Universal health coverage for US veterans: a goal within reach

The crisis of 2014 within the US Department of Veterans Aff airs (VA) health system, centred on appointment waiting times, has brought to light substantial defi ciencies 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 benefi ts 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. Uninsured veterans are more likely to be younger, single, African-American, on low income, and to have been deployed to Iraq or Afghanistan. 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, 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. Expansion of Medicaid coverage for individuals and families with low incomes under the terms of the Aff ordable Care Act (ACA) could substantially reduce the number of uninsured veterans. The ACA’s individual mandate provides a fi nancial 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 benefi ts. Although eligibility for insurance is not synonymous with access to health care, universal coverage is an important fi rst 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. We identifi ed 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 2010 as modelled in published research; present state decision making about the Medicaid expansion; ACA-related income cutoff s for tax credits; and eligibility for VA health-care coverage. Eligibility for VA health-care benefi ts is estimated using data from the American Community Survey. 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. 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. 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 Number of uninsured veterans Expanding Medicaid*