**Transcript of Cyberseminar**

**HERC Health Economics Seminar**

**Uninsured Veterans Eligible for Medicaid Under ACA**

**Presenters: Jennifer Haley, MA, and Genevieve M. Kenney, PhD, Urban Institute Health Policy Center**

**November 12, 2013**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact Jennifer Haley, Urban Institute Health Policy Center,**jhaley@urban.org**; or Genevieve M. Kenney, Urban Institute Health Policy Center,**jkenney@urban.org**.*

Host:I’m Jean Yoon with the Health Economics Resource Center. And today we’re pleased to have health policy experts from The Urban Institute and VA policy leaders on this Cyber-Seminar to talk about an important and timely issue. We’ll be talking about potential eligibility and enrollment of Veterans and new insurance programs under the Affordable Care Act. As these new insurance options go into effect, many in the VA want to be able to understand how to continue meeting their demand for VA care and continue providing high quality care to Veterans. We hope that the information presented here can be helpful to VA operations and research in thinking about the potential implications of these new options. And because having good data will be important, HERC is also helping to set up an operations resource work group to look at impacts of ACA on VA demand. If this is something that you’re interested in, feel free to contact me for more details. Now I’m pleased to introduce Genevieve Kenney and Jennifer Haley from the Urban Institute. Jennifer Haley is a Research Associate in the Health Policy Center, and Genevieve Kenney is the Co-Director and Senior Fellow in the House Policy Center. They both are involved in research that looks at the implications of the Affordable Care Act, Medicaid coverage, and Family Planning Services in a state effort to enroll more children and adults in Medicaid and CHIP. We will later be joined by Duane Flemming who is Director of Policy Analysis and Forecasting, and DeAnn Farr, who is Director of Health Systems Data Analyses in the VA Office of Policy and Planning. They’ll be giving a response to the presentation. Then we’ll also have time at the end for questions. Please feel free to type in your questions in the Q&A panel. Right now I’ll turn things over to Jenny Haley.

Jennifer Haley:Thank you so much. We’re excited to participate today. We’d like to start by thanking the VA for giving us the opportunity to share our research findings today, and we also want to let you know how much we appreciate the many VA people who have been really generous with their time and comments over the course of our research. It’s been very helpful. Today we’re presenting research founded by the Robert Wood Johnson Foundation on Uninsured Veterans and Family Members. We’re really excited to do this. Thank you again. To give you an overview of what we’re presenting in this seminar, first we’ll briefly describe the data source and methods that we use for the research we’re presenting today. We’ll show estimates of the number of uninsured Veterans and family members overall, and including differences across states and subgroups. We’ll look at some findings on associations between coverage status and health care access. We’ll go through some coverage options for these uninsured Veterans and their families, those currently and under the Affordable Care Act. So we’ll talk about Medicaid, Exchange Coverage, and VA care. Then we’ll conclude with some research questions that we’ve identified. 

The data source we used for this research is the 2008-2010 American Community Survey. The ACS is a large, national, annual survey connected by the U.S. Census Bureau. It includes over a hundred thousand nonelderly Veterans nationally each year and samples in each state. We identified nonelderly Veterans as those ages 19 to 64 who had ever served on active duty, including reservists who had served in active role, but are no longer serving. Nonelderly members of Veterans’ families were identified as those ages 0 to 64 that are the spouses or children of nonelderly Veterans and live in the same household. Then to approximate eligibility for coverage under the ACA, we categorized individuals according to their families Modified Adjusted Gross Income, or MAGI. This is the income definition that will be used to determine eligibility for coverage under the ACA. Additional analysis uses the 2009 and 2010 National Health Interview Survey to examine associations between insurance coverage and health care access. 

To examine uninsurance among Veterans and family members, we used the ACS as an indicator of insurance coverage at the time of the survey. So it’s a point-in-time insurance. The survey asked about insurance through an employer or union, purchased directly from an insurance company, Medicare, Medicaid, and so on. And you can see that it did include VA care as an option. We classify Veterans as uninsured if they report neither using VA care nor any of the other types of comprehensive health insurance coverage that are listed in the questionnaire. Like a study based on survey data, there is inherent imprecision in the estimates due to sampling error. There is the potential for measurement error in coverage status, Veterans status, income, and Medicaid eligibility status. Estimates will vary across data sources, time periods, and methodologies. But we did benchmark our estimates with those from other surveys and we looked at the ACS data across various data years. We found the findings to be quite robust. 

