Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1696592356057.pdf (United States)
FINAL EDITS STATEMENT OF SHEREEF ELNAHAL, MD, MBA UNDER SECRETARY FOR HEALTH VETERANS HEALTH ADMINISTRATION (VHA) DEPARTMENT OF VETERANS AFFAIRS (VA) BEFORE THE HOUSE COMMITTEE ON VETERANS’ AFFAIRS September 15, 2022 Good afternoon, Chairman Takano, Ranking Member Bost, and Members of the Committee.

I appreciate the opportunity to discuss women Veterans’ access to health care, including the reproductive health care services available to Veterans.
I am accompanied today by Dr. Patricia Hayes, Chief Officer, Office of Women’s Health; Dr. Amanda Johnson, Director of Reproductive Health, Office of Women’s Health; and Dr. Julianne Flynn, Acting Deputy Assistant Under Secretary for Health, Office of Integrated Veterans Care.

Introduction VHA strives to be a national leader in the provision of health care for women and pregnant Veterans, thereby raising the standard of care for all Americans.
We are committed to ensuring Veterans receive safe, high-quality health care and have therefore undergone a tremendous transformation over the last several years.

As demand for our services grows, Veterans are telling us they see a real difference, and their trust in us is higher than ever.

Over 600,000 women Veterans use VA health care, and that number is growing.

About half of the women Veterans enrolled for VA health care are in a reproductive age range.
Currently, VA maternity benefits cover peripartum care for around 6,000 unique Veterans each year.

While VA refers Veterans to community providers for their maternity care, we continue to provide important wrap- around health care services including primary, specialty and mental health care before, during and after pregnancy.
VA reproductive health services have long included fertility services, contraceptives, menopause care, maternity care and life-saving treatment related to pregnancy, such as medically needed care for Veterans presenting with ectopic pregnancy and miscarriage.

Generally stated, reproductive health is a core and vital component of comprehensive health care.

Further, VHA is dedicated to achieving equity and eliminating racial and ethnic disparities in reproductive health access and outcomes among Veterans.
Expansion of Reproductive Health Services Since the recent Supreme Court decision that overturned Roe v. Wade (Dobbs v. Jackson Women’s Health Organization, 142 S. Ct. 2228 (2022)), certain States have begun to enforce abortion bans that create urgent risks to the lives and health of pregnant Veterans and VA beneficiaries.
To protect the lives and health of Veterans, VA Page 1 of 8 modified its regulations to expand reproductive health care, thus ensuring Veterans who receive the health care under the medical benefits package and VA beneficiaries of the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) can access needed and medically necessary and appropriate reproductive health services through VA, no matter where they live.
In exercising its Federal authority, VA will now provide certain abortion-related services to Veterans and CHAMPVA beneficiaries.

This medical care includes abortion counseling and access to abortions when the life or the health of the pregnant Veteran or CHAMPVA beneficiary would be endangered if the pregnancy were carried to term or the pregnancy is the result of an act of rape or incest.
Access to abortion counseling and abortions is essential for preserving the life and health of Veterans and CHAMPVA beneficiaries.

Restricting access to abortion care has well-documented adverse health consequences, including increased risk of loss of future fertility, significant morbidity, or death.

Veterans are also at greater risk of experiencing pregnancy-related complications due to increased rates of chronic health conditions.
Therefore, to protect the life and health of pregnant Veterans and eligible beneficiaries, VA determined that it was necessary to provide access to abortion counseling and — in some cases — abortions.

VA provides both fertility care and maternity care services, which may include abortion services as part of the course of medical treatment when the life or health of the Veteran would be endangered if the pregnancy were carried to term or the pregnancy is a result of an act of rape or incest.
The population of Veterans who use VA for maternity care is at increased risk for maternal morbidity and mortality as they are older than the average non-Veteran giving birth.1 They also have higher prevalence of cardiovascular conditions2 and are more likely to be people of color, who experience higher maternal morbidity and mortality rates.3 Further, barriers limiting abortion access most profoundly affect communities that already face health care and social inequities.4 Under the amended regulatory authority, VA now will offer abortion counseling and access to abortions when the life or health of the pregnant Veteran or eligible CHAMPVA beneficiary would be endangered if the pregnancy were carried to term or when the pregnancy is the result of an act of rape or incest.
Self-reporting from the 1 Shaw JG, Joyce VR, Schmitt SK, Frayne SM, Shaw KA, Danielsen B, Kimerling R, Asch SM, Phibbs CS.

