2016, Vol. 5, No. 4 >Article 13 by Christine Eibner, Heather Krull, Kristine Brown, Matthew Cefalu, Andrew W. Mulcahy, Michael Pollard, Kanaka Shetty, David M. Adamson, Ernesto F. L. Amaral, Philip Armour, Trinidad Beleche, Olena Bogdan, Jaime L. Hastings, Kandice A. Kapinos, Amii M. Kress, Joshua Mendelsohn, Rachel Ross, Carolyn M. Rutter, Robin M. Weinick, Dulani Woods, Susan D. Hosek, Carrie M. Farmer
This Article RAND
Health Quarterly, 2016; 5(4):13
Abstract
The Veterans Access, Choice, and Accountability Act of 2014
addressed the need for access to timely, high-quality health care for veterans.
Section 201 of the legislation called for an independent assessment of various
aspects of veterans' health care. The RAND Corporation was tasked with an
assessment of the current and projected demographics and health care needs of
patients served by the Department of Veterans Affairs (VA). The number of U.S.
veterans will continue to decline over the next decade, and the demographic mix
and geographic locations of these veterans will change. While the number of
veterans using VA health care has increased over time, demand will level off in
the coming years. Veterans have more favorable economic circumstances than
non-veterans, but they are also older and more likely to be diagnosed with many
health conditions. Not all veterans are eligible for or use VA health care.
Whether and to what extent an eligible veteran uses VA health care depends on a
number of factors, including access to other sources of health care. Veterans
who rely on VA health care are older and less healthy than veterans who do not,
and the prevalence of costly conditions in this population is projected to
increase. Potential changes to VA policy and the context for VA health care,
including effects of the Affordable Care Act, could affect demand. Analysis of
a range of data sources provided insight into how the veteran population is
likely to change in the next decade.
For more information, see RAND RR-1165/1-VA at https://www.rand.org/pubs/research_reports/RR1165z1.html
Full Text
The Department of Veterans Affairs (VA) provides health care
to eligible veterans. In this study, we describe the current and projected
characteristics and health care needs of the U.S. veteran population as whole,
as well as the population of veterans who receive health care from VA. This
analysis was conducted in response to the Veterans Access, Choice, and
Accountability Act of 2014 (Section 201), which mandated “an independent
assessment of current and projected demographics and unique health care needs
of the patient population served by the Department.”
Study Purpose and Approach
We examined the demographic characteristics of the current
and projected population of U.S. Veterans and patients of the VA health care
system. In addition, we examined the unique health care needs of the patient
population currently served by VA and projected the health care needs of
Veterans who might become patients in the future. We use the term Veteran to
describe all Veterans, whether or not they use VA health care services, and the
term VA patients to describe Veterans who received at least
some health care from VA in the past year.
This study addresses four overarching research questions:
·
What are the demographic
characteristics of the U.S. Veteran population, and how are these projected to
change between 2015 and 2024?
·
To what extent do Veterans,
including VA patients, rely on VA for their health care?
·
What are the current health care
needs of the Veteran population, including both VA patients and non-VA
patients, and how do these compare with the needs of the non-Veteran
population? How will the needs of Veterans in general and the VA patient
population specifically evolve over time given current policies?
·
How might the projected number of
Veterans and VA patients change because of external forces or changes in VA
policies?
To address the research questions, we conducted a series of
analytic activities: Using a cohort-based approach, we estimated the size and
demographic composition of the Veteran population; using the projected number
of Veterans as a baseline, we estimated future enrollment in the VA health care
system, the future size of the VA patient population, and the share of health
care services that current Veterans receive from VA; we combined several data
sources to assess the unique health care needs of Veterans and VA patients
compared with non-Veterans; we used a modeling approach to assess how the
number of VA patients and their health conditions might evolve over time; and
we conducted scenario testing to understand how VA policies and external
factors might affect the size of the Veteran population and the number of VA
patients.
Background
VA provides health care services to enrolled Veterans who
seek care at VA facilities, or—in some cases—through contracted care purchased
from the civilian sector. Eligibility for VA health care has evolved over time,
and today's eligibility rules are rooted in the Veterans Health Care
Eligibility Reform Act of 1996. The law mandated health care for
service-connected health conditions and for Veterans with a service-connected
disability rated at 50 percent or higher. The Secretary of Veterans
Affairs has legal discretion over the provision of all other care, but VA must
maintain specialized treatment and rehabilitation programs for spinal injuries,
blindness, amputations, mental illness, and other serious service-connected
health conditions.
