In January 2014, the Affordable Care Act (ACA) increased health insurance options for many non-elderly Veterans (<65 years old). Little is known about Veterans' VA and non-VA insurance enrollment decisions and related influences on care seeking; yet this information is essential to strategic planning, efficient resource allocation, and meeting goals for high quality, accessible care.
This study sought to understand Veterans' decision-making and behavior regarding health insurance coverage and related impacts on VA and non-VA healthcare utilization and care coordination. Specific aims were 1) Ascertain Veterans' utilization of VA services following implementation of the ACA among previously enrolled and newly enrolled Veterans age <65 years old residing in diverse areas nationwide, including overall and in priority demographic and clinical subgroups; 2) Determine the impact of the ACA on utilization of non-VA services among enrolled Veterans age <65 years old, including overall and in VA priority demographic and clinical subgroups; and 3) Describe previously enrolled and newly enrolled Veterans' ACA insurance enrollment choices and experiences with care coordination immediately following ACA implementation.
We used a mixed methods approach to study the association of the ACA with Veterans' healthcare utilization and drivers of Veterans' decision-making regarding insurance enrollment and healthcare utilization. Our quantitative analysis used data from national databases during pre-ACA (2012-2013) and post-ACA (2014-2015) periods (Aim 1) and data from surveys of Veterans in the Midwest in 2015 (Aims 2 and 3). The qualitative analyses involved semi-structured telephone interviews with Veterans to assess decision making regarding non-VA use, information sharing across systems of care, and patient/provider communication about dual use following implementation of ACA (Aim 3).
Aim 1 (Veterans' utilization of VA services): Among men and women who were VA users before ACA implementation, 6.5% fewer men and 4.3% fewer women used VA healthcare after implementation. Adjusting for pre-ACA trends in utilization and covariates, the odds of having an outpatient visit after compared to before ACA implementation decreased among men and women. However, when examining the association of ACA coverage availability with VA utilization in patients with diabetes, a high-need group, fewer men and women with diabetes (than those without) discontinued VA outpatient use (3.6% of men, 2.7% of women). This suggests differences in the association of ACA insurance coverage availability and use of VA services between this high-need group and other VA users <65 overall with more patients with diabetes choosing to continue VA use. Among Veterans with spinal cord injury (SCI), another high-need group, the number of visits to VA SCI clinics were 7% higher in the post-ACA period compared to the pre-period. These results indicated that Veterans with SCI sought VA care in larger numbers even after ACA implementation, suggesting that the aging Veteran population with SCI continues to value the lifelong, comprehensive care provided by VA.
Aim 2 (Veterans' utilization of non-VA services): Using survey data, we examined non-VA healthcare utilization among those with diabetes mellitus plus comorbidities (DM+), SCI, mental health (MH) conditions, and other Veterans who enrolled in VA healthcare before FY2014. We also examined non-VA healthcare use for Veterans who enrolled in VA after FY2014 ("recent enrollees"). There were 4,521 survey respondents. After weighting to adjust for non-response, 64% overall reported no outside VA use in 2015 (ranging from 48% of recent enrollees to 69% with DM+). We found 25% had non-VA outpatient visits (ranging from 19% with DM+ to 42% of recent enrollees), and 16% had non-VA prescription medications (ranging from 10% with DM+ to 32% of recent enrollees).
Aim 3 (Insurance enrollment choices and care coordination experiences): We found that 66% of survey respondents reported no insurance outside VA in 2015 (ranging from 40% of recent enrollees to 73% with DM+). Overall only 1% reported receiving insurance through the ACA. However, 13% reported private group health insurance coverage (ranging from 6% with DM+ to 34% of recent enrollees). Among Veterans with non-VA insurance, the most frequently reported reasons were 'backup for emergency care' (44%) and 'needed insurance for family' (38%). Among those with non-VA insurance, most frequently reported reasons for no ACA coverage were 'already had other non-VA insurance' (38%), 'VA care was free' (34%), 'employer offered insurance' (26%), 'content with other non-VA insurance' (23%), and 'ACA premiums were too high' (11%). Among Veterans with no outside insurance, most frequently reported reasons were 'could not afford non-VA insurance' (61%), 'satisfied with VA benefits' (58%), 'unemployed' (31%), and 'thought VA quality was better' (28%). Among Veterans with no outside insurance, most frequently reported reasons for no ACA coverage were 'VA care was free' (60%), 'did not need non-VA insurance' (46%), and 'ACA premiums were too high' (39%). Most Veterans (89%) who used both VA and non-VA health care in the past 12 months indicated that sharing health information with their providers was 'extremely' or 'very' important. While 70% of dual users of VA and non-VA services reported discussing non-VA care with their VA provider, only 61% of dual users reported discussing VA care with their non-VA provider. While 27% of dual users reported 'never' sharing outside VA medical record information with their VA provider, 29% reported 'never' sharing VA medical record information with their non-VA provider. To provide additional context for Veterans insurance and healthcare use decisions, we included interview and survey questions about the Veterans Choice Program (VCP), which was also implemented in 2014. Veterans with higher odds of reporting VCP use or intended use were women, lived further from VA, or had worse health status (p<0.01). Key VCP-related themes from semi-structured interviews included positive experiences (timeliness of care, location of care, access to services, scheduling improvements, and coverage of services), and negative experiences (complicated scheduling processes, inconveniently located appointments, delays securing appointments, billing confusion, and communication breakdowns).
Implementation of the ACA had the potential to increase insurance options for substantial numbers of Veterans. Our results suggest that select high-need groups (i.e., those with diabetes or SCI) continued seeking VA care after ACA implementation to a greater extent than VA users <65 overall.
- Stroupe KT, Martinez R, Hogan TP, Gordon EJ, Gonzalez B, Kale I, Osteen C, Tarlov E, Weaver FM, Hynes DM, Smith BM. Experiences with the Veterans' Choice Program. Journal of general internal medicine. 2019 Oct 1; 34(10):2141-2149.
- Martinez RN, Gordon EJ, Tully S, Silva A, Tarlov E, French DD, Huo Z, Smith BM, Gordon HS, Stroupe KT. A Mixed-Methods Study of Veterans Affairs Providers' Experiences Communicating With Patients About the Affordable Care Act. Military medicine. 2017 May 1; 182(5):e1715-e1723.
- Silva A, Tarlov E, French DD, Huo Z, Martinez RN, Stroupe KT. Veterans Affairs Health System Enrollment and Health Care Utilization After the Affordable Care Act: Initial Insights. Military medicine. 2016 May 1; 181(5):469-75.