This is the estimated number of uninsured Veterans and family members according to the ACS. We were able to identify an estimated 1.3 million uninsured Veterans, about 645,000 uninsured spouses of Veterans, 318,000 uninsured children of Veterans, for a total of an estimate 2.3 million Veterans and family members combined who are uninsured. This is a 10.5% uninsurance rate among nonelderly Veterans, and a 7.4% uninsurance rate among their nonelderly family members. It’s notable that both of these rates are lower than among the U.S. population overall at 17.9%, but it still has been surprising to many to find out that there are so many uninsured Veterans. The next slide is a map that shows variation in estimated uninsurance rates among nonelderly Veterans across states. You can see that Veterans in four states, Massachusetts, Hawaii, Vermont, and North Dakota have uninsurance rates below 6%. Another four states have uninsurance rates below 7%. Those states are Connecticut, Maryland, Virginia, and Minnesota. But then there are four states with uninsurance rates of over 14%, and another six states with uninsurance rates of over 13%. In looking at the three largest states, California, Florida, and Texas, they each contain a hundred thousand uninsured Veterans or more in each of those three states. 

There is a notable variation across states, and in addition we found that the pattern of state variation remains similar when we adjusted for differences across states in the socioeconomic and demographic characteristics of Veterans. What that means is that for almost all of the states with significantly higher or significantly lower uninsurance rates for Veterans relative to the rest of the nation, that uninsurance rate remains significantly higher or lower when we controlled for the characteristics of the Veterans in each state. This suggests that the state variation and uninsurance among Veterans is not explained by these observed differences in the characteristics of Veterans in the different states. We also on this slide shaded the states according to whether or not they’re expanding Medicaid under the ACA next year using the latest information we have on state decisions. The expanding states are in yellow and the other ones are in maroon. The uninsurance rate overall for Veterans in the expanding states is 9.6% and in the nonexpanding states it’s a 11.5%. Not shown here there’s some variation in addition for the Veterans family members across states. 

We also examined differences in the characteristics of the uninsured compared to those with insurance coverage.  Compared with insured Veterans, uninsured Veterans have served more recently, more than 4 in 10 served in the past two decades. They are younger. Nearly half of uninsured Veterans are below age 45 compared with 29.5% of the insured Veterans. The uninsurance rates among Hispanic and Black Veterans were statistically significantly higher than the rate for White Veterans. We also found that uninsured Veterans report fewer service-related disabilities, or functional limitations. This could reflect greater eligibility for or use of VA care among those with service-connected injuries and illnesses, but we still found that 17.3% of uninsured Veterans reported a disability or a functional limitation. In contrast, the uninsured family members of Veterans have higher rates of functional limitations than their insured counterparts. We in addition found that uninsured Veterans report lower levels of education, higher levels of unemployment, lower rates of full-time work, and they are less likely than insured Veterans to be married. These characteristics are interesting because they’re in general related to access to employer coverage. The fact that they have these characteristics could contribute to their lack of coverage. In addition, when you look at those characteristics among the uninsured family members, they also have the same indications that they might have lower access to employer coverage than among the insured family members of Veterans. 

The implications of this are that uninsured Veterans and family members report greater unmet health needs than those with insurance coverage. This is the analysis using the National Health Interview Survey. Among Veterans 41.2% of those who were uninsured reported having any unmet health needs in the past year. This is compared with just 12.7% of Veterans with insurance coverage. Over a third had delayed care due to cost, compared with just 8.4% of the insured. Similarly for the family members of Veterans, over half had an unmet health need, compared with just 12.3% of those with insurance coverage. And almost half had delayed care due to cost in the past year. On all of these the uninsured have significantly greater unmet needs or delayed care than those with insurance coverage. In addition, some uninsured Veterans appear to have health problems. A third report at least one chronic health condition. About 15% report being in fair or poor health, and about that many report being limited by physical, mental, or emotional problems. And about four in ten report experiencing negative feelings that interfered with their activities. 

