**Department of Veterans Affairs**

**Advisory Committee on Women Veterans**

**June 16-19, 1998**

**Minutes**

The June meeting of the Advisory Committee on Women Veterans convened at
8:00 am, on June 16,1998, in Washington, DC.

**[Advisory Members Present]{.underline}** **[VA Staff
Present]{.underline}**

Dr. Linda Schwartz, Chair Ms. Joan Furey, Director 00W

Dr, Lois Johns, Vice Chair Ms. Kathy Zeiler, Director, WVHP, VHA

Ms. Karen Ray Dr. Susan Mather, ACMD, VHA

Ms. Bertha Cruz Hall Ms. Maryanne Carson, EA, 00W

Ms. Joy Ilem Ms. Lynn Howell, NCS

Ms. Veronica A'zera

Ms. Connie Evans **[Members Absent]{.underline}**

Ms. Sherry Blede

Ms. Lory Manning Ms. Jan McSparren

COL. Christine Cook

Mr. Douglas Russell

BG Clara Adams-Ender (Ret)

BG Connie Slewitzke (Ret)

LTC Sandy Lewis (DACOWITS)

# Opening Activities

The Advisory meeting was called to order at 8:000am by the Chair and
round-table introductions were made.

Ms. Furey introduced the Honorable Togo D. West Jr., Secretary,
Department of Veterans Affairs. Secretary West welcomed the Committee
and provided opening remarks. He focused on his commitment to provide
exceptional service to women veterans; the importance of the activities
of the Advisory Committee; and the seriousness with which he reviews
their recommendations. Secretary West then presented certificates for
exceptional service to Brigadier Generals Connie Slewitzke and Clara
Adams-Ender, whose terms expired. Certificates of appointments were
presented to: Veronica Azera, National Legislative Director, AMVETS;
Sherry E. Blede, National Legislative Committee, VFW; Bertha Cruz Hall,
Texas Veterans Commission; Joy J. Ilem, National Appeals Board, DAV;
Captain Lory Manning, US Naval Reserve, Director, Women Military
Project, Women's Research & Education Institute; and CSM Douglas
Russell, USA, Ret.

Ms. Furey reviewed the agenda with the Committee and highlighted the
following:

1.  The Committee will receive briefings from the key organizations
    within VA

2.  In response to the Committee's request at the last meeting the
    following individuals will also provide briefings

-   Mr. H. David Burge, Director, National Center for Veterans
    Statistics. Mr. Burge will discuss the year 2000 survey of veterans.
    Each member received a copy of the 1995 survey for review prior to
    this meeting. Please be sure to address any concerns or
    recommendations regarding the past survey so we can improve upon the
    survey in 2000. Issues of particular concern to women should be
    emphasized.

-   Mr. Everett Chasen, Director News Service Office of Public Affairs,
    will discuss their role in outreach to veterans. Mr. Chasen met with
    General Slewitske and her subcommittee on outreach earlier this
    year.

-   Dr. Rebecca Klemm, from the Klemm Anaysis Group will give an
    overview of their research project on assessing the health status of
    women veterans of the Persian Gulf War. Klemm Analysis Group has
    been contracted by VA to do this study.

-   Dr. Katherine Skinner from VA's Health Research and Education
    Division in Bedford, Massachusetts is the primary investigator of
    VA's National Study on the Health Status of Women Veterans. She will
    present the preliminary findings of that study.

#### II. Briefings and Presentations {#ii.-briefings-and-presentations .unnumbered}

1.  **Dr. Thomas Garthwaite, Deputy Under Secretary for Health**

Dr. Garthwaite commented on VHA's commitment to improving services for
all veterans and improving VA's ability to measure the outcomes of it's
services. In the area of women's health, he highlighted the following
accomplishments:

-   Improved privacy in VA facilities

-   Established of Women's Clinics

-   Met the preventive health measures outlined in HHS's " Healthy
    People 2000 initiative" (e.g. cholesterol screening, smoking
    cessation education, gender specific cancer screening)

-   Developed VA physician fellowships in women's health

-   Future of Reproductive Health Care and Infertility Treatment in VA

-   Mental Health Services for Women Veterans

The following issues were discussed in the question and answer period:

-   **What is the impact of the highway appropriations bill on
    healthcare benefits for veterans?** The highway appropriations bill
    does not directly affect the current healthcare available for
    veterans. The controversial issue surrounding the tobacco bill
    relates to whether or not the government should provide compensation
    to veterans who develop smoking-related illnesses. In fact, we now
    treat and will continue to treat individuals for smoking related
    illnesses. Treatment is a separate issue from compensation.

-   **Is my understanding correct that any veteran who has a 50% or
    higher service-connected disability is automatically enrolled in
    VA's healthcare system.** This is correct. Veterans in other
    eligibility categories will be provided care based on their priority
    categories. VA determines if it has the resources to treat them each
    year.

-   **Will the monies obtained through third party billing be returned
    to the treating facility?** The money obtained through Medical Care
    Cost Recovery will be returned to the Network. The Network will
    distribute the funds to the medical centers in its service delivery
    area.

-   **How can you assure equitable distribution of resources.**
    **Couldn't hospitals successful in attracting veterans and
    recovering costs from third party reimbursement see a portion of
    those funds sent to hospitals less successful in doing this.** Yes,
    this is a possibility, but the VISN Director must submit a plan of
    how he plans to distribute the money to assure his VISN meets
    national goals and it is reviewed for overall soundness. If there
    are specific problems in specific areas we can address them on an
    individual basis.

-   **Additional questions centered on requests for clarification on
    enrollment, co-pay determinations, access to Tri Care and Medicare
    subvention.** Clarification on these issues were provided and can be
    found in the transcribed proceedings of this meeting.

