Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1696592517675.pdf (United States)
STATEMENT OF JOY J. ILEM NATIONAL LEGISLATIVE DIRECTOR COMMITTEE ON VETERANS’ AFFAIRS SUBCOMMITTEE ON HEALTH UNITED STATES HOUSE OF REPRESENTATIVES JULY 1, 2020 Chairwoman Brownley, Ranking Member Dunn and Members of the Subcommittee: Thank you for inviting DAV (Disabled American Veterans) to provide a statement on veterans’ access to reproductive health care and services through the Department of Veterans Affairs (VA).
As you know, DAV represents more than one million wartime service-disabled veterans—many with serious injuries or illnesses that have impacted their overall health and well-being.

DAV is pleased to offer our views on this important issue under consideration by the Subcommittee.
Madam Chairwoman, DAV’s two reports on women veterans released in 2014 and 2018—Women Veterans: The Long Journey Home and Women Veterans: The Journey Ahead both included recommendations regarding women veterans’ access to reproductive health.

Reproductive health is a critical part of persons’ overall well-being and health.

For women, reproductive health encompasses gynecological health at all ages and stages of their life.
Starting with the Persian Gulf War and followed by the wars in Iraq and Afghanistan, we began to see an increasing number of women serving on active duty, in reserve units and the National Guard.

After troops began returning from those deployments, VA began to see increasing numbers of younger women veterans seeking services from the VA health care system.
This subpopulation of women veterans are more racially and ethnically diverse and more likely to have service-connected disabilities and more complex health histories.
According to VA, there was a 175% increase in women seeking VA health care services between 2000 and 2015.1 Likewise, the number of women veterans in their childbearing years grew 2.3-fold over the same period.2 Women veterans’ reliance on the Veterans Health Administration (VHA) has also significantly increased especially among women of past service eras.

For women veterans, their military experiences can also influence their reproductive health in important ways.
Given the increasing numbers of women serving in the military and women veterans, it is critical to understand the health impact of service-related toxic exposures on their reproductive health.

Over a relatively short time period, VA was challenged to put in place the comprehensive health services, including reproductive health care services, that younger women in their childbearing years required.
VA also had to look at the variations in the women 1 Sourcebook: Women Veterans in the Veterans Health Administration (Sourcebook).

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2 Sourcebook.

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4: p. 22. veterans population it served, which was rapidly changing and included a wide range of ages.

To its credit, VA looked at reproductive health across the age spectrum and focused on developing a life course approach to health care for women veterans.
VA understood that care for women of childbearing age is important, but equal emphasis had to be placed on care for women across the lifespan as they age.

VA had to build a women’s health program that ensured women veterans of all ages would have access to the same comprehensive primary health care services as their male counterparts, which included gender-specific care, maternity care through menopausal care.
This required knowledgeable providers with expertise in women’s health and the creation of a mini-residency training program for clinical staff to develop and maintain their skills in women’s health.

While a few VA facilities may offer pre and post-natal care to women veterans, none offer labor, delivery and recovery services or care to newborn infants.

Women veterans are referred to the community for these services as well as infertility services which are limited by law to certain veterans.
Access to basic gynecological screenings and more complex gender-specific care or surgical needs may also be referred to the community if a qualified women’s health provider is not available on site or due to a lower volume of women in certain locations.

About 120 VA facilities offer onsite mammography services.

These programmatic gaps require VA to refer more of women’s care through community partners, which presents challenges in continuity and coordination of care for some women veterans.
VA’s 2018 Volume 4 Sourcebook: Women Veterans in the Veterans Health Administration, indicates that women using VA are more likely to use contract services than their male peers.

(37% of women compared to 23% of male patients used some purchased care in fiscal year (FY) 2015).
3 For reproductive care in women ages 18-44, a growing portion of the population are using obstetrics or gynecological care only in purchased care settings.4 Given these findings, care coordination and training for community providers in VA’s Community Care Network is essential to ensure truly integrated care and good health outcomes for women veterans using VA services.
To ensure that women veterans receive care using a “whole health” approach, we urge VA to work toward establishing Women’s Comprehensive Care Clinics wherever it is feasibly possible to do so.

