Transcripts For CSPAN3 Hearing On Health Care For Women Veterans 20220927

Good afternoon, i call this hearing to order. Without objection, the chair is authorized to declare resets it anytime. The Committee Procedures for remote hearing remain the same. If youre experiencing connectivity issues, make sure you or your staff contact our designated Technical Support so those issues can be resolved immediately. If you wish to have a document inserted into the record please ask for unanimous consent and have your staff email the document to Veterans Affairs dot hearings at mail dot house. Gov. Without objection, members will be recognized in order of seniority for questioning witness of the day. This will make it easier to ensure all members participating have an opportunity to be recognized. Does any member have a question about the procedures for this hearing . Hearing none we will proceed. I will recognize myself for an opening statement. Over the last years we have often seen women as the Fastest Growing covert among veterans. Our hearing today will examine Women Veterans access to the full spectrum of medical care. Including Reproductive Health care through the Veterans Health administration. Todays hearing also offers an opportunity to reflect on the meaning of since the day of the revolutionary war. Women veterans have signed up to fight for and defend our countrys founding idea of freedom. Thats why they served and thats why they continue to serve. But listen closely to my colleagues on the other side of the aisle. It will be abundantly clear that women that ims freedom to make choices that are better for their own personal health and medical providers freedom to exercise clinical judgment are under attack play attention to the kind of legislation they support. There are so extreme that all but one of the republican colleagues on this committee have 1011, have build the criminalizing Womens Health care. It would effectively negate womans bodily autonomy once the spare meets the egg with no exceptions. The practical effect of this is that Womens Health care choices become murder. And they have no right to refuse to lifesaving cancer treatments or use iuds or emergency contraception. It also takes away the choice of women to pursue science based Family Building treatments, such as in vitro fertilization. Since the Dobbs Decision, weve seen a stark contrast between those who claim to be prolife and those who actually want to defend life, the freedom to choose, and the freedom to respect the right to privacy. One veterans have worn the uniform of our country with pride. Thats why its an insult to their service that they would be denied for making the most personal choices about their bodies and their lives. In reflecting on the effect of the recent Supreme Court decision one of the witnesses on our second panel said, in the written testimony, quote, the moral injury of having served our country to protect the constitution is no longer protecting me, and the ones i love, wasnt still is absolutely devastating, and. Fortunately President Biden and secretary mcdonald are taking action to avert eminent and future harm to veterans by restoring certain Reproductive Health care freedoms that were eliminated in the wake of the Supreme Courts decision. Six days ago, va published an interim final rule that removes its longstanding prohibition on abortion counseling, and authorizes via medical facilities to in cases of rape, incest, and health of the women. This ruling is a strong first step that finally puts va on par with all other federal Health Care Programs. This rule promote better equity between men and women who receive care at va by removing the gag order on what doctors can discuss with a woman patients. No such gag order has existed for men. And its unacceptable that it should ever be exercised against Women Veterans who served alongside brothers in arms and deserve the full carer theyve earned in need. Most importantly this rule will save womens lives and protect their health. For decades va providers have had to call him favors in the community to procure lifesaving abortion care for women. Before this interim final rule, pregnant veterans with life threatening pregnancy complications returned away. But in the wake of dobbs abortion bans have been triggered in multiple states, and Community Care is no longer an option. Now, va can provide the abortion care necessary to save womens lives when their communities and states. They can save veteran women lives when their communities and states wealth. Va came to this decision after listening to Va Health Care providers and veterans across the country. Congress needs to listen to veterans and providers to. Over the last several decades i and chairwoman brownley along with several colleagues including fellow Committee Members have been doing just that. Since early august weve traveled with our staff to four different states and the navajo nation. We drove more than 1600 miles, visited six different va medical facilities, and conducted seven listening sessions to hear from women in each location about their experience at the va. I came away from these visits light and about the challenges va is facing and awestruck by the determination and strength of Women Veterans. We met with Clinical Care teams and Women Veteran Program Managers like stephanie in Oklahoma City and in temple, texas, cindy in las vegas, and pat in phoenix va employees are serving veterans in creative ways. Spending hours doing outreach. Thinking of new ways to show veteran women that the va is a place for them. We have seen what leading Womens Health care means, including at va facilities with dedicated womens clinics, separate entrances, lactation facilities, integrated mental of care and an overall experience designed and delivered for Women Veterans unique needs. I will tell you that among the va providers and Women Veterans ive met with last week, the news of the secretarys recent regulatory action was met with approval applause and. We asked unanswered, unequivocally, Women Veterans want v8 provide the full spectrum of care where they are fully partners in their own Health Care Providers. There was applause at the va, finally joining other Health Care Programs in providing lifesaving reproductive care. And hope that the critical step will be a sign va is ready to truly welcome Women Veterans and provide that full spectrum of care. After wide listening sessions with Women Veterans last week, a young veteran shared her reaction. Quote, i felt seen, i felt her, and i felt hopeful for the future of Womens Health care at via, and quote. Weve been fielding an Online Survey to hear from veterans across the country about experiences receiving Reproductive Health care, contraceptive care, and in futility treatment of you. As of this week weve received over 450 responses from veterans. The overwhelming majority support via supporting abortion counseling and abortion care in circumstances like those covered by the secretarys new regulation. 90 of survey respondents have said va should provide abortion counseling and 73 of respondents said va should always or sometimes provide abortion care. The survey is still alive on the committees website and i encourage any veterans tried to access Reproductive Health here at va to complete it. Visit veterans dot house. Gov and click the button at the shop to share your story your responses will remain anonymous should you wish them to be. I also want to thank secretary mcdonough and President Biden for the courageous and strong regulatory action will save womens lives, that will save veteran womens lives. I look forward to working with the secretary to ensure va as everything it needs to supplement, to implement those rules successfully. I know much more needs to be done to improve Women Veterans experiences at the. I see the implementation of this rule as a big leap moment for the department. If implemented well i hope this will attract even more providers to practice at va and more Women Veterans to seek care. This is an opportunity to improve the whole spectrum of health care for Women Veterans. Indeed, i heard a lot of hope in my conversations with Women Veterans last week. There was also frustration about longstanding challenges. Majority of womens care is sent out to the community. Caseload for womens kara coordinators make it hard and difficult for Women Veterans to reach their providers and yet scheduled appointments in a timely matter. Some Va Health Care providers are not as well trained or is committed as they should be in caring for women. Deficiencies in private, and anti harassment measures still exist and va facilities. However, these are challenges that can be addressed if we collectively commit to doing so. In phoenix alone over 11,000 women have chosen to receive their care at va. And this is an astounding in laudable number. It means we will be 11,001 in the best experience possible and the health care theyve earned and deserve. Im pleased that the other leaders on the panel how vha can put it plan into action that will serve Women Veterans. Also hear directly from veterans that Womens Health providers about their experiences so we can now hear more about the va challenges and develop ways to address them. Theyre watching and listening to what we have does. Theyre listening closely to who wants to deny them the most basic autonomy, and who wants the support the freedom they fought for thank you, and i recognize Ranking Member boss for his opening comments. Thank you, mister chairman. Ill discuss the care that va provides to Women Veterans. Id like to start with a couple of stories. I know this young man thats 42 years old. He serves as a judge in my hometown and he also is a Lieutenant Colonel in the United States marine corps reserve. Hes an outstanding citizen, he has been a blessing to the people in his community, he has worked hard, he has served this nation. 43 years ago, a young 17yearold girl had to make a choice. About three teachers told her, dont ruin your life. This is very inconvenient to be print. And she made the choice to keep the child. That child is my son, and that womans my wife. Fast forward, fast forward to 20 years ago. My daughter, the day after my sons wedding, and matteroffact, came to us and she had to be rushed to a hospital in st. Louis because she was pregnant with twins. And the twins had what was known as a joint communication, a shared umbilical cords. She was 25 weeks along, if they could just get rid of 26, just 26 weeks along the babies with the. One of the babies died in the womb causing her to go into labor. At 25 and a half weeks and we have she filed for every breath. And, mister chairman, strengthening services to Women Veterans is a priority of mine and you shouldnt question that, or anyone else on this panel, you know me. You know that we want to fight for womens rights and their ability to be served by our veterans, i r b to deal with any issue they might have. Those honorably have served our country in uniform have served the best health care and support that we can provide regardless of gender. Ive got a granddaughter that just joined the navy, as a marine thats kind of hard on me but ill get over it. I would teaser about it. But you know, getting the health care they need is starting to include starts, families on their own way and that doesnt include abortion. Im proudly prolife. I believe its a matter of my faith that importunes room i also believe as a matter of law the va doesnt have the authority to offer abortions. Congress made that clear in 1992. By prohibiting va from providing abortion. 30 years later that prohibition remains in place. Its not changed. It has not been repealed. It has not been replaced by subsequent congressional action. Thats why im so outraged by the announcement the va will provision providing abortions to certain veterans, and va beneficiaries, and abortion counseling to anyone in those groups. This is not only wrong its illegal. Let me say it again, its illegal. The president and his cronies are willfully ignoring the constitution by acting like laws are mere suggestions the Biden Administration has made it downright its shameful. Its undemocratic. And it marks the duty members of congress have to represent the will of the American People in washington with our actions, with actions like this the president is doing exactly what he falsely accused duly elected republican representatives doing last week. Following the law isnt an option, its a requirement. By ignoring the law va is violating the wishes and values of millions of americans who dont want their tax dollars used to pay for abortion at va or anywhere else. Im one of those americans. And the law is clear, and its on our side. Ill never stop fighting to ensure that the sanctity of life is protected at the va and everywhere else. Im working with my colleagues on the Appropriations Committee and the senate to consider sanctions against va for violating the anti deficiency act. Abortion is not health care no matter what those on the other side of this issue may feel the right to life is sacred. American values enshrined in the declaration of independence. Its one of the rights. Service members and veterans throughout history have fought and defied to defend. Im committed to defending it now. For them and for their unborn children. Mister chairman, without a yield back. Thank you, Ranking Member boss. The 91 law that you cite was superseded in the 1996 law that authorizes the va to create its own medical benefits packages, its own package. And the amendment does not apply to the va. Secretary has the authority to create the medical benefits package that characterizes the entire array of services that happens under the Veterans Health administration. I will recognize myself for questions. Five minutes. Im sorry. It be helpful if i introduce the witnesses. The witness panelist, lets begin we have with us today, im happy and pleased to see with us, dr. Sharif, newly confirmed undersecretary for health for the Veterans Health administration. Accompanied by patricia hayes, chief officer of Womens Health, Veterans Health administration for the u. S. Department of affairs. Dr. Johnson, director for women s Reproductive Health for the Veterans Health administration. U. S. Department of energy affairs, and dr. Julian, flynn, assistant, acting assistant for secretary of health for Community Care for the Veterans Health administration than the u. S. Department of Veterans Affairs, dr. Sharif omaha, you are recognized for your opening statement. Good afternoon, mister chairman, Ranking Member, boss, the members of the community, i appreciate the opportunity discuss womens veteran act. Including the Reproductive Health care available to veterans. Im accompanied by dr. Perez, our chief officer of the office of Womens Health, dr. Amanda johnson, director of Reproductive Health in the office of Womens Health, and dr. Julie and film, our acting deputy undersecretary, assistant undersecretary for health of the office of integrated veterans care. On behalf of the department i want to thank the committee for its laser focus and continued collaboration on the whole health of all Women Veterans. This critical relationship is reflected in the resources that congress has repeatedly secured for va in the office of Womens Health. Its a priority of this administration to ensure comprehensive care for Women Veterans as seen in President Bidens budget request of 9. 