[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
ACHIEVING HEALTH EQUITY FOR
AMERICA'S MINORITY VETERANS
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HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
SECOND SESSION
__________
TUESDAY, FEBRUARY 11, 2020
__________
Serial No. 116-55
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via http://govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
48-993 WASHINGTON : 2023
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COMMITTEE ON VETERANS' AFFAIRS
MARK TAKANO, California, Chairman
JULIA BROWNLEY, California DAVID P. ROE, Tennessee, 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
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TUESDAY, FEBRUARY 11, 2020
Page
OPENING STATEMENTS
Honorable Julia Brownley, Chairwoman............................. 1
Honorable Neal P. Dunn, Ranking Member........................... 2
WITNESSES
Dr. Carolyn Clancy, MD, Deputy Under Secretary for Discovery,
Education and Affiliate Networks, Veterans' Health
Administration................................................. 3
Accompanied by:
Dr. Ernest Moy, MD, Executive Director, Office of Health
Equity, Veterans' Health Administration
Dr. Donna Washington, MD, MPH, Attending Physician, VA
Greater Los Angeles Healthcare System, Department of
Veterans Affairs
Ms. Kayla Williams, Senior Fellow and Military, Veterans, and
Society Program Director, Center for a New American Security... 5
Ms. Melissa Bryant, Legislative Director, The American Legion.... 7
APPENDIX
Prepared Statements Of Witnesses
Dr. Carolyn Clancy, MD Prepared Statement........................ 25
Ms. Kayla Williams Prepared Statement............................ 28
Ms. Melissa Bryant Prepared Statement............................ 34
Statements For The Record
National Council on Urban Indian Health.......................... 39
National Indian Health Board..................................... 40
ACHIEVING HEALTH EQUITY FOR
AMERICA'S MINORITY VETERANS
----------
TUESDAY, FEBRUARY 11, 2020
U.S. House of Representatives
Subcommittee on Health
Committee on Veterans' Affairs
Washington, D.C.
The subcommittee met, pursuant to notice, at 2:32 p.m., in
room 210, House Visitors Center, Hon. Julia Brownley
[chairwoman of the subcommittee] presiding.
Present: Representatives Brownley, Lamb, Brindisi, Rose,
Cisneros, and Dunn.
Also present: Representative Roe.
OPENING STATEMENT OF JULIA BROWNLEY, CHAIRWOMAN
Ms. Brownley. Good afternoon and welcome to the
Subcommittee on Health's hearing on Achieving Health Equity for
Minority Veterans.
In the next 25 years, America will be a majority minority
country. Today, minorities disproportionately serve in the U.S.
military. As America changes, so too will the veteran
population, and so must the institution that provides their
health care. The types of services, the competencies it
develops, and the manner of outreach it conducts must meet the
unique needs of its patients.
To better meet new needs, VA must address current
struggles, from implicit bias in medical providers and front-
line staff, to incomplete and missing data. VA should be the
leader in American health care that can dynamically meet the
needs of an increasing diverse and intersectional patient
population.
The GAO report from December 2019 found VA's Health Equity
Action Plan, originally drafted in 2014 and reissued again in
2018, had no measurable outcomes to date. No one is accountable
for the success or failure of its efforts and, to make matters
more concerning, VA's data on race and ethnicity is
inconsistent, if not all together missing.
Last month, I traveled to Cheyenne River and Standing Rock
Indian Reservations, where I heard numerous concerns from
veterans of culture insensitivity and racial bias perpetrated
by VA patients and staff. At last week's joint hearing, we
heard how women's experiences with VA can have a deeply
discouraging impact on their willingness to continue to receive
care at the VA. As this committee knows all too well, no
veteran is immune from harassment and assault inside
facilities.
We know racial bias in health care contributes to different
outcomes and increased fatalities. Providers with unconscious
or conscious stereotypes about minorities may contribute to how
they respond to a patient's concern. We know the legacies of
horror such as Tuskegee experiments and the forced
sterilization of Native women, compounded with experiences of
racial bias and culturally insensitive providers contribute
greatly to mistrust of health systems by people of color.
Ms. Williams highlighted in her written testimony during
focus groups participants reported that VA providers take the
pain and symptoms of people of color, particularly women, less
seriously than those of their white counterparts, providing a
barrier to correct health diagnoses and contributing to a lack
of trust. It is the undoing of bias and the building of trust
that VA must work toward.
VA's patients are only becoming more female and more
ethnically and racially diverse. The realignment of a system
built to serve white, straight men has to be a priority from a
matter of patient safety to customer satisfaction. VA should be
the leader in closing the chasm between minority and white
health status in the United States.
With that, I would like to recognize Dr. 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, and thank our
witnesses for spending time with us today. It is a pleasure to
be back here in the committee room with you again this year.
As the veteran population continues to diversify, we must
ensure that the Department of Veterans Affairs is equipped to
provide all those who have bravely served our great Nation with
equitable, high-quality health care.
Last year, this subcommittee held a hearing to discuss how
the VA is caring for a growing number of women who are seeking
VA care, and today we are discussing how the VA is caring for a
growing number of veterans who are members of racial and ethnic
minorities. By 2040, military veterans are expected to be
majority minorities in the country. Concerns about the
disparities in health care for minorities have long existed; it
is not unique to the VA either.
I will note that the VA's Office of Health Equity received
increased funding and staff allocations in 2019 to support its
important mission of identifying and eliminating inequities in
care for minority veterans. The office's work culminated last
Fiscal Year in the release of a new version of its Health
Equity Action Plan. I look forward to hearing this afternoon
about how the VA is going to track the progress in
implementation of that plan and what metrics they plan to
assess.
I think all of us, the VA, Congress, veterans themselves,
all want to ensure that every single one of the brave men and
women who have served our country and worn its uniform are well
taken care of. Service and patriotism know no race or gender.
I am grateful to the witnesses and audience members for
being here today. I look forward to a productive conversation.
I will apologize to the Chairwoman in advance that I must
leave early; however, it is in the service of veterans. We have
a veterans STEM bill that is being signed into law this
afternoon, so I am going to be attending that ceremony.
With that, I yield back.
Ms. Brownley. Thank you, Dr. Dunn.
We have one panel today. With us is Dr. Carolyn Clancy, she
is the Deputy Under Secretary for Discovery, Education, and
Affiliate Networks at the Veterans Health Administration. She
is accompanied by Dr. Ernest Moy, the Executive Director of
Health Equity, and Dr. Donna Washington, an attending physician
at the Greater Los Angeles Health System.
Then we also have Ms. Kayla Williams. She is a Senior
Fellow and Military, Veterans, and Society Program Director at
the Center for a New American Security.
Last, but certainly not least, Ms. Melissa Bryant, the
Legislative Director for The American Legion.
Welcome all of you, thank you for being here. With that, I
recognize Dr. Clancy.
STATEMENT OF CAROLYN CLANCY
Dr. Clancy. Good afternoon, Chairwoman Brownley, Ranking
Member Dunn, and distinguished members of the subcommittee. I
appreciate the opportunity to discuss our continued progress in
achieving health equity for minority veterans.
I am accompanied today by Dr. Ernest Moy, the Executive
Director of the Office of Health Equity, and Dr. Donna
Washington, Attending Physician and Researcher at the Greater
Los Angeles Healthcare System.
Our goal at VA is to shorten the distance veterans need to
go for care and to leave no one behind. Health equity means
that all veterans receive timely access to safe, high-quality
care that helps them achieve their highest level of health
regardless of age, gender, race, ethnicity, sexual orientation,
and geography.
Overall, there are few differences in the quality of
services delivered to veterans by Veterans Health
Administration (VHA) related to race and ethnicity. Preventive
care and care for chronic diseases are delivered similarly for
all groups within VHA, in contrast to the private sector where
systematic disparities are too common.
While the delivery of services is equitable, outcomes of
care for racial and ethnic minority veterans in our system
often lag behind outcomes achieved by non-Hispanic white
veterans. For example, despite receiving comparable services,
racial and ethnic minority veterans with diabetes are more
likely to have poor glucose control and less likely to have
good control of blood pressure and cholesterol.
There are also interactions between gender, race, and
ethnicity in these outcomes. For example, non-Hispanic black
veterans with diabetes are less likely than non-Hispanic white
veterans to have good blood pressure and glucose control
regardless of sex. Among veterans with heart disease, women,
regardless of their demographic background, are less likely to
have good cholesterol control compared with either non-Hispanic
black or white men. In comparison to commercial plans,
achievement of control of these cardiovascular risk factors are
much better in VA, but we are not done yet.
Health equity also includes factors outside the direct
provision of care that impact patient outcomes, including
individual's education, income, geography, and other factors.
The Office of Health Equity has a broad charge, including
analyzing data on disparities, raising awareness about
veterans' equity issues, working with our medical centers to
improve outcomes for all veterans, and supporting workforce
diversity and inclusion within VHA.
We have successfully addressed what are often referred to
as the social determinants of health on a large scale; for
example, reducing homelessness and food insecurity among
veterans. We also, unlike most health care systems, have the
capacity to address other determinants such as education,
employment, and social isolation in conjunction with the
Benefits Administration and Veterans Service Organizations, and
others. Consequently, the Office has supported the development
of two unique tools, one allows our medical centers to identify
and address social determinants in their particular
populations, a second actually is an equity-guided improvement
strategy, which uses equity information at VA medical centers
to identify specific groups of veterans at a higher risk of
receiving lower quality of care.
In the December 2019 GAO report, there was a recommendation
that the Office develop performance measures and clear lines of
accountability to track progress toward equity for veterans,
and to assess and improve the accuracy of racial and ethnic
coding in VA systems.
In response to the first, the Office, along with the Health
Equity Coalition, which is comprised of leaders across the
Department of Veterans Affairs, have updated the Health Equity
Action Plan, laying out a roadmap for the future.
In response to the second recommendation, the Office is
partnering with researchers and supporting two assessments, the
first led by Dr. Washington will formally determine the quality
of coding by comparing existing racial and ethnic coding in the
electronic record with self-reported survey information,
because the self-report is considered the gold standard. A
second assessment will collect race and ethnicity information
in VA medical centers directly from veterans using an iPad,
which will minimize staff discomfort when asking for this
information, particularly in a situation where there are a lot
of people around.
It is worth noting that race and ethnicity data are missing
on about 7 percent of our veterans, which is better than that
seen typically in the private sector.
We are also proud to report our progress in fostering a
more inclusive patient experience for women and lesbian, gay,
bisexual and transgender (LGBT) communities. The Office works
with our Office of Women's Health Services to support
assessments of equity issues faced by women veterans and share
data. I think you have heard about the research we are
supporting that involves close collaboration between
researchers, providers, and the women patients themselves. The
Office also works with LGBTQ coordinators to support
assessments of equity issues by these veterans.
The Office has also served as VA's point of contact with
the Health Care Equality Index, a major benchmarking tool
throughout the health care industry, and is sponsoring work
with the CDC to examine LGBT veterans, because they cannot be
systematically identified in our current data systems. It is
our expectation that it will be possible once Cerner is
implemented to capture that information systematically.
Our goal is to meet veterans where they live and work, so
we can work with them to ensure they achieve their goals by
teaching them skills, connecting them to resources, and
providing the care they need along the way. We are committed to
advancing our outreach and empowerment to further restore the
trust of veterans every day and continue to improve access to
care.
We agree with the Chairwoman's statement that VA should
lead in this area and that is exactly our aspiration. Our goal
is to give our Nation's veterans the top quality experience and
care that they have earned and deserve. We appreciate this
committee's continued support as we identify challenges and
find new ways to care for our veterans, and look forward to
your questions.
[The Prepared Statement Of Carolyn Clancy Appears In The
Appendix]
Ms. Brownley. Thank you very much.
I now recognize Ms. Williams for 5 minutes.
STATEMENT OF KAYLA WILLIAMS
Ms. Williams. Chairwoman Brownley, Ranking Member Dunn,
distinguished members of the subcommittee, thank you so much
for this opportunity to discuss this under-explored topic.
Overall, I fully agree that VA is an excellent source of
health care, boasting low wait times, high quality, military
cultural competence, and low cost. However, not all groups of
veterans find VA to be equally welcoming, accessible, or
adequate.
My testimony is drawn primarily from the forthcoming Center
for New American Security (CNAS) report New York State Minority
Veteran Needs
Assessment, supported by the New York State Health
Foundation. Given the time limit, today I will focus my spoken
remarks on racial, ethnic minority, and LGBT veterans.
As mentioned, racial minorities experience bias in health
care that can and does lead to worse outcomes, such as the
higher maternal mortality rates among African American and
American Indian and Alaskan Native women. Racial bias in health
care causes preventable deaths.
Stereotypes about minority individual's pain tolerance and
symptoms have been reported to influence medical providers and
to disregarding complaints by minority patients, and CNAS focus
group participants express beliefs that these challenges extend
into the VA system. Some reported that VA medical providers
take the pain and symptoms of people of color, particularly
women, less seriously than those of their white counterparts,
creating a barrier to correct diagnoses and contributing to a
lack of trust.
Advocates for minority veterans also argued that VA
providers are inadequately culturally knowledgeable, negatively
affecting the provision of care. For example, a number of
participants emphasize the need for providers to understand a
lower willingness in the African American community to seek out
mental health care. One participant said, ``In black culture,
there is not a lot of tendency to seek help for mental
incapacity. You can not just have a doctor say, here is a
service, come and get treatment. If they at VA understood the
cultural aspects, they have to understand talking to a person
that there is a reason they are not accessing services.''
Implicit and explicit biases of health care providers
negatively affect minority veterans. Participants felt that
they received substandard treatment by doctors.
LGBT veterans also face barriers in accessing VA health
care, including staff with inadequate knowledge and openly
hostile fellow patients. This is particularly concerning given
that a higher percentage of gay servicemembers suffer from Post
Traumatic Stress Disorder (PTSD) and other mental health
conditions.
Importantly, while LGBT status is not causal for PTSD or
suicide, it is a risk factor. Stigma, prejudice, and
discrimination create a hostile and stressful social
environment that causes mental health problems, a phenomenon
known as minority stress.
Gender confirmation surgery is specifically excluded from
the VA medical benefits package. This is not in alignment with
accepted standards of care for gender dysphoria. Because VA
health care is minimum essential coverage under the Affordable
Care Act, veterans who are enrolled in VA health care do not
qualify for subsidies in the health insurance marketplace.
Accordingly, these veterans may be unable to enroll in a plan
that would provide this medically necessary. Crucially, there
are dramatic reductions in suicide among transgender
individuals who receive appropriate transition-related care,
denying it violates VA's stated commitment to suicide
prevention.
Additionally, VA does not provide IVF for same-sex couples,
another discriminatory practice that should be eliminated.
VA should work to become more welcoming for all minority
veterans by implementing trauma-informed and dignity-affirming
care, including effective cultural awareness training for
employees, updating waiting room reading material, posters, and
television channel default settings to be more inclusive;
increasing Veterans Experience Office efforts to alleviate
disparities in the experiences of minority veterans; expanding
the nascent End Harassment Campaign to include the harassment
of LGBT and racial/ethnic minority veterans; and replicating
VA's existing secret shopper model of ensuring that front-line
staff members are aware of resources for MST survivors to also
include minority veteran coordinators and LGBT veteran care
coordinators at VA medical centers nationwide.
Additionally, VA should carefully review all policies and
provisions of the medical benefits package to eliminate those
that discriminate against women and LGBT individuals. Should VA
be unwilling or unable to take these actions independently, I
urge Congress to pass legislation requiring VA to cover gender-
confirmation surgery and IVF for same-sex couples.
VA is a top-tier provider of health care. Identifying and
eliminating any barriers that make it less welcoming and
effective for the rapidly growing population of minority
veterans is an important part of ensuring health equity for all
who have served our great Nation.
Thank you, and I look forward to any questions you may
have.
[The Prepared Statement Of Kayla Williams Appears In The
Appendix]
Ms. Brownley. Thank you very much, Ms. Williams.
I now recognize Ms. Bryant.
STATEMENT OF MELISSA BRYANT
Ms. Bryant. Staff Sergeant Herman A. Day fought in the
Italian campaign of Word War II. He was assigned to the 92d
Infantry, the Buffalo Soldiers, the Colored Division. Reports
at the time cited poor combat performance, low morale, and
malinger. The 92d Infantry Division was considered of inferior
quality by both German and U.S. commands.
Many historians have begun to reevaluate the combat record
of the 92d Division as concurrent reports of its honorable
performance have continued to surface. Numerous veterans at the
division believe that the reports of poor performance were
motivated by racist sentiments present within the senior
officer ranks. To wit, the 92d Division commander asked the
Army--or advised the Army, rather, against ever again using
African American soldiers as combat troops. Even as evidence
mounts in support of the division's honorable conduct, some
still seek to suppress these facts.
Staff Sergeant Herman A. Day was killed in action in Italy
75 years ago on February 10th, 1945; he was my grandfather.
I never had the opportunity to ask him about the racial
prejudices he faced during his service, but it is well
documented what he endured. Despite Presidential executive
order to desegregate the Armed Forces in 1948, the stain on the
U.S. military history lives on, and reflects the racial and
ethnic biases many minorities still face when using the
Veterans Health Administration services, hence why I share this
personal story.