In general, a Veteran must have served in the U.S. military
for at least 24 months and received an honorable discharge to enroll for VA
health care. Some exceptions are permitted; for example, Veterans serving less
than 24 months may be eligible if they were medically retired from military
service due to a service-connected condition. To implement the 1996 law, VA
established a priority system for determining which groups of Veterans will be
authorized for care within the authorized budget. This structure places
Veterans in one of eight priority groups based on their service-connected
disability rating, income, and other factors. A Veteran's priority group
designation affects his or her eligibility to receive care through VA, as well
as his or her cost-sharing requirements (that is, whether co-payments are
required and, if so, how much). Currently, enrollment is limited to recent
combat Veterans, Veterans with qualifying incomes, and Veterans with
service-connected or other disabilities. Based on our analysis of VA
administrative data, about 9 million Veterans (42 percent of all
Veterans) were enrolled in 2014. Non-enrolled Veterans include a mix of
Veterans who are ineligible to enroll and Veterans who are eligible to enroll
but choose not to do so.
Use of VA health care depends on a number of factors,
including the total number of Veterans in the population, Veterans' eligibility
to enroll for services, Veterans' enrollment decisions when eligible, and
Veterans' decisions to seek VA health care services when enrolled. Because many
Veterans have access to health care through other sources, such as employer
insurance or Medicare, not all will choose to enroll, and those who do enroll
may choose not to use VA for all of their health care needs. In addition, both
VA policy and factors external to VA can affect Veterans' use of services. For
example, a policy change enabling higher-income Veterans to enroll could
increase demand for VA services. Similarly, a future military conflict could
increase the number of Veterans in the pipeline and affect their health care
needs. In our analysis, we distinguish VA enrollees from VA patients; a VA
patient is an enrollee who has used VA health care in the past year.
In this assessment, we used data from VA and from other
federal sources, such as the U.S. Census Bureau, to estimate the total number
of Veterans and VA patients, to project the size of these populations over
time, and to estimate the health care needs of these populations. Our baseline
estimates and projections assumed that VA policies and other factors that might
affect Veterans' demand for services are constant, with adjustments for policy
changes that have already been announced (such as the President's plan to
reduce the size of the U.S. military). In scenario testing, we considered how
uncertain future events, such as a future conflict or a change in VA
eligibility policy, might affect the size and health care needs of the Veteran
and VA patient populations.
Key Findings
Current and Projected Demographic Trends in the Veteran
Population
Today's Veterans generally enjoy favorable socioeconomic
outcomes relative to their non-Veteran counterparts. Using data from the American Community Survey (ACS),
we find that Veterans are less likely to be unemployed, less likely to be
living below the poverty line, and more likely to have graduated from high
school, on average, than non-Veterans (Figure 1). Veterans are also more
likely than non-Veterans to have medical insurance; only 7 percent of
female Veterans and 6 percent of male Veterans were uninsured during the
2009 to 2013 time period, according to the ACS. In contrast, 15 percent of
female non-Veterans and 22 percent of male non-Veterans were uninsured
during this time period. Rates of uninsurance among the Veteran population may
be low in part because many Veterans have access to free insurance through VA.
Insurance rates in the United States have increased since 2013, due to the
implementation of the Patient Protection and Affordable Care Act (ACA) (Office
of the Assistant Secretary for Planning and Evaluation, 2015). We did not have
data, however, that allowed us to compare post-ACA insurance rates between
Veterans and non-Veterans.
Figure 1. Socioeconomic
Characteristics of the Veteran and Non-Veteran Civilian Population, by Sex,
2009–2013
Homelessness is declining among Veterans. Homelessness remains a significant problem among
Veterans. Veterans are overrepresented in the U.S. adult homeless population:
In 2010, Veterans accounted for approximately 10 percent of the adult
population; however, they represented a disproportionate share of the homeless
adult (16 percent) and sheltered homeless adult (13 percent)
populations (National Center for Veterans Analysis and Statistics, 2012).
Notwithstanding this, the rate of homelessness among Veterans has declined
since 2010. According to the U.S. Department of Housing and Urban Development,
there were 49,933 homeless Veterans in 2014, representing less than 0.25 percent
of the total Veteran population. Between 2010 and 2014, the number of homeless
Veterans declined by 33 percent (U.S. Department of Housing and Urban
Development, 2014).
VA patients tend to be older and less socioeconomically well
off than Veterans who do not rely on VA for care. Using data from the Medical Expenditure Panel Survey
(MEPS), we are able to compare Veterans who use VA care with Veterans who do
not use VA care (Table 1). VA patients are older and less well-off from a
socioeconomic standpoint than Veterans who do not use VA for care. For example,
9 percent of VA patients have less than a high school education, compared
with 6 percent of Veterans. VA patients' average household incomes are
more than 20 percent lower than incomes for non-patient Veterans. VA
patients are also far less likely to be employed than non-VA patients.[1] Partly,
these differences are by design, because higher-income Veterans may not be
eligible for VA services.
