WASHINGTON—VA is straining its capacity and struggling against a culture that can sometimes be hostile to women as it responds to what VA officials consider a “tsunami wave of women veterans” over the last decade.

Today, women make up more than 16% of active-duty servicemembers and 19% of reserve forces. The number of women using VA for their healthcare has tripled since 2001, growing from 159,000 to 500,000 today. Since 2014, VA has tracked access to its healthcare facilities by gender and identified small but persistent disparities in access for women veterans, who overall are waiting longer for appointments than their male counterparts.

While VA has made considerable efforts to expand its services to provide access to care for these women entering its system, it has been hampered by budget crunches and the difficulties in recruitment and retention that is a challenge for federal and civilian healthcare systems alike.

“The number of women veterans enrolling in VA healthcare is increasing, placing new demands on VA’s healthcare system,” Patricia Hayes, PhD, VA’s chief consultant for Women’s Health Services, told members of the House Appropriations Subcommittee at a hearing last month. “Based on the upward trend of women in all service branches, the expected number of women veterans using VA healthcare will rise rapidly, and the complexity of injuries of returning troops is also likely to increase.”

To ensure that women veterans have someone in their corner wherever they seek care, every VHA healthcare system now has a full-time Women Veterans Program manager tasked with advocating for the healthcare needs of women at that facility. VA currently has at least two women’s health primary care providers at every VAMC with the goal of eventually having at least one at every site of VA care.

“[Our goal is that], wherever a woman comes for care, there will be a designated women’s health provider,” Hayes explained. “We’ve grown from having very few of those and only having them at the women’s centers at larger facilities to having at least two of them at every medical center.”

Hayes expressed regret that this effort is lagging at VA’s community based outpatient clinics, where only about 90% have a women’s healthcare provider on staff. To try and bridge that gap, VA will be sending training teams to CBOCs this year to train existing staff to be women’s healthcare providers. But demand is outpacing training capacity.

“We are challenged to continue to offer all of these trainings and do all the things that we need to do to meet the expanded demand,” Hayes admitted.

More Providers Needed

One inescapable factor in that lack of capacity has been a relatively stagnant budget. VA’s funding for women’s health programs has increased by about 15% since 2014, totaling about $500 million this year. Asked what she could do with more funding, Hayes immediately cited recruitment and retention as the department’s biggest resource-related challenge.

“The need for primary care providers in women’s health is critical. As is retaining the ones that we have,” she explained. “The retention, the pay, the incentive pay—these are issues we have difficulty with. Hiring in rural areas is extremely difficult.”

There are currently 43,000 job vacancies across the VA healthcare system—an increase of 14,000 from 2017. Specialty providers, especially mental health providers top the list of vacancies. This strongly impacts women veterans, since VA has witnessed a 154% increase over the last decade in the number of women accessing mental healthcare. According to Hayes, over 40% of women using VA care having been diagnosed with at least one mental illness and many struggle with multiple, clinically complex conditions, such as trauma, mood, and eating disorders.

“It’s not just about money; it’s about getting the right force in there,” Hayes said. “We have many, many more [providers] than we did a few years ago. But there’s turnover. And there’s more women coming in the door.”

Another pernicious barrier for women accessing care at VA is the culture and atmosphere of the medical centers they’re walking into, Hayes explained. While VA can train its staff to treat its women patients with care and respect, there is still harassment by other veteran patients to consider.

About improving the culture at VA’s medical centers, Hayes said, “We are not there yet. Far from it. We have to improve through the work that we do with veterans and staff to make sure that the culture is safe, respectful and civil and that women do feel secure. And we’re doing some major efforts on harassment of veterans by veterans.”

Hayes testified that she has met personally with VISN directors and medical center directors on this issue. “We’re making everyone accountable for gender and sexual harassment,” she declared.

Separate Faciities?

Legislators questioned whether one solution might lie in creating separate facilities for women’s health programs. Rep. John Carter (R-TX) cited the recent transfer of the Women’s Recovery in Supportive Environment program, which treats victims of military sexual trauma and combat trauma, from the VAMC in Temple, TX, to Waco in the same state.

Susan McCutcheon, RN ED, VA’s national mental health director for family services, women’s mental health, and military sexual trauma, testified that segregating by gender is not always the best therapeutic solution.

“Some women prefer women-only groups. But some women prefer mixed-gender groups. VA doesn’t promote one model over another,” McCutcheon explained. “Because women eventually have to go out into their communities where there are men, and to have that opportunity to interact with males in a therapeutic, protective environment can be part of some women’s treatment plans. Sometimes we’ll work with a woman individually and build up some skills so that she’ll then want to enter a mixed gender group.”

Hayes added that, while that creating these kinds of separate facilities might be an easier solution than eliminating veteran-on-veteran sexual harassment, it’s not feasible for most VA sites, and the culture at VA will still need to change as more women enter the system.

“Women veterans don’t just want to have a separate place,” she declared. “They want to be in a place where they are welcomed like every veteran should be welcome and that they feel secure in that setting.”