Selection of Higher Risk Pregnancies into Veterans Health Administration Programs: Discoveries from Linked Department of Veterans Affairs and California Birth Data.

Health Serv Res.

2018 Dec;53 Suppl 3(Suppl Suppl 3):5260-5284. doi: 10.1111/1475-6773.13041.

Epub 2018 Sep 10.

PMID: 30198185; PMCID: PMC6235819.


2 Combellick JL, Bastian LA, Altemus M, Womack JA, Brandt CA, Smith A, Haskell SG.

Severe Maternal Morbidity Among a Cohort of Post-9/11 Women Veterans.

J Womens Health (Larchmt).

2020 Apr;29(4):577-584. doi: 10.1089/jwh.2019.7948.

Epub 2020 Jan 6.

PMID: 31905319.

3 Combellick JL, Bastian LA, Altemus M, Womack JA, Brandt CA, Smith A, Haskell SG.

Severe Maternal Morbidity Among a Cohort of Post-9/11 Women Veterans.

J Womens Health (Larchmt).


2020 Apr;29(4):577-584. doi: 10.1089/jwh.2019.7948.

Epub 2020 Jan 6.

PMID: 31905319.

4 Alexa L Solazzo.

Different and Not Equal: The Uneven Association of Race, Poverty, and Abortion Laws on Abortion Timing, Social Problems, Volume 66, Issue 4, November 2019, Pages 519–547, https://doi.org/10.1093/socpro/spy015.

Page 2 of 8 pregnant Veteran or CHAMPVA beneficiary constitutes sufficient evidence that an act of rape or incest occurred.
We underscore that the decision to include these services is overwhelmingly a patient safety decision, as providing these services to protect the health and lives of pregnant Veterans and other beneficiaries is the primary concern of VA. VA will provide this care to Veterans whenever an appropriate health care professional determines that the care is needed to promote, preserve, or restore the health of the Veteran and is in accord with generally accepted standards of medical practice.
Additionally, this care is a CHAMPVA-covered service.

After a positive pregnancy test, most individuals engage in a conversation with their provider about pregnancy options.

Abortion counseling, when indicated, may be part of a discussion about pregnancy options and is a component of comprehensive reproductive health care.

The ability of VA to offer abortion counseling aligns with counseling offered or covered by VA regarding any other health care decision.
This allows VA health care providers to discuss information and answer questions to ensure the Veteran can make an informed decision about their health care options.

If authorized under VA’s Veterans Community Care Program, VA will pay for abortion counseling from providers in the community, where available.
In addition, if authorized under the Veterans Community Care Program, VA will pay for abortions from providers in the community, where available, in cases where the life or health of the Veteran is endangered if the pregnancy were carried to term, or the pregnancy is the result of an act of rape or incest.

It is important to emphasize that VA is taking these steps with our primary mission in mind: to preserve the lives and health of pregnant Veterans and CHAMPVA beneficiaries.
Access to abortions will be provided when the lives or health of pregnant Veterans or eligible CHAMPVA beneficiaries would be endangered if the pregnancy were carried to term or when the pregnancy is the result of an act of rape or incest, thus meeting our commitment to our patients.

VA is accepting comments on the rule and will consider those comments in the coming months.
Implementation of Expanded Reproductive Health Services Where a VHA facility currently has capability to provide any of the new reproductive health services, it may do so as of the date the Interim Final Rule was published.
Additionally, VA is taking significant steps across the system to implement access to abortion care when the life or health of the pregnant Veteran or CHAMPVA beneficiary would be endangered if the pregnancy were carried to term or when the pregnancy is the result of an act of rape or incest.

An implementation plan is under development.


Should an abortion be needed, VA anticipates that medication abortion will be a common type of care provided and is working to ensure that providers have access to training where needed, as well as needed medications, consistent with applicable U.S. Food and Drug Administration requirements.

Page 3 of 8 Qualitative pregnancy testing will be required at all VA sites of care, including community-based clinics.
VA medical centers (VAMC) will require both qualitative (whether a patient is pregnant or not) and quantitative (the level of pregnancy hormone in the blood) testing, and VA is now conducting a logistics scan of this lab capability.

