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Universal health coverage for US veterans: a goal within reach Dave A Chokshi, Benjamin D Sommers Lancet 2015; 385: 2320–21 Published Online November 24, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61254-X Department of Population Health, NYU Langone Medical Center, New York, NY, USA (D A Chokshi MD); and Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA (B D Sommers MD) Correspondence to: Dr Dave A Chokshi, New York City Health and Hospitals Corporation, New York, NY 10013, USA [email protected]

The crisis of 2014 within the US Department of Veterans Affairs (VA) health system, centred on appointment waiting times, has brought to light substantial deficiencies in access to health care for veterans. Yet the fact that many veterans have no coverage for health care at all receives far less attention from the media and policy makers. Although some Americans might falsely assume that the VA health system covers all veterans, most veterans are covered by private insurance or other government programmes. There are about 22 million veterans in the USA. 8·9 million veterans are enrolled in the VA health benefits programme and 6 million receive treatment every year at 151 VA medical centres and other facilities. However, many veterans are not eligible for VA coverage, and even among those eligible, some have not enrolled. The net result is that more than 1 million veterans had no coverage for health care in 2010.1 Uninsured veterans are more likely to be younger, single, African-American, on low income, and to have been deployed to Iraq or Afghanistan.2 Compared with insured veterans, uninsured veterans are more likely to use the emergency department and less likely to use outpatient medical care. Moreover, veterans often have substantial unmet health-care needs, with a high prevalence of chronic diseases, mental health disorders including post-traumatic stress disorder, and other sequelae of trauma, including spinal cord injury and traumatic brain injury. In a national survey done by the Washington Post and Kaiser Family Foundation,3 43% of war veterans deployed to Iraq and Afghanistan thought that their present physical health was worse than it had been before their military service. Number of uninsured veterans

Expanding Medicaid*

Texas

126 000

No

Florida

95 000

No

California

88 000

Yes

North Carolina

54 000

No

Georgia

53 000

No

Ohio

52 000

Yes

Illinois

40 000

Yes

Pennsylvania

39 000

Yes

Michigan

37 000

Yes

Virginia

36 000

No

Authors’ analysis of data from the 2012 American Community Survey.4 *As of Oct 26, 2014.

Table: US states with the most uninsured veterans (2012) and present Medicaid expansion plans

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Expansion of Medicaid coverage for individuals and families with low incomes under the terms of the Affordable Care Act (ACA) could substantially reduce the number of uninsured veterans. The ACA’s individual mandate provides a financial incentive to all US citizens to obtain health insurance or exemption from it. Veterans can qualify for Medicaid in states electing to expand their coverage for health care, for federal tax credits to purchase plans on the Health Insurance Marketplace, or for VA health benefits. Although eligibility for insurance is not synonymous with access to health care, universal coverage is an important first step towards access to quality health care. With the introduction of the ACA, universal coverage for veterans could be an achievable goal, albeit one that requires renewed commitment and policy attention. To estimate the present number and distribution of uninsured veterans in the USA, we analysed the 2012 Census Bureau’s American Community Survey.4 We identified how many US citizens aged between 18 years and 64 years with reported active military service were uninsured at the time of the survey, both at the national level and by state. We then estimated the number of veterans that were eligible for subsidised health care in 2014. For this estimation, we considered state Medicaid criteria before the introduction of the ACA in 20105 as modelled in published research;6 present state decision making about the Medicaid expansion; ACA-related income cutoffs for tax credits; and eligibility for VA health-care coverage. Eligibility for VA health-care benefits is estimated using data from the American Community Survey.4 We took a conservative approach, identifying those who have a service-connected disability, Vietnam-era service, or household income below the national VA-income threshold.7 We estimated that in 2012 more than 1·2 million veterans in the USA did not have health insurance, which is similar to previous estimates.1 The largest populations of uninsured veterans were mainly in southern states that are not currently expanding Medicaid within the ACA: 126 000 in Texas, 95 000 in Florida, 54 000 in North Carolina, and 53 000 in Georgia. California, which is expanding Medicaid in 2014, had 88 000 uninsured veterans (table). Encouragingly, most uninsured veterans are eligible for subsidised coverage of health care. Despite almost half the states not expanding Medicaid, we estimate that 25% of uninsured veterans are eligible for Medicaid, 46% are eligible for ACA tax credits to purchase Health Insurance Marketplace coverage, and 16% are not eligible for Medicaid or tax credits, but could be eligible for VA www.thelancet.com Vol 385 June 6, 2015