We’re going to move next onto coverage options for these uninsured Veterans and family members. First we’ll go through some of their options for coverage under current law. Medicaid was created in 1965. It is jointly funded by the federal government and the states, and it’s overseen by the Centers for Medicare and Medicaid Services. Most care is obtained through private providers, often through managed care networks. States are required to cover low-income children, pregnant women, people with disabilities, and other categories of people. They have to provide certain mandatory services, but they do have flexibility over eligibility, benefits, payment, and delivery systems. For children whose family incomes are higher than the Medicaid levels but still considered low-income, additional coverage is provided through the Children’s Health Insurance Program, or CHIP. That was enacted in 1997 and it’s currently authorized through 2015. 

To give you a sense of the eligibility levels for these programs, the Medicaid and CHIP thresholds for children are quite expansive. About half of states cover children at 250% of the federal poverty level or higher. Overall, an estimated two-thirds of uninsured children qualify under current Medicaid and CHIP law. On the other hand, the Medicaid thresholds for adults are much lower. The majority of states do not provide any Medicaid coverage to nondisabled, non-pregnant adults who don’t have dependent children in the household. For parents who do have dependent children, the median eligibility thresholds are currently 61% of the federal poverty level for working parents, and 37% for a nonworking parent with a variation across states. As a result, relatively few adults qualify for Medicaid. Only about 1 in 10 uninsured Veterans and spouses qualify under current rules. 

The next slide will show a little bit of detail about this. Overall, about 1 in 10 uninsured Veterans qualify for Medicaid under current law. And about a quarter of uninsured family members of Veterans qualify, but the rate for the family members reflects low rates for the spouses of Veterans. They’re at about 1 in 10, similar to the rate for the Veterans themselves. The majority of uninsured children of Veterans do qualify. Overall it’s about a quarter, but this means that although many Veterans and spouses do not qualify for Medicaid currently, many of the uninsured children of Veterans could be enrolled in Medicaid or CHIP now. Another option for many of these Veterans of course is VA care. As you know, priority is based on Veteran status, discharge status, service-related disabilities, income, and other factors. Overall the income threshold for VA priority is higher than Medicaid thresholds. Over 8 million Veterans are enrolled in VA care, but dual coverage is common having VA care along with Medicare, Medicaid, or private insurance. Of the 12.5 million nonelderly Veterans identified in the ACS, an estimated 2.8 million report VA use, but fewer than a million of those report only using the VA as their only source of insurance coverage. Our data from the ACS doesn’t give us enough information to estimate the number of uninsured Veterans that could be eligible for VA care, but many low-income uninsured Veterans likely do quality. However, most spouses and children of Veterans are not eligible for VA care. Next I’m going to hand this over to Jenny Kenney who will talk about how these coverage options could change under the ACA. 

Genevieve Kenney:Thank you so much Jenny Haley. When we consider how the Affordable Care Act might affect coverage for Veterans and their family members I think the most starting place is to be clear that the Affordable Care Act was not targeted at Veterans specifically, and that it does not change the VA or other military health care systems. With that said a number of the provisions that are aimed at increase health insurance coverage generally, could affect Veterans and their families. In particular the requirement that individuals have coverage, the so-called individual mandate, is expected. This is embodied in CBO and micro-simulations projections that many people have done to lead to across the board increases in health insurance coverage, even when the mandate is not specifically binding to a particular individual. It’s important to note that VA coverage does satisfy the individual coverage mandate. In addition, you’ve probably been hearing a lot about navigators and other kinds of assisters that have been trained across the country on health insurance coverage options under the Affordable Care Act. There is more on the ground help for people to get health insurance coverage than has been the case historically. There is the potential for the screening questions that are used in data matches through the enrollment process to make a VA aware of Veterans who are uninsured and uninsured Veterans aware of new coverage options. The outreach efforts have raised the topic of health insurance coverage to an all time high I think. More importantly there are new coverage options. 