These clinics offer many advantages to care and are preferred by many women veterans who often have complex health care needs.
These clinics operate with Patient-Aligned Care Teams (PACT), that include primary care, specialty care coordinators and mental health providers, which adds to the quality of care for women veterans.

For many women, these self- contained clinics, which are often child-friendly, offer a safe and more welcoming environment for care.
Women veterans who have experienced sexual trauma often indicate the value of women’s clinics that are able to provide more privacy, more security and separate entry and egress to the clinic.

According to VA, however, only about one quarter of unique women’s clinic stops occurred in these settings in FY 2017.5 VA must continue to work on ensuring women veterans have access to health care providers that are proficient in women’s health at all VA care sites (as of FY 2018, there were 3Sourcebook.

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4 Sourcebook.

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5 2018 Women's Assessment Tool for Comprehensive Health (WATCH): An update on the Implementation of Comprehensive Women’s Health, 3/19/2019.

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2 still about 15% of VA health care facilities that lacked a designated women’s health provider).6 DAV is pleased to note, however that VA has increased training through its women’s health mini-residencies and women’s mental health champion programs.
We are also pleased that VA has developed a specialized training program to bring mini-residency training to providers living in rural areas that are interested in treating women veterans, thus increasing access and expertise, particularly in areas of the country where workforce shortages affect access to gynecologists and obstetricians.
Another promising program launched in FY 2020—the National Women’s Reproductive Mental Health Consultation Program—makes expert consultation available to all VA clinicians treating patients with premenstrual, perinatal, and perimenopausal mood disorders and mental health conditions that can be affected by gynecologic conditions.
Consultations have focused on highly complex patient presentations and prescribing considerations and reaffirm the critical need for this national resource.7 Without this program, key mental health care needs of women might not be detected or treated and DAV supports increased funding and support for this unique program.
We offer the Subcommittee the following positions on reproductive health care services for women veterans in VA. Copayments for Prescription Medication: Medicaid and private insurers consider contraceptive pharmaceuticals and devices preventive care and generally do not require copayments for this care.
Veterans should also receive these services at no cost and the mail order pharmacy should be able to fill a year-long prescription in any increment providers order whether annual, in 90-day or 30-day increments.

DAV Resolution No.

365 calls for legislation to eliminate copayments for VA health care and medication for service-connected disabled veterans.
Prenatal and Maternity Care: VA supports many pregnant women veterans who are at high risk for adverse health outcomes for themselves during pregnancy or for their newborns because of advanced age or service-connected conditions including post-traumatic stress disorder (PTSD) and depression.8 9 Given that women veterans using VA experience higher risk pregnancies that can result in pre- term delivery and low birthweight newborns, we urge Congress to extend the period it covers newborn care from 7 to at least 14 days.
VA should also cover the cost for the necessary emergency transportation of newborns to care facilities to obtain necessary critical care services (with or without the mother).

DAV Resolution No.
DAV Resolution No.

020 seeks to ensure the provision of health care services and specialized programs, inclusive of gender-specific services, by VA to eligible women veterans are provided to the same degree and extent that services are provided to eligible 6 2018 WATCH: An update on the Implementation of Comprehensive Women’s Health, 3/19/2019.

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7 Statement of Department of Veterans Affairs Secretary Robert Wilkie to Senate Veterans’ Affairs Committee, Review of the FY 2021 Budget and FY 2022 Advance Appropriations Request and Oversight of CARES Act Supplemental Appropriations for the Department of Veterans Affairs.

June 3, 2020.

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8 Katon, J., et al.

Prenatal care for women veterans who use Department of Veterans Affairs Health Care.

In Press.

Women’s Health Issues.

(4)377-381.

9 Sourcebook.

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3 male veterans, inclusive of counseling and/or psychological services incident to combat exposure or sexual trauma.

