Of the 8.4 million veterans enrolled for VHA care, 65 percent obtained some form of VA care; however, little is known about regional differences and temporal changes in the reliance on VA care, in particular, to its sensitivity to factors that are external to VA policy intervention. With a high prevalence of low income veterans, especially among the nonelderly (age< 65 years), reliance on VA care depends heavily on a range of external factors: state public assistance (Medicaid), area-level economic indicators (unemployment and housing price index), local non-VA health care provider availability and out-of-pocket health care costs.
Veterans' utilization of Veterans Affairs (VA) healthcare is likely influenced by community factors external to the VA, including Medicaid eligibility and unemployment, though such factors are rarely considered in models predicting such utilization. We measured the sensitivity of VA utilization to changes in such factors (hereafter, "external determinants"), including the 2014 Medicaid expansion following the Affordable Care Act.
We merged national VA healthcare enrollment and utilization data with area-level data on Medicaid policy, unemployment, employer-sponsored insurance, housing prices and non-VA physician availability (2008-2014). For veterans aged 18-64 and =65, we estimated the sensitivity of annual individual VA healthcare utilization, measured by the cost ($) of care received, to changes in external determinants using longitudinal regression models controlling for individual fixed effects. Sensitivity was measured as the percentage change in annual utilization associated with a 10 percent annual increase in the value of an external determinant. We estimated sensitivity for type of service (inpatient, outpatient, pharmacy, Fee Basis) and for subgroups, including states by Medicaid expansion status.
We examined 8.02 million Veterans over an average of 5.2 years; 56% were aged 18-64 during the study period. Annual individual VA healthcare utilization ranged between $3,853 and $4,617 across years among both age groups. All external determinants exhibited sizable variation over time; Medicaid eligibility increased 33% between 2013 and 2014. All external determinants were associated with small but significant changes in VA healthcare utilization. For veterans aged 18-64, sensitivity was modest for all external determinants: Medicaid eligibility (-0.31% in 2014), employer-sponsored coverage (-1.40%), unemployment ratio (0.65%) housing price index (0.92%) and non-VA physician availability (1.20%). Overall, external determinants were associated with a $245 million increase in national VA spending between 2013 and 2014. Sensitivity was sizable among subgroups; in states that expanded Medicaid in 2014, this expansion was associated with 9.1% ($826 million) reduction in VA utilization among those aged 18-64; the corresponding change in non-expansion states ($18 million) was not significant. Among veterans aged =65, VA utilization was positively associated with increases in housing price index (2.24%) and non-VA provider availability (2.27%).
Policymakers should consider the role of external determinants in allocating VA resources to meet local demand.
- Hanchate AD, Frakt AB, Kressin NR, Trivedi A, Linsky A, Abdulkerim H, Stolzmann KL, Mohr DC, Pizer SD. External Determinants of Veterans' Utilization of VA Health Care. Health services research. 2018 Dec 1; 53(6):4224-4247.