8 billion for fiscal year 2023. One important aspect of this work is delivering Reproductive Health Care Services when veteran learned when where they are new. The services we offer include fertility, contraceptive, menopause, karen Maternity Care, and life saving treatment related to pregnancy. As a result of the Supreme Court decision that overturned roe v. Wade, certain states have begun to boris abortion bans and restrictions creating urgent therefore, the a modified its regulations to expand Reproductive Health care. When medically necessary veal offer abortion counseling and provide abortions when the life or health of the veteran would be endangered and if the pregnancy were carried to term or their pregnancy would be the result of rape or incest. Self reporting for pregnant veterans constitutes sufficient evidence of a act of rape or incest. Its a safety decision first and foremost to ensure enroll veterans in va veterans can access Life Saving Services at va no matter where they live. Protecting the health and lives of pregnant veterans is a primary concern of you. Its important to emphasize that va is taking steps with the primary mission in mind to preserve the lives and health of veterans. Theres nothing more important than that. This Emergency Authority allows us to save lives as we progress toward implementation. As this will be a new service, we recognize that significant steps will be need to be taken across the system to implement it. And while a formal implementation is under development, i want to note a few areas we are working toward. We believe medication for abortion will be first available type of proportion refined it. We are working to ensure providers have access to training as well as medications. Pregnancy testing will be required at all va sites of care. We must also survey the ability of pelvic ultrasound to assess early pregnancy. Ensuring staff is necessary at sites is critical to providing the services. In cases where va is not immediate care, available to provide media care, veterans only to travel to community or other va sites. Circumstances were veterans normally qualify for transportation benefits for Health Care Services that va provides more generally. So too will veterans qualify for transportation to sites that can safely deliver that care. They will continue to follow policy requirements to ensure practitioners have completed missionary training and education are at va sites of care, where these services can be delivered safely. Prior to this expansion of services, abortion and abortion counseling were considered an excluded service in the Community Care network or cc and contract. The provider agreements will need to be adjusted by the tps to allow for abortions and abortion counseling has covered services. During this interim period veterans care agreements will be developed as used as a bridge but until the cc in contract modifications are completed for the services. Finally, the physical safety of our veterans, providers and staff is always a critical consideration. Acknowledging the potential divisiveness and emotional response to this issue, va is alerting security across the system to develop strategies for highrisk sites. In conclusion, the amendment to include Abortion Services and abortion counseling in cases that threaten the life or health of pregnant veterans or va beneficiaries reflects our relentless focus on veterans. We are committed to providing veterans with access to well class Health Care Services, including Reproductive Health care. They ever and through service through our nation. The yays are chairman to stand by that commitment. Mister chairman, this concludes my remarks. My colleagues and i are prepared to answer questions that you may colleagues may have. Thank you, doctor. Its a pleasure to have you before our committee. I recognize myself for five minutes of questioning. Ill begin with you, doctor. Your most recent employer was a non va community hospital. Based on experience and your knowledge about the state of Reproductive Health care access in this country post pandemic, can you tell looks about the capacity of Community Providers to care for pregnant veterans and provide abortions, and how that influenced the va decision to issue last fridays interim final rule . Thank, you mister chair, i indeed lead a hospital in newark, new jersey. Thats a state that does it for the services, permit these services i should say, two women across the state. So there are ways for veterans to get that care outside a va in new jersey. But that simply is not the case across the country. Especially after the Dobbs Decision. Part of the emergency that we are responding to is related to the fact that states have leveled restriction, certain states across the country, in terms of access to the services. In many of these states the baseline availability of Reproductive Health Care Services was much less bennett is and other parts of the country, including new jersey. Between 10 to 20 cases of veterans a year that are Womens Health have told me about. We have actually had to send veterans for lifesaving care to community facilities, ask them to do these services to save veterans lives. And then come around and say, we cant pay for these services. Given that the baseline availability of these services was variable across the country, and certainly more limited in certain states, we could not contend with the Safety Environment after the Dobbs Decision in terms of restrictions to the services, state by state. These 10 to 12 Women Veterans that you speak of, more or less per year, these are Women Veterans who are facing lifethreatening Health Conditions. Is that correct . Thats right, mister chairman. And for them to not have the option to seek an abortion procedure because its not available to the va because of the rules we have in place, their lives are endangered. In these cases, yes, mister chairman. And also were particularly concerned about the environment after the Dobbs Decision. Whereby some states are restricting these Services Even more than they were before. And we could simply not contend with that environment of safety for veterans. Another point i want to mention, mister chair, is that we feel this is needed care, especially in this context. And as a general matter if these veterans are under a care and we know they could save their lives we have to do. And under the previous regulatory environment, have a practitioner theoretically was not able to talk to a woman veteran about a procedure that could save your life, is that correct . Thats correct, mister chairman. To what extent our Community Providers overextended . And what is the effect of Health System consolidations and hospital closures on veterans access to lifesaving care . Having let an institution outside a va recently i can tell you that access to Health Care Services is more broadly being strained across the country. I can tell you that there will be times for a lot of critical pieces of the care and the hospital was providing. Restrained by not only new and evolving Public Health issues as we proceed to the endemic phase of the pandemic. But also the fact that we were catching up to delayed and for care as a result of the pandemic. So those things are layered upon our concerns india for access to these services outside of you. And part of that led to our decision to say that we have to respond to those emergencies and offer the services to Women Veterans across the country. We can anticipate, just knowing the data annual needs that arise of 10 to 20 Women Veterans across the country to face lifethreatening pregnancies. We can anticipate that each succeeding year were likely, giving the numbers of veterans that we would see, 10 to 20 veterans facing life threatening situations Going Forward each are. Thats a reasonable prediction to make, right . Its true, mister chairman, this is the fastestgrowing veteran demographic that we have. We have hundreds of thousands of Women Veterans of child bearing age. So i think if those trends continue and we very much expect them to, you may see even more of those veterans requiring lifesaving care, yet another reason this is an important move. My time is up. I certainly see and i want to confirm and validate to you the basis of this emergency. And i confirm you for taking Decisive Action along with the senator. I recognize Ranking Member so boss. Thank you mister chairman. Doctor elnahal, if you would respond, please respond yes or no, only yes or no for the following questions. Yes or no, did Congress Express expressly the hit prohibit the aim of by in section 106 of public law one or twos dash 585. The vas interpretation of that law, sir. Yes or no. Your answer is no, well actually, it is. Yes the true answer is yes because that law was passed. You are not using that law to try to undermine the that a second. Yes or no, was congress ever expressed, has it expressly repealed or the prohibition in the law . I am not aware of that. The answer is no. The correct answer, of course, in all of this, congress, did prohibit private va from providing Abortion Services in 1992. That prohibition has never been repealed. Even though some comments have been made that you are using another twist on a different section of the law to try to get there. So it is still in law today. Where i come from, we tried to follow the law. It disturbs me that one of your first acts, as under sector of health is to disobey the law so blatantly. Especially on an issue that is quite literally a matter of life and death for most innocent, helpless, and defenseless among us that the Previous Administration of both parties have been declined to pursue in the absence of a legal mandate. Yet legal mandate that the va certainly does not have today. My office says a series of questions. Detailed questions last week about how va some would operationalize this rule. My question should have been fairly basic, we did not get the answer until yesterday, for example, we ask a va plans to have a late term abortions for womens in their third and final week of pregnancy. Some third trimester in the final week of pregnancy. We asked the va if they would perform abortions on minors in camps, if so, if the patient, or if the parental consent are notice would be required. We ask how va provides providers with moral objections would be excused from providing abortions, counseling, or a performing abortions. The va blew past the questions they learn to respond to our questions. When we did receive the answer to my question, as i said yesterday, many of the responses were non or half answers. Setting aside the basic illegality of this effort, how can you justify proposing such a significant change without being able to provide timely responses to basic questions about it . Dr. , and then im going to ask this question as well with that, all you have talked about so far when the question came up earlier is about emergency situations. You are proposals and what you have answered us goes way far past emergency. Also passes well past the do you have a response . Yes, congressman. I understand that you are taking this position around our authority. I want to say that we respectfully disagree with that. Our Council Consultation with the department of justice. What i can tell you is, when we were trying to be responsive to the urgent situation that faced veterans across the country after the Supreme Court decision that overturned roe v. Wade, what we wanted to do would ensure the clinicians can exercise their judgment without having to take extra steps to determine whether they felt was needed to preserve the life and health of the veterans. We wanted to make sure they were free to exercise their rights, to ensure that veterans needs or cared for. You are admitting that it does go a lot further than just emergency situations . We trust our clinicians, congressman, to make the right decisions for veterans. Can you answer my question. Your decisions, the way that you are putting the rules together goes much further than just the safety of our veterans. I think all of it has to do, congressman, with the safety and health of our veterans. Lets go with one of the questions that i asked, i am already over on time. I would like to just find out, at first we got a livable answer on if a clinician, for moral reasons, wants to not perform this. The answer honorably was yes. Then the answer that we received was, each case would be weighed out whether or not we would have that. I think there is a lot of issues that you will have with this, across the spectrum. More than just hearing is going to take to figure out where we are going with this. The question of legality will probably be found out in the courts in sometime. With that, i am out of time, i yield back, thank you mr. Chairman for letting me go over. Thank you. I now recognize the chairwoman brownlee of the committee, five minutes. Thank you mister chairman. Thank you all for being here. Doctor elnahal, thank you for the previous conversation earlier this week. I was glad to be able to have a longer conversation with you on this issue. I certainly thank you and the secretary for moving forward with this important rule and Service Within the va. I applaud the fact that the way you described it is not just life, but for the health of the Women Veteran. I think that is very, very important. I will say in response to mr. Bost, bosts comment, albeit i respect his position on this, i dont think he respects mine. I certainly do honor and respect his. I think its more likely that the va will find many, many more than ten or 12 women a year requiring emergency or life saving bought abortions. Vingup until this point, there s a va guyger rule. Va providers could not even discuss the without experiencing, sometimes major complications and their pregnancy. I think there will be more, i think it will save more lives as a consequence. I do want to say that i will continue to advocate that i believe the womens rights to choose and make decisions around her own body should be part of the Overall Health care provided by the va. I will continue to advocate for that. I feel very, very strongly that it is the right thing for the v a to do. So, having said that, i wanted to go and ask, first of all, to dr. Elnahal, if there is anything you need from us in terms of trying to execute this rule. If you need something, a decision by congress or so forth, i hope you will speak with us and let as work as a team. I did want to ask dr. Johnson a question, because the last time we discussed my veteran infertility treatment act, it was at a legislative hearing, it was two days before the dobbs Supreme Court decision. Now in a post world, i believe it is crucial that we make ivf care a part of the va medical package. Unrelated to a Service Connection, marital status, gender identity, sexual orientation, race, or ethnicity. Doctor johnson, do you consider ivf to be part of essential health care . My apologies. I think Family Building services are part of essential health care, i think it follows our responsibility to promote, reserve, and restore the health the health of the veterans who served our country. Very good. Doctor elnahal, this is something as well i want to work with you. They are putting a right foot forward. As you have said in your opening comments, you know, Women Veterans are the Fastest Growing cohort within the veteran community. I think we can all recognize that we have a ways to go to bring equity to services for our Women Veterans. We have made a strong steps, but we have many more steps to go. Particularly in a postroe world, i think its important, as you have thought about access to abortion in the event of life, health, rape, incest its important that we look at a full benefits package to include ivf without a Service Connection barrier to it. It is just part of a Womans Health care. If you want to make a comment, i would love to hear it. My thoughts align with dr. Johnsons exactly on this. I think part of this reason that we lead among Women Veterans in terms of trust has to be with not just what you mentioned around these previous restrictions on being able to discuss the full scope of Reproductive Health care, but also the services that follow that. I look forward to working with you, congresswoman, on this. Thank you very much. Last and not least with a second spare, i know in the second panel, and