2.  **Ms. Nora Egan, Deputy Under Secretary for Benefits Veterans**

Ms. Egan provided the Committee with a general overview of the changes
underway in Veterans Benefits Administration. The following items were
highlighted:

-   Instituted Formal Evaluation of VBA Mission, Core Values,
    Organizational Structure( creation of nine Service Delivery
    Networks), Employee Education

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-   Implementation of Environmental Scans: Assessing the perception of
    VBA's services from its stakeholders, e.g., veterans, veteran
    service organizations, Senators and Congressman, Office of
    Management and Budget.

-   Identification of Key Issues: quality of claim development;
    timeliness in claims processing; high percentage of remands from
    Board of Veterans Issues; underachieving information technology;
    poor communication with stakeholders

-   Increased focus on vocational rehabilitation efforts to improve
    employment rates of veterans enrolled in program

-   Review of long-term goals/strategic plan

-   Introduction of "Balanced Scorecard" management process which
    measures five areas of productivity: 1) timeliness, 2) quality, 3)
    customer, satisfaction, 4) cost per claim and, 5) employee
    development

The following issues were addressed during the question and answer
period.

-   **What provisions does VA make for assuring that separating service
    members who are being discharged from military hospitals receive
    information about VA benefits, as they are often unable to attend
    Transition Assistance Briefings?** VBA is trying to improve its
    outreach initiatives to separating service members and improve
    coordination and collaboration between DOD and VA. Additionally, VBA
    has a few pilot programs underway where VA staff is assigned to
    discharge centers to do C&P exams and follow-up. We are working
    toward improving our communication with the service members at these
    sites to assure they are familiar with VA benefits at the time of
    discharge.

-   **Could you address the issue of the low utilization of the
    Montgomery GI bill( MGIB)?** VBA is very concerned about the low
    utilization of the MGIB and we are trying to determine the best way
    to assess what the problem is so we might work toward increasing
    utilization of the program.

-   **There is ongoing frustration among many women veterans that they
    are unable to gain comprehensive information about VA or VA benefits
    at any one particular site. Could you expand on your comments about
    the increased training initiatives between VBA and VHA?** Both VBA
    and VHA are aware of the difficulties you are referring to and are
    trying to work together, both locally and nationally to improve both
    training and communication of VA staff on various benefit issues,
    information and processing. **(Interjection by Dr. Mather follows)**
    Some of this has been done already. In women's health for example we
    have had joint training on sexual trauma, and are developing one on
    gynecological disorders. Additionally we just completed such a
    program on undiagnosed illnesses in Persian Gulf veterans. So we are
    beginning to improve in this area.

3.  **Dr. Alphonso Batres, Director Readjustment Counseling Service**

Dr. Batres provided the Committee with an overview of RCS services and
activities and provided information on the number of women seen in the
program in FY'97. Highlights of presentation were:

-   Viewing of a videotape describing Readjustment Counseling Service

-   RCS saw 8,345 women in the vet center program in FY '97.

-   The number of female staff employed by RCS has increased by 15% in
    the last 3 years.

-   RCS, in collaboration with local VHA medical centers, has
    tele-medicine sites located in 20 vet centers across the country.
    Located in remote areas, these sites provide veterans with access to
    medical care, health screening and education via satellite. Four of
    these sites are located on Native American Reservations. We are also
    planning on developing sites in some of our large urban areas to see
    if that will assist some of our other under-served veterans in
    accessing and improving their health.

The following issues were addressed in the question and answer period:

-   **What Native American Reservations are the Tele-medicine Centers
    on?**

> They are located on the Navajo/Hopi Reservation in Arizona; in Martin,
> South Dakota; between the Sioux reservations at Rosebud; Pine Ridge;
> and in Telya, Oklahoma, a large Cherokee community.

4.  **Vincent Barilie, Deputy Director, National Cemetery
    Administration**

Mr. Barilie provided an overview of NCS. Highlights of his slide
presentation included:

-   The National Cemetery Administration is composed of 115 cemeteries;
    employs approximately 1300 staff; and has a budget of \$171,000,000.
    Area offices are located in Philadelphia, PA; Atlanta, GA; and
    Denver, CO.

-   Arlington National Cemetery is not operated by VA, it is
    administered by the Department of the Army.

-   VA National Cemeteries are classified into three categories:

1)  Open -- full range of burial services are available

2)  Cremation -- burial services are available for cremated remains
    only. Full casket sites are not available

3)  Closed -- burial services are available for the interment of a
    family member in the same grave site, whether it be full casket or
    cremated remains.

-   VA directed 70,000 burials in FY '97. The National Cemetery in
    Calverton, New York was our busiest cemetery with over 7,300
    burials.

-   Between now and the year 2006 ,we project 20,000 veterans will pass
    away, resulting in the number of annual interments increasing to
    over 100,000 (including veteran and spouse).

-   Other services provided by NCS include the provision of
    headstone/marker for the deceased, and the Presidential Memorial
    Certificate Program.

-   Two new cemeteries have been opened since 1992: San Joaquin Valley
    and Tacoma, Washington. Four new cemeteries are scheduled to open in
    1999: Saratoga, NY; Cleveland, Ohio; Chicago, Ill; and Dallas/Fort
    Worth, TX.

-   NCS works with State governments in developing and funding State
    veterans' cemeteries through a State veterans cemetery, State grant
    program.

-   Approximately 45% of burials in National Cemeteries receive military
    honors. About half of these are done by military units and half by
    veteran service organizations.

The following issues were addressed in the question and answer period:

-   **What provisions are made for addressing problems of maintenance
    and upkeep of State-run veterans' cemeteries?** VA's works very
    closely with the States to assure these cemeteries operate properly.
    In some cases we have sent one of our cemetery directors to the
    State to work with their staff. The States do have a problem
    regarding their plot allowance of \$150, which is woefully low.
    Presently, VA has a legislative proposal in Congress to increase the
    Federal share of the funding from 50% to 100%, as well as provide
    the State with initial start-up equipment. This would help them
    defray the up-front costs. There are no provisions for VA to take
    over these cemeteries because they are the responsibility of the
    individual States.