Table 1. Socioeconomic
Characteristics of Veterans, by VA Patient Status, 2006–2012
|
Characteristic
|
Veterans, VA Patients
|
Veterans, Non-VA Patients
|
|
Over age 65
|
52.2%
|
38.7%
|
|
Married
|
62.6%
|
68.0%
|
|
Less than high school education
|
9.1%
|
5.8%
|
|
Employed*
|
41.3%
|
62.8%
|
|
Average household income
|
$35,981
|
$45,278
|
SOURCE: RAND analysis of MEPS, 2006–2012.
NOTES: Veterans, VA patients and Veterans,
non-VA patients are mutually exclusive categories. Sample size, VA patients =
4,871, and sample size, non-VA patients = 7,442.
*Non-employed individuals include both people
who are unemployed and people who are out of the labor force, such as retirees.
We project that the population of U.S. Veterans will
decrease by 19 percent over the next 10 years. The U.S. Veteran population has been decreasing for
the past three decades, and this trend will continue. There were
27.5 million Veterans in the United States as of the 1990 Census; we
estimate that there were 21.6 million Veterans in 2014. Over the next
10 years, our projections, drawing on VA, U.S. Census, and U.S. Department
of Defense (DoD) data, show that the Veteran population will decline to
17.5 million, a decrease of 19 percent relative to 2014 levels
(Figure 2). Given the strong preexisting trends and the President's
ongoing drawdown in the size of the active duty military population (Hagel, 2014;
Parrish, 2011; Office of the Under Secretary of Defense [Comptroller], 2015),
the reduction in the size of the Veteran population is inevitable, absent a
major policy change to increase the size of the military (for example, if an
unanticipated large-scale conflict were to materialize).
Figure 2. The Number of U.S.
Veterans Will Decline by 19 Percent by 2024
Geographic distribution of Veterans will shift slightly. We estimate that, geographically, the Veteran
population will become more concentrated in urban areas, and the relative
proportion of the Veteran population in the Ohio River Valley region will
diminish.
There will be modest changes in the demographic mix, by sex
and race/ethnicity. Currently,
Veterans are more likely than non-Veterans to be male, and are on average much
older. We estimate that approximately 92 percent of the Veteran population
was male in 2014. We also estimate that 75 percent of Veterans were age 55
or older, compared with only 34 percent of the non-Veteran population. By
2024, this will shift somewhat: The proportion of female Veterans will increase
3 percentage points, from 8 to 11 percent, by 2024, and the share of
non-Hispanic white males will decrease from 80 to 74 percent over the same
period. Mean age will increase slightly; the population will have a higher
proportion of both older and younger Veterans.
These projections are based on historic separation rates,
the anticipated decrease in military end-strength over the next several years,
and an assumption that there are no significant new conflicts during the
projection period.
Enrollment and Reliance on VA Health Care
The number of Veterans receiving VA health care is projected
to level off over the next 10 years. While
the Veteran population is projected to decline by 19 percent over the next
10 years, the number of VA patients is projected to increase until 2019.
Use of VA health care has increased across all demographic groups since 2005,
and the fraction of Veterans under age 35 who are VA patients has increased
threefold. The growth of VA use by Veterans may be related to outreach efforts
on the part of VA, policies that have expanded the list of conditions granting
presumptive eligibility for VA services, and streamlined enrollment processes.
Continued increases in the rates of VA use are expected to slow the decline in
the number of VA patients. Nevertheless, in years beyond 2019, VA may begin to experience
slight declines in the volume of patients. Because VA will be coming off a
period of more than a decade of expanded use, careful monitoring and new
policies may be necessary to address the leveling-off and possible reduction in
demand for services that could occur after 2019.
Health care planning for VA is complicated by the fact that
most Veterans have more than one possible source of health coverage. The extent to which Veterans use VA care as opposed to
care from other sources is captured in the concept of reliance, by
which we mean the fraction of Veterans' total care that is provided by or paid
for by VA. Reliance on VA versus other sources of care varies by type of care,
but it averages below 50 percent for many routine services. Across all types
of care, Veterans under age 30 are the most reliant on VA, and those over age
65 are least reliant.