reading the testimony of the second panel, there is this strong consistency and a message that we go through all of the testimonies to say still, that the va is generally not an open inclusive place for women to walk into. And be served without harassment. We have to continue to work on that. I know the debra census sampson took a big joint step in that direction, but we need to make sure that it is executed, it is skilled across the enterprise, as you said in your testimony, it is unacceptable otherwise. You are sent a letter yesterday to the secretary regarding the motto, the motto is, lets not going to change overnight the culture of the va, but i think its a first very important step to release signal and communicate to the Women Veterans that we respect and are grateful for their service to our country for the lgbtq community, we are grateful in recognizing their service to our country. I think the motto would be a long way in going to say, the va is very much committed to inclusivity. Thank you very much, i will yield back, mister chairman. Thank you, chairman brownlee. I now recognize general bergman for five minutes. Thank you, mister chairman, today is a unit they for a lot of reasons. I will start with, 54 days before an election. I was very uniquely surprised by the slideshow in your opening remarks. In the military, i dont know if there is a rubbish rules of order, but in the military would go into article 133, of become unbecoming. This light show is not something to be used in a campaign commercial, that is just a personal view pellets of how we open the meeting. I would also suggest, as a correlation to that, the conduct unbecoming goes to all levels of leadership. The two marines dang standing behind President Biden in a speech a couple of weeks ago in the grass blues, that was conduct unbecoming. Now lets get to the point at hand. Doctor elnahal, vas response from the Ranking Member bost states the va warp that allow mental Health Providers to allow Abortion Services to veterans. Yes or no . Yes, congressman. They will be part of a number of types of providers. Yes, but mental Health Providers. Yes. Okay. Va mental Health Providers are they trained in aesthetics, maternal health, how to conduct an abortion procedure where the risks of such a procedure . Congressman, i think yes or no . Are they trained . In the military we dont send anybody, we are talking about veterans here, we dont send anybody into a bullet to ask them to do something that they are not trained to do. Are these people trained . They are Mental Health counselors. They are probably very good. Are they trained . Yes or no . Congressman, they are trained in discussing a clinical options for care. Okay hot, if they are trained in discussing clinical options, who provides the Expert Opinions for the veterans sitting next to them who may or may not understand what the options are . What is the training that is going to be given to the people who work for you to be able to provide that veteran with a really realistic risk assessed decision for them . What is the plan thats a fair question, congressman. We have great programming that dr. Hayes can speak to on comprehensive training and Womens Health across multiple sets of classes and providers. Im talking about specifically mental Health Providers talking to women, veterans, that are already under a great deal of stress. Your mental Health Care Providers are trained to deal with that stress. But who is going to be the subject Matter Expert sitting with them when that veteran has a question . Have we laid that out . Is there a plan . Can we see it . The plan for how this will be best introduced, in order to put the veteran at the center of this decision, would be that we will conduct training. First, its necessary to understand that what happens is somebody gets a positive pregnancy test from the gynecologist or their health care provider. You are missing at the point. Youve got people on your staff, mental Health Providers that will provide of this. Now lets talk about the veteran who is the result of a pregnancy test, or whatever it is. We are talking about the people that you train and deploy to help these veterans who are under stress. What is the plan . Yes, sir. The Mental Health council will be only part of a team, the will be working with a gynecologist. Theyre all going to sit in the counseling session . They may all be there. When they may well, i mean, again, if im under stress in a situation and i got someone advising me, i want to make sure that i can get answers right then and right there, is this going to be one of these things will rekick the can down the road, come back next week . I because i am not qualified to answer your question . Is there a plan . We cannot provide the plan exactly today. I would suggest lets keep the cart behind the horse, lets get the plan together before we start putting Women Veterans at risk for making a decision that they could later regret because they got that information. With that, i yield back. In formation. With tha thank you, general b, i want you to know the same committee will gather to the firm today to hold a hearing on veterans suicide prevention. I will not give one man to help is not help, we know that Mental Health challenges are related to trauma, and they also occur with pregnancy and pregnancy complications. The va testimony today, doctor elnahal noted the horrible statistic that nearly 60 of pregnancy associated deaths among Women Veterans in va care or related to suicide, homicide, and overdose. And that Mental Health conditions were affecting 78 of veterans who died and pregnancy associated events. These statistics are horrendous. But they reflect very real dangerous for very real women. Many of you may not know that the interpersonal violence, again, it is much worse when a veteran when a woman becomes pregnant. Suicidal thoughts and behaviors also are accounted for. Pregnancy is a risk factor for violence. Obviously, a reasonable person can understand that Mental Health considerations are every bit as important as physical Health Factors in weighing decisions. Pregnant veterans and their clinicians must be able to consider and make decisions on the basis of all Health Factors full staff. I now recognize representative underwood for five minutes. Thank you, mister chairman. Earlier this summer, the americans lost a constitutional right for the First Time Ever when the extremist approve court and overturned roe v. Wade. Theyve been working for decades to impose extreme laws banning abortion. Now they are succeeding. Sometimes, without exceptions even for rape and incest. That is why it is so important that the eight taking a critical step in the opposite direction of this month. Finally, providing veterans with access to abortion counseling, and abortion care in cases of rape, incest, or when the life of a pregnant veteran is in danger. As a registered nurse, i applaud this rule from the va, which is grounded in medical evidence, it is critical for patient safety. Doctor omaha, in announcing this rule, you announced that the va came to us decision, quote, after listening to Va Health Care providers and veterans across the country who sounded the alarm that abortion restrictions are creating a medical emergency for those who serve. Can you share some of the stories you heard from veterans and Va Health Care professionals and underscore the need for this . Absolutely, congresswoman. I wanted to start by saying thank you for your advocacy and your work on this, particularly for women of color, that is the priority we sure at well. Doctor hayes, doctor johnson, thank, you i want them to weigh in. I think its important to understand that the way in which we work very individually with veterans is at the heart of this matter. We need to be able to talk with veterans, talk about their personal response to their own pregnancy tests and be able to go with that in terms of what did they need. The kind of things that we encounter are these 1 to 1 tragic situations that a person has to make that decision for themselves about their own lifethreatening medical conditions. The pregnancy that they have. It is a 1 to 1 kind of situation. We could give detail after detail, but more importantly, if individual veteran who is in the situation that we need to be able to help at that point. To preserve her life, restore her health. Thank you very much. Doctor omaha, we know that they are spreading false information about Reproductive Health, often deliberately, but the goal of discouraging abortion and limiting access even further. How is the va planning to combat the information and misinformation around this rule . I think, congresswoman, the discussions that are the providers could now have about Abortion Services as an option to veterans, it i think the most important and significant opportunity to dispel any misinformation or misunderstanding about these services, the risks, the benefits, and i think a lot of people will be borne out in the latitude that the clinician is now finally have to have these discussions. I dont know, doctor johnson, if you want to add to that with your experiences. No, i completely agree with you. I think what we strive to do and you do well is practice evidence based medicine. Part of that is the care that our provider provides to veterans, also part of the communications that we develop for veterans directly, about the care and options that they receive. I encourage your office to be in close touch to those communications. Professionals within the va. And the outreach team. Thats the great work with the vso. Thats an opportunity to make sure that the veterans that you serve understand the facts about this rule, federal change. Okay, have you seen a lot of confusion i was about what is legal and not legal of roe being overturned . Sorry, we have seen a lot of confusion of what is legal and what is not legal. What actions of the va taking to communicate with veterans to ensure they are aware of the Reproductive Health services they are now eligible . I think they dynamic you are describing, congresswoman, is a big factor in our assessment of the risk after the post Supreme Court decision to overturn roe v. Wade. The degree to which the services can be provided very. You have some states, for example, that have this affirmative defense mechanism, which essentially means they have to be charged with a crime in order to justify the clinical decision. That weighed in heavily in the assessment of a risk against these state laws. I think more generally, they are going to be communicating as much as we can across the population of Women Veterans about the availability of these services. And the parameters in which the clinicians will offer them. Doctor, elnahal, you mentioned plans to strengthen the care availability program, as you said, the bipartisan protecting moms who serve act, we were signed into law by President Biden last year. Provides new funding for initiatives to for mobility and disparities among how all these investments enhanced the care and support provided to veterans during and after the pregnancy . Thank you for the legislation, congresswoman. It does allow us to expand the effort, in this really important clinical area. I will ask dr. Johnson to describe that in more detail. Thank you. I echo dr. Elnahals gratitude. Our goal is to strengthen, and expand our care which we know is a vulnerable time for families, particularly in areas of perinatal Mental Health. Inter partner violence. Food and housing securities. In addition, we are looking at targeted ways to intervene for the veterans most at risk for complications of pregnancy. For example, veterans with ptsd, hypertensive disorder, or severe preeclampsia so that we can further support pregnant people. Thank you for your testimony today. I yield back. Thank you, representative underwood. Mr. Rosen gayle, i recognize you for five minutes. Thank you, mister chair, you call me offguard, i thought i was going after as each of you have been sent here by the administration, the most proabortion administration that has ever been elected, quite frankly, i have no questions for you. I want to make a statement. Millions of americans, millions of americans have relied upon the Hyde Amendment and the veteran Health Care Act of 1992 to be assured that their tax dollars would not be used to fund abortions, a board of asians, or abortion Counseling Services. They felt assured because it was in law. Law. Now, the Veterans Administration at a bunch of unelected bureaucrats who dont have to answer to the voters of this country. I am sure we in this world know that the distance between a rule and a law. A rule, to supersede the rule of law and use pack taxpayer dollars for abortions, and abortion counseling. Its my understanding the state of alabama already filed a lawsuit to stop this overreach of power by the Veterans Administration. Quite frankly, i look forward to it be overturned by the courts, and i find to do whatever i can to support that effort. I yield back. Thank, you mr. Rosendale. We now recognize chairman pattis for five minutes. Thank you mister chairman, and the panel what you are doing to meet the needs of our Women Veterans. I want to mention a problem in my district, it continuing construction on the Womens Health clinic. It open in 2023, and the veterans are looking forward to that. It will go a long way to provide high quality equity Equity Health care environment that still need. We know a key barrier for Women Veterans, which they have cited and accessing gender specific care, its a poor experience of general safety and comfort in the environments at the va facilities. In accordance with it requires facilities to follow certain standards related to the environment to care for Women Veterans. Policies, specify privacy, dignity, since the security, and safety consideration that all clinical spaces in the Va Medical Centers must meet. To ensure compliance with the standards, they conduct regular expect inspections. Va relies on facilities to solve the compliance. They found in the two most recent reports on the Women Veteran health care that facilities dont always accurately self report information about their compliance with the standards, the va lacks a mechanism to independently validate the compliance. Maybe dr. Hayes, i can ask this a view, what oversight and accountability mechanisms exist for the va to validate the accuracy of facilities self reported data . Congressman, thank you. I appreciate the major concern that you voiced about the veteran experience, the Women Veteran experience and walking to a va. We have been concerned about the harassment, we have a major focus because the level of harassment of the veterans, male or female, is unacceptable. We will continue to have that effort before most. When you talk about the environment, you are absolutely correct, there is a self report. We have done two things in the last year. One is from up the policy, published the policy about what must be, again, required to be in the facility. That is matched with what is the walk around tablet base. That tablet this survey is looped up to a higher level. We will continue to have those reported at the level, what efficiency is noted. Terrific. With you, doctor hayes. Despite the number of Women Veterans that are utilizing health care, we know only a minority of them choose to receive the gender specific care in va. Again some of the issues that you already covered, i want to commend va for its campaign to designated women health with public eight pcps, to only 85 of Women Veterans. These are critically important to ensure the va can provide quality gender specific care at its facilities. Many Women Veterans have expressed to the committee they lack the confidence in the clinical competencies of the particularly for whom Womens Health is not their focus or specialty. Im wondering if you can address that and share any