[Senate Hearing 118-291]
[From the U.S. Government Publishing Office]
S. Hrg. 118-291
CARING FOR ALL WHO HAVE
BORNE THE BATTLE: ENSURING EQUITY FOR
WOMEN VETERANS AT VA
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED EIGHTEENTH CONGRESS
SECOND SESSION
__________
APRIL 10, 2024
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
55-576 PDF WASHINGTON : 2025
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SENATE COMMITTEE ON VETERANS' AFFAIRS
Jon Tester, Montana, Chairman
Patty Murray, Washington Jerry Moran, Kansas, Ranking
Bernard Sanders, Vermont Member
Sherrod Brown, Ohio John Boozman, Arkansas
Richard Blumenthal, Connecticut Bill Cassidy, Louisiana
Mazie K. Hirono, Hawaii Mike Rounds, South Dakota
Joe Manchin III, West Virginia Thom Tillis, North Carolina
Kyrsten Sinema, Arizona Dan Sullivan, Alaska
Margaret Wood Hassan, New Hampshire Marsha Blackburn, Tennessee
Angus S. King, Jr., Maine Kevin Cramer, North Dakota
Tommy Tuberville, Alabama
Tony McClain, Staff Director
David Shearman, Republican Staff Director
C O N T E N T S
----------
April 10, 2024
SENATORS
Page
Hon. Jon Tester, Chairman, U.S. Senator from Montana............. 1
Hon. Jerry Moran, Ranking Member, U.S. Senator from Kansas....... 2
Hon. Patty Murray, U.S. Senator from Washington.................. 7
Hon. Angus S. King, Jr., U.S. Senator from Maine................. 12
Hon. John Boozman, U.S. Senator from Arkansas.................... 15
Hon. Richard Blumenthal, U.S. Senator from Connecticut........... 16
Hon. Mazie K. Hirono, U.S. Senator from Hawaii................... 19
Hon. Margaret Wood Hassan, U.S. Senator from New Hampshire....... 32
WITNESSES
Panel I
Erica Scavella, MD, FACP, FACHE, Assistant Under Secretary for
Health for Clinical Services, Veterans Health Administration,
Department of Veterans Affairs accompanied by Sally Haskell,
MD, Acting Chief Officer, Office of Women's Health; Amanda
Johnson, MD, FACOG, Acting Deputy Chief Officer, Office of
Women's Health; and Kenesha Britton, Assistant Deputy Under
Secretary, National Contact Operations, Office of Field
Operations, Veterans Benefits Administration................... 3
Jennifer Baptiste, MD, Deputy Assistant Inspector General, Office
of Healthcare Inspections, Office of Inspector General,
Department of Veterans Affairs................................. 5
Panel II
Alissa Engel, PhD, LCPC, LMFT, Mental Health Therapist, Veteran.. 23
Julie Howell, Associate Legislative Director, Paralyzed Veterans
of America..................................................... 25
Kirsten Laha-Walsh, PhD, Government Affairs Specialist, Wounded
Warrior Project................................................ 27
Naomi Mathis, Assistant National Legislative Director, Disabled
American Veterans.............................................. 29
APPENDIX
Prepared Statements
Erica Scavella, MD, FACP, FACHE, Assistant Under Secretary for
Health for Clinical Services, Veterans Health Administration,
Department of Veterans Affairs................................. 43
Jennifer Baptiste, MD, Deputy Assistant Inspector General, Office
of Healthcare Inspections, Office of Inspector General,
Department of Veterans Affairs................................. 49
Alissa Engel, PhD, LCPC, LMFT, Mental Health Therapist, Veteran.. 65
Prepared Statements (cont.)
Julie Howell, Associate Legislative Director, Paralyzed Veterans
of America..................................................... 73
Kirsten Laha-Walsh, PhD, Government Affairs Specialist, Wounded
Warrior Project................................................ 82
Naomi Mathis, Assistant National Legislative Director, Disabled
American Veterans.............................................. 96
Questions for the Record
Department of Veterans Affairs responses to questions submitted
by:
Hon. Kyrsten Sinema............................................ 111
Hon. Tommy Tuberville.......................................... 121
Hon. Angus S. King, Jr......................................... 126
Alissa Engel responses to questions submitted by:
Hon. Angus S. King, Jr......................................... 130
Paralyzed Veterans of America responses to questions submitted
by:
Hon. Angus S. King, Jr......................................... 132
Wounded Warrior Project responses to questions submitted by:
Hon. Angus S. King, Jr......................................... 135
Disabled American Veterans responses to questions submitted by:
Hon. Angus S. King, Jr......................................... 139
Statements for the Record
Astellas Pharma US, Inc., Christie Bloomquist, Vice President,
Government Affairs and Policy.................................. 147
Vietnam Veterans of America, James McCormick, Director Government
Affairs........................................................ 149
CARING FOR ALL WHO HAVE
BORNE THE BATTLE: ENSURING EQUITY
FOR WOMEN VETERANS AT VA
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WEDNESDAY, APRIL 10, 2024
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 3:30 p.m., in
Room SR-418, Russell Senate Office Building, Hon. Jon Tester,
Chairman of the Committee, presiding.
Present: Senators Tester, Murray, Brown, Blumenthal,
Hirono, Hassan, King, Moran, Boozman, Cassidy, and Tuberville.
OPENING STATEMENT OF HON. JON TESTER,
CHAIRMAN, U.S. SENATOR FROM MONTANA
Chairman Tester. I'm going to call this meeting of the
Veterans' Affairs Committee to order. I want to welcome
everybody to today's hearing to ensure the Department of
Veterans Affairs is meeting the needs of women's veterans.
Today, women make up more than 11 percent of the veteran
population. The number's projected to be 15 percent by 2035,
with women making up 17 percent of the active-duty military
force, and 21 percent of the reserve component. We know that
these numbers are going to grow.
With that in mind, the Committee has worked in recent years
to ensure the VA is providing equitable, high-quality care to
women veterans. In 2021, the Deborah Sampson Act, a bill, which
I led with Senator Boozman, was signed into law. It continues
to help eliminate barriers to healthcare and services faced by
women veterans, including survivors of military sexual trauma.
MST impacts both men and women. I hope today's hearing will
address what the VA is doing to improve care and benefits
provided to survivors of MST.
I'm encouraged by VA's improvements to its MST claims
process since the passage of the Deborah Sampson bill, but I
won't stop fighting until all MST survivors have access to fair
claims process and high-quality care that they have earned.
That is why I continue to push for passage of my bill with
Senator Murkowski, the Servicemembers and Veterans Empowerment
and Support Act. This bill would expand the evidentiary
standard for MST survivors, applying for VA disability
benefits.
Today, I also look forward to hearing updates from the VA
on another critical law, the MAMMO Act, another bill led by
Senator Boozman to expand veterans access to breast cancer
screening and care. That law includes a pilot program on
telescreening mammography services that will give us
information on how to best streamline care in rural states like
Montana, where the VA doesn't offer in-house mammography
services.
The MAMMO Act and Deborah Sampson Act represent great
strides in improving healthcare and benefits provided to women
veterans. We know that our work is far from done, and that's
why we're lucky to have a second panel with us today made up of
entirely women who have served our country, including Dr.
Alissa Engel from the great State of Montana.
We'll hear from these women about where the VA is
succeeding in meeting the needs of women veterans and where
they need to improve. Women veterans, including rural women
veterans, and those with specific needs like spinal cord
injuries need our support. So, I do want thank all the
witnesses that are here today. And with that, I'll turn it over
to my friend and colleague, the Ranking Member, Senator Moran.
OPENING STATEMENT OF HON. JERRY MORAN,
RANKING MEMBER, U.S. SENATOR FROM KANSAS
Senator Moran. Chairman. Thank you. I'm pleased to be here
today, and this is an important topic and I'm glad we're having
this hearing. I welcome our witnesses and everyone who's
gathered here for this hearing on the needs of women veterans.
Women have made immense sacrifices and honorable service to
their country since the American Revolution, but far too often,
their contributions go unrecognized and often underappreciated.
A single hearing is unlikely to fully capture the complexity of
this topic, but conversations like the ones we will have this
afternoon are important pathways to make certain that women
veterans, and their service are recognized, appreciated,
especially when they need access, benefits, and services from
the VA.
Our witnesses will share with us in a few minutes, I'm
sure, that the VA has made strides to be more welcoming to
women, to make gender-specific services to women more
accessible. As you said, Mr. Chairman, the work is never over.
We say that frequently, perhaps every hearing, every topic that
we're involved in. But I would indicate that's true today in
this hearing, and it's particularly true when it comes to women
serving and who have served, who are now living in rural areas,
and aging women who have unique needs the VA must proactively
address.
In preparation for today's hearing, we reached out to women
veterans in Kansas to learn about their experiences. These
women told me how grateful they are for the VA, and that they
have seen VA change for the better over the last several years.
Each had similar stories, however, about the challenges
that still exist for women. One told me that the only time she
hears from the VA is when they're reminding her to pay a bill.
Although this woman is an active user of the VA healthcare
system, she has still not had toxic exposure screening and had
to seek out on her own information about the PACT Act.
Because Kansas is such a rural state, women veterans either
rely on community care or have long distances to travel to a
VA, which they sometimes cannot do because of family and
professional obligations or poor health. Each veteran we talked
to said the VA has made accessing community healthcare
difficult, even for services like maternity care, which is only
provided in the community. One woman had to find a new doctor
for her third pregnancy because her prior one was no longer
willing to work with the VA.
Though hearing directly from advocates is certainly
valuable, and I look forward to that today. I hope today's
hearing will shed light on how the VA, and perhaps this
Committee, and the Congress can do more in moving forward for
women everywhere. Our duty is to make certain that they receive
the support and care they deserve, and I thank you, Mr.
Chairman. I thank our witnesses.
Chairman Tester. Thank you, Senator Moran. I want to
welcome our first panel witnesses to this afternoon's hearing.
I'll introduce you right now. From the VA, we have Dr. Erica
Scavella, Assistant Under Secretary for Health for Clinical
Services at the Veterans Health Administration. She is joined
by Dr. Sally Haskell, Acting Chief Officer for VA's Office of
Women's Health, and Dr. Amanda Johnson, Acting Deputy Chief
Officer for the Office of Women's Health.
Also from the VA is Kenesha Britton, Assistant Deputy Under
Secretary in the Veterans Benefits Administration, Office of
Field Operations. And finally, last, but certainly not least,
from the VA Office of Inspector General. We always appreciate
having the Inspector General here. We're joined by Dr. Jennifer
Baptiste, Deputy Assistant Inspector General in the Office of
Healthcare Inspections.
Dr. Scavella, we'll start with you. Know your entire
written statement will be a part of the document. We'll try to
hold it to five minutes. Thank you.
PANEL I
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STATEMENT OF ERICA SCAVELLA, MD, FACP, FACHE, ASSISTANT UNDER
SECRETARY FOR HEALTH FOR CLINICAL SERVICES, VETERANS HEALTH
ADMINISTRATION, DEPARTMENT OF VETERANS AFFAIRS ACCOMPANIED BY
SALLY HASKELL, MD, ACTING CHIEF OFFICER, OFFICE OF WOMEN'S
HEALTH; AMANDA JOHNSON, MD, FACOG, ACTING DEPUTY CHIEF OFFICER,
OFFICE OF WOMEN'S HEALTH; AND KENESHA BRITTON, ASSISTANT DEPUTY
UNDER SECRETARY, NATIONAL CONTACT OPERATIONS, OFFICE OF FIELD
OPERATIONS, VETERANS BENEFITS ADMINISTRATION
Dr. Scavella. Thank you, sir. Good afternoon, Chairman
Tester, Ranking Member Moran, and Committee Members. My name is
Dr. Scavella, and I'm the Assistant Under Secretary for Health
for Clinical Services at the Veterans Health Administration.
