About 6 percent of American adults are veterans of the U.S. military—including both candidates for vice president this election cycle—down from 18 percent in 1980. But their needs are getting more complex, driven by an aging population, differences in post-9/11 service, and changes in medical care delivery. Preventing suicide and homelessness remain among top policy concerns, but added to that list are issues of exposure to toxins, trauma, brain injuries, and technology challenges facing the Department of Veterans Affairs.
We asked Carrie M. Farmer and Rajeev Ramchand, codirectors of the RAND Epstein Family Veterans Policy Research Institute, to discuss some of the high-profile issues facing veterans and the VA. Farmer is senior policy researcher at RAND who has led multiple studies assessing the delivery of health care to veterans and service members. Ramchand is a senior behavioral scientist at RAND whose work includes research on suicide, mental health, and military and veteran caregivers.
VA-delivered health care versus private sector care for veterans has generated a complicated debate. How do you envision this evolving over the next decade?
Carrie Farmer Over 9 million veterans are enrolled in VA health care and receive care at hundreds of VA hospitals and thousands of outpatient clinics across the country. That demand has been growing for the last decade or so because of the aging veteran population and the influx of veterans who served after 9/11. This has put pressure on VA, sometimes leading to longer wait times for appointments. Congress expanded the use of private sector care with two significant bills in 2014 and 2018 to relieve the pressure on VA but also with the intention to provide veterans with more control over where they receive health care. As a result, nearly a quarter of VA health care is now provided in the private sector and paid for by VA.
The costs of private sector care have increased dramatically, and there is little evidence to suggest that the care is any more timely or of better quality. In fact, there is some evidence to suggest the opposite. Still, veterans are entitled to choose private sector care (with some limitations), so the question for the future is how to sustain these two models of health care. As more of the VA budget goes to private sector care, that could mean less funding for care delivered by VA, leading to the need to close facilities and shrink the VA health care workforce, which would result in fewer veterans being able to access VA-delivered care. At some point, this will become a budget crisis, and Congress will need to decide what to do.
Are there specific policies or initiatives that might reduce veteran suicide rates?
Rajeev Ramchand RAND’s recent research suggests that restrictive state firearm laws are associated with lower firearm suicide rates, and lower total suicide rates, so that is one policy lever. Maintaining the quality of care in VA community care is also important for ensuring that veterans are appropriately screened for suicide risk and offered evidence-based care. I am also increasingly interested in economic and housing policies as potentially reducing suicide risk. The group of veteran patients within VA at highest risk of suicide (PDF) are those who enroll and are categorized in Priority Group 5, or those veterans without a disability but with limited financial resources. There is evidence that tax credits and increases in minimum wage are associated with fewer suicides overall, and this may hold promise particularly for this group of veterans.
More than 1 million veterans have made claims under the PACT Act, which grants benefits to those exposed to toxins. Are there other steps that are necessary to care for veterans who were harmed by their service in less-obvious ways?
Ramchand In addition to the “unseen” toxic exposures, we still need to pay attention to veterans with “unseen” health conditions, including traumatic brain injury and mental health conditions. We need to continue to research new treatment options and enhance support for these veterans’ families and caregivers. We need to be specifically planning for the long-term effects of traumatic brain injury, which might include earlier onset or more significant forms of cognitive decline. Finally, because smoking remains more prevalent among service members than civilians, we should be ramping up our anti-smoking efforts as well as continued early detection and treatment of respiratory health conditions, which also are higher among veterans than nonveterans.
In addition to the ‘unseen’ toxic exposures, we still need to pay attention to veterans with ‘unseen’ health conditions, including traumatic brain injury and mental health conditions.
Farmer One thing I am concerned about is how veterans who are not connected to VA health care, or are getting care from private sector providers, are going to have these needs met. Non-VA providers do not routinely ask whether their patients have served in the U.S. military and are not usually familiar with the potential health concerns more common among veterans. They do not screen veterans for toxic exposures, suicide risk, or military sexual trauma, for example, and do not have training to identify and address health problems resulting from toxic exposures, where symptoms and certain types of cancers can be atypical or occur among younger populations. Improving provider education about these issues and coaching veterans to advocate for themselves with their providers may be two ways to start to address this concern.
Transitioning out of military service can be difficult, especially if the economy is slowing. How might the United States enhance employment opportunities for veterans?
Ramchand The veteran unemployment rate is actually lower than the nonveteran unemployment rate. But this does not mean we are doing all we can to find good, meaningful jobs for veterans, whether that be jobs more resilient to a recession or those that are physically and mentally safe. We have new research that points to the need for the federal government to evaluate and account for the $14.3 billion it invests in supporting transitioning veterans. There are many nonprofit organizations that complement the services the federal government offers, and formalizing these public-private partnerships could also strengthen the employment supports offered to veterans.
Women who are veterans have different health care needs. What can VA do, or are they doing now, to ensure that women receive comprehensive and tailored care?