As Jenny Haley indicated, the Medicaid expansion is a major potential expansion of coverage to poor and near poor adults. The presence of new subsidies for coverage through the marketplaces, or the exchanges, that have been established throughout the country. Again an important distinction for the Veterans is that those who are receiving care from the VA are not eligible for exchange subsidies. I’ll get back to that in a little bit. They can still purchase unsubsidized coverage through the exchanges, but they’ll have a choice to make if they’re eligible for exchange subsidies and are uninsured in terms of VA versus exchange subsidies. As Jenny described, the Medicaid expansion under the Affordable Care Act is really targeted at adults below 138% of the federal poverty level, and that’s an income of about $24,000 for a family of three. That represents a major expansion and eligibility for adults who don’t meet the traditional categorical requirements with respect to a disability, or being a parent or pregnant. It has its most potential affects in terms of eligibility on the so-called childless adults. Those are adults who are not living with a dependent child of age 18 and under. But as you saw from the map, not all states are choosing to expand Medicaid at this point in time. In a minute I’ll be sharing some analysis that takes into account the most up to date information that we have from the Center for Medicare and Medicaid Services that indicates what of the new eligibility thresholds will be across the country for adults as of January 1, 2014.

The original analysis that we did this past spring took into account stated positions by governors in the spring, but now we have hard decisions that have been made since then. That’s what we are using now to look at the implications for uninsured Veterans and their family members. As of late October and the current information provided by CMS, there are 26 states, including the District of Columbia, that are intending to expand Medicaid eligibility as of January 1, 2014. You may have seen news reports reporting that Ohio has recently announced its intention to expand Medicaid. Other states like Pennsylvania and New Hampshire are still considering expanding at this point in time. Other major expansion of coverage or provision of new financial assistance for health insurance coverage is through new subsidies that will be available for individuals and family members who qualify for coverage up through the new health insurance marketplaces. The top income band which you can qualify for subsidies is 400% of the federal poverty level, and the subsidies decrease with income up to that point. 

A key piece is that the individual must demonstrate that they don’t have access to affordable employer coverage. Eligibility for subsidized coverage is as with Medicaid, requires that you’re a legal resident of the United States. And in the case of subsidy eligibility, you cannot be eligible for any other form of public coverage. You can’t hold Medicaid, exchange subsidies, or VA services, and qualify for exchange subsidies. You have to have income as defined in the tax code up to 400% the federal poverty level. There has been a lot of concern around how the affordability criteria has been defined, and the affordability depends on the cost to the family of obtaining coverage for the workers in the family. There is a concern that they may make it difficult for families to get access to exchange subsidies on behalf of dependents. Finally, who qualifies for exchange subsidies depends on state decisions regarding the Medicaid expansion. In states that have expanded Medicaid in the 26 states and in the District of Columbia, the exchange eligible population will have income above 138% of the federal poverty level. But in the states that have not expanded Medicaid, the exchange eligible population will have incomes of 100% of the federal poverty level or above. And what you can see when you look at the Medicaid and the exchange subsidy pieces together is that the gap that’s left in the states that are not expanding Medicaid is for the uninsured individuals with incomes below 100% of the federal poverty level. They will not be eligible for Medicaid or for new assistance through the subsidies.

The VA has assessed potential effects of the Affordable Care Act on its system and in public testimony projected another 66,000 Veterans would be seeking VA care. As I indicated, the individual mandate could boost enrollment in VA care among uninsured Veterans, but it’s also possible that some of the new options could cause current users of the VA to choose other options. It’s also very likely that we’ll see more Veterans supplementing VA care with new Medicaid coverage. We’ll see a dual enrollment increase for Veterans, and that raises concerns about potential increases in fragmentation of care. As Jenny Haley said, given that about half the states are not expanding Medicaid, the question becomes, “How many uninsured Veterans and their family members can be helped by Medicaid in the coming year? How many will not have that as a new option?” The analysis that we did estimates that about 500,000 Veterans overall nationwide are uninsured and have incomes that could qualify them for Medicaid coverage under the Medicaid expansion if all states were to qualify. Comparable estimates that we have for the spouses are that about 170,000 uninsured spouses could qualify for Medicaid nationwide if they lives in a state that expanded Medicaid under the ACA. 