Chairwoman Brownley, Ranking Member Dunn, and distinguished
members who serve on the subcommittee, on behalf of our
National Commander, James W. ``Bill'' Oxford, we thank you for
the opportunity to discuss the topic of how VA addresses health
inequities for minorities across the Veterans Health
Administration. I proudly represent the The American Legion and
appreciate the opportunity to assist this subcommittee in
better understanding this critical topic.
We must ensure that the institutions we built to care for
our Nation's veterans give every veteran, regardless of gender,
race, sexual orientation, or creed, the quality of care and
support that they deserve. Why? Because recent studies show
that racial and ethnic minority veterans represent nearly 22
percent of the total veteran population. VA projects that the
minority population will continue to rise over the next few
decades and reach an estimated 35 percent of the total veteran
population by 2040.
Often the only woman-of-color officer in my units, I can
point to many occasions where I have helped soldiers who came
to me for advice, counsel, or reporting of incidents dealing
with racial, gender, sexual orientation discrimination,
harassment, or even assault within the ranks.
My service was also during the time of Don't Ask, Don't
Tell, where I had the truly unfortunate duty of separating
troops from service due to their sexual orientation. This is
relevant, because, depending on discharge status, LGBT would
not have the same access to veteran benefits, adding an overall
distrust of the military and veteran health care systems.
Notably, The American Legion is the only Veterans Service
Organization that assists veterans with discharge upgrades and
represents them before service discharge upgrade boards and
hearings.
Many clinical outcomes have significant racial gaps in data
collected for conditions such as hypertension, cardiovascular
events, diabetes, and labor and delivery. A grim example of
disparity in health care outcomes as due to racial bias is in
the nationwide maternal mortality rate in minority women, who
are two to three times more likely to die from pregnancy-
related causes than white women. A widely publicized U.S.
Supreme petition last year unsuccessfully challenged the Feres
doctrine, Daniel v. United States, which involved the death of
a Navy nurse who died in childbirth in the same labor and
delivery board in which she served at Bremerton Naval Base.
This is a chilling example of where the deceased was also a
racial minority, her pain was ignored, and it shows how this
nationwide trend can be reflected in our military and in our
veterans, and may color the perception of disparate care
provided to minority women at both military and veteran medical
centers.
I should also note that the petitioner in this case, the
widower, Walter Daniel, is my classmate and friend of over 20
years.
It becomes necessary to ask why these care inequities exist
in the microcosm that is our community; in research, to what
extent these disparities are attributable to negative outcomes.
Chairwoman Brownley, Ranking Member Dunn, and distinguished
members who proudly serve on this subcommittee, The American
Legion thanks you for the opportunity to illuminate the
positions of the nearly 2 million veterans of this
organization. It is the priority of The American Legion that
all of our Nation's veterans receive the same quality of care
and support we expect from the VA. By action of this committee,
we can see that it is a priority for you as well.
As we unpack the myriad reasons why minority veterans on
the whole report either negative health care outcomes or
unequal treatment under the law at the VA, The American Legion
stands ready to support this subcommittee with observations and
expertise.
Thank you.
[The Prepared Statement Of Melissa Bryant Appears In The
Appendix]
Ms. Brownley. Thank you, Ms. Bryant, and thank you for
sharing your story and your grandfather's story with us here
today. I appreciate it.
I will now recognize myself for 5 minutes.
The first question that I had, I want to go to actually the
application for health benefits, which I think is probably,
maybe one of the VA's first touches, you know, on a VA, and the
application asks for a lot of information, sex, gender
identity, and so forth. In reading through this, in question
box number 4 it says, ``Are you Spanish, Hispanic, or Latino?''
I am just wondering if Spanish, is that a mistake? I do not
think Spanish is an ethnicity. I do not think the U.S. Census
Bureau uses it as an ethnicity, Office of Management and Budget
(OMB). Is that a mistake or----
Dr. Clancy. I will have to take that for the record. I
would point out that about two thirds of people who sign up for
our health care system are actually signing up in person and
are probably being asked that question verbally, but I will
check on that. I had not actually seen that application. Thank
you.
Ms. Brownley. OK. Well, let me just point out a couple of
other things that you can take back. One is, when asking race,
there is a box for American Indian or Alaska Native, but they
do not ask for the tribe, which is an important piece of
information. Nowhere on the form does it talk about the
language needed to use with either the veteran or the veteran's
family. We have heard many, many stories of particularly our
Native veterans who, you know, go back to their land and speak
their language and, as they grow older, they have not spoken
English in a very, very long time, and that becomes a barrier
to their health care. I think that would be a good question to
ask.
Then also on the back of the form, it also asks if you are
eligible for Medicaid. It does not ask the question if you are
eligible for Indian Health Services, which I think is an
important piece of information to have. Having just traveled to
Indian country, it is very clear that the VA does not have a
good handle on our Native veterans and where they are getting
their health care, whether it is the VA or Indian Health
Services, or a combination of both; the counts are very, very
difficult to attain.
If you could take that back, because I feel like, as you
said, when they first sign up, this is probably something that
they are asked, but this is certainly an important touch point
and I just think that there is more information that needs to
be included.
I wanted to ask you, Dr. Clancy, also you mentioned in your
testimony that the VA collects the survey of health care
experiences of patients, which is the VA's sort of national
standardized publicly reported patient survey, but it goes on
to say that we do not really collect the racial and ethnic
groups because the number of minority veterans responding to
this survey is too small. Is that an accurate statement?
Dr. Clancy. There are two sources of information that we
get from veterans on the out-patient basis, one is the survey
you just referenced, the other is real-time information where
veterans can go to a kiosk in any of our facilities and report
on their experience that day, and we think that that is--it is
called V-Signals--we think that is very important in terms of
service recovery and so forth. It is that survey, not the
Survey of Healthcare Experience of Patients (SHCEP) survey,
which actually very few people are actually indicating their
race or ethnicity.
I think that as we look into sources of missing data, we
might be able to pick that back up, but this is like real-time,
very short surveys that are now being deployed at all our
facilities.
Ms. Brownley. Do they ask ethnicity and gender and----
Dr. Clancy. They do, but I do not believe that many people
fill it out. We have some work to do there.
Ms. Brownley. Well, it just seems to me in terms of the
survey, I think that, you know, if we do not have many minority
veterans filling out the survey and/or putting that data
onsite----
Dr. Clancy. Right.
Ms. Brownley.--you know, I wonder what the problem is and
why that is, and I just feel like it is something that we
should--if that is an issue where we can not collect the data,
what are we going to do, what are we going to do to make sure
that we do collect the data, because the data, you know, is
really the starting point in terms of providing high-quality
health care to each and every one of our veterans, particularly
our minority veterans.
Do you have an answer for that or----
Dr. Clancy. No, but I will get back to you----
Ms. Brownley. OK.
Dr. Clancy.--with a more thorough answer. This is
relatively new information, but it is especially important
because it actually gets at a dimension that the SHCEP surveys
do not, because it actually gets more at veteran trust in our
system and in the Department, which is hugely important to
health care outcomes. We will get back to you.
Ms. Brownley. OK. If I run out of time--I have run out of
time, so I will yield back and yield to Ranking Member Dunn.
Mr. Dunn. Thank you very much, Madam Chair.
I will direct my first question to Dr. Washington, if I
may. You know, we have read that minority vets are less likely
to be treated for hepatitis C, even though they--I mean, with
the same instance, so why do you think that is and what are we
doing to try to correct that?
Dr. Clancy. I am sorry----
Mr. Dunn. I directed the question to Dr. Washington. I
think you are the attending physician on the wards, right? Hit
your microphone.
Dr. Washington. Thanks for that question. I am the
attending physician, that is correct. Your question is, why are
minority veterans less likely to be treated for hepatitis C?
Mr. Dunn. I assume that is, you know, per capita. Of 100
cases, minority get--they get treatment less often, why would
that be?
Dr. Washington. That is a really excellent question. I
actually do not have the answer for that. I do know certainly
that is the case that minority veterans are more likely to have
hepatitis C, that though they had very high treatment rates in
comparison to treatment rates outside of the VA, that there are
definitely racial/ethnic differences, as you mentioned, within
the VA.
Mr. Dunn. Do you have any eyes on that, Dr. Moy? Any
insights?
Dr. Moy. I do not have anything to add to that.
Mr. Dunn. Dr. Clancy.
Dr. Clancy. No, except to note that at one point we were
doing special outreach to Hispanics with hep C for treatment,
because we were very concerned that we were missing them.
I will say that for every facility in our system, every
facility got a list of the veterans who were hep C positive, so
that they could do outreach. I have not seen it stratified by
minority status, but would be happy to look into that.
Mr. Dunn. Also, Dr. Clancy, you know, when these new hep C
treatments--and there are a number of them--started becoming
available some 5 or 6 years ago, what steps did the VA take to
include those in the, you know, treatment for minorities and in
fact all of your population? You had to be progressive--it was
expensive, but what would you----
Dr. Clancy. Well, it was expensive and, it was so
expensive, we had to come back to the Congress to say we
actually need more resources, and to Congress who was swiftly
responsive, for which we are very, very appreciative. Fast
forward several years, we have cured 100,000 veterans of
hepatitis C, which I do not think any health care system can
claim. I simply have not seen the data in terms of----
Mr. Dunn. Just stratify----
Dr. Clancy. Yes.
Mr. Dunn.--do you have a sense of how many are untreated?
Dr. Clancy. I believe that we have reached the vast
majority of people who are eligible for treatment. That brings
up the question, what do I mean, eligible for treatment? People
who do not have ongoing substance use or other disorders that
would make treatment a bit risky for them, or people who
actually refuse to be treated, but we have been able to reach a
very high proportion of the veterans with hep C.
Mr. Dunn. That is a counseling problem.
Dr. Moy, let me ask you a question here. Do the patient
satisfaction rates vary between minority veterans and white
veterans?
Dr. Moy. Yes, they do. The SHCEP surveys do indicate that
minorities tend to be less satisfied with the patient-provider
communication than----
Mr. Dunn. Can you quantify that?
Dr. Moy. Yes, we can quantify it. Actually, Dr. Washington
is our expert----
Mr. Dunn. OK.
Dr. Moy.--on the SHCEP by race and ethnicity.
Mr. Dunn. Great. Dr. Washington.
Dr. Washington. I am regretting that I did not bring those
exact numbers with me. We can certainly get back to you with
the exact numbers.
Mr. Dunn. I would like to--but do you have a ballpark?
Dr. Washington. I will have to look at----
Mr. Dunn. OK.
Dr. Washington.--my numbers, I do not want to----
Mr. Dunn. We are going to hold you to it, though----
Dr. Washington.--misspeak.
Mr. Dunn.--I want to see those numbers.
How about the cost? Can you compare the cost of treating
minority veterans with the cost of treating non-minority?
Dr. Washington. We did not look at cost in our analyses.
Mr. Dunn. That might--Dr. Clancy, would you speculate on
that? Does that have any bearing on the rate of treatment or--
--
Dr. Clancy. Well, cost is important, but as a system with
more or less a global budget, right, where sort of simulating
what things would cost, the biggest issue of concern to us is
are people not getting treatments because we did not try hard
enough, because they did not trust us when we spoke to them and
said we are recommending that you get treated with this regimen
or medication, or whatever it is.
In general, I think the larger concern in the field of
health equity is that in fact it costs less because of the
factors I just mentioned.
Mr. Dunn. Yes, curing the disease is generally----
Dr. Clancy. Yes.
Mr. Dunn.--cheaper than treating it chronically.
Dr. Clancy. Yes.
Mr. Dunn. You do not see any deliberate attempt to not
treat minorities given costs; is that fair to say?
Dr. Clancy. Yes.
Mr. Dunn. OK. With that, I yield back. Thank you.
Ms. Brownley. Thank you, Dr. Dunn.
Mr. Cisneros, you have 5 minutes for questioning.
Mr. Cisneros. Thank you, Madam Chairwoman, and thank you
all for being here today.
Dr. Clancy, the Health Equity Committee created in 2012 and
chaired by the Director of the Office of Health Equity was
created as a steering committee dedicated to minority veteran
health issues, amongst others, in order to oversee timely
completion of initiatives and ensure the commitment of
appropriate organizational resources. However, between the
years of 2015 and 2019, that committee did not meet on a
regular basis. How can it provide adequate oversight of the
VA's minority veteran health initiatives if it does not meet
for 4 years.
Dr. Clancy. I think it is fair to say that with new
leadership in place that we have a reason to have much, much
higher expectations. I think that would be the easiest way to
respond to your question.
You are absolutely right. If the committee does not meet,
how can they possibly do anything? Under current leadership for
VHA with Dr. Stone, where he is putting a very, very high
premium on consistency across our system; not good for this
State compared to others, but, you know, good for all veterans
regardless of where you get your care. This sometimes is called
highly reliable care. We now have a framework to actually move
forward and make sure that disparities and tracking that in
performance are routinely included.
Mr. Cisneros. When is the next meeting scheduled, when is
that committee scheduled to meet?
Dr. Clancy. Dr. Moy.
Dr. Moy. March 2nd.
Mr. Cisneros. March 2nd?
Dr. Moy. Yes.
Mr. Cisneros. Are they going to meet on a regular basis now
or how often will they meet?
Dr. Moy. Yes, we have been meeting monthly for about the
last year. Then we are just tapering down to every 6 weeks,
because we have finished our Health Equity Action Plan update,
as well as our operational plans for the fiscal year.
Mr. Cisneros. OK. In 2014, Office of Health Equality (OHE)
identified activities to make improvements in five focus areas,
but VA could not track progress because there were no
performance measures and are no clear lines of accountability
for offices. How can we track improvement and track performance
if we do not create any performance measures? Has that changed?
Dr. Moy. Yes. With the guidance of the Health Equity
Coalition, we have created a 5-year Health Equity Action Plan
that was endorsed by our Under Secretary this past fall and we
just finished creating our Fiscal Year 2020 operational plan.
The Health Equity Coalition at the end of our Fiscal Year will
compare what we said that we would do with what we actually
did. I think we are highly accountable at this point.
Mr. Cisneros. All right. Can you share that with us?
Dr. Moy. Yes. It is on our website, but, yes, we would be
glad to do that.
Mr. Cisneros. All right.
Dr. Clancy. I would just add that it is under Dr. Moy's
leadership that really we have got facility-specific
information routinely provided and I think that is a very key
picture, right? Because if you are just looking at a global
national report, we all know the response to that is, we are
doing great, but it must be those other people, right? When it
is about where you provide care, it says a very different
implication.
Mr. Cisneros. According to the December 2019 Government
Accountability Office (GAO) report, the VA cannot ensure the
accuracy of race and ethnicity information labeled in the
electronic health records. Dr. Clancy, how has this impacted
the VA's ability to gather retrospective data in order to
measure the effectiveness of minority health care?
Dr. Clancy. I am going to turn to Dr. Washington, who is
going to be helping us a lot with this as we try to make
improvements.
Dr. Washington. Thanks for that question. We have a study
underway, the study to which Dr. Clancy referred to in response
to the GAO report, that is looking to exactly quantify what
that rate of missing data is, as well as inaccurate data, and
we will be retrospectively reevaluating some of our measures of
differences by race and ethnicity to look at the impact of
those inconsistencies in race and ethnicity data coding.
Mr. Cisneros. Will you be asking individuals to self-
identify, so we can get----
Dr. Washington. Actually the Survey of Health Care
Experiences of Patients does ask individuals to self-identify.
We will be using several years of that data as sort of the gold
standard for race and ethnicity data, and we will be combining
that with the electronic health record report of race and
ethnicity, so that we can see not only what the overall
national inaccuracies are, but we will be able to hone in at
the health care system level, so that we can identify if there
are particular areas or particular sites in which we need to
look more closely at the practices.
Mr. Cisneros. All right. With that, I yield back my time.
Ms. Brownley. Thank you, Mr. Cisneros.
I now recognize Mr. Rose for 5 minutes.
Mr. Rose. Thank you, Madam Chairwoman.
Ms. Williams, thank you for--I am looking at this New York
State assessment. If you were crowned Empress of New York for a
day, give me two or three things that you think New York needs
to change as quickly as possible as it pertains to this issue?
Ms. Williams. Among the things that I think are most
important to realize are that veterans do not leave the
military and go and live in veteran bubbles. We do not live in
veteran barracks and work in veteran-employment situations
only. All of the situations that can be challenging for
minorities in the broader community also affect veterans who
happen to be minorities. I think it is imperative at the State
level, given the current national situation, to carefully seek
to identify any laws or policies that are going to be
disproportionately affecting minorities at the Federal level
and do what they can at the State level to address those.
For example, New York already provides some protections for
LGBT folks that are not available at the national level.
Seeking out additional areas like that I think is incredibly
important.
Mr. Rose. What do you think that the VA should be doing in
New York?
Ms. Williams. I think VA nationally should address the
inequities already identified, such as the lack of provision of
gender-confirmation surgery. There are also some
disproportionate challenges for women, such as the fact that
women vets can be charged copayments for birth control in VA,
which cannot happen in----
Mr. Rose. Are there any ways the VA looks worse than the
rest of--in New York it looks worse than the rest of the
country?
Ms. Williams. Unfortunately, we are not able to assess it
on the health level, and that is the primary area that VA is
able to provide care. We are really excited to hear that VA is
releasing a report soon, I think that is going to be really
beneficial for all of us.