Joining me today are Dr. Sally Haskell and Amanda Johnson,
respectively, the Acting Chief Officer and Acting Deputy Chief
Officer within the Office of Women's Health. I'm also
accompanied by Ms. Kenesha Britton, who is the Assistant Deputy
Under Secretary for Benefits for National Contact Field
Operations within the Veterans Benefit Administration.
Thank you for the invitation to testify before you today.
Addressing the unique needs of women veterans is crucial. Since
2001, the number of vet women using veteran services has
tripled going from 158,000 to over 625,000 enrollees within the
last calendar year. As we wrap up our 100th year of providing
women's healthcare, we aim to set a higher standard of care and
become a national leader in women's healthcare.
We proudly provide comprehensive care for our enrolled
women and gender-diverse veterans, including preventive, acute,
and chronic disease management, reproductive healthcare, and
mental healthcare. To address gender-specific health concerns,
we have developed several primary healthcare policies, one of
which includes assigning a woman to a trained woman's health
primary care provider. Should she choose to have that.
As of September 2023, all healthcare systems have at least
three primary care providers who are specializing in women's
health. A major component of the comprehensive care that we
provide includes a range of essential reproductive health
services, including contraception, pregnancy-related care,
fertility counseling, sexually transmitted infection screening,
and specialty medical and surgical management of gynecological
conditions.
VA provides comprehensive and specialized gynecological
care through a network of skilled professionals at state-of-
the-art facilities. Initiatives like the Gynecology Community
of Practice and Virtual Grand Rounds to enhance the equality of
care access to essential reproductive care, including abortion
care, is vital for our patients if they are experiencing a
condition that may affect the life of the veteran.
VA is dedicated to supporting women veterans' mental health
needs and well-being through a range of initiatives. This
includes expanding access to evidence-based services,
increasing awareness of gender-specific resources like women-
only therapy, and women-led peer support groups. Specialized
care is offered for conditions like post-traumatic stress
disorder, depression, anxiety, and reproductive mental health
issues like postpartum depression.
VA additionally offers innovative resources to support
clinicians, including a national network of women mental health
champions. At each VA Medical Center. VA has trained over 120
clinicians since 2022, specifically in women's health. VA is
dedicated to ensuring that every woman veteran receives the
benefits she deserves, and continuously expands its outreach
and services to better support women veterans.
The department recently organized nearly 140 events
tailored specifically to meet the needs of women veterans, and
provides a web-based course to enhance that education. Thanks
in part to this effort, we have over 702,000 women who are
currently receiving disability compensation benefits, setting a
record with a 26 percent increase over the past five years.
Finally, we recently implemented various reforms to improve
the military sexual trauma or MST-related claims process for
both male and female survivors. In fiscal year 2023, we had
over 43,000 MST-related claims that were processed, with women
receiving 62 percent of the MST-related benefits. Ongoing work
is being done to address under development, examination, and
medical opinion-related errors, and improper denials.
To ensure timely decisions for MST survivors, VA is
reaffirming its commitment to enhancing workload management
strategies, increasing full-time employees at our operation
centers, analyzing trends and common errors, and conducting a
claims quality stand down day for our MST claims processors.
Our commitment to ensuring that women veterans receive the
care, support, and respect they deserve remains unwavering.
VA's women-centered programs have made significant strides in
improving their well-being, especially as their enrollment with
NDA reaches new levels. We must maintain this momentum and
protect the progress achieved through our continued
collaboration.
Thank you so much for this opportunity to update you on our
efforts, comprehensively providing care for women veterans.
Chairman Tester and Ranking Member Moran, this concludes my
testimony, and we are ready for your questions.
[The prepared statement of Dr. Scavella appears on page 43
of the Appendix.]
Chairman Tester. To the second. And I assume Dr. Scavella,
Britton, Haskell, and Johnson are with you.
And we will now hear from Jennifer Baptiste.
STATEMENT OF JENNIFER BAPTISTE, MD, DEPUTY ASSISTANT INSPECTOR
GENERAL, OFFICE OF HEALTHCARE INSPECTIONS, OFFICE OF INSPECTOR
GENERAL, DEPARTMENT OF VETERANS AFFAIRS
Dr. Baptiste. Chairman Tester, Ranking Member Moran, and
Committee Members, thank you for the opportunity to discuss the
OIG's oversight of VA programs and initiatives that focus on
serving women veterans.
The OIG's Women's Health Program was implemented to help
ensure VA is meeting the healthcare needs of this expanding
population. More women veterans are accessing VA at a younger
age, underscoring the need for maternity and gynecologic care
to be readily available. Access to gender-specific cancer
screenings, such as for breast and cervical cancer, and
diligent follow-up of test results are necessary. Women often
present with unique symptoms for acute and chronic health
conditions such as cardiovascular disease.
VA must ensure its care providers are equipped to detect
and manage women's distinct healthcare needs. Also, expanding
outreach and screening for MST and mental health conditions
could make more eligible women veterans aware of the care and
benefits available to them.
Our work has found that frontline VA staff are
overwhelmingly dedicated to providing high quality care to
women veterans. We recognize the commitment VA has shown in
increasing the availability of gender-specific resources while
working to create a safe and welcoming environment.
As the number of women veterans continues to rise, however,
VA faces significant challenges in ensuring access to women's
primary care providers and gender-specific care within their
facilities and in the community. Recent OIG reports on VHA
women's health providers, the mammography program and
reproductive health services highlight several areas for which
improvements affecting gender-specific care are needed.
Those reports have highlighted that there is still
important work to be done on maintaining a welcoming
environment and access to clinicians that are fully supported
and trained in treating women veterans. We have reviewed and
substantiated allegations of inappropriate conduct by a
gynecologist and lack of advocacy by a chaperone. We have also
confirmed that a facility's Women Veterans' Healthcare program
was under-resourced and largely overlooked.
Failures of the type the OIG has reported can undermine
women veterans trust in VA.
Coordinating care that women veterans receive in the
community is also critically important because some gender-
specific care such as maternity care, is not generally provided
within VA facilities.
Women veterans may also be referred to the community for
gynecologic care and cancer screenings. Test results, therefore
must be timely communicated and medical records returned
promptly back to VA.
Program coordinators who support the care of women
veterans, including maternity care, MST, and intimate partner
violence coordinators largely do so as collateral duties.
They have reported to OIG that they often lack sufficient
resources, administrative support, and protected time to
effectively serve women veterans. Other related OIG oversight
work has demonstrated the importance of appropriate screening
and support for victims of sexual violence, as well as the need
for MST benefits claims to be processed more accurately and
timely by VBA.
We recently released a report that found approximately half
of the veterans who reported sexual assault to DoD while on
active duty, did not use VA healthcare, and a third had not
received a service-connected disability rating, suggesting the
need for better outreach to veterans and ensuring a welcoming
environment for those veterans to receive care.
In closing, the OIG's portfolio work to date highlights the
challenges VA must overcome if they want to engage more women
veterans who will rely on and trust VA for their care. The OIG
Women's Health Program is currently conducting a national
review to assess maternity care coordinators workloads and
fulfillment of their duties, with a follow-on review that will
include the experiences of veterans who have received maternity
care coordinated by VHA.
Additionally, the OIG audit staff continue to monitor the
processing of MST claims for VA benefits that have
disproportionately affected women veterans. We will continue to
monitor VA's progress on addressing the needs of women veterans
and to provide practical and meaningful recommendations for
improvements.
We appreciate the opportunity to participate in this
hearing. It is fitting that this hearing falls during the month
VA highlights sexual assault awareness and prevention. The OIG
is committed to being a voice for survivors and providing VA
with information to improve its efforts.
Chairman Tester, Ranking Member Moran, and Members of the
Committee, this concludes my statement. I would be happy to
answer any questions you may have.
[The prepared statement of Dr. Baptiste appears on page 49
of the Appendix.]
Chairman Tester. Dr. Baptiste and Dr. Scavella, thank you
both for your testimony. We appreciate it. Appreciate your
work. I will turn to the dean of this Committee for your
questions. Senator Murray.
HON. PATTY MURRAY,
U.S. SENATOR FROM WASHINGTON
Senator Murray. Thank you, Senator Tester. Thank you, all
of you. Really appreciate it having this hearing on really an
important topic because we all know that women are the fastest
growing demographic within the veteran population.
In my home State of Washington, the Puget Sound VA saw a 7
percent increase in women veterans who are using their services
over the past two years. In February, I met with women veterans
in Seattle who told me about the barriers they are facing in
receiving healthcare through the VA. I heard from a veteran
who--she was looking for care at American Lake VA which was
very close to where she lived, but the women's clinic was
completely full. So she had to go to the Seattle VA to get
care--close but not close. And I know alot of other women
veterans are facing the same stories. Her story is not unique.
I hear that all the time. Many women are having the trouble
getting the care that they need.
And additionally, mammography services are an important
part of healthcare for women veterans. But right now, VISN 20,
which covers Washington, Oregon, Idaho, and Alaska is the only
VISN without in-house mammography. And that is really not
acceptable. So Dr. Scavella, does the VA have plans to expand
their in-house mammography services to VISN 20?
Dr. Scavella. Thank you for that question. We are always
aiming to provide services at the point of care where veterans
find it most convenient and most accessible. We do face
challenges just like the rest of the United States in having
qualified employees to provide these services. So that is a
challenge for us, but we will continue to work to make sure we
have services that are accessible within your systems.
There's also a quality-of-care component related to
providing mammography in that you need to make sure that the
mammographers, the persons performing the procedures, are
adequately trained and are able to keep their skills. So, I can
look specifically into any of the demographics there. I would
like to ask Dr. Haskell if she has any specific information to
answer your question.
Ms. Haskell. Yes. Thank you, Senator Murray, for your
question. VA currently has in-house mammography at 78 sites,
and it's really been increasing very rapidly over the last
number of years. And we are looking at additional ways of
providing mammography, as you probably know, through
teleradiology, as well as potentially looking into more mobile
mammography services.
So these are some things that the National Radiology
program is working on. I think as Dr. Scavella says we are
limited in that we want our mammography programs to be very
high-quality care. And in order to do that, we need to ensure
that there are certain number of women at a facility.
There are requirements both for the radiology technologist
and the radiologist themselves, that they need to do a certain
number of cases per year in order to be qualified and
certified. So we look carefully at those numbers.
And we are also--I do want to say that we're very aware of
that VISN 20 gap, and I know that the radiology program is
looking at it very carefully----
Senator Murray. Okay. If I could just ask----
Ms. Haskell. Yes.
Senator Murray [continuing]. Can you take a look and get
back to me and tell me if you're not going to do it, or if you
are, when it's going to happen. And I want it to be the answer
to the second question not the first there, so.
Ms. Haskell. Absolutely. Thank you.
------------------------------------------------------------------------
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VA Response: Like any other clinical service, we consistently look at a
variety of options as we address changes with our enrolled Veteran
populations. According to most recent data, American Lake and Seattle
have sufficient women Veteran populations to support adding
mammography, though the population is dispersed along I-5 corridor and
east/west with minimal fixed density. We currently accommodate the
needs through Community Care (CC) requests for this service and follow-
up diagnostic services as needed. Wait times for mammograms do not
appear to be a barrier in most locations in the Puget Sound area.
Depending on the review of updated data, with emphasis given to the
preferences of women Veteran enrollees, there are many options to
consider, including continuation of the current CC referrals. In
addition:
VISN leadership is actively involved in reviewing this issue
with Puget Sound leadership, along with our Women's Health Coordinator
and the National Program Offices for Women's Health and Radiology. We
consistently monitor growth, interest, and demand as demographics
continue to change and shift with regard to women Veteran enrollees.
