points of care. For these reasons, we strongly support H.R. 
4096, in accordance with DAV Resolution No. 020.
  Draft bill, to establish in the Department of Veterans Affairs, the 
            Office of Women's Health and for other purposes
    Chairwoman Brownley, DAV is happy to lend its support to your draft 
bill establishing an Office of Women's Health within the VHA. The 
Office would be responsible for evaluation, oversight and improvement 
of women veterans' health services in VA and in the community; 
development and implementation of standards of care; and identifying 
and correcting deficiencies in standards of care for women. 
Additionally, the Office would oversee distribution of resources for 
these purposes and promote expansion and improvement of clinical, 
research and educational activities with respect to women's health 
services within the Department. We believe this change will 
significantly improve the tracking and use of centralized funding for 
women's programs ensuring resources are used for intended purposes, and 
specifically, allowing VA to address long-standing issues affecting 
women veterans' access to comprehensive gender-specific health care.
    The current Women's Health Services office is understaffed and 
lacks control over resources to assure that administrative priorities 
of the office are implemented. Without control over resources, the 
director is beholden to other program offices and facility director's 
priorities that may not be in line with the women's health program 
office priorities. This hampers the full resourcing of the women's 
health centers which are widely regarded as the model that is most 
likely to ensure high-quality, comprehensive care and satisfaction for 
women veterans. It creates challenges in training and hiring designated 
women's health providers in facilities that lack them in order to 
ensure appropriate care for women veterans at all sites of care. It 
also hampers the ability to ensure that awareness campaigns and 
campaigns to address sexual harassment, and increase the awareness of 
women's special needs are given appropriate support.
    While DAV does not have a resolution specifically calling for the 
establishment of an Office of Women's Health, we have addressed the 
need to elevate the program to that status in our report, Women 
Veterans: The Journey Ahead.\14\ Given existing and persistent 
challenges within the Department to address many issues related to 
women veterans, we support this draft measure as it may be a necessary 
prerequisite to establish such an office to ensure that women's health 
care programs can be enhanced in a manner that ensures the equity and 
availability in women's services as we call for under DAV Resolution 
No. 020.
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    \14\ DAV. Women Veterans: The Journey Ahead. P. 3.
---------------------------------------------------------------------------
    Chairwoman Brownley, this concludes my testimony. Thank you for 
inviting DAV to testify at today's hearing. I would be pleased to 
address any questions related to the bills under consideration by the 
Subcommittee.

                                 
                  Prepared Statement of Roscoe Butler
    Chairwoman Brownley, Ranking Member Dunn, and members of the 
Subcommittee, Paralyzed Veterans of America (PVA) would like to thank 
you for this opportunity to provide our views on some of the pending 
legislation you will be reviewing today.

H.R. 3867, the ``Violence Against Women Veterans Act''

    PVA supports H.R. 3867, the ``Violence Against Women Veterans 
Act.'' We believe that any veteran-male or female-who experienced 
domestic violence or sexual assault while serving on active duty should 
have access to appropriate health care and services to help them 
overcome the trauma they encountered while serving our nation at home 
and abroad. When VA is not able to provide the needed care or services, 
this legislation would authorize the Secretary of Veterans Affairs (VA) 
to establish partnerships with domestic violence shelters and programs; 
rape crisis centers; state domestic violence and sexual assault 
coalitions; and such other health care or service providers. 
Partnerships like these could help veterans who experienced domestic 
violence receive the care and services they need and deserve.

H.R. 4096, the ``Improving Oversight of Women Veterans' Care Act of 
    2019"

    PVA supports H.R. 4096, the ``Improving Oversight of Women 
Veterans' Care Act of 2019.'' This legislation would require the Under 
Secretary for Health to submit to Congress an annual report on the 
ability of women veterans to access gender-specific care in the 
community, including the average waiting period between the veteran's 
preferred appointment date and the date on which the appointment is 
completed, reasons VA could not fulfill the appointment, and the 
driving time required for appointments. It would also require each 
medical facility to report to the Secretary, on a quarterly basis, the 
compliance and noncompliance of the facility with the environment care 
standards for women veterans, as defined in Veterans Health 
Administration (VHA) Directive 1330.01(1). Each report is to name the 
person at the facility who is responsible for compliance and provide 
the facility plan to strengthen the environment of care standards.
    According to a December 2016 U.S. Government Accountability Office 
Report (17-52), VHA does not have data and performance measures for 
women veterans' access to gender-specific care delivered through the 
Veterans Choice Program. However, VHA does collect data to evaluate 
women veterans' access to gender-specific care received through PC3 - a 
different community care program. The report also found VHA does not 
have accurate or complete data regarding medical centers' compliance, 
or noncompliance with the environment of care standards for women 
veterans.
    If VA cannot meet the needs of women veterans and refers them to 
providers in the community, then VA must still ensure that the care is 
quality, appropriate care that best meets the veterans' needs. Holding 
VA and community care providers to different standards is unacceptable. 
VA must be able to ensure the care a veteran receives, whether provided 
by VA or in the community, is the best clinical option available. As 
such, Congress must have the data to conduct the appropriate oversight 
on that care.

H.R. 1163, the ``VA Hiring Enhancement Act''

    PVA encourages many efforts to bolster staffing levels at VA 
facilities, particularly within the Spinal Cord Injury System of Care, 
which the historical data shows is one of the most difficult areas to 
recruit and retain physicians and nursing staff. We strongly support 
the ``VA Hiring Enhancement Act,'' which seeks to release physicians 
from ``non-compete agreements'' for the purpose of serving at VA. It 
would also allow VA to begin recruiting and hiring physicians on a 
contingent basis up to two years before they complete their residency. 
These contingent-appointed physicians would still have to satisfy VA's 
requirements in order to receive a permanent appointment. Removing 
these barriers would help encourage more of the best and brightest 
doctors and nurse practitioners coming out of medical school to pursue 
a career with VA.

H.R. 2628, the ``Veterans Early Treatment for Chronic Ailment 
    Resurgence through Examinations Act of 2019'' or the ``VET CARE Act 
    of 2019"

    PVA supports H.R. 2628, which would expand eligibility for VA 
dental care to certain veterans. Studies show a person's oral health 
has a major impact on their physical health and gum disease is often 
associated with diabetes, heart disease, and many other serious medical 
conditions.
    Even though dental benefits are the bridge to health and wellness, 
VA closely rations these services citing the severe underfunding of its 
dental departments. Currently, VA dental care is limited to a small 
number of veterans such as those who are 100 percent disabled or have a 
service-connected dental condition, former prisoners of war, and 
homeless veterans. Dental care may also be available if a dental 
condition is aggravating a service-connected condition or complicates 
treatment of that condition.
    Simply put, the VET CARE Act would require VA to establish a four-
year pilot program for older veterans with type 2 diabetes. Since the 
VA spends most of its health care costs on treating veterans with 
chronic conditions like diabetes, expanding dental coverage to these 
individuals will help improve their overall health and may bring those 
costs down.

H.R. 2681, to direct the Secretary of Veterans Affairs to submit to 
    Congress a report on the availability of prosthetic items for women 
    veterans from the Department of Veterans Affairs

    PVA supports H.R. 2681 which directs the VA Secretary to submit to 
Congress a report on the availability of prosthetic items for women 
veterans from VA. Female veterans are more likely than male veterans to 
receive a prosthesis that does not properly fit. This can cause these 
women additional medical problems, such as socket burn, and higher 
rates of hip and knee osteoarthritis. Women veterans in need of 
prosthetics appliances are on an increase, and VA must ensure 
prosthesis for women veterans meet all of their health and social 
needs.

H.R. 2816, the ``Vietnam-Era Veterans Hepatitis C Testing Enhancement 
    Act of 2019"

    PVA supports this legislation which directs VA to carry out a one-
year pilot program making hepatitis C testing available to covered 
veterans at outreach events organized by veterans service organizations 
(VSOs). Veterans who have this disease need to be identified in order 
to receive treatment for it. We believe that increasing outreach 
through VSOs will facilitate these efforts.

H.R. 2982, the ``Women Veterans Health Care Accountability Act''

    PVA supports H.R. 2982, which directs the VA Secretary to conduct a 
study of the barriers for women veterans to health care from VA. 
Accessibility at VA facilities to gender-specific care has been an area 
of concern for many of our members.

Ingress/Egress

    The first hurdle women veterans may encounter is the entrance to 
the woman's health clinic. Many clinics were hastily established so 
they did not receive the careful level of planning necessary to ensure 
wheelchair users could enter the facility. For example, the entrance to 
a VA women's health care clinic we recently visited did not have an 
automatic door for patients to use. To complicate matters further, the 
entrance was not visible to staff so they could not see if a patient 
outside required assistance, nor was there an external bell for the 
patient to alert someone. In this case, it was an outside entrance, so 
any patient needing assistance would be exposed to the elements until 
someone came along to help them.

Accessible Exam Rooms

    Accessibility to doctors' offices is essential in providing medical 
care to people with severe or catastrophically disabilities, but often 
this is the next hurdle a women veteran may encounter at VA. Some of 
VA's exam rooms are too small to accommodate a women veteran in a 
wheelchair and a portable lift. Other rooms may not be big enough for a 
larger wheelchair to enter at all. A portable lift would be unnecessary 
if the examination rooms had a built-in lift to hoist a women veteran 
from her wheelchair to the examination table, but many women's health 
clinics do not have these lifts installed.
    Barriers like these tend to make individuals with severe 
disabilities less likely to get their routine preventative medical 
care. It is a major concern because wheelchair users face the insidious 
health threat of having to sit all day. Loss of muscle tone and 
diminished circulation cause pressure sores to develop, and it is very 
important that seemingly minor problems like these be detected and 
treated early before turning into major, and possibly life-threatening, 
problems. However, if the patient is unable to enter the exam room or 
be placed upon the exam table, the physician will be forced to examine 
the patient in her wheelchair, diminishing the quality of the exam and 
any care provided.

Mammography Examinations

    Some VA medical centers do not have diagnostic equipment to conduct 
mammography examinations. For the facilities that do, wait times are 
excessively long (two months or longer), or the equipment is 
inaccessible for women veterans in wheelchairs, particularly 
quadriplegics. While there are mammography machines that allow women 
with physical disabilities to lay on an exam table, not every VA health 
care facility has this type of equipment.
    In light of these concerns, we believe that H.R. 2982 should 
specifically address the need to evaluate the barriers faced by women 
veterans with spinal cord injuries and disorders in receiving proper 
gender-specific health care.

H.R. 3036, the ``Breaking Barriers for Women Veterans Act''

    Making VA facilities work for women veterans is the goal of H.R. 
3036. This legislation directs VA to ensure each of its medical 
facilities has at least one full or part-time women's health primary 
care provider; provides $1 million in funding each fiscal year for a 
Women Veterans Health Care Mini-Residency Program; and ensures that 
providers in the community network are equipped with training nodules 
specific to women veterans. To verify that these standards are being 
met, the bill also instructs VA to conduct a study to make sure that 
staffing levels specific to women veterans are appropriate. PVA 
supports H.R. 3036 because it will strengthen VA's ability to deliver 
easily accessible, high quality care for women veterans at VA 
facilities.