Both VA policy, such as policies to enhance Veterans' access
to VA services, and external trends, such as the cost and availability of
private health insurance, can affect Veterans' reliance on VA. However, VA has
limited visibility into patients' reliance. While VA has access to data on care
obtained at VA facilities, it is difficult to track how much care Veterans
consume outside the VA system—for example, through private health insurance.
Yet understanding reliance is critical for planning, because shifts in reliance
can affect the total amount of care that Veterans obtain from VA facilities.
We analyzed reliance using data from MEPS and compared these
estimates with reliance estimates used in VA's Enrollee Health Care Projection
Model (EHCPM). MEPS is a survey of health care utilization and spending
conducted by the Agency for Healthcare Research and Quality (AHRQ). The EHCPM
is a forecasting model sponsored by VA, which relies on VA survey data,
Medicare claims data, and proprietary data from the actuarial firm Milliman.
Using MEPS data, we found that younger Veterans,
lower-income Veterans, Veterans in rural areas, Veterans without other access
to health insurance coverage, and Veterans with poorer self-reported health
status rely more than other Veterans on VA. However, the estimated share of
care obtained through VA is generally lower in the MEPS estimates than in the
EHCPM estimates. For example, MEPS indicates that VA patients obtain
30 percent of their prescription drugs through VA, compared with ECHPM's
estimate that enrollees obtain 66 percent of their prescriptions from VA.
Because the EHCPM estimates are in part based on proprietary methods, we were
unable to ascertain fully the reasons for these differences. However, a general
conclusion is that VA might benefit from validating current reliance estimates
and investing in survey approaches to better understand Veterans' total health
care needs.
Unique Health Care Needs of Veterans and VA Patients
To identify the unique health care needs of Veterans and the
VA patient population,[2] we first compared the prevalence of
key health conditions among the current Veteran population with those among the
non-Veteran population. We then compared the prevalence of key health
conditions among VA patients with those among Veterans who do not use VA health
care and analyzed which characteristics (including the presence of particular
health conditions) were associated with receiving care at VA facilities. Our
analysis relied on MEPS, which collects information on all care received,
regardless of payer, and information on Veteran status and use of VA services.
With MEPS data, we can analyze all of a Veteran's diagnosed health conditions,
regardless of whether the Veteran used VA health services. We can also use MEPS
data to compare Veterans with non-Veterans
We examined both unadjusted prevalence rates of these health
conditions and adjusted prevalence rates, which accounted for key demographic
characteristics, such as age and sex. Both rates provide unique information
with relevance to policy issues.
Unadjusted prevalence rates provide a snapshot of the overall Veteran population
and enable us to compare how Veterans and VA patients may differ from civilians
in terms of their health care needs. Unadjusted rates, however, do not account
for the fact that Veterans are typically older and more likely to be male than
civilians. Nevertheless, these numbers are useful for planning purposes. For
example, the fact that Veterans have a much higher rate of diabetes than
non-Veterans is useful for determining the types of providers and services that
Veterans need, even if most of the difference between Veterans and non-Veterans
can be explained by factors such as age and sex.
Adjusted prevalence rates help
us understand how Veterans' and VA patients' health care needs may differ from
the needs of demographically similar non-Veterans. As a result, these
comparisons inform our understanding of how the experience of being a Veteran
affects health. However, because they already account for demographic
differences, without careful interpretation, the adjusted prevalence rates may
appear to understate key differences in health care needs between Veterans and
non-Veterans at the population level.
We also projected the prevalence of the health conditions of
Veterans and VA patients forward over the next 10 years, accounting for
predicted changes in their demographic composition and their service
experiences.
Veterans have a higher unadjusted prevalence of diagnosed
health conditions than non-Veterans. The
diagnosed prevalence of many common chronic health conditions, unadjusted for
differences in demographic characteristics, is higher among Veterans than non-Veterans.
For example, the prevalence of diabetes and gastroesophageal reflux disease
(GERD) disorders among Veterans is substantially higher than for non-Veterans
(Figure 3). Veterans are more likely than non-Veterans to be diagnosed
with cancer, hearing loss, and PTSD. Mental health conditions, generally, are
equally prevalent in the Veteran and non-Veteran populations. Because Veterans
are more likely to have insurance than non-Veterans, some of these differences
could reflect that Veterans are more likely to receive diagnoses than
non-Veterans. Nevertheless, understanding differences in diagnosed conditions
sheds light on differences in conditions that Veterans and non-Veterans are
being treated for under existing policies. As such, these analyses inform our
understanding of whether Veteran providers are likely to treat a different mix
of conditions than civilian providers. Our analyses suggest that VA providers
are likely to be treating a sicker population with more chronic conditions,
such as cancer, diabetes, and chronic obstructive pulmonary disease (COPD),
than the population expected by civilian providers.
