Veterans and the Affordable Care Act.

VIEWPOINT Veterans and the Affordable Care Act Kenneth W. Kizer, MD, MPH A RMED CONFLICT HAS BEEN A FREQUENT OCCUR - rence throughout US history. During the last cen- tury, the United States has fought 8 wars that to- gether span more than 35 years, not counting numerous conflicts that are not officially considered wars. In view of the many health consequences of war, the po- tential effect of the Affordable Care Act (ACA) on health care for veterans warrants careful consideration. In 2011, there were 22.2 million veterans of service in the US Armed Forces. Veterans are a highly diverse population but can be grouped into 3 categories from a health insur- ance perspective. Approximately 37% are enrolled in the De- partment of Veterans Affairs (VA) health care system in ac- cordance with a congressionally mandated eligibility system based on having a service-connected disability, low in- come and net worth, or other prescribed circumstances. More than 80% of VA enrollees older than 65 years are also cov- ered by Medicare and about 25% of enrollees are beneficia- ries of 2 or more non-VA federal health plans (eg, Medi- care, Medicaid, TRICARE, or Indian Health Service). Another 56% of veterans have private health insurance or are cov- ered by a non-VA federal health plan, while 7% have no health insurance. These latter veterans are poor or near poor but have incomes or net worth that exceed the mean test thresh- olds for VA health care eligibility. 1 The ACA will not affect health care for the majority of veterans differently than it will affect nonveterans, and the ACA will not change eligibility for VA health care, covered benefits, co-payment for services, or how the VA health care system is administered or operated. Nonetheless, the ACA may affect health care for many veterans through its effects on access, fragmentation and quality of care, utiliza- tion of services, the health care work force, and federal expenditures. The ACA will expand health insurance coverage for low-income persons through Medicaid and state health insurance exchanges, which should make health insurance available to uninsured veterans. The new insurance cover- age options will also be available to many VA health care enrollees, expanding their health care choices and poten- tially increasing convenience and timeliness of care but also fragmenting care. Fragmentation of care is of concern ©2012 American Medical Association. All rights reserved. because it diminishes continuity and coordination of care, resulting in more emergency department use, hospitaliza- tions, diagnostic interventions, and adverse events. The VA serves an especially large number of persons with chronic medical conditions or behavioral health diagnoses— populations especially vulnerable to untoward conse- quences resulting from fragmented care. Veterans with dual or multiple health plan eligibility are known to have more fragmented care, although associated untoward effects have not been well studied. Some data sug- gest that veterans receiving care from both VA and non-VA sources are more likely to be rehospitalized and to die within a year compared with VA-only users, although the reasons for the disproportionate mortality have not been studied. 2 VA/Medicare dual-eligible veterans with myocardial infarc- tions who use both plans undergo more invasive cardiac pro- cedures without gaining a survival advantage over VA-only users, but adverse events associated with greater use of in- vasive procedures by non-VA clinicians have again not been analyzed. 3 More health care choices may adversely affect the qual- ity of care for some veterans in ways other than fragment- ing care. Physicians in private practice may not be pre- pared to treat conditions prevalent among veterans. For example, the Reaching Rural Veterans Initiative in Penn- sylvania found that private practice primary care clinicians lacked knowledge of posttraumatic stress and other mental health disorders prevalent among veterans and were unfa- miliar with VA treatment resources for such conditions. 4 Ad- ditionally, numerous studies have shown that VA enroll- ees are significantly more likely than persons receiving care from non-VA clinicians to receive evidence-based treat- ment and recommended services for prevention and early diagnosis of cancer, cardiovascular disease, diabetes, and in- fectious diseases. 5-7 VA enrollees with non-VA health insurance are known to use less VA care than those having only VA coverage, so expanding health care insurance for veterans may decrease use of VA facilities. Volume-sensitive services (eg, inten- sive care or complex surgery) at some smaller VA hospitals Author Affiliations: University of California Davis School of Medicine, Betty Irene Moore School of Nursing, Institute for Population Health Improvement, Univer- sity of California Davis Health System, Sacramento. Corresponding Author: Kenneth W. Kizer, MD, MPH, Institute for Population Health Improvement, University of California Davis Health System, 4800 Second St, Ste 2600, Sacramento, CA 95817 (kenneth.kizer@ucdmc.ucdavis.edu). JAMA, February 22/29, 2012—Vol 307, No. 8 789 Downloaded from jama.ama-assn.org by Kenneth Kizer on February 21, 2012