Discussion Draft, to amend title 38, United States Code, to establish 
    in the Department of Veterans Affairs the Office of Women's Health, 
    and for other purposes

    VA's Center for Women Veterans was established by Congress in 
November 1994 (P.L. 103-446) to monitor and coordinate VA's 
administration of health care and benefits services, and programs for 
women veterans. It also serves as an advocate for a cultural 
transformation (both within VA and in the general public) in 
recognizing the service and contributions of women veterans and works 
to raise awareness of the responsibility to treat women veterans with 
dignity and respect. Establishing a separate Office of Women's Health 
would elevate the good work currently being done by the Women's Health 
Services Program Office; therefore, we support this proposed 
legislation.

H.R. 2645, the ``Newborn Care Improvement Act of 2019"

    PVA supports H.R. 2645 which would raise the number of days a 
newborn under VA care could stay in the hospital from 7 to 14. Most 
newborn births are without complications, but if problems develop, the 
infant may be required to remain in the hospital for an undetermined 
period. H.R. 2645 ensures the newborn is covered for a greater period 
of time so women veterans and their families can focus on their child's 
health rather than worrying about how to pay for the hospital bill.

H.R. 2752, the ``VA Newborn Emergency Treatment Act''

    VA's current newborn care authority provides hospital care but does 
not cover emergency transportation when medically necessary 
transportation is required. PVA supports H.R. 2752 which would 
authorize the VA Secretary to furnish medically necessary 
transportation for newborn children of certain women veterans. This 
common sense legislation will ensure that women veterans are not forced 
to think about the cost of such transportation when considering 
emergent care options for their newborns.

H.R. 2798, the ``Building Supportive Networks for Women Veterans Act''

    PVA supports H.R. 2798, the ``Building Supportive Networks for 
Women Veterans Act,'' which would make the existing pilot on counseling 
in retreat settings for newly separated women veterans a permanent 
program. This legislation provides VA with the authority to extend the 
program using the same measurements and eligibility requirements. PVA 
supported the original program established by the ``Caregivers and 
Veterans Omnibus Health Services Act of 2010'' and has been pleased to 
see it continue.
    In surveys conducted after the program, participants consistently 
showed better understanding of how to develop support systems and to 
access resources at VA and in their communities. The OEF/OIF women 
veterans at these retreats are most often coping with effects of severe 
Post-Traumatic Stress and Military Sexual Trauma. They work with 
counselors and peers, building on existing support. If needed, there is 
financial and occupational counseling. To be eligible, women veterans 
must have been deployed in OEF/OIF, and have completed at least three 
sessions of counseling in the past six months.
    The program, managed by the Readjustment Counseling Service, has 
been a marked success since its inception in 2011. The results have 
been overwhelmingly positive for women veterans, who experience 
consistent reductions in stress symptoms as a result of their 
participation. Other long-lasting improvements included increased 
coping skills. It is essential for women veterans that Congress make 
this program permanent. We believe the value and efficacy of this 
program is undeniable.

H.R. 1527, the ``Long-Term Care Veterans Choice Act''

    PVA supports the ``Long-Term Care Veterans Choice Act'' which would 
authorize VA to enter into contracts or agreements for the transfer of 
veterans to non-VA adult foster homes for certain veterans who are 
unable to live independently. PVA believes that VA's primary obligation 
involving long-term support services is to provide veterans with 
quality medical care in a healthy and safe environment. This should 
include access to a medical foster home as desired by the veteran.
    As it relates to veterans with a catastrophic injury or disability, 
it is PVA's position that adult foster homes are only appropriate for 
disabled veterans who do not require regular monitoring by licensed 
providers, but rather have a catastrophic injury or disability and can 
sustain a high level of independence. When these veterans are 
transferred to adult foster homes, care coordination with VA's 
specialized systems of care is vital to the veterans' overall health 
and well-being.
    This bill requires the veteran to receive VA home health services 
as a condition to being transferred. As such, PVA believes that if a 
veteran with a spinal cord injury or disorder is eligible and willing 
to be transferred to an adult foster home, the VA must have an 
established system in place that requires the VA home-based primary 
care team to coordinate care with the VA Spinal Cord Injury (SCI) 
Center and the SCI primary care team that is in closest proximity to 
the adult foster home. When caring for a veteran with a catastrophic 
injury or disability this specialized expertise is extremely important 
to prevent and treat associated illnesses that can quickly manifest and 
jeopardize the health of the veteran. Thus, these veterans must also be 
regularly evaluated by specialized providers who are trained to meet 
the needs of their specific conditions.

H.R. 2972, to direct the Secretary of Veterans Affairs to improve the 
    communications of the Department of Veterans Affairs relating to 
    services available for women veterans, and for other purposes

    PVA supports H.R. 2972 which would expand the capabilities of VA's 
Women Veterans Call Center by including a text messaging capability and 
establishing a single website where women veterans can find information 
about the benefits and services available to them. The call center 
already has text messaging capability, but the benefit of having a one-
stop resource for information on women veterans' health care and 
benefits cannot be overstated.

H.R. 3224, to amend title 38, United States Code, to provide for 
    increased access to Department of Veterans Affairs medical care for 
    women veterans

    Without additional clarification, PVA cannot support H.R. 3224 as 
written. Subsection 1720J(a) would require that the Secretary ensure 
that gender-specific services are continuously available at every VA 
medical center and community-based outpatient clinic. However, H.R. 
3224 does not define the type of ``Gender-Specific Services'' VA is 
required to provide. VHA Directive 1330.01(02), Health Care Services 
for Women Veterans breaks down gender-specific care into several 
categories, e.g., primary care and specialty care. It is gender-
specific specialty care which concerns PVA. VHA Directive 1330.01(02), 
paragraph j, provides a list of gender-specific specialty services that 
must be available in-house to the greatest extent possible. If gender-
specific specialty services are not available in-house, such services 
must be provided through non-VA medical care, contractual or sharing 
agreements, academic affiliates, or other VA medical facilities within 
a reasonable traveling distance (less than 50 miles).
    Unless additional clarification is provided, VA could interpret 
Congress's intent with this legislation as a requirement to offer all 
gender-specific services in each VA medical center or community based 
outpatient clinic. There are a number of gender-specific specialty 
services listed in the directive that VA medical centers and community-
based outpatient clinics are not capable of providing-particularly when 
it comes to maternity and newborn care.\1\ PVA recommends that this 
legislation be amended to include language defining the types of 
gender-specific services that VA would be required to provide.
---------------------------------------------------------------------------
    \1\ VHA DIRECTIVE 1330.01(2), "Health Care Services for Women 
Veterans"

---------------------------------------------------------------------------
H.R. 3798, the ``Equal Access to Contraception for Veterans Act''

    The Affordable Care Act (ACA) prevents individuals with insurance 
from being charged pharmaceutical co-payments for all 11 categories of 
preventive medicine as determined by the U.S. Preventive Task Force and 
Centers for Disease Control and Prevention. Yet, with VA being exempt 
from the ACA, Section 1722A(a)(3) requires VA to charge for these 
categories with exemptions provided by the Secretary for immunizations 
and smoking cessation. Veterans are experiencing a disparity in co-
payment requirements for the remaining nine categories including 
contraceptives women veterans receive from the pharmacy. PVA supports 
H.R. 3798 which eliminates this undue and unjust barrier to accessing 
birth control that only women veterans and the uninsured must face.
    Again, PVA appreciates this opportunity to express our views on 
some of the many important pieces of legislation being examined today. 
We look forward to working with the Subcommittee to improve the quality 
and accessibility of health care for women veterans, and to enhance the 
quality of health care benefits for veterans in general.
    footnotes (1)

                                 
                       STATEMENTS FOR THE RECORD

                           Honorable Max Rose
    Thank you, Chairwoman Brownley, and Ranking Member Dunn, for having 
this forum to provide due attention to the pending legislation before 
us. We are faced here with an issue of persistent disparities of health 
care access between male and female veterans. The Department of 
Veterans' Affairs (VA) has an influx of women veterans entering their 
systems but they have been unable to keep up with increased demand.
    Funding for health services specifically for women in VA has 
increased about 16% over the last five years, totaling just over $500 
million in 2019. But that figure is less than 1% of overall veterans' 
health spending, even though women veterans represent one of the 
fastest growing populations using VA health care. The number of women 
using Veterans Health Administration services has also tripled since 
2001, a group expected to grow much larger in the coming years.
    However, as our women veterans seek health care, they are either 
faced with a lack of resources to meet their specific needs or they 
must jump through hoops due to administrative delays and short 
staffing. It is alarming to see that women make up both 10% of the 
veteran population, and nearly 16% of the active-duty military force, 
yet there are still major questions as to whether VA can effectively 
serve this large portion of current and future veterans.
    There needs to be an increase in resources and H.R. 3036, The 
Breaking Barriers for Women Veterans Act, would be an important first 
step in bridging the gender health care gap. This bill would require 
the VA to implement improvements to better serve women veterans, 
including upgrading existing medical facilities. Additionally, the VA 
must ensure its medical facilities have at least one full-time or part-
time women's health provider, and establish training modules for 
community providers that are specific to women veterans.
    The VA needs to be able to properly serve these women and their 
health care needs. Women veterans shouldn't have their health put at 
risk because their local VA facility doesn't have the appropriate 
resources to take care of them or because they need to wait extended 
periods of time due to administrative delays.
    I would like to thank Paralyzed Veterans of America, Iraq and 
Afghanistan Veterans of America, and Disabled American Veterans for 
their support of this legislation, along with the bipartisan group of 
colleagues currently co-sponsoring.
    Thank you for your consideration, and I urge the passage of this 
legislation.