You can see that the Medicaid expansion, given that it has been selected in just half the states, leaves most uninsured Veterans not qualifying for Medicaid under the Affordable Care Act. So while there’s great potential for Medicaid to pick up many of these uninsured vets, many low-income uninsured Veterans live in the states that are not expanding Medicaid. And that’s partly a function of the fact that some of the larger states in terms of uninsurance like Texas, Florida, and North Carolina, have not adopted the Medicaid expansion at this point in time. You see the same breakdown in terms of uninsured Veterans in this income band that could qualify for Medicaid as to whether they live in a state that’s expanding or not expanding in terms of their spouses. 

When we look at eligibility for exchange coverage there are a good number of uninsured Veterans that are in the income band that could make them eligible for exchange subsidies. It’s the same for their spouses. As I said before the Veterans in this income band that are holding VA coverage have a new option, which is to purchase coverage through the exchange, but they would not be eligible for subsidies. As we look ahead and think about the change that the Affordable Care Act represents and focus on Veterans and their family members in terms of coverage, there are questions that seem particularly critical to explore. How well are ACA outreach and enrollment efforts working specifically for Veterans and their families to the extent to which the navigators and the other consumer assisters are trained on the options that are there for Veterans? How well are the websites and enrollment systems doing at interfacing with the VA and handling a VA eligibility enrollment the extent to which this is varying across the country? There’s likely a variation with respect to the policy choices that states have made not only with respect to the Medicaid expansions, but also in terms of whether they’re running their own marketplace and how well the enrollment website they’re using is operating, and to the extent to which there are many enrollment assisters on the ground or a few. That’s also something that varies considerably across states.

Every move beyond the initial ACA coverage rollout and the rollout of the major coverage provisions, it will be really critical to focus on to what extent are uninsured Veterans and family members gaining coverage in 2014 and beyond. Who is tracking VA, Medicaid, and exchange enrollment for those groups? Who is gaining? Who is remaining uninsured? To what extent are coverage gaps shrinking across states? In what states are coverage gaps highest for vets and their family members? We need to better understand the geographic nature of the uninsurance problem facing Veterans, and to drill down and understand better the role of cost-sharing implications of decisions that Veterans might be faced with in terms of their coverage with caps on cost-sharing in Medicaid, low copays for VA coverage, and potentially higher cost-sharing for those who get coverage on the marketplaces. Finally I think that this research raises questions about what the ongoing barriers are to both obtaining VA coverage, Medicaid, and other types of coverage, but also care. What are the impacts of the ACA coverage expansions on other changes on access to care, financial burdens, and health and functioning of Veterans and their family members? To the extent that a growing number of Veterans do have coverage from multiple sources, it’s critical that we understand the policies and practices that better promote positive outcomes for vets with dual coverage. I wanted to close with links to two papers in which this presentation has been drawn, and to say that we’re very much looking forward to hearing the comments and reflections of Duane and DeAnn and from those who are participating in the webinar. So with that I’ll hand it off.

Host:Thank you very much Genevieve for your presentation. Duane Flemming from the office of Policy Analysis and Forecasting will now give a response. Duane, do we have you on the line?

Genevieve Kenney:Duane if you can hear us we can’t hear you. You need to dial *0 and ask the operator to moderate your line. Jean, do you want to take care of that question while we’re waiting for Duane?

Host:Sure. Somebody asked about the presentation where it showed that there were 1.3 million uninsured Veterans. They wanted to know how many were eligible for VHA coverage. It might be difficult to figure that out from the American Community Survey. The eligibility for VA care depends on income. I don’t know if you looked into that at all Jenny?

Genevieve Kenney:This is Jenny Kenney. I’ll start by saying that that is probably the single most frequent question that Jenny Haley and I get on this research of how many of these Veterans qualifies for VA care, and what do we know about why they’re not enrolled. First, we felt that we could not replicate the eligibility determination process with the information we had on that survey. I’ll turn it over to Jenny Haley to add whatever she thinks is relevant there. But I have to say to the extent that there are folks who are participating who are aware of research on this question, it would be really useful to share it, because we haven’t found it and it doesn’t seem like its well known what the answers to those questions are. 