VA also must survey the availability of pelvic ultrasound to assess early pregnancy, as appropriate.

Simultaneously, VA will ensure that all necessary staffing and equipment are available at sites providing these services.
Provider guidance and training, to the extent training is necessary, also are being finalized.

In cases where VA is not immediately able to provide needed care, Veterans will need to travel to other VA sites or VA contracted community sites, where available.

VAMCs will continue to adhere to existing credentialing and privileging policy requirements and will ensure practitioners who have completed any necessary training and education should be granted appropriate clinical privileges.
VA also is committed to ensuring appropriate processes are followed when employees believe fulfilling their assigned duties would compromise their sincerely held moral and religious beliefs.

VA employees may request not to participate in or facilitate the provision of some clinical care.

When this occurs, VA will go through the religious accommodation process.
VA respects the moral and religious beliefs of its employees and will ensure that all appropriate processes with respect to accommodating those beliefs are followed.

In addition, the safety of patients, providers, and staff is always a critical consideration.
VA is performing security risk assessments continually across the enterprise, which allows for augmentation of existing security resources when indicated based on real-time risk analysis and ensures a comprehensive security posture at our facilities for the safety and protection of all patients, employees and visitors.
Regarding VA authorized community care, VA is actively working to identify options on how to obtain these services in the community, including through our Community Care Network contracts and Veterans Care Agreements.

Women’s Health Innovation and Staffing Enhancements (WHISE) Beyond VHA’s expansion of reproductive health services, we continue to work to ensure that women Veterans and eligible VA beneficiaries who receive comprehensive, world-class care at VA.
The number of women Veterans enrolling in VA health care is increasing rapidly.

More women are choosing VA for their health care than ever before, with women accounting for over 30% of the increase in Veterans served over the past 5 years.

The number of women Veterans using VA health care services has more than tripled since 2001, growing from 159,810 to more than 600,000 today.

VA is committed to providing high-quality, equitable care to women Veterans at all sites of care.
To address the growing number of women Veterans who are eligible for health care, VA is strategically improving services and access for women Veterans.

Page 4 of 8 Recognizing the need to address rapidly the staffing gaps in women’s health personnel, including primary care providers, gynecologists, mental health providers, care coordinators and others across VA, in fiscal year (FY) 2021 VA launched the Women’s Health Innovation and Staffing Enhancements (WHISE) program.
WHISE provides an opportunity for sites to apply for funding for women’s health personnel or programs, such as pelvic floor physical therapy or lactation support, to mitigate local gaps in both the capability and capacity to deliver care to women Veterans.

VA has continued to enhance the quality of care for Veterans by requiring that women are offered an assignment to designated Women’s Health Primary Care Providers (WH- PCP).
These providers offer general primary care and gender-specific primary care in the context of a longitudinal patient/provider relationship.
VA research has shown that women Veterans assigned to designated WH-PCPs have higher satisfaction and higher quality of care than women assigned to other providers.5 6 In addition, the Congressionally mandated Barriers to Care Survey, which was completed in 2015 and surveyed over 8,000 women Veterans, found that women assigned to women’s health providers were more satisfied overall with their care and reported higher comfort levels and feelings of safety in VA facilities.
Currently, development of the second Barriers to Care Survey is underway.

Presently, 85.1% of women Veterans assigned to Primary Care are assigned to WH-PCPs nationwide.

All VA health care systems have at least two designated WH-PCPs, and 93% of community-based outpatient clinics have at least one WH-PCP.

VA has continued to train more providers at the Community based outpatient clinics to reach our goal of at least two WH-PCPs at every site of care.
Fertility and Family-Building Services Fertility and family-building services are essential components of the care provided to Veterans.

Infertility services are in demand within VA, with over 7,000 new cases of male infertility and 5,500 new cases of female infertility diagnosed between FY 2018 and FY 2020.

VA provides a wide range of evaluations and treatments of infertility for all eligible Veterans regardless of sexual orientation, gender identity and marital status.
This care includes fertility preservation for Veterans with medical indications (for example, for Veterans with cancer diagnoses).

Certain Veterans with service-connected conditions causing infertility and their spouses are eligible for in-vitro fertilization/assisted reproductive services.