Figure 3. Veterans Have
Higher Diagnosed Prevalence of Several Key Health Conditions (Unadjusted
Prevalence)
Veterans also have a higher adjusted prevalence of key
health conditions than non-Veterans. For
some conditions, adjusting for demographic characteristics substantially
reduces the difference in prevalence rates between Veterans and non-Veterans.
For example, Veterans are twice as likely to have diabetes as non-Veterans in
the unadjusted model, but after adjusting for demographic characteristics, the
prevalence rate among Veterans is only 13 percent higher. In the adjusted
model, Veterans are more likely to have mental health conditions than non-Veterans,
while differences were not statistically significant in the unadjusted model.
Even though fewer than 5 percent of Veterans are diagnosed with PTSD, it
is even rarer in the non-Veteran population. After controlling for age and
other factors (Figure 4), Veterans are 13.5 times more likely than
non-Veterans to be diagnosed with PTSD.
Figure 4. Veterans Have a
Higher Prevalence of Several Key Health Conditions (Adjusted Prevalence)
VA patients are typically less healthy than Veterans who do
not use VA health care. Compared with Veterans seen by private health care
providers, Veterans who received treatment from VA had higher rates of cancer,
diabetes, hypertension, PTSD, ischemic heart disease (IHD), and other
conditions (Figure 5). These differences reflect VA patients' older age,
and also reflect the eligibility criteria for enrolling in VA care, which
depend in part on health status. Among VA patients, the unadjusted prevalence
of common chronic conditions (e.g., diabetes, cancer) is 51 to 96 percent
higher for VA patients relative to Veterans who do not use VA care; however,
rates of PTSD are several orders of magnitude higher among VA patients relative
to non-patients. Adjusting for demographic characteristics slightly reduces
differences in prevalence rates between patients and non-patients.
Figure 5. VA Patients Have a
Higher Prevalence of Several Key Health Conditions (Unadjusted Prevalence)
According to the MEPS data in Figure 5, about
25 percent of all patients who accessed care at VA had a mental health
condition, and 3.3 percent had PTSD.[3] Rates of PTSD are
substantially higher among Veterans under age 35. When combined with the
otherwise rare conditions related to combat—amputation, traumatic brain injury
(TBI), blindness, and severe burns—and the vulnerable circumstances of some
patients, VA handles a patient mix that differs from what community providers
typically see.
The prevalence of many common conditions is projected to
increase among Veterans over the next 10 years. We estimate that aging in
the Veteran population will lead to increases in the prevalence of several
common health conditions among Veterans over the next 10 years.
Figure 6 shows projected unadjusted prevalence for hypertension, diabetes,
IHD, and mental health conditions. Among all Veterans, we estimate that the
prevalence rates for diabetes and hypertension will increase by about 12 and
8 percent, respectively, between 2015 and 2024. However, while aging will
tend to increase the prevalence of IHD, we estimate that prevalence rates for
IHD will decline during 2015–2024. This finding is consistent with
long-standing trends toward decreasing prevalence of acute coronary syndrome
across all age groups in the U.S. population (Krumholz, Normand, & Wang, 2014;
Talbott et al., 2013). However, this decline largely represents an
extrapolation of recent declines in the prevalence of IHD noted in MEPS. The
relatively large confidence bands suggest that the trend is uncertain and
actual prevalence may not decline as sharply. Mental health conditions increase
moderately over time, with prevalence rates rising by about 6.8 percent.
Figure 6. Projected
Unadjusted Prevalence of Selected Health Conditions Among Veterans (2015–2024)
Figure 6 reports prevalence rates among all Veterans,
which we estimated using a combination of data sources, including MEPS and MHS
data, on service members who recently converted from active duty to Veteran
status. In general, prevalence rates among VA patients increase somewhat more
than prevalence rates for all Veterans. As a result, the gap in prevalence
rates between VA patients and Veterans who do no use VA health care is
projected to increase over time.
Scenarios
We examined five scenarios, based on hypothetical future
changes to VA policy or to the environment surrounding VA health care.
Scenario 1: Broader VA eligibility. Higher-income Veterans without disabilities are
currently ineligible to enroll for VA coverage or to receive care at VA.
Expanding eligibility to currently excluded groups could lead to more than
4.8 million newly eligible Veterans and as many as 2.1 million new VA
patients, amounting to a 35-percent increase in the size of VA's patient
population.