oversight accountability rules that the va is utilizing to monitor the situation. Im actually concerned, as you say you found that Women Veterans are saying they are not confident with the competency of the Womens Health providers. We do conduct significant training, we just surpassed this week yesterday and today having trained 10,000 of the women Health Care Providers, specifically in gender specific. We put it as a high priority that folks not only go through the training but go through the competencies through continuing education and practice by seeing the number of Women Veterans. I wanted to assure you that we are focused on the competency and the fact that our women are actually reporting High Satisfaction and high comfort in our care. To work with you on the concerns, see what we can do to meet any additional gaps that are being identified. Maybe we can continue to new to communicate, and that there are details with specific case cases, we can only iterate that do you. To reiterate, after an additional training, the refresher, and there is continuing education that is provided . Not provided, but required for them to be continuing to be a health woman health provider. We do monitor that you. Really thank you for your responses. I yield back. Thank you, chairman pappas. I now recognize representative mueller makes for five minutes. Thank you very much, thank you our panel for being here. I am a physician, i am a veteran, a female veteran. I am somewhat confused by some what im hearing here today if i understand this correctly, the va feels it has to make a rule that violates law, that has been passed by members of congress who the public feels is the body that makes laws because the urgency of the Dobbs Decision and the potential for state laws restricting abortions for a life Emergency Care of women. So exactly how many states prohibit abortions in the life of the mother . Congresswoman, the concern exactly how many states prohibit abortions for saving the life of a mother . I am assuming you research this since that is the reason for your rule. It is not just premium so you dont know the answer to that question, would that be fair to say . Thank you that is what as concern. You also said that these are lifesaving procedures. In what trimester of pregnancy are these lifesaving procedures conducted . For the 10 to 20 female veterans that contact is . You certainly various, congresswoman. I will ask dr. Hayes if she is a summary of that. You certainly need to understand that the types of what trimester, please . No, maam. Do you not know the trimester . We do. Thank you. We also know that mental Health Providers are able to provide counseling. To mental Health Providers, do they discuss counts cancer care with veterans, either male or female . So they discuss cataract surgery . And other pro surgeries in the hospitals . Do they discuss joint replacement, some of these, im sure veterans that have their joints replaced, or cataract surgery have Mental Health issues. Do they discuss hysterectomies . Do they discuss cancer treatments, mastectomy, chemotherapy, Radiation Therapy for Breast Cancer patients . Are they involving counseling of these patients . Congresswoman, the multi disciplinary care model that dr. Hayes and the office of Womens Health have implemented across the spectrum of Womens Health care does include mental Health Providers. You have mental Health Providers in your continuum of care, mental Health Providers are giving counseling for all of these issues . As you know, congresswoman, these are often its a simple yes or no. Are they involved in counseling for all types of care for Women Veterans . Or for male veterans . They are certainly involved, congresswoman, with sensitive discussions on the gravity you also said that you have had our approach of 10 to 20 female veterans who needed life saving abortions abortions. Im expecting that you think this would be limiting the number of abortions that would be performed . We project, congresswoman, that about 1000 Women Veterans a year would receive the service. There is medical research and medical literature that the more procedures one physician does, the better quality of care they deliver. So do you think that if 10 to 20, or 1000 procedures are performed in one year, in the entirety of the United States, in the entire va system, that they will have the level of expertise that they need to provide women a quality of care . Because if i were that Women Veteran, i would ask the same thing that people ask me if cataract surgery, how many have i done. How many have i performed . In what trimester have i performed . They have the expertise and knowledge in order to perform that . I would be extremely concerned as a female veteran to be approaching in the a facility to be counseled by a Mental Health provider, even in your continuum of care, for a provider that has performed very little procedures. My personal viewpoint is that there are exceptions for rape, incest, in the life of the mother. I think for the va to go on a rule making tacked against the wishes of congress and the public is unconscionable. Thank you, i yield back my time. Thank you, representative millermeeks. I now call representative for five minutes. Thank you mister chairman for holding this important meeting. My home state of texas has the most Women Veterans of any state and the country. It has one of the nations strictest, laws banning abortion for the number of socialization fertilization. With a narrow exception for the health of the mother. This is a law that was written in 1925, it came into effect after the Supreme Courts recent ruling. That means that every Women Veteran, when you have the most of any in the country who was raped, women who served the nation, who was raped, and has a pregnancy as a result of that, theyll be forced to have the pregnancy to term, or find a way to leave the state if the va is not able to offer the care. Every texas woman veteran whose life is in danger because of the complication with the pregnancy, which intestine me money, you note, you had a greater risk of experiencing pregnancy related complications, increased related Health Conditions. Everybody with the Health Condition would be subject to the legal winds, basically, of some of the hospitals or places they may seek care. This is not a hypothetical scenario. There are texas women who were turned away with life risking conditions because the hospital was worried if it provided this care, that they would be subject to criminal penalties. I finally, in a felony, in fact, due to the 1925 law. Thats why, it is decision in the best interest for protecting our Women Veterans health, both physical and mental. I want to talk about how this law will interact with our laws in texas. I appreciate that i am our clarifies that the Va Health Care professionals are preempted from state and local laws surrounding abortion as a federal agency. States like texas, were providing abortion is a felony, there is a possibility of being sued in addition to providing them, do you anticipate va providers still may have concerns about their liability in providing care to patients . How does the va attend to address those concerns and make sure the providers are comfortable providing Abortion Services to the veterans. Congressman, that is a good question. We do anticipate that. Which is why we clarify as much as possible how and the fact that, when these clinicians are doing their work on federal property, or referring veterans for care in the community, we are doing so with the authority of federal law, which is enforced by the so, we will do everything we can to make sure we communicate that they are protected, they will be protected by the federal government. I do want to talk about Community Care, i know not many women receive their gender specific care, you mentioned the testimony, in the community, you said the va would pay for abortion counseling and services for the services we are available. Suffolk texas, where abortion is banned, and Abortion Providers have been out of offering care, how does the va intend to make sure the veterans have cared to the Community Providers that can offer abortion care . Its correct, congressman, that Community Providers in state where there are restrictions will not be available to treat the veterans because of the state laws. And so, that is why, by adding it to the medical benefits package, we are making clear that benefits such as travel to sites of care where they can get this necessary care will be offered by the va, where its offered by any other type of service in where they otherwise qualify. That is the strength of adding it to the medical benefits package, which clearly under the secretaries authority. I agree with you, thats a very important point. The cost and difficulty associated is to do the travel yourself as often prohibited for many women. I want to quickly, in the minute i have left, just to address how we are going to inform the texas veterans about these services, and what the va plans are for outreach in this case, and how we will ensure that they have access to the services . Thats a big priority, congressman, to make sure that we communicate as far and wide as possible to the Women Veterans. The services that are available, and new, being offered as a result of this, my colleagues and Womens Health office want to comment . We do very much know that it is important to have this messaging out to veterans. We ask a little leeway because this is the sixth day that we have had the ability to discuss this publicly, and get messaging out. We are very clear that we need to get this rolling for veterans. We want to make sure the information we get out is correct. And also have in place the access that they will need, if we send that information, we want to make sure that you get the care they need. Thank you for your testimony. In states like texas, womens lives are absolutely at risk because of the 1925 law that is in place. Because of the extremely narrow exceptions in place. Because of the fear that provide to the services, you could be facing a felony or be sued. Thats why its important for texas Women Veterans that you offer this. I want to thank you for watching this decision. Thank you for your testimony. Thank, you representative allred. I now represents a recognize representative ellzey for five minutes. Thank you, mister chairman. The question from doctor millermeeks about which states prevent or, prohibit abortions in the case of there are no states that do that, there are no states that do that. Please dont continue to use that framework as a reasoning for this. It is disappointing to see. Dr. , have you consider the possibility that that this rule will put Health Care Providers, and the administrators in legal jeopardy, both criminal and civil for violating federal and state laws. Yes or no . Well, congressman, there may be attempts from state to state, whereas other jurisdictions to do that, and so what we are trying to do is make clear that with the authority under federal supremacy, which is constitutional authority, as well as a secretary authority under the medical benefits package with emergency rule protects the clinicians in the full force of the federal government, they will be there for them. I thought you would say that. Describe for me and the American People the procedure in which you are allowing the va facility to end the life of an eight and a half month old child. Describe a medical detail. Whoever is qualified to do that. Congressman, the services that we will be providing under these rule, by definition, in the language of the role, are in place to protect the life and health of the veteran. I can see the question will not be answered, i will be happy to accept a written answer for the record. Thank you, doctor. In the case of medical emergency, the va will be provided and the non va beneficiaries, even abortions were va is the criteria are met. For those who dont understand what is actually happening here, this is a workaround for jobs and for individual states, which only sent back to the states, dobbs sends it back to the states, these are a workaround for the federalization using the va as unusual to legalize abortion paid for by the federal government. Knowledge knowing that the va is not being held to the highest amendment. I think that is pretty cynical. I look forward to appropriations language next session, which will further clarify that. I think, overall, the vague language that you referred to in 1996 doesnt say anything about abortion. But the 1992 law is very specific about abortion. If someone wants to repeal the law from 1992, they will use specific language. That was not done heel here. I will leave the rest of my time. This seems pretty cynical on the part of the va. As a veteran of 20 years who cares for my sailors, soldiers, and marines that i lead into combat, that nobody is being prevented from receiving medical care under the va, im very proud of what we do in this committee. Im very proud of what the va generally. Does this rule is very much another example of this Administration Using an elected bureaucracy to make a lot where it has no power to do so. I yield back my time. Thank, you representative ellzey. I now recognize representative frankel for five minutes. Let me thank you, and thank brownlee the department for your efforts to advance abortion counseling and care for veterans. I think i speak for the majority of americans when i say a woman should be in charge of her own Reproductive Health care. Her future, her life, and the medical decision should be made by a woman with her doctor, not by politicians, especially politicians who have no idea of the circumstances of her life. I will just say simply that abortion is part of health care. The it just, today, i believe an access, obviously, to full reproductive care to all women. Today we are talking about Women Veterans. Think about it, some of them are willing to risk their root lives, they are standing up for our freedom, dont they deserve their freedom. Isnt that what we are talking about . The freedom of Women Veterans . To determine their own future. Thank you, thank you, thank you. Representative allred had some questions i wanted to follow up on, just in terms of how this gets implemented. The concept to me is the right one. The benefit package now, does that mean that the va will pay for counseling and for abortion care for all veterans . Congresswoman, abortion counseling will be made available to any veteran. And Abortion Services will be limited to situations clinically for the life and health of the mother will be put at risk if they carried to term, or in cases of rape or incest. Okay, i am assuming that is up to a doctors determination . Yes, maam. Just, i am from florida, so you know representative allred, we had to deal with an oppressive autocrat that think that they should be in charge of womens lives, and i think they would do anything to try to, you know, stop, to put obstacles in front of this new policy. Under your program, what a woman be able to go, and the doctor would be safe from the legal restrictions at a va clinic . What about at a private Doctors Office that is, were working for the va . Congresswoman, where you have the federal employees doing clinical work on our property, the va property, they would be protected under federal supremacy. The full force of the federal government will be there for them should they be challenged on that. When it comes to Community Providers, those protections would not necessarily be available. So, that is where we have to factor in with our Implementation Plan of ways we can deliver care to the veterans and states, including possibly transporting them, should they qualify for a travel benefit under our medical benefits package more generally to v a saints or Community Providers that can do those work. Yeah, that is especially going to be challenging for like