Over 700 couples have received service- connected infertility services, including in-vitro fertilization/assisted reproductive technology services through VA since FY 2017.
5 Bastian LA, Trentalange M, Murphy TE, Brandt C, Bean-Mayberry B, Maisel NC, Wright SM, Gaetano VS, Allore H, Skanderson M, Reyes-Harvey E, Yano E, Rose D, Haskell SG.

Association between Women Veterans’ Experiences with VA Outpatient Health Care and Designation as a Women’s Health Provider in Primary Care Clinics.

Women’s Health Issues, Nov-Dec 2014, 24(6): 605-12.
6 Bean-Mayberry B, Bastian L, Trentalange M, Murphy T, Skanderson M, Allore H, Reyes- Harvey E, Maisel N, Gaetano V, Wright S, Haskell SG, Brandt C. Associations Between Provider Designation and Female-specific Cancer Screening in Women Veterans.

Medical Care, April 2015, Suppl 1:S47-S54.

Page 5 of 8 Maternity Care Coordination VA is leveraging our maternity care coordination program and the tremendous resources that exist within VA to enhance the support of pregnant and postpartum Veterans.
The Office of Women’s Health is collaborating with the Office of Mental Health and Suicide Prevention (OMHSP), the Intimate Partner Violence Assistance Program (IPVAP), VA Homeless Program Office (HPO) and others to ensure pregnant and postpartum Veterans are connected to the services they need.

We also are expanding our maternity care coordination services to follow Veterans for 1 year postpartum, which is a particularly vulnerable time for families.
A significant number of Veterans use maternity services.

In FY 2021, 39% of women Veterans using VA were of reproductive age (between age 18 and 44).

There were 11,412 new pregnancies diagnosed among users of VA care in FY 2021, and VA provided coverage for 5,904 deliveries.

Maternity care is not provided in VA facilities; instead, it is provided through VA-authorized care in the community.
Pregnant and postpartum Veterans continue to receive care in VA for other conditions and also may need primary care, emergency care and require coordination of Community Care services.

To support pregnant and postpartum Veterans, VA has developed a Maternity Care Coordination program in all VA health care systems to ensure coordination of care in VA and in the community.

In FY 2021, there were 154 Maternity Care Coordinators (MCC) across the system with MCC’s covering all VA medical centers.
VA MCCs support pregnant Veterans through every stage of pregnancy and postpartum.

MCCs help pregnant Veterans navigate health care services inside and outside of VA, connect to community resources, cope with pregnancy loss, connect to needed care after delivery and answer questions about billing.
MCCs screen Veterans for intimate partner violence; perinatal mental health conditions; substance use disorders; homelessness and food insecurity; and ensure Veterans are connected to appropriate resources and needed services.

VA also has enhanced our capacity to provide lactation services to Veterans.
VA has funded the training of lactation support providers and developed a lactation support toolkit and a lactation support community of practice to ensure Veterans have access to the lactation support they need.

Maternal Morbidity and Mortality VA recognizes that severe maternal morbidity and mortality rates are higher in the United States than in other high-income countries and that Black and American Indian/Alaska Native people are disproportionately affected.
In 2021, VA undertook a quality improvement project to assess causes, frequency and characteristics of pregnancy-associated deaths among Veterans who use VA maternity care benefits to understand ways in which the VA could best serve Veterans of reproductive age.

This population is known to be at high risk for pregnancy complications due to factors such as hypertension, mental health conditions, age and race.

Between 2010 and 2019, VA covered care for 39,766 pregnancies.
Among these, 27 pregnancy-associated deaths were confirmed.

The pregnancy-associated Page 6 of 8 mortality ratio among Veterans using VA maternity care was 67.9 per 100,000 live births.

This ratio is significantly higher than reports from a semi-national analysis at 42.3 per 100,000 live births in the general population.7 Over half of the pregnancy-associated deaths occurred in the late postpartum period, and nearly 60% of pregnancy-associated deaths were related to suicide, homicide or overdose.
Overall, mental health conditions affected 78% of pregnancies among Veterans who died in pregnancy-associated events.

VA is acting to develop innovative system-wide perinatal interventions for this high-risk population.