Jennifer Haley:I definetely agree with that. Other people have suggested to us that they think that most low-income uninsured Veterans would qualify given the eligibility rules that the VA uses. But we can’t really generate any specific estimates using this data unfortunately. So apparently there are some barriers to these Veterans enrolling in VA care, and that’s another big question about what are some of those reasons that those who could qualify are not currently enrolled? Maybe they don’t realize that the VA care is available, they don’t realize that they could qualify, or there are geographical barriers. That’s an interesting question. 

Host:Okay. Thank you. Duane’s office may have looked at this question as well. Do we have you on the line?

Duane Flemming:Yes. Thanks. This is Duane Flemming and DeAnn Farr. We appreciate your patience and have worked out the technical logistics to get unmuted. Thanks again to the folks with the Urban Institute for the presentation today. This information has been really interesting and relevant for us. It has certainly been of value to us and the VA as we implement ACA. From our prospective we recognize the three goals or objectives of the ACA, which is to improve access to affordable health care, to control costs, and to improve our nation’s health care delivery system. As noted in the presentation, we said that the impact of the VA is a net increase of about 66,000 additional enrollees, and that is above and beyond those Veterans that we expected to enroll on an annual basis. That’s only the impact in 2014 and we expect that the total impact will be realized over a period of about three years. That would be consistent with the experience in Massachusetts when they implemented their universal mandate, and also similar to the analysis that the Congressional Budget Office did when they looked at the impact of ACA. The net increase represents two cohorts from our perspective. One would be that many would disenroll from the VA to take the premium tax credit if they’re otherwise eligible. Remember that the premium tax eligibility is not just based on income, but it’s based on the fact that they have access to no other insurance. Many of the folks who come to the VA are going to be the young invincibles. That’s the term to describe a lot of those youngsters, as our Secretary refers to them, who are young and healthy. You can’t break them. They’re not going to get sick. The VA is a very attractive option for them because it doesn’t cost anything to enroll. We don’t have deductibles. Our copays are pretty modest, and it also enables them to check the box and satisfy the mandate to have health coverage. Remember for the Medicaid population with the Veterans that are currently enrolled with the VA and now become eligible for Medicaid, they can still remain enrolled with the VA. That’s good news for them and those are some of the key message points that we have been communicating. 

In terms of the key drivers regarding Veterans and their decisions to enroll, there are three main key drivers based on the information that we’ve gathered over time from our annual survey of enrollees. The first key driver is service connection. If a Veteran is service-connected, they are more than likely going to enroll with VA for health care. Other factors include the geographic proximity. How approximate is a VA site of care relative to where the Veteran lives? The closer they live the greater the probably of them enrolling. And finally, who’s making that decision regarding health care in that family unit? Typically it’s often times that maybe there’s another spouse. If that’s the case, then we see that that also impacts the Veterans decision to enroll. In terms of Medicaid expansion, you saw in the presentation where 26 states including D.C. are expanding Medicaid. Currently there are 22 states not expanding, and 3 are still undecided. We continue to monitor that, because that impacts our strategy in terms of our targeted outreach efforts. I’m going to talk about that in just a minute.

In terms of what we’ve been doing here in the VHA Office of Policy and Planning over the last two years is really analyzing data, assessing the impact, and working to develop our strategic communications plan to educate, inform, and to engage Veterans, other eligible beneficiaries, our workforce, and other stakeholders to communicate to them what ACA means to them. It’s also to enlist their support to help spread the word. We’ve also been working very closely with other federal agencies, and those efforts have been very fruitful. In terms of communication efforts with Veterans, we began this at the end of July 2013. We work very closely with HHS and the administration to make sure all of our communication materials were nested together so that we provide consistent messaging to minimize the confusion. Our Chief Business Office, who maintains the enrollment process, expanded the call centers of operation. That way when Veterans have questions about ACA and they call the call center, they’re going to be able to get through. We’ve also launched an interactive website and a health benefits explorer tool that are very easy to navigate and use so that Veterans or others can go to those sites and get that information. For a quick commercial announcement, that website is www.va.gov/aca. That’s where you’re going to find all of this great information. We’ve also in terms of our outreach and communication efforts mailed 8.45 million letters to enroll Veterans. We did that from the end of July to the end of September. So before the marketplaces and everything came live on October 1st, we had already communicated to all of our enrolled Veterans letting them know that they are good to go if they’re enrolled, because they had minimum essential coverage. 