in florida, if you live in miami, florida, the next state that allows abortion care is literally hundreds of miles away from florida. You will probably find that around the country, there are certain parts of the south, parts of the midwest, women who live in rural areas, those are all going to be problematic. So i hope you really focus in on that. I have 46 seconds to ask one more question, which is, have you made, is contraception now going to be fully paid by the va, or do we still require copays . I will defer to dr. Hayes to answer that question. Thank you. The contra exception copay its ellens exist existence, we will give you Additional Details how it runs under regulation, and how that is still pending within the va. We did submit a supportive legislative request to have contraceptive copays removed. I think that is a good idea. Does it have to be done by the congress . Or can your department do that . I think that is best handled in a written response to outline how exactly that might take place. May i disrespectfully suggests that, that is a good idea. To get that done. Thank you. I yield back. Mister chairman, that is another initiative for you. Mission accepted. Thank, you representative frankel. Mr. Bost, i would like to go out to a second round of questions. Okay, great, great. I want to discuss briefly before i ask dr. Hayes a question, situations in which counseling about abortion is essentially to a Womans Health and safety. My colleagues on the other side would love to, are insisting that there is no legal basis for the final rule that has been put forward. If that is true, they want, they dont want to see even counseling about abortion happening, but lets imagine a scenario that is unfortunately not so uncommon. A woman with even a wanted pregnancy discovers that she has cancer. Her decision must be able to counter council her about the risk of chemotherapy to the fetus, and talk with her about difficult choices to save her own life. All of my colleagues suggesting that the physician should not be able to convey life and death situation to a woman veteran . Again, a physician in the situation, the va prior to this rule would not be able to discuss this situation with a woman cancer patient. Who would definitely want to know whether or not certain medications and the chemotherapy would affect her health, and even her life. A woman with a diagnosis of bipolar discord or is offered lithium. A medication that can be effective in treating symptoms that are so often tragically lead to suicide. This very same medication is toxic to a fetus, it requires a long lead time to come along for a woman, not something you can turn off and on, its in the bodily system. Women in the situation may face difficult decisions about their own physical and Mental Health, and the health of the fetus. Of course, they should be able to talk to a physician, and a Mental Health provider. Are the veterans diagnosed with depressions or commonly described prescribed medication like prozac rizzo lock . They may have birth effects. And women are able to report conversations with their doctors about these medications and risks to the pregnancies. The medication must often provide epilepsy and other disorders, after a 10 they will therefore run the risk of running these procedures without this medication causing lifelong harm to the fetus. I cannot believe my colleagues wants to get between a woman and her physician. I can go on, there are several more examples of both Mental Health and physical health is essential, the women not get between a woman and her physician. A veteran woman and her physician. A veteran who has worn the uniform on this country, who fought for the freedom of all of us, is not able to get even Life Saving Health saving counseling. This is absurd. Doctor hayes, you have served veterans title earthly for decades, one of the things you had to do, that we only recently learned about is big for lifesaving care and the a providers were not allowed to do so. In fact, they were not allowed to talk to veterans about lifesaving procedures i understand there are a dozen so these a, year but my colleague chairman brownlee, believe there is more, i am with her on this, counseling on Abortion Services that can save womens lives are not even prepared to be talked, about but the brave va physicians who put the life of our Women Veterans ahead of even their own potential livelihood, i understand there are can you explain to the committee what these cases entail . What the frontline staff in your office had to do to get women the help they need . Thank you for pointing out essentially what we often know is very tragic, stressful situations for the veterans who may require the kind of counseling that you outline in terms of having their own Mental Health provider involved. You are looking at exactly the kind of very rare, but very critical lifethreatening situations, when someone has cancer, when someone later in their pregnancy, the pregnancy itself is causing a medical condition that the women will die without the medical intervention. So its a case by case situation, there are any number of medical complications that can make this happen. When they do happen, we have to be able to find a way to have that women decide, what is her choice about this tragic situation . What does she want to have done . What does she want to do . Frankly, that might be her own Mental Health counselor that could be working with her to help her through those decisions. It as a veteran of the it is also the medical information that is provided about her life, about her health, about her Mental Health that will help her incoming with her choice. Thank, you doctor johnson. I now recognize representative rosendale for five minutes. Mister chair, i dont have any more questions. Did not have any questions. Again, this is the most proabortion administration that we ever encountered. We know they are going to support abortion at every option that they have. We know that they are going to take advantage of unfortunately, the rulemaking process, i am glad the state of alabama is filing a lawsuit. I imagine there will be many other states that will join in. My hope is that they can be granted a stay, so that we can keep this rule from being implemented. What i really had preferred is there is much more conversations about support for crisis pregnancy centers, and adoption services, and those type of things. I think the va has taken it upon themselves to act as god, and make determinations about what which women are supposed to be giving birth and which arent. So they will be giving abortion Counseling Services to women at many times that have tried very hard to begin a family, and it would be quite offended to even hear this information. I have no further questions for this panel. Thank you, mr. Rosendale. Chairman brownlee, i recognize you for five minutes. Thank you mister chairman. To follow up on representatives frankels questions around protection for Community Care providers. Is this something that you looked into and know definitively that they would be protective under federal supremacy . Or is it something that still, im not a lawyer, is it something that could be looked into that a change in the contract terms could protect them under federal supremacy . I will say that nor am i a lawyer, madam chairman, i think that is best offered back to you after this hearing for the record. What we looked into about their options on that, and ultimately the determination we made that can be questionable basically based on the Community Providers needing to adhere to the jurisdiction of their states. And, because, in essence, this rule becomes effective immediately, correct . Yes, madam chairwoman. Effective as a publication in the federal register. With a period of Public Comment that we will strongly consider and certainly respond to. Very good. I think you said in your opening comments, or at least in your written comments, that a larger percentage of the abortions that would take place would be through medication abortions, is that correct . Yes it is. Thats what we anticipate based on the Womens Health teams analysis, if you would like to speak to the analysis, dr. Hayes, for dr. Johnson. Yes, we anticipate about 1000 abortions throughout the enterprise annually. The majority of abortions are performed in the United States, the first trimester abortions. And the majority of those about abortions are medication abortions. I know that some of the, you know, during the covid pandemic, the va worked with fda to really expedite some additional drugs to be in the portfolio of drugs available to the va. I hope you will look at what they did there and replicate that to bring these drugs on board, as soon as possible. I will just say that we will, congresswoman, be working with both the fta manufacturers of these drugs, and also through all of our Pharmacy Benefits Management Program make sure that we are complying with all of their rules in doing so. Terrific. I wanted to go back to the Maternity Care coordination, you know, in my travels, i spent time in oklahoma and in texas. Talked to all of the Va Medical Centers in every city that we visited, and we talked to the Maternity Care coordinators within the va, and you know, in some areas it was working pretty effectively, and others, it was very inconsistent i will say. From Medical Center to Medical Center. One thing that seemed to be consistent now, and i will say that both oklahoma and texas, if women are the largest growing cohort, they are growing exponentially in oklahoma and texas. In all cases, every place that i visited, these medical Care Coordinators were handling 2 to 300 cases. Its a huge caseload. Some of them were only able to sort of meet with the veterans at the beginning of the pregnancy, and maybe once after the pregnancy. Some more doing more than that. I just think that we have to take a hard look at, you know, to make sure that these Maternity Care coordinators are in a place where they can fully do their job and they can really be a partner to the woman who is going through her pregnancy and can be an advocate, quite frankly with the Community Care dog who is handling them. I just, you know, i bring this up because i think it is, i mean, with Maternity Care it is all in the community. And, you know, we really have to have, sort of, full authority and be able to advocate for our patients who are out there receiving care. With a caseload of 2 to 300, i think its just virtually impossible to do so. So, i will yield back without. Thank you, chairwoman browser. I would like to now dismissed the panel, the first panel. I want to thank you again for being here. You are now excused, will now move to the second panel. I know call upper second panel. Our second panel is doctor jenny ryan whos with us virtually, professor and division chief of reproductive endocrinology and fertility. The university of washington Medical Center. She has earned degrees from several universities, dr. Ryan was once named a womans Reproductive Health research scholar. And comes with a plethora of knowledge on todays hearing topic. She does have to get to a surgery, so, she will be testifying and will not be available for questions. Lindsay church is a u. S. Navy veteran. And is no stranger to this committee, as a strong advocate for veterans. Lindsay has testified before this committee on numerous occasions. And we look forward to hearing from lindsey today. We also have with us, caleb williams, army veteran. She is a senior policy researcher outran corporation, she recently served as the assistant secretary of public and Inter Governmental Affairs at the apartment she has authored the memoirs, love my rifle more than you, young and female in the u. S. Army, and plenty of time when we get home, love undercover in the aftermath of a war. I want to thank all of our panelists for being here. We look forward to hearing from you. I remind our witnesses to pause for two or three seconds before speaking and answering questions. Dr. Ryan, i know that you have to get going soon. You are recognized for five minutes to deliver your testimony. Thank you. My interest in veterans Reproductive Health began veterans. That revealed an alarming 62 have experienced attempted or completed Sexual Assault. This trauma was associate not only with sexually transmitted infection and ptsd, but also with higher rates of infertility and postpartum depression. Most remarkably, one in four of the rape survivors reported they delayed having a family or decided against it because of the rape. Chairman to cano, Ranking Member roseville, and distinguished members of the committee, thank you for the opportunity to testify on behalf of my patients and their families. Thank you for the work youve done in the past to support our Veterans Health care needs. My name is dr. Ryan, i am here on behalf of the american site society for american medicine, and my capacity is a researcher and im the division chief of our at washington, ive worked since 2015 as a clinician and researcher at the iowa city da and the at times as a subject Matter Expert to Womens Health services. The views expressed in this testimony however are my own, they do not necessarily reflect the official policy or position of the university of washington, or the u. S. Government. In order to better understand the connection between trauma and later Reproductive Health, we followed our pilot work with a five year interview study of 3018 women and men veterans from around the country. We found significantly higher rates of infertility in veterans done in communities samples. Indeed, two and five Women Veterans and one in three men veterans trying to get pregnant werent able to do so after 12 months. Infertility seem to be a particular problem for those with ptsd and more toxic environmental exposures during their service. And we are just beginning to understand all the elements of military service that may predispose our veterans to higher rates of infertility. Its become increasingly frustrating and concerning that the veterans i see suffering from this infertility are barely receiving the seamless comprehensive Reproductive Health care they need and deserve. I can find examples every week of patients exhausted and discouraged by a structural issues an unfair rules that exacerbate disparities and inequities. I hope that hearing some other stories will start us on a path towards bridging these gaps. There is a quadruple amputee that i cared for his technicals were damaged by the idea that took away his limbs, he didnt qualify for ivf or any fertility care for his wife because he didnt have any viable sperm remaining. There is a veteran couple who successfully navigated the long path to ivf treatment and receive multiple bills for their care and were sent to collection, which impacted their credit score and their beloved to buy a home. There is a woman veteran i saw just last week whose trans woman partner due to hormone therapy, forced to pay for news anonymous donor sperm rather than having a fully genetically related childcare ivf because gender in congress see is not a Service Connected disability. And there is every woman who is polycystic ovarian disease or endometriosis or infection went undiagnosed during their military service, leaving them unable to access the full spectrum of infertility care they need because they were not disability related for these diseases during va and will then. And every veteran whose lifetime trauma has caused him completely understood effects on their beloved have children. Leaving us unable to treat them. Infertility is a disease, and just like for any other disease, the va should provide access to full Spectrum Care without restriction. As has been mentioned multiple times, women of reproductive age are the fastest subset of users. For many such as those who stories i have shared, the ability to become apparent hinges on access to