                                 
                       Honorable Gus M. Bilirakis
    Chairwoman Brownley, Ranking Member Dunn, and distinguished members 
of the Subcommittee, as a fellow member of the House Veterans Affairs 
Committee and former member of this Subcommittee, I would like to thank 
you all for the opportunity to present this statement regarding my 
bill, H.R. 2628, the Veterans Early Treatment for Chronic Ailment 
Resurgence through Examinations Act, or the VET CARE Act.
    I have been proud to serve on this Committee during my entire 
tenure in Congress and have always said that caring for Veterans is one 
of my top priorities. I am also proud to represent Florida's 12th 
Congressional District, which is home to thousands of Veterans in the 
Tampa Bay area.
    Many of my Veteran constituents have come to me over the years 
expressing their desire to add dental care to the VA's medical benefits 
package. Currently, the Department of Veterans Affairs (VA) provides 
outpatient dental care for a limited number of the Veteran population - 
specifically 100% rated service-connected disabled Veterans. It also 
provides dental services to Veterans who are disabled due to a specific 
debilitating dental condition. Otherwise, the access that many Veterans 
have to these services is limited. Some may be able to sign up for the 
VA Dental Insurance Program (VADIP), which provides a discounted, low-
cost insurance plan provided by private insurers. But I believe we need 
to do more to move this issue forward.
    The old saying goes an ounce of prevention is worth a pound of 
cure, and many small studies suggest that regular dental care equates 
to lower overall health care costs and better health outcomes. One such 
study published in the American Journal of Preventive Medicine, 
conducted by University of Pennsylvania professor Dr. Marjorie 
Jeffcoat, found that regular periodontal checkups lead to reduced 
hospitalizations and overall medical cost savings in care for chronic 
conditions such as cardiovascular disease, cerebral vascular disease, 
and diabetes. It is off this study that I based the VET CARE Act, which 
would expand this research to determine the potential health benefits 
to Veterans and the potential cost savings to the VA associated with 
periodontal care. My bill would require the VA to create a four-year 
pilot program to provide dental services to 1,500 Veterans diagnosed 
with type-2 diabetes, at five selected VA Medical Centers. To be 
eligible for the pilot, Veterans must not already be receiving regular 
periodontal care. Additionally, Veterans with service-connected 
disability ratings would receive preference for participation.
    Each treated Veteran will receive appropriate periodontal 
evaluation and treatment on an annual basis during the pilot. 
Throughout and at the conclusion of the pilot, the overall health of 
the treated Veterans will be recorded. Those results will be compared 
to Veterans outside the pilot to determine if providing Veterans with 
dental care equates to fewer complications of chronic ailments. If so, 
an analysis can be done to determine if the lower costs of overall 
health care due to fewer chronic ailments saves the VA enough money to 
reallocate funds to provide more Veterans with dental care. The data 
recorded and collected by the VA would also be able to be distributed 
to the research community for further study.
    Finally, at the end of the four-year pilot period, Veterans who 
participated in the program will receive information on how they may 
continue to obtain dental services and treatment in the community, 
including information about enrolling in VADIP. Currently, VA is 
prohibited from advising its patients to go to non-profits and other 
providers in the community for dental care. H.R. 2628 would amend 
section 1712 of Title 38 to enable VA providers to have that 
conversation with those Veterans who apply for the pilot program by 
giving them a list of those potential providers in the community and 
advising patients of opportunities for dental care through VADIP and 
other partners in the community for low to no cost dental care. One 
example of this is the ``Stars, Stripes, and Smiles'' event that my 
office has hosted annually with our local West Pasco Dental Association 
to provide oral health care for Veterans' untreated dental pain and 
infections free of charge. In this way, we can ensure that we are 
providing the essential continuity of care for Veterans in need of 
further treatment.
    I believe we must give Veterans the health care they have earned 
and deserve. If we can improve on this care by providing preventive 
dental services that leads to fewer complications of chronic ailments, 
it not only shows that we are looking at the long-term outlook of their 
health, it could also prove to be cost-effective. The VET CARE Act is a 
practical, common-sense way to demonstrate this approach for dental 
services, replicating already established research in the community.
    To conclude, I am proud of the work that this Committee has 
consistently done over the years on a bipartisan basis for our nation's 
Veterans, our true American heroes. I am grateful that the Subcommittee 
has continued this bipartisan tradition by bringing my bill up for 
further discussion, and I once again thank the Subcommittee for giving 
me the chance to express my support for this important legislation for 
the record. I welcome the opportunity to continue the conversation 
further, discuss any questions or concerns you may have, and to find 
common ground to advance policy solutions that help our Veterans and 
their families.

                                 
                        Honorable J. Luis Correa
    Chairwoman Brownley, Ranking Member Dunn, and Members of the 
Subcommittee, I thank you for the opportunity to submit testimony in 
support of my bipartisan legislation: H.R. 4096, the ``Improving 
Oversight of Women Veterans' Care Act.''
    According to the U.S. Department of Veterans Affairs (VA), there 
were over 2 million women veterans in 2016. Although women represent 
the fastest growing cohort of veterans, women veterans continue to face 
challenges in receiving health care services.
    In 2016, the Government Accountability Office (GAO) reported that 
the Veterans Health Administration (VHA) had limited information on VA 
medical centers' (VAMCs) compliance with environment of care standards 
for women veterans. VHA policies require that VA medical facilities 
meet certain privacy and safety factors, conduct regular inspections, 
and report instances of noncompliance. Yet, of the VAMCs inspected, GAO 
found that noncompliance, such as the lack of privacy curtains in 
examination and inpatient rooms, had not been reported. Additionally, 
GAO found that VHA did not have performance measures for monitoring 
women veterans' access to gender-specific care provided by non-VA 
physicians under the then-Veterans Choice Program.
    In response, the ``Improving Oversight of Women Veterans' Care 
Act'' directs VA to establish and disseminate environment of care 
standards and inspection policies to VAMCs. To encourage compliance, 
VAMCs will be ineligible for a five-star end of year rating unless the 
facility meets the environment of care standards. Additionally, the 
bill requires VA to submit an annual report to Congress regarding women 
veterans' accessibility via community care to gender-specific health 
care services, such as maternity care.
    It is important that VA evolve and adapt to ensure that women 
veterans receive health care in a timely, dignified, and safe manner.
    Chairwoman Brownley and Ranking Member Dunn, I want to thank you 
for the inclusion of my bipartisan bill on the agenda today. I 
appreciate the work that the Members of this Subcommittee do to ensure 
quality health care for our nation's veterans, and I look forward to 
working with you all to move this policy forward.

                                 
                        Honorable Vicky Hartzler
    Chairwoman Brownley, Ranking Member Dunn, and distinguished members 
of the Subcommittee, I want to applaud you for your commitment and 
dedication to improving outcomes for our veterans and for allowing me 
to share my views on the Department of Veterans Affairs' (VA) critical 
staffing issue that is impacting the care our veterans receive.
    Our veterans deserve the best. Unfortunately, top-notch care is 
often hampered by a shortage of doctors at the VA. I believe that this 
bill, which I introduced along with Representatives Bost, Correa, 
Lesko, Mooney, Rouzer, and Wilson will help the VA fill some of these 
vacancies. Our bill has three main provisions.
    First, it would allow physicians to be released from non-compete 
agreements only for the purpose of serving in the VA for at least one 
year. Non-compete agreements are supposed to prevent a physician from 
building up a patient base, and then taking those patients with them as 
they set up their own practice. A physician moving to the VA simply 
does not fit that description. This provision would ensure that a non-
compete agreement is never used to keep a physician from serving 
veterans at a VA facility, and only applies to such a circumstance.
    Second, our bill updates the minimum training requirements for VA 
physicians. Completion of a medical residency is widely accepted as 
standard comprehensive training for clinical physicians in the United 
States. However, current law only requires that a physician be licensed 
in order to treat veterans. In the case of some medical specialties, 
the difference between licensing and completing residency can represent 
six years of training. Some have suggested that this provision would 
exacerbate the shortage of physicians at the VA by shrinking the pool 
from which the VA can hire. However, the VA currently hires almost 
exclusively those physicians which have completed residency training, 
so this provision would not result in such an impact.
    Others have rightly submitted that veterans are largely satisfied 
with the quality of care they receive at the VA. They, therefore, 
submit that we do not need to legislate a higher standard. I contend 
that as long as Congress sees fit to impose any standard on the VA 
regarding those caring for veterans, we have a duty to ensure that the 
standard is appropriate. Completion of residency training is the 
accepted standard in this nation, and we should never expect veterans 
to accept anything less. This is a common-sense update to something 
Federal law already addresses and ensures that only fully trained 
physicians care for those who have served our nation.
    Finally, our bill would place veterans' hospitals on a level 
playing field with the private sector when it comes to recruiting 
timelines. Often, private sector health care providers begin recruiting 
medical residents as they begin their final year of residency, 
sometimes even earlier. Most residents have school debt they will need 
to start paying off-an average of $190,000. During residency they treat 
patients and work upwards of 80 hours a week, sometimes with single 
shifts up to 28 hours. These residents-rightfully motivated to secure a 
post-residency job with better pay and better hours-often accept a 
solid job offer from the private sector before VA recruiters are able 
to get their recruiting process started.
    Our bill authorizes VA recruiters to make job offers to physicians 
up to 2 years prior to fulfilling all of the VA's requirements, 
contingent on meeting all requirements before they begin treating 
veterans. It offers job security to medical residents who want to work 
at the VA when they complete their training and allows VA facilities 
and recruiters to shore up appointments further in advance, helping 
them to plan and forecast medical workforce needs. VA recruiters are 
already pitching a great opportunity for physicians, and we owe them 
policies that make them as competitive as possible with private sector 
recruiters. I believe that advancement of this legislation will help 
begin to fill the VA's many vacant health care positions.
    We've worked closely with this Committee's staff, VA recruiters, 
and VSOs on this bill, and I'm pleased to report that it has garnered 
wide support and formal endorsement from 10 VSOs including the American 
Legion, Blinded Veterans Association, AMVETS, Disabled American 
Veterans and Paralyzed Veterans of America. We are forever indebted to 
the brave men and women who serve in uniform and we owe them our 
continued support as veterans. It's my hope we can work together to 
move this bill to the House floor soon.
    Thank you, again, for your time and consideration.


                                 
                      Honorable Susie Lee (NV-03)
    September 9, 2019
    Chairman Takano, Ranking Member Roe, Chairwoman Brownley, and 
Ranking Member Dunn, Today I speak to the importance of my legislation, 
the Newborn Care Improvement Act, to the needs of veterans - 
particularly women.
    As you may know, currently, veterans are eligible to receive seven 
days of newborn care following the birth of their baby, after which 
they must find and sign up for health insurance for their newborn. Very 
often, the new mothers receiving medical care from the Department of 
Veterans Affairs (VA) face challenges with time, finances, and 
complicated insurance choices while adapting to the new challenges of 
parenthood. My bipartisan legislation would double the available time 
of newborn care to fourteen days, providing additional time for a 
veteran to find the best health coverage for the needs of their family 
and baby.
    I am proud to have introduced this critical, bipartisan legislation 
and know that it is one piece of a pivotal movement in improving the 
care provided to our women veterans at the VA. As I have said before, 
and want to reaffirm, again, our women veterans deserve the best health 
care and maternal care available to them and their families. Starting a 
family can be an overwhelming time for any parent, making it even more 
important to ensure our veterans have the resources and time they need 
to get the best maternal care possible.
    I ask my colleagues to join me in passing this legislation and help 
improve the lives of the veterans in my district and across our 
grateful nation.

                                 
                     Honorable Chris Pappas (NH-01)
    Good morning to my esteemed colleagues and members of the House 
Veterans Affairs Subcommittee on Health. I appreciate the opportunity 
to submit my statement for the record in support of the passage of my 
bill, H.R. 2681, concerning the availability of prosthetics for women 
veterans.
    Earlier this year, I was shocked to learn that many of our female 
veterans are forced to use prosthetic items that were originally 
designed for men. Prosthetics designed for a different gender are not 
just cosmetically different, but in practice they may have differences 
that make a difficult transition even more burdensome for our veterans. 
For instance, a prosthetic item designed for a man will likely be on a 
larger scale and proportion than one designed for a woman. So, while a 
female veteran may receive a prosthetic for a lower leg injury whose 
socket technically fits, the foot of the device is likely to be much 
larger than her own. This creates additional problems in her 
rehabilitation process and is very often emotionally difficult.
    My bill, co-sponsored by Representative Elise Stefanik (NY-21), 
requires VA to assess the availability of prosthetic items made 
specifically for female veterans available at VA medical facilities and 
to present their findings to Congress. This will give us a better idea 
of what options currently exist and where we can work with VA to ensure 
that our female veterans have access to prosthetic items that enhance 
their quality of life.
    Women represent roughly 16% of the United States active duty force, 
18% of the officer corps, and the 2,000,000 female veterans in our 
country represent the fastest group of veterans. They serve honorably 
and openly alongside their male counterparts and return home from 
deployment with the same psychological and physical wounds. When they 
do, they deserve to know that they will receive the highest-quality, 
specialized care that we can provide - and that includes prosthetic 
items that are specifically designed for them.
    I appreciate the Subcommittee's time and consideration and urge the 
passage of my bill.
    Thank you.