The next step was looking at the Veterans who aren’t enrolled and communicating with them. To that effort, we mailed 160,000 letters to Veterans that are receiving their GI bill education benefit and who are not enrolled with VA health care to let them know that that is an option for them and see if they would be interested in enrolling. And then we’ve also began our outreach to target other non-enrolled Veterans. This has been probably the biggest nut to crack. It’s been working collaboratively throughout the department. At the VA level there’s a U.S. vets database that has over 19 million records. So it’s pretty complete, especially for those who are under 65.  We’re able to merge that with the Veterans that are enrolled. That way we can identify non-enrolled Veterans under 65 by marital status, income level, and gender. We also conducted a travel time analysis so we know how far they are. How many minutes they are from the nearest VA primary care site? We have a variable, which is called the propensity to have health insurance. So we’re able to identify those Veterans that meet these criteria who are most likely to not have health insurance coverage. And when we look at that data, it aligns very closely with the 1.3 million uninsured Veterans that are estimated by the American Community Survey Report. We created all of this data. We created tables and workbooks, and we put those out to each of our VISNs and shared this information to educate with them. We have had 13 conference calls with networks to explore targeted outreach. So the VISNs are able to assess their system capacity to welcome new Veteran enrollees, because we want to make sure that this is a positive experience when these Veterans receive this letter and go to the community-based outpatient clinic, that they’re not going to see a ‘no vacancy sign” on the front door. We want them to get in and begin receiving VA health care. 

We also have unidentified non-enrolled Veterans that are receiving VA pensions. There are not a lot of them. There is less than 20,000 I think, but these are the poorest of the poor. So we want to make sure that we’re reaching out to them so we can get them enrolled and signed by with VA health care. The other component that we’re doing is that in addition to the 13 VISNs that we’re working with on this targeted outreach, we’re also looking at VISNs that have states that are not expanding Medicaid, because there are a number of Veterans in those states that are going to be so poor that they’re not going to be able to have affordable health care. If health care costs are more than 9-1/2% of their household income, then it’s not affordable. So that’s another at risk population that we’re working to identify, so that way we can follow-up with the VISNs and get some letters out to those folks letting them also know about VA health care. They’re going to meet the eligibility criteria, and we want to make sure that they also have the health care that they really need. So that’s very quickly a brief description of some of the analyses and outreach that we’ve been working on. DeAnn, did you have any other comments to share?

DeAnn Farr:No, that’s a terrific summary.

Duane Flemming:Okay. I guess what we can maybe do is I’ll pause here and see if there are any questions from folks on the call.

Host:Thanks so much for your response Duane. It was a very useful summary of what the VHA has done in terms of reaching out to Veterans and enrolling them into the VA. There are several questions right now in the queue. Someone asked, “Are there any statistics that address rural uninsured Veterans versus urban uninsured Veterans?

Genevieve Kenney:Yes. There are two ways of going at that. You can get that data, those estimates from the American Community Survey. However, the Office of Rural Health recently told me that they thought that they were underreporting the number of rural Veterans. I think it’s because of the differences in the way that the VA defines rurality to the way that the other systems report rurality. We just did an analysis of that and we found that there are probably twenty different ways of defining rurality. Ours best aligns with the industry standard and so we think that we’re right. So you can get that from the American Community Survey. We also tracked it ourselves when we did the geographic voting of the U.S. vets data and added an urban, rural, and highly rural indicator on that. We reported that back to the Office of Rural Health. So yes, there is absolutely a way to determine the difference between rural, highly rural, and urban. 

Host:Jenny and Genevieve, I don’t know if you found that rural Veterans have higher rates of uninsurance than urban Veterans.

Genevieve Kenney:I will have to get back with you on that. It wasn’t a substantively difference to my recollection, but I can get back with you on that.