Scenario 2: Including hypertension presumptively as a
service-connected condition for Vietnam Veterans. According to the Institute of Medicine of the National
Academies (IOM), there is increasingly solid evidence that hypertension among
Vietnam-era Veterans is related to service in the Vietnam Theater of
Operations. As yet, VA has not added hypertension to the list of presumptive
conditions for Vietnam-era Veterans. If hypertension were included, we estimate
that this would translate into 363,000 new VA patients, an increase of
6.4 percent in VA's total patient population.
Scenario 3: Hypothetical future conflict. How would demand for VA health care services be
affected by future military conflict? In examining 36 possible scenarios, we
found that the vast majority of them project between 500,000 and 925,000 new VA
patients by 2024. However, most low-conflict scenarios anticipate 500,000 and
600,000 new patients, while most high-conflict scenarios predict between
750,000 and 925,000. This suggests that even moderate levels of deployment
could substantially increase the size of the incoming cohort of VA patients. In
fact, our projections suggest that, for every new patient that would have entered
the VA system in more-peaceful times, approximately 1.5 new patients will enter
the VA system following a major conflict. However, previous cohorts, especially
the Vietnam cohort, were much larger than recent cohorts, so the difference
will be small relative to the entire VA patient population.
Scenario 4: Expanding access to VA care by extending the
Veterans Choice Act or by other means. Surveys
have shown that 1.8 million Veterans reported not using VA care due at
least in part to access barriers. We estimate that if these barriers were
removed, at most an additional 235,000 Veterans per year might use VA.
Scenario 5: Effects of the ACA. Policy changes associated with the ACA could have
conflicting effects on Veterans' use of VA health care. The individual mandate,
which requires most individuals to obtain health insurance coverage, could
increase Veterans' propensity to enroll in the VA system. However, ACA's
coverage expansions, which include expanded Medicaid eligibility and subsidies
to buy individual market insurance, could cause some current enrollees to use
fewer VA services. Our analysis found that the net impact of ACA coverage
expansions on the number of VA patients is relatively modest: We estimate
98,000 fewer VA patients under base assumptions, although other plausible
assumptions result in increases in VA patient counts.
Conclusions and Recommendations
Overall Conclusions
The number of Veterans has been declining for three decades,
and our analysis of the Veteran population over the next 10 years suggests
that this trend will continue. The total number of Veterans is expected to
decrease by 19 percent between 2014 and 2024. The median age of the
population will continue to increase, and Veterans are projected to become more
geographically concentrated over this period.
Veterans are more likely than non-Veterans to be diagnosed
with health conditions, including those that are chronic and in some cases
linked to service in the military. Although some of these differences may be
explained by the age and sex characteristics of Veterans compared with
non-Veterans, differences remain after these characteristics are taken into
account. The higher adjusted prevalence rates may be related to the challenges
of serving in the military and in combat.
Among all Veterans, those who receive at least some of their
health care from VA are generally more likely than Veterans who do not use VA
health care to be diagnosed with many of the conditions we examined in this
assessment. This result may be related to the fact that eligibility to receive
VA services is based, in part, on Veterans' disability status and whether they
are rated for service-connected conditions.
Assessing trends in Veterans' health care needs is
complicated, because assessing the need or demand for health care requires an
understanding of the extent to which Veterans rely on VA to meet those needs.
During the past three decades, the number of Veterans has decreased while the
number of VA patients has increased. This is due in part to an increase in the
number of Veterans who have been rated for service-connected disabilities, as
well as policy changes that made more Veterans eligible for VA health care
benefits (due to presumptive eligibility), that made it easier for Veterans to
apply for benefits, and that gave the benefit of the doubt to Veterans in cases
where there was uncertainty. Looking to the future, our patient projection
models suggest that the number of VA patients will continue to increase through
2019, but could level off or decline in subsequent years.
In addition to VA policies, external policies (such as the
ACA) and other trends (such as the cost of civilian health care) may influence
the way Veterans interact with VA's health care system. Our analysis of five
potential future scenarios illustrates the extent to which policy may affect
the projected number of Veterans and VA patients. Among them, expanding
eligibility rules to include higher-income Veterans, entering future conflicts,
and improving access to VA health care generated the largest increases in new
Veterans and VA patients.
Finally, VA data systems and U.S. data collection efforts
more broadly have significant limitations that hinder planners' ability to
assess how demand for VA services might change over time. For example, there
has not been a full accounting of the U.S. Veteran population since the 2000
Census. In addition, current VA data collection systems do not assess detailed
information on Veterans' health care conditions and health care utilization
patterns. Important data gaps include that data are often completely
unavailable for Veterans who are not currently eligible or enrolled in VA
health programs. Even among those who use VA care regularly, VA has detailed
information only on care paid for or provided by VA, or paid for by the federal
Medicare program. Additional data collection would be needed to fully
understand Veterans' total health care needs, including use of care currently
provided by the civilian sector. Understanding these gaps is important because
shifts in patient reliance and changes in eligibility rules could cause more
Veterans to seek care at VA and could change the mix of care sought from VA
versus civilian providers.