I also do want to give one quick shout-out to VA on other
areas; this is broader than New York, but there are some areas
of real strength. For example, the Minority Veterans Program,
which is collecting genetic data from veterans, is doing some
really groundbreaking research that is also beneficial in this
area. They recently released, for example, a report on levels
of anxiety and identified genetic loci that are different
between African American and white veterans.
VA is doing some great things, and I want to continue to
support and encourage that across the board, in New York and
nationally.
Ms. Bryant. You mean the Million Veteran Program?
Ms. Williams. I am sorry, that is what I meant.
Ms. Bryant. Yes.
Ms. Williams. Thank you very much, Melissa.
Ms. Bryant. You are welcome.
Ms. Williams. It was a long week.
Mr. Rose. Sure. Thank you.
Ms. Williams. Million Veteran Program. Thank you.
Mr. Rose. One thing that I have noticed in New York and
around the rest of the country is that, while indeed, you know,
Global War on Terrorism (GWOT) veterans look like the country
and the beautiful cultural mosaic that it is, but our Vietnam
vets and Korean War vets of color experienced particular
trauma, you know, fighting for freedom abroad, not exactly
finding that same freedom here at home. In your analyses, what
particular challenges have you seen for veterans of color who
are older, from those earlier conflicts?
Ms. Williams. When we did a focus group in Northwestern New
York, we definitely encountered older veterans of color who
were struggling with serious economic problems that are, again,
related to the economic conditions in the region, and some of
the Federal-level protections that try to help with that, so
Federal hiring preferences, for example, are less relevant to
those veterans, because there are not very many Federal jobs
there.
Finding ways that we can improve the economic outcomes of
minority veterans in Upstate New York where, you know, things
are not as vibrant economically as say in the city, I think is
really incredibly important, especially as they are reaching,
you know, in some cases the end of their earning years and are
going to be looking at ways to manage moving forward. That
definitely is something that is a challenge, although, of
course, that population does tend to be whiter.
Mr. Rose. Sure.
Ms. Williams. Yes, the social supports are not as strong
for minority veterans.
Mr. Rose. Would anyone else like to touch on----
Ms. Bryant. I would----
Mr. Rose.--that point? Yes.
Ms. Bryant.--please, Representative Rose. I completely
concur with everything that Kayla said and, in addition to
that, on the benefits side there is impact to health care
outcomes. Studies have historically shown that there is racial
bias, implicit bias that is injected into lower rating
decisions that are given for service-connected claims.
There is automatically, as I touched on in my opening
statement, there is a distrust that follows in particular the
African American community, but it flows into the Hispanic
community for those that are bilingual speakers, and it really
does go back for the history of our country's Armed Forces to
where that distrust lives on through generations.
For the Vietnam era, as you articulated already, they came
home to an unwelcome environment. If you think of those who
were fighting through the civil rights movement at the same
time of fighting through battles in Vietnam, when they came
home, they were automatically distrustful of the VA. That is
compounded by the overall distrust of the VA by the Vietnam
generation to begin with, but when they got older and they
started filing their claims and they started going to claims
officers.
Last year, we have seen at The American Legion as reported
through our System Worth Saving program, as reported to our
service officers who are out in the field, that there is a bias
that can be injected into claims that are submitted by
minorities.
Mr. Rose. Fantastic. Thank you.
Ms. Brownley. Thank you, Mr. Rose.
No other members are present, so I have a few more
questions that I would really like to ask.
The first question is, in 2016, the VA Health Equity
Report, it states that most of the research on racial/ethnic
disparities among veterans has focused on single clinical
conditions or on limited racial/ethnic minority groups
comparisons. There is limited evidence on health and health
care for racial/ethnic groups of veterans other than black and
white.
Dr. Clancy or Dr. Washington, is there more research going
on, research on disparities that have occurred since then or
anything that is currently underway?
Dr. Washington. Yes. Actually, there is quite a bit
underway. With respect to the single conditions, then what we
have done is to systematically look at all different medical
conditions--I should say, diagnosed medical and mental health
conditions by race and ethnicity, as well as by sex and rural
residence in rural geographic areas, and have catalogued that
across the VA. That information is available in the National
Veterans Health Equity Report, which is publicly available on
the Office of Health Equity website.
In addition, then we have looked beyond diagnoses to start
looking at differences in mortality by race and ethnicity. In
fact late last year then we published a report that compares
disparities in all cause mortality, as well as cardiovascular
and cancer mortality, by race and ethnicity among veterans with
similar conditions in the broader U.S. population.
That information is available. We were gratified to find
that many of the racial and ethnic differences present outside
of the VA are either smaller or nonexistent within VA.
Ms. Brownley. Thank you.
You know, I lead a Women Veterans Task Force and so we have
been talking a lot around issues that impact women veterans and
trying to find inequities and address those. One of the issues
that always tends to come up is that, if women are a minority,
and then breaking down women, you know, African American women,
LGBT women, Asian women, Latina women, and it does not seem
like we--you either have, you know, Latinas and women, but
not--you can not break that out.
Dr. Clancy. Well, we are starting to support more research
on that and in fact we saw a publication just the other day,
which we will get you a copy of. What I found striking was,
while it might be plausible to imagine, if you are female and
you are a member of one of these other groups, that that would
be additive, it actually was not a consistent pattern. I think
we have a lot to learn about why that is, why is it that it
would look one way for diabetes and a different way for mental
health, and so forth. But I think that is why the work that Dr.
Washington is going to do helping us to make sure that that
data on race and ethnicity are accurate would be most
important.
Ms. Brownley. Thank you for that.
Ms. Bryant, in terms of The American Legion, do they have
programs that are, you know, reaching out to minorities that
maybe we could learn from?
Ms. Bryant. The American Legion does have their programs
that reach out to all veterans, of course, and recognizing the
intersectionality that you just mentioned, myself being one of
them, being a woman of color, but there are also specific
measures that we even recognize internally that we should
probably look at in order to ensure that outreach is
appropriate.
Through all of our programs, whether it is on the economic
opportunity side or on the health care side, through our System
Worth Saving program where we ferret out information of what is
happening down at the Veterans Integrated Services Network
(VISN) and down at the medical center level, we try to find
where those systemic challenges may come, nine times out of ten
it is involved with outreach. Then what we are looking at doing
is looking even within our resolution process, as we are a
resolution-based organization, in what we should be doing to
give greater attention to minority veterans.
Ms. Brownley. Thank you for that.
Ms. Williams, too I am, you know, very interested in the
findings that you have shared and the focus groups that you are
doing and finding, determining things like veterans of color
were taken less seriously for pain concerns than white
veterans. I think this is very valuable information and, just
from your vantage point, how should the VA move forward, you
know, to provide more patient-centered competent care like
that?
Secondary to that question, I would be interested if the VA
is doing any kind of focus groups like Ms. Williams'
organization is doing to understand some of the disparities and
maybe biases and other kinds of things that exist.
Ms. Williams.
Ms. Williams. I think VA has a great opportunity to use the
existing survey data that it has to identify where there may be
pockets that are particularly problematic, particular VISNs or
medical centers. The Veterans Experience Office, which is also
collecting a great deal of survey data, is another source that
they can draw on to identify challenges and try to explore how
to improve them.
My experience at VA is that VA is swimming in data, the
challenge is analyzing it and then figuring out how to take
appropriate action.
One step that I would put forward that undercuts my
previous position. When I ran the Center for Women Veterans at
VA, there is a Women Veterans Program governance board that has
all of the senior leaders across VA sit on this governance
board. It is supposed to meet periodically and address cross-
cutting issues, because some of these problems that we are
talking about, they cross departments within the agency, right?
Something can be a health issue, but also have a benefits
component. Having folks from across the different business
lines sitting together to tackle problems is beneficial.
My belief at this point is that it should be reconfigured
to be a governance board for all traditionally under-served
populations with subcommittees for women, racial/ethnic
minorities, LGBT veterans, Military Sexual Trauma (MST)
survivors, others that may have these cross-cutting challenges,
so that teams across VA can come together and identify the best
way to solve the problems, and communicate publicly about what
they are doing to solve the problems and deal with all the
nuances of the issue.
Thank you.
Ms. Brownley. Yes, thank you.
Dr. Clancy. We will take that back. I agree with you,
because, I mean, one way to effectively--to create a perception
that maybe we are minimizing problems is to cut it into too
many little pieces and I think bringing it together, there is a
lot of value in that.
Thanks.
Ms. Brownley. Dr. Clancy, back to the other question that I
had, is the VA doing any kind of focus groups to understand,
you know, what the experiences are for our minority population
amongst veterans. If we can collect--I think the collecting of
the data is obviously critically important, I do not want to
discount that, but we could have, you know, perfect data----
Dr. Clancy. Right.
Ms. Brownley.--but if we are not applying what we are
learning to the practice in terms of servicing our veterans,
then it is really useless, because we know with those component
pieces there are cultural competencies and other issues.
I am just wondering if the VA does sort of take a deeper
dive in looking at focus groups to help determine that?
Dr. Clancy. Focus groups are a very consistent feature of
much of the research we are doing on disparities in health care
and certainly a very big part of what we are doing in terms of
the End Harassment Campaign.
One reason I am such a fan of Dr. Washington's work with
Dr. Yano--and I am pretty sure that you have heard about this--
is this notion that the research itself starts with a
collaboration between researchers, providers, and patients, so
that when patients do bring up issues it is easy or relatively
straightforward to say, gosh, we had not thought about that
when we wrote this application, but that does not mean we can
not act on it now.
To do a survey to ask how many times have you felt
discriminated against or gotten some kind of communication you
thought was biased, that is hugely important.
The other technique that we have used in some circumstances
that grew out of research, but is actually part of ongoing
operations, is so-called standardized patients. In about five
or six facilities now veterans are given the opportunity to
bring in an audio recorder to their encounters and this is used
under peer-review protections, but the primary care clinicians
get a lot of feedback about did they miss cues from the
patient. For example, just using Melissa's example about mental
health. When you said, gosh, what you need to do is go see the
mental health provider, this patient was kind of telling you
that it is not easy for me. You know, it is very much a
collegial kind of conversation.
We have also trained actors in some settings, particularly
for resource referral centers related to the homeless program,
to try to find out, are there systematic issues.
Interestingly--I am sorry Representative Rose left--older
African Americans were an issue and the program made changes to
fix that.
Ms. Brownley. Thank you, thank you for that.
I just think this is really important, because I know the
VA will say, you know, we have collected the data, we are doing
training, but how to really--you know, really be able to sort
of see in and witness in the examination room or in a mental
health setting, wherever it might be, that these practices and
what we are learning are actually being applied I think is
really important.
I mentioned in my opening comments that I recently visited
Cheyenne River and Standing Rock. Well, I have also been to the
American Territories in the Pacific and have been to Puerto
Rico to look at VA health services there. It is abundantly
clear when you go to these locations that the quality of care
for our veterans who have served our country is less than what
we see in the continental United States, and I think some of
that is definitely a cultural divide, you know, without
question. I think we just--you know, we need to do a deeper,
deeper dive.
In a day or two we are going to have a hearing on our
community care networks and we still do not even have someone
who is going to take care of Hawaii and American Territories.
You know, my first reaction to that is that should be first on
the list and not last on the list, because it is where--you
know, it is hitting where the most desperate needs are. I think
the VA has got to do a better job and be more vigilant and be
sort of a model of continuous improvement in terms of these
cultural competencies, because we are--the veteran population
is changing and I do not think that we are fully prepared.
I am going to be anxious to see, you know, what kind of--
from the data, how that data gets applied to real applications,
so that our--you know, our veterans are feeling welcomed to the
VA, all of our minority veterans, you know, being able to, as
we were talking about, crossing over. I think Ms. Williams'
idea is an excellent one, but there is a lot more work that
needs to be done.
Just before I close and let everybody go home, I just
wanted to point out, and I think that this is pretty alarming,
but there was a recent Military Times poll that found that more
than half of active duty minority servicemembers have
personally witnessed examples of white nationalism or
ideological-driven racism within the ranks. I think, as Ms.
Bryant's written testimony confirms, that we can only assume
that this experience will continue on, continues on into the
veteran community. This is alarming to me. I guess the question
is, are we thinking about effective strategies for addressing
this issue in the veteran space, and also what are the health
impacts of experiencing white nationalism and ideological-
driven racism.
Ms. Williams. Dr. Clancy. Dr. Washington.
Ms. Bryant. I will just quickly dovetail on your point,
ma'am, and that is I often find myself saying this in
testimony, that what happens when we are in uniform does not
change when we come off of uniform. I can speak for myself, I
can speak for being a representative of focus groups when I
worked in DOD and when I worked in a government capacity where,
again, that--first of all, there is an isolationism that sort
of happens when you are a minority and when you are an
intersectional minority such as I am, you are often the only
one in the room and you are the only one who is the
representative for others to come to as well.
I can certainly assure that I saw tattoos, that I saw
plenty of people who were affiliated with white nationalism and
it saddens me--I have been out since 2009--that it is still
being reported today. I am glad that you raised that, because I
was actually reading as a part of my research for this
testimony a Guardian article that speaks to the same challenges
in the Royal Air Force (RAF) with our friends in the UK.
Clearly, this is a problem of racism that still persists
and I--again, without getting too emotional in my plea, I can
not imagine that my late grandfather would imagine his
granddaughter still talking about the same issues that he faced
75 years ago.
Ms. Williams. I think you are absolutely right. Minority
stress is real. Having to endure discrimination is bad for
health outcomes. We see that white nationalism and sexism and
homophobia and transphobia, they often hang together. If we are
seeing spikes in any of these, we are likely to see them in
others. That is why I recommended that the End Harassment
campaign that VA has launched, which is a terrific start for
dealing with sexism and gender discrimination and sexual
harassment, that as more is learned about what messaging is
effective that that should be expanded to also tackle racial
harassment and homophobic and transphobic harassment within VA
facilities as well, because it is incredibly important that the
place that folks go to get health care, if nowhere else, should
be a place where they are safe, where they are welcomed, they
are comfortable, and they do not have to endure these types of
experiences.
Certainly, VA, unlike other sectors of care, has an
obligation to care for all veterans, even those who behave
inappropriately toward their fellow patients, but there systems
in place that can be used to ensure that folks who do behave
inappropriately can be put into the disruptive patient behavior
management system and have escorts or whatever may need to be
done to ensure that those around them are able to access care
safely.
Thank you.
Ms. Brownley. Thank you.
Dr. Washington or Dr. Clancy, anything else to add?
Dr. Clancy. I think it is fair to say we share your
concerns and a lot of this comes back to what kind of trust, do
veterans trust that we have got their backs, that we will
provide them the appropriate care regardless of their
background. If you have had such negative experiences, there is
a lot of research that shows that you are not going to come in
immediately presuming trust.
I was mentioning earlier the V-Signals, which is part of
the Veterans Experience Office, is giving us the opportunity to
address issues that people raise with us in something close to
real time, not literally that instant, but--and I will say that
a lot of our network and facility leaders have been surprised,
not particularly related to minority issues, but areas where
they thought things were working pretty well. The veteran said,
well, actually, no, it is not, and they made changes and so
forth.
I can not change how people--no one can change how people
think. I do think two things need to happen: one is that we
need to act on the information when people share their concerns
and, if we do not, that is a failure, because we will lose an
opportunity to gain trust, and that is really the most
important aspect of what we can do.
Having worked in the field of disparities for a number of
years before I came to VA, one of the advice when people would
say, well, what would you tell patients to do right now and a
lot of it is to speak up and to just say I am worried that I am
still having pain, for example, to use your example, and I know
you gave me medicine, but it is really not working, can we talk
about other solutions. But if people speak up and we do not
hear them, that will not be effective.
Ms. Brownley. Well, we have to create a culture where it is
safe to speak up and say that. You are right, we can not change
how people think, but we can ensure that once a veteran enters
a VA space that it is free of bias and it is not tolerated and
that has to be left at the door.
Oh, I am sorry.
Ms. Williams. No, I am so sorry. I wanted to mention that--
well, of course, my bias is to worry about how veterans are
receiving care and the environment of care for them, I think we
should also be concerned about VA providers. I understand in
the health care system more generally for health care providers
being on the receiving end of racist and sexist comments is
also a problem. So let us be concerned about the staff and
making sure that they also are able to perform their jobs in an
environment where they are being treated with dignity and
respect.
Ms. Brownley. Yes, thank you for bringing that up, because
that is an important component piece of it.
Well, I want to thank you all for being here. I think this
is the first time we have had a hearing on minority veterans I
think in a very, very long time. Having an afternoon hearing is
always difficult, because there are too many competing
circumstances, but it was important I think to at least begin
to start to have this conversation and I want to continue the
conversation.
Dr. Washington, thank you for traveling from LA to here to
join us today. I am surprised I did not see you on the
airplane, because I usually do.
Dr. Washington. I was looking for you.
Ms. Brownley. Any way, I appreciate everyone being here and
I look forward to continuing this conversation through the
Subcommittee on Health and also through the Women Veterans Task
Force. Thank you.
With that, we will adjourn.
[Whereupon, at 3:39 p.m., the subcommittee was adjourned.]
?