                                 
                      Honorable Elise M. Stefanik
    Good morning Chairman Takano, Ranking Member Roe, and members of 
the Committee. I am grateful for the opportunity to testify before the 
House Veterans' Affairs Committee and discuss issues very important to 
my district. I proudly represent New York's 21st Congressional 
District-where nearly one in ten adults is a veteran. That's what makes 
the work of this Committee deeply personal to me and my constituents.
    Tomorrow the Subcommittee on Health will discuss and debate several 
important pieces of legislation concerning Veterans' health care, many 
of which have a special focus on improving the access and quality of 
care for women veterans. I applaud the Committee, as well as your 
staffs, for focusing on this ever-important topic.
    Another topic that the Subcommittee will discuss tomorrow is 
H.R.2816, the Vietnam Era Veterans Hepatitis C Testing Enhancement Act. 
This is an incredibly important bill. To help my colleagues understand 
why, I would like to share a story with you:

    In 1970, Danny Kaifetz, a young man from the North Country, 
volunteered to serve in the United States Marine Corps while the 
country was embroiled in the Vietnam War. Danny completed training at 
Parris Island, and went on to Jungle Warfare School and Combat Infantry 
Training at Camp Lejeune. At some point during training-as any one of 
my colleagues who has been through boot camp knows-all the recruits 
were lined up, like a factory assembly line, and were inoculated with 
the necessary vaccinations. Back then the Armed Forces, to include the 
Marine Corps, used the Ped-O-Jet air inoculation device, or ``jet-
gun,'' to quickly vaccinate one recruit to the next. And as difficult 
as it for us to image today, medics were not required to sterilize the 
devices in between the inoculations. In fact, page 38 of the operator's 
manual, explicitly states ``sterilization not requiredbetween 
injections.'' As we now know, this practice exposed thousands of 
recruits to dangerous, and often deadly, blood-borne diseases. 
Contamination happened without discrimination-to volunteers and to 
those who were drafted. To those who went on to serve honorably for 
several years and those who didn't make it through training. To those 
who saw combat and bear the emotional burdens of a horrific war and 
those who, through some good fortune, were spared.
    Danny Kaifetz thought he was one of the lucky ones who was able to 
serve his country and fellow Marines without going to combat. He 
proudly fulfilled his duty and was distinguished with the Meritorious 
Service Medal at the completion of his service contract. But, 
unbeknownst to him, Danny did not leave the military unharmed.
    Nearly forty years later, in 2011, Danny was diagnosed with 
Hepatitis C. He sought and received treatment at the VA, and today Mr. 
Kaifetz will tell you with gratitude that he owes his life to the 
outstanding medical staff at New York VA.
    As you all know, Congress dedicated significant resources to enable 
the VA to test and treat veterans for the hepatitis C virus, and VA has 
made significant progress to date. However, these efforts primarily 
focus on Veterans enrolled in the VA, testing only 78% of the two 
million Vietnam-era Veterans enrolled in VA care. Estimates indicate as 
many as 1 in 10 of the eight million surviving Vietnam Era 
servicemember may be infected with hepatitis C due to the cross-
contamination. Of those who do not meet VA eligibility criteria, as 
many as seven million are considered at high-risk for hepatitis C 
infection and unaware of their status. Our veterans deserve better.
    The Vietnam Era Veterans Hepatitis C Testing Enhancement Act 
focuses on Hepatitis C screening and does not take away from the VA's 
efforts, rather enhances them. Furthermore, the bill is budget neutral 
by utilizing resources previously allocated by Congress through the 
Honoring America's Veterans and Caring for Camp Lejeune Families Act 
(P.L.112-154). The concept has proven successful at a local level due 
to the extraordinary efforts led by my constituent, Danny Kaifetz, and 
American Legion Post 1619. We owe it to a generation of veterans to 
provide this valuable screening tool. I urge my colleagues to join the 
American Liver Foundation, the AIDS Institute, and Vietnam Veterans of 
America to support H.R.2816.
    Mr. Chairman and Ranking Member, I thank you for the opportunity to 
speak with you today. And I thank the entire Committee and staff for 
the invaluable work you do to support our nation's heroes. I look 
forward to working with you. I yield back.

                                 
                       Honorable Nydia Velazquez
    Mr. Chairman Takano, Ranking Member Roe, and members of the 
Committee, I submit this written statement today in support of H.R. 
3867, the Violence Against Women's Veterans Act of 2019. Although 
military sexual trauma (MST) is not a new issue, it currently lacks 
resources to combat it effectively. Every sexual assault in the 
military is a failure to protect the men and women who have volunteered 
to defend us. Today I'd like to thank the Committee for considering my 
legislation that will better help our servicemembers who have been 
victims of domestic violence.
    Based on a 2014 study examining prevalence of MST, it is estimated 
that one-third of females in the military screen positive for MST, and 
the rates are higher for younger veterans.\1\ MST refers to sexual 
harassment or sexual assault that occur in military settings. MST is 
the leading cause of post-traumatic stress disorder among female 
veterans resulting in many other mental health issues surpassing combat 
trauma.\2\
---------------------------------------------------------------------------
    \1\ Cichowski, Sara et al. ``Female Veterans' Experiences with VHA 
Treatment for Military Sexual Trauma.'' Federal practitioner: for the 
health care professionals of the VA, DoD, and PHS vol. 36,1 (2019): 41-
47.
    \2\ O'Brien BS, Sher L. ``Military sexual trauma as a determinant 
in the development of mental and physical illness in male and female 
veterans.'' International Journal of Adolescent Health and Medicine. 
vol 25,3 (2013): 74-269
---------------------------------------------------------------------------
    The number of women servicemembers and veterans is at an all-time 
high, with continued growth expected. Yet women servicemembers continue 
to face serious challenges in service; approximately 1 in 4 experience 
sexual assault or sexual harassment. Women veterans who experienced MST 
are more likely to suffer adverse outcomes such as mental health 
conditions, substance use, discharge from the military, unemployment, 
and homelessness. Sadly, women veterans make up the fastest-growing 
segment of the homeless population.\3\
---------------------------------------------------------------------------
    \3\ Hamilton AB, Poza I, Washington DL. ``Homelessness and trauma 
go hand-in-hand'': pathways to homelessness among women veterans. 
Women's Health Issues: Official publication of the Jacob's Institute of 
Women's Health. vol. 21 (2011): 9-203
---------------------------------------------------------------------------
    For many of our veterans, the biggest battle of their lives will 
not be fought during deployment, but with the difficult memory of their 
abusers replaying in their minds. It is heartbreaking to think that our 
veterans, individuals who have fought for our freedoms, would have to 
endure this hardship.
    For these reasons we need to improve the services provided by the 
VA. The Violence Against Women Veterans Act seeks to accomplish this by 
requiring an integration of VA services with proven, existing 
community-based programs that serve domestic violence or sexual assault 
victims.
    With the establishment of the National Task Force on Domestic 
Violence, H.R. 3867 enables us to gather information on how to best 
provide comprehensive support to our veterans and seeks to create a 
network of local coordinators that facilitate cooperation between the 
VA and social services and assist domestic violence shelters and rape 
crisis centers in providing services to veterans. This is a vital 
component considering the number of sexual assaults reported by members 
of the U.S. armed forces is about a third of the total reported in a 
confidential survey of servicemembers.
    Currently the VA does not have a comprehensive national program to 
address intimate partner violence (IPV). Notably, H.R. 3867 requires 
the Advisory Committee on Women Veterans to conduct an assessment of 
the effects of IPV on women. This required assessment, jointly with the 
VA convened Domestic Violence Task Force will define the scope of and 
design a plan for evaluating domestic violence among Veterans.
    We can and must play a role in helping women veterans understand 
symptoms that they experience, to recognize MST and IPV, to know where 
to seek help and directly connect our Veterans with the help they need 
to improve the quality of their lives.
    Members of the U.S. Army, Navy, Air Force, Marines, and Coast Guard 
courageously take an oath of enlistment to support and defend the 
United States. It is our obligation to take care of those who serve.

                                 
                   Minority Veterans Of America (MVA)
Prepared by: Lindsay Church, Executive Director

with inputs from Katherine Pratt, Director of Advocacy, and Kiersten 
    Down, Board of Directors