(This has been an ongoing, regularly discussed topic throughout the
years and will continue to be as Puget Sound strives to meet the needs
at current and future sites of care.)
The VISN 20 team is working with the Puget Sound team to review
feasibility of a VA/DoD partnership with Madigan.
There are several options to consider for a VA-directed
mammography program if deemed appropriate and consistent with the women
Veterans' preferences, including telescreening mammography and a
traditional screening mammography program at a local VA site of care.
------------------------------------------------------------------------
Senator Murray. Thank you. Earlier this year, DoD announced
that it's going to expand its IVF services to single and
unmarried service members, and will allow service members to
utilize donor gametes. I was really excited to hear that the VA
is following DoDs footsteps in its IVF expansion. This is
really great news for active-duty service members and veterans,
and I know we have a lot of work to be done to make sure
everyone has the access they need. Which is exactly why I
introduced the Veteran Families Health Services Act, which will
expand IVF services to more service members and their families.
And I'll be working very hard to get that passed.
But Dr. Scavella, if you can just talk about how this
recent expansion will help more women veterans and speak to why
IVF care is so crucial for veterans who cannot conceive
naturally.
Dr. Scavella. You know, thank you for that question. It's
fitting, again, that we're having this hearing one month after
Women's Health Women's History Month. And it's one year and one
month post the Secretary providing a new mission statement,
which includes women in the mission statement.
We now can offer IVF services to women veterans who may be
unmarried, veterans in same sex marriages and other non-marital
unions. And we can also now use the gametes, the embryos and
eggs and sperm from donors as opposed to previous legislation
and rules and regulations. So it has expanded the opportunity
for us to provide that care. We're really excited by the
release that the Secretary signed last month, as well as the
entry into the federal registry.
Senator Murray. Well, thank you. And Mr. Chairman, I'll
just say that when we ask our men and women to serve our
country, we tell them we will take care of them when they go
home. To tell them that doesn't include having a family to me
is outrageous. So I think this is really important and I
appreciate the work you're doing on it, and we will continue to
do everything we can to make sure we get this done for
families.
Chairman Tester. I agree with you, Senator Murray. I also
appreciate your work. Senator Moran.
Senator Moran. Dr. Scavella, one of the women that my staff
spoke to, women veteran, in preparation for this hearing is
being reassigned a new primary care provider as her current one
is retiring. She is concerned she will be assigned a male
physician. On the other hand, on my way to the airport on
Monday, I stopped unannounced at a VA clinic in Kansas City,
Kansas, and visited with the veterans in the lobby.
And this female veteran was telling me that she's getting
good care, but she'd prefer just to be treated as a veteran,
not a woman veteran. My staff tells me that's not an unusual
circumstance. And in the view of this woman, she believed that
she was not offered that opportunity. She was only eligible for
care on the women's clinic side of the VA.
So one, my understanding now is that that's not the case. I
don't know what the educational or comments were made to this
veteran in the waiting room, but in each instance, they're
looking for a specific kind of provider. One, just the general
VA, and one would really like to have a woman doctor. Tell me
how this works at the VA.
Dr. Scavella. Yes. So, thank you for that question. Ranking
Member Moran. I am a 25-year-old year veteran of working within
Department of Veterans' Affairs, and I took care of women and
men in Baltimore and was very proud to do so. I had some women
who wanted to see whomever they could and did not have a
preference. And I had some women who specifically wanted a
specific gender, whether it was a male physician or a female
physician. And it is their choice.
We are currently in the--in this current day, we are
required to offer women veterans the opportunity to have the
clinician of their choice. They can choose a woman, they can
choose a man. And we continue to do that. It is their choice,
and so we find some who really feel really safe in those sex
concordant relationships for their provision of care, or there
are some that don't have a preference. We just need to make
sure we meet their needs.
Senator Moran. Doctor, this Committee has been attempting
to help the VA solve its provider shortage. We just heard about
that in mammography. Is there a shortage in doctors who are
female at the VA? So, if you ask for a doctor who's a female,
is that a given?
Dr. Scavella. So, I think we do reflect the U.S. population
for women who are in medicine. We may be a little still
discordant as far as having how many women? I'm going to
actually ask Dr. Haskell. She knows that number, but I don't
think so.
Ms. Haskell. I did want to say that in regard to--well,
first of all, let me answer your question, which is that I do
believe that more than 50 percent of the providers in VA, at
least in primary care, and in mental health, I believe are
female. So we don't have a shortage of female providers, but I
didn't want to say in regard to women being able to have a
choice of providers that we require that all women are offered
assignment to a women's health provider.
But our goal is really to have at least 85 percent of all
women assigned to women's health providers. So it means that we
are taking into account the fact that there will certainly be
some women who prefer to be assigned to a regular primary care
provider, not in a specific women's clinic.
Senator Moran. I didn't know exactly how to ask that
question, what the right words were, but I can assure this,
this testimony will assure the veteran I visited with that she
has the choice. And even if it's offered, it doesn't have to be
accepted.
Ms. Haskell. Exactly. That's correct. Thank you.
Senator Moran. Let me talk a moment about a kind of a
common complaint, and that is the community care. And it's, at
least the veterans we visited with are concerned that the
doctors, the providers are not being paid in a timely fashion.
They're leaving, they're taking away the opportunity to provide
community care to veterans. In many places we need to be
growing community care in particularly rural places and with
maternity care only being provided within the community.
Are we cognizant of the fact that we need to make sure that
community care works for the provider and for the veteran? In
other words, are we caring for the timeliness of payment those
kind of things that make community care still a viable option
in places across the country for maternity care and for places
across rural America for veterans and their wide array of need
for medical services?
Dr. Scavella. So, thank you for that question. Since I see
we're out of time, I'll actually defer to Dr. Johnson for that
answer.
Senator Moran. Dr. Johnson?
Ms. Johnson. Yes. Thank you very much. I think that's an
important concern and a critical concern, and absolutely our
maternity care is provided entirely in the community. And the
reason for that is we cover about 7,000 deliveries across our
large integrated healthcare system. And in order to provide
high quality maternity care, we really require enough volume to
provide that care in a safe manner.
So, if we're doing 7,000 deliveries a year across a large
integrated healthcare system, we just don't have enough volume
to build that infrastructure within VA, which would include
neonatologists, NICUs, neonatal intensivists, all of those
things that we need to have in place to provide safe maternity
care.
And I, as an OB-GYN, who actually works in a rural area am
well aware of the needs of women in those states and what we
have as a healthcare system is a priority to ensure that our
community care networks are adequate so that we are able to
provide that care to the veterans we serve no matter where they
live.
And then, also leverage our telehealth ability that we have
within our healthcare system to provide our veterans with
tablets that have broadband access. So even those folks in
rural areas are able to connect with their providers remotely
if that's possible.
Now, for some OB care, that has to be done face-to-face,
and we're aware that for folks living in rural areas, they may
need to travel for some of that. One of the programs that I'm
very proud of is our Maternity Care Coordination program. And
Dr. Baptiste mentioned a little bit, we work quite closely
together when we look at whether our Maternity Care
Coordination program is meeting the needs of veterans we serve.
But that program was developed to recognize that we have
veterans who are using maternity care who are automatically
getting dual care. Meaning, they get care in VA for their
mental health care, their primary care, and they must be
getting care in the community. So it's really critical to have
that care coordination piece that works to center the veteran
and their needs with both their community provider and their VA
providers.
Senator Moran. Dr. Johnson, thank you. You've testified
before us before, and I appreciate your testimony. Senator
King, I'm sorry that that Senator Tester allowed me a third
question, and then I'm leaving to return to Intelligence
Committee where you and I came from.
Ms. Britton, the 2018 VA Inspector General Report found
that 49 percent of military sexual trauma claims were not
properly processed. The result of that was that veterans,
according to the Inspector General, were being prematurely
denied benefits they were owed.
In 2021, the IG followed up with recommendations and found
about 57 percent of denied MST claims were still not being
properly reviewed. It doesn't seem that the VA has this right
yet. Can you explain how the percentage of MST claims being
improperly processed increased by such an alarming percentage
after the 2018 IG report and what actions VBA is taking to make
sure that doesn't continue?
Ms. Britton. Thank you, sir. First and foremost, I would
like to say that we do recognize the declination in the
accuracy rate of the MST claims processing. As a result of the
2021 IG report, we did centralize our claims processing to
specialized sites to process our MST cases. With those cases
being centralized we provided specialized training to those
claims processors to ensure that they have the necessary
technical knowledge to be able to process those MST cases.
We started out with five sites to process those cases, and
we most recently centralized to one location under one senior
executive with those specialized claims processors. We have
within our receipt the special focus review that yielded a 71
percent accuracy rate for FY '23 for MST teams claims
processing.
What centralizing the claims has done for us is it's
allowed us to really hone in on the errors that we've seen in
the claims process. With the special focus review, we took a
deep dive into that and we are revamping how we're doing
quality.
So we generally look at our employee quality, which is 97
percent. With the 71 percent that was achieved on the special
focus review, we actually took a step back and we modified how
we're assessing our MST cases. Now we will begin looking at
those MST cases in the accuracy level of those on a monthly
basis as opposed to an annual basis, which is what we've
traditionally done as directed in the OIG report. This would
allow us to do three reviews at the employee level which also
expands the number of reviews that we're doing annually.
So, with that special focus review, we did a little bit
over 200 reviews. This would give us the opportunity to look at
15,000 of those MST cases to make sure that we're assessing the
accuracy of those in flight. So, we'll no longer be waiting
until claims are completed to look at whether or not they are
done right. We will do in-process reviews along the way, and
instead of doing that at the claim level, we will do that at
the employee level to make sure that those employees are being
trained properly.
We are looking at our top error trends. We are developing
targeted training to make sure that those claims processors
have that training. And I am happy to report that even though
we have seen that 71 percent accuracy rate, we have seen an
increase in the grant rate for our MST survivors. So we've seen
a grant increase in the grant rate from 2011. It was at 56
percent, so we're now looking at 62 percent for our grant rate
for our MST survivors.
Senator Moran. Ms. Britton, it'd be unfair to my colleagues
to ask any follow-up questions, but perhaps we can--after the
hearing my staff and you can have a conversation and/or we can
have a conversation elsewhere. We'll follow-up with you. Thank
you.
Ms. Britton. Absolutely. Thank you, sir.
Senator Moran. You're welcome.
Chairman Tester. Senator Angus King.
HON. ANGUS S. KING, JR.,
U.S. SENATOR FROM MAINE
Senator King. Thank you, Mr. Chairman. I'd like to thank
the Chairman and the Ranking Member for this hearing. I think
it's such an important topic and important for our focus.
Ms. Britton, I've heard a lot of testimony. That answer you
just gave is one of the best and most clear, concise, and
informative answers that I've ever heard in this Committee. So,
thank you for that.
Dr. Scavella, I think it was Dr. Baptiste had mentioned
only half of the MST victims use VA care. It seems to me that
just cries out for outreach. Talk to me about how do we
increase that number because it's a tragedy if there are people
who need care that cares available, but they never asked, they
never knock on the door. What are we doing about outreach?
Dr. Scavella. Thank you for that question, Senator King.
So, one of the things that Deputy Secretary Bradsher is very
concerned about is making sure that the women veterans feel
that they have a place within VA to receive their care, and
that they are coming to us for that care. We know----
Senator King. Is there a perception among women veterans
that the VA is male dominated, it's a service mostly for male
veterans?