-   **Is VA supporting legislation to provide VA burial benefits to
    members of the National Guard?** I am unable to comment on that at
    the moment, We have just become aware of that legislative initiative
    and must study it further.

-   **There has been a lot of talk about the difficulties in providing
    military honors to deceased veterans, particularly among the active
    duty forces. Is there someone who is going to assume responsibility
    for organizing these efforts with the VSOs and military?** The 1998
    Defense Authorization Bill authorized the military to provide
    funeral honors, however it did not provide funds to support them.
    This is one of our biggest challenges. We are hoping to have an
    executive roundtable in the fall with representatives from the
    involved organizations to try to develop a plan to provide the
    honors.

5.  **Mr. H. David Burge, Director, Center for Veterans Analysis &
    Statistics**

Mr. Burge discussed the Department's plans for the Year 2000 survey of
veterans. Committee members received a copy of the 1995 survey in their
pre-meeting packets. Highlights of Mr. Burge's presentation included:

-   Ms. Susan Krumhaus, Project Director of the 2000 survey was
    introduced

-   Overview of Survey: Purpose, Methodology, Sample size, Example of
    information obtained (Handout)

-   Opportunity for input into design and questions

-   Review of Demographic data on the women veteran population, present
    and projected: (Handout)

The following issues were discussed during the question and answer
period:

-   **Are you considering over-sampling the number of women surveyed in
    order to assure you have a sample size large enough to provide
    accurate data?** Yes, we are considering the possibility of
    over-sampling in some populations**.**

-   **Are you going to collect data on homeless veterans?** It is very
    difficult to survey homeless veterans, as they have no fixed address
    or phone number. It may be possible to develop some form of
    supplement to be used in places that provide homeless services, but
    that will have to be reviewed by the survey team.

6.  **Mr. Everett Chasen, Director News Service Public Affairs**

Mr. Chasen gave an overview of the News Service under the Office of
Public Affairs, which basically takes reporter's and national news
media's calls into Central Office, field facilities, hospitals, regional
offices or cemeteries. Last year an estimated 2,778 calls were received.
He also gave an overview of Public Affairs role in outreach. Public
Affairs is organized into three different services:

-   Field Operation Service: coordinates public affairs aspects of field
    service sites for Secretary and Deputy Secretary; respond to field
    facility requests for information and issues related to the
    Department; promote VA research through a national storage program
    based in New York and interact with reporters that cover medial
    issues; provide guidance and support to field facilities during
    crisis; and provide training for facility public affairs officers
    (PAO).

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-   Internal Communications and Special Projects: distribute monthly
    news letters which include the *Vanguard* and *Federal Handbook for
    Veterans and Dependents* and hometown news release which sends news
    to participants hometown papers; television and radio public service
    announcements including the VA Report, which is a televised
    12-minute update from film clips from TV stations; special message
    videos where the Secretary addresses everyone; and VA pamphlets.
    Special projects include special events such as Veterans Day;
    special games including wheelchair games, winter sports, clinics and
    creative arts, and Golden Age games.

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-   News Service: arranges briefings, news conferences and interviews;
    prepare field guidance when there is a breaking story; provides the
    Secretary and senior management advice and counsel on controversial
    issues relating to the Department; prepares daily clip of newspaper
    summaries.

Current outreach efforts are focusing on Gulf War veterans. Our goal is
to assure the are familiar with how to access the network of information
we have developed; assure they understand that they receive priority
care at VA facilities and understand the compensation process, as well
as communicate goals; accomplishments and activities of VA Gulf
research.

7.  **Dr. Rebecca Klemm, Klemm Analysis Group**

The Klemm Anaysis group has received a number of contracts from VA to
study the health status of veterans. This group supervised the Women
Vietnam Veterans Reproductive Outcome Study and is currently involved in
a number of studies relating to Persian Gulf Veterans. Dr. Klemm
provided an overview of the research currently being done on women
veterans.

-   Health Outcomes among Women Vietnam Veterans: epidemiological
    investigation of the reproductive outcomes and development of some
    cancers in women Vietnam Veterans. Involves three stages:
    1)telephone interview, 2)mail survey, 3)review of medical records.
    Currently in final stages and final report is due in VACO in
    September 1998.

-   Health outcomes among Persian Gulf Veterans: Similar in scope to
    Vietnam veteran study. A study of the health status of women n
    veterans based on both self-report and a review of health records.
    It will also incorporate comparisons with women who served in other
    parts of the world. We will be trying to identify linkages to
    various physical and psychological exposures also. It is a very
    large study that will include women in all branches of the service.
    10,000 who served in the Persian Gulf and 10,000 who served
    elsewhere.

-   Funded, follow-up study with Georgetown where women will have
    clinical follow-up on illnesses such as fibromyalgia, chronic
    fatigue, etc. We hope to be able to then compare the participants'
    self-report, and diagnosed illness with their exposure to various
    environmental and psychological stresses.

-   Army Chemical Corp veterans health study: Study of the health status
    of veterans who served in the Army Chemical Corp during the Vietnam
    era and their children. Currently we have not found any women who
    served in this Corp during that time. Study is in the pilot stage.
    Involves 3000 chemical Corp veterans and 3000 non-chemical Corp
    veterans. Anticipated completion date: summer of 2001.

-   Alternative Medical Practices in VA: Investigation of complimentary
    and alternative medical practices within VA. We will be visiting
    sites across the country to assist us in identifying and defining
    alternative medicine and practices to assure we have a broad
    perspective on what is actually being practiced across the country.
    It is the first review of this kind of practice in VA and will
    provide preliminary guidance on what practices should or should not
    be adapted within VA on a continuing basis.

