Williams 1

Tarik Williams

Melina Martin

English Comp 2

6 May 2019

Research Essay: Healthcare for Veterans

The Veterans Choice, Accountability and Transparency Act (The Choice Act) was passed

in August 2014 in response to an “access crisis” involving long waitlists and delays in care.

According to Amy K. Rosen, et al of Health Research and Educational Trust, an organization that

has spent 75 years transforming health care through research and education, “the policy’s primary

intent was to ensure that Veterans had timely access to high-quality care through increased use of

community providers paid for by the Veterans Administration (VHA). (Rosen 5438) Allegations

were made that these delays in service contributed to the death of some veterans.

The Choice Act expanded the availability of community care to reduce wait times for

appointments and limit travel time to medical facilities. More specifically, the Choice Act allows

veterans who can prove they must drive for at least 30 minutes to a VHA facility to select a non-

VHA healthcare facility closer to home to satisfy their health care needs. The Choice Act allows

veterans to receive care from a non-VHA healthcare facility if the appointment time at a VHA

facility is more than a 20-day wait.

Bureaucrats believed this change of integrating healthcare services was the most

transformative legislation since the G.I. Bill and that it puts veteran affairs on the road to becoming

a 21st-century healthcare institution. However, in evaluating whether we are doing enough for our

veterans we must ask the question, does shifting patients and funding from the federal VHA
 Williams 2

Medical System to private sector healthcare substantially remove barriers to veteran healthcare

services? It is my position that shifting patients and funding from the federal VHA Medical System

to private sector healthcare does not substantially remove the overall barriers to healthcare

services. At first glance the changes by the Choice Act seem great because it removes some of the

barriers that keep veterans from receiving health care services. But there needs to be a more

holistic approach to this problem because other barriers exist and need to be addressed in addition

to the changes in travel time and wait time.

Shifting patients and funding from the federal VHA Medical System to private sector

healthcare will not substantially remove barriers to healthcare services because it does not

address the personal struggles and disparities based on demographics and income. If people are

in poor health, are homeless or have legal or financial issues causing them difficulties in

maintaining their daily lives or ability to meet responsibilities that puts restraints on what they

can or can’t do. This includes the cost of health care (for example co-pays and patient portion of

fees) and the cost to travel to and from a VHA medical facility. Ann M. Cheney, et al. of the

BMC Health Services Research, one of the largest peer-review journal publishers in the country,

found that lack of transportation or gas money is a barrier to health care. (Cheney 10) People

will always prioritize their spending based on importance. If the choice is buying food for your

family versus travelling to a VHA health care facility one will probably pick buying food for

their family.

According to Kenneth W. Kizer, et al. of the Journal of Hospital & Health Services

Administration and online international peer-review scholarly publishing company, forty percent

of homeless adult males in the United States are veterans. And VHA patients are more likely to

be unemployed than others. (Kizer 3) Most military veterans in the United States are more likely
 Williams 3

than the general population to live in rural areas and often have limited geographic access to

VHA facilities. Proponents of the Choice Act cannot say that it substantially removes barriers to

veteran health care when most (77.9%) of the 416,338 VHA healthcare users who were eligible

for the Veterans Choice program based on distance lived in rural counties where 16% lived in

areas with a shortage in non-VHA primary care facilities and 70% shortage in non-VHA mental

health care services. Put simply by Kyle H. Sheetz and Carolyn M. Clancy of the Health

Services Research, the official journal of the Academy of Health, one in five Americans live in

rural communities, but for veterans it's one in three live in areas with limited capacity of health

care facilities (Sheetz 4120) of any kind.

Surprisingly, according to Michael Ohl, Doctor and Professor of Medicine from BMC

Health Services Research on availability of healthcare providers, VHA delivered healthcare for

the overall adult population in counties that were farther (40 miles plus) from VHA facilities

than those within 20 miles. (Ohl 1) Proponents of the Choice Act believe veterans will get faster

and better care which is misleading when facts reveal that most veterans live in rural areas that

are underserved by private health and mental health care providers. The facts, as stated by Alexa

Smith-Osborne, School of Social Work, University of Texas, Arlington in the Social Work

Health research study on veterans, most veterans who utilize their veterans’ health care benefits

have lower income, poorer health status and fewer sources of health insurance/benefits (Smith-

Osborne 82) diminishes the argument that veterans will get faster and better care based solely on

shifting patients and funding from federal healthcare to private healthcare.