ivf and care for their veteran parton. Current restrictions to this access are discriminatory, unnecessarily complex. They ultimately perpetuate the status quo of inadequate Reproductive Health care for Women Veterans. I am also deeply concerned as a Reproductive Health provider and former Abortion Provider that accessible abortion care is not a part of Reproductive Health care through the. Abortion cares Reproductive Health care. Every person should have the right to decide whether, when, and how they become apparent. This is vital to showing our veterans the respect they deserve and helping them and their families to flourish. No veteran should have to cobble their Reproductive Health together piece by piece, not knowing where they can access which aspect of their care, legally, affordably, and without judgment. Every patient and their story stays with you. The ones we remember longestare those who wish she couldve helped more. As services are more available and more functional. Today, you all have the chance to help us help our patients by removing the roadblocks they face. Our veterans know what they need to survive and thrive. We are here is researchers and Health Care Providers to listen to them and get them what they need with your support. So, thank you again for this opportunity to testify. Thank you for taking steps towards better serving our veterans who have given so much this country. Thank you, dr. Ryan. I wish you well on the surgery you need to perform. Thank you. Im sorry you cant be with us to answer questions. Your expertise would have been i think greatly enlightening. I now turn to Lindsay Church. Lindsay, five adults. Chairman takano, Ranking Member rosendale, and members of the committee. My name is lindsey church, im a Third Generation veteran of the United States navy. I serve from 2008 to 2012 as a i have appeared before this committee before as the executive director of minority veterans of america. I am here today to share my personal story. As a veteran and military child, i am no stranger to sacrificing for the greater good. In uniform it was my duty to protect and defend the constitution of the United States. I served as a queer person under dont ask dont tell, understood that there was some rights i wouldnt enjoy while serving, but that i will be afforded when i became a civilian. Among them was the right to an abortion and to live a safe and healthy life as a queer person. During my service i experienced complication of a birth defect that caused my sternum to be severely inverted. As a result of a failed corrective surgery performed by navy doctors, i have had nine surgeries on my rib cage and spine and missing 36 inches of ribs and all the cartilage of my chest was hospitalized for nearly 60 days and have a spinal cord stimulator that controls my pain. After my sixth surgery i had to face that my physical disabilities meant i couldnt carry a child. I was medically retired in 2012 and have received care through his womens clinics for the past ten years. Last year, my wife, just, and i began planning to start a family. We were excited the nervous. It was clear we could not turned a va for support for two reasons. First, va offers fertility treatment to veterans when its caused by a service conducted disability, but only some, minded and qualify. Second, where the samesex marriage, va limits our ui and ivf to legally married veterans with opposite sex gametes. In spite of it, all we began our journey to start a family last fall. We worked with a fertility clinic and developed a care plan, most of which we paid for out of pocket. In april, we attempted i. E. Why for the first time. Well waiting to learn of justice pregnant, the draft Supreme Court opinion in the dobbs v. Jackson case was leaked. Four days later, we learned just was pregnant, the happiest and scariest moment of our life. The decision and dobbs was delivered on june 24th. Two weeks later, we learned during a routine ultrasound that our childs abdomen was distended to the point of concern. It took 33 days and then to just the 16th week of pregnancy to get the tests we needed to understand that her child had a fetal bladder deformity and couldnt produce amniotic fluid. Through it all, we felt like we were racing oclock. We knew the day we had to make a decision or we may be forced to leave the state again abortion. The moral injury of having served the country to protect a constitution that low longer protected my family when it needed most was absolutely devastating. We made the most painful and most compassionate decision for the child we loved so much to end the pregnancy. We wanted our baby more than anything in the world. We couldnt imagine a lie for all they knew was suffering. I was born with a severe genetic deformity. I could not imagine this life for them. At justice pre out for a dilation and evacuation procedure we learned our baby had no heartbeat and had passed days prior. The procedure for a second term a stern miscarriage was the same as it was front abortion, the only thing that change was the urgency for care. She access care not through which just qualifies for, but through a Community Based clinic in richmond, virginia. She access care because state insurance cover the procedure we had not va providers, we lived in a state that didnt restrict access. Vas new Reproductive Health Services Policy will allow veterans, family members, and caretakers to access abortion counseling and abortion care in the case of rape and incest, and when the pregnancy threatens the life or health of the patient. This policy will save lives. It will save the lives of veterans and families across the Country Living in states that limit are completely ban abortion. One month earlier my family couldve turned va for care. For the policy to serve the veterans who are most likely to need access to care and least likely to have it, including racial and ethnic minorities, and those living in poverty, it is imperative that Congress Passed comprehensive National Policy to protect abortion and other Reproductive Health services. Finally, as i mentioned earlier in this testimony, i received nearly all of my care through va for ten years. For a decade i navigated a Health System that is unable to see, understand or serve veterans like me. I expect that if i choose va for care, i will be consistently misgendered treated like i dont belong or dont matter, and they wont be safe in va facilities. Last year i was harassed by a richmond va staff member while using a womans restroom. It wasnt the first time ive experience to be a harassment, nor was at the last. But it was what pushed me to finally seek care outside a va. I am one of many veterans leaving va because the department isnt equipped to provide positive Patient Health experiences to women and gender minority veterans. From mottos, to pronouns to bathrooms, many fear using va because it continues to be traumatizing. No one should have to endure what we do for health care. Thank you for the opportunity to testify. I look forward to your questions. Thank you Lindsay Church for that very moving testimony. I now call on miss williams to deliver her testimony, five minutes. Chairman takano congressman rosendale, distinguished members of the committee, thank you for the opportunity to discuss one veterans access to the full spectrum of medical care, including Reproductive Health care. Im testifying today as a senior policy researcher at rand. I also formerly served as director of the center for Women Veterans at the department of Veterans Affairs. I am also of a patient, i choose to get comprehensive and integrated care from a patient line carotene va, where my Health Care Providers understand my military specific risks and exposures. Among Women Veterans using Va Health Care, 43 are of reproductive age, and to meet the fundaMental Health care needs of Women Veterans, it is important for va to provide the full spectrum of Reproductive Health care. On july 1st, 2020, i testified before the subcommittee on health about this topic. Recognizing va is areas of strength while also noting that there were deficits related to provision of in vitro fertilization contraception, and abortion. Since that time va has announced significant changes in its provision of equitable lifesaving care on which i will focus my remarks today. The recent dobbs v. Jackson Supreme Court decision overturning the constitutional right to abortion. This ruling will limit some Women Veterans access to the full scope of Reproductive Health care as those living in many states will no longer have access to abortion care in their communities. This could have a direct impact on their health since abortion can be medically necessary. The interim final rule on Reproductive Health services that va published last friday supports Women Veterans access to abortion treatment by removing the exclusion on abortion counseling from the medical benefits package and allowing enrolled veterans to obtain abortions if determined needed by a Health Care Professional when the lie for the health of the pregnant veteran would be endangered if the pregnancy were carried to term or the pregnancy is the result of an act of rape or incest. While not expensive enough to cover all situations in which abortion could be beneficial for enrollees, this rule will protect the lives and health of vulnerable veterans. Va estimates that 72 of current veteran vha users who are capable of pregnancy have a Service Connected disability of 30 or higher. They have high burdens of chronic disease, and a significant rate of Mental Health conditions. Some of these are associated with worst pregnancy outcomes. Women veterans with ptsd, for example, are more likely to experience gestational diabetes, preeclampsia, and preterm birth. Accordingly, it is exceedingly important that they be able to access the care their providers deemed to be medically necessary. Reason restrictions on Reproductive Health care at the state level mean that women in certain states are no longer able to access such care from non va providers, to ensure Optimal Health outcomes for Women Veterans, the va must be able to provide that care. Although all states have exceptions for the life of the mother and most allow abortions for the Womens Health, restrictive abortion policies are having a Chilling Effect that can delay needed care, including treatment for cancer. Providers in some states may face prosecution and jail for providing abortion treatment and may delay or deny needed health care for pregnant women given these risks. Access to medication needed for other services can also be affected. Pharmacist are reluctant to fill prescriptions for drugs that can have multiple uses, including but not limited to, medical abortions. Such as managing miscarriage or treating chronic disease. Vas interim final rule allows veterans to access care, there are va providers determine is necessary to promote health or protect life. It is also important that va be able to provide the services directly because va provides high quality, evidencebased culturally competent care. For example, va trans providers to provide trauma informed pelvic examinations for Women Veterans have experienced military sexual trauma. In addition, fragmented care can lead to worse health outcomes. Ensuring the va is able to provide the full spectrum of reproductive care to vulnerable pregnant patients is an important part of comprehensive and integrated care. In conclusion veterans and beneficiaries who need abortion counseling and covered abortions will benefit from being able to receive these Services Within the va system optimizing their continuity of care and access to needed support. Thank you again for inviting me to testify before you today on this important topic. I look forward to answering any questions you might have. Thank you for your testimony, miss williams. I will now recognize myself for five minutes for questioning. Lindsay and your testimony you outline how current reproductive assistance through va is exclusively offered to heterosexual couples. Can you talk about why access to Reproductive Health care for services for all gender identities and sexual orientations is so important . Thank you for your question chairman. As an lgbtq person, as a community, we are required to look to the services such as donated sperm, are you why, ivf to be able to actually have children. And so, being able to access the service as a queer family will empower us through the only method that were going to be able to start a family. My family was fortunate in the sense that we were able to pay out of pocket, there are so many folks in the community that dont have those resources. Much of the Queer Community experiences economic barriers, housing, employment that continue to make their experiences around Family Planning multifaceted. Va has the opportunity to step in and provide hope to our community, especially folks that cant prove their Service Connection. As i mentioned, i am one of many people that cant prove Service Connection to be able to access those benefits, removing some of those regulatory bars will offer us hope. Im someone who believes that Service Connections should not be a reason, should not be, it should not be predicated, we should not predicate the availability of reproductive services, the full array of Reproductive Health, including fertility, in the big scheme of things, it is not cost prohibitive. Very few people, very few veterans are going to encounter that. And, as you said, you had the ability to pair of pocket. But typically, typically i would say a big share of our veterans that use the va system are low income people. I think miss williams can you comment on that . You know, the type of Women Veterans that user system or veterans and general that tend to have limited incomes. Research has shown that vha users are, they tend to be of lower socioeconomic status then veteran non vha users. So yes, that is correct. And so a veteran that needs Reproductive Health care Fertility Services, and who might need ivf, veterans are essentially deprived of access to Fertility Services. And i think most americans would be outraged that people who have worn uniform of our country and who may have difficult to prove connections to, i mean, that theyre infertility is connected to their service, we should just give them the benefit of the doubt like weve done with the pact act. We give the veteran of the doubt. Dont deny them services such as Fertility Services so they can have children. I think most americans would say, that is the fair thing to do. I dont know, i mean, do you wish to pine on what i said . I will just note that when my spouse and i were struggling with infertility it was, we were unable to access fertility care either. At that stage in our lives we were unable to afford it. And so, from a very personal perspective i do agree that anybody who needs to be able to access care to expand their families should have that opportunity. Lindsay look like you wanted to say something. I did service they give the best years of their lives reproductive years, i mean a person that hires out of the military is gonna get 18 to 38. By the time outlined in dr. Ryans testimony included testimonies of Women Veterans who flew helicopters for this country and make sure that we were staffed at war came back, and then were too old to be able to access care, or be able to start a family naturally. They should have access. If you give your years of fertility to this country, you should be able to access those benefits after the fact. Thank you for, you know bringing for that example. And lets understand that the 170 members of this congress, all of them of the other side of the aisle, and including nearly, actually, all of the members of this committee who are, the republican members of this committee, save one, have signed on to hr 10 11. Which would make access to ivf impossible. It would make it illegal. And