Dr. Scavella. I would say from the perspective of many,
including some anecdotes, that I've heard from her and others
that some women who have served don't see themselves as
veterans. They don't see themselves as having a place here or
deserving of receiving the services that we can provide both
through VHA, VBA, and NCA through the cemetery services.
Senator King. Let's go back to outreach.
Dr. Scavella. So back to outreach. We are involved with the
TAP program that takes place within the one year post- and pre-
separation from the service.
Senator King. When it happens. Sometimes it doesn't happen.
[Pause.]
Dr. Scavella. That's correct.
Senator King. That's between me and the Defense Department.
Dr. Scavella. Yes, since I can't comment on what's
happening at the Department of Defense. But the VA is actively
engaged with trying to improve the TAP program to make sure
that we have a presence. The Women's Veteran Services programs
and things that are available to women as they're separating,
are presented at that. There's a separate session for them to
hear about what we have. So, we are actively trying to make
sure that they know that they have a place here.
The other thing I will say is that we do know that
approximately one in three women veterans have experienced
military sexual trauma, approximately one in five calling----
Senator King. It's an appalling number.
Dr. Scavella. Correct.
Senator King. And it's probably underreported,
Dr. Scavella. Correct. Probably underreported.
Approximately one in five have experienced intimate partner
violence. So between those two and just the burdens on women in
general, we are working really hard to make sure that when they
do come into our system, that we are proactively screening
them, bringing them in for services, connecting them to mental
health care, which can be either a risk factor for those two,
or they could be things that develop after having experienced
it.
Senator King. I would hope that you might develop an
additional special outreach over and above the TAP program,
just a letter or some kind of communication even before
mustering out so that women veterans know that there is a place
that they can go.
Let me move on. We're dealing with particularly MST and
other issues that are involved with mental health issues;
stigma, PTSD. I guess the first question is, do we have the
capacity in terms of mental health professionals to deal with
these issues? Because I know in my State of Maine, there's a
problem of mental health professionals generally let alone in
the VA. Where do we stand on that on that score?
Dr. Scavella. Thank you for that question. So we do have
specific women mental health coordinators at each facility that
can help our veterans with that. We also do have a variety of
outreach programs that women's health office is actually
leading. So we are doing all of those things to make sure that
they are receiving the care. I'd love to allow Dr. Haskell and
Johnson to add to my answer.
Senator King. Well, one thing I hope behavioral health
lends itself to telemedicine and we found in the private sector
that it increases people's attendance at their appointments,
less stigma. They don't have to sit in an office and worry
about who's next to them. So, I hope that's one of the options
that's being pursued.
Dr. Scavella. We are using telehealth, yes. Thank you.
Ms. Haskell. Yes. If I could just make a few more comments
about outreach. We do have a very robust outreach program
through the Office of Women's Health through our Women Veterans
Call Center, where we make outgoing calls to women veterans to
actually--and women veterans who are not using VA, to inform
them about benefits and services that are available. And that's
been in existence since 2013, and I think we've called over 2
million women veterans or made over 2 million phone calls. So
that's a very effective program.
And then you were talking about the TAP program. So there's
a women's-specific module called the Women's Health Transition
Training. It was actually developed by our Office of Women's
Health in conjunction with DoD and VBA, and has now been taken
over by VBA and it's available to all women. And that's a
session that's fully devoted to educating them about the
benefits and services that are available specifically to women.
Senator King. I'm going to have a suggestion. Dr. Scavella,
when I was Governor, I used to occasionally call the state's
800 numbers. My chief of staff called it scaring the staff, but
it would be informative for you to check just--and also, to
have kind of a secret shopper, you know what I mean? So that we
don't have to wait for complaints to come in.
Let's see what feedback there is in the community that
we're serving, and actively seek that kind of information,
because there may be very simple blockages that we don't know.
So, I would urge you to do that. My final question, I'm
invoking the Moran rule here, Mr. Chairman, sorry.
[Laughter.]
Senator King. This won't be the first time. Dr. Baptiste,
is the VA listening to you? That's my basic question. You've
made a lot of recommendations. Your work, the IG, has done a
lot of really good work, and I just want to be sure that it's
being implemented and that somebody's paying attention. Are you
satisfied with implementation?
Dr. Baptiste. So in our reviews, we do make recommendations
and follow----
Senator King. That's my question.
Dr. Baptiste. Yes.
Senator King. Are they following your recommendations?
Dr. Baptiste. And then we follow the action plans and
actions that VA takes to ensure that the improvements are
sustained and effective. And in addition what we would expect
is when we conduct an inspection at a particular facility, that
leadership at other facilities review our recommendations,
review our findings, use that as a tool to review their own
programs and make improvements.
Senator King. I hope you will follow up, because doing
reports and studies doesn't matter unless the recommendations
are implemented. So I think that should be very much a part of
your mission.
Dr. Baptiste. We do have a robust follow-up process.
Senator King. Thank you. Thank you, Mr. Chairman.
Chairman Tester. Senator Boozman.
HON. JOHN BOOZMAN,
U.S. SENATOR FROM ARKANSAS
Senator Boozman. Thank you very much. Mr. Chairman, thank
you for holding this hearing you and Ranking Member Moran. It's
so, so very important.
I want to thank the members of both panels for being here
today. Your expertise on the issues facing our veterans across
the country enables Congress to do our jobs more effectively.
You're making the VA and veteran experience better, not just
for women, but for all veterans.
We need to create a culture at the VA that welcomes women
veterans, and makes them feel like they belong. It's long
overdue that we update the belief that when a woman seeks care
at the VA, it's because her husband is the veteran. The great
State of Arkansas is home to over 19,000 women and veterans,
and I couldn't be prouder to represent them here today.
And also, I want to thank all of you all for the great job
that you do, representing them in your own way. Women are
currently the fastest growing demographic in both our active
duty and veterans' populations. Breast cancer is the most
diagnosed cancer among women in the United States. The
Committee worked hard. We especially want to thank Senator
Tester for his championing the SERVICE Act. It requires the VA
to conduct mammograms for all women who served in areas
associated with burn pits, other toxic exposures.
Dr. Scavella, can you update us on the implementation of
the SERVICE Act at the VA and what issues, if any, you're
seeing on the ground?
Dr. Scavella. Yes, thank you for that question. So we are
really proud that we have fully implemented the SERVICE Act. We
are providing updates on all of the different sections in the
SERVICE Act to make sure that we are responding and meeting the
needs of our women veterans.
I want to turn it over to Dr. Haskell, who was intimately
involved in that work to provide some details.
Ms. Haskell. Yes, thank you, Senator Boozman. So we have
been implementing the SERVICE Act actively since I guess last
year. And essentially the way we are implementing it is
offering all of the women who served in these areas where they
may have had potential toxic exposure a breast cancer risk
assessment, and then we would order mammograms for those who
it's felt to be clinically appropriate based on their toxic
exposure as well as their personal and family history.
So what we've done is we have created a templated note in
the electronic health record where the providers can conduct
that breast cancer risk assessment. And then the note actually
guides the provider about whether they should order a mammogram
or whether they should, or refer the woman to some more
extensive evaluation and testing, such as seeing a high-risk
breast oncologist or another specialist.
And so we've not only created the template, but we've also
created a dashboard that's available to the field so that the
providers in the field can see all of the women in their panels
who are eligible for the SERVICE Act, breast cancer risk
assessment.
So, it's progressing nicely, and many sites are doing
active outreach where they're actually making phone calls to
women on those lists in the dashboard to encourage them to come
in for their breast cancer risk assessment.
Senator Boozman. Oh, good. That's a very good story.
Ms. Haskell. Thank you.
Senator Boozman. Also working with Chairman Tester, we got
signed into law the MAMMO for Veterans Act, which is a little
bit different in that it requires the VA to develop a strategic
plan to improve breast imaging services, create a pilot program
for veterans in areas where the VA does not offer in-house
mammography, expand veterans access to clinical trials to
partnerships with the National Cancer Institute. It also
required the IG to report on mammography services furnished by
the VA.
Dr. Baptiste, I was pleased in your testimony that your
investigation did not identify concerns related to access and
use of mammograms at the VA. Could you please speak to the
findings and recommendations we should expect to see in this
report as it will be published soon?
Dr. Baptiste. Our review found concerns that frontline
staff were not aware of the Women's Oncology System of
Excellence. I believe VA refers to it as the Breast and
Gynecologic Oncology System of Excellence. And so that was one
of our concerns and part of our recommendation.
The second is regarding the cancer registry. We found that
data on veterans with a cancer diagnosis were not being entered
into that cancer registry.
Senator Boozman. Okay. Very good. So with that, I'll yield
back.
Chairman Tester. Senator Blumenthal.
Senator Boozman. I started to be like Angus and ask a
question that ran over, but I'm going to defer.
HON. RICHARD BLUMENTHAL,
U.S. SENATOR FROM CONNECTICUT
Senator Blumenthal. You should always try to be like
Senator King. [Laughter.] Thanks to the Chairman and Ranking
Member for having this hearing. Very, very important topic.
Thank you for all of your great work on it. We're going to have
a witness from the DAV, which recently did a report on women's
mental health. Some of their findings are pretty disturbing.
I'm sure you're familiar with them.
That report found that between 2020 and 2021, suicide rate
among women veterans rose 24 percent. It also found that women
are twice as likely to attempt suicide than male veteran.
They're three times more likely to choose a firearm as a means
of suicide. And more than 50 percent of deaths for women
veterans are by self-inflicted firearm injury. Why is that?
What can we do about it?
Dr. Scavella. So, thank you for that question, Senator
Blumenthal. Each time we hear of a tragic case, we are
devastated, especially when it's our women veterans. We have
done a lot of research and continue to do a lot of research
into the area. We do have a Women's Health Research Network
that does a lot of the analysis post-event to try to help us to
inform.
We understand that women veterans do have a unique set of
mental health conditions, including PTSD, depression, anxiety
that could contribute to this. They typically have a slightly
different burden with regards to taking care of families. That
also adds to that. We find that our women veterans are younger
which is also a risk factor for some of the things associated
with both military sexual trauma and intimate partner violence.
They tend to be younger and that may be the reason why they may
be in more financial turmoil and not as established. So all of
these things contribute to their mental health concerns. That's
one issue.
The other is because of their training in the military.
They are adept with using firearms they have access to.
Approximately, 38 percent of our women veterans have firearms
available to them, and they are using those. So we do have,
within the Office of Suicide Prevention and the Office of
Mental Health, we are looking at managing the mental health
issues.
And then with suicide prevention, in addition to community
partnerships, we have a Lethal Means Safety Initiative where we
are trying to put time between a thought and an action by
having firearms locked. We continue to work with women veterans
who have either had suicidal ideation and have not committed an
act to try to understand what would help them to potentially
not be successful if they have those thoughts again. We're
continue to do many, many research efforts to look at this.
Senator Blumenthal. So, they're younger, perhaps more
likely to be in financial trouble, victims of sexual assault or
other similar trauma, and you're doing more research? How
systematic is the research? In other words, you have ongoing
specific studies, or is it a case by case?
Dr. Scavella. So, I'll start, but I will turn it over to my
colleagues. So, the research is not just looking following an
event. We do have REACH VET, which is using analytics tools to
take a look at risk factors for women to proactively reach out
to them before they may even know that they may be, you know,
at risk. So we're using both real-time tools. This is all on
top of an ongoing, very intensive mental health care that
they're receiving within either their women's health clinic
program or within their mental health clinic. We have
integration of mental health in primary care. So there are many
things that are going on and these are things we are doing on
top of that but I want to see if either Dr. Johnson or Dr.
Haskell would like to add to my answer.
