color: SOME SOLDIER'S MOM: New Veterans' Caregivers Bill -- A Response to Molly

Sunday, April 25, 2010

New Veterans' Caregivers Bill -- A Response to Molly

So Molly Pitcher said to my last post:

WOW. Where to start. Every veteran is entitled to treatment at a VA whether service connected or not. If you are service connected over 50% all treatment is free. Women do not receive adequate care. I would suggest reading recent GAO reports on the matter. What you take for granted in your private physicians office, I thank Congress for. Childcare: women vets are WAY younger than male vets. therefore childcare is a HUGE barrier to care. Its also true for most OIF/OEF vets. However, women are getting the spot light. It will benefit the single dad tho too. so why complain? To answer you question about a admitted vet: way too early to tell, these are pilot programs. Women are a small minority in the VA. We fight extremely hard to get equitable care (and it is not equitable). Please do some reading before writing against what we work hard for. Check out GAO please. I will be interested in what you post then. I mean you no disrespect and have a huge amount of respect for any mother with as many children as you in the service, however how many are daughters? Follow up with me at my email, and I will be happy to send you the different reports.

Different niches of veterans have been fighting for whats best for them since there were veterans groups. Women are finally doing the same. Don't discount that. esp. when they are the smallest minority in the VA.
Wow. Where to start? I was going to respond via email (but I didn't see an addy at her address), but when I thought about it, I realized it was a good opportunity to educate people -- not just on this particular bill, but on the Veterans Administration health care system... although I am far from an expert (Lord, can anyone be an expert on that bureacracy?) but I'll talk a little just on the points Molly makes.

Shall we begin?

First, Molly: I did read the 2009 GAO report; heh. To imagine that you had but I hadn't. Thanks for offering to provide copies, but I have them*:

On to the specifics.
Molly: Every veteran is entitled to treatment at a VA whether service connected or not. If you are service connected over 50% all treatment is free.

Molly, you really should have clicked on the link with the big red HERE that took you to the VA eligibility page (my emphasis):
1.VA must determine your eligibility [for VA health care] status as a veteran by reviewing your
◦Character of Discharge from active military service, and your
◦Length of active military service [snip].
2.VA must determine whether you qualify for one of the eight enrollment Priority Groups.
+ Enrollment Restriction:  In order to ensure the availability of quality and timely health care to veterans with service connected conditions, special authority based on military service, low income, and those with special health care needs, in January 2003 VA made the difficult decision to stop enrolling new Priority Group 8 (high income) veterans whose income exceeded VA Income Thresholds.
IF you are enrolled in the VA, care for ALL service-connected conditions is free -- even if it is not rated at or above 50% disabled (you're just in a lower priority group which has its own problems of getting services). The rules for care and medications you receive via the VA for non-service conditions are complex (can you say convoluted?) but the bottom line is that you MAY have to pay a co-pay or fee. Or not. Results may vary.
However, here's where I think Molly got the service-connected over 50% is free   (my emphasis)
Certain veterans do not need to be enrolled to receive medical care benefits.
You do not have to be enrolled if you:
•Have been determined by VA to be 50% or more disabled from service-connected (SC) conditions
•Are seeking care for a VA rated service-connected disability only
•It is less than one year since you were discharged for a disability that the military determined was incurred or aggravated by your service, but that VA has not yet rated
yeah. but it's still free. And it is true that any veteran can walk into the VA to seek treatment; whether it's free and how long the wait is a different story.

Molly: Women do not receive adequate care.
Horse hockey.  The 2009 GAO report found that there were varying levels of compliance with privacy configurations of check-in areas, waiting rooms and exam rooms at SOME VA facilities -- but made no finding or recommendation with respect to the SERVICES PROVIDED TO WOMEN VETERANS. Your statement that "women do not receive adequate care" is a talking point and a sensationalist headline, but not substantiated by the "recent GAO report" you so readily refer me.