i think most americans would say thats extreme. And i would say, it is unpatriotic. I would say its unpatriotic that we would deny that fertility opportunity to the women, the men and women, actually, probably some men to, men and women in this country have won the uniform of our country. I will now call on and recognize representative rosen dale for five minutes. Thank you very much, mister chair. I would just like to start off by saying that the continued proclamation by the pro abortionists Witnesses Today that the Dobbs Decision, which was recently decided by the Supreme Court of the United States overturns the right, the constitutional right to an abortion. It is false. And your continued use of that statement doesnt make it so, unfortunately. It might make the evening news but it doesnt make it sell. Miss williams, if i heard correctly even after the Dobbs Decision, even after the Dobbs Decision, okay, it has been released from others life is in danger, she will still be able to receive the standard of care to save her life under the laws of every state. Is that not correct . It is my understanding that wall the right may be there, many providers are so concerned that they are hesitating i have loss of anecdotal information. If i heard you correctly, im just gonna go ahead and say, you answer, i just want to cut it off right at the answer. If a mothers life is in danger she will still be able to receive the standard of care to save her life under the laws of every state, correct . In terms of the standard of care to save her life. The laws do not prevent saving a womans life. The laws do not prevent a medical professional from saving the life of any woman. Correct . Are you telling me that the medical industry, okay cannot go out under any circumstance have an accident on the highway, youre in a hospital, whatever it is, that if a mothers life is in danger she will still be able to receive the standard of care to save her life under the laws of every state . Sir im sorry, you phrase that let me ask in a simple way. Could you tell me a single state that is going to prohibit saving a mothers life . I had no point said that. Yeah, okay. You testified then abortion bans are having a Chilling Effect on providers who would be the ones who provided this care. It seems to me that the proabortion discourse is instrumentally conflating standard of care with elective abortion. Not a single republican here opposes care for mothers whose lives unfortunately were threatened. But all of us oppose abortion. Conflating the two is irresponsible, fearmongering. I would suggest that the proportion is consider that if they are concerned about this Chilling Effect so, mister chair, earlier you stated that you dont believe that the services should be predicated on the Service Connected disabilities. And, lindsey, you stated the same thing. Miss williams, i guess you probably feel the same way. The problem is, we have laws in this land. While you all may have opinions about what services should be delivered and when they should be delivered and who they should be delivered to we have guidelines we have laws it is based upon Service Connected disabilities. So, this is what all of these hearings are about today. That is that the Veterans Administration is trying to bypass those very laws and use the rulemaking process to be delivering services that the law specifically prohibits. Specifically prohibits and calls the taxpayers of this mission to be paying for them. That is what our job is. That is what our job is. So, mister chair, with that i yield back. Well, thank you, mr. Rosen del. Our mind too that i believe you are somebody who the coof hr 10 11, which would in fact, if passed into law prohibit life saving procedures for women who have a lifethreatening pregnancy. I repeat. And you know, what youre saying is with regard to certain state laws, it may be true for a woman whos in active emergency and actively dying. But make no mistake, many of these states that have prohibited abortion and narrowed the exceptions for one abortion might be permitted do not attempt to women who are at risk of dying or of disability. Remember, va could not even councilwoman about lifesaving procedures prior to this interim final rule, they could not even do the counseling. So, i now recognize miss brownley for five minutes. Thank you, mister chairman. While were on this topic of ivf and fertility. I just want to put in my two cents on it as well. And you know, fertility is a medical condition. You know, full stop. And, just like everything else, every medical condition that the va, you know, service veterans, for their health care, and fertility is just a condition. And it is also very very hard to accurately diagnose the cause of infertility. Currently, the va addresses infertility and treats women and men for their infertility throughout the va. Many times they are successful in treating that, but when you get to a place where all else fails, then ivf is the only option. And so, it is abundantly clear to me that we need to treat this as just a part of our Health Care Services and infertility is like cancer, its like appendicitis, its like anything else. It needs to be addressed. By a medical facility and then medical provider. So, i just wanted to add that. I think miss church, your testimony, thank you for sharing your personal story. I know it is not easy. You have come and testified, advocating for veterans all the time. Not sharing your own personal life, so, i thank you, it takes a lot of courage to come forward and do that. So, i guess my question to you is, you know, what can the department do to make the va a more positive environment for gender minorities, women, and lgbtq plus veterans . Thank you for your question and your kind remarks. Thank you. From my perspective, va has to take this as the large and the small. Large cultural symbols like the motto emblazoned on every single building is and helping anyone feel more comfortable. In fact, it might as well say we only serve men here. Our communities need access to care and every time they walk through a facility, they are denied that, denied the belief that they understand that. So, well it doesnt seem significant, if we cant even start with a model thats not exclusionary, then were in a bad place. Second, it is the small things. Its also like training and education, not just saying we have training in education, but mandating it. Bystander intervention, that doesnt enter that would be awesome. Facilities should be safe, we shouldnt have to worry about what bathrooms are going to, we shouldnt have to worry but very necessary functions. I was on the way to get an xray and all i needed to do is use the restroom. So, training and education, thats not just offered but mandatory by every va employee, women, gender minorities, the Broader Community and understanding who we are, it is not controversial, its just better care. And then the last is, i think it is representative habits there was talk about Data Collection asking questions where that date is collected . I can tell you its not being collected correctly. My wife had to give a pronouns conversation to the patient advocate who is one of the reportable like, folks of the facility that i should be able to go talk to. Who am i gonna tell . So, its the big things in the small things. Its about culture that sees us, recognizes us and centers us when building care and facilities and everything that theyre doing. Thank you very much for that. And miss williams, you know, in your testimony you really sort of built a very strong argument why abortion counseling is really important. You talk about the fact that va users attended [inaudible] economic status. You say that Women Veterans who use the va have high burdens of chronic disease and a significant rate of Mental Health conditions. You go on to say that, you know, pregnant women, Women Veterans have extremely high rates of depression and often discontinue medications for this and other conditions. So, i agree with you. Its a very important to have abortion counseling where the woman and her doctor can talk about who knows their condition and can talk about what their options might be and what their risks might be. But do you also think that because of those factors amongst our Women Veterans that the likelihood of more lifethreatening situations will occur that may indeed require an abortion if ones life is at risk . One reason that i think va be able to provide the care is to click this type of data. If va is unable to know about the full scope of Reproductive Health care that Women Veterans may require, if Women Veterans, pregnant veterans, are seeking care, this type of care in other settings, may not be communicating that their providers, we may not be able to ever truly know the answer to that question by having the data required to track it thoroughly. And, so, i could guess the answer to your question, i would rather be able to come back and tell you in five years. A data driven person representing a data driven organization. Yes, i do understand. Thank you for that. I also want to add, just on this argument about, you know, all states will provide abortions in the event of a womans life or death. You know, and again, we dont have the data on this, but we hear anecdotal stories, ive heard anecdotal stories within the va as well that women will come and have a condition, you know, she may be bleeding out, whatever, but will get stabilized, doctor wilson that women home. And wait until it becomes an emergency and then under those conditions may be treated to save her life. But the physician knowingly does this, sends her away knowing that the eventuality of all of this is that she is going to be back and her life is gonna be threatened and she will need to be treated. Thats just, it is unacceptable, i mean, it is just absolutely unacceptable. So, it is, again, i just, you know, i thank the va for taking these steps and moving forward. Without a doubt, life, lives are going to be saved without question. And, that is the least of what we can do to service our women. I will just close out here by saying that i wanted to just, you know, thank doctor hayes for all the work that youve been doing and continuing to do. I know this has created a lot of work for you in your office. I know youre working around the clock to make all of this happen and to have clarity across the country with regards to this new role on the va. So, you know, i really do think you, ive enjoyed so much working with you over the years as we have Work Together to better serve our Women Veterans, i just thank you for all the hard work that you continue to do, with that i yield back. Thank you. I am going to do one more round of questioning, questions. So, miss williams, i want to give you some time to respond more fully to the questions that mr. Roosevelt asked you about, i mean, i quibble with his assessment that states will allow you know, always, in all cases, you know, you know, abortions in a lifesaving situation. Lets talk about, you are on a train afloat when you said a Chilling Effect. Can you explain more what youre thinking about the Chilling Effect that various states, state laws have had and what you are about to say . I think that representative brownley also talked a bit about this and the fact that providers can feel so strongly the need to be confident that it is an imminent risk that they may delay procedures to a point where there could be other effects to long term fertility for long term health. And i personally really strongly believe that we should be able to rely on the expertise of our Health Care Providers and trust that they will be able to make decisions based on what is the best interest of our health and our life, and not on what their fears are of whether or not there could be consequences to them beyond focusing on health and life. And if i may be so bold as to share i mentioned that we struggled with infertility in the past. We went on to adopt our son, i then eventually did give birth to my daughter. I have also lost a pregnancy to miscarriage. And i needed medication very similar to that used for abortion to pass the products and prevent sepsis, which would have caused Serious Problems in the long term, possibly threatened my life. I also went on to donate a kidney to a stranger, i want to just note that my belief in the inherent dignity and the life of all people is very deep and unwavering. Thank you. Well, thank you, miss williams, as i said in my opening statement, Women Veterans such as you and lindsey fought for our freedom and fought for womens freedom to be able to make choices and protection of their own health. And the interest of their own health and life. Their own also for the freedom of medical professionals to exercise their best judgment and to use their knowledge. I dont believe the government or politics should get in between medical providers and their patience, Women Veteran patients. And so, i thank you very much, both of you for your courage and your testimony. Sharing your personal experiences. And, i just want to ask you also about your research that links ptsd diagnoses to higher risk of pregnancy complications like preeclampsia and pre term birth. Can you walk us through how he is new regulation will help improve the quality of care for veterans with Mental Health diagnoses such as ptsd. Let me be very clear that i unfortunately im not skilled enough to have done that research myself. I am citing other research by fantastic medical professionals who are much more qualified to do that specific type of research. But the hard work, by these holly qualified va providers has shown that ptsd diagnoses are associated with these negative outcomes. And preeclampsia can lead to a clamp, which is a lifethreatening condition. Thats why it is so important that va providers be able to counsel their patients on risks and be able to make the right decisions about what kind of care to offer them if they do reach a stage where abortion may be needed to promote health and protect life. Thank you. Ranking member rosen dale. Thank you, mister chair. Just a little comment. When you have health care that is provided by the government and funded by the taxpayers across this nation, the reality of it is that Congress Makes the decision about what is and is not covered. Thats how it works. Whether youre talking about medicare, whether youre talking about medicaid, or whether youre talking about the Veterans Administration. That is just the way it works. And while we had some anecdotal stories and some fears that one might experience, what we have not had is a single example of a state that would cause the va or any facility to prohibit the standard of care that would save the life of a mother if it is in jeopardy. No one has been able to state that. In regards to the Veterans Administration congress has made the decision that care will be delivered when there is a Service Connected disability. Congress made that decision. No different than we all got together this year and we passed the pact act, im really pleased to have been able to support that. Okay . We made the decision to make that investment. When it comes to health care delivery, congress has to go through that process. And so, until they do, what were witnessing today is a complete disregard for congress and the rule of law. So, with that i yield back. Mr. Rosenthal, i just have a simple disagreement. The 1996 law that Congress Passed empowered the secretary to define the benefit package va. And, therefore, the benefit package that has been set forth is rooted in law, is rooted in statute, it is rude and congressional action. I now recognize chairwoman broadly. Im gonna change the subject a little bit. So, miss williams, my question that i wanted to ask of you is really sort of through your research, youve done a lot in terms of shedding light on both the challenges experienced by Women Veterans