The following issues were discussed in the question and answer period:

**Clarification: Persian Gulf Study:** The Persian Gulf veterans in the
expanded clinical follow-up to be done by Georgetown, will be selected
from the pool of veterans in the larger study.\
**Comment: Army Chemical Corp Study:** It is important to consider rank
and position of individuals in the analysis of findings.

**Comment:** Acknowledgment by Committee of the importance of this work
and how we have overlooked studying the impact of these exposures on
veterans health for a long time.

8.  **Mr. Phil Riggin, Deputy Assistant Secretary for Congressional
    Affairs**

Mr. Riggin provided an overview of the activities of the Office of
Congressional Affairs and VA legislative initiatives.

-   Extension of Sexual Trauma Counseling Authority: VA supports this
    extension and has initiated a legislative proposal to extend it
    indefinitely

-   Maternity Care for Women Veterans: VA General Counsel issued an
    opinion indicating that the provision of maternity care to women
    veterans fell within the purview of care that can be provided by
    Veterans Health Administration. However VA is not authorized to
    provide care to newborns under present law. VA would need
    legislative authorization to provide any care to newborns.

-   Medicare subvention: There are two bills in the Congress right now
    that would authorize VA to bill Medicare for services provided to
    Medicare recipients. HR 828 (Stump-Thomas Bill), and S 2054. Both
    bills face some difficulty in obtaining the approval necessary for
    enactment. VA strongly supports Medicare subvention legislation and
    considers in one of our legislative priorities.

-   ISTEA Bill: Inter-Service Transportation Surface Bill. This is the
    bill that authorized many transportation projects around the
    country. It was recently signed by the President. This bill contains
    language that would prohibit the payment of VA compensation for
    tobacco related disability. This is a very controversial bill that
    the Veterans organizations are very concerned about, so you may be
    hearing more about it in the future.

-   Global Tobacco Settlement Legislation: This is a measure which would
    require the tobacco companies to reimburse the Federal Government
    for certain expenses associated with providing benefits and services
    to individuals (not just veterans) suffering from tobacco related
    disabilities, provide funding to support smoking cessation
    initiatives and foster the establishment of initiatives that would
    limit teenage smoking. A recent amendment to this bill includes a
    provision that the Department of Veterans Affairs receive three
    billion dollars over 5 years, to provide reimbursement for the
    treatment of veterans with smoking related disorders. This
    legislation is under review and has not yet been passed.

-   Research funding: VA's research budget has been increased by 10
    million dollars.

The following issues were discussed during the question and answer
period.

-   **It seems like the laws authorizing VA to provide sexual trauma
    counseling always have a sunset provision. Why can't the VA receive
    authorization to provide this treatment without any time limits on
    it?** I agree with you and this makes sense, I am not sure why the
    reauthorization was only granted for four years. Discussion from
    Committee: There is some indication that there was a compromise
    reached between those congressional members who wanted to eliminate
    the sunset provision and those members that wanted to eliminate the
    sexual trauma counseling program. VA does support the sexual trauma
    counseling program and will work to have reauthorize as necessary.

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-   **VA General Counsel also rendered an opinion indicating that
    selected reservists and National Guard members who experience sexual
    trauma during a period of training are not eligible for VA's sexual
    trauma counseling program. Is the only way to remedy this through
    legislation, and what is VA doing in response to this
    interpretation?** Congressman Guitteriez has incorporated a
    provision allowing VA to provide this counseling to National Guard
    and reservists, it is presently being considered by the HVAC.

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-   **I'd like to revisit the tobacco legislation issue. Am I right that
    it says that VA will pay compensation to any veteran who develops a
    tobacco related illness, if they smoked while in service? Would this
    include illnesses that may or may not be related to tobacco use, for
    example: heart disease, hypertension.** There has been a lot of
    discussion around these issues because, as you well know, some of
    these illnesses develop in non-smokers as well as smokers. The
    current administration is trying to prohibit the payment of
    compensation for those disabilities that are strictly related to
    tobacco use. There is no question that it is a tough issue and will
    require considerable study if it is enacted.

#### 9. Dr. Katherine Skinner, Health Services and Research Division, Bedford, MA {#dr.-katherine-skinner-health-services-and-research-division-bedford-ma .unnumbered}

Dr. Skinner discussed the VA Women's Health Project. The data presented
is unpublished data and as such must be seen and preliminary findings
are not ready for public dissemination. Our overarching question for
this study was:

What is the effect of military service on the physical, mental and
social functioning of women veterans. Thus, there were four study
objectives:

1)  Examine the health-related quality of life in women veterans who are
    users of the VA healthcare system.

2)  Compare the health- related quality of life of women and men users
    of VA healthcare services.

3)  Identify patient characteristics related to health-related quality,
    social demographics, disease status and military experience.

4)  Relationship of health-related quality of life to the use of VA
    healthcare services.

The findings of the study are in Appendix A

10. Ms. Helen Cohen, Chief of Staff to the Assistant Secretary for
    Veteran's Employment and Training, Department of Labor

Ms. Cohen gave an overview of Veteran's Employment and Training Division
of the Department of Labor and discussed recent initiatives they have
undertaken to improve employment opportunities for veterans.

-   Interagency Task Force on Certification and Licensing of Military
    Personnel: joint DOL/VA/DOD task force to assist active duty
    personnel in obtaining certification and licenses necessary for
    civilian employment while they are still on active duty. It is hoped
    this will ease their transition to civilian life and reduce periods
    of unemployment and/or underemployment. Our contractor has
    determined that there are 67 military occupation specialties which
    has civilian counterparts that require certification or licensure.