From my perspective the change in shifting patients and funding from federal to private

health care is only a step in the right direction but does not substantially remove veteran

healthcare barriers mainly because it does not address the many other barriers based on personal
 Williams 4

struggles, demographics and income disparities. It rather paints a false picture by leading us to

believe that shifting to private care will greatly affect travel time and wait time, therefore,

veterans will have greater access to health care. For proponents of the Choice Act to say,

reported in The New York Times, “Measuring commuting time rather than distance will greatly

open the private sector to veterans in rural and high-traffic urban areas” (Steinhauer 1) is simply

not true since most veterans live in areas that do not have an adequate number of private

healthcare or mental health care providers. Based on all of the aforementioned factors it is clear

that shifting patients and funding from VHA healthcare to private healthcare standing alone

would not substantially remove veterans’ barriers to healthcare.

Equally important is trust. Lack of trust is a huge barrier. At the time of the

implementation of the Choice Act veterans were not confident in the services provided by both

the VHA and non-VHA providers for different reasons. Some veterans didn’t trust the VHA

system because of problematic processes that lead to a lack of availability of timely doctor visits

and limited follow-up care. Veterans also expressed that long wait times between appointments,

slow response to requests and turnover in staff lead to a lack of continuity in care. All of these

issues are what lead to lack of trust in the Administration and its services. Those who supported

shifting to private care would point to the scandal in 2014 that waiting lists were being hidden

within the VHA as reported by the New York Times renowned and awarded reporter Jennifer

Steinhauer (Steinhauer 1) but they fail to acknowledge that the changes in the Choice Act can

only successfully affect this problem if there are a sufficient amount of non- VHA facilities in

the most affected communities to fill the gap. According to BMC Health Services Research it

was also a problem for veterans that at one time the VHA provided limited or no specialized

care. (Cheney 10) However, stated in a Health Services Research commentary “the VA is well
 Williams 5

known to provide certain services with higher quality, or lower cost, than the private sector.”

(Sheetz 4120) Insurers and others in healthcare deliverers focus on nearer-term needs and risks

whereas the VA is responsible for the entire lifespan of eligible veterans. (Sheetz 4121)

On the flip side, some veterans only trust the VHA system and will only go to private

facilities for major issues or hospitalization. Despite an increase in community care in 2015, the

Health Research and Educational Trust study shows VHA continues to be the primary source of

health care services for veterans. (Rosen 5450) Elderly veterans with Medicare who could use

private care typically go to VHA for primary services. Research by University of Washington

Professor Chuan-Fen Liu, et al. in their Health Services Research shows in 2016, 52 percent of

all VHA enrollees were also covered by Medicare, including 92 percent of enrollees age 65+

(Liu 5140) used VHA for primary services. Those with mental illness, substance abuse or

amputations have greater reliance on VHA care. Even though there are issues with veteran

mistrust in the VHA, veterans have a hard time trusting non-military health care providers

because they feel that they don’t understand their military experiences. Despite the increased

access to and use of community care services, there was still little understanding of the clinical

conditions of veterans who use the services, the type of care they use and the expected costs

associated with their clinical care. (Rosen 5440) The issue of mistrust begs the question of

whether shifting patients and funding from VHA to non-VHA medical providers substantially

removes barriers to veteran health care.

Just as personal struggles and disparities in demographics and income are barriers to

veteran healthcare so is mistrust in the VHA and non-VHA healthcare services and must be

addressed to significantly affect access to veteran healthcare. It would follow that people go

where they feel most comfortable or secure that their needs will be met whether it’s a physical,
 Williams 6

psychological or emotional need. It would seem that to invest in the VHA medical services

would be investing in our veterans since there is more trust and utilization of their services.

Though overall processes needed tweaking the services were overall good quality and lower cost.

There are good arguments for using both public and private facilities if used efficiently and

collaboratively which is what the Trump Administration required within its subsequent Mission

Act of 2018. It is my position if veteran distrust in the services or processes is not addressed

shifting patients and funding from VHA healthcare to private healthcare standing alone would

not substantially remove veterans’ barriers to healthcare.

Even if we addressed the personal struggles, the disparities in income and demographics

and the mistrust in the healthcare providers there would still be a need to address mental health

issues. Mental health is another barrier that affects utilization of the health systems. Veterans

hesitate to get assistance for mental health because they feel as if they will be seen as crazy by

family, friends and others. And they feel like they must ‘suck it up’ to not be seen as weak. Most

times this internalizing of the issues leads to alcohol and drug use to mast the pain that they

won’t address. Results from Charles Maynard, PhD, et al. of the Journal of Rehabilitation

Research and Development, peer-review research focus on veteran issues, show that even though

most veterans have multiple disabilities one of the most prevalent conditions is posttraumatic

stress disorder (PTSD). (Maynard 404)

Without addressing mental health, it will be very difficult for veterans to navigate VA

benefits and healthcare services due to of lack of understanding or misunderstanding of VA

benefits and mental health care services. BMC Health Services Research concluded this

knowledge gap impedes initial enrollment and once enrolled veterans struggle with lack of

awareness of services. (Cheney 10)