accessing care and the importance of a smooth military to civilian transition for all veterans. So, im trying to merge those two component pieces together. You know, if you could share with us what you think are ways in which we can better support our Women Veterans and our Women Veterans health as they transition from the military to civilian life and what we could be doing better . In terms of supporting the transition of Women Veterans, i think the program that started out as a pilot to provide and has not been expanded nationwide is a incredibly positive development and being able to support that transition, ensure that Women Veterans know about the full scope of health care that vas able to provide. Because so many veterans dont know that va provides the maternal Care Coordinator program, for example, i think how much i spent on supplies to know that va provides free storage bags, free nursing bras, free nipple cream, these are things that are incredibly helpful. For transitioning Service Woman to know that they can go to va and get that level and standard of care is incredibly helpful. And its also beneficial for them to be able to know that they can expect the same standard of care now within va that they couldnt d. O. D. If, for example, theyve experienced a Sexual Assault and leave the military. Previously they wouldve been able to expect abortion care and d. O. D. , walk out the door, enter a va facility, and not be able to access the same level of care for that traumatic event. For them to be able to be informed that they will be able to expect the same level of care within the department of Veterans Affairs, they will also help give them the comfort to know that they can enroll in va and expect that high quality care should also support them in the transition and their willingness to come to via. Coming to va is important because we know that the quality of care is high, that va providers have more cultural competence, especially military specific issues, such as the pact act that has been mentioned today. A big expansion. And we want to make sure that women vets are coming to get this evidence based care, this culturally competent care, that they have burned through their Honorable Service and the department of Veterans Affairs. Thank you very much. I have no more questions, mister chair. Thank you, i would like to ask, thank you very much, i would like to ask Ranking Member rose until she has a closing comments. Thank you, mister chair. I appreciate it. I am distraught today. As we listen to the Veterans Administration attempt to justify using a rulemaking process to completely disregard the rule of law that people have relied upon for years, which for habited or shuns, and abortion Counseling Services by the Veterans Administration, and paid for by the american taxpayers. Its clearly an overreach by the Veterans Administration and the lawsuit has already been filed. I am hopeful that the courts will overturn this rule and i hope that theyre able to obtain a stay that this rule is never implemented. Thank you, mister chair, i yield back. Thank you, Ranking Member rosen del. I should have thanked our panel before i recognized her final comments. But thank you very much, both of you, for your service to our country, for your courage, and sharing your own personal experiences, as well as your expertise. So, you know, i would like to excuse the second panel. I will now go to my final statement. Lets be clear that the rule that the Ranking Member seeks to stay and hopes will be stayed would return us back to the days, not, i mean, when i say days, its just a week ago, before this rule took effect, when va could not treats for lifethreatening conditions when an emergency abortion may be necessary. This is what my colleague, Ranking Member, acting Ranking Member rosen bill that seeks to do. Prior to this rule va could not treat severe preeclampsia early in pregnancy. It could not treat heavy bleeding leading to a hemorrhagic shock. It could not treat placental abrupt and causing hemorrhage. It could not true water breaks early in pregnancy causing infection. It could not treat ectopic pregnancies. These conditions, by the way, could be treated at a Department Defence medical facility, they could be treated in a federal prison for women who are incarcerated in prisons. But for the women who wore the uniform of the United States of america, who, again, i will say, fought for our freedoms, they could not be treated for these for lifethreatening conditions when an abortion may be necessary. To me, this is an insult to all the women who have worn the uniform of our country. I think secretary mcdonough and President Biden for standing up for the women who have served our country proudly. I think all those women who served our country and put their lives at risk for all of us. And we now have a step forward in having their backs and offering them a care that they deserve, but i believe the American People will agree that we should not be hoping for a stay, that we should be hoping for an affirmation that this rule is very much necessary, is very much fair and, you know, it is time that we afforded our Women Veterans the same level of care that are active Duty Service Members receive and the women in our federal prisons receive. So, with that, i will adjourn this hearing and thank every participant today. All members well have five legislative days to revise and extend their remarks. Again, thank you for appearing before us today. This hearing is now adjourned. The january Six Committee returns wednesday for its ninth hearing. Ahead of the release of the written report. Expected by the end of the year. You can watch the hearing, live, beginning at 1 pm eastern on cspan 3, cspan now, or anytime on demand at cspan. Org. Cspan is your unfiltered view of government. Were funded by these Television Companies and more, including cox. Homework can be hard. But squatting in a diner for internet workers even harder. Thats why were providing lower income students access to affordable internet, so, homework can just be homework. Cox connect to compete. Cox, along with these other television providers, giving you a front row seat to democracy. The Senate Banking Committee Hears testimony from financial policy professionals about predatory banking practices, including student loan services. Among the topics discussed were buy now pay later products, and a perceived benefits of earn wage access. The Senate Committee on banking, housing and anothers will come to order. We apologize for Senate Committee on banking housing, and we apologize for the delay this morning. We dont like to start the hearing late, sometimes we have to. Thank you to the four of you for joining us, good to see all of you. Some of you have been in front of this committee before or have worked around here before so welcome, especially to those of you. This hearing is in a hybrid format. Our witnesses are in person, members have the option to appear in person or virtually. Hard work should pay off for everyone, thats the american dream. Thats with the dignity of work is all about, its a concept that pope leo the 13th spoke about in the late 19th early 20th centurys. Popularized by dr. King. When work has dignity you can support yourself and your family and your future. But we all know what has happened over the last four decades. Corporate profits have gone up, the stock market has soared, expected of compensation has exploded. Wages have not kept up with the cost of living, millions of workers with fulltime jobs who aspire to middle class cant join it no matter how hard they work. Even people we may define as middle class dont feel much security and stability. When workers are forced to find ways to make up for the gap between what theyre paid and what they should earn, what are they left with . That. Sometimes people have to borrow money, products that are well designed and transparent and regulated can help workers pay off an unexpected car repair, or help with grocery covers or medical expense. With workers last weekend in this committee, too often these products arent well designed. They are really transparent, they are not well regulated, for far too many workers the only credit products available lead to more dead and more financial instability. We have discussed in the committee the impact predatory lenders have on families. Today we examine the impact some newer Consumer Financial products have on workers. Companies tell us these new products are innovative, theyre easy to use, they will give people more options, but so often, innovation is just a new way for companies to make money while trapping people in debt. New or credit products they could help could sue mers Paper Products and with installments with new Consumer Protections, yet many of these products come with hidden fees, they lack transparency, they arent underwritten properly and encourage for multiple purchases and multiple online stories, racking up that they cant afford to repay. Consumers like breonna horribly, as a college student, she started off with one of these loans, the first one, then two, then three, then a company told her they were raising her credit limit lemon from 100 to 1,000. Initially, 18yearold breonna wasnt too concerned, as she put, it the companies believe in my ability to repay my dad, that i did as well. With the approval of more and more credit, brianna was juggling 1500 dollars in loans with different payments, with different payment plans throughout the, month her account kept getting overdrawn. The story gets to the core of the problem, with little to no underwriting, buy now Pay Later Companies dont get some has credit with, and without proper term disclosures, could swimmers are left in the dark. This model to work for consumers, we need real rules, Companies Must follow them, and we need proper disclosure. Then there are new Consumer Products that use a socalled tip model, structuring themselves to deliver deliberately avoid disclosing their terms, deliberately avoiding import disclosures product like overdraft coverage, earned wage advances that are not offered in conjunction with where consumers are asked to pay a tip to the lender instead of a fee, or an Interest Rate to use the product. Companies claim that because a tip is not presented as a finance charge or an Interest Rate, truth in lending and other Consumer Protection laws like the military lending laws act to not apply. The tip is just, quote, voluntary, they say. But of course, theyre not voluntary at all. Its just a way to cheat the system and hide the true cost of workers, employer based earned withdrawn Consumer Protections can in fact help workers cover unexpected emergencies, though the better alternative would simply be for the companies to pay their workers enough to live on. Then there are dead products that are so predatory, so offensive, they should have no place in our financial system. Seems like training, repayment, agreement provisions, appropriately known as traps. I will say this for that term, that was invented, it was certainly truth in advertising. These contracts allow employers to recoup the cost of training its an offensive concept. Its the employers job to train the workers. On the job training isnt some special perks for workers, its a smart investment for companies. Traps require workers to pay back their employers for training if they leave their job within a certain period of time. Sadly, workers with debt its a modernday version of the script that left coal miners exhausted, destitute, and trapped by their employers. Remember with tennessee ernie fort saying about owing his soul to the Company Store . You load 16 tons, what do you, get another day older and deeper in debt. Employers use traps to prevent workers from pursuing higher paying are better opportunities. They decide how much the training would supposedly cost on the market, and they go after the workers, threatening their credit and their economic mobility. Last, week cassie paintings from colorado told members of the committee about her experience with traps. Miss paintings for suitors during covid19, and at the start of her job, her employer made her sign unemployment contract buried in the fine print and said that if she left before two years, she would be indebted to her employer for 70 500 for the supposed training they provided. When she decided to leave her nursing job because of a bad work environment, her employer took 1,000 out of her second to last paycheck to pay back her training. That was half a paycheck. Her former employer told her they will send the rest of the amount to collections. Last i checked, indentured servitude was illegal in the United States of america, but it looks like some enterprising companies are rebranding it with these new employer contracts. Thats the focus of todays hearing, to ensure that socalled innovation is not a substitute for good pay, and does not come at the cost of workerss dignity of work. Thank, you mister chairman. And thank you for kindly delaying the start of this hearing. Thank you to the witnesses for your patience, i was unavoidably delayed. I appreciate the accommodation. Todays hearing, of course, is about new Consumer Financial products. In the last decade, weve seen Financial Institutions develop Technology Oriented solutions to meet consumers needs. These new choices create a more competitive marketplace, all of which benefits consumers. As long as consumers have truthful and Accurate Information about Financial Products, its the consumers who are best positioned to decide what products to use. Any regulation of Financial Products should fit the product to, make room for innovation, and maximize consumer choice. Too often, however, the response from some of my friends on the other side of the aisle is to see something new and panic. Lets talk about some of these new products. One of them is called the pay now pay later im sorry, buy now pay later, or bnpl. This typically allows consumers to make purchases now, often online, and repay them in for interest free installments later. This service can be a very attractive way for consumers to manage their cash flow to paying goods and Services Without having to pay any interest. Thats especially true for consumers who dont have or dont want to use a credit card for such purposes. This might explain why bnpl is most popular among younger consumers who have shorter credit histories. If sensibly suspend further purchases until they are paid. And in some charges, there is a late feat. Interestingly, bnpl did not primarily make their money from consumers at all a small percentage of transactions to offer retailers who are willing to do this because they dont have to pay credit card interchange fees on being p l payments, and offering bnpl can offer customer loyalty. Another new or Financial Product that provides consumers with short term funding is earned wage access, or ewa. Many people dont have savings available to pay for unexpected expenses that can arise in between pay periods, like car repairs or medical bills. By advancing them the amount of income theyve already earned at that point in the pay period there are various cwa products available, and in some cases, employers select and pay the fee for the service as an employee benefit. According to a recent study, the recent feed the user papered vance was between 2. 59 and 6. 27. Thats less than 5 of the amount advanced. In short, the marketplace competition has successfully generated more and cheaper Online Options for many consumers to meet their needs. This is a reminder that Market Competition other newer Financial Products include forms of care that have existed for a long time but with innovation and how they are provided. In recent, years Financial Institutions primarily Community Banks have begun to partner with Financial Technology companies, or thin techs, to improve products and reach more consumers. Bank fintech