Ms. Haskell. I think that was really a pretty thorough
answer Dr. Scavella. But I did want to say that we are very
concerned especially about the use of firearms. And that we
have formed a work group between the Office of Women's Health
and the Office of Mental and Suicide Prevention. And we are
looking at several specific ways to really focus in on this and
one is the training about lethal means safety and the gun
locks. And training not only for veterans but also for their
providers. To ensure that all of our women are actually
screened for firearm ownership and given a gun lock if they
would like to have one.
We also have for all of our veterans in primary care--they
do get suicide screening and depression screening. So that's
available as well. And then the other thing that the work group
is focusing on is really ensuring that all of our care in the
VA is what we call trauma-informed care. And that's just sort
of ensuring that that our providers are aware that any veteran
who comes to the VA may have had a trauma experience and that
may impact their engagement with healthcare. And we know that
when veterans use VA, they are less likely to commit suicide
than those who are not using VA services. So we want to really
encourage our women to be engaged in and follow through.
Senator Blumenthal. Can I interrupt you----
Ms. Haskell. Yes. Go ahead
Senator Blumenthal [continuing]. Because my time's about to
expire. The numbers of women using VA services has increased
over the recent past. Do you have numbers as to what percentage
of the women veterans are taking advantage of VA services as
compared to the percentage of men, and what the trends are in
increased use by women of the VA, those overall numbers?
Dr. Scavella. Yes. Thank you for that question. So there
are approximately over 6 million active veterans using our
services. Of those, approximately 10 percent, 625,000 to
630,000 are women veterans. We do find that the women veterans
who are coming into our system tend to be younger. They're
also, you know, of all different ages, but they're younger.
They're in this cohort that we're concerned about.
Senator Blumenthal. But what percentage of all the women
veterans are taking advantage of the VA as compared to what
percentage of all the men? Do you understand my question? In
other words, perhaps 6 million is what percentage of all the
men--male veterans out there and 625,000 is what percentage of
all the women veteran?
Dr. Scavella. Yes, I can talk about the enrolled. I'll ask
Dr. Haskell if she knows about the total in the U.S.
population.
Ms. Haskell. We do follow those numbers. We call it market
penetration, would be the, you know, sort of percent that are
using the VA compared to the percent that are available in the
market. And I would have to get back to you on the current
exact number, but I believe it's somewhere around 40, 42, or 45
percent for women veterans and slightly higher for men. But
again----
Senator Blumenthal. Could you get back to me? I don't want
to take the----
Ms. Haskell. Yes.
Senator Blumenthal [continuing]. The Committee's time----
Ms. Haskell. Yes.
Senator Blumenthal [continuing]. With it now, and I
appreciate your letting me----
Chairman Tester. Before we get to Senator Hirono. Just to
be clear, you're saying 45 percent of the eligible women
veterans are in the VA?
Dr. Scavella. I believe that's true, but again----
Chairman Tester. Okay, that's fine. You could be off a
percent, or two, or five.
Dr. Scavella. We need to get back to you with the exact----
Chairman Tester. We've got a ballpark figure----
Senator Blumenthal. And if you could get us--if you could
confirm those numbers and get us the most current ones, and
then the similar percentage for the men--male veterans. Thank
you.
------------------------------------------------------------------------
-------------------------------------------------------------------------
VA Response: As of September 30, 2023, according to the most recent
data, the market penetration for male Veteran enrollees was 46.5%, and
for female Veteran enrollees, it was 44.4%.
------------------------------------------------------------------------
Chairman Tester. Senator Hirono.
HON. MAZIE K. HIRONO,
U.S. SENATOR FROM HAWAII
Senator Hirono. Thank you, Mr. Chairman. I'm glad that
Senator Blumenthal focused on the incidents of women veterans
committing suicide. Whenever any veteran commits suicide, in
fact, whenever any enlisted person commits suicide, that is a
matter of concern to us. But in particular, it's very
distressing that the incidents of women veterans committing
suicide is going up not down. Is that right? That's what it
sounds like to me.
Dr. Scavella. Correct.
Senator Hirono. Yes. So, thank you for citing some of the
reasons or some of the circumstances that could lead to their
suicide rates. But some of these conditions do not happen once
they separate from the military. Are they not experiencing
sexual trauma while they're in service? So, what is happening
within them while they're still in active duty that, you know,
will help when they get into the veteran status in terms of the
support that they get once they're in veteran status,
Is there some continuity of services that we provide to
women when they're in active duty as well as when they
transition to veteran status?
Dr. Scavella. That's a great question, Senator Hirono. I
think we would need to look at some of the DoD data related to
the penetration. We did see similar trends in women active
service members, but I cannot compare our 24 percent to theirs.
I think there are some concerns that women--some of the
things that actually do help them are the connectedness that
they have with each other and those bonds that help to actually
reduce the risk. But we do need to look at that. I don't have
the answer to that particular question. I want to see if Dr.
Haskell or Dr. Johnson does.
Ms. Haskell. No, I don't think I have anything to add to
that.
Senator Hirono. So, but my question is, is there some kind
of a programmatic or other ways that you are already connecting
to women service members before they reach veteran status? Is
there a program like that?
Dr. Scavella. I'll turn it over to Ms. Britton who has some
information based on the work she's doing.
Senator Hirono. Please.
Ms. Britton. Thank you, ma'am. So for our VA Solid Start
Program, we actually target veterans that received a mental
health exam within their last year on active duty. In FY '24,
so far, we've successfully connected with over 136,000 women
veterans--actually, veterans.
But of those veterans, 32,000 of them were identified as
priority veterans. There are three calls that are made to those
veterans within the first year of them exiting active duty. So,
one within the first 90 days, the second one within 180 days,
and then a final call before the one-year anniversary of their
release from active duty.
So that is a connection that we're able to make with the VA
Solid Start call agents. Those are personalized conversations.
We keep them with the same representative for the entire year
so that they can gain a level of trust as it relates to the
engagement.
We do track the referrals that we make to the crisis
hotline, and in FY '22, we had a total of 9 female veterans
that we connected to the crisis hotline. And in FY '23, we
connected 4. So far in FY '24, and this does not contradict the
increases that Dr. Scavella talked about, but we have not
received any crisis calls from women veterans in FY '24 that
have needed to be referred to the crisis hotline.
Senator Hirono. This is not a criticism, but do you--
because I think you're doing your best, but do you think that
more needs to be done in terms of connecting with the female
service members while they're in service?
Dr. Scavella. Yes. I think we need to explore this to see
if there is some type of transition. We do know just based on
other work we're doing, that that one year of transition
between being an active service member to being a veteran, that
there is a lot of instability during that one year. And it's
possible that even though we have implemented several programs
to perhaps--there's something or some things that we are not
providing in support.
Senator Hirono. So, every service except for the Air Force
is having recruitment issues. So I would imagine that there is
an increasing number of women signing up, and I think that we
can see those numbers get even higher as the recruitment
efforts to produce more female recruits. So I think that what
you-all are doing to identify--well, I'm talking about the
people who are in service, but I do see continuity of service
kind of an issue that needs to take place. So whatever you're
doing in that regard. Thank you.
I know that historically that the medical studies have not
particularly focused on the particular healthcare needs of
women. And to the extent that VA has particular programs or
healthcare programs that reach female veterans, can the VA be a
leader in ensuring gender equity in terms of producing the kind
of research that would be useful in providing healthcare to
women or particularly female veterans?
Dr. Scavella. Yes. So, thank you for that question. We do
have an active Women's Health Research Network that is doing a
variety of research projects, looking at all things that affect
women veterans, the unique needs that they have as they
separate, the unique needs that they have as far as different
mental health conditions, reproductive health concerns, and all
of the things that surround that, as well as those who may have
been exposed to toxins, et cetera. So we do have a robust
number of research projects ongoing and being published.
Senator Hirono. Thank you. Thank you, Mr. Chairman.
Chairman Tester. Thank you, Senator Hirono. When I first
got on this Committee, veterans never talked to me about their
doctors. They could always request the doctor they got. That
changed sometime half a dozen years ago. I think I got a
complaint from a veteran that said, ``I want to see the same
doctor I saw last time I was in, and they wouldn't let me do
it.''
There was a question asked earlier that talked about you
could have your clinician of choice for women, and I assume
that applies to men. And is that a new policy or is that--by
the way, I applaud it. I think it's the right thing to do. I
think the veteran should be able to stick with a person that
knows in the VA. When did this change?
Dr. Scavella. So, we've always tried to take the
considerations and requests of our patients into consideration.
There are times when we cannot adhere to the requests.
Chairman Tester. Yes, because you're busy.
Dr. Scavella. It could be unethical, et cetera, but we do
try to make sure we're providing our veterans with----
Chairman Tester. Well, I applaud that. Okay, Dr. Baptiste,
I'm going to tax your memory for a second. The ranking member
talked about what I believe he talked about was an OIG report
and how the VA was addressing those OIG recommendations.
I think the follow up he wanted to ask, and the follow up
I'm going to ask is, Ms. Britton talked about what they were
doing. I want to know your opinion about what they were doing.
Did they address the challenges? And look, I don't want you
guys to get into a fight there on the panel. I know you are
friends. But the truth is, is that the OIG provides our
eyeballs into the VA. And if what they're doing isn't
addressing the problem, I really want to know, and if it is, I
really want to know.
Dr. Baptiste. Sure. So, as you pointed out, our audit
division has issued two reports reviewing MST claims, and we
recognize that VBA has set up these MST operation centers to
centralize the processing of those claims. There is one
recommendation still open from our 2021 report regarding the
review of some denied claims. And we are concerned that there
may still be some inappropriately denied claims. Our audit
group is planning to review that again in the near future.
Chairman Tester. And this is a question for you then, Ms.
Britton. The review of denied claims, are you guys in process
at doing that before they review your review?
Ms. Britton. Yes, sir. So my staff and I, we actually have
met with the OIG staff several times over the last year to
review the recommendation as well as the centralization of the
MST cases.
As it relates to the 9,700 reviews, there were a little
over 90 cases that were identified by the OIG that we needed to
re-review. Based on the overturn rate of those 90 plus cases,
we actually expanded the review and we reviewed 9,700 cases.
Chairman Tester. The bottom line is, did it result in any
of those denied claims being undenied?
Ms. Britton. Yes, sir. We have a 62 percent overturn rate
of the re-reviews that we've done, which has resulted in over
$69 million.
Chairman Tester. And has there been a process put in place
to make it so that those denial of claims that are bona fide
claims don't happen to begin with?
Ms. Britton. That is the increased training that we've
done. So we've done training on the markers which is an area
where we know that specialized experience is required.
Chairman Tester. Okay. I talked about the Deborah Sampson
Act earlier in my opening statement. And we talked about some
of the things it could do. From your eyeballs, Dr. Scavella,
what tangible improvements has the VA seen as a result of the
measures in the Deborah Sampson Act, and does Congress need to
do anything else?
Ms. Scavella. Thank you for that question. So I do want to
turn that over to Ms. Britton because she has been
predominantly working on that.
Ms. Britton. So with the Deborah Sampson Act, we have
implemented those recommendations. For Section 5205 which is
the recommendation that speaks to the women's veteran service
coordinators, we do have those coordinators at all of our
regional offices. For 5501, which is the military sexual trauma
conditions, that is related to the MST processing site and the
improved training that I spoke about with the markers.
We do have implemented as part of a mandatory requirement
for our MST, for our examinations, that all veterans are given
the option in the examination notification letter to select a
gender-specific examiner.
And then also with 5503 which is the piece that speaks
about the OIG and their review, we did receive over 48,000
claims in FY '23. We've completed over 43,000. As I stated
earlier, that grant rate has improved over the past few years
from 2011 up until to date. We've seen a significant increase
in the grant rate.
Chairman Tester. Okay. I mean, I think the bottom line is
here is we all need to be on the same page when it comes to
women's health, in particularly, military sexual trauma.