-   Establishment of Internet Reference site: This site would allow
    active duty military personnel to enter their preferred occupation
    and State of residence after discharge and they would receive
    information regarding the State requirements for certification or
    licensure. Additionally it would also provide them information on
    what additional training they would need (based on their current
    Military MOS) to qualify for certification/licensure in the state.

-   Pilot Project: Skills two 2000: We have collaborated with Microsoft
    and arranged pilot programs at four active military sites where
    active duty service member can enroll in a group of courses leading
    to a Skills certificate from Microsoft. This certifies an individual
    has a certain level computer skills and increases their chances of
    employment in high tech industries. The pilot program sites are:
    Fort Lewis, Norfolk, San Diego and Atlanta Air Force Base (?Warner
    Robbins) Separating service members will be informed of this program
    through TAP workshops and those interested will be required to take
    an aptitude test to determine their appropriateness for the program.
    Those personnel selected will have their tuition and fees paid by
    Microsoft.

-   Pilot Project-Communication Workers of America & Veterans Research
    Education Institute: This program is designed similar to Microsoft
    pilot but involves the skills needed in the telecommunication
    industry. Job options include everything from cable installers to
    customer service representatives.

-   TAP Program: DOL/VETS is interested in increasing the number of
    spouses who attend the TAP workshops.

-   Priority Employment Service: Working with Office of Federal
    Compliance Programs to be sure that America's Job Act and America's
    Talent Bank continue to provide Priority service to veterans as
    required by law. These are Employment banks, funded by DOL, that are
    available on the Internet.

-   National Veteran Training Institute (NVTI): Established a new
    curriculum that incorporates diversity training and sensitivity to
    State veterans employment counselors to counteract complaints of
    discrimination "job typing" and other complaints from veterans.

11. Ms. Cornelia H. Moore, Regional Director, Women's Bureau, Department
    of Labor

Ms. Moore notified the Committee of a DOL Women's Bureau Project
entitled Women Veterans Original Arts Poster Contest, designed to
increase their awareness of the work of women veterans

12. **Mr. Willie Hensley, Director, Center for Minority Veterans**

The Center for Minority Veterans was established in the same legislation
that established the Center for Women Veterans -- P.L.103-446. It also
established the Advisory Committee on Minority Veterans. Both Center's
and Advisory Committee's have similar missions although the
constituencies are different.

According to the law, minority veterans are defined as African
Americans, Hispanics, Asian Americans, Pacific Islanders and Native
Americans. Within the Native American category there are three groups of
veterans: Alaskan natives, Hawaiian Natives and American Indians. Over
the last two years the Center has worked at deterring what major issues
these five groups experienced in relation to VA. They are as follows:

-   African Americans: 1) Questions regarding possible disparity between
    African American and non-minority veterans in C&P ratings: We are
    unable to validate, one way or the other, the reality of this
    concern so we have established a study that will match VBA files
    with files from the Department's of the Army, Navy, Air Force and
    Marines, by race and ethnicity. This will assist us in determining
    the rates at which veterans are being compensated and allow for some
    ethnic and racial comparisons. 2) Medical Care: There is question in
    both the veteran and civilian population regarding differences in
    medical treatment of minorities and non-minorities, in a variety of
    illnesses. We have worked with the Office of Research to assure the
    development of research protocols designed to assess this issue in
    VA and determine what, if any, variations exist in the treatment of
    minority and non-minority veterans. 3) Homelessness: minority
    veterans represent the largest percentage of the homeless veterans.

-   Hispanics: 1) Language barrier: Many Hispanic veterans are not
    fluent in the English language and have difficulty understanding
    printed material available through VA. Center has worked to increase
    the number of VA information and outreach publications available in
    a Spanish language edition. 2) Access to medical care: Hispanic
    veterans complain about having to travel long distances to access
    care. The development of community-based outpatient clinics has
    begun to address this problem and as more clinics are developed we
    hope to see this issue diminish in importance. 3) Lack of
    statistical data: Generally speaking, there is a lack of good
    statistical data on Hispanic veterans which hinders us in
    identifying and responding to issues in that segment of the veteran
    population.

-   Native Americans: 1) Access to medical care: Reservation-based
    Native Americans encounter many problems in accessing VA care,
    including -- living in remote, isolated areas, poor or no personal
    transportation, absence of public transportation. We are hoping to
    increase some services on the Reservation through sharing agreements
    with Indian Health Service and/or VA, establishment of Reservation-
    based vet centers and the introduction of tele-medicine. 2) Post
    Traumatic Stress Disorder: According to a national study on PTSD in
    minority populations, Native Americans suffer with a higher rate of
    PTSD than any other group of veterans we serve. 52 to 57% of Native
    American's who served in Vietnam have PTSD compared to 27% of
    Hispanics, the second highest group. So, we are working on improving
    outreach to assure these veterans are familiar with, and have access
    to VA services and benefits designed to assist them. Readjustment
    Counseling Service, under the direction of Dr. Alfonso Batres is
    working to establish Vet Centers on the Reservations and has so far
    established them on the Hopi and Navajo Reservation. Others are
    planned for Oklahoma, in support of the Cherokee nation and South
    Dakota, in support of the Sioux. 3) Native American Home Loan
    Program: Reservation-based Native Americans have encountered
    difficulty in obtaining VA home loans because Reservation land is
    considered trust land, belonging to the tribe and not the
    individual. The NAHLP remedied this by providing VA the authority to
    make loans to individuals buying homes on trust land. However, there
    are a number of steps that must be taken by both the veteran and the
    tribe before the loan has been granted. This has created some
    difficulties in getting these loans approved. We are working to do
    more outreach and education to tribal leaders and veterans about the
    loans and the conditions that must be met for individual's to
    qualify for them. 4) homelessness, as with the African Americans,
    homelessness among this population is a significant concern.