Recommendations for Consideration
Prepare for a Changing Veteran Landscape
The number of VA patients has been increasing since 2005,
despite the three-decades-long decline in the size of the Veteran population.
We estimate that this increase will continue through 2019. However, in 2020 and
beyond, it is likely that the size of the VA patient population will level off
or even decrease. Total demand for VA services during this time period will be
heavily influenced by utilization patterns among patients; if the health care
needs of the population are significant or the cost of outside options is high,
patients may use more care than they have in previous years. Nonetheless, there
is a possibility that demand for services will level off or decline as the
continued growth in the patient population slows or even reverses. The likely
short-term growth in demand, followed by a leveling-off or decline in the next
decade, may make it difficult to ensure that the size of the VA health system
is tailored to fully meet the needs of the population in the near term without
becoming inefficiently large in the long run. Increasing the use of care
purchased from the civilian sector may enable VA to meet short-run increases in
demand without requiring costly investment in facilities, infrastructure, and
personnel that could become less needed in the future.
Improve Tracking of Some Veteran Populations
Because the 2010 Census did not capture information on
Veteran status, there has not been a full-scale accounting of the U.S. Veteran
population since 2000. As a result, VA must estimate the size of the Veteran
population using data from more than 15 years ago, coupled with smaller
surveys and information on personnel losses from DoD. While ACS provides
information on a sample of Veterans (1,197,923 Veterans in the 2009–2013
sample), this is not a full accounting of the Veteran population. An updated
census of the Veteran population would enable a definitive count of all
Veterans, while also helping to refine sampling procedures for the yearly
surveys of samples of the population. Given that the events of September 11,
2001, set off prolonged U.S. engagement in oversees conflict and changed DoD
accession and personnel retention policies that affect the flow of service
members from active duty to Veteran status, it seems that the nation is overdue
for an updated census of the Veteran population. We recommend asking about
Veteran status in the 2020 Census.
In addition, little is currently known about how the
utilization patterns and health care needs of Veterans from the conflicts in
Afghanistan and Iraq will evolve over time. Yet, Afghanistan and Iraq Veterans
are more likely to have service-connected disabilities than other Veterans and
are automatically eligible for VA health care for five years after leaving the
military. Historically, Veterans have relied less on VA health care as they
age, gain access to other health insurance (e.g., through an employer), and
start families. However, it is not clear the extent to which these patterns
will hold for newer Veterans, who have different exposures and enhanced
eligibility relative to previous cohorts. Closely monitoring this population
may help VA planners to prepare as these Veterans age and their health care
needs and utilization patterns shift.
Anticipate Potential Shifts in the Geographic Distribution of
Veterans, and Align VA Facilities and Services to Meet These Needs
While our estimates suggest that the geographic distribution
of Veterans will remain relatively stable over time, there may be several
opportunities to streamline or shift VA resources to ensure adequate capacity
in all parts of the country. Given projected declines in the size of the
Veteran population living in the Ohio River Valley and upper Midwest, it may be
possible to consolidate relatively proximal VA facilities in those regions. At
the same time, some areas of projected Veteran population growth—including
Montana, Wyoming, and Colorado—are not currently well covered by VA facilities.
While the absolute size of the Veteran population in these areas will remain
small, there may be opportunities to use telehealth and community-based
outpatient clinic (CBOC) services to meet Veterans' needs in these areas. There
may be a more pressing need to expand VA coverage in the Southwest, where
Veterans Affairs Medical Centers (VAMCs) are currently widely spaced, and where
growth in the Veteran population is expected to be significant. Finally, we
estimate that the Veteran population under age 35 will increase in the regions
around Los Angeles; Dallas; Washington, D.C.; and northern New Jersey by 2024.
VA facilities in these areas might monitor growth in utilization among younger
Veterans to ensure that they are able to meet the needs of this group.
Improve Collection of Data on Veteran Health Care Utilization
and Reliance
Fully understanding the needs of the patient population
served by VA will require data that do not currently exist. These data would
capture information on all sources of health care that are used by an
individual—including when and where care is delivered, what diagnoses are recorded
and procedures performed, and who pays for the services—as well as what needs
for care are unmet, and why. The data would also require a large enough sample
of Veterans to ensure that it is representative of the population, and to allow
VA to track the prevalence of relatively rare service-connected conditions.