And in the end, statistics are really good, except I get
lost in them. I just want to make sure that the women veterans
are getting what they need when they go to the VA and they're
not being turned away. They're not being hit with red tape.
They're being accommodated with the challenges they have.
With that, we're going to get to the second panel because
they're very, very important also. But I want to thank all of
you for your testimony and you are dismissed, as I would say
when I was a school teacher, and we'll bring up the second
panel.
Ms. Scavella. Thank you.
Chairman Tester. I'm going to start introducing
reintroducing the second panel now. First up that's going to
testify first is going to be Dr. Alissa Engel. Alissa is a
Montanan, wears many hats. Dr. Engel is a veteran, a therapist
specializing in military and veteran community, a volunteer
mentor coordinator for Montana's Eighth Judicial District
Veterans Treatment Court, and she is a current member of the
Montana International Guard.
We also have Julie Howell that is an Associate Legislative
Director at PVA, that's Paralyzed Veterans of America. We have
Dr. Kirsten Laha-Walsh, who is a Government Affairs Specialist
for the Wounded Warriors Project. And Naomi Mathis, the
Assistant National Legislative Director for the DAV, Disabled
American Veterans.
And we want to thank all four of you for being here today.
And as I said, we will start with you Dr. Engel, thank you for
making the trek from Montana. It is good to see you again, and
you may proceed. No, this Great Falls, Montana, one of the most
beautiful places on earth.
And the four of your entire written statement will be part
of the record. I would like to ask you to keep your verbal
statement within five minutes. Thank you.
PANEL II
----------
STATEMENT OF ALISSA ENGEL, PHD, LCPC, LMFT, MENTAL HEALTH
THERAPIST, VETERAN
Ms. Engel. Good afternoon, Chairman Tester, Ranking Member
Moran, and Committee Members. Thank you for the opportunity to
speak with you all today.
I'd like to focus on military sexual trauma and the claims
process. It is crucial that MST claims be processed accurately
and in a timely manner. The consequences of an incorrect denial
are catastrophic. When we have an MST claim filed, we are being
handed the opportunity to right a wrong for that veteran. This
is a privilege that they don't have to give us because by that
point, they've already been through hell.
I touched on the topics of institutional betrayal and moral
injury in my written testimony because both play a role in the
nature and type of PTSD we see with MST. The inclusion of one
or both often results in the development of what we call
complex PTSD.
A denied MST claim is a just another layer of institutional
betrayal. Many victims wait to report, if they report at all,
until they are discharged from the military, assuming it will
be safer or because they desperately need the resources. When
their claim is denied and they're left feeling betrayed,
worthless, abandoned, and unsafe all over again, and the
institution that should be helping and protecting has just
further complicated their trauma.
Conversely, having a claim approved is a powerful healing
tool. It's the equivalent of a guilty verdict in court. It
doesn't eliminate the trauma memory, and it doesn't heal the
trauma reactions, but it also doesn't compound the trauma, and
it lays a priceless foundation for healing.
A validated disability claim tells the victim, we believe
you. What happened to you wasn't your fault, and it shouldn't
have happened on our watch. It tells the victim that as a
Nation, we truly are grateful and that we will stand beside
them.
Given the current MST claims processing procedures, we
cannot look at our women vets in the eye and honestly tell them
that be we believe them and will provide them with the services
they need to heal. We must enact the necessary changes to
create an impeccable trauma-informed claims processing
procedure.
When I accompanied the marine veteran that I referred to in
my written testimony to her claims appointment with the VSO,
she couldn't focus. She froze. She didn't remember what was
discussed in the meeting. This just illustrates how complicated
and terrifying the process is; how trauma instinctively throws
the veteran into survival mode and shuts down the brain's
ability to manage such a complicated process.
It's also very difficult to prove MST when most victims
don't report, they don't seek medical care and they don't tell
anyone for years. Neither of the women veterans I spoke about
in my written testimony, reported their assaults to the
military. They do not have DoD documentation to substantiate
their claim. They have their story that they've told, maybe one
or two people in a fragmented memory. That's how sexual trauma
works.
If you sit with someone who trusts you enough to tell you
their story, the pain and betrayal are palpable. But earning
this level of trust takes time. The current claims process
doesn't allow examiners the luxury of time. They see a veteran
who enters the exam room in pure survival mode one time. The
examiner might be a male, they're in a sterile and foreign
meeting space, and they're asking questions about the worst
moments of that veteran's life. It's impossible to get an
accurate determination under these circumstances.
The VA must find a better way to substantiate MST claims.
Why do we presume dishonesty until proven otherwise? What if we
created our processes based on research, which gives us an
overwhelming amount of evidence that victims tell the truth?
The consequences of denying a valid claim are far greater than
the consequences of approving the very rare false claim.
In addition to improving MST claims processing, we must
also fix the referral and authorization system. When a woman
veteran is ready to engage in mental health care or care
related to other MST injuries, it is imperative that they have
easy access to a network of highly trained professionals.
In grad school, I invited the dean of the law school and
the director of the Veteran Law Clinic to sit on my
dissertation defense committee. It's pretty risky business to
invite a lawyer to ask you as many questions as they want about
your research, but she only asked me one, and it will haunt me
forever.
She told me that her high school-age daughter was
interested in going to the Air Force Academy and that she had a
very competitive application. And then she asked me if I
thought she should encourage it. And my answer was, ``I don't
know.'' Which is also the answer you really don't ever want to
give in a dissertation defense. But it was the honest answer
with the MST epidemic raging and the aftercare lacking.
I can't in good conscience encourage anyone to send their
child to basic training. My hope is that in the very near
future, thanks to the good work of so many, I'll be able to
say, ``Yes, absolutely. The military is a wonderful career path
for your daughter.''
Thank you for your time, and I welcome any questions.
[The prepared statement of Ms. Engel appears on page 65 of
the Appendix.]
Chairman Tester. Doctor, thank you. There will be
questions. Julie Howell.
STATEMENT OF JULIE HOWELL, ASSOCIATE LEGISLATIVE DIRECTOR,
PARALYZED VETERANS OF AMERICA
Ms. Howell. Chairman Tester, Ranking Member Moran, and
Members of the Committee, Paralyzed Veterans of America, thanks
you for the opportunity to present our views on the current
state of care for women veterans.
Few veterans understand the full scope of benefits offered
by VA better than PVA members. Ensuring the women members of
PVA have timely access to quality care will help VA be better
positioned to deliver care for all veterans, particularly those
with complex illnesses and injuries.
We've all heard that women are the fastest growing
demographic or the fastest growing cohort of veterans using the
VA accounting for nearly 30 percent of all new VA enrollees. It
is our obligation to ensure that all women veterans encounter
barrier free access to healthcare and benefits.
We commend Congress on several legislative victories for
women veterans over the past few years, such as the MAMMO Act,
the SERVICE Act, the MST Claims Coordination Act, and the
Deborah Sampson Act. Collectively, these bills represent a huge
investment in women veterans. However, as we all know, there's
still plenty of work to be done.
In our written statement, you will find several topics that
we believe need additional attention. But in the interest of
time, I'd like to focus on a few areas that are of the utmost
concern to PVA. The Deborah Sampson Act was a major achievement
that became the vehicle to draw attention to the deficiencies
encountered by women veterans when accessing VA.
While many women veterans have benefited from its passage,
it's had little impact on PVAs women members. VA still lacks
critical accessibility accommodations that our members rely on.
Barriers for our women members that they encounter when
accessing gender-specific care are an issue and VA needs to
take them seriously.
It starts with parking lots with limited disability
parking, check-in counters that are too high, waiting in exam
rooms that are too small, limited ceiling lifts, and a general
lack of accessible medical diagnostic equipment. This is why we
support the Veterans Accessibility Advisory Committee Act to
ensure that VA prioritizes accessibility for all of our
disabled veterans.
I'd also like to take a minute to discuss the very
sensitive issue of military sexual trauma. MST is pervasive,
and we must do everything we can to treat survivors with the
utmost care and respect. Mr. Chairman, in a 2021 survey of our
women members, nearly 40 percent of them reported that they had
experience with MST. Forty percent know a provision within the
DSA mandate that survivors could pick the preferred gender of
the providers they engage with. However, we are hearing from
our service officers that that is not always offered and that
is not standard across the board.
Many of our members are filing their MST claims decades
after their experience. And for SCI/D veterans, some of those
physical long-range symptoms of MST are incapable of
manifesting. However, that doesn't make their trauma or their
experiences any less real. VBA staff need to understand the
nuance that comes with working claims for veterans with complex
injuries.
We thank Chairman Tester for the reintroduction of the
Service Member and Veteran and Empowerment and Support Act of
2023, which we believe may help address some of these concerns.
Finally, when people imagine a disabled veteran and their
caregiver, most people imagine an older male veteran with his
wife by his side. So in contrast, I would like to introduce the
Committee to Ann Robinson. Ann Robinson is an army veteran, a
PVA, a national vice president, a wife, a mother, a
grandmother, and my friend.
Ann was injured in a military vehicle accident in 1999, and
Harry has been her dedicated caregiver and loving husband ever
since her injury. Ann's level of need is significant, and while
Harry has constantly been by her side, they need additional
help. Recent expansions of the Veteran-Directed Care Program
have provided Ann an opportunity to hire direct care workers.
However, it hasn't been that easy.
The VDC Program only allows Ann to pay her workers around
$19 an hour. And after more than 100 interviews, the few folks
that were qualified and hired left for higher paying jobs. In
her home of San Antonio, the staff she needs generally earn
upwards of $35 an hour.
The lack of direct care workers is a nationwide crisis, one
that hits disabled veterans with the greatest support needs
quite hard. Our Nation must increase efforts to grow this
workforce, and VA needs to help by ensuring veterans with a
catastrophic injuries and illnesses are able to secure needed
direct care workers in line with market demands.
In closing, we commend the Committee for working toward the
passage of the Elizabeth Dole Home Care Act. PVA members are
eager to see this bill become law. We urge Congress to pass
this as soon as possible because our Nation's most vulnerable
veterans should receive care in the comfort of their home
should they choose.
Many argue that this level of care costs too much. However,
in recent years, we've talked a lot about the true cost of war
and in many like her have earned their benefits. The lifelong
supports that they need are the true cost of military service.
Thank you to the Committee for giving PVA this opportunity to
share our views, and I'm happy to answer any questions.
[The prepared statement of Ms. Howell appears on page 73 of
the Appendix.]
Chairman Tester. Thank you, Julie. If we can't take care of
our veterans when they come home, we shouldn't send them off to
begin with. Kristen, you're up.
STATEMENT OF KIRSTEN LAHA-WALSH, PHD, GOVERNMENT AFFAIRS
SPECIALIST, WOUNDED WARRIOR PROJECT
Dr. Laha-Walsh. Good afternoon, Chairman Tester, Ranking
Member Moran, and distinguished Members of the Committee. On
behalf of Wounded Warrior Project, I want to thank you for the
opportunity to speak before you today about how Congress, VA,
and the wider community can better support women veterans.
Since 2003, Wounded Warrior Project has been working to
transform the way America's injured Post-9/11 veterans are
empowered, employed, and engaged in their communities. For the
past 20 years, we have supported warriors through and beyond
their transitions to civilian life with services in mental
health, physical health, peer connection, career counseling,
and financial wellness. We currently offer these services to
over 200,000 veterans across the country, and we are welcoming
hundreds more every month.
And as key context to today's hearing, I want to briefly
highlight how we are serving more than 35,000 women warriors.
We have taken deliberate steps through our Women Warriors
Initiative, which supports these veterans through tailored
programs and services such as women only peer support groups,
or culturally competent mental healthcare that can be offered
in gender-specific cohorts.