    Chairwoman Brownley, Ranking Member Dunn, and distinguished members 
of the House Veterans Affairs Committee, Subcommittee on Health; on 
behalf of the Minority Veterans of America, an organization dedicated 
to creating community belonging and advancing equity for minority and 
underrepresented veterans, we thank you for the invitation to submit a 
statement for the record today and to share our position regarding 
legislation to support women veterans at the Department of Veterans 
Affairs.
                                Summary
    As an organization, Minority Veterans of America (MVA) is pleased 
to see that Congress is taking steps to address issues of disparate 
health care for women and pre-9/11 veterans in the Department of 
Veterans Affairs (VA). The recent attention to and support of women 
veterans that the House of Representatives has taken with the 
introduction of the Women Veterans Task Force has resulted in 
legislation that works to address the concerns that organizations who 
serve women veterans have been bringing forward for years.
    We are disappointed that much of the proposed legislation has not 
taken an intersectional approach and seeks to address one subpopulation 
of veterans in a binary way that fails to understand how other 
identities such as race, gender orientation (i.e. transgender and 
gender non- conforming veterans), LGBTQ status, or religious identity 
factor into the lives of our women veterans. This is important, 
especially in the area of research surrounding the barriers that women 
veterans experience when accessing their VA benefits. While women 
veterans broadly are in need of unique and increased medical care, the 
same can be said for transgender veterans who continue to receive 
inadequate and incomplete care through the VA system.
    Additionally, few of these bills include any reference to funding 
or allocation of money to complete the task addressed. We understand 
that many of these bills are requests for action, but in order for the 
legislation to be properly implemented, they should be supported with 
at least the promise of an increase in funds to ensure that the task is 
accomplished properly.
    Finally, it would be worthwhile to see greater reference to 
collaboration with existing centers that can support the requisite 
changes to the VA system. Of note, the Center for Women Veterans should 
serve as an excellent resource to answer the questions asked in HR 3636 
and for implementing a centralized website as proposed in HR 2972. It 
is telling that in 2019 we don't even know how many women veterans are 
in each state nor do we understand how or if they use their VA benefits 
for their health care. These pieces of legislation are an excellent 
first step at better serving and understanding women veterans, but we 
would like to see more intersectionality and consideration beyond the 
binary in these and future bills.
                                HR 2628
    Veterans Early Treatment for Chronic Ailment Resurgence through 
                        Examination Act of 2019
    We support the Department of Veterans Affairs enacting legislation 
and changes to expand access to dental coverage broadly. The current 
levels at which dental coverage is offered covers only a small portion 
of the veteran community. In the communities we serve, particularly 
veterans of color who face greater health disparities and student 
veterans who do not have access to dental coverage through other means, 
this coverage is desperately needed. Currently, many veterans struggle 
to find adequate access to dental insurance and for this reason, their 
oral health suffers greatly after service.
    The greatest concerns we have regarding this legislation center on 
the limiting nature of the qualifications for the pilot. Of greatest 
concern is the age limitation which states that a veteran must be 
between the ages of 40 and 70 years old. As we struggle to find ways to 
better serve the youngest generation of our nation's veterans, this 
limitation effectively eliminates a large portion of the veterans who 
served after 9/11. Additionally, the disqualification of individuals 
who are in need of periodontal surgery limits access to care for those 
with the most severe dental needs.
    The position of MVA is that dental care should be broadened to 
serve a greater portion of our community. The current level of care for 
most veterans is unacceptable as we recognize the link between better 
oral health and improved health outcomes. This pilot legislation seeks 
to prove what civilian institutions, such as the U.S. Department of 
Health and Human Services and the Mayo Clinic, have already proven - 
better oral health leads to improved health outcomes.
                                HR 2645
                  Newborn Care Improvement Act of 2019
    MVA supports the extension of the coverage for newborn care for 
women veterans from the current seven days to the 14 days. The issue 
with this legislation is that there is little known about maternity 
care or maternity benefits that the VA provides or can provide. Many 
women veterans are unaware of the benefits that are currently offered 
and the current materials available, even on the Center for Women 
Veterans' site are ambiguous and does not provide details on what, if 
any, care is provided.
    For this legislation to be impactful, it will be important to 
understand how many veterans are currently using this benefit and how 
the outreach about these benefits can be expanded. It should not be the 
veterans responsibility to navigate a process that is convoluted, the 
information needs to be readily available and easily accessible. In 
addition, there is concern among providers that women veterans are not 
being admitted to community care within the window of 30 days that the 
VA holds as the standard. The next step to improving this benefit is to 
assess what the wait time is for expectant mothers between when the 
referral is issued by the provider and when they are admitted by the 
community based provider.
                                HR 2681
    MVA supports seeking to better understand the availability of 
prosthetics available to women veterans. In order to be inclusive of 
all women veterans, this legislation will need to include prosthetic 
availability for transgender veterans. The prosthesis necessary for 
transgender veterans are both medically necessary and, in the absence 
of the VA performing gender affirming surgeries, is the best that the 
VA currently offers to our transgender veterans. The availability of 
these devices should not be limited to specific hospitals or areas of 
the country.
                                HR 2752
                   VA Newborn Emergency Treatment Act
    MVA supports the expansion of newborn emergency treatment. This 
legislation to amend the current code to include transportation for 
newborn children in emergency situations will require further 
clarification as to who ``certain women veterans'' are. This 
legislation and outreach about the services available need to be 
targeted in nature to ensure that the communities of women veterans who 
experience the highest rates of premature birth and other 
complications, primarily women of color, have this information 
available to them. It is imperative now that marginalized populations 
gain access to pre- and post-natal care.
                                HR 2798
          Building Supportive Networks for Women Veterans Act
    As an organization, MVA supports the reintegration of women 
veterans through means that support the holistic transition of the 
individual. It is our belief that alternative treatments create 
opportunities for veterans to choose the methods that work best for 
them in their process or journey. It is not, however, our position that 
the VA should be facilitating these retreat settings themselves. There 
are currently many retreat style programs that exist in the community 
that are doing excellent work. Rather than creating new programs, the 
VA should contract with or allocate funding to support programs with 
proven records of success. With the current lack of confidence of the 
women veteran community broadly, it is not prudent to create a program 
that requires more trust on the part of the veteran without a proven 
track record of supportive care.
    Additionally, we would like to see that veterans of all genders 
have access to the same treatment setting to support better 
reintegration. Without offering this to the entire community, there is 
a chance of creating a greater stigma for women veterans as they take 
advantage of these programs.
    Finally, the limitation of access to those who have returned from 
prolonged deployments severely limits the number of women veterans who 
can take advantage of a program designed to help them more successfully 
reintegrate. Women veterans encounter a range of traumas such as Post-
Traumatic Stress, Traumatic Brain Injury, and rape and sexual assault, 
among others, while serving that could benefit from this type of 
program.
                                HR 2972
    MVA supports the existence of a centralized website for women 
veterans though, the creation of a new site seems duplicative in 
nature. If the VA seeks to create this site to ensure that there is 
easily accessible information available to women veterans, it will be 
imperative to integrate this site with the current site administered by 
the Center for Women Veterans. Rather than creating anything new and 
causing confusion for the user, the current site should be overhauled 
and usability testing conducted to ensure it is accessible for 
individuals with differing abilities.
                                HR 2982
             Women Veterans Health Care Accountability Act
    MVA supports the study of health barriers impacting women veterans' 
access to care. In order for this study to be comprehensive, it is 
imperative that it be extended in the following ways:
    Expansion of questions surrounding the stigma of seeking mental 
health care services to include seeking mental and physical health care 
services at the VA specifically. While there is a stigma in the 
community of veterans broadly regarding receiving mental health 
treatment, there is also a stigma that is just as strong against using 
any form of VA care. It is important to note where women veterans feel 
most comfortable receiving their mental health care to expand services 
in this manner.
    Expansion of questions surrounding the personal safety and comfort 
of patients as well as the gender sensitivity of staff and providers at 
VA facilities to include behavior carried out by patients. While it is 
extremely important to include questions regarding staff and providers 
at the VA, it is often not only the providers that are the perpetrators 
of behavior that makes women veterans feel unsafe or unwelcome in VA 
facilities. This will be important to developing solutions and 
strategies for addressing the concerns of women veterans.
    Introduce a question about the VA's motto to gauge the impact to 
the community of women veterans. As it stands, the VA's motto is 
outdated and does not include women or gender diverse individuals. In 
this study of the barriers to access, this is an important topic to 
understand the feelings of the community and how the motto contributes 
to a culture that is exclusionary to women veterans.
    Additionally, the results of this study should be mandatorily 
reviewed by each department of the VA that serves women veterans. This 
information is imperative to creating truly inclusive programs and 
should not be siloed within the Center for Women Veterans. To impact 
the necessary changes, all departments of the VA need to be involved in 
helping to create solutions to the issues that women veterans are 
experiencing across the organization.
                                HR 3036
                Breaking Barriers for Women Veterans Act
    MVA supports facility upgrades to better serve women veterans 
across the VA health care system. The appropriation of $20 million to 
support this legislation along with additional funding to provide 
training to providers of health care for women veterans in the 
community is important to ensuring this legislation is executed 
properly. We encourage the addition of greater oversight measures to 
this legislation to ensure that all monies are distributed to the 
necessary infrastructure upgrades and not reallocated to other projects 
and priorities in a flat funded organization.
                                HR 3224
    As an organization, we are supportive of the expansion of the VA's 
hours to ensure that women veterans are able to access their care on 
schedules that work with their own. The issue with this legislation is 
that the VA is already struggling with being understaffed and is barely 
able to serve the veterans who are waiting for care within their normal 
hours. Should this legislation be enacted, especially without the 
promise of additional monetary support, it's unclear as to if this can 
be accomplished. As a whole, the VA needs to place an emphasis on 
filling the alarming number of vacancies system-wide and ensure that 
the veterans using the system, in its current iteration, are able to 
receive care as well as looking at extending the hours of operation.
                                HR 3636
                   Caring for Our Women Veterans Act
    MVA believes that it is imperative that the VA maintain accurate 
reporting regarding the number of women veterans using the VA for their 
care. It is telling that in 2019, the number of women veterans in each 
state using care is not readily available with the VA's Center for 
Women Veterans already in existence.
    When these surveys are being conducted at VA facilities across the 
country, numbers should also be collected on other identities that can 
inform care and point to underserved populations. It is the 
recommendation of MVA that reporting also be conducted across identity 
groups such as race/ethnicity, gender orientation (i.e. cis-, trans-, 
and non-binary), sexual orientation (if disclosed), and religious 
identity. These identities can help to better assist the VA and 
Congress to identify underserved populations and more accurately 
prescribe actions that will address the department's deficiencies 
through providing culturally appropriate care.
    Additionally, data should be collected regarding the number of 
patients who used the VA multiple times in the year and the number of 
patients that have only used their benefits once. These data sets will 
point to patient retention and attrition more accurately.
    Lastly, in regards to the number of providers at each facility 
dedicated to the care of women veterans, it is important for the 
community to understand what the goal is in regards to the ratio of 
patients to providers is. In some cases, staff sizes are larger and 
more able to adequately support and serve the women veterans in that 
area or region but in smaller cities and rural areas, there are very 
few dedicated providers. What is the long-term goal or outcome?
                                HR 3867
                  Violence Against Women Veterans Act
    MVA opposes HR 3867 as it is written as the language of this bill 
is extremely problematic and has the potential to further stigmatize 
women veterans. While we recognize and support the need for expanded 
services for survivors of military sexual assault and sexual violence 
as well as survivors of domestic violence, this legislation further 
marginalizes women by identifying them as the primary community that 
experiences rape, sexual assault, and domestic violence. While women 
have higher instances of sexual assault and violence per capita, there 
is still a large population of male and gender diverse survivors that 
need access to this same level of care but may not feel included by the 
title of this bill and the binary gender references throughout.
    This legislation also does not take into account that members of 
the LGBTQ community experience greater instances of sexual violence in 
the civilian population than their heterosexual counterparts in the 
general public. In the absence of the military collecting and reporting 
on the LGBTQ status of servicemembers, the assumption must be made that 
the military population is reflective of the general population. As we 
engage with and support the minority and underrepresented veteran 
community, we see a direct correlation between a history of sexual 
assault and violence and our members' LGBTQ status. Members who are 
LGBTQ are more likely to be survivors of rape or sexual assault while 
serving than their heterosexual counterparts.
    Additionally, HR 3867 only accounts for veterans and the 
coordinated care network to serve them but does not account for or 
discuss collaboration with the Department of Defense where many 
instances of sexual assault and domestic violence begin. This bill, 
while intended to be holistic in nature, does nothing to move toward a 
culture of prevention.
 Bill to establish in the Department of Veterans Affairs the Office of 
                             Women's Health
    MVA supports Congresswoman Brownley's legislation proposing the 
creation of the Office of Women's Health as well as the Director of 
Women's Health in the VA. The creation of this office will allow for 
greater oversight of the overall care available to women veterans. As 
this legislation is introduced, it will be important to include a 
funding note that will allow for this legislation to be enacted and the 
office to be funded. The expansion of care and oversight of the 
offerings to women veterans is imperative to the overall success of the 
VA's women veteran program. Moving forward, we would like to see 
collaboration with the VA's current Center for Women Veterans to ensure 
that silos are not created within the system and that both offices are 
able to work side-by-side to achieve better care for our women 
veterans. This legislation and the prioritization of women veterans in 
the VA system is long overdue.
    Additionally, we recommend that this and all legislation intended 
to support women veterans explicitly note the support of transgender 
women veterans and veterans who do not identify as women but are in 
need of gynecological care. This will ensure equitable access for all 
women veterans in the VA system.

