SAN FRANCISCO — Already pilloried for long wait times for medical appointments, the beleaguered Department of Veterans Affairs has fallen short of another commitment: to attend to the needs of the rising ranks of female veterans returning from Iraq and Afghanistan, many of them of child-bearing age.
Even the head of the VA's office of women's health acknowledges that persistent shortcomings remain in caring for the 390,000 female vets seen last year at its hospitals and clinics — despite an investment of more than $1.3 billion since 2008, including the training of hundreds of medical professionals in the fundamentals of treating the female body.
According to an Associated Press review of VA internal documents, inspector general reports and interviews:
—Nationwide, nearly one in four VA hospitals does not have a fulltime gynecologist on staff. And about 140 of the 920 community-based clinics serving veterans in rural areas do not have a designated women's health provider, despite the goal that every clinic would have one.
—When community-based clinics refer veterans to a nearby university or other private medical facility to be screened for breast cancer, more than half the time their mammogram results are not provided to patients within two weeks, as required under VA policy.
—Female veterans have been placed on the VA's Electronic Wait List, which consists of all new patients for whom appointments cannot be scheduled in 90 days or less, at a higher rate than male veterans.
—And according to a VA presentation last year, female veterans of child-bearing age were far more likely to be given medications that can cause birth defects than were women being treated through a private HMO.
"Are there problems? Yes," said Dr. Patricia Hayes, the VA's chief consultant for women's health in an AP interview. "The good news for our health care system is that as the number of women increases dramatically, we are going to continue to be able to adjust to these circumstances quickly."
The 5.3 million male veterans who used the VA system in fiscal year 2013 far outnumbered female patients, but the number of women receiving care at VA has more than doubled since 2000. The tens of thousands of predominantly young, female veterans returning home has dramatically changed the VA's patient load, and the system has yet to fully catch up. Also, as the total veteran population continues to decrease, the female veteran population has been increasing year after year, according to a 2013 VA report.
All enrolled veterans can use what the VA describes as its "comprehensive medical benefits package," though certain benefits may vary by individual and ailment, just like for medical care outside the VA system. The VA typically covers all female-specific medical needs, aside from abortions and in-vitro fertilization.
The strategic initiatives, which sprang from recommendations issued six years ago to enhance women's health system-wide, have kick started research about women veterans' experience of sexual harassment, assault or rape in a military setting; established working groups about how to build prosthetics for female soldiers; and even led to installation of women's restrooms at the more than 1,000 VA facilities.
Yet enduring problems with the delivery of care for women veterans are surfacing now amid the growing criticism of the VA's handling of patient care nationwide and allegations of misconduct, lengthy wait times and potential unnecessary deaths.
Used to treating the men who served in Vietnam, Korea or World War II, many of the VA's practitioners until a few years ago were unaccustomed to treating menopause or giving advice about birth control.
The study on distribution of prescription medication that could cause birth defects is illustrative of the lagging awareness; one of every two women veterans has received medication from a VA pharmacy that could cause birth defects, compared to one in every six women who received drugs care through a private health care system, said the study's author, Eleanor Bimla Schwarz, a senior medical expert on reproductive health with VA.
Schwarz, who also directs women's health research at the University of Pittsburgh, pointed out that while she does not believe any of the veterans surveyed were pregnant at the time, it is critical to keep in mind that many new female veterans are of child-bearing age, a higher percentage are on medication than in the general population and the majority of these women are not on contraception.
Hayes said the VA seeks to place a trained, designated women's provider in every facility and expects to install a "one-stop" health care model that allows women to go to one provider for a range of services, including annual physicals, mental health services, gynecological care and mammograms. Until that happens, however, some VA clinics have limited gender-specific health treatments available for women.
Army Sgt. Ashley Morris, who worked as an operating room technician for six months in 2008-2009 at a military hospital in Baghdad's Green Zone that treated soldiers hit by suicide bombs or wounded in firefights, said that promised transformation is badly needed. She returned having flashbacks and suffering from post-traumatic stress disorder, and spent a month hospitalized in a psychiatric facility in Pueblo, Colorado.
Now back home in Albertville, Alabama, she said she was ordered in March by a physician at the nearby community-based VA clinic to get a mammogram, given her mother's medical history. But Morris said she had to wait so long to get an outside appointment that she never made it to the doctor, in part, she said, because the VA would not reimburse her for the gas mileage to get to the private screening center 65 miles away in Birmingham.
"As a young female coming home from Iraq, they don't have the care that we need at the local clinic," said Morris, 26. "If it's anything over psych medications, I have to go to Birmingham, and they've stopped compensating me for driving there." VA policy says any veteran who has been approved to get care at an outside facility will be reimbursed for gas mileage or get their transport paid for by the system, said VA spokeswoman Ndidi Mojay.
Jeffrey Hester, spokesman for the VA in Birmingham, said he was not aware of Morris' circumstances.
Female veterans are more likely than their male counterparts to be referred outside the VA system for specialty care, Hayes acknowledged. Nearly one-third of all female patients received at least one day of treatment at a non-VA facility in fiscal year 2012, as compared to 15 percent of their male counterparts, according to the most recent data Hayes supplied.
Many female veterans report having to drive hours to get to a facility that offers specialized gender-specific care, while some of them tell of struggling to get the VA to pick up the tab for them to see a nearby private doctor.
Army Sgt. LaQuisha Gallmon of Greenville, South Carolina, whose daughter was born two months ago, said she had been authorized to see a private physician of her choice for prenatal visits and delivery. But because the paperwork hadn't been fully processed when she went to an outside emergency room for complications in her sixth month of pregnancy, VA has refused to pay the $700 bill, she said.
"I called the VA women's clinic and they told me everything was approved for me to get outside care and I should be getting the packet in the mail," said Gallmon, 32, who served six years in Iraq, Germany and Fort Gordon, Georgia. "Right after that, I wound up in the ER for complications, and a week later I received the letter saying they wouldn't pay for it."
The VA typically covers prenatal and pregnancy-related care through arrangements with community health care providers, said Mojay.
According to a recent opinion by the American College of Obstetricians and Gynecologists, the VA has an urgent need to continue training providers in female reproductive health and contraception.
Women appear to face particular difficulties getting gender-specific care in community-based clinics, 15 percent of which lacked a designated women's care provider at the end of fiscal year 2013, according to data supplied by VA. Separately, in a report published last year, the VA OIG found that 60 percent of the female patients at community clinics who were surveyed by government inspectors did not receive results of their normal breast cancer screenings within the required two weeks and results for 45 percent of them never made it into the VA's electronic health records.
The agency said it has since changed the system so physicians can better track abnormal mammogram results through the VA's internal computerized health records, and says patients with abnormal results are "typically" informed within three days. Hayes said she did not yet have results showing how widely the improvements have been adopted, or what specific progress had been made on the concerns raised by government investigators, especially for women vets who were tested outside a VA hospital.
Hayes said the VA plans to improve its software system so physicians get a more extensive, visible warning to ask patients about their possible pregnancy status and interest in conceiving when prescribing medication that could cause birth defects.
"We want to make it right for our veterans to have the best kind of care, and women are included in that goal," she added.