Farmer Veteran women are growing in number and as a proportion of the overall veteran population. Right now, women make up 10 percent of the veteran population and 30 percent of new VA patients. Veteran women are younger than veteran men, less likely to be White, and more likely to have kids—and have different health care needs, like reproductive health care and treatment for military sexual trauma. VA has been making strides to provide more women-centric care, but many veteran women still feel unwelcome at VA facilities and are unable to access needed care. For example, not every VA facility has a gynecologist on staff. Private-sector care is an option for veteran women, but as I mentioned earlier, private sector providers lack military cultural competence and are unlikely to provide care that is sensitive to survivors of military sexual trauma. Additional efforts to improve VA care for veteran women, including closely monitoring access to gender-specific care, is needed.
Veteran women are younger than veteran men, less likely to be White, and more likely to have kids—and have different health care needs, like reproductive health care and treatment for military sexual trauma.
Attempts to update the computer/technology infrastructure of VA hospitals has been a fiasco. What are your thoughts on the current state of the transition to new medical records systems?
Farmer Moving to a new electronic health record (EHR) is difficult for any health system and has proven to be exceptionally challenging for VA. The long-term goal is to integrate with MHS Genesis, the EHR used by the Department of Defense, allowing veterans a seamless transition from military health care to VA. A new VA EHR should also have interoperability with non-VA systems, ensuring that veterans’ private sector care records can be shared with VA to improve care coordination. VA had one of the first and the best EHRs; its system, VistA, was built at VA and was customized for each VA medical center. While this was beneficial, it has made moving to a new, uniform EHR more difficult. The new EHR needs to account for all of the idiosyncrasies of each of the local instances of VistA. And things have not gone well, obviously. Still, VistA must be replaced. The challenge for the next administration is how to move forward. Change will most likely continue to be slow to ensure that patient care is not harmed in the process.
Why is it important that veterans whose military service was classified as “other than honorable” have that revisited or changed? What would that mean?
Ramchand An “other than honorable,” or OTH, discharge is an administrative, nonpunitive, discharge that has a huge impact on the benefits available to veterans. Unfortunately, veterans with OTH discharges are at increased risk of many adverse outcomes, including suicide and homelessness. Veterans with an OTH discharge can appeal the decision to the DoD or to the VA, and there are new efforts to increase their access to lawyers and organizations that can assist with these appeals. However, DoD also plays a role in applying more scrutiny about whose services are characterized as “other than honorable,” and there are potential biases in commanders’ decisions to use OTH discharges.
Is it difficult for rural veterans to access care? If so, what can be done about that?
Farmer It is difficult for anyone living in a rural area to access care—there are fewer doctors and other health care providers, fewer hospitals, and people must drive long distances to get to their appointments. So the rural health care challenge is not unique to veterans. To meet the needs of rural veterans, VA has greatly increased the use of telehealth (PDF). While health care providers can typically only practice in the state or states in which they are licensed, VA health care providers can treat patients across state lines. This means that VA can draw upon its nearly 400,000 providers across the country to provide telehealth care to rural veterans. Of course, not all care can be provided virtually, so veterans needing in-person care living far from a VA facility can receive care from other providers in their community, paid for by VA.
Is progress being made on the issue of homelessness among veterans? What is working and what’s not?
Ramchand Homelessness among veterans is a national problem with very local solutions. Much of what RAND’s housing experts wrote about homelessness in the general population applies to the veteran population as well. However, one recent change is promising: a new HUD policy will exclude veterans’ service-connected disability benefits when calculating their annual income to qualify for housing vouchers through the HUD-VASH program.
Do you see the difficulties facing veterans as having any bearing on the military recruiting shortfalls the United States is facing?
Ramchand In a recent poll of American adults, we found over half would discourage or strongly discourage a young person close to from them enlisting in the military. Almost 40 percent would discourage or strongly discourage applying to a service academy or enrolling in ROTC. We find evidence that these sentiments are influenced by how adults perceive veterans. It’s unclear whether these attitudes and perceptions carry over into actual deficiencies in recruitment, but they certainly make those whose job it is to find new recruits more challenging.
What is needed to ensure that veterans have access to new and emerging treatments for mental health conditions, including psychedelics like MDMA and psilocybin?
Ramchand Currently, psychedelics are not approved for treatment in the United States except in very narrow circumstances. There is increasing evidence of benefits from such treatments under specific prescribed conditions, however, and VA is engaged in research on that. Nonetheless, veterans are using psychedelics: whether on retreats to countries where these treatments are more readily accessible, in states that currently or plan to allow use under supervision, or places that have deprioritized enforcement of psychedelic-related offenses. Continued research to determine the effectiveness of psychedelics for treating mental health conditions is critical to ensure that new treatments are safe and available to those veterans who might benefit from them. Given that some veterans are already using psychedelics on their own, we need to ensure that their health care providers are prepared to have informed conversations about these new treatments.