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A P P E N D I X
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Prepared Statement of Witnesses
----------
Prepared Statement of Carolyn Clancy
Good afternoon Chairwoman Brownley, Ranking Member Dunn, and
distinguished Members of the Subcommittee. I appreciate the opportunity
to discuss our continued progress in achieving health equity for
Minority Veterans. I am accompanied today by Dr. Ernest Moy, Executive
Director, Office of Health Equity, and Dr. Donna Washington, Attending
Physician at the Greater Los Angeles Healthcare System.
Introduction
The health and well-being of our Nation's men and women who have
served in uniform are the highest priority for VA. VA is committed to
providing timely access to high-quality, recovery-oriented, evidence-
based health care that anticipates and responds to Veterans' needs and
supports the reintegration of returning Servicemembers and to shorten
the distance between people in need of Veterans services. At VA, we are
working to increase our reach among all Veterans, regardless of age,
gender, race, ethnicity, and sexual orientation to ensure all of our
Veterans receive and find access to quality and inclusive care from our
health care systems. Today, I will talk about some of the successes and
challenges we face in achieving health equity for Veterans, some of the
programs that make this happen, and how the recent GAO report is
guiding future improvement.
Care for Minority Veterans
VA has worked hard to try to get all Veterans the care they need.
We are proud of our successes, but understand that there is still much
work to be done. Overall, there are few differences \1\ in the quality
of services delivered to Veterans by VHA related to race and ethnicity.
Preventive care and care for chronic diseases are delivered at
comparable rates inside VHA, in contrast to care in the private sector
where disparities are common. For example, \2\ prior to the launch of
VHA's Health Equity Action Plan, rates of colorectal cancer screening
for Black Veterans who used VHA lagged rates for White Veterans. Now,
\3\ there are no significant differences in rates of colorectal cancer
screening among White, Black, and Hispanic Veterans who use VHA, and
the overall rate is about 80 percent; in the private sector,
disparities are common and overall rates lower, averaging, for example,
60-65 percent among commercial health plans that provide data to NCQA.
Within VHA, colorectal cancer screening rates among American Indian/
Alaska Natives are 75 percent; while superior to the private sector,
additional study is needed to understand why this rate differs from
other groups within VHA. While delivery of services is equitable, \4\
outcomes of care for racial and ethnic minority Veterans in VHA often
lag behind outcomes achieved by non-Hispanic White Veterans. For
example, while receiving comparable services, racial and ethnic
minority Veterans with diabetes are more likely to have poor glucose
control and less likely to have good control of blood pressure and
cholesterol. There are sex, race, and ethnicity differences in these
outcomes. For example, non-Hispanic Black Veterans with diabetes are
less likely than non-Hispanic White Veterans to have good blood
pressure and glucose control, irrespective of sex. Among Veterans with
heart disease, women, irrespective of race and ethnicity, are less
likely to have good cholesterol control compared with either non-
Hispanic Black or non-Hispanic White male Veterans. In comparison to
commercial plans, achievement of control of these cardiovascular risk
factors are much higher with VA, and VA racial and ethnic disparities
are smaller.
---------------------------------------------------------------------------
\1\ Trivedi AM, Grebla RC, Wright SM, Washington DL. Despite
improved quality of care in the Veterans Affairs health system, racial
disparity persists for important clinical outcomes. Health Aff. 2011
Apr;30(4):707-15.
\2\ Trivedi AM, Grebla RC, Wright SM, Washington DL. Despite
improved quality of care in the Veterans Affairs health system, racial
disparity persists for important clinical outcomes. Health Affairs.
2011 Apr;30(4):707-15.
\3\ May FP, Yano EM, Provenzale D, Steers WN, Washington DL. Race,
Poverty, and Mental Health Drive Colorectal Cancer Screening
Disparities in the Veterans Affairs Healthcare System. Medical Care.
2019 Oct;57(10):773-780.
\4\ Washington DL, Steers WN, Huynh AK, Frayne SM, Uchendu US,
Riopelle D, Yano EM, Saechao FS, Hoggatt KJ. Racial And Ethnic
Disparities Persist At Veterans Health Administration Patient-Centered
Medical Homes. Health Affairs. 2017 Jun 1;36(6):1086-94.
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\5\ Mortality differences favoring non-Hispanic White Veterans also
exist although they are typically smaller than mortality differences
among the U.S. population as a whole. For example, heart disease and
cancer are the leading causes of death for women in both VA and the
U.S. general population - accounting for about one-half of deaths. \6\
In the U.S. population, non-Hispanic Black women have a higher death
rate than non-Hispanic White women for all causes, heart disease, and
cancer mortality. Among VA health care users, these disparities have
been eliminated. Non-Hispanic Black women Veterans who use VHA do not
experience higher death rates than White women, unlike non-Hispanic
Black women in the U.S. general population.
---------------------------------------------------------------------------
\5\ Wong MS, Hoggatt KJ, Steers WN, Frayne SM, Huynh AK, Yano EM,
Saechao FS, Ziaeian B, Washington DL. Racial/ethnic disparities in
mortality across the Veterans Health Administration. Health Equity.
2019 Apr 8; 3(1):99-108.
\6\ Wong MS, Hoggatt KJ, Steers WN, Frayne SM, Huynh AK, Yano EM,
Saechao FS, Ziaeian B, Washington DL. Racial/ethnic disparities in
mortality across the Veterans Health Administration. Health Equity.
2019 Apr 8; 3(1):99-108.
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Smaller disparities in health outcomes among racial and ethnic
minority Veterans compared with non-Veterans may be attributed in part
to fewer financial barriers to care. A recent Health Affairs article
\7\ showed that ``Substantial racial/ethnic disparities in cost-related
medication nonadherence were consistently present among people with
non-VHA coverage, but not among VHA enrollees. For instance, among
those with non-VHA coverage, 5.9 percent of whites couldn't afford a
prescription drug, versus 8.6 percent of Hispanics and 10.6 percent of
Blacks. However, no significant racial/ethnic differences were present
among people with VHA coverage.''
---------------------------------------------------------------------------
\7\ Gaffney A, Bor DH, Himmelstein DU, Woolhandler S, McCormick D.
The Effect Of Veterans Health Administration Coverage On Cost-Related
Medication Nonadherence. Health Aff (Millwood). 2020 Jan;39(1):33-40.
doi: 10.1377/hlthaff.2019.00481. PubMed PMID: 31905070.
---------------------------------------------------------------------------
Office of Health Equity Efforts
The Office of Health Equity (OHE) has a broad charge including
gathering and analyzing data on disparities among Veterans, developing
communication products to raise awareness about equity issues faced by
Veterans, working with VA medical centers (VAMC) to improve outcomes of
care for all Veterans, and supporting workforce diversity and inclusion
within VHA. VA has successfully addressed social determinants of health
on a large scale, such as reducing homelessness and food insecurity
among Veterans. VA also has the capacity to address other determinants
such as education, employment, and social isolation in conjunction with
Veterans Service Organizations. Consequently, OHE supported the
development of the Accessing Circumstances, Offering Resources for Need
(ACORN) project to screen Veterans for a broad range of social
determinants, which disproportionately affect communities of color, and
match them with appropriate social services. OHE has also developed the
Equity-Guided Improvement Strategy (EGIS) which uses equity information
at VAMCs to target specific groups of Veterans for quality improvement
and connect them with services tailored to their needs.
December 2019 Government Accountability Office (GAO) Report
Recommendations and Responses
A GAO report released in December recommended that VHA develop
performance measures and clear lines of accountability to track
progress toward equity for Veterans and assess and improve the accuracy
of racial and ethnic coding in VHA systems.
In response to this recommendation, OHE has updated the Health
Equity Action Plan (HEAP) and developed an operational plan for Fiscal
Year (FY) 2020 with performance measures and clear lines of
accountability. These plans were developed with the aid and support of
a Health Equity Coalition consisting of a variety of VA health equity
stakeholders. This Coalition will assess achievement of performance
goals at the end of the Fiscal Year and assist the development of
future operational plans and performance measures.
Race and ethnicity data are missing on about 7 percent of Veterans
in VHA, which is better than typically seen in the private sector. The
quality of coding is mixed; with the highest missing data rates being
11 percent, 10 percent, and 9 percent, respectively, for Hispanic,
Asian, and Native Hawaiian/Other Pacific Islander Veterans, in a recent
year. In response to the second GAO recommendation, OHE and Health
Services Research & Development are supporting two assessments: one
assessment, led by
Dr. Washington, will formally determine the quality of coding by
comparing existing racial and ethnic coding in the electronic health
record with self-reported survey information from VHA's Survey of
Health Care Experiences of Patients, since self-reported identification
of race and ethnicity is the gold standard; a second assessment will
collect race and ethnicity information in VAMCs directly from Veterans
using an iPad because staff discomfort with asking for this information
has been cited as a major reason race and ethnicity data are missing.
Women and LGBTQ Veterans
VA is making progress in fostering a more inclusive patient
experience for women and our Lesbian, Gay, Bisexual, Transgender, and
Queer (LGBTQ) community. A recent study set out to identify patterns of
risk and resilience by the intersections of race/ ethnicity (a combined
measure in that study) and sexual orientation in mental health symptom
severity, sexism, and social support among women Veterans.\8\ The study
found that among women Veterans, minority race/ethnicity or minority
sexual orientation were associated with higher levels of mental health
symptoms and experiences of sexism, when compared with White,
heterosexual women Veterans. As the study noted, ``However, women
Veterans with both minority race/ethnicity and minority sexual
orientation did not always fare worse than White, heterosexual women
Veterans,'' with respect to severity of symptoms, suggesting that women
at the intersection of these minority identities may develop resilience
from their lived experience.
---------------------------------------------------------------------------
\8\ Lehavot K, Beckman KL, Chen JA, Simpson TL, Williams EC. Race/
Ethnicity and Sexual Orientation Disparities in Mental Health, Sexism,
and Social Support among Women Veterans. Psychol Sex Orientat Gend
Divers. 2019;6(3):347-358. doi: 10.1037/sgd0000333. PubMed PMID:
31435497; PubMed Central PMCID: PMC6703561.
---------------------------------------------------------------------------
OHE works with VHA Women's Health Services to support assessments
of equity issues faced by women Veterans. Data sources are often
shared; for example, the Women's Health Evaluation Initiative data base
that was developed to monitor equity issues for women Veterans, was
adapted and expanded to create the National Veterans Health Equity
Report (which reported on equity issues by race/ethnicity, sex,
rurality of residence, mental health disorders, and age). OHE also
works with the LGBTQ coordinators, present at every VAMC, to support
assessments of equity issues faced by LGBTQ Veterans. OHE has served as
the VA point of contact with the Healthcare Equality Index, the major
national LGBTQ benchmarking tool, and is sponsoring work with the
Centers for Disease Control and Prevention to study LGBT Veterans
because they cannot be identified systematically in VHA's current data
systems. However, in the new Cerner Electronic Healthcare Record
system, it will be possible to capture information on sexual
orientation in a systematic fashion.
Patient Experience
VA recognizes the importance of patient experience, communication,
and trust. We understand that patients who trust their clinicians and
care teams are more likely to modify their health behaviors and have
better outcomes. When Veterans respond to certain Veterans Experience
Office (VEO) surveys, they have an opportunity to self-identify their
race and ethnicity. VEO analyzed Veteran feedback based on self-
identification of race as Asian, American Indian or Alaska Native,
Black or African American, Native Hawaiian or Other Pacific Islander,
or White. VEO also analyzed Veteran feedback based on identification of
their ethnicity as Hispanic or Latino versus not Hispanic or Latino.
The results showed the following insights about Veteran experience
based on age, gender, and self-reported race and ethnicity:
Veterans ages 70 and over in the Outpatient Surveys had
the highest percentage reporting that they had trust in VA facilities
for meeting their healthcare needs; Veterans under 30 had the lowest
percentage reporting trust. Additionally, male Veterans report higher
trust than female Veterans. Trust for all age groups as well as both
men and women has increased since the third quarter of Fiscal Year
2017.
Veterans who self-identify as White show the highest
trust in the Outpatient Surveys; Veterans who self-identify as American
Indian or Alaskan Native Veterans show the lowest trust. Additionally,
Veterans who identify as non-Hispanic or Latino show higher trust than
Veterans who identify as Hispanic or Latino. Trust for all self-
reported races and ethnicities has increased since the third quarter of
Fiscal Year 2017.
Conclusion
VA's goal is to meet Veterans where they live and work so VA can
work with them to ensure they can achieve their goals by teaching them
skills, connecting them to resources, and providing the care need along
the way. We are committed to advancing our outreach and empowerment to
further restore the trust of Veterans every day and continue to improve
access to care. Our objective is to give our Nation's Veterans the top-
quality experience and care they have earned and deserve. We appreciate
this Committee's continued support and encouragement as we identify
challenges and find new ways to care for Veterans.
______
Prepared Statement of Kayla Williams
Despite criticisms VA is an excellent source of health care,
boasting low wait times, high quality, cultural competence, and low
cost for many veterans.\1\ Studies have shown that wait times at VA
facilities are shorter than in the private sector.\2\ Systematic
studies have examined the relative quality of care between the Veterans
Health Administration (VHA) and outside health care providers and shown
that VA provides better or equal outcomes in regard to safety and
effectiveness for patients.\3\ VA also provides substantially better-
quality mental health care, a prime consideration for many veterans.\4\
However, not all groups of veterans find VA to be equally welcoming,
accessible, or able to provide adequate care. There can also be
significant variation across VA Medical Centers (VAMCs), and there are
widely acknowledged challenges gaining initial access to the VA system.
The following testimony centering on disparities among minority
veterans - women, racial/ethnic minorities, and LGBT individuals -
using VA health care is drawn primarily from the forthcoming CNAS
report New York State Minority Veterans Needs Assessment.\5\
---------------------------------------------------------------------------
\1\ Terri Tanielian, Coreen Farris, Caroline Epley, et al., ``Ready
to Serve: Community-Based Provider Capacity to Deliver Culturally
Competent, Quality Mental Health Care to Veterans and Their Families''
(RAND Corporation, 2014), https://www.rand.org/content/dam/rand/pubs/
research_reports/RR800/RR806/RAND_RR806.pdf.
\2\ Madeline Penn, Saurabha Bhatnagar, and SreyRam Kuy,
``Comparison of Wait Times for New Patients Between the Private Sector
and United States Department of Veterans Affairs Medical Centers,''
JAMA (January 18, 2019), https://jamanetwork.com/journals/
jamanetworkopen/fullarticle/2720917.
\3\ Claire O'Hanlon, Christina Huang, Elizabeth Sloss, et al.,
``Comparing VA and Non-VA Quality of Care: A Systemic Review,'' Journal
of General Internal Medicine, 32 no. 1 (July 2016), https://
www.ncbi.nlm.nih.gov/pmc/articles/PMC5215146/.
\4\ Katherine Watkins, Brad Smith, Ayse Akincigil, et al., ``The
Quality of Medication Treatment for Mental Disorders in the Department
of Veterans Affairs and in Private-Sector Plans,'' Psychiatric
Services, 67 no. 4 (April 2016), https://www.ncbi.nlm.nih.gov/pubmed/
26567931.
\5\ Nathalie Grogan, Emma Moore, Brent Peabody, Margaret Seymour,
and Kayla Williams, ``New York State Minority Veterans Needs
Assessment,'' (Center for a New American Security, February 2020),
forthcoming.
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Different veteran populations use the VA at different rates. This
may partly be because not all veterans have the same knowledge base
about how to access VA health care or disability assistance,
particularly those who transitioned out of the military before the
Veterans Opportunity to Work (VOW) to Hire Heroes Act mandating
improvements to the Transition Assistance Program was signed into law
in 2011. Veterans' own perception of self may also influence their
comfort or willingness in seeking out care and benefits from VA:
previous experiences specific to minority group populations can deter
veterans from using VA for their health care at all. Minority and
underrepresented groups, in particular women, racial/ethnic minorities,
students, and veterans in rural areas, tend to be at increased risk for
negative health care outcomes in large part due to lack of awareness,
ineligibility for certain programs, and concerns about stigma against
them or lack of confidentiality.
Accordingly, as the veteran population changes, so must training
and assumptions of VA staff and even fellow patients, as well as what
types of care are covered and how outreach is conducted.\6\
---------------------------------------------------------------------------
\6\ Rebecca Price et al., ``Comparing Quality of Care in Veterans
Affairs and Non-Veterans Affairs Settings,'' Journal of General
Internal Medicine, 33 no. 10 (October 2018), 1631-1638, https://
www.rand.org/pubs/external_publications/EP67588.html.
---------------------------------------------------------------------------
Women Veterans
Overall health outcomes for military-affiliated women have been
deteriorating over the last 15 years, for both physical and mental
health challenges and conditions.\7\ Of particular concern for this
hearing because it can affect willingness to seek care at VA
facilities, military women experience sexual harassment and assault at
significantly higher rates than; military sexual trauma (MST), the
umbrella term that covers both severe or pervasive sexual harassment
and sexual assault experienced during service, is correlated with a
range of negative health outcomes.\8\ According to a DoD survey, in
2018, 6.2 percent of active-duty women and 0.7 percent of men
experienced a past-year sexual assault.\9\ The same survey estimated
that 24.2 percent of women and 6.3 percent of men had experienced
sexual harassment in the previous year, and 16 percent of women and 2.3
percent of men had experienced gender discrimination. Nationwide, over
the course of a lifetime, an estimated 27.5 percent of women and 11
percent of men experience unwanted sexual contact; women veterans are
also at increased risk of having experienced pre-service sexual
assault. Accordingly, women veterans may have complex trauma due to
exposure to multiple traumatic events prior to, during, and after
military service. MST is also more strongly correlated to PTSD than
either combat trauma or civilian sexual assault; following the high
rates of exposure in service, a significant percentage of women
veterans screen positive for MST.\10\
---------------------------------------------------------------------------
\7\ Kate Hendricks Thomas and Kyleanne Hunter, eds., Invisible
Veterans: What Happens When Military Women Become Civilians Again
(Santa Barbara, CA: Praeger, 2019), 57.