Host:Okay. The next question asks, “How long and cumbersome is the current process of VA enrollment?”

Duane Flemming:Great question. That’s one of the other things that we did that I did not mention is we have streamlined the enrollment process. There are four different ways that a Veteran can enroll. They can enroll online. The process is probably less than twenty minutes to enroll. They can fill out a paper application and mail it in. They can do it via web chat, or they can just stop in at any of our sites of care and apply for enrollment. The application has been streamlined to collect only the minimum necessary information so that we can determine their eligibility, and we encourage all Veterans to apply for enrollment. We don’t want them to exclude themselves by saying, “Gee. I don’t think I’m eligible.” 

Host:Great. Somebody else asks, “Does the VA tend to enroll Veterans who are already covered by other health insurance, such as a spouse’s insurance?”

Duane Flemming:I would say that that is a benefit that the Veteran has earned. We recognize that our medical benefits package is certainly very competitive. And I think that the VA is recognized for certain niche services, particularly in the area of mental health. It’s a personal decision for the Veteran, and if they have other insurance we would certainly welcome them and we look forward to serving them.

Host:Great. Another asks, “For states that joined the Medicaid expansion, will the referral process acceptance be quicker?” I believe that this person is comparing it with traditional Medicaid. Jenny and Genevieve, you might want to weigh in on this.

Genevieve Kenney:I don’t think we know yet. The handoff between the marketplaces and Medicaid is still evolving. And I don’t think that we know how quickly that’s going to proceed. Then there are a lot of changes that could make it much faster. There is no asset requirement in Medicaid under the Affordable Care Act. There is a much greater goal of using data matches instead of paperwork that people have to fill out and documentation that people have to directly provide. So there’s a potential for it to be shorter, but right now during this initial phase we really can’t judge whether that’s going to happen.

Host:Sure. The next question asks, “I understand that the marketplace is pricing vets much higher due to their complexity. Do we know anything about the number and their impact on vets?”

Genevieve Kenney:The first thing I’d say is that my expertise is public health insurance coverage. But I know for sure that there’s no underwriting in the exchange plan. So if they’re going to the marketplace, only their age and in some states their smoking status is relevant. There is no health information that is affecting the premiums that people are receiving, so long as it’s a plan that offered to the new marketplaces.

Host:Okay. Thanks for clarifying that. Another question asks, “Are navigators trained on the option for Veterans?” Did you have any preliminary findings on this?

Duane Flemming:This is Duane. In terms of navigator training, we have been working with HHS and shared with them our communication material. So that’s the area that we are also working on to at least give them some minimum information. So at least if they ask, “Are you a Veteran,” and the individual responds, “Affirmative,” then we’ve got resources that they can point to like with our website www.va.gov/aca. That will help to determine their eligibility. 

Host:Great. The last question asks, “Will this drive more vets to us?” I’m assuming they’re referring to the mandate.

Duane Flemming:As the Undersecretary testified back in April, we estimate that we will see a modest net increase. But we at this point don’t have any data indicating that new Veteran enrollment with the VA as a result of ACA is going to overwhelm our system.

Host:Okay. Great. Thanks so much. That was all of the questions in the queue and actually we’re at the end of the hour too. So the timing worked out pretty well. I wanted to thank everyone so much for participating in today’s Cyber-Seminar. We had Genevieve Kenney and Jenny Haley from the Urban Institute and Duane Flemming and DeAnn Farr from the VHA Office of Policy and Planning. Heidi, do you have any final comments or words about getting a copy of the slides?

Moderator:I will bring it all the way back to the beginning here. If anyone is looking for a copy of the slides, there is a link on your screen right now. Click here for today’s handout and it will open up today’s slides in a separate browser window that you can save or print out. It’s your choice. I’m going to be closing this meeting out in just a moment. And when I do that you will have a feedback form pop up on your screen. We would really appreciate it if you would take a few moments to fill that out. We really do read through all of your feedback and we will pass it onto the presenters. We also use that to incorporate into our current and upcoming sessions. I also want to thank all of our presenters and discussants for today’s session. Thank you to the audience for joining us for today’s HSR&D Cyber-Seminar, and we hope to see you at a future session. Thank you.

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