                                 
                    Military Women's Coalition (MWC)
    Chairwoman Brownley, Ranking Member Dunn and members of the 
Committee, thank you for the opportunity for the Military Women's 
Coalition to provide a statement for the record on the health 
legislation before the Committee today.
    Background: The MWC is a national coalition of formal and informal 
organizations who work collaboratively to serve and support US active 
duty, Guard, reserve, Veteran and retired service women by uniting and 
elevating their voices to influence policy and improve their well-
being. Our vision is that someday military women are fully integrated, 
equally respected and equally supported members of the military and 
veteran community and their contributions are recognized as essential 
to national defense. Currently there are 18 organizations in the 
Coalition from across in the nation.
    Better Health care for Women Veterans: Members of the MWC are 
particularly concerned about the health care provided to women veterans 
as good care has often been lacking in many areas. The MWC is 
encouraged to see so many efforts underway to rectify failures and 
shortcomings in the existing system. Although the MWC supports all of 
the legislation under consideration we strongly support the following 
legislation:

HR 3636
HR 2972
HR 2645
HR 2681
HR 3224
HR 2752
HR 2628
HR 2816
HR 1527
HR 3798
HR 3867
HR 4096
Draft Bill
    A few members of the MWC expressed reservations about some of the 
proposed legislation. Their concerns had to do with vague language, 
costs and redundancy.
    HR 3036 There were concerns about cost and therefore execution of 
this legislation.
    HR 2798 There were concerns about cost and the vagueness of the 
language in this legislation.
    HR 2982 Several organizations felt that another study is a waste of 
money because the needs have already been identified in other studies.
    HR 1163 Several organizations abstained from providing support or 
opposition to this legislation.
    This statement is submitted on behalf of the Military Women's 
Coalition by Ellen L. Haring, the Coalition Steering Committee Chair.

Sincerely,

Ellen L. Haring, PhD
Steering Committee Chair
Military Women's Coalition

MWC Steering Committee Organizations

Service Women's Action Network
Women in Military Service For America
Protect Our Defenders
GA Military Women
Service: Women Who Serve Pink Berets
Red Feather Ranch
WINC: For All Women Veterans
Northeast Florida Women Veterans
Combat Female Veterans Families United
Veteran Women Enterprise Center

                                 
                     Veterans Of Foreign Wars (VFW)
CARLOS FUENTES, DIRECTOR
NATIONAL LEGISLATIVE SERVICE

    Chairwoman Brownley, Ranking Member Dunn, and members of the 
Subcommittee, on behalf of the women and men of the Veterans of Foreign 
Wars of the United States (VFW) and its Auxiliary, thank you for the 
opportunity to provide our remarks on legislation pending before this 
Subcommittee.

H.R. 1163, VA Hiring Enhancement Act

Section 2

    The VFW supports this section which would remove barriers for 
employment of health care providers who were required to sign a non-
compete contract with previous employers. By removing this barrier more 
medical professionals who want to treat veterans would be able to 
pursue a career at the Department of Veterans Affairs (VA) medical 
facilities.

Section 3

    This section is intended to authorize VA to hire physicians who are 
in the process of completing a residency and to codify training 
requirements for VA providers. The VFW is concerned that this section 
may unintentionally limit VA's authority to offer contingent employment 
offers to physicians who are completing a residency. Section 206 of 
Public Law 115-46, VA Choice and Quality Employment Act of 2017, 
authorized VA to hire students and recent graduates. This section may 
limit such authority to a two-year period for physicians. The VFW 
recommends removing such limitation.

H.R. 1527, Long-Term Care Veterans Choice Act

    The VFW supports this legislation which would authorize VA to enter 
into contract agreements for non-VA medical foster homes. By expanding 
this option of long-term care to veterans who are unable to live 
independently but do not want to be institutionalized, Congress would 
be providing veterans with the ability to receive the care they need 
while also maintaining their quality of life. The VFW urges Congress to 
pass this legislation, which would provide more options for veterans to 
decide what form of long-term care is right for them.

H.R. 2628, VET CARE Act of 2019

    The VFW supports this legislation which would improve dental care 
provided to veterans by VA through a pilot program, and expand outreach 
regarding the VA Dental Insurance Program (VADIP). While the VFW would 
prefer to see legislation that would expand eligibility for VA dental 
care to all veterans who are eligible for VA health care, the VFW 
supports this bill.
    For the past five years, the VFW has partnered with Student 
Veterans of America (SVA) to select ten student veterans from across 
the country to research and advocate for the improvement of an issue 
that is important to veterans. VFW-SVA fellow and George Washington 
University student Tammy Barlet focused her semester-long research 
project on dental health for veterans. In her research, Tammy found 
that four out of 10 veterans describe their oral health as poor to fair 
and that veterans are at higher risk of developing gingivitis compared 
to their civilian counterparts. Lifestyle behaviors such as poor eating 
habits, smoking, and chewing tobacco; mental illness, including 
depression, anxiety disorder, and post-traumatic stress disorder; toxic 
exposures; rural versus urban environments; gender; and polypharmacy 
are some of the factors that increase a veteran's risk of developing 
gingivitis. Tammy also found that a healthy smile is linked to job 
security. In fact, VA is currently authorized to extract teeth from 
veterans who are inpatients, but does not have the authority to replace 
such teeth with prosthetics or dentures unless the veterans is 
otherwise eligible for VA dental care. The VFW has heard from veterans 
who felt embarrassed to attend employment interviews or go back to work 
with missing teeth.
    There is a large disparity between VA and Department of Defense 
(DoD) dental coverage, which can have a significant impact on the 
health and quality of life for veterans. To this day, servicemembers 
are required to maintain a high level of dental readiness, to the 
extent that they are placed on a non-deployable status if they fail to 
receive a dental evaluation every year. However, only veterans who are 
100 percent service-connected disabled, certain homeless veterans, and 
those who have a service-connected dental condition are eligible for VA 
dental care. The majority of veterans enrolled in VA health care are 
unjustly denied access to VA dental care. Instead, they are offered the 
ability to purchase dental insurance through VA, which has high costs 
and poor coverage. VFW members who are asked for feedback on VADIP 
report that it is better than nothing. Those who have worn our nation's 
uniform deserve the best, not ``better than nothing.''
    However, it is important for veterans to know that VADIP is an 
option. For that reason, the VFW supports requiring VA to provide 
information on VADIP to veterans. The VFW would recommend that the 
Subcommittee expand the outreach requirement to include outreach at all 
VA medical centers and through the VA Welcome Kit. All VA health care 
enrolled veterans are sent a VA Welcome Kit which details their VA 
benefits. The only mention in the kit of dental care is in reference to 
a one-time appointment veterans are able to receive if they are within 
180-days from their military service separation date.
    This draft legislation would create a pilot program to expand 
dental care services to veterans who are enrolled in VA at five 
locations across the country. The pilot is also limited to 1,500 
veterans who are between 40 and 70 years of age, do not receive regular 
periodontal care, and have been diagnosed with type 2 diabetes. The VFW 
understands that veterans who need dental care access the most must be 
prioritized, but would urge the Subcommittee to expand the eligibility 
to include all veterans enrolled in VA health care.

H.R. 2645, Newborn Care Improvement Act of 2019

    The VFW supports this legislation, which would expand VA's 
authority to provide health care to a newborn child, whose delivery is 
furnished by VA, from seven to 14 days post-birth.
    My wife and I are expecting our first child this month and recently 
discussed our options for providing him with health care coverage. 
Before this month, VA was my only health care option. I am fortunate 
that the VFW's employee-sponsored health care plan open enrollment was 
this past month, so I was able to enroll in the VFW's employee-
sponsored health insurance so my son can have health coverage after he 
is born. If he were born before the open enrollment period, I would 
have needed to wait months or up to a year to enroll him. Women 
veterans in my situation may not be so lucky. Women veterans who rely 
on VA health care for their maternity care have seven days to find 
health care coverage for their child. The time following the birth of a 
child is a hectic time for new parents. Whether their newborns have 
health care coverage is the last thing on their minds.
    According to the Centers for Disease Control and Prevention, 
newborn screenings are vital to diagnosing and preventing certain 
health conditions that can affect a child's livelihood and long-term 
health. The VFW understands the importance of high-quality newborn 
health care and its long term impact on the lives of veterans and their 
families. To align this bill with common practice in the private 
sector, the VFW urges the Subcommittee to expand the time a newborn 
child is covered by VA to 30 days. Doing so would ensure newborns 
receive the proper post-natal health care they need.

H.R. 2681, to direct the Secretary of Veterans Affairs to submit to 
    Congress a report on the availability of prosthetic items for women 
    veterans from VA

    The VFW supports this legislation, which would require VA to review 
whether VA provides prosthetics that meet the needs of women veterans. 
VFW members have reported being prescribed VA prosthetic items such as 
shoes and eyeglasses, but not being able to receive them because VA did 
not have women's shoes or frames they could use. The VFW supports an 
audit of availability of such items.

H.R. 2752, VA Newborn Emergency Treatment Act

    The VFW supports this legislation which would expand VA's current 
authority to cover the cost of emergency transportation for eligible 
newborn babies. Under current law, VA is authorized to provide seven 
days of medical coverage for newborn children, but that coverage does 
not include emergency transportation if a newborn requires treatment 
that is not available at the medical facility where the child was born.
    The VFW has long supported expanding the length of time a veteran's 
newborn child is provided medical coverage by VA, and believes also 
expanding current legislation to include emergency transportation is 
common sense. If a veteran gives birth to a child who then has an 
emergency medical situation which the birthing facility is unable to 
address, VA must cover the cost of transporting such newborn to a 
facility that can provide the required care. Veterans in this situation 
are already under a great deal of stress, and it is unjust to then add 
the burden of emergency transportation costs.

H.R. 2798, Building Supportive Networks for Women Veterans Act

    This legislation would establish a permanent program of retreat 
counseling services for women veterans. The VA pilot counseling retreat 
program has served as an invaluable tool to help newly discharged 
veterans seamlessly transition back to civilian life. The VFW supports 
making this program permanent.
    Another successful program created by the Caregivers and Omnibus 
Health Services Act of 2010 is the child care pilot program. This 
program has been well received by veterans at all four pilot sites and 
has also contributed to the success of the counseling retreat program. 
The VFW has heard from veterans who say they could not have completed 
their treatment programs if not for the services offered through VA's 
child care pilot program.
    The VFW thanks the Subcommittee and Chairwoman Brownley for 
securing House passage of H.R. 840, the Veterans' Access to Child Care 
Act, which would make the child care pilot permanent. The VFW is 
hopeful that the Senate would follow your lead and pass it as well.

H.R. 2816, Vietnam-Era Veterans Hepatitis C Testing Enhancement Act of 
    2019

    This legislation would require VA to host outreach events with 
veterans organizations to expand hepatitis C (HCV) testing. The VFW 
agrees with the intent of the bill, but does not believe it is needed.
    The VFW lauds VA for its efforts to test for and cure HCV. It 
recently announced that the VA health care system has cured more than 
100,000 veterans with HCV. In an effort to maximize outreach, VA has 
reached out to veterans organizations and made itself available for 
organizations that would like to host testing evets, similar to what is 
required by this legislation. VA medical staff is present at the VFW 
National Convention every year and has conducted such testing.
    The VFW does support the provision to require VA to report to 
Congress activities it conducts as part of the HCV campaign.

H.R. 2972, to improve the communications of VA relating to services 
    available for women veterans

    The VFW supports this legislation, which would rightfully expand 
the authority of the VA Women Veterans Call Center to communicate via 
text message, and ensure women veterans are able to easily connect with 
women's health coordinators at their VA medical facilities.