\8\ S.G. Smith, J. Chen, K.C. Basile, L.K. Gilbert, M.T. Merrick,
N. Patel, M. Walling, and A. Jain, ``The National Intimate Partner and
Sexual Violence Survey: 2010-2012 State Report'' (Centers for Disease
Control and Prevention, April 2017), https://www.cdc.gov/
violenceprevention/pdf/NISVS-StateReportBook.pdf; and ``Military Sexual
Assault Fact Sheet,'' Protect Our Defenders, https://
www.protectourdefenders.com/factsheet/.
\9\ Smith et al., ``The National Intimate Partner and Sexual
Violence Survey: 2010-2012 State Report.''
\10\ Deborah Yaeger, Naomi Himmelfarb, Alison Cammack, and Jim
Mintz, ``DSM-IV Diagnosed Posttraumatic Stress Disorder in Women
Veterans With and Without Military Sexual Trauma,'' Journal of General
Internal Medicine, 21 no. 3 (March 2006), S65-S69, https://
www.ncbi.nlm.nih.gov/pmc/articles/PMC1513167/; and ``Military Sexual
Trauma in Recent Veterans,'' U.S. Department of Veterans Affairs,
https://www.publichealth.va.gov/epidemiology/studies/new-generation/
military-sexual-trauma-infographic.asp.
---------------------------------------------------------------------------
Experiences with fellow patients and VA staff can affect veterans'
willingness to engage with the system, trust the care they receive, and
seek care in the first place. For example, 25 percent of women veterans
reported inappropriate/unwanted comments or behavior by men veterans
while at VA.\11\ Women veterans who reported harassment were less
likely to report feeling welcome to VA, which related to delaying and/
or missing care. One stakeholder in CNAS interviews said about
experiencing harassment at VA: ``A veteran doesn't necessarily go back
to VA. If they have a negative experience, they're not coming back.''
Women with a history of MST are more likely to find this to be an
insurmountable barrier to care. Women veterans strongly encouraged each
VA center to have a women's care coordinator employed to change the
all-male culture of VA centers. While each VAMC is required to have a
women veterans program manager to advise and advocate for women
veterans, the amount of influence that individual has within the
facility varies substantially.
---------------------------------------------------------------------------
\11\ 2015 VA Health Services Research and Development, through an
interview with 1,387 women veterans in 2015. Of the women reporting an
incident on VA grounds, 61 percent reported harassment, 16 percent
reported that their veteran status was questioned, 7 percent reported
both harassment and that their veteran status was question, and 5
percent reported threatening/criminal behavior.
---------------------------------------------------------------------------
As a smaller share of the veteran population, women veterans have
historically not felt informed of their benefit entitlement or welcomed
at VA facilities. A vast disparity between VA users and nonusers
illustrated lack of awareness that specifically addressed women's
health services: 67 percent of users received information compared with
only 21 percent of nonusers.\12\ One of the biggest factors, according
to interviews with stakeholders and advocates for women veterans, is
barriers to receiving care. One example given was, ``When women show
up, they are challenged whether they served; they're asked questions
that their male counterparts aren't asked.''
---------------------------------------------------------------------------
\12\ ``Study of Barriers for Women Veterans to VA Health Care''
(U.S. Department of Veterans Affairs, April 2015), https://
www.womenshealth.va.gov/docs/Womens %20Health %20Services_Barriers
%20to %20Care %20Final %20Report_April2015.pdf.
---------------------------------------------------------------------------
Stakeholders routinely reported that women are often reluctant to
seek services at VA Medical Centers as they are, or are perceived to
be, male-dominated spaces and thus less sympathetic, understanding, or
welcoming to women. Women veterans reported being mistaken for a spouse
or partner of a veteran rather than veterans themselves, or otherwise
questioned as to why they are entitled to veterans' benefits. Women who
have experienced military sexual assault are particularly untrusting of
VA care and often elect not to reenter a military environment; however,
few providers in the civilian setting are familiar with the effects of
MST.
Despite these challenges, there has been a rapid and significant
increase in VHA usage by women veterans--a 45.4 percent increase since
2007, though the women veteran population has increased only by 7.7
percent.\13\ It is imperative that VA strategically plan for the
substantial and ongoing growth in the population of women veterans it
serve. In particular, given the high rates of mental health conditions
and MST, the Office of Mental Health Services and Suicide Prevention
should develop a strategic plan to support women veterans' mental
health needs within the PACT model as well as with increased funding
and training for providers. Additionally, VA should modify or eliminate
two discriminatory policies: the medical benefits package bars abortion
and abortion counseling, with no exceptions for rape, incest, or life
endangerment of the woman; and VA may charge a co-payment for birth
control for some patients.\14\ This is out of alignment with all other
federally provided health care and medical best practices.
---------------------------------------------------------------------------
\13\ ``VA Utilization Profile Fiscal Year 2016,'' 7-9.
\14\ https://thehill.com/opinion/healthcare/418102-congress-should-
enhance-reproductive-health-care-for-women-veterans
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Racial/Ethnic Minority Veterans
In the United States more broadly, studies have shown that racial
minorities experience bias in health care that can and does lead to
increased fatalities. As the Centers for Disease Control and Prevention
published in May 2019, maternal mortality is three times higher among
African American and AIAN women than white women in the general
population, demonstrating that racial bias in health care causes
preventable deaths.\15\ The legacy of the Tuskegee experiments also
contributes to lingering mistrust of the health care system among
people of color more broadly. Stereotypes about minority individuals'
pain tolerance and symptoms have been reported to influence medical
providers into disregarding complaints by minority patients.\16\ A few
CNAS focus group participants specifically reported that medical
providers at VA centers take the pain and symptoms of people of color,
particularly women, less seriously than those of their white
counterparts, providing a barrier to correct health diagnoses and
contributing to a lack of trust.
---------------------------------------------------------------------------
\15\ Roni Caryn Rabin, ``Huge Racial Disparities Found in Deaths
Linked to Pregnancy,'' The New York Times, May 7, 2019, https://
www.nytimes.com/2019/05/07/health/pregnancy-deaths-.html.
\16\ Kelly Hoffman, Sophie Trawalter, Jordan R. Axt, and M. Norman
Oliver, ``Racial bias in pain assessment and treatment recommendations,
and false beliefs about biological differences between blacks and
whites,'' Proceedings of the National Academy of Sciences, 113 no. 16
(2016), 4296-4301, https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC4843483/.
---------------------------------------------------------------------------
Advocates for minority veterans also argued that providers,
representatives, and VSOs are not culturally knowledgeable and are
unable to offer culturally competent care. Focus group participants
perceived providers as not sufficiently trained on cultural differences
or adequately connected to the minority populations they are serving. A
number of participants emphasized a lower willingness in the African
American community to seek out mental health care, and this cultural
difference needs to be examined by leadership to better care for black
veterans suffering from mental health issues: ``In black culture there
isn't a lot of tendency to seek help for mental incapacity. You can't
just have a doctor say here's a service, come and get treatment. If
they understood the cultural aspects, they have to understand talking
to a person that there's a reason they're not accessing services.''\17\
Similar to the experiences of minority communities, civilian and
veteran alike, across other life domains, implicit and explicit biases
of health care providers negatively affect minority veterans.
Participants felt they received substandard treatment by doctors.
---------------------------------------------------------------------------
\17\ ``African American Mental Health,'' National Alliance on
Mental Illness, https://www.nami.org/find-support/diverse-communities/
african-americans.
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Despite these perceived challenges, between 2005 and 2014, minority
veterans enrolled in VA health care at much higher rates, an increase
of 43 percent, while nonminority veterans enrollment increased only 24
percent.\18\ The causes for this differential increase in enrollment
are unclear and could indicate greater need for VA health care due to
economic factors or be a reflection of growth in the minority veteran
population. Increases in VA utilization overall likely reflect enhanced
outreach and changes to eligibility that expand access to all combat
veterans for 5 years after service. The overall VA benefit usage rate
was 49 percent: Native Hawaiian/Other Pacific Islander veterans were
the most likely to use VA (59 percent), followed by black (54 percent)
and Hispanic veterans (53 percent).\19\ American Indian / Alaska Native
(45 percent) and Asian (42 percent) veterans were the least likely to
use VA benefits. American Indian and Alaska Natives are more likely
than their non-Native veteran counterparts to lack health insurance and
proper health care.\20\ (Native American veterans present a unique case
as they are covered by three jurisdictions - Federal, State, and
tribal. Due to these complexities, we recommend a separate hearing
specifically focused on their access to care.)
---------------------------------------------------------------------------
\18\ ``Minority Veterans Report: Military Service History and VA
Benefit Utilization Statistics'' (U.S. Department of Veterans Affairs'
National Center for Veterans Analysis and Statistics, March 2017),
https://www.va.gov/vetdata/docs/SpecialReports/
Minority_Veterans_Report.pdf.
\19\ ``Profile of Veterans: 2017,'' 39.
\20\ Kevin J. Allis, Chief Executive Officer of the National
Congress of American Indians, testimony to the Subcommittee on Health,
Committee on Veterans' Affairs, U.S. House of Representatives, October
30, 2019, 2, https://docs.house.gov/meetings/VR/VR03/20191030/110128/
HHRG-116-VR03-Wstate-AllisK-20191030-U2.pdf.
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LGBT Veterans
LGBT veterans are more likely to have experienced sexual assault
and trauma prior to and during service, influencing health and well-
being outcomes post-service, and the LGBT community on the whole is at
higher risk of stigma and violence than other groups.\21\ While health-
care-related data regarding LGBT veterans is limited due to historical
policy barriers to the disclosure of sexual orientation and gender
identity, the Health Related Behaviors Survey has shown that among
active-duty personnel, LGBT individuals were more likely to report
having ever experienced physical abuse or unwanted sexual contact.\22\
Similarly, a significantly higher percentage of LGB service members
reported past-year sexual assault than did their non-LGB counterparts
in the 2018 Workplace and Gender Relations Survey (WGRA) of Active Duty
Members (which tracked LGB but not transgender service members): 9
percent of LGB women compared with 4.8 percent of non-LGB women and 3.7
percent of LGB men compared with 0.4 percent of non-LGB men.\23\ LGB
service members in another study were twice as likely to experience
military sexual assault, which was directly linked to PTSD and
depression among LGB veterans: 40 percent of LGB veterans have PTSD
symptoms compared with 30 percent of non-LGB veterans.\24\
---------------------------------------------------------------------------
\21\ ``Sexual Assault and the LGBTQ Community,'' Human Rights
Campaign, https://www.hrc.org/resources/sexual-assault-and-the-lgbt-
community.
\22\ Meadows et al., ``2015 Department of Defense Health Related
Behaviors Survey (HRBS).''
\23\ ``Annex 1: 2018 Workplace and Gender Relations Survey of
Active Duty Members Overview Report.''
\24\ Carrie Lucas, Jeremy Goldbach, Mary Rose Mamey, Sara Kintzle,
and Carl Andrew Castro, ``Military Sexual Assault as a Mediator of the
Association Between Posttraumatic Stress Disorder and Depression Among
Lesbian, Gay, and Bisexual Veterans,'' Journal of Traumatic Stress, 31
no. 4 (August 7, 2018), https://onlinelibrary.wiley.com/doi/10.1002/
jts.22308.
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The Healthcare Equality Index, developed by the Office of Health
Equity in partnership with the Human Rights Campaign, showed only 49
percent of VA Medical Centers were classified as ``Leaders,'' or ``Top
Performers,'' the two highest designations awarded, as of 2019.\25\
This data is reinforced by input from stakeholders and veterans. A
common thread across interviews and focus groups regarding LGBT
veterans was the importance of cultural competency and mandatory
trainings for VA personnel to better serve the LGBT veteran population.
Multiple advocates highlighted the variety of barriers LGBT veterans
face in accessing health care, many of which are unique to their sexual
orientation and/or gender identity, during CNAS interviews. One
described it as, ``You're dealing with medical providers that aren't
receiving necessary training to properly assess issues that you're
going through and provide unnecessary treatments.'' According to
numerous stakeholders, many LGBT veterans tend not to feel comfortable
claiming veteran status and are therefore less willing or likely to
seek out VA health care. Similar to those barriers for women veterans,
LGBT veterans report a reluctance to visit VA medical centers,
specifically reporting that they are often dominated by older veterans
who typically have more conservative views on sexual orientation and
gender identity. One stakeholder noted that LGBT veterans experience
disproportionate negative health outcomes not because of their identity
but rather because of the stigma and discrimination they face for who
they are, or due to providers who ``don't understand these implicit
things they should about LGBT people.'' However, according to the 2015
U.S. Transgender Survey, 87 percent of transgender veteran respondents
had reported being treated respectfully at the VA all or most of the
time.\26\
---------------------------------------------------------------------------
\25\ Criteria include patient and employment nondiscrimination,
equal visitation, patient services and support, and training in LGBTQ
patient-centered care, among others. ``Healthcare Equality Index,''
U.S. Department of Veterans Affairs' Office of Health Equity, https://
www.va.gov/HEALTHEQUITY/Healthcare_Equality_Index.asp.
\26\ ``Military Service by Transgender People: Data from the 2015
U.S. Transgender Survey.''
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These barriers to care are particularly concerning for the LGBT
veteran population given that among the active duty force, a
significantly higher percentage of gay service members suffer from PTSD
(53 percent) compared with heterosexual service members (17 percent).
This is even more acute for lesbian service members, 67 percent of whom
suffer from PTSD compared with 19 percent of heterosexual female
service members.\27\ While LGBT status is not causal for PTSD or
suicide, sexual orientation is considered a risk factor.\28\ LGBT
individuals are more likely to have reported binge drinking, cigarette
smoking, moderate to severe depression, and suicidal ideation and
attempts.\29\ Rates of suicidal ideation are two to three times higher
for the LGBT community and suicide attempts two to seven times more
frequent. Those with gender dysphoria attempt suicide at a rate 20
times higher.\30\ Research has shown that ``stigma, prejudice, and
discrimination create a hostile and stressful social environment that
causes mental health problems,'' known as minority stress; efforts to
reduce homophobia and transphobia are an important component of broader
efforts to improve mental health in the veteran community.\31\
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\27\ Meadows et al., ``2015 Department of Defense Health Related
Behaviors Survey (HRBS).''
\28\ Wendy Lakso, ``VA sets standards in suicide risk assessment,
offers support to community providers,'' VAntage Point blog on
blogs.VA.gov, January 2, 2019, https://www.blogs.va.gov/VAntage/55281/
va-sets-standards-in-suicide-risk-assessment-offers-support-to-
community-providers/.
\29\ Meadows et al., ``2015 Department of Defense Health Related
Behaviors Survey (HRBS).''
\30\ Thomas and Hunter, Invisible Veterans, 115-117; State of
California, Department of Insurance, ``Economic Impact Assessment:
Gender Nondiscrimination in Health Insurance,'' Regulation File Number:
REG-2011-00023, April 13, 2012, http://transgenderlawcenter.org/wp-
content/uploads/2013/04/Economic-Impact-Assessment-Gender-
Nondiscrimination-In-Health-Insurance.pdf.
\31\ Ilan H. Meyer, ``Prejudice, Social Stress, and Mental Health
in Lesbian, Gay, and Bisexual Populations: Conceptual Issues and
Research Evidence,''Psychological Bulletin, 129 no. 5 (2003), 674-697,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2072932/.
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In terms of transgender-specific health care, gender confirmation
surgery is specifically excluded from the VA medical benefits package;
additionally, VA does not provide any surgery for strictly cosmetic
purposes.\32\ This is not in alignment with generally accepted
standards of care for those with gender dysphoria.\33\ Additionally,
because VA health care is considered ``minimum essential coverage''
under the Affordable Care Act, veterans who are enrolled in VA health
care do not qualify for subsidies in the Health Insurance Marketplace;
accordingly, these veterans may be financially unable to enroll in a
plan that would provide this medically necessary care.\34\ Crucially,
observational studies have shown dramatic reductions in suicide
ideation, suicide attempts, and suicides among transgender individuals
who receive appropriate transition-related care. Excluding this care
from the VA medical benefits package does not align with standards of
care or VA's stated commitment to suicide prevention. Additionally, VA
does not provide in vitro fertilization for same-sex couples, another
discriminatory practice that should be promptly eliminated.
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\32\ U.S. Department of Veterans Affairs, Providing Health Care for
Transgender and Intersex Veterans, VHA Directive 1341 (May 23, 2018),
https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=6431.