-   Cultural Sensitivity: This area is a major issue for all minority
    veterans and is an area where we are working to improve the
    sensitivity and understanding of VA staff providing services to
    these individuals.

-   Minority Veteran Vendor Opportunities: The Center hosts vendor
    seminars around the country to explain to minority veterans the
    opportunities for contracts for vendors with VA.

-   Minority Veteran Coordinators: We have 280 minority coordinators
    across the country. This program is very similar to the women
    veterans' coordinator program which you are all familiar with. The
    coordinators accept the responsibility of the MVC program along with
    their other duties. It is a collateral assignment.

The following issues were discussed during the question and answer
period.

-   **Do you feel there is any value in having a tribal veteran
    representative to assist veterans within their own tribe?** Yes, we
    feel the tribal veteran representative is a very valuable program
    and promotes the use of benefits by Native American veterans. It is
    especially valuable to those veterans living on the Reservation who
    are physically removed from the areas were VA services are usually
    located.

-   **The issue of discrepancy in the treatment of minorities and
    non-minorities has also been identified between men and women**,
    **it seems to me we've done enough research and really need to begin
    to educate people about these issues.** The Department of Health and
    Human Services has established an Office on Minority Health and they
    have begun to hold annual conferences and other seminars to do just
    that. Needless to say however, the research is important as it
    provides validation for the issue sand specifics regarding treatment
    practices.

13. **Ms. Kathleen Zeiler, Director, Women Veterans' Health Programs**

Ms. Zeiler gave an overview of the Women Veterans Health Program,
highlights of her presentation included:

-   Women Veterans Coordinators' Time Study: completed and is in Dr.
    Kizer's Office for review. It's clear that the coordinators are very
    busy and their clinical loads are increasing, reducing the time
    available for outreach. We are taking the findings of this under
    review.

-   Reproductive health: Women's health has submitted a white paper to
    Dr. Kizer on Reproductive Health Issues in both men and women. We
    proposed a generous package of benefits to assist veterans with both
    infertility treatment, and in the case of women veterans, pregnancy
    care. This package is under review by the Health Benefits task
    force. As was mentioned earlier we do have some issues related to
    newborn care following a successful pregnancy/delivery. It is our
    recommendation that we provide newborn care for a proscribed period
    of time, not to exceed 28 days.

-   Women's Comprehensive Health Clinics: the eight centers that are
    established to provide, care, consultation, education and research
    on women's issues are now required to file an annual report with my
    office.

-   Women Veterans' Health Program Newsletter: Newsletter designed for
    women veteran coordinators and healthcare providers, to update them
    on women's health issues.

-   Federal Practitioner: published a two-part series of articles and
    self-study packets on sexual trauma that provide continuing
    education credit to clinicians who complete the test included in the
    magazine and return it for scoring.

-   Women Veterans Survey: Executive summary distributed: 11% decrease
    in the number of women inpatients and an 11% increase in the number
    of women outpatients. We continue to see consistent increase in the
    number of women seen and the percentage of women receiving
    gender-specific screening exams, e.g.. mammography/pap smears.

-   Heathy Women 2000: this program, established by the Department of
    Health and Human Services, sets goals for health promotion
    activities in a number of area. In women's health, VA has met or
    exceeded the established goals in most of the areas measured,
    including cervical cancer screening, influenza vaccinations,
    counseling for tobacco us and physical activity.

-   Primary Care Initiatives: 1) A Women's Health Guide; a pocket size
    reference book that primary care providers can keep with them at all
    times is under development at this time. 2) establishment of a
    mental health mini-residency for primary care providers; and breast
    center development program are scheduled for the fall.
    Mini-residencies in women's primary care continue.

-   Education: Two satellite TV programs on sexual trauma counseling,
    one for mental health providers and one for primary care providers.

The Question and answer period focused on the impact of community-based
clinics on women's health and VA 's responsibility and role in assuring
contract providers were educated about women veterans health issues.

14. **Mr. Gunner Kent, Veterans Service Organizations Liaison**

Mr. Kent gave an overview of his role as VSO liaison which included:

-   Primary advisor to the Secretary on the Veterans Service
    Organizations

-   44 recognized veterans groups: these are groups either charged by
    Congress or recognized by the VA to handle VA claims

-   8 "special interest group" organizations, e.g., Retired Officers
    Association

-   Numerous smaller organizations: e.g., WAVES

Mr. Kent identified the following issues as concerns of VSO's

-   Reorganization of VHA

-   Transportation Bill and impact on veterans with tobacco related
    disabilities

-   Coordination of Groups in the common interest.

15. Mr. R. Kent Simonis, Director Health Administration

Mr. Simonis provided an overview of Eligibility Reform and it's impact
on VA healthcare. The following points were emphasized during the
presentation:

-   New system emphasizes preventive medicine and outpatient care as
    compared to the old system that emphasized inpatient care.

-   Relaxes regulations around the issuance of prosthetic devices.
    Eligibility for the provision of sensory aids (eyeglasses/hearing
    aids) will be more restrictive

-   Inclusion of maternity benefits

-   Exclusions: cosmetic surgery and other procedures listed in the
    National Health Benefits act

-   Rules governing the provision of non-VA care have not changed.
    Non-VA care is provided under different statutory authority and is
    not included in the eligibility reform legislation.

-   Rolling Enrollment: allows veterans to apply for VA care at any time
    during the year. No restriction on when someone can apply for VA
    care. However, the priority categories VA will treat will be
    determined each year. So enrollment, per se, does not guarantee you
    will be eligible for care indefinitely.

-   Automatic Enrollment (eligibility): The following veterans are
    formally enrolled in VA and do not have to enroll again to receive
    benefits: 1) veterans who have a service-connected disability rated
    50% or greater, 2) veterans being treated for a service-connected
    disability only, and 3) veterans who are separated within one year
    of active military service for a disability.