H.R. 2982, Women Veterans Health Care Accountability Act

    This legislation would require VA to conduct a comprehensive study 
of women veterans health care. The VFW supports this bill and has a 
recommendation to improve it.
    In 2016, the VFW conducted a survey of nearly 2,000 women veterans 
as a way to evaluate the performance of VA in caring for women 
veterans. Over the past three years, we have worked with VA and 
Congress to address health care, identity and outreach, and 
homelessness issues identified in the survey. We found that women 
veterans overwhelmingly prefer to receive their health care from women 
primary care providers, and are more likely to be satisfied with their 
VA health care experience when they receive care from female providers.
    VFW members reported concerns regarding gender-specific 
competencies in specialty clinics. For example, veterans reported 
having problems finding prosthetic options suitable for women, leaving 
them with no choice but to use uncomfortable products that do not fit 
properly. In orthopedics, veterans reported that doctors fail to treat 
them with their gender in mind. VFW members have also voiced concerns 
about the lack of gender-specific training for mental health care 
providers. The VFW thanks the Subcommittee for considering this 
legislation which would commission a study to evaluate whether VA has 
been successful in addressing these issues, and require it to develop a 
plan to further improve health care for women veterans.
    The VFW survey of women veterans also found that older women 
veterans were less likely to report receiving disability compensation, 
but equally as likely to have been injured or made ill as a result of 
their military service. Similarly, older veterans were less likely to 
report that they use VA health care, but equally as likely to report 
being eligible for VA health care than their younger counterparts. We 
were also concerned that several respondents who reported being 55-
years-old and older believed they did not rate the same benefits as 
their male counterparts, which is an egregious misperception that must 
be addressed. No veteran should be left to wonder what, if any, VA 
benefits she is eligible to receive. It must be clear that women 
veterans have earned the exact same benefits as male veterans. That is 
why the VFW urges the Subcommittee to expand the scope of the study to 
include an analysis of non-health care programs and benefits that serve 
women veterans.

H.R. 3036, Breaking Barriers for Women Veterans Act

    The VFW support this legislation which would require VA to evaluate 
whether VA's infrastructure must be modified to meet the health care 
and privacy needs of women veterans, increase staffing, and establish 
women-centric training for community care providers.
    Barriers to health care is a significant concern for VFW members. 
Particularly, VA must be more proactive than reactive when it comes to 
access to gender-specific care for women veterans. As the women veteran 
population continues to grow, VA must ensure it provides care and 
services tailored to their unique health care needs. Veterans deserve 
access to the best treatment and care this nation has to offer. That is 
why it is crucial for VA to outfit existing facilities with basic 
necessities, such as curtains for privacy in women's clinics. These 
clinics also need to maintain at least one primary care provider with 
expertise in women's health who is able to train others.
    However, the VFW recommends removing the option of one part-time 
provider. A part-time provider would limit access to care for woman 
veterans and decrease the provider's ability to maintain gender-
specific expertise. While we understand that not every VA medical 
facility can have a doctor who devotes 100 percent of clinical time 
exclusively to women veterans, it is unacceptable for veterans to wait 
for care simply because the provider at their facility is only there on 
certain days of the week. The primary duty of Designated Women's Health 
Primary Care Providers must be to care for women veterans, but some 
should have the ability to see male veterans to fill their schedules or 
panels. Regardless, the VFW believes that all VA medical facilities 
must have at least one full-time provider trained to care for the 
unique needs of women veterans.

H.R. 3224, to provide for increased access to VA medical care for women 
    veterans

    The VFW supports this legislation, which would require VA to 
continually make available gender-specific services. VFW members have 
reported facing delays or barriers to accessing gender-specific 
services at remote locations and at facilities that have the demand for 
gender-specific service, such as mammogram machines, but have failed to 
do so or have inaccessible services. The VFW does suggest, however, 
that the report required by this legislation include data on timeliness 
of gender-specific services. Some facilities may have gender-specific 
services available, but wait times prevent veterans from utilizing 
them.

H.R. 3636, Caring for Our Women Veterans Act

    The VFW supports this legislation, which would require reports on 
staffing and locations that provide care to women veterans. All three 
reports required by this bill are due 90 days following enactment of 
the bill and annually thereafter. To ensure uniformity in reporting, 
the VFW recommends consolidating the three reports into one 
comprehensive report.

H.R. 3798, Equal Access to Contraception for Veterans Act

    This legislation would require VA to provide veterans contraceptive 
items without copayments. The VFW cannot support this bill because it 
is too narrow. The VFW recommends the Subcommittee consider and advance 
H.R. 3932, Veterans Preventive Health Coverage Fairness Act. The VA 
formulary currently carries all categories of pharmaceuticals deemed 
preventive by the U.S. Preventive Services Task Force. However, VA is 
exempt from requirements to provide preventive care and services 
without cost-shares.
    Cost is a significant barrier for veterans who use VA health care, 
whom have been found to have lower income on average than veterans who 
do not use VA health care. There are currently 11 categories of 
preventive medications found to be effective by the U.S. Preventive 
Services Task Force, which include contraceptives and aspirin to lower 
the risk of cardiovascular disease. Cardiovascular disease is the 
number one cause of death in the United States and is highly prevalent 
among the veteran population. Additionally, folic acid is recommended 
for pregnant women to prevent neural tube defects. It is unjust to 
require women veterans to pay for the cost of medication to prevent 
such birth defects. Vitamin D is another preventive medicine which is 
often prescribed to prevent bone fractures, which benefits traumatic 
brain injury patients with hindbrain injuries. There is also breast 
cancer prevention medication which is useful not just for individuals 
with a family medical history of breast cancer, but for Camp Lejeune 
toxic water survivors who have been found to suffer from increased 
rates of breast cancer. These pharmaceuticals have been found to 
prevent possible deadly disease and to lower long-term health care 
costs.
    This legislation would leave out veterans who are in need of other 
preventive medicines. That is why the VFW calls on the Subcommittee to 
consider and pass H.R. 3932, Veterans Preventive Health Coverage 
Fairness Act, which would eliminate this inequity and ensure veterans 
have access to lifesaving preventive medicine.

H.R. 3867, Violence Against Women Veterans Act

    The VFW supports this legislation, which would enhance VA's efforts 
to address domestic violence and sexual assault. While the language of 
the bill does not explicitly limit the program, study, and taskforce 
created by this bill to women veterans, the VFW recommends the 
Subcommittee make clear that such provisions apply to all veterans.
    Sexual assault continues to be a problem within DoD for all active, 
reserve, and guard components and for veterans of all backgrounds 
without regard to age, gender, or race. Most survivors of military 
sexual trauma (MST) are males, but women are disproportionately 
affected. While DoD continues to increase its efforts to reduce or 
eliminate sexual trauma within the military service, the number of 
servicemembers affected by MST is slow to decline. The VFW agrees that 
a collaborative effort in awareness, reporting, prevention, and 
response among all branches of the Federal and state governments is 
needed.
    VA has a national MST screening program that screens all patients 
enrolled in VA for MST. National data from this program reveals that 
about one in four women, and one in 100 men, respond affirmatively to 
having experienced sexual trauma while serving their country. All 
veterans who screen positive are offered a referral for free MST-
related treatment, but notably does not trigger the VA disability 
claims process. Previous years of VA data show growing numbers 
exceeding 100,000 veterans receive care for MST-related treatment.
    In fiscal year 2017, 3,681 men and 8,080 women submitted claims to 
VBA for health problems related to MST. Of those claims, 55 percent of 
claims from males and 42 percent of claims from females were denied. 
This is why the VFW encourages Congress to continue its oversight 
efforts on VA care related to MST and VBA's process of handling MST 
claims. It can take many years for survivors to even acknowledge a 
trauma occurred, and sharing details with advocates and care providers 
can be extremely difficult. Survivors of sexual assault often report 
they feel re-traumatized when they have to recount their experiences to 
compensation and pension examiners. Therefore, we encourage VA to 
employ the clinical and counseling expertise of sexual trauma experts 
within the community to ensure VA can provide the care and benefits 
sexual assault survivors deserve.

H.R. 4096, Improving Oversight of Women Veterans' Care Act of 2019

    The VFW supports this legislation which would require VA to report 
on gender-specific community care, and increase compliance of VA women 
veterans health care policies.
    Due to a lack of capacity of gender-specific services at VA medical 
facilities, women veterans are often required to rely on community care 
for services such as mammography, obstetric care, and gynecological 
care. In the VFW's women veterans survey, nearly 40 percent of women 
who reported using VA community care said they did so for gender-
specific services. This legislation would ensure veterans who rely on 
community care are provided the best possible care available and would 
ensure such care complies with best practices.
    This legislation would also require increased compliance with VA's 
women veterans health care policy. However, it references a women's 
health handbook that the VFW was unable to find. VA has published 
Veterans Health Administration (VHA) Directive 1330.01, which 
establishes standards for the delivery of health care to women veterans 
and specifies the roles and responsibilities of staff. VA often issues 
directives and guidance to the field, but fails to conduct the 
appropriate quality assurance to verify compliance. The VFW supports 
requiring VA to enforce compliance with VHA Directive 1330.01.

Draft bill to establish in VA the Office of Women's Health

    The VFW support this legislation, which would establish an officer 
of Women's Health to provide centralized monitoring and standardized 
implementation of VA women veterans health care policy and programs. 
The VFW has enjoyed a great partnership with the VHA Patient Care 
Services Women's Health Services office. This office has been integral 
in ensuring VA is ready and able to provide high-quality care for women 
veterans. Elevating this important office would ensure more can be done 
for the brave women who have worn our nation's uniform.

                                 
   National Association Of State Women Veteran Coordinators (NASWVC)
    Chairwoman Julia Brownley, Ranking Member Dr. Neal Dunn, and 
members of the Subcommittee on Health, on behalf of the National 
Association of State Women Veteran Coordinators thank you for this 
opportunity to share support for Women Veterans nationwide.
    Today is a small but vital step toward progressing the quality of 
life for Women Veterans across the country. The National Association of 
State Women Veteran Coordinators (NASWVC) has worked tirelessly to 
ensure that our voices do not go unheard. We are an alliance which 
represents Women Veterans from all of America and her territories, from 
the sandy beaches of Florida, to the snow-capped mountains of Alaska 
and into the proud territories of Puerto Rico and Guam. On this day, we 
are proud to stand as one in such a venue.
    Women Veterans are the fastest growing Veteran group. We total 
approximately 2 million and account for over 9% of the U.S. Veteran 
population but are projected to account for 15% by the year 2025. 
Currently, women account for 22% of enrollees in military academies - a 
sharp increase in only a few decades. Their graduation rates are 
currently on par with their male counterparts.\1\
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    \1\ https://www.rand.org/pubs/research--briefs/RB9496/index1.html
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    The National Association of State Women Veteran Coordinators 
recognizes that there are four pressing issues facing Women Veterans 
today: 1) Military sexual trauma (MST) 2) Homelessness 3) Suicide and 
4) Access to health care. Because these issues are all linked together 
as both negative outcomes and risk factors, NASWVC has made them 
priority issues, or pillars, upon which we will base our education, 
policy, and outreach for the next year. While each of the bills before 
the Committee are important, NASWVC has chosen seven to overwhelmingly 
endorse, as they are each tied intrinsically to one or more of our 
stated priority areas.

    HR2681: While in service, Women Veterans experienced the problems 
that are associated with wearing gear designed for men (for example, 
flak vests, which can leave permanent scarring on the hips), and once 
discharged report to the VA for care only to find that the same 
conditions exist. While a woman is pregnant her center of gravity and 
balance will be greatly different. Wearing a prosthetic designed for a 
man will indeed hinder her mobility during much of her pregnancy. 
Properly fitted prosthetics, from insoles to artificial limbs, are 
important for both physical and mental health and can define for a 
Woman Veteran not only how she feels about herself but the importance 
she sees the VA placing on her as a Veteran. It can go so far as to 
determine whether she returns to the VA for care. This is why NASWVC is 
happy to support HR2681.