Through our physical health and wellness program, we offer
female-focused opportunities such as multi-week courses that
provide education on topics such as perimenopause and
postmenopause challenges and experiences. And in fiscal year
2023, more than 5,000 women participated in our connection
programming to build bonds with other veterans in their areas,
and over 130 women stepped up to serve as warrior and peer
leaders in their local communities.
Most notably for today, I am pleased to share insights we
gained through the development of our ``2023 Women Warriors
Report.'' The report serves as a beacon shedding light on the
experiences, struggles, and triumphs of our women veterans.
While our written hearing statement includes more perspective,
I'd like to highlight three of our key focus areas in the Women
Warriors Report, and to provide insight into the policy
recommendations we develop through our data.
First, the report highlights the critical importance of
mental health support for women veterans. Anxiety is the number
one injury or health problem reported by women warriors, and
like PTSD and depression is reported at a higher rate than
males. But while women warriors are also more likely to report
moderate or severe mental health symptoms, they are also more
likely to seek support and care than male warriors.
It is incumbent upon us to expand access to mental health
services to meet the warrior where they are, de-stigmatize
seeking help, and foster a culture of care and compassion
within our veteran community. Congress should continue to help
VA retain, recruit, and train mental health providers and
continue oversight to ensure VA is creating community referrals
for care if it cannot provide timely services itself.
We also encourage the Committee to consider broader issues
such as women veterans not feeling respected within their
communities, which can lead to feeling isolated, left out, or
lonely, all of which were reported as top issues for women
warriors.
A second central focus of the report pertains to healthcare
access and quality. Women warriors are more likely to navigate
the VA system with three in four using VA medical centers for
primary care. However, only 61.9 percent use VA for women's
healthcare-specific services.
In recent years, women veterans have often cited feeling
harassed at VA medical facilities, which has dissuaded use by
many. But VA has worked hard in recent years to ensure women
veterans feel safe and appreciated while accessing healthcare.
Another challenge presented was that more than half of our
women warriors reported delaying or putting off getting
healthcare, with barriers including, a lack of cultural
competency from providers and staff. This issue is especially
important for individuals who have survived MST.
With over two-thirds of our women warriors experiencing
sexual harassment while in service and more than 2 in 5
reporting having experienced sexual assault, it is imperative
that VA support services through the benefits process as well
as through healthcare. More broadly, from accessing gender-
specific care that is culturally competent, to feeling listened
to by providers and staff, there is a critical need for
tailored, comprehensive benefits and healthcare initiatives
that prioritize the well-being of our women veteran population.
A third focus centered around the financial wellness for
women warriors, which included topics such as career
advancement and leadership opportunities for women with a
military background. Despite being more educated, women
warriors face greater struggles with employment than males.
With 1 in 10 women warriors reporting unemployment, we've heard
many stories about adverse factors like a lack of professional
mentorship, difficulty translating military skills to the
civilian workforce, and finding employers who are supportive.
Congress can help take proactive steps to address issues
like these by continuing to invest in workforce training and
education initiatives such as the Edith Nourse Rogers STEM
Scholarship and VET TEC programs. Both have a high potential to
benefit women warriors, specifically.
In the coming days, weeks, and months, we look forward to
continued discussions with leaders, VSO partners, and the
broader community, along with opportunities to translate the
insights and finding of this report into tangible initiatives
and concrete action. We are steadfast in our commitment to our
women warriors, ensuring that they receive the respect,
recognition, and support they so rightfully deserve.
Thank you, again, for the opportunity to testify before you
this afternoon. I look forward to answering any questions you
may have.
[The prepared statement of Dr. Laha-Walsh appears on page
82 of the Appendix.]
Chairman Tester. Kristen, thank you for your testimony.
Naomi, you have the floor.
STATEMENT OF NAOMI MATHIS, ASSISTANT NATIONAL LEGISLATIVE
DIRECTOR, DISABLED AMERICAN VETERANS
Ms. Mathis. Thank you, Chairman Tester. We appreciate the
opportunity to discuss DAV's new report, ``Women Veterans: The
Journey to Mental Wellness.''
Our report comes on the heels of VA's most recent veteran
suicide prevention report, which showed overall increased rates
of suicide for veterans. However, the most alarming finding was
that the suicide rate among women veterans jumped more than 24
percent in 2021. That's nearly four times higher than the
increase among male veterans, and vastly higher than the
increase among non-veteran women.
Our report looked at the unique risk factors contributing
to the staggering rate of suicide among women veterans, and the
challenges and obstacles women veterans face on their journeys
to mental wellness. DAV offers more than 50 legislative and
policy recommendations that have the potential to save the
lives of women veterans.
The issue of lethal means safety is especially important as
firearms were used in more than half of women veterans'
suicide. In fact, the rate of women veterans dying by firearm
suicide was nearly three times higher than for non-veteran
women. VA has included women veterans in its lethal means
safety campaigns. Unfortunately, some women veterans felt the
ads did not make clear why it was so important to keep their
firearms safely stored.
DAV recommended the VA should conduct additional focus
groups with women veterans to determine the most effective
secure firearm storage messages and messengers for this
population.
We also found that military sexual trauma, MST, and
interpersonal violence, IPV, led to an increased risk for
suicidal ideation and self-harm behaviors among women veterans.
One in three women veterans enrolled in VA care report
experiencing MST, and one in five women veterans using VA
primary care reported experiencing IPV or domestic assault. For
these reasons, DAV strongly recommends that MST and IPV be
essential pillars of VA suicide prevention reports.
Research also shows there is a direct link between trauma
and substance use disorder, as well as eating disorders, which
often stems from an attempt to control chronic pain or to cope
with post-traumatic stress. The risk of suicide death among
women veterans with active substance use disorder is more than
two times the rate of male veterans.
Unfortunately, most women veterans with at-risk alcohol use
are not in treatment, citing stigma and discomfort with mixed
gender programs as reasons for not engaging in treatment.
We found geography and barriers to accessing mental
healthcare can be another risk factor for suicide. Research
shows that there is a 20 percent increased risk for suicide
among rural veterans. Mr. Chairman, as you know, one in four
women veterans who use VA healthcare services live in rural
areas. And rural women veterans have higher rates of suicide by
firearm than their urban women veteran peers.
Perhaps the most underappreciated aspect of women veterans
health is the relationship and impact of reproductive health
issues on mental health. During the lifecycle of women;
pregnancy, birth, and menopause can bring about significant
hormonal shifts and increase the possibility for mental health
issues, including increased risk for postpartum depression and
poor mother infant bonding.
I know firsthand how dramatically pregnancy can impact a
person's mental health. Following my service in Iraq, I was
diagnosed with PTSD. Later, I became pregnant and medical
complications forced me to give birth to my son two months
early. Subsequently, I began experiencing severe postpartum
depression. One day while my baby boy was sleeping on the bed,
I started having terrible intrusive thoughts that threatened to
harm both of us.
This served as a wake-up call for me, and I quickly got the
mental healthcare I needed. While I was fortunate to get the
right help to get through my crisis, many women veterans are
not even aware of the powerful impact hormonal changes can have
on their mental health.
In conclusion, the successes and gaps in DAV's report
highlight the importance of continuing to invest in VA women-
centered research programs and services, and targeted suicide
prevention efforts.
Mr. Chairman, this completes my statement, and I look
forward to answering any questions the Committee may have.
[The prepared statement of Ms. Mathis appears on page 96 of
the Appendix.]
Chairman Tester. I appreciate all your testimonies. Thank
you very, very, very much. And I'll start with Senator King, if
you have questions.
Senator King [presiding]. I do. All of the discussion today
has about been treating MST, and it's ramifications and
implications, and the terrible toll that it takes. But I'm
sitting here saying, ``Shouldn't we be doing more to prevent it
from happening in the first place?'' Am I correct that the
figure is 1 in 3 female veterans report military sexual trauma?
That's unacceptable.
And I also serve on the Armed Services Committee. We've had
a lot of work over the last 10 years led by Kirsten Gillibrand,
as you know, on changing the rules and the regulations. But it
seems to me we're really talking about a culture change, that
this kind of conduct is just unacceptable. But your testimony
has been very powerful, and I agree with everything you said
about better treatment; more than one interview, more training.
But Mr. Chairman, we also--I'm the Chairman. Okay.
[Laughter.]
Senator King. Well, in that case, no, but we really have to
keep--I hope you'll work with us, with my office on dealing
with these issues not only here, but in the Armed Services
Committee. Because if there's more than we can do, let's do it.
But the hardest thing is culture change. But I remember
many years ago when drunk driving was an epidemic in this
country, and it became not cool sometime in the '70s and '80s,
and now the level is much reduced. It was a culture change. And
so, we need to be thinking about that.
Ms. Howell, you talked about outreach, suggestions for
improving outreach. You heard my questions of the prior panel.
What can we do specifically better contact the TAP? What is it
going to take to get more women veterans into the system where
help is available?
Ms. Howell. Thank you for that question, sir. The work that
VA is doing to get the word out in TAP is great. That's also a
very small portion of the veteran population. Most veterans
engage with VA several years after they've already separated.
That's the way this usually works. They engage with all the
support services years after----
Senator King. Yes. One of the most dangerous periods is
the----
Ms. Howell. Is that transition.
Senator King [continuing]. Immediate post-separation.
Ms. Howell. If I may just take a second, sir. One of the
questions you asked to the first panel was, how come such few,
like, why such a small percentage of women veterans are
actually engaging with VA? What do we need to get them there?
But then you also just answered your own question in that
this trauma happens at DoD, and then we expect VA to fix the
problem. Women are not going to--many women are not comfortable
going to VA because what happens when you run into a bunch of
people that you then assume are a danger and a threat?
Like my neighbor commented earlier, women are not a
monolith, no veteran group is, we need various channels to be
able to create a net so that all of those outreach efforts can
align. You can do your standard, let's go have 140,000 touch
points with veterans throughout a year, but if you're not
engaging with the local communities that those women feel
comfortable in, you're going to miss those folks.
We can't spend all of our time--while it, yes, it's
absolutely critical to focus on transitioning service members,
plenty of MST claims come in decades after these women serve.
We don't feel comfortable addressing that concern in the
moment. It's a trauma response, as was said earlier. So we
can't think that any one outreach method is going to be a in
catchment for all veterans.
Senator King. Well, to the extent you all have ideas along
this, we don't have to do it all right here, be in touch with
us, with the Committee, with the Chairman, with my office,
because the most valuable commodity around here are ideas. And
you're in touch with the field to tell us what can be done,
what the steps are.
One of my problems on armed services since the very
beginning of my tenure here is that I believe that the Defense
Department should spend as much time, money, and effort on
transition out as they do on recruiting in. And we are looking
for all kinds of ways to improve the handoff, for example, by
notifying the state veterans' officer when somebody is going to
be coming out and going to their state.
So, a lot of those rules, but please give me as much help
as you possibly can. Your testimony has been very sobering.
Dr. Engel, you, you talked about the process. I like the
idea that one interview is not enough. Is the process
improving? I don't want to be like your dissertation.
[Laughter.]
Ms. Engel. I was thinking that. I don't think so. I don't
think that MST reporting process is improving.
Senator King. Well, tell me how? You don't have to tell me
now, my time is expired, but we have this little digital clock
in front of us that governs our life. But seriously, don't let
your input to this Committee end today. If you have thoughts
how to improve it; require two interviews, ensure that there
are female intake officers? What should the criteria be? What
is the standard? All of those things help us to understand that
because we may be in a position to fix it.
Ms. Engel. Yes, sir.
Senator King. Thank you. Thank you all very much. Your
testimony is very important. Really appreciate it.