As a matter of fact, the recommendations in the 2009 GAO report were to improve compliance WITH EXISTING PRIVACY POLICIES and mandates relating to access to information on women veterans services via the VA website and its materials. As the GAO noted, many of the problems with privacy compliance have to do with the lack of space, current [physical] configurations of VA facilities, standardizing reporting of implementation of privacy measures; special note is made that many of the VA facilities were having difficulty meeting the "one-stop care" measure because they could not attract physicians and mental health providers with gender-specific (i.e., women's health) training to satisfy the mandate -- especially at facilities that treat few women veterans.

The GAO report does enumerate many gender-specific services provided to women veterans:
The VA facilities GAO visited provided basic gender-specific and outpatient mental health services to women veterans on site, and some facilities also provided specialized services for women. Seventeen of the 19 medical facilities GAO visited offered basic gender-specific services including pelvic examinations and cervical cancer screening on site, and 15 offered access to one or more female providers for gender-specific care. The availability of specialized gender-specific services--such as treatment of reproductive cancers--and mental health services for women varied by service and facility. While some VAMCs offered a broad array of specialized gender-specific care on site, smaller CBOCs referred women to other VA or non-VA facilities for many or most of these services. Nationally, 9 VAMCs have residential mental health programs that are for women only or have dedicated cohorts for women.
One of the GAO's recommendations is for the VA to improve the information about these services and to make the information highly visible on the VA website. (see Summary, para. 2, and recommendations, generally). In their report (p. 10), the GAO said, "VA Facilities Provided Basic and Specialized Gender-Specific Services and Mental Health Services to Women Veterans, though Not All Services Were Provided On Site at Each VA Facility." They go on to note that those facilities that did not provide every female-specific service referred female veterans to other [VA] facilities for such care (same practice as for all veterans when services required are not offered at the closest VA facility). The GAO also reports that all facilities planned to offer all female-specific services in the future. In not one case did the GAO cite inadequacy of care or a disparity in care given to male v. /female veterans.

Is that a justification for the VA facilities for not having implemented the privacy measures that were noted all the way back in 1982 (and '92 and '94...)? Hell no. Should have been done LONG ago. But inadequate privacy is not the same as inadequate or inequitable care.

Now, if you were referring to the VA's Report of the Under Secretary for Health Workgroup, Provision of Primary Care to Women Veterans and the discussions of women veterans' dissatisfaction (performance) ratings for VA services... or the mismatch in utilization of services (immunizations, colo-rectal screenings, etc.) between male and female veterans, the assumption being that these services are not being offered or communicated as well to female veterans? OK. I get that. Something that needs attention. However, utilization of care is not the same as adequacy or equity of care. I heard no such allegations of inequity by the female veterans appearing before the Committee on Veterans Affairs (see discussion a bit later) nor did I read or hear examples of services provided to male veterans that women veterans did not also receive. Does that mean there aren't any disparities? No, but no one has recently spoken to some disparity or a level of disparity that exists and requires attention. Do service levels and quality differ from facility to facility? Yes, they do. But those measures are across the board and not explicit to women veterans. Poor (and exceptional) service affect men veterans at those facilities as well.

Molly: childcare is a HUGE barrier to care.
The GAO report (in addressing the "one-stop care" model mandated to better meet the needs of female veterans) states [at p.2]  (my emphasis),
Because many of these women work or have child care responsibilities, multiple visits can be problematic, especially when services are not available in the evenings or on weekends.
[Note that the footnote to this entry states that under current law, the VA cannot provide child care nor operate childcare facilities.]

Even in facilities that have "one-stop" providers, the GAO notes [p. 26, para. 2] that many of the women veterans themselves have opted to have their gynecological care from a VA provider separate from their VA PCP.  The GAO report does not say or even intimate that child care is a significant problem or bar to access and offers no facts, figures, suggestions or recommendation for such.

In fact, since the GAO report is silent on the issue, I was curious where the impetus had come from. Seems the child care "thing" resulted from testimony from two of five [hand-selected] female veteran panelists representing various veterans' organizations that appeared before the  July 2009 Senate Committee on Veterans Affairs Hearing on "Women Veterans: Bridging the Gaps in Care".