    HR2982, HR3036, and HR3636: Substance use, mental health disorders, 
eating disorders, and MST are all risk factors associated with suicide 
and homelessness. The VA offers care specific to each of these issues 
for Women Veterans, yet not enough Women Veterans are using these 
services because of barriers to care or accessibility issues. Barriers 
to care for Women Veterans in many ways look different than they do for 
men. Aside from commonalities such as wait times, Women Veterans also 
report that safety, child care, comfort, and appropriate, and properly 
trained providers can all be barriers to obtaining care at the VA. 
Additionally, one in three Women Veterans experienced some form of 
military sexual trauma while on active duty\2\, which has been 
associated with increased physical health symptoms, impaired health 
status, and more chronic health problems in veterans\3\. Obtaining 
physical and mental health care can mitigate the symptoms and reduce 
the negative outcomes of MST and the other risk factors, making early 
and ongoing access to health care vital. In 2015, 22% (or approximately 
456,000) Women Veterans, used VA health care. What's more notable, 
however, is the difference in use among those who are enrolled and not 
using VA health care (13 .5%) or are not enrolled (64.1%)\4\
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    \2\ Iovine-Wong, P.E., C. Nichols-Hadeed, J. T. Stone, et al. 2019. 
Intimate partner violence, suicide, and their overlapping risk in women 
veterans: a review of the literature. Military Medicine.
    \3\ Suris, A. Lind, L. 2008. Military Sexual Trauma : A Review of 
Prevalence and Associated Health Consequences in Veterans, Trauma 
Violence Abuse DOI: 10.1177/1524838008324419
    \4\ The Past, Present and Future of Women Veterans, Department of 
Veterans Affairs, National Center for Veterans Analysis and Statistics, 
February 2017
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    The Department of Veterans Affairs has found that among Veterans 
with suicide ideation, there is a substantial decrease in risk between 
those who use and those who do not use the VA. Since 2001, the rate of 
suicide among Veterans who use the VA increased by 8%, while among 
those who did not use the VA it increased by 38.6%. However, when 
examining that difference through a gender lens, the rate difference 
for Women Veterans is more obvious, at 4.6% increase for women who use 
the VA vs 98 % those who do not\5\. Analyzing the data in this way, 
becomes more apparent that reducing barriers and connecting women to 
services is a vital step in helping to reduce suicide attempts.
---------------------------------------------------------------------------
    \5\ https://www.va.gov/opa/publications/factsheets/Suicide--
Prevention--FactSheet--New--VA--Stats--070616--1400.pdf
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    Environmental factors are indeed often listed by Women Veterans as 
a barrier to care at the VA. While steps have been made to reduce these 
factors within Women's Health Clinics, departments outside Women's 
Health Clinics where women must receive services that extend beyond 
their reproductive and breast health (e.g. lab, internal medicine, 
oncology, etc.) are too often unfriendly environments for Women 
Veterans in the VA. Environmental factors could run the gamut from the 
arrangement of chairs in waiting rooms to an exam room with no curtain, 
which leaves the veteran exposed when the door opens.
    Truly integrated care is a consideration that is also a challenge 
outside Women's Health Clinics. It means not receiving a letter 
addressed to ``Mr.'' (or not being called Mr. when in the waiting 
room); not having the option of a female provider - especially when you 
have MST or another form of personal trauma; not having to wear ``one 
size fits all'' drawstring pants that are four sizes too big; or not 
being forced to wear pajamas cut for a man's body yet being disallowed 
to wear a brassiere or undershirt and feeling exposed. While those who 
have not experienced such trauma may consider these small things, they 
can mean the difference between feeling comfortable and safe enough to 
get the needed care versus resorting to detrimental self-help 
practices. These small examples are easy to remedy but such simple 
things can be important. Ensuring that these changes happen not just in 
larger medical facilities but are also examined and changed in 
Community Based Outpatient Clinics will be a critical to step to 
removing barriers for women veterans.
    Supporting Women Veterans in the U.S. and territories and serving 
all Women Veterans regardless of status for over 20 years, the NASWVC 
offers its full support for HB2982, HR3036, and HR3636. We recommend 
that throughout the nation the NASWVC along with the state level Women 
Veteran coordinators be involved as partners throughout each of the 
survey processes.

    HR 2798: The National Association of State Women Veteran 
Coordinators acknowledge that one-third of women in the military screen 
positive for MST\6\, and some surveys have shown this number to be as 
high as 59% (2016 Oregon survey of women veterans\7\). PTSD is one of 
the three most prevalent diagnostic issues Women Veterans face\8\; and 
sexual assault is more likely to result in symptoms of PTSD than are 
most other types of trauma, including combat\9\, yet there remains a 
scarcity of retreat centers for Women Veterans in the United States 
that address MST, and for many women this is not something they seek 
care for until decades after separation. There are large sections of 
the country where there are no retreat options available. Recent 
research by the Department of Defense has found that the rate of sexual 
assault, rape, and harassment during active duty increased 30% from 
2016 to 2018. While women are 20% of the military, they are 63% of 
assault victims\10\. Given the overwhelming number of Women Veterans 
who live with military sexual trauma, NASWVC recommends that Military 
Sexual Trauma be listed specifically as one of the Covered Services for 
retreat settings for Women Veterans newly separated. Given the 
importance of early intervention and treatment that can help ameliorate 
risk factors for homelessness, suicide, and substance abuse, NASWVC 
wholeheartedly supports HR2798.
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    \6\ Klingensmith K, Tsai J, Mota N, et al. Military sexual trauma 
in US veterans: results from the national health and resilience in 
veterans study. J Clin Psychiatry. 2014;75(10):e1133-e1139.
    \7\ https://www.oregon.gov/odva/Connect/Documents/FinancialReports/
2016%20ODVA%20Women%20Veterans%20Health%20Care%20Study.pdf
    \8\  https://www.womenshealth.va.gov/WOMENSHEALTH/
latestinformation/facts.asp
    \9\ https://www.mentalhealth.va.gov/docs/top--10--public.pdf
    \10\ https://www.sapr.mil/sites/default/files/DoD--Annual--Report--
on--Sexual--Assault--in--the--Military.pdf

    HR 3867: Women Veterans are at a higher risk (approximately 33%) 
than civilian women (24%) for experiencing intimate partner violence 
during their lifetime\11\. Although the VA does offer IPV services, the 
survivors may not use the VA for a variety of reasons. For a variety of 
reasons, however, including accessibility, but they may be willing to 
utilize their community crisis intervention services. These community 
services can be the first line of defense for women seeking safety and 
shelter and to help prevent survivors and their families from having to 
choose between becoming homeless and having to remain with their 
abuser. Partnering with community crisis centers and state coalitions 
offers the Department of Veterans Affairs another opportunity to 
provide partner training on serving women veterans, and it provides 
increased opportunities to enroll women in VA for benefits and services 
vital to their well-being. Like MST, IPV is also a risk factor for 
homelessness. NASWVC supports the passage of HR3867.
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    \11\ Iovine-Wong, P.E., C. Nichols-Hadeed, J. T. Stone, et al. 
2019. Intimate partner violence, suicide, and their overlapping risk in 
women veterans: a review of the literature. Military Medicine.

    HR4096: State Women Veteran Coordinators work one-on-one with Women 
Veterans and frequently hear that there are insufficient gender-
specific or gender-inclusive services at the VA. Moreover, Women 
Veterans speak to this as a barrier, citing this as a reason for not 
returning. It is not unusual for Women Veterans, especially those who 
have MST, to prefer women providers. Too often, however, the VA's 
answer to a request for a female provider is ``if there is one 
available.'' It is not unusual for the Woman Veteran to not know until 
she shows up that the provider is a male, which can cause her to feel 
as though she has no choice but to submit to the uncomfortable 
experience. This experience may drive her decision to not return to the 
VA for care. Having staff that is sensitive to the unique experiences, 
challenges and issues faced by Women Veterans instead of seeing them as 
problematic or inconvenient will go far in enhancing the environment of 
care for Women Veterans at the Department of Veterans Affairs. NASWVC 
members are in nearly every state and are happy to partner with their 
local VA medical facilities as women's health team members and 
participate in inspection and improvement teams. NASWVC strongly 
supports HR4096
    Thank you for the opportunity to provide a platform for the voices 
that often go unheard. Any progress that can be made toward providing a 
better quality of life for women veterans is paramount. Legislation is 
a major step in the right direction.
    On behalf of the National Associate of State Women Veterans 
Coordinators, again, we thank you.

                                 
                 Service Women's Action Network (SWAN)
    Chairman Takano, Ranking Member Poe and members of the Committee, 
thank you for the opportunity for the Service Women's Action Network to 
provide a statement for the record on the health legislation before the 
Committee today.

    Background: SWAN members have consistently expressed 
dissatisfaction with the quality, completeness and ease of access to 
health care provided to women veterans by the Department of Veterans 
Affairs. Their view is that the great disproportion between the 
percentage of male and female veterans who access VA health care steers 
VA to health care policies, practices and allocations of fiscal and 
personnel resources to the needs of men.'

    Better Health care for Women Veterans: Both the Department of 
Veterans Affairs and Congress have taken actions over the years to 
safeguard women veterans' access to quality health care, but too often 
these efforts have fallen short both with respect to ease of access and 
to quality and completeness of the care given to women. Women will soon 
constitute 20% of the veterans' population. SWAN is pleased to see that 
the House Veterans Affairs Committee is considering the following 
legislation which should bring women veterans closer to receiving their 
earned health care with the same ease, quality and completeness as 
their brother veterans. SWAN, therefore, supports all of the bills 
under consideration by the Committee today.
    We put particular importance on, and, therefore, strongly support 
the following:

H.R 2645 which raises to 14 days the emergency care that newborns can 
    receive when necessary.

H.R. 2681 which requires a report on the availability of prosthetic 
    items tailored to women's needs and bodies.

H.R. 2752 which provides medically necessary transport for newborns.

H.R. 2972 which directs the Secretary of Veterans Affairs to improve 
    communications to women veterans about the VA services available to 
    them.

H.R. 2982 which directs the Secretary of Veterans Affairs to conduct a 
    study on the barriers women veterans face when trying to access VA 
    health care.

H.R. 3036 which directs the Secretary of Veterans Affairs to provide a 
    plan on the requirements to retrofit VA facilities and staffing to 
    better support women veterans' health care.

H.R. 3224 which requires VA to conduct a study on extending the hours 
    during which women veterans can obtain routine health care at VA 
    medical facilities.

H.R. 3798 which limits co-pays for contraceptives.

H.R. 4096 which requires an annual report to Congress on veterans' 
    access to gender-specific services under the newlv let Communitv 
    Care contracts.
    Thank you for the opportunity to comment on this legislation.\1\
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    \1\ Disabled Veterans of America, February 2017, "The Past, Present 
and Future of Women Veterans" states that 92.5% percent of users are 
men while only 7.5 percent are women--

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Sincerely,

Ellen L. Haring, PhD
Colonel, US Army retire
CEO, Service Women's Action Network

                                 [all]