 Williams 7

More today than ever we are in a society that puts a lot of emphasis on what others think

about them, i.e. the ‘like me’ era. Surely military veterans want to appear strong because they’ve

had to be in all they’ve gone through. And certainly, people will gravitate toward where they feel

comfortable. The fact that veterans appear to have distrust or lack of confidence with both VA

health care and non-VA health care presents a challenge to utilizing a collaborative network to

better meet their healthcare needs. More emphasis needs to be put on working together for the

overall best interest of the veteran. Again, it is my position that to shift patients and funding

from VA health care to private health care will not substantially remove veterans’ barriers to

health care without addressing some of the other issues that create barriers to veteran healthcare

services.

Those who support the Choice Act would disagree with my position looking through a

narrow lens. They will focus on the effects on reduction on wait times and traffic times. In some

instances, they are correct but in most not true. If most veterans are low income, unemployed and

in rural areas where there is limited non-VA health care facilities the outcome cannot be great.

They may argue that this change has contributed to us doing remarkably well in caring for those

who have served and sacrificed their lives for our freedoms. We have made gallant attempts but

remarkable outcomes we’ve missed because we did not address many of the other issues that

keep veterans from seeking healthcare services. Studying the subsequent actions taken by the

Trump Administration will render how much we missed the mark with the Choice Act.

In conclusion the Choice Act was a good attempt to improve veteran health care.

However, more barriers needed to be addressed to truly have a greater impact on veteran

healthcare. There is an obvious need for more studies to know the real issues veterans face and

strategies to address them. Continued reorganization of the current healthcare system must
 Williams 8

continue. It was okay for those in support of the Choice Act to get excited about the change in

travel and wait time as a starting point, but they were incorrect in believing that it would

substantially make a difference in addressing overall barriers. There should have been a focus

put on the other root causes to answer the question of why veterans did not seek needed

healthcare. Root causes such as personal struggles, demographics, income disparities, lack of

trust and confidence, and mental health issues that created a lack of information or

misinformation needed to be addressed. Based on all the reasons above shifting patients and

funding from federal Veterans Administration Medical System to private sector healthcare would

not and did not substantially remove barriers to veteran healthcare services. Note: The Mission

Act of 2018 addresses not all but a lot of the issues not addressed in The Choice Act.
 Williams 9

Work cited

Cheney, Ann M., et al. “Veteran-Centered Barriers to VA Mental Healthcare Services

Use.” BMC Health Services Research, vol. 18, no. 1, July 2018, p. N.PAG. EBSCOhost,

Kizer, Kenneth W., et al. "The veterans' healthcare system: preparing for the twenty-first

century." Hospital & Health Services Administration, Fall 1997, p. 283+. Academic

OneFile, doi:10.1186/s12913-018-3346-9.

Liu, Chuan-Fen, et al. "Fee-for-Service Medicare-Enrolled Elderly Veterans Are Increasingly

Voting with Their Feet to Use More VA and Less Medicare, 2003-2014." Health Services

Research, Dec. 2018, p. 5140+. Academic OneFile,

Maynard, Charles, PhD, et al. “Department of Veterans Affairs compensation and medical care

benefits accorded to veterans with major limb loss. Journal of Rehabilitation Research &

Development, August 2, 2009, pp. 403-408.

Ohl, Michael E., et al. “‘Availability of Healthcare Providers for Rural Veterans Eligible for

Purchased Care under the Veterans Choice Act.’” BMC Health Services Research, vol.

18, no. 1, May 2018, p. N.PAG. EBSCOhost, doi:10.1186/s12913-018-3108-8.

Peterson, Kim, et al. “Mortality Disparities in Racial/Ethnic Minority Groups in the Veterans

Health Administration: An Evidence Review and Map.” American Journal of Public

Health, vol. 108, no. 3, Mar. 2018, pp. e1–e11. EBSCOhost,

doi:10.2105/AJPH.2017.304246.

Petersen, Laura A., et al. "Relationship between clinical conditions and use of Veterans Affairs

health care among Medicare-enrolled veterans." Health Services Research, June 2010, p.

762+. Academic OneFile,

 Williams 10

Rosen, Amy K., et al. "Differences in Risk Scores of Veterans Receiving Community Care

Purchased by the Veterans Health Administration." Health Services Research, Dec. 2018,

p. 5438+. Academic OneFile,

Smith-Osborne, Alexa. “Veterans Administration Health Care Policies as a Protective

Mechanism Supporting an Expected Life Trajectory after Military Service.” Social Work

in Public Health, vol. 28, no. 2, Mar. 2013, pp. 81–96. EBSCOhost,

doi:10.1080/19371918.2011.552038.