\33\ Eli Coleman, Walter Bockting, Marsha Botzer, Peggy Cohen-
Kettenis, Griet DeCuypere, Jamie Feldman, Lin Fraser, et al.,
``Standards of Care for the Health of Transsexual, Transgender, and
Gender-Nonconforming People, Version 7,'' International Journal of
Transgenderism, 13 no. 4 (2012), 165-232, https://wpath.org/media/cms/
Documents/SOC %20v7/Standards %20of %20Care_V7 %20Full
%20Book_English.pdf.
\34\ ``The Affordable Care Act, VA, and You,'' U.S. Department of
Veterans Affairs, https://www.va.gov/health/aca/FAQ.asp; and Coleman,
Bockting, Botzer, Cohen-Kettenis, DeCuypere, Feldman, Fraser, et al.,
``Standards of Care for the Health of Transsexual, Transgender, and
Gender-Nonconforming People, Version 7.''
---------------------------------------------------------------------------
Discharge status may have an outsized impact on LGBT veterans, who
may have been involuntarily separated from the military under the DADT
policy. If separated with an OTH discharge, these veterans would not
have the same access to veteran benefits, compounding an overall
distrust of the military and veteran system and a feeling of unwelcome.
The approximately 14,000 service members separated from the military
under DADT may need to appeal their discharge status.\35\ While these
individuals can now request a discharge upgrade, they may have been
denied access to care and benefits for many years, and the upgrade
process takes time. Members of the LGBT community repeatedly report
fear and mistrust in deciding whether to access their VA services. One
stakeholder noted that an administrative separation code indicates when
a discharge was related to homosexual behavior even when a veteran
retains access to benefits. Many veterans fear that involuntarily
``coming out'' to health care providers due to service records will
lead to less than optimal care from a provider who does not support
their identity or sexual orientation.
---------------------------------------------------------------------------
\35\ ``Don't Ask, Don't Tell Is Repealed,'' U.S. Department of
Defense, 2011, https://archive.defense.gov/home/features/2010/
0610_dadt/.
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A number of stakeholders referenced the current political
environment's impact on minority populations, particularly the LGBT
community, and their willingness to access care, in some cases
mistaking DoD policy for VA policy. For example, one advocate said
debates over the military's ``trans ban'' affect ability to provide
care to the LGBT community at the State level due to mistrust in the
community and confusion over legal status. Transgender individuals also
express fear of being misgendered by health care practitioners, a
microaggression in a space that deals with very personal issues that
can lead to a lack of trust in the health care system as a whole.
Advocates for transgender veterans note that being misgendered in
health care environments can lead to negative mental health outcomes,
which is supported by studies relating misgendering to increased
stress.\36\
---------------------------------------------------------------------------
\36\ K.A. McLemore, ``A minority stress perspective on transgender
individuals' experiences with misgendering,'' Stigma and Health, 3 no.
1 (2018), 53-64, https://doi.org/10.1037/sah0000070.
---------------------------------------------------------------------------
A damaging misconception is that VA facilities do not include any
LGBT health services. While the absence of available gender
confirmation surgery negatively impacts transgender veterans who have
not medically transitioned, other LGBT health care options at the VA do
exist. Lack of trust in health care providers is insidious and leads to
suboptimal health outcomes. For example, providers do not always
advertise that they offer pre-exposure prophylaxis (PrEP), making it
less likely LGBT patients will obtain a prescription for this vital
HIV-prevention drug. Providers also may not explicitly offer screening
for sexually transmitted diseases (STDs), putting the onus on the
patient, which can be a charged request and difficult without a
trusting relationship. A second layer of challenges LGBT veterans face
is discrepancies with health care itself. Many LGBT veterans experience
a lack of consistency across VA facilities. Each VA Medical Center is
supposed to have an LGBT veteran care coordinator (VCC) on hand to
serve as a patient advocate and assist LGBT-sensitive staff trainings.
However, quality of VCCs varies widely. CNAS site visits identified
significant variation in the LGBT-focused materials available in
waiting rooms, ranging from confusion over the acronym ``LGBT'' to
comprehensive informational material, welcoming posters, and competent
staff. Additionally, other patients can contribute to VA Medical
Centers being unwelcoming: One representative of a veteran-serving
nonprofit reported witnessing transgender veterans being subjected to
inappropriate verbal and nonverbal behavior from fellow patients
because of their transgender status.
A number of LGBT advocates noted the lack of effective outreach by
VA to these populations. This lack of public awareness leads to
increased confusion and/or ignorance of entitlements and benefits. VSOs
have historically fulfilled this outreach role, helping veterans and
transitioning service members navigate online services and file
comprehensive claims. According to advocates and LGBT veterans, these
spaces and organizations are often hostile or triggering spaces,
leaving this community without assistance navigating a cumbersome
bureaucracy. Improving these spaces is one recommended solution, though
additional outreach to nontraditional veteran spaces may be more
useful.
LGBT veterans expressed that VA needed to specifically ask about
sexual orientation upon intake to normalize and clarify LGBT status
from the beginning. Such a question would remove the ``dirty secret''
aspect of sexual orientation and make it more clinical, rather than
something veterans have to worry about. Veterans also agreed that the
location of LGBT veteran care coordinators' offices in VA centers on
the mental health floor likened LGBT status to mental health issues. Of
trans veterans, 40 percent have received health care through VA, of
which 75 percent continue to receive health care.\37\ Of these
veterans, 72 percent said they were out as trans to their health care
provider and 47 percent reported they were always treated respectfully.
The majority of trans veterans--79 percent--reported satisfaction with
VA care, higher than the satisfaction expressed by ethnic minorities
and low-income veterans, despite the challenges noted above.\38\
---------------------------------------------------------------------------
\37\ S.E. James, J.L. Herman, S. Rankin, M. Keisling, L. Mottet,
and M. Anafi, ``The Report of the 2015 U.S. Transgender Survey''
(National Center for Transgender Equality, 2016), https://
www.transequality.org/sites/default/files/docs/USTS-Full-Report-
FINAL.PDF.
\38\ ``Women Veterans: The Journey Ahead'' (DAV, 2018), https://
www.dav.org/wp-content/uploads/2018_Women-Veterans-Report-Sequel.pdf.
---------------------------------------------------------------------------
Conclusion
VA should improve data collection, analysis, and publication on
health outcomes of all minority veterans, particularly from an
intersectional lens, to enhance Congress' ability to conduct effective
oversight. In addition, VA should work to become more welcoming for all
minority veterans. Recommendations include implementing trauma-informed
and dignity-affirming care, including effective cultural awareness
training for all employees; updating waiting room reading material,
posters, and television channel default settings to be more inclusive;
expanding Veterans Experience Office efforts using human-centered
design concepts to identify and alleviate disparities in the
experiences of minority veterans; expanding the nascent End Harassment
campaign to include the harassment LGBT and racial/ethnic minority
veterans experience; and expanding the ``secret shopper'' model of
ensuring that front-line staff members are aware of resources for MST
survivors such as LGBT VCCs, minority veteran coordinators, and women
veteran coordinators at VA Medical Centers nationwide.
Additionally, VA should carefully review all policies and
provisions of the medical benefits package to eliminate provisions that
discriminate against women, veterans of color, and LGBT individuals.
Should VA be unwilling or unable to take these actions independently, I
urge Congress to consider legislation to require VA to cover gender
confirmation surgery, a medically necessary and evidence-based
treatment for gender dysphoria in transgender individuals; cover in
vitro fertilization for same-sex couples; eliminate the blanket ban on
abortion and abortion counseling, with no exceptions for rape, incest,
or life endangerment of the woman; and eliminate co-payments for birth
control. Overall, VA is a top-tier provider of health care. Identifying
and eliminating barriers that make it less welcoming and effective for
minority veterans is an important part of ensuring health equity for
all who have served our great nation.
______
Prepared Statement of Melissa Bryant
Chairwoman Brownley, Ranking Member Dunn, and distinguished members
who proudly serve on this subcommittee; on behalf of our National
Commander, James W. ``Bill'' Oxford, thank you for the opportunity to
discuss the important issue of how the Department of Veterans Affairs
(VA) addresses health inequities for minorities across the Veterans
Health Administration (VHA). I proudly represent The American Legion
and appreciate the opportunity to assist this subcommittee in better
understanding this issue, how it impacts minority veterans, and provide
recommendations for improvement to the system.
Above all, we must ensure that the institutions we built to care
for our Nation's veterans give every veteran regardless of race,
gender, sexual orientation, or creed the quality care and support they
deserve.
Recent statistics show that racial and ethnic minority veterans
represent nearly 22 percent of the total veteran population, nearly 19
million who are living today. VA projects that the minority population
will continue to rise over the next few decades and reach an estimated
35 percent of the total veteran population by 2040. In recent years, VA
has made improvements in the advancement of veteran's health care in VA
medical facilities nationwide. However, there is still much work to do
to meet the overall health care needs of all veterans. There are also
many research gaps that exist, which makes it difficult to identify,
analyze, and resolve specific issues in inequities in overall care for
the minority veteran population.
Sadly, I can point to my own dealings with harassment and
discrimination from my peers, superior officers, and subordinates in my
lifetime. It was a double burden I faced while on active duty, when the
intersectionality of being both a black and female officer would creep
into misogynistic and prejudiced comments made toward me. Now as a
veterans advocate, I still hear the misogynistic and prejudicial
comments in our community. At best, these comments are casual
dismissals of my credentials and expertise to have earned a seat at the
table; at worst, these comments mean just what these hurtful comments
sound like--flagrant disregard for my service, and ultimately an
emotional barrier to seeking additional care through VHA, where the
veteran culture often mirrors the experience of minority
servicemembers.
To its credit, VA has already identified some of the more prominent
issues the department currently faces with attending to minority
veterans' health needs:
Challenges with the Accuracy of Medical Records
VA has cited concerns about the accuracy of medical records,
particularly when referencing the completeness and accuracy of the race
and ethnicity data of veterans. These concerns include:
Difficulty determining if race and ethnicity information
is correctly captured in a veteran's health record through either
veteran self-reporting or VA staff capture.\1\
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\1\ https://www.gao.gov/assets/710/703145.pdf
Trouble confirming that relevant race/ethnicity
informational values are reliable in the health record because of the
possibility of necessary data being missing from the records.\2\
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\2\ https://www.gao.gov/assets/710/703145.pdf
Conflicting race and ethnic data calls into question the
accuracy of information when race or ethnicity information is
recorded.\3\
---------------------------------------------------------------------------
\3\ https://www.gao.gov/assets/710/703145.pdf
The American Legion is encouraged by the forthcoming improvements
in race and ethnicity data collection that will be achieved with the
implementation of the Cerner Electronic Health Records Modernization
(EHRM) efforts. Accurate data may help dispel or correct any
deficiencies in care for minority veterans. The American Legion also
will continue to advocate that VA's EHR initiative remains fully and
adequately funded and that VA and Cerner regularly report EHR progress
and status to Congress.
Supporting American Legion Resolution: Resolution 83 (August 2016):
Virtual Lifetime Electronic Record.
Problems with Outreach and Trust Among Minority Veterans
As a military intelligence officer who led women and men in both
combat and garrison, some my most salient experiences are from times
when the true beliefs of soldiers you would normally trust with your
life in battle would surface. As one of the few, if not only, women
officers (and often the only woman of color officer) in my units, I can
point to many occasions where I have helped soldiers who came to me for
advice, counsel, or reporting of incidents dealing with racial,
gendered, or sexual orientation discrimination, harassment or even
assault in the ranks. My service was also during the time of the Don't
Ask, Don't Tell (DADT) policy era, where I had the truly unfortunate
duty of involuntarily separating troops from service due to their
sexual orientation.
There are current difficulties among all veterans, including
minority veterans, on understanding the eligibility requirements and
scope of services available to them. For example, discharge status may
have greater impact on Lesbian, Gay, Bisexual, Transgender, or Queer
(LGBTQ) veterans, who may have been involuntarily separated from the
military under the DADT policy. Depending on discharge status, these
veterans would not have the same access to veteran benefits,
compounding an overall distrust of the military and veteran system. The
American Legion is the only Veteran Service Organization that assists
veterans with discharge upgrades and represents them before service
discharge upgrade boards and hearings.
VHA must continue to build trust among all veterans to make their
system the premier medical provider that veterans desire to go for
their healthcare needs. Efforts should include increased communications
outreach to all categories of minority and women veterans to inform
them of their eligibility for health care. VHA can also increase its
information dissemination concerning the development of better
community care network (CCN) accesses and health care choices, as
provided by the services developed in the MISSION Act of 2019, which
include contractor provided services. These services allow increased
access to urgent cares, expansions of eligibility for community care,
veteran-centered and control of scheduling appointments, as well as
better coordination and customer services. VA should also better
publicize the Million Veteran Program to its minority and women veteran
patients and encourage their participation in the program.
Care for Diseases Found More Prevalently in Minority Veterans
Some diseases have been found to be more prevalent in minority
veteran populations, and further study is needed to determine why this
may be the case. Prostate cancer is the most commonly diagnosed form of
the disease found in veterans; for example, African American veterans
are diagnosed at younger ages than the general veteran population. VHA
must aggressively work to provide the best treatment and care for any
veterans who may be diagnosed with this form of cancer. Some factors
that VHA should note are: in general, African American men are at an
increased risk of developing prostate cancer than white men or other
men of color. They are also at a greater risk of getting an incorrect
diagnosis of cancer, and more likely to die from the disease \4\. Early
detection can help contribute to an almost 100 percent cure rate.
Efforts must continue to determine if military service and/or combat
specific areas of operation have any correlation to increases in
prostate cancer diagnosis or any disparities in treatment.
---------------------------------------------------------------------------
\4\ https://zerocancer.org/learn/about-prostate-cancer/risks/
african-americans-prostate-cancer/
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The American Legion continues to advocate for research that
continues to assess the possible connections between cancer and any
exposures that veterans may have encountered due to their service,
including Agent Orange exposures, burn pits and other airborne toxins,
radiation exposure, depleted uranium exposure, or environmental and
other toxic exposures which may affect veterans.
Relevant resolutions:
o Resolution 130 (August 2016): Radiation Exposure
o Resolution 55 (August 2016): Radiation Exposure
o Resolution 271 ( August 2016): Request Study by the
Department of Veterans
Affairs on the Medical Effects of Exposure to Depleted
Uranium
o Resolution 35 (August 2016): Agent Orange
o Resolution 118 (August 2016): Environmental Exposures
o Resolution 127 (August 2016): ProState Cancer Research and
Treatment
o Resolution 41 (August 2017): Radiation-Exposed Veterans
o Resolution 11 (August 2019): Environmental Exposures at Fort
McClellan
Knowledge Gaps
Many clinical outcomes have significant racial gaps in data
collected for conditions such as hypertension, cardiovascular events,
diabetes, and labor and delivery. A grim example of the disparity in
healthcare outcomes due to racial bias is the nationwide maternal
mortality rate in African American, American Indian, and Alaska Native
women, who are two to three times more likely to die from pregnancy-
related causes than white women - and this disparity increases with
age.\5\ A widely publicized U.S. Supreme Court petition last year
unsuccessfully challenged Feres doctrine, Daniel v. United States,
which involved the maternal death of an active duty Navy Nurse who died
in childbirth in the same Labor and Maternity Ward in which she served
at Naval Station Bremerton.\6\ In this case, the deceased was also a
racial minority, a chilling example of this national trend within the
military, which may color the perception of disparate care provided to
minority women by both military and veterans medical centers.
---------------------------------------------------------------------------
\5\ https://www.cdc.gov/media/releases/2019/p0905-racial-ethnic-
disparities-pregnancy-deaths.html
\6\ https://www.supremecourt.gov/opinions/18pdf/18-460_1b7d.pdf
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It becomes necessary to ask why these instances exist in the
microcosm that is our community, and research if disparities are
attributable to a higher concentration of minority veterans using
lower-performing VA medical facilities, if there is a difference in the
quality of care between white and minority veterans receiving care at
the same facility, or if there are other factors which have yet to be
identified.\7\ The American Legion realizes that many significant
improvements in VA's health care systems have occurred in recent years,
but will continue to advocate for further study that yields a reduction
in any disparities which may affect minority veterans and their life
expectancy.
---------------------------------------------------------------------------
\7\ https://www.healthaffairs.org/doi/full/10.1377/
hlthaff.2011.0074
---------------------------------------------------------------------------
Since 2003, The American Legion has conducted over 300 System Worth
Saving site visits to assess the quality of care, challenges and best
practices of VHA's health care systems at many of its medical centers
and community-based outpatient clinics across the country. Although the
program's main focus is to gather information from all veterans and
provide recommendations for the best possible care for all veterans in
VHA's system, these visits continue to highlight examples of minority
and women veterans discussing their particular issues during the
program's town hall meetings.
Relevant resolutions:
o Resolution 147 (August 2016): Women Veterans
Conclusion
Chairwoman Brownley, Ranking Member Dunn, and distinguished members
who proudly serve on this subcommittee, The American Legion thanks you
for the opportunity to illuminate the positions of the nearly two
million veteran members of this organization. It is a priority of The
American Legion that all our Nation's veterans receive the same quality
care and support we expect from VA. By the action of this committee, we
can see that it is for you as well. We call on Congress to direct VA to
conduct and/or continue existing studies into the inequity or
disparities of care--real or perceived--contained within today's
testimony, and more. As we unpack the myriad reasons why minority
veterans on the whole report either negative healthcare outcomes or
unequal treatment under the law at VA, The American Legion stands ready
to support this subcommittee with observations and expertise.