Chairman Tester [presiding]. Senator Hassan.
HON. MARGARET WOOD HASSAN,
U.S. SENATOR FROM NEW HAMPSHIRE
Senator Hassan. Thank you, Mr. Chair. And I just want to
echo what Senator King just said. Your testimony is really,
really important, and it also can be really, really hard. No
matter how practiced you get at this sharing personal details
and wearing the experiences of so many other veterans who
you're speaking for today is a hard thing to do. So we are
really, really grateful to you for that.
I wanted to start with a question to Dr. Laha-Walsh. In its
``2023 Women's Warriors Report,'' the Wounded Warrior Project
discussed several difficulties faced by women veterans,
including a lack of support as they transition from military
service to civilian life. So you discussed this in your
testimony and you mentioned that many women warriors are more
likely to experience loneliness, isolation, and a lack of
respect for their military services compared to their male
peers.
As more women veterans leave the military and enter
civilian life, one of the strongest ties to their service is
their connection with the VA. So Doctor, what can the VA do to
help address the loneliness, isolation, and other issues that
women veterans disproportionately face?
Dr. Laha-Walsh. Thank you for the question. We have several
recommendations in our report that we believe would address
certain aspects of connecting women veterans to engage more
with their community. We have also made recommendations,
specifically, around increasing eligibility for scholarships
because we also see a lot of women veterans and women warriors,
specifically, that are wanting to pursue higher education.
But I would say, specifically, there is a recommendation in
our report that focuses around building out a professional
mentorship network. A lot of women veterans feel that they have
to compete amongst other women veterans while in service. So
when they get out, they don't have a net to fall socially.
Many women warriors in our focus groups last year also
spoke about the, the need to separate their civilian friends
from their military background friends. They didn't want to co-
mingle or intermix the groups. So, providing a professional
mentorship network would allow women veterans who have achieved
career milestones to support those in the transition process
and it would be facilitated by VA.
We believe that program potentially would not only increase
productivity within connectivity, but also would stimulate
further conversations about what women veterans can do to
support each other on the outside.
Senator Hassan. Thank you. That's very helpful. Ms. Howell,
in your testimony, you discussed some of the challenges that
women veterans with spinal cord injury and disease face. You
specifically discussed how difficult it is for these veterans
to receive gender-specific care through the VA's spinal cord
injury and disease system because of the high level of
coordination required between this system and the VA's Women
health clinics.
You also stated that many women's clinics are not
physically accessible for paralyzed women veterans. So, what
can the VA do to make care more accessible and more effective
for women veterans with spinal cord injury and disease?
Ms. Howell. Thank you for that question, Senator. I think
what is true of all things within VA, particularly around
gender-specific care, is coordination. VA is very siloed. Most
of us up here are VA users. One of the very unique things about
VA as compared to community care at large is that there is that
continuum; your doctors are tracking, everyone's got access to
full records. You don't have to necessarily be proactive about
that outreach.
However, within VA for women that are using the SCI
centers, that coordination is very hit or miss. It relies on a
coordinator to be in the SCI center that's willing to take the
time to build those relationships. You need a women's health
clinic or a gender-specific provider that has the bandwidth to
go over to the SCI unit, because more often than not, the
women's health clinic is going to lack those fundamental
accessibility requirements that keep our women members safe.
And so, that cross team coordination, that takes a lot of
bandwidth, and it takes a lot of effort, and sometimes it takes
an external pressure to make sure that people are making those
connections so that the PVA women members can receive
accessible gender-specific care, either in an accessible
women's clinic or through the SCI center.
Senator Hassan. Okay. Thank you very much. And Mr. Chair, I
yield my time.
Chairman Tester. Yes. Thank you, Senator Hassan. I'm going
to start with you Dr. Engel. I share many of your concerns
about the military sexual trauma claims process and would like
your input on a change that may help use the process for
survivors.
When so many sexual assaults go unreported in the military,
it is my belief that we need to require the VA to consider non-
DoD evidence. Check out those sources when reviewing claims for
all MST-related mental health conditions. I'd like you to
comment on that. I would like you to tell me if this could
potentially change the impact for MST survivors, or if this is
not something that's worthwhile.
Ms. Engel. Thank you for that question. I absolutely think
that that would make it better for survivors. Like we've talked
about they typically don't report, or they report after a large
amount of time goes by. And when they do report, it tends to be
people that they're close to; their spouses, their friends,
their family. Not the formal channels.
So if we allow non-DoD proof, it really opens up the door
there. The other piece about--that is when we're looking at
trauma-informed care, we always want to give the power and
control back to the veteran that was taken from them. And right
now they're kind of put in a position where I get my disability
claim for my MST, but I have to do these things that I don't
want to do, or I don't get my claim. By doing what you're
suggesting, sir, it gives them more power and control. They get
to choose what evidence they want to bring instead of having to
produce certain evidence.
Chairman Tester. Okay. Thank you. I'm grateful for the
support all the VSOs that are up here today for the
Servicemembers and Veterans Empowerment and Support Act. I
appreciate that. It would expand evidentiary standard for MST
claims and make improvements in that claims process. So thank
you for that because if we want to do right by MST survivors,
we need to give them a stronger voice, you, a stronger voice in
this process.
So this is for the PVA, and Women Warriors, and DAV. Can
you each take a moment to describe the impact this bill would
have on MST survivors and their access to VA healthcare and
benefits? You can go in any order you want.
Ms. Mathis. Thank you for that question, sir. DAV strongly
supports this legislation. In fact, we did a grassroots
campaign on it, which resulted in over 22,000 emails from our
members in support of this bill.
And this bill will help ensure veterans are aware of access
to care and services for conditions related to their trauma,
and they don't face unnecessary hardships throughout the claims
process.
Dr. Laha-Walsh. Again, thank you for the question. We found
that women veterans are actually more likely to include more
non-direct evidence, which include the word performance
records, financial documents, demonstrating unexplained
financial situations. So because of that and many other things,
we support strongly the SAVES Act.
We also are very supportive of ensuring that all guard and
reserve members are able to receive MST-related services,
including mental health care, which is also provisioned within
this bill. And we very strongly support that.
Chairman Tester. Julie?
Ms. Howell. Thank you for the question, sir. I just want to
highlight that nearly 36,000 service members reported sexual
assault in FY '22 according to DoD, and as we've already
discussed, that's only the reported ones.
I think that your piece of legislation will be critical in
making sure that when veterans come forward with their claim,
that they don't feel the need to provide the textbook
evidentiary support. I think that will provide a comfort level
for people that are applying for these claims. That will see an
increase in applications.
I also think for PVA, in particular, Section 206, will have
a really profound impact. The study on training and processing
of claims. PVA believes that critical information can be
gleaned from the process by that section in particular.
And as I mentioned in my testimony the complications that
come with veterans with complex injuries and comorbidities when
they're filing an MST claim, a lot of those long-range physical
manifestations don't necessarily manifest with our membership.
So, I think being able to present that case with the
evidence that you have will go a long way. And that study will
show whether or not VBA is sticking to it.
Chairman Tester. I'm going to ask a few more questions,
then I'll get to you, Senator King, if that's okay.
Naomi, I want to talk to you about something on a personal
level and in a more general level. And this deals with mental
health. You talked about in your opening statement, the impact
of childbirth had and the thoughts that went through your head.
But something happened, and you went and got help. Have you
ever thought about why that occurred? Was it because of your
association with DAV, or was it the fact that you've got
somebody that knows you well enough to understand when there
was a challenge, or? Talk to me.
Because sometimes this doesn't happen and you don't get
help, and then, you know, it's like any other health that I'm
on. If you don't get health help, it gets worse. Talk to me.
Ms. Mathis. Thank you, sir. I would say at the time I was
in acute PTSD. I was in the throes of PTSD after coming back
from Iraq as a combat veteran and dealing with that, and then
the hormonal changes with having my child along with
polypharmacy. I was on several medications. They were trying to
figure out how--you know, which medication would actually work
for me.
And as that incident happened, it just scared me in what I
would potentially do to both of us. And so, it wasn't really
anything specific. It was just myself trying to will myself out
of it, and really crawl up out of that hole that I was in, and
my ability to reach out and say, hey, something's not right.
This is not okay. I'm scared.
Chairman Tester. And you were able to get ahold of somebody
that could help you.
Ms. Mathis. I was able to get ahold of someone, and that's
why peer support is so important. And social support, it's
really a protective factor when it comes to suicide prevention.
Chairman Tester. 100 percent. And I think it's one of the
reasons you see a 20 percent higher rate of suicide in rural
America, because isolation is something that happens
automatically if you're living where there is no people.
I just want really quickly, and I'll get to you, Angus,
half the suicides committed by women. Did I get this right are
done with guns?
Ms. Mathis. Yes, sir. More than 50 percent, actually.
Chairman Tester. Okay. And the rate has went up by 24
percent. At least that's what the 2021 study said. I'm a
farmer, okay, I'm not a mental health professional at any sense
of the imagination, but I have always been told that suicide by
guns with women is rare.
Ms. Mathis. In fact, and I'm not a doctor either, but from
what we found, they generally use medication. So overdoses or
strangulation is the--usually.
Chairman Tester. So the question here is, is this something
that's outside the norm for veterans?
Ms. Mathis. It seems to be. Yes, sir. Well, it seems to be
that veterans that is the----
Chairman Tester. For women veterans.
Ms. Mathis [continuing]. For women veterans, that is the
method that's chosen compared to their non-veteran peers.
Chairman Tester. Yes. And I guess it probably takes
somebody, I mean, maybe it's familiarity, but oftentimes
familiarity with guns will make it so you don't use it. But
maybe not. I could be wrong.
Ms. Mathis. Which is why it's important, sir. There is a
time between the thought of suicide, and having that
accessibility, and actually potentially taking their life by a
gun.
Chairman Tester. It's interesting you say that because
about a month ago, I had a gentleman in my office, a guy
veteran, that tried to commit suicide with a gun, and the
bullet didn't fire. And he immediately went and got help.
And he's alive today because it, you know, the blunt
instrument didn't work. And he's living a great life, by the
way. Living a great life, but he went and got help just like
you did. And the problem, it can be fixed. The stigma needs to
be taken away so that people understand this. Angus.
Senator King. I just want to be sure in our discussion here
to get on the record, that I suspect there's nobody in this
room who wants to fix these problems more than Dr. Scavella.
And everyone I've worked with at the VA care deeply. They
wouldn't be there otherwise.
And so, I don't want to leave hanging that somehow the VA,
they don't care. They're too bureaucratic. The VA people I've
worked with at the CBOC in Maine, at Togus, the Veterans
Hospital in Maine, they're people who are there by choice. So I
just wanted to be sure, Mr. Chairman, that was on the record.
The four women who preceded you care about this issue
deeply, and what we need to do is come together to share
experiences and find solutions. So, thank you for that. And I
want to thank our prior panel as well. Thank you.
Chairman Tester. The only thing I would add to that is not
only the four women who work for the VA, but the woman who
works for the IG cares about it too. And thank, thank you all
for your testimony today. I very much appreciate you guys
taking the time to be here to talk about this very, very
important issue.
This isn't the last time, by the way, we are going to deal
with this. We are going to have a roundtable that includes more
Veterans Service Organizations, more people's perspective
because this is an issue we've got to find solutions for
because honestly it's a bad deal.
And I would say this, Angus, you talked about training to
get out of service. I think if the military started doing that,
it would help in the recruitment greatly. I don't think there's
any doubt about that.
So, I want to thank the witnesses for testifying. We will
keep this record open for a week for comment. This hearing is
now adjourned.
[Whereupon, at 5:23 p.m., the hearing was adjourned.]
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