According to the summary of the panel's testimony provided by Women's Rights/, the panelists "spoke about the vital need for child care at VA facilities, as well [as] the importance of making VA clinics and hospitals more child-friendly."  I watched the video of the hearing to ascertain who said what and the basis of this dire need. Ms Olds of the VFW listed child care among the needs of women veterans on par with hiring more physicians and mental healthcare providers, access to service, and outreach to women veterans, etc. It was a big issue for panelist Ms Williams, as well (she sits on the Board of a women's veterans organization whose name was not in her written testimony and I could not understand the organization's name from viewing her testimony.)

Ms Williams regales the Committee and guests with shocking stories of a woman veteran who had to change her child's diaper on the floor at a VAMC while waiting for appointments and of another who was told emphatically that if she couldn't find child care for her child, she should just not show up. I don't doubt for a second these stories are true -- who would make such things up?  I find no study, no data, no survey -- nothing in sworn testimony or reports or news stories -- to indicate whether, in fact, lack of childcare impacts in any way access to health care for veterans (male or female); there are just anecdotal accounts that it's a problem for two veterans.

In her testimony before the Committee, Ms Olds referred to the VA's  Report of the Under Secretary for Health Workgroup, Provision of Primary Care to Women Veterans and pointed to their findings generally -- which led me to think it contained facts or a discussion or study or recommendation on child care, but I could find no such information in that report on the need for child care. I did find (my emphasis): 
While no-show rates for general primary care have a target of 13 percent, the no-show rates for women’s gender-specific prevention clinics have ranged from 14 percent to well over 28 percent at most facilities. (f/n 70)   Factors related to no-show rates for women’s clinics differ from those for men, e.g., not missing work and childcare and eldercare responsibilities.
Don't get me wrong. I was a working mother with young children before most of the women on that panel were born; my former DIL is a working mother; we have a daughter who expects to be a working mother in a few years; and six nieces -- four of whom are currently mothers of very young children. I fully -- and I mean FULLY -- understand the problems of balancing work, family and all our other commitments as women -- including to our own health -- and the child care issue. It all just leads me to ask how all the mothers of young children in America who are NOT veterans get to medical appointments and what do they do with their children... and makes me wonder where all the child care facilities are in non-government hospitals and medical facilities around the country?

I am ok if the VA provides a stipend to cover child care costs the same way mileage is reimbursed, but not OK with using funds to create and staff child care facilities. Of course they should outfit restroom facilities with changing tables -- but childcare? I'd also be OK with the VA partnering with child care providers or day care centers to provide occasional care for veterans' children while they are at the VA. [Side note to Molly: My son would not really benefit from childcare at the VAMC since he and his child's mother -- also an enrolled veteran, fwiw -- provide child care for their child for ALL of their personal commitments.] 

Frankly, while it may be a problem for SOME women veterans -- and I empathize, I sincerely do -- is it a "HUGE" impediment in access to care? No.

Since both the GAO report and the VA Report also found that having a job could also be a factor that prevented female veterans from accessing care, is it proposed the VA pay them, too? Perhaps the Congress that is so willing to pass inane and often over-reaching laws should MAKE employers give veterans time off for medical appointments? Maybe it can be illegal to fire or suspend a veteran-employee for attending medical appointments? (Sure... one more reason not to hire a vet.) Besides, every attempt at legislating decency throughout history has failed.  Not sure what will have to be done about elder care responsibilities... (well, if Obamacare comes to pass, we won't have to worry about us elders. ok. /snark)

WHY should the VA provide newborn services? OK. I do get that the VA offers obstetrical care -- but not at its facilities. They do cover it... so I see where the whole newborn services got there... but that's not mentioned in the GAO report or the VA's report either!  Maternity and neo-natal care is available through private providers or community health care providers -- at facilities far better equipped to provide such services. In fact, the GAO notes that veterans requiring obstetrical care are routinely referred to non-VA facilities for such care and the report contains no note nor offers a recommendation to provide newborn services or provides a justification.

The use of resources to provide these services to the very small number of female veterans that might require them is a misplacement of resources. Could it be nominal in the scheme of things? Sure. But where does it end?

Molly: Women are a small minority in the VA.
You make my very point: if women veterans are such a small percentage of the overall veteran population (8% of 23,067,000) -- and child-bearing female veterans an even smaller percentage -- why siphon off dollars, resources (space and staff) and create programs for that small group of veterans when there are so many other needs to be met that could serve ALL veterans?