As always, The American Legion thanks this committee for the
opportunity to elucidate the position of the nearly 2 million veteran
members of this organization. For additional information regarding this
testimony, please contact Ms. Melissa Bryant, Legislative Director, at
[email protected] or (202) 263-2981.
Statements for the Record
----------
Prepared Statement of National Council on Urban Indian Health
My name is Sonya Tetnowski, I am a member of the Makah Tribe, a
U.S. Army Veteran Paratrooper, and the Chief Executive Officer of the
Indian Health Center of Santa Clara Valley in California. I'm also the
Vice President of the National Council of Urban Indian Health (NCUIH),
as well as President of the California Consortium for Urban Indian
Health (CCUIH). NCUIH represents the 41 Title V Urban Indian
Organizations (UIOs) across the Nation. UIOs provide high-quality,
culturally competent care to urban Indian populations, which constitute
more than 70 percent of all American Indians and Alaska Natives (AI/
ANs). I would like to thank Chairwoman Brownley, Ranking Member Dunn
and other distinguished members of the subcommittee for holding this
important hearing on the critical issue of health equity for minority
Veterans. My testimony will focus on the need for equitable treatment
of AI/AN Veterans living in urban communities.
NCUIH believes the single most important thing the Department of
Veterans Affairs (VA) can do to improve the equitable healthcare
efforts to AI/AN Veterans, is to fully implement the VA and Indian
Health Services' Memorandum of Understanding (VA-IHS MOU) and
Reimbursement Agreement for Direct Health Care Services. This would
allow UIOs to be reimbursed for providing culturally competent care to
AI/AN Veterans residing in urban areas. Despite an embattled history
between tribal people and the U.S. Government, and as an inherited
responsibility to safeguard the lands of their ancestors, AI/ANs serve
this country at a higher rate than any other group in the Nation. A
significant number of these Veterans live in urban areas and often seek
out the high-quality, culturally competent care of their local UIO.
UIOs were formally recognized by Congress following the end of the
Termination Era in 1976 under the Indian Health Care Improvement Act
(IHCIA) to fulfill the Federal Government's health care-related trust
responsibility to Indians who live off the reservation. Each UIO is led
by a Board of Directors that must be majority Indian. They are
collectively represented by the National Council of Urban Indian Health
(NCUIH), which is a 501(c)(3), member-based organization devoted to the
development of quality, accessible, and culturally sensitive healthcare
programs for AI/ANs living in urban communities. UIOs are a critical
part of the Indian Health Service (IHS), which uses a three-prong
approach to provide health care: Indian Health Services, Tribal
Programs, and Urban Indian Organizations commonly referred to as the I/
T/U system.
VA-IHS MOU Historical Background
In February 2003, the VA and IHS signed a Memorandum of
Understanding (MOU) and updated this MOU in October 2010. The very
first paragraph of the MOU states: ``the intent of this MOU (is) to
facilitate collaboration between IHS and VA, and not limit initiatives,
projects, or interactions between the agencies in any way.'' The MOU
recognizes the importance of a coordinated and cohesive effort on a
national scope, while also acknowledging that the implementation of
such efforts requires local adaptation to meet the needs of individual
tribes, villages, islands, and communities, as well as local VA, IHS,
Tribal, and Urban Indian health programs.''
In December 2012, the two agencies signed a reimbursement agreement
allowing the VA to financially compensate IHS for health care provided
to AI/ANs that are part of the VA's system of patient enrollment. While
this MOU has been implemented for IHS and tribal providers, it has not
been implemented for UIOs, despite the fact that UIOs are explicitly
mentioned in the original language of the 2010 MOU, and provide
healthcare within IHS's own I/T/U system. Leaving out UIOs is a
violation of the MOU since the agencies agreed to ``not limit
initiatives, projects, or interactions between the agencies in any
way.'' Not reimbursing UIOs for services provided to Native Veterans is
limiting this vulnerable, underserved population from the healthcare
they need and deserve. NCUIH and UIO leaders have been testifying
before Congress for several years to correct this oversight and to
fully implement the MOU. Members have said this is an ``easy fix,'' and
``an oversight,'' so we are happy to see that there is now a bill to
address this issue once and for all. We support the extensive efforts
of the Veterans Administration and the work they do but AI/AN Veterans
should be allowed to seek care and support that best suits their unique
needs, and our UIO's can provide that support. NCUIH supports H.R.
4153, the Health Care Access for Urban Native Veterans Act, introduced
by Congressman Khanna along with 27 additional Co--Sponsors. H.R. 4153
is a necessary and critical piece of legislation, one that will make a
real meaningful difference in the funding for health care services
provided by UIOs across the United States. We maintain that as part of
the I/T/U system, the VA already has the authority to reimburse title V
UIOs, but we are happy Congress is taking the next step to address this
important issue.
Between 2012 and 2015, the VA reimbursed over $16.1 million for
direct services provided by IHS and Tribal Health Programs covering
5,000 eligible Veterans under the IHS-VA MOU. In spite of the Federal
trust responsibility to AI/ANs, the VA had decided to deem UIOs
ineligible to enter into the reimbursement agreement under the IHS-VA
MOU. For context, UIOs are already extremely underfunded and receive
less than $400 per patient from IHS, versus national health expenditure
rates of almost $10,000 per patient. In 2018, UIOs received a total of
$51.3 million to support 41 programs, and that is before IHS's
administrative costs are removed, which is already less than 1 percent
of the total IHS budget. UIOs only receive one line-item appropriation
in the IHS budget-the urban Indian health line item. UIOs don't receive
purchase and referred care dollars, Federal Tort Claims Act (FTCA)
coverage, 100 percent Federal Medical Assistance Percentage (FMAP), or
facilities funding. In fact, a few UIOs temporarily closed during the
shutdown due to the lack of parity within the IHS system. VA
reimbursement, even half of the $16.1 million, would drastically help
our facilities. It is time to fix this issue for good.
Today, AI/AN service members face some of the lowest health
outcomes and the largest barriers to quality and culturally competent
health services. AI/AN Veterans are more likely to be uninsured,
homeless, and impoverished than Veterans of other ethnicities. The high
rates of mental and behavioral health disorders such as depression,
suicide, and post-traumatic stress disorder (PTSD) is linked to the
predisposal that AI/AN people have to these same disorders without
facing combat. AI/AN Veterans deserve clear and careful attention in
order to ensure they receive the highest quality of care our country
can afford to provide them.
In urban areas, AI/ANs may experience difficult geographical
distances from their homelands and from their traditional practices.
UIOs serve as important centers for health care services and as
cultural support and provide a sense of community while providing
primary care, dental, and behavioral health services to AI/AN Veterans.
The national interest of serving AI/AN Veterans will be best carried
out when Congress extends the collaborative arrangements already agreed
to by the VA and IHS to include the bulk of our Nation's AI/AN
Veterans.
Thank you again for holding today's hearing and for the Sub-
committee's support of urban Indian health care issues. I am available,
along with NCUIH staff, to answer any questions related to this
testimony or related urban Indian health issues.
______
Prepared Statement of National Indian Health Board
Chairwoman Brownley, Ranking Member Dunn, and Members of the
Subcommittee, thank you for holding this important hearing on
``Achieving Health Equity for America's Minority Veterans.'' On behalf
of the National Indian Health Board (NIHB) and the 574 federally
recognized sovereign Tribal Nations we serve, I submit this testimony
for the record.
By current estimates from the Department of Veterans' Affairs (VA),
there are roughly 146,000 American Indian and Alaska Native (AI/AN)
Veterans, with Native Servicemembers enlisting at higher rates than any
other ethnicity nationwide. Indeed, the Department of Defense continues
to acknowledge the indispensable role of AI/AN Servicemembers
throughout American history. Native Veterans are highly respected
throughout Indian Country, in recognition of what they have sacrificed
to protect Tribal communities and the United States. Yet despite the
bravery, sacrifice, and steadfast commitment to protecting the
sovereignty of Tribal Nations and the entire United States, Native
Veterans continue to experience among the worst health outcomes, and
among the greatest challenges in receiving quality health services.
Overall, our communities face the starkest health disparities and
among the lowest health outcomes. Life expectancy for our people is 5.5
years less than the national average, while in some states our people
are dying as much as two decades earlier than Whites.\1\ Overall, AI/
ANs have higher rates of death associated with most types of cancer,
chronic liver disease and cirrhosis, type II diabetes, drug overdose
deaths, assault/homicide, intentional self-harm/suicide, and chronic
lower respiratory diseases.\2\ From 1999 to 2015, AI/ANs experienced
the highest percentage increase in drug overdose deaths overall at 519
percent.\3\ Infant mortality rates for AI/ANs are 1.3 times the
national average, with infant mortality rates having declined for all
ethnicities from 2005 to 2014 except among AI/ANs.\4\
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\1\ U.S. Department of Health and Human Services, Indian Health
Service, Fiscal Year 2019, Justification of Estimates for
Appropriations Committees, CJ-147, https://www.ihs.gov/
budgetformulation/includes/themes/responsive2017/display_objects/
documents/FY2019Congre ssionalJustification.pdf
\2\ Ibid
\3\ Mack KA, Jones CM, Ballesteros MF. Illicit Drug Use, Illicit
Drug Use Disorders, and Drug Overdose Deaths in Metropolitan and
Nonmetropolitan Areas--United States. MMWR Surveill Summ 2017;66(No.
SS-19):1-12.DOI: http://dx.doi.org/10.15585/mmwr.ss6619a1external icon
\4\ T.J. Mathews and Anne K. Driscoll, ``Trends in Infant Mortality
in the United States, 2005-2014,'' National Center for Health
Statistics, Division of Vital Statistics, March 2017, at 1, https://
www.cdc.gov/nchs/data/databriefs/db279.pdf.
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Health disparities among Native Veterans are equally dire, if not
worse in certain cases. In a 2016 consultation report from the U.S.
Department of Veterans' Affairs, access to medical care was
consistently ranked as the top priority for Tribal Nations and Native
Veterans.\5\ Compared to White Veterans, Native Veterans are 1.6 times
more likely to be uninsured; twice as likely to experience delays in
care; and 2.9 times more likely to experience transportation challenges
in accessing care.\6\
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\5\ U.S. Department of Veterans' Affairs. 2016. Tribal Consultation
Report. https://www.va.gov/TRIBALGOVERNMENT/docs/VA-2016-Consultation-
Report_508_FINAL.pdf
\6\ Johnson, P. J., Carlson, K. F., & Hearst, M. O. (2010).
Healthcare disparities for American Indian veterans in the United
States: a population-based study. Medical care, 48(6), 563-569.
doi:10.1097/MLR.0b013e3181d5f9e1
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Destructive Federal Indian policies and unresponsive human service
systems have left Native Veterans and their communities with unresolved
historical and intergenerational trauma. From 2001 to 2015, suicide
rates among Native Veterans increased by 62 percent (50 in 2001 to 128
in 2015).\7\ In Fiscal Year 2014, the Office of Health Equity within
VHA reported significantly higher rates of mental health disorders
among Native Veterans compared to non-Hispanic White Veterans,
including in rates of PTSD (20.5 percent vs. 11.6 percent), depression
symptoms (18.7 percent vs. 15.2 percent), and major depressive disorder
(7.9 percent vs. 5.8 percent).\8\
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\7\ VA, Veteran Suicide by Race/Ethnicity: Assessments Among All
Veterans and Veterans Receiving VHA Health Services, 2001-2014 (Aug.
2017) (citing CDC statistics).
\8\ Lauren Korshak, MS, RCEP, Office of Health Equity and Donna L.
Washington, MD, MPH, Health Equity-QUERI National Partnered Evaluation
Center, and Stephanie Birdwell, M.S.W., Office of Tribal Government
Relations
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Among all Veterans, Native Veterans are more likely to have a
disability, service-connected or otherwise.\9\ Native Veterans are
exponentially more likely to be homeless, with some studies showing
that 26 percent of low-income Native Veterans experienced homelessness
at some point compared to 13 percent of all low-income Veterans.\10\
There exists a paucity of Native Veteran specific health, housing, and
economic resources and programs that are accessible and culturally
appropriate. It is essential that the VHA work with IHS and Tribes to
create more resources specifically for Native Veterans.
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\9\ U.S. Department of Veterans Affairs. (2015a). American Indian
and Alaska Native Veterans: 2013 American Community Survey. Retrieved
from https://www.va.gov/vetdata/docs/SpecialReports/AIANReport2015.pdf
\10\ US Department of Housing and Urban Development, US Department
of Veterans Affairs, National Center on Homelessness Among Veterans.
Veteran Homelessness: A Supplemental Report to the 2010 Annual Homeless
Assessment Report to Congress. Washington, DC.2011:56
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The VA's Veteran Outreach Toolkit lists AI/ANs as an ``at-risk''
population, citing this troubling suicide rate. Additionally, AI/ANs
grapple with complex behavioral health issues at higher rates than any
other population--for children of AI/AN veterans, this is compounded by
the return of a parent who may suffer from post-traumatic stress
disorder (PTSD). Outreach events for AI/AN communities should be a VA
priority to increase wellness, decrease stigma, and prevent suicide. It
is essential that the VHA continue to engage with Tribal leaders,
through consultation, to assist in carrying out these activities.
Federal Trust Responsibility
Over the course of a century, sovereign Tribal Nations and the
United States signed over 300 Treaties requiring the Federal Government
to assume specific, enduring, and legally enforceable fiduciary
obligations to the Tribes. The terms codified in those Treaties -
including for provisions of quality and comprehensive health resources
and services - have been reaffirmed by the United States Constitution,
Supreme Court decisions, Federal legislation and regulations, and even
Presidential executive orders. These Federal promises have no
expiration date, and collectively form the basis for what we now refer
to as the Federal trust responsibility. Moreover, the United States has
a dual responsibility to Native Veterans - one obligation specific to
their political status as members of federally recognized Tribes, and
one obligation specific to their service in the Armed Services of the
United States.
In 1955, Congress established the Indian Health Service (IHS) in
partial fulfillment of its constitutional obligations for health
services to all AI/ANs. The IHS is charged with a similar mission as
the VHA as it relates to administering quality health services, with
the exception of the following differences: (1) the Federal Government
has Treaty and Trust obligations to provide health care for all
American Indians and Alaska Natives; (2) IHS is severely and
chronically underfunded in comparison to the VHA, with per capita
medical expenditures within IHS at $4,078 in Fiscal Year (FY) 2017
compared to $10,692 in VHA per capita medical spending that same year
\11\; and (3) unlike IHS, the VHA has been protected from government
shutdowns and continuing resolutions (CRs) because Congress enacted
advance appropriations for the VHA a decade ago.\12\
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\11\ The full IHS Tribal Budget Formulation Workgroup
Recommendations are available at https://www.nihb.org/docs/04242019/
307871_NIHB %20IHS %20Budget %20Book_WEB.PDF
\12\ See 38 U.S.C. 117; P.L. 111-81
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Tribal Nations have consistently communicated that the VA must do
significantly more to meet its trust obligations to Native Veterans.
Our people serve at higher rates than any demographic nationwide, and
should not be afforded the worst health outcomes. Congress must act on
the legislative and policy priorities outlined below in order to reduce
health disparities among Native Veterans.
Funding Levels for IHS versus VHA: The Need for Advance Appropriations
1. Tribes and NIHB strongly urge Congress to pass bipartisan
legislation that would enact advance appropriations for Indian
programs
By the most recent estimates, federally operated IHS facilities,
Tribally operated health facilities and programs, and urban Indian
health programs collectively serve roughly 2.6 million AI/ANs
nationwide. In comparison, the VHA serves roughly 6.9 million Veterans
through 18 regional networks. In Fiscal Year 2019 discretionary
appropriations for IHS equaled roughly $5.8 billion; in comparison,
spending within the VHA totaled over $76 billion. In effect, this means
that while the VHA service population is roughly only three times the
size of the Indian health system, its discretionary appropriations are
approximately 13 times higher than for IHS.
According to the IHS Tribal Budget Formulation Workgroup, IHS
appropriations must reach nearly $38 billion - phased in over 12 years
- in order to fully meet current health needs. In other words, even if
today IHS were fully funded at the level of need identified by
sovereign Tribal Nations, it would only equal half the total Fiscal
Year 2019 discretionary appropriation for the VHA. Indeed, the Federal
Government's continued abrogation of its trust responsibility for
health services for AI/ANs is clearly exemplified by the gravity of the
divide in health funding for the VHA versus IHS.
Although the IHS budget has nominally increased by 2-3 percent each
year, these increases are barely sufficient to keep up with rising
medical and non-medical inflation, population growth, facility
maintenance costs, and other expenses. According to a 2018 report by
the Government Accountability Office (GAO-19-74R), from 2013 to 2017,
IHS annual spending increased by roughly 18 percent and per capita
spending increased by roughly 12 percent; in comparison, annual
spending under the VHA increased by 32 percent and per capita spending
increased by 25 percent during the same time period.\13\ The widening
gap in funding levels between IHS and the VHA only serves to perpetuate
the disproportionately higher levels of health disparities experienced
by Native Veterans and AI/ANs overall.