Infertility Treatment and Resources: Veterans or the spouses of veterans who have sustained injuries during military service that make it impossible for them to have a child without fertility treatment services are eligible to receive assisted reproductive technology, including in vitro fertilization (IVF).
VA must provide IVF services as required by law and regulation without undue hardship for the veteran or the veteran’s spouse.

One DAV member reported she had to drive 5 hours from home each way to obtain IVF services, even though there was a fertility clinic available much closer to her home, because VA was unable to negotiate an acceptable rate of reimbursement with the local provider.
The veteran indicated that due to the long drive and time sensitivity for initial labs and testing she had to take two weeks off work to undergo and complete the process.

After three IVF attempts the veteran reported she gave up trying to utilize the benefit.10 Given the specialized nature of these services, veterans should be given every consideration possible to have a successful outcome.
As part of the authorization and approved process for these specialized clinical services, VA must take into account a veteran’s individual circumstances and work with its third-party intermediaries and community partners to do what is in the best interest of the veteran.

DAV Resolution No.

020 calls on VA to improve services to meet the unique needs of women veterans who were catastrophically wounded, suffering amputations, blindness, spinal cord injury and traumatic brain injury.
Continuity of Care during Natural Disasters and Pandemics: As we understand it, VA has done a relatively good job with maternity care during the pandemic.

Given the potential vulnerability of pregnant women to COVID-19, there was early guidance that allowed women to forego the usual required in-house testing to confirm pregnancy and obtain immediate referral to a community provider.
It is less clear if there were any specific challenges obtaining contraceptive care, but it appeared VA rapidly expanded and offered access to care through telehealth and video conferencing to patients who were scheduled for routine exams and needed medication refills.
DAV did suggest however, that more specific outreach should be conducted during these types of emergencies for women veterans with significant mental health challenges or women who may be at higher risk for suicide, homelessness, intimate partner violence or dealing with a substance use disorder.

VA Women Veterans Program Managers (WVPM), Women’s Mental Health Champions and health coordinators for breast health, maternity care and infertility services play a vital role in women veterans health outcomes.
Unfortunately, not all VA medical centers have these positions filled and, if they are filled, they are often collateral duties.

For example: in FY 2018, full-time WVPMs were present at 121/140 VA Health Care Systems (HCS) while women’s health directors or champions were present in 135/140.
While nearly 78% of VA HCS had maternity care coordinators, only 11% were full-time, dedicated staff; 74% of HCS had mammography coordinators—12% were full-time and 64% had PAP coordinators, with only 10 Women Veterans: The Journey Ahead, p. 21 4 21% of whom were assigned on a full-time basis.11 While not all facilities have the volume of women patients to support full-time women’s health coordinators, we frequently hear complaints from these coordinators that they do not have enough time to fully meet the needs of women veterans they serve.
For VA to fulfill its goal of providing women veterans equal access to well-coordinated comprehensive primary care and gender-sensitive services these critical positions must be filled at all locations and at levels that allow them to carry out these important responsibilities and provide the care women veterans need and deserve.

DAV supports the provisions included in H.R.

3224, the Deborah Sampson Act, requiring a report on staffing levels for WVPMs.
The Subcommittee should also request VA provide, in addition to the staffing levels for these positions at all sites of care, the number of women they serve to determine appropriate levels of time that should be authorized to meet demand for services.

Reproductive health is an important component of comprehensive care.
Despite ongoing challenges and shortcomings—the VA health care system is the best place for women veterans with service-connected conditions and complex health histories and for those who have experienced sexual or combat-related trauma.
VA conducts targeted research and provides comprehensive, evidence-based care and specialized services to meet the unique needs of veterans—and women veterans, like their male counterparts, should be able to take advantage of this unique system of tailored and comprehensive services.
More access to care in the community and the lack of availability for certain gender-specific services for women in VA requires Congress to provide continued oversight and targeted resources for women’s health services to ensure women veterans have timely and equal access to comprehensive health care at all VA sites of care or in coordination with its community partners.

Madam Chairwoman, thank you for holding this important hearing.
We appreciate your continuing leadership and focus on the health care needs our nation’s women veterans.

11 WATCH Report, 2019. p. 16-18.

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