The original VA medical system's mission was quite explicit: "to provide care to veterans with service-connected disabilities. In addition, to the extent that staff and facilities are available, VA facilities can provide care for non-service disabilities to veterans who are unable to defray the cost of care elsewhere."

It seems that the purpose of the VA is now to be everything it can be to every single veteran -- that qualifies. The money earmarked (and I use that term deliberately) for these new expanded women-only services (some of which are not detailed) could well be used to expand the eligibility to veterans -- including women veterans -- who remain excluded from all VA medical services because they are above the even newly-revised financial threshold and do not have combat- or service-connected conditions.

I am not against providing services to female veterans. On the contrary: female veterans -- like male veterans -- have earned every service at the highest level. Where there are deficiencies -- in either male or female care -- they should be addressed. However, I am opposed to creating special programs that apply to a very tiny minority of veterans when the needs of ALL veterans -- male & female -- are better served by the use of those funds and facilities... especially when no need has been empirically established for things like childcare and newborn services. In fact, the money being spent on these measures could easily have been used to bolster and expand the class of providers caring for the wounded or increase the comepnsation level.
Molly: What you take for granted in your private physicians office
I take nothing for granted.

Molly: I mean you no disrespect
sure you do... if even a little or you wouldn't have admonished me as you did.

have a huge amount of respect for any mother with as many children as you in the service, however how many are daughters?
Jeez. I'm surprised you didn't pull the race card... or the chickenhawk argument... and you didn't mention that in addition to the three sons (two are veterans and one is active), my father was a disabled veteran, my husband is a veteran (note: 25 years, 2 combat tours, and not eligible to enroll for VA medical services!), one sister is a veteran of the USMC in the 70's, and we have a nephew also serving (AF). As for the daughter? She went to medical school. Aren't my husband and three sons enough?

Molly: I will be interested in what you post then.
Well, now you know.


* Here's the links to the 1982 GAO Report , 1992 Report , the (limited scope) 1994 Testimony (report) and of course, the GAO's and VA's 2009 Report is linked above.

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At 4/26/2010 11:03 AM , Blogger Kanani said...

I ran a surgical practice in the private sector for over a decade, and have been involved in the medical side of practices for over 23 years. Most of our patients were in an economic bracket that had them teetering on the brink of "not making it." Some had insurance, others did not.

Let me say this about child care.

We discouraged women from bringing in children to the office. Why?

Because almost all our new patients were stressed not knowing whether or not they had something dire (but most were convinced they did!). So we opted to keep the waiting room calm to balance the war raging inside the patient's mind.

In addition, it was always extremely awkward to break the news to a patient about her condition --especially if it were stage IV cancer when a child was with her.

Other times, mothers would try to bring their sick child in who was home from school. We always rescheduled them. Why? Because our staff didn't want to get sick, and to have a sick surgeon is even worse.

But as for us providing childcare, we never felt it was our responsibility. That's a matter of asking a friend, a neighbor, of reaching out to the community around you and making a connection.

As it is, the VA has to make a decision. Do they spend precious dollars on child care facilities or in hiring new physicians and other practitioners?

Quality child care facilities have to be licensed and certified, they should have licensed childcare providers. And that's a huge amount of money to install them in all VA hospitals.

Our staff was composed of working women. They were the ones who came up and enforced these policies. We encouraged women to make that connection to find someone to take care of the children so you can go to the doctor. The ones who say, "I can't" are dealing with something far deeper.

Newborn care. Okay, do we set up pediatric facilities at a hospital set up to take care of adults?
I don't think so. Pediatrics is a specialized area --especially pediatric surgery, oncology, and any other sub specialty. These services are best contracted out into outside service providers. You're going to be far better off at a facility that does deliveries, neo-natal, and newborns all the time, than one that does it intermittently, or doesn't have a full program.

I will agree that much more can and should be done to ensure equitable access to services for gender-specific conditions and needs. But providing child care facilities and newborn services are ones that will only be done if siphoning off dollars away from treatment programs that benefit everyone --both adult men and women.


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