Creating these data would enable an analysis of the extent to which Veterans
currently rely on VA for health care, as well as how that reliance may change
as a result of internal VA policies or external factors. It would also provide
insight into where VA succeeds in meeting the health care needs of its patient
population and what types of obstacles exist in delivering needed care. In
addition, by collecting information on Veterans who are not currently patients,
the data would enable VA to better plan for changes in the demand for services
that might occur if VA eligibility rules changed, or if additional Veterans
chose to enroll.
Current surveys of Veterans do not capture comprehensive
information on health care use, particularly among Veterans who are not
currently eligible for or enrolled in the VA system. While MEPS contains
information on all the care that respondents receive regardless of payer, the
survey contains only a small sample of Veterans, and this sample may not be
adequately representative of the population. VA might consider fielding a
comprehensive survey of all Veterans, aimed at assessing their total health
care use patterns, including use of non-VA care. Such a survey could be modeled
on the MEPS Household Component (MEPS-HC), which collects utilization data
across all sources of care for the general population. Potentially, VA could
work with AHRQ (the organization that fields MEPS-HC) to include a more robust
sample of Veterans in its survey.
Incorporate Separation Patterns and Health Care Needs of Current
Service Members into Projections
In this assessment, we incorporated data on current service
members—who will become Veterans in the future—in several of our analyses,
including (1) counts of service member separations in our demographic analysis
to augment Census data of Veterans from 2000, (2) diagnosed health conditions
of separating service members who received care through the Military Health
System (MHS), and (3) estimated number of service members who would separate
and become Veterans in the case of a hypothetical future conflict.
At present, VA does not have access to DoD MHS encounter
data. Such data could enable VA planners to analyze health care needs among
current active duty service personnel who may become Veterans in the future.
For this study, we utilized MHS data from 2008 to 2014 to explore whether
current service members (future Veterans) have different health care needs from
current Veterans. We estimate that service members are much more likely than
current Veterans to have a diagnosed musculoskeletal condition or asthma at the
time of separation from service. On the other hand, the prevalence of mental
health conditions is higher in the existing Veteran population than among
separating service members. This result may reflect a disincentive to seek care
for mental health conditions while serving in the military. To the extent that
individuals who separate from the military and become Veterans during the 2015–2024
projection window have different health care needs from the patients currently
being served by VA, adding MHS data is critical for projecting the needs that
VA must meet in the future.
Develop an Analytic Framework to Perform Scenario Testing
Our analysis of five future scenarios highlights the
importance of developing methods and models that can respond quickly and
agilely to policy changes. While some of the policy changes we considered
resulted in modest changes in number of new Veterans and new VA patients,
others estimated as many as hundreds of thousands of new Veterans and patients.
The VA Office of the Actuary (OACT) has a Veteran Healthcare Scenario Model
that is able to estimate, for instance, how changes in demographic
characteristics or economic conditions (such as employment or income) may
affect demand for VA services and related costs. Expanding this model to
include such events as changes in the civilian health sector, unanticipated
changes in perceptions about health care quality, and groundbreaking new
technologies, to name a few, will enable VA to address the types of
uncertainties that current models may not address. Having methods in place to
estimate the effects of these types of changes on Veteran demand for health
care services will improve VA's efforts to meet the health care needs of its
patient population.
References
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Notes
[1] The remaining 37.2 percent of non-VA patients and
58.7 percent of VA patients who are not employed include both unemployed
individuals and people who are out of the labor force because, for example,
they are retired or disabled and unable to work.
[2] We define the unique health
care needs of Veterans as those that disproportionately affect Veterans
relative to non-Veterans. These include both service-connected conditions,
such as posttraumatic stress disorder (PTSD), and other conditions that are
more prevalent among Veterans than non-Veterans, including diabetes and cancer.
[3] PTSD prevalence rates for VA
patients are higher in the VA administrative encounter data than in the MEPS
data. The higher prevalence in the encounter data could reflect that these data
are more recent than MEPS, especially because we pool six years of data
(2006–2012) in our MEPS analysis. In addition, MEPS data could be biased
downward if people are reluctant to report mental health conditions in surveys,
while VA encounter data could be biased upward if some encounters reflect
“rule-out” diagnoses.
The research described in this article was sponsored by the
U.S. Department of Veterans Affairs and conducted by RAND Health, a division of
the RAND Corporation.
RELATED RESOURCES REPORT
Dec 31, 2015 Christine Eibner @Chrissyeibner, Heather Krull, et al.
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