-   Initial Registration/Only Registration: Individual will not have to
    enroll again if they relocate. We will have a master record that
    will give us the right information for the right patient, when and
    where we need it. Patients will have the opportunity to update their
    records every year, so we can be sure they are accurate and current.

-   Eligibility for care is consistent: Regardless of where you access
    care you will be eligible for the same service. Care will not vary
    from State to State or from one geographical area to another.

The following issues were discussed during the question and answer
period.

-   Will the care I receive change from one VA to another, in other
    words, if I am accepted for care at a VA hospital in Florida and
    move to Montana, will my enrollment change? No. The decision on
    which category of veteran will be eligible to receive VA care will
    be a national one and will be effective nationwide for one year. So,
    if in October of 1998, VA decides to treat all veterans through
    priority Category 7, we will care for all patients in Categories 1-7
    who access our services, until September 30, 1999. At which time we
    will treat all patients in the categories selected for enrollment in
    FY 1999. The categories we select to treat will be determined by the
    resources available for each year through Congressional
    Appropriations and Medical Care Cost Recovery Revenues.

-   What are the priority groups? They are as follows:

Priority 1: veterans who are 50% service-connected or greater

Priority 2: veterans who are 30% or 40% service-connected

Priority 3: veterans who are 10% or 20% service-connected

Priority 4: NSC veterans who are POW's, or in receipt of VA pension

Priority 5: NSC veterans with low incomes

Priority 6: NSC veterans who have been exposed to chemical or

Radiation or other environmental hazards while on active duty

Priority 7: Any veteran not included in one of the 6 prior groups.

-   Are individuals eligible for Tricare ,eligible for VA care also? Not
    necessarily. Tricare is a DoD healthcare program for military
    retiree's and dependents. Although some VA's have sharing agreements
    with DoD that make them designated Tricare providers, not all are.
    So, an individual who is eligible for Tricare may also be eligible
    for VA care, if the fall into one of the 7 priority categories.
    Thus, they must be a veteran. But then they will access care through
    VA and not through Tricare.

-   Can you enroll online? Unfortunately, not yet, but we do hope to
    have that capability in the future.

-   How far in advance will an individual know which category will be
    accepted for care? Currently we must make that decision by August 1
    for the October 1^st^ fiscal year. We are hoping eventually to be
    able to provide this information one year in advance, so we would
    publish our enrollment priorities by October 1^st^ of the preceding
    year. Giving veterans one year to determine what to do if their
    enrollment priority changes.

16. **Lynda Petty, Veterans Benefits Administration**

Ms. Petty provided a specific update on women's issues in VBA. These
included:

-   Overview of VBA

-   Regional WVC Coordinator: We now have a regional coordinator for
    women's programs in each of our 4 area offices. These individuals
    oversee issues in the 58 regional offices and assist the local WVC's
    in addressing issues. They also provide me with assistance in
    obtaining and disseminating information needed at the National,
    Regional or local level.

-   VBA Intranet: Establishing an internal web page for VBA coordinators
    where they can readily obtain information on programs, services and
    benefits

-   Establish performance standards for WVC's. As the WVC responsibility
    is a collateral duty no performance standards have been established.
    I am hoping to change that in the near future.

-   Training: We need to improve our training for the WVC's , although
    we did have a joint training with VHA in San Antonio and some
    regional conferences. We also had two satellite TV conferences on
    sexual trauma and the compensation and pension process. All of which
    were well received.

-   Compensation & Pension Women's Advisory Group: Established in 1995.
    Has been very productive over the last few years. Among their
    accomplishments are: Developed policies and procedures on the rating
    decision process in sexual trauma; reviewed rating schedule for
    gynecological disorders; developed and implemented education and
    training on developing claims for sexual trauma; reviewed PTSD
    ratings for sexual trauma; recommended changes to assure
    correspondence is gender sensitive.

The question and answer session included the following discussion:

-   In spite of the work being done, we continue to see claims being
    denied by Rating Boards or BVA. Often the C&P exam is not sufficient
    to support the claim. Is anything being done to address this? Yes,
    we have instituted training on these issues and are looking at how
    mental disorders in general are being evaluated: Including whether
    women with PTSD are being given other diagnosis. But one of the
    difficulties we encounter with PTSD due to sexual trauma, is that
    the diagnosis of PTSD alone is not enough to grant
    service-connection. There must also be credible evidence linking the
    stressor to military service. Unfortunately, this documentation is
    often difficult to find. The markers are simply that: If you have
    enough of them, you may be able to demonstrate there's a
    "preponderance of evidence" to support the veterans' claim.
    Unfortunately, this is more the exception than the rule. We still
    have many women without any real supporting evidence and it is
    unlikely they will be able to receive a SC rating.

-   Can you discuss disability ratings and percentages granted? The
    rating schedule is very large and very complex. Once it is
    determined that a veteran has a disabling condition that is
    service-connected, the rating specialist must review the rating
    schedule for that particular illness and determine, according to the
    established guidelines, what rate he should be giving. The rates
    range from 0%-100%. (This was followed by a lengthy discussion on
    how ratings are determined.)

17. **Kenneth Clark, Chief Network Officer**

Mr. Clark provided an overview of the Network Strategic Plan Summary
1998-2002 and addressed the following issues:

-   Definition of Network: A geographical area incorporating a number of
    VA facilities that are tied to one corporate office. There are 22
    Networks in VA healthcare system.

-   VA has moved from a model of inpatient specialty care to more of a
    managed care model: primary care provided in an outpatient setting.

-   50% of future residencies funded by VA will be in primary care

-   Principles of VHA's Transformation/Reorganization

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-   All healthcare is local: Assess the needs of the community and
    develop a way to respond to them. This can best be done in small
    geographical networks.

