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


                      ACHIEVING HEALTH EQUITY FOR
                      AMERICA'S MINORITY VETERANS

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

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

                              ----------                              

                       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.]

?

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


                         A  P  P  E  N  D  I  X

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


                    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    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

---------------------------------------------------------------------------
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.
---------------------------------------------------------------------------
    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.

---------------------------------------------------------------------------
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.
---------------------------------------------------------------------------
    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.''
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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/.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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/.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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\
---------------------------------------------------------------------------
    \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/
---------------------------------------------------------------------------
    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
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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.

                                 [all]