Viewpoint

health-care coverage. Only 13% of the uninsured veteran population (about 154 000 veterans) are not eligible for subsidised coverage, with many located in states that have chosen not to expand Medicaid. If all states were to expand Medicaid, an additional 43 000 uninsured veterans would become eligible for subsidised coverage. Universal health coverage for veterans is therefore— in large part due to the ACA—a goal within reach. To achieve this goal, we believe that three policy advances are necessary. First, the Obama Administration should prioritise universal health coverage for veterans. To call for expanded coverage might seem ill-timed when the VA health system is struggling to keep pace with demand. Yet, paradoxically, the present crisis could provide an opportunity to address these related access problems. Congress has passed legislation that facilitates veterans to receive health-care services from outside the VA and increases the capacity of the VA by providing funding for additional doctors and medical facilities. Marketplace plans and Medicaid expansion could also help some veterans access care outside the VA system. Second, state-level action should be implemented to achieve universal coverage. Medicaid expansion programmes in non-participating states would provide coverage for thousands of low-income uninsured veterans and their families, and providing them with health insurance could be a persuasive argument for expansion among lawmakers generally opposed to the ACA. Third, both federal and state policy makers should build stronger partnerships with veterans’ organisations (eg, American Legion, Veterans of Foreign Wars, and Disabled American Veterans) to reach out and enrol uninsured veterans. An increase in the number of veterans who are eligible for health insurance will only translate into better access to care if they actually register for the coverage for which they are eligible. This enrolment in coverage might be particularly challenging for some subpopulations of veterans, such as homeless individuals and those with serious mental illness. Again, however, state decision making on the basis of political opposition to health-care reform is likely to hamper these efforts, since many states have passed onerous laws restricting the ability of community groups to serve as health insurance navigators under the ACA. Several political considerations affect the impetus for universal coverage of veterans. The misperception that the VA health-care system covers all veterans—combined with the present access limitations—might make some policy makers reluctant to call attention to the issue of uninsured veterans. At the federal level, there have been several competing priorities with respect to ACA implementation, such as building the Health Insurance Marketplace and undertaking a broad public enrolment campaign. Furthermore, the coordination that would be needed across federal agencies has proven challenging. www.thelancet.com Vol 385 June 6, 2015

For example, evidence has shown some duplicate payments for veterans’ care across the VA health-care system and Medicare and fragmentation caused by dual or many health-care plan eligibility.8 Finally, the decision taken by each state on Medicaid expansion will probably have the greatest ramifications for veterans without coverage—but the veteran population has rarely been included in these state-level debates. Here, we have shown that a substantial number of US veterans are presently uninsured and we have proposed a solution towards universal health coverage. The proportion of veterans without health-care coverage has remained consistent in the past two decades. The ACA provides a unique opportunity to address the issue—provided that the outstanding political issues surrounding the law can be overcome. Meanwhile, the drawdown of forces from Iraq and Afghanistan means that hundreds of thousands of new young veterans are returning to their homes, and this group is at the highest risk to not have coverage among all US veterans.2 As we begin to look beyond the short-term implementation of the ACA and the appointment waiting time crisis within the VA, a renewed focus on veterans’ coverage warrants our attention. Contributors DAC had the idea, wrote the first draft, revised subsequent drafts, and finalised this Viewpoint. BDS did the data analysis, contributed to the first draft, and revised subsequent drafts of this Viewpoint. Declaration of interests DAC was a White House (US) Fellow in the Department of Veterans Affairs from 2012 to 2013. BDS is a part-time adviser in the Office of the Assistant Secretary for Planning and Evaluation in the US Department of Health and Human Services. Acknowledgments The views expressed in this Viewpoint are those of the authors and do not necessarily reflect the policies or views of the authors’ respective institutions. References 1 Haley J, Kenney GM. Uninsured veterans and family members: state and national estimates of expanded Medicaid eligibility under the ACA. Washington, DC: Urban Institute, 2013. 2 Tsai J, Rosenheck R. Uninsured veterans who will need to obtain insurance coverage under the Patient Protection and Affordable Care Act. Am J Public Health 2014; 104: e57–e62. 3 The Washington Post, Kaiser Family Foundation. After the wars— Post-Kaiser survey of Afghanistan and Iraq war veterans. The Washington Post (Washington, DC), Nov 12. http://www. washingtonpost.com/politics/polling/wars-postkaiser-surveyafghanistan-iraq-war/2014/04/02/3e8f2380-b7a6-11e3-9eb3c254bdb4414d_page.html (accessed July 11, 2014). 4 United States Census Bureau. American community survey, 2012. http://www.census.gov/acs/www/data_documentation/2012_ release/ (accessed July 11, 2014). 5 Kaiser Commission on Medicaid and the uninsured. Where are states today? Medicaid and state-funded coverage eligibility levels for low-income adults. Washington, DC: Kaiser Family Foundation, 2009. 6 Sommers BD, Graves JA, Swartz K, Rosenbaum S. Medicaid and marketplace eligibility changes will occur often in all States; policy options can ease impact. Health Aff 2014; 33: 700–07. 7 Department of Veterans Affairs. Health care benefits overview. Washington, DC: Department of Veterans Affairs, 2012. 8 Kizer KW. Veterans and the Affordable Care Act. JAMA 2012; 307: 789–90.

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Universal health coverage for US veterans: a goal within reach.

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