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\13\ Government Accountability Office. 2018. Indian Health Service:
Spending Levels and Characteristics of IHS and Three Other Federal
Health Care Programs. Retrieved from https://www.gao.gov/assets/700/
695871.pdf
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Unequivocally, the U.S. Federal Government has a moral and ethical
obligation to ensure all U.S. Veterans can access quality health
services - and it must continue to honor this responsibility. But the
U.S. also has a Trust obligation to ensure all AI/ANs, including Native
Veterans, can receive quality health services, that it continuously
fails to honor. It is long past due for the Federal Government to make
good on its constitutional obligation to Native Veterans an all AI/AN
Peoples.
The discrepancies do not end with chronic underfunding of IHS. Of
the four major Federal healthcare entities, IHS is the only one subject
to the devastating impacts of government shutdowns and continuing
resolutions (CRs). This is because Medicare and Medicaid receive
mandatory appropriations, and the VHA was authorized by Congress to
receive advance appropriations nearly a decade ago. As a result, the
VHA has been insulated from every government shutdown, CR, and
discretionary sequestration over the past decade. While it is true that
no sector of government is fully spared by the repercussions of endless
shutdowns and CRs, those repercussions are neither equal nor
generalizable across all entities. In fact, the worst consequences are
levied on Indian Country.
For instance, during the 2013 Federal budget sequester, the IHS
budget was slashed by 5.1 percent--or $221 million - levied on top of
the damage elicited by that year's government shutdown. In fact, IHS
was the only federally funded healthcare entity that was subject to
full sequestration because Congress had already exempted the VHA when
it authorized it to receive advance appropriations. Once again, during
the most recent 35-day government shutdown - the Nation's longest and
most economically disastrous - IHS was the only Federal healthcare
entity to be shut down. While direct care services remained non-exempt,
providers were not receiving pay. Administrative and technical support
staff - responsible for scheduling patient visits, conducting
referrals, and processing health records - were furloughed. Contracts
with private entities for sanitation services and facilities upgrades
went weeks without payments, prompting many Tribes to exhaust
alternative resources to stay current on bills.
Several Tribes shared that they lost physicians to hospitals and
clinics not impacted by the shutdown. Some Tribal leaders even shared
how administrative staff volunteered to go unpaid so that the Tribe had
resources to keep physicians on the payroll. These are just a few
examples of the everyday sacrifices and ongoing struggles that widen
the chasm between the health services afforded to AI/ANs and those
afforded to the Nation at large. While it is impossible to measure the
full scope of adversity brought on by the 35-day government shutdown,
one reality remains clear - Indian Country was both unequivocally and
disproportionately impacted.
In 2018, GAO released a report examining the benefits of
authorizing advance appropriations for the IHS and thus establishing
parity between IHS and the VHA (GAO-18-652). The report outlined how
Congress has been forced to use short-term or full-year CRs in all but
four of the last 40 years. In fact, only once in the past two decades -
in Fiscal Year 2006 - has Congress successfully passed the Interior,
Environment, and Related Agencies appropriations package (which funds
IHS) before the end of the fiscal year. As a result, year after year,
the Indian health system is curtailed from making meaningful
improvements toward the availability and quality of health services and
programs, further restraining efforts to advance quality of life and
health outcomes for AI/ANs.
While a CR is always preferable to a government shutdown, they are
not devoid of obstacles that directly impact patient care. Because of
budget authority constraints under a CR, IHS is prohibited from
initiating any new activities or projects that were not expressly
authorized or appropriated in the previous fiscal year. In addition,
under a CR, IHS must exercise significant precaution over expenditures,
and is generally limited to simply maintain operations as opposed to
improve them. When you compound the impact of chronic underfunding and
endless use of CRs, the inevitable result are the chronic and pervasive
health disparities seen across Indian Country. As such, Tribal Nations
and NIHB strongly urge Congress to pass bipartisan legislation that
would authorize advance appropriations for Indian programs.
Lack of IHS and VHA Care Coordination and Reimbursement Agreements
1. NIHB recommends that Congress clarify statutory language
under section 405(c) of the Indian Health Care Improvement Act
and make explicit the VHA's requirement to reimburse IHS and
Tribes for services under Purchased/Referred Care (PRC).
By law, an AI/AN Veteran is eligible for services under both the
VHA and IHS. A 2011 report showed that approximately one-quarter of
IHS-enrolled Veterans use the VHA for health care, commonly receiving
treatment for diabetes mellitus, hypertension or cardiovascular disease
from both Federal entities.\14\ According to the VA, more than 2,800
AI/AN Veterans are served at IHS facilities.\15\ In instances where an
AI/AN veteran is eligible for a particular health care service from
both the VA and IHS, the VA is the primary payer. Under section 2901(b)
of the Patient Protection and Affordable Care Act (ACA), health
programs operated by the IHS, Tribes and Tribal organizations, and
urban Indian organizations (collectively referred to as the ``I/T/U''
system) are payers of last resort regardless of whether or not a
specific agreement for reimbursement is in place.
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\14\ Kramer, BJ, Wang M, Jouldjian S, Lee ML, Finke B, Saliba D.
Healthcare for American Indian and Alaska native veterans: The roles of
the veterans health administration and the Indian Health Service.
Medical Care.
\15\ VA/IHS listening session held on May 15, 2019
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Section 407(a)(2) of the Indian Health Care Improvement Act (IHCIA)
reaffirms the goals of the 2003 Memorandum of Understanding (MOU)
between the VHA and IHS established to improve care coordination for
Native Veterans. In addition, during permanent reauthorization of
IHCIA, section 405(c) was amended to require the VHA to reimburse IHS
and Tribes for health services provided under the Purchased/Referred
Care (PRC) program. In 2010, the VHA and IHS modernized their 2003 MOU
to further improve care coordination for Native Veterans by bolstering
health facility and provider resource sharing; strengthening
interoperability of electronic health records (EHRs); engaging in joint
credentialing and staff training to help Native Veterans better
navigate IHS and VHA eligibility requirements; simplifying referral
processes; and increasing coordination of specialty services such as
for mental and behavioral health.
According to a 2019 GAO report (GAO-19-291), since implementation
of the 2010 MOU, the VHA has reported entering into 114 signed
agreements with Tribal Health Programs (THPs), along with 77
implementation agreements to strengthen care coordination. While a
single national reimbursement agreement exists between federally
operated IHS facilities and the VHA, THPs continue to exercise their
sovereignty by entering into individual agreements with the VHA. From
2014 to 2018, those reimbursement agreements with THPs alone increased
by 113 percent.
VA reimbursements to IHS and THPs overall during that same time
period increased by 75 percent, reaching $84.3 million in total. Yet
these increased reimbursements still represent just a fraction of 1
percent of the VA's annual budget. While recent increases in the
quantity of agreements and reimbursements demonstrates a positive
trend, there continue to be significant challenges in care coordination
between the VHA and IHS. The 2019 GAO report highlighted three
overarching challenges related to care coordination: ongoing issues in
patient referrals between I/T/U facilities and the VHA; significant
problems in EHR interoperability; and high staff turnover within both
VHA and IHS. These complications continue to stifle Native Veterans'
access to health care, erodes patient trust in both IHS and VHA health
systems, and obstructs efforts to improve health outcomes.
These issues are exacerbated by VHA claims that no statutory
obligation exists for reimbursement of specialty and referral services
provided through IHS or THPs. To clarify, the VHA currently reimburses
IHS and THPs for care that they provide directly under the MOU. Despite
repeated requests from Tribes, the VA has not provided reimbursement
for PRC specialty and referral care provided through IHS/THPs. This is
highly problematic, as AI/AN Veterans should have the freedom to obtain
care from either the VA or an Indian health program. If a Veteran
chooses an Indian health program, that program should be reimbursed
even if the service could have been provided by a VA facility or
program in the same community.
But because that doesn't happen, it creates greater care
coordination issues and burdensome requirements for Native Veterans.
For example, if a Native veteran goes to an IHS or THP for service and
needs a referral, the same patient must be seen within the VA system
before a referral can be secured. This means the VHA is paying for the
same services twice, first for those primary care services provided to
the Veteran in the IHS or THP facility, and then again when the patient
goes back to the VHA for the same primary care service to then receive
a VHA referral. This is neither a good use of Federal funding, nor is
it navigable for veterans. In order to provide the care that Native
Veterans need, many THPs are treating Veterans or referring them out
for specialty care and paying for it themselves so that they can be
treated in a timely and competent manner. For those Veterans that do go
back to the VHA for referrals, there is often delayed treatment and a
significantly different standard of care provided.
As a step toward mitigating the confusion surrounding reimbursement
for care provided by the VHA, NIHB recommends the VHA include PRC in
future IHS/THP reimbursement agreements, so that there is no further
rationing of health care provided by IHS and THPs to Native Veterans
and other eligible AI/ANs. Ultimately, however, NIHB recommends that
Congress clarify the statutory language under section 405(c) of IHCIA
and make explicit VHA's requirement to reimburse under PRC.
2. NIHB also strongly supports the GAO recommendation that the
VHA work with IHS to create written policy or guidelines to
clarify how referrals from IHS and THP facilities to VHA
facilities for specialty care should be managed, and to
establish specific targets for measuring action on MOU
performance measures.
The GAO report cited how, for example, facilities reported
conflicting information about the processes for referring Native
Veterans from IHS or Tribal facilities to VHA, and VA headquarters
officials confirmed that there is no national policy or guide on this
topic. One of the leading collaboration practices identified by GAO is
to have written guidance and agreements to document how agencies will
collaborate. Without written policy or guidance documents on how
referrals should be managed, neither agency can ensure that VHA, IHS,
and Tribal facilities have consistent understanding of the options
available for referral of Native Veterans for specialty care.
As is currently the case, the result is duplicative care for Native
Veteran and duplicative costs for the Federal Government. NIHB has
heard that some Native Veterans prefer to simply hand carry their EHR
records from their IHS provider to their VHA provider to avoid having
to receive the same care twice. In short, lack of written policy
perpetuates this burdensome, pointless, and complicated process that
only serves to frustrate patients, worsen administrative red tape, and
increase expenditures.
For numerous Tribes, and especially for the Veterans themselves, it
is an undue barrier to constantly have to refer patients back and forth
to the VA that ultimately wastes time and delays access to care. The
GAO identified that IHS and VA lack sufficient measures for
quantifiable assessments of progress toward MOU goals and objectives.
Although the VHA and IHS have created 15 performance measures, no
specific targets or indicators have been established that allow Tribes
to measure progress toward achieving the goals and objectives of the
MOU.
3. Tribes and NIHB have strongly recommended that the VHA
consult with Tribes and work through their MOU with IHS to
create and publish a living list of available Veterans
Liaisons/Tribal Veterans Representatives across all IHS and VHA
regions
The VHA must do more outreach and education with Native Veterans to
improve care coordination. Tribes and NIHB have consistently stressed
the need for VHA to create toolkits and guides to assist Native
Veterans in navigating care access. The paucity of currently available
newsletters, outreach workers and liaisons such as Tribal Veteran
Service Officers (TVSOs), and online resources specifically for Native
Veterans also sends the message that care for Native Veterans is not a
priority. But despite repeated Tribal demands, the agency has yet to
implement this request.
A closely related issue is the fact that Native Veterans are still
charged copays and deductibles when receiving services under the VHA.
The Federal Government's trust responsibility for health services
extends to all Native Veterans. In recognition of this, AI/ANs do not
have copays or deductibles for services received at an I/T/U facility.
Additionally, the ACA further affirmed the trust responsibility when it
included language at Section 1402 to exempt all AI/ANs under 300
percent of the Federal poverty level from co-pays and deductibles on
plans purchased on the health insurance Marketplace.
4. Congress should pass legislation exempting Native Veterans
from copays and deductibles
Section 222 of IHCIA prohibits cost sharing of AI/ANs in cases
where an AI/AN receives a referral from the from an IHS or THP under
the PRC program. Like IHS and the Marketplace, the VHA is another means
by which the Federal Government must uphold its trust responsibility to
AI/ANs. As such, it is imperative that Congress enact legislation that
requires the VHA to similarly exempt AI/AN Veterans from copays and
deductibles in the VA system in recognition of the Federal trust
responsibility. Importantly, copay costs should not be shifted to IHS
or Tribes. The VHA must absorb these costs on behalf of AI/AN Veterans
in recognition of their Trust and Treaty obligations to AI/AN Peoples.
5. Congress should pass the bipartisan H.R. 2791 - Department
of Veterans Affair Tribal Advisory Committee Act of 2019
Tribal Nations and NIHB have also strongly advocated for the
seating of a Tribal Advisory Committee (TAC) within the Office of the
Secretary at the VA. Establishing a Veteran TAC is essential for
strengthening the government-to-government relationship, and improving
VA accountability to Native Veteran health needs. Through the seating
of a TAC, top VA officials would have the ability to hear directly from
Tribal leaders about the unique health priorities and challenges that
impact Native Veterans. In addition, it would help prevent the
development of new rules or policies that would adversely affect care
for Native Veterans. As such, Tribes and NIHB strongly support the
bipartisan H.R. 2791, introduced by Representative Deb Haaland, and
urges the House VA Committee to vote to pass this significant
legislation.
EHR Interoperability and Health Information Technology (IT)
Modernization
1. Congress must ensure parity between the VA and IHS in
appropriations and technical assistance for health IT
modernization
The Resource and Patient Management System (RPMS) - which is the
primary health IT system used across the Indian health system - was
developed in close partnership with the VHA and has become partially
dependent on the VHA health IT system, known as the Veterans
Information Systems and Technology Architecture (VistA). The RPMS is an
early adoption of VistA for outpatient use, and the legacy system was
designed with the decision to keep the same underlying code
infrastructure as VistA. IHS began developing different clinical
applications for their outpatient services, and the VHA adopted code
from RPMS to provide this functionality for VistA.
RPMS eventually began to use additional VistA code as the need for
inpatient functionality increased. This type of enhancement and support
for both the IHS and VHA was made possible because VistA's software
components were designed as an Open Source solution. The RPMS suite is
able to run on mid-range personal computer hardware platforms, while
applications can operate individually or as an integrated suite with
some availability to interface with commercial-off-the-shelf (COTS)
software products.
Currently, the RPMS manages clinical, financial, and administrative
information throughout the I/T/U, although, it is deployed at various
levels across the service delivery types. However, in recent years,
many Tribes and even several Urban Indian Health Programs (UIHPs) have
elected to purchase their own COTS systems that provide a wider suite
of services than RPMS, have stronger interoperability capabilities, and
are significantly more navigable and modern systems to use. As a
result, there exists a growing patchwork of EHR platforms across the
Indian health system.
When the VA announced its decision to replace VistA with a COTS
system in 2017 (Cerner), concentrated efforts to re-evaluate the Indian
Health IT system accelerated, and arose significant concerns as to how
VHA and I/T/U EHR interoperability would continue. In 2018, IHS
launched a Health IT Modernization Project to evaluate the current I/T/
U health IT framework, and to, through Tribal consultation, key
informant interviews, and national surveys, develop a series of next
steps and recommendations toward modernizing health IT in Indian
Country.
Difficulties in achieving IT interoperability among VA, IHS, and
THP facilities pose significant problems for Native Veterans' care
coordination. Unfortunately, the VHA and IHS have yet to identify a
systemic solution toward increasing EHR interoperability between I/T/U
and VHA hospitals, clinics, and health stations. A resulting scenario
includes situations where a THP provider - having treated a Veteran and
referred them to the VHA for specialty care - would not receive the
Veteran's follow-up records as quickly as if they had streamlined
access to each other's systems.
Now that the VHA is transitioning to the Cerner system, it has
worsened concerns around care coordination and sharing of EHRs between
I/T/U and VHA systems. The fact is, Native Veterans are suffering today
from the lack of health IT interoperability. It is shameful that Native
Veterans are put in a position where they have to find their own
solutions to streamline EHR sharing, most shockingly exemplified by
anecdotes of AI/AN Veterans hand carrying their health records between
their IHS and VHA provider.
Congress must ensure that the Indian health system is fully
integrated across the development and implementation of the VHA's
transition to Cerner; however, thus far it has failed to do so. By the
most current estimates, the transition to Cerner will take up to 10
years to fully implement, with a current price tag of roughly $16
billion. None of the existing estimates include calculations of how
much it will cost to include IHS in this transition; however, through
its Health IT Modernization Project, IHS is attempting to arrive at an
estimated dollar figure for this cost.
Tribes and NIHB were pleased to see that the Fiscal Year 2020
President's Budget included a request for a new $20 million line item
in the IHS budget to assist with health IT modernization, and that this
request was included in the House-passed Fiscal Year 2020 Interior
Appropriations package. But in comparison, the Fiscal Year 2020 House
Military Construction Appropriations bill budgeted $1.6 billion to
assist VHA in its transition. Ensuring EHR interoperability between I/
T/U and VHA health systems will be impossible if Congress fails to
establish parity in appropriations for VHA and IHS health IT
modernization.
Conclusion
The Federal Government has a dual responsibility to Native Veterans
that continues to be ignored. As the only national Tribal organization
dedicated exclusively to advocating for the fulfillment of the Federal
trust responsibility for health, NIHB is committed to ensuring the
highest health status and outcomes for Native Veterans. We applaud the
House VA Subcommittee for Health for holding this important hearing,
and stand ready to work with Congress in a bipartisan manner to enact
legislation that strengthens the government-government relationship,
improves access to care for Native Veterans, and raises health
outcomes.
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