-   Decentralize decision-making: increase accountability and
    flexibility of provider

-   Increase quality and efficiency: reduce cost

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-   Results: 1) Closed 43% of our beds, 2) decreased inpatient admission
    24%, 3) 6.6 million increase in ambulatory care visits, 4) decreased
    by 25,000 the number of FTEE (-13%) 5) increased outpatient
    procedures from 30% of our total procedures to 70%. Patients are
    spending less

> and less time in the hospital, decreasing their chances of hospital
> acquired infections and other problems. 6) treated 10% more patients
> between 1994 and 1997.

-   Medical Care Cost Recovery: estimate VA will collect \$600 million
    nationwide in FY 1998 through this program

-   Customer Service Standards/Customer satisfaction: established
    benchmarks to evaluate patient satisfaction based on private sector
    surveys. Have trained 85% of our staff in this area. Goals:

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-   Reduce waiting times

-   Reduce variations in quality

-   Improve access and convenience

-   Attract and retain quality staff

-   Develop Innovative programming

-   Establish preventive medicine indexes

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-   Comparing VA practices with private and public sector: establish
    benchmarks for chronic disease management and preventive care.
    Incorporating "Healthy People 2000" goals into VA care.

The question and answer period covered the following areas:

-   **What is the conflict between VA and HCFA over Medicare
    subvention?** HCFA's basic objection to providing Medicare benefits
    to individuals treated in VA hospitals is that they are both Federal
    benefits and one agency should not be billing another agency for
    care they are giving under a separate entitlement.

-   **If a VA hospital has a sharing agreement to provide services to
    non-veterans will that affect their ability to provide care to
    veterans because of resource constraints?** That issue has arisen in
    the few places where we have sharing agreements to provide care to
    non-veterans prisoners. Because this has been such an unpopular
    decision, the Secretary has decided we will no longer do that.
    However, veterans will receive care based on the eligibility
    category they fall into, regardless of what other services VA
    provides.

-   **How do you assure that in your quest for efficiency and cost
    effectiveness, you are not diminishing services that the veteran
    values?** We realize this is a question that is going to be raised
    we are incorporating studies that will help us to determine how
    effective our changes are in regard to the veterans health status.
    For example, as we decrease our inpatient stays on psychiatry and
    improve our outpatient care, we will measure our success by
    following our patient readmission rates, to assure they are
    benefiting from their care, and not just going through a swinging
    door of recidivism. We will be working to develop quality indicators
    for all our programs so we have confidence that we are indeed
    providing the quality of care we would like to give.

-   **What is done to assure staff are trained in responding sensitively
    to the needs of veterans, including minorities and women?** The
    networks and facilities are responsible for addressing the issues of
    sensitivity training for their staff. As I mentioned earlier, we
    have had training in customer satisfaction and we do try to work
    closely with our people to assure they are responsive to the
    community they serve.

-   **What are your goals for increasing the number of veterans served
    by VA, and do you have a specific emphasis on increasing the number
    of women veterans you serve?** At this point, although we have
    incorporated this into our overall strategic plan, we have left the
    actual numbers up to the individual VISN's to determine.

-   **What percentage of the community- based clinics are contract
    clinics?** About 50% of the CBOC's are contract clinics.

-   **What consideration is being given to allowing individual medical
    centers the right to retain control over their own budgets and
    revenue streams, rather than allowing the VISN complete control over
    the funds?** The best way for me to answer that is to say that, if
    we are going to run a decentralized system we need to monitor the
    overall outcomes and not meddle in day-to-day decisions. We are very
    sensitive to the issue of fiscal responsibility and expect the
    network director to be held accountable.

#### III. Old Business {#iii.-old-business .unnumbered}

**Topic:** Electronic ticketing

**Discussion:** travel options

**Action:** Members will be notified by phone with followup letter of
meeting dates as soon as date is established

#### IV. New Business {#iv.-new-business .unnumbered}

**Topic:** Proposal to Secretary to allocate more funding for Committee
work

**Discussion:** Funding must be justified, but cannot be used to support
a summit. Committee asked for money for site visits and focus groups to
look at different settings and rural areas throughout the United States.
Since budget is already in place, it was agreed to focus on the year
2000.

**Action:** A copy of 1997/1998 Access to Care Report will be given to
the Committee so a plan can be developed from it to present to the
Secretary to justify the funding request.

**Topic:** Subcommittee working group reports

**Discussion:** Subcommittee met separately, chairs are responsible for
minutes

Action: None

**Topic:** The 1998 Report of the Advisory Committee

**Discussion:** A subcommittee consisting of Dr. Schwartz, Dr. Johns,
COL. Cook and Mrs. Ray was formed to develop an initial draft of the
1998 report. The draft should be distributed prior to the September
1998, so that Committee members can review and comment on it at that
time.

**Action:** None

**Topic:** Upcoming site visit

**Discussion**: Proposed that everyone not visit the same places as a
group, but break into teams. Instead of having open hearings have small
focus groups and listen to related situations.

**Action:** It was decided that since this was the first site visit for
the new members, the Committee would stay together as a group. Focus
groups would not benefit the veterans and the Committee's time would not
be maximized. It was agreed to hold a town meeting for the women veteran
community on Saturday morning.

**Topic:** Location of site visit

**Discussion:** Places of consideration were New York, Chicago and
Philadelphia

**Action:** Chicago was selected

# Miscellaneous

a.  A special presentation was made to the Chair, Linda Schwartz, for
    the successful completion of her doctorate degree from the Yale
    University School of Public Health;

b.  Members attended a Senate reception;

c\. Members visited the Women's Memorial hosted by General Wilma Vaught

The meeting was adjourned at 4:00pm.

Respectfully submitted,

Joan A. Furey