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The Impact of the Affordable Care Act on VA's Dual Eligible Population

The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act (collectively referred to as the Affordable Care Act (ACA)) represents comprehensive reform of the health care delivery system and is intended to expand access to coverage, control health care costs, and improve the health care delivery system. When fully implemented, ACA will provide some Veterans with new options for health care, such as purchasing private health insurance through the soon to be established health insurance marketplaces or from Medicaid if the Veteran resides in a state that expands Medicaid eligibility

Dual eligible Veterans are those Veterans who are enrolled in VA health care as well as another health care program (i.e. Medicare, Medicaid, TRICARE, etc). Of the 6.5 million Veterans who received health care coverage under VA, Medicare, or Medicaid in fiscal year 2006 (which is the most recent data VA had), approximately one-third used more than one system of care. Veterans with dual and/or triple eligibility experience fragmented care, which diminishes continuity and coordination of care, resulting in more emergency department use, hospitalizations, diagnostic interventions, and adverse events.1

ACA will not change Veterans' current eligibility for VA health care, covered benefits, or co-payments for services. However, ACA is expected to have an impact on the coordination of care for dual eligible Veterans. As such, VA must understand its dual eligible Veterans in light of the changing health care environment. The ACA contains several provisions intended to improve care for dual eligible beneficiaries through better coordination of care, improved quality measures, and increased access to home and community-based long-term care services.2, 3

To better understand dual and triple eligibles among enrolled Veterans and to identify potential policy and program interventions for these Veterans, the VHA Office of Policy and Planning conducted several analyses. Medicare and Medicaid claims data from fiscal year 2006 was merged with VA utilization data to identify dual/triple system users. Based on their health care utilization in FY 2006, Veterans were classified into seven distinct user groups in order to compare the demographic characteristics, geographic distribution, and the morbidity/mortality of Veterans in these different user groups with a particular focus on those in the following dual/triple user groups: (1) VHA and Medicare; (2) VHA and Medicaid; and (3) VHA, Medicare, and Medicaid.

Demographic characteristics. Medicaid use was associated with being female and being of a younger age, on average, when compared to Medicare or VHA use. One-fifth of Medicaid only users were female compared to one-tenth of VA only users and onetwentieth of Medicare only users. Medicare users were older on average than individuals who used VHA and/or Medicaid. The average age for Medicare only users was 75.1 years compared to 56.2 years for VHA only and 49.8 years for Medicaid only. Medicare-Medicaid-VA triple users and Medicare-Medicaid dual users had the highest mortality rates (47.9 percent and 57.7 percent, respectively) of all the cohorts studied. VHA only users had the lowest reported mortality rate (10.7 percent).

Geographic distribution. In 2006, Medicare-VA users were concentrated in California, Texas, Pennsylvania, New York, Illinois, Ohio, North Carolina, Michigan, Missouri, Indiana, Georgia, and Tennessee. Medicaid-VA users were concentrated in New York, Pennsylvania, Tennessee, Florida, and Ohio.

Diagnostic picture. Overall, diabetes mellitus was the most common diagnosis among Veterans with a prevalence of 24.2 percent. Heart disease was the second most common diagnostic category (22.3 percent), followed by lung disease (16.6 percent), neoplasms (14.0 percent), and vascular disorders (11.6 percent). Although prevalence rates varied among types of users (for example, the combined prevalence for Medicaid only users was 17.4 percent compared to 83.4 percent among users of all three systems), diabetes and heart disease were each among the five most prevalent diagnoses for all seven cohorts. The prevalence of psychiatric and substance use disorders is higher among Veterans who use Medicaid and/or Medicare in addition to VHA services than those Veterans who used only VHA services.

Our findings indicate that Veterans who received care exclusively from VA had better health profiles than their dual or triple eligible users. Since VA serves a large number of dual and triple eligibles, this represents an opportunity for VA to enhance service delivery and improve care coordination for these socially and clinically complex patients.

There remain a number of unknowns regarding exactly how ACA will be implemented in terms of the health insurance marketplaces and Medicaid expansion. States are still deciding whether they will expand Medicaid eligibility but a number of states are indeed opting to expand and receive the additional federal funds for these newly eligible beneficiaries. Except for those individuals who, if otherwise eligible, seek the premium tax credit to defray the cost of insurance premiums, VA will continue to have a population of dual eligibles even after ACA is implemented in 2014. The VHA Office of Policy and Planning will continue its efforts to analyze the impact of ACA on VA's dual and triple eligible population in order to improve the quality and continuity of care for our Veterans.

  1. Kizer, K.W. "Veterans and the Affordable Care Act," Journal of the American Medical Association 2012; 307(8):789-90.
  2. Kaiser Family Foundation. Affordable Care Act Provisions Relating to the Care of Dually Eligible Medicare and Medicaid Beneficiaries. May 2011. Available at
  3. Mechanic, D. "Seizing Opportunities under the Affordable Care Act for Transforming the Mental and Behavioral Health System," Health Affairs 2012; 31(2):376-82.

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