VA is leveraging our maternity care coordination program and the tremendous resources that exist within VA to enhance the support of pregnant and postpartum Veterans.
VA’s current stepped care, collaborative treatment model for substance use disorder, including opioid use disorder, will be initiated to support women Veterans with substance use disorder at four pilot sites early in Fiscal Year 2023.

In addition, a VA-based maternal mortality review committee has been initiated to identify and reduce preventable contributors and causes of adverse outcomes.
Ensuring a Safe, Welcoming Environment VA understands that for Veterans to trust us with their care, we must ensure a safe, welcoming environment.

VA knows that a proactively inclusive culture is essential to ensure Veterans and their families and caregivers; employees; and all who interact with VA have a safe and welcoming experience of care and services.
We are committed to providing a safe, welcoming and equitable environment for all the Veterans and beneficiaries we serve and for the workforce that makes it possible for us to accomplish our mission.

VA leadership has been clear that any form of discrimination, harassment or assault has no place at any VA facility.

VA will not waver on that commitment.

Anything less not only corrodes our ethos but also is counter to our core values of Integrity, Commitment, Advocacy, Respect and Excellence (I CARE).
Harassment by or against VA employees, Veterans, other beneficiaries, or visitors is strictly prohibited.

VA has made sweeping progress in strengthening policies, training and reporting procedures to underscore this stance, including through implementation of the Deborah Sampson Act.

VA places Veterans, other beneficiaries, and employees at the forefront of all our efforts.
In September 2021, VA established the Secretary’s Work Group on Sexual Assault and Harassment Prevention, which is an expert group of Veterans Service Organization representatives, advocates, State Directors of Veterans Affairs, Tribal representatives, VA employees serving in a personal capacity and survivors of sexual assault and harassment.

The input of this exceptional group, in addition to VA’s ongoing Veteran engagement and outreach efforts, is informing VA’s way forward.
We, as an 7 Gemmill, A., Kiang M., Alexander, M. Trends in pregnancy-associated mortality involving opioids in the United States, 2007–2016.

American Journal of Obstetrics and Gynecology.

Volume 220, Issue I, P115- 116, January 01, 2019.

Page 7 of 8 organization, are grateful for the commitment, courage and expertise of each volunteer member of this group.
To ensure action on the insight of the Secretary’s Work Group and set a direction for VA’s future efforts, Secretary McDonough simultaneously chartered an official Sub- Council of VA enterprise governance: the Sexual Harassment and Assault Prevention/Survivor Care and Support Sub-Council.

At present the Sub-Council is working to establish a robust and comprehensive enterprise operating model by clarifying and unifying prevention and response operations across the VA enterprise.
VA expects that a unified model will enable a seamless experience of prevention and response for Veterans and employees.

Once completed, this unified model will be the first of its kind in the Department’s history, and its development is made possible by the sustained emphasis and attention on this issue from senior leaders and subject matter experts alike.

Importantly, VA places emphasis on our mission to care for Veteran survivors of sexual harassment and assault throughout their lives.
For many Veterans, incidents of sexual harassment or assault may have occurred before or beyond their engagement with VA.

Therefore, VA believes that this makes it even more important for us to lead on this issue, and we take pride in our mission to cultivate the health and resilience of survivors.

In addition, LGBTQ+ Veterans have historically faced stigma, stress, discrimination and health care disparities, and VA is acting to ensure each LGBTQ+ Veteran experiences a welcoming, safe environment.
Estimates suggest that women are over-represented among LGBTQ+ Veterans.8 Each VAMC appoints an LGBTQ+ Veteran Care Coordinator to assist LGBTQ+ Veterans in navigating their health care, and VA is working to implement new diversity, equity and inclusion initiatives focused on the needs of LGBTQ+ Veterans.

Ensuring the equitable, excellent experience of health care for each LGBTQ+ Veteran we serve is central to our mission.
Conclusion VA is honored to provide world-class health care, inclusive of reproductive health care, to each Veteran and eligible VA beneficiary we serve.

VA is committed to maintaining excellence and furnishing care that protects the lives and health of those who served our Nation and their dependents.

This concludes my testimony.

My colleagues and I are prepared to answer any questions you may have.

8 Gates, G. (2010).

Lesbian, gay, and bisexual men and women in the US military: Updated estimates.
UCLA: The Williams Institute.

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