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June 13, 2016
Do Veterans Have Choices in How They Access Health Care?
Introduction
Group 1) do not pay any copays for both service-connected
Following the challenges encountered in the implementation
and nonservice-connected care. Other groups of veterans,
of the temporary Veterans Choice Program (VCP)
such as veterans who are considered to be catastrophically
established by the Veterans Access, Choice and
disabled (Priority Group 4), are also exempt from
Accountability Act of 2014 (P.L. 113-146, as amended),
outpatient, inpatient, and prescription copays. Nonservice-
Congress required (P.L. 114-41) the Department of Veterans
connected care veterans (who are required to pay) pay a
Affairs (VA), Veterans Health Administration (VHA), to
copayment of $15 per primary care visit, $50 per specialty
submit a plan to consolidate and streamline the numerous
care visit, and up to $97 per day for care in a veterans long-
programs that authorize care for veterans in the community
term care facility. In addition, for outpatient medications for
(non-VA care). The plan (http://tinyurl.com/nmyyorn) was
nonservice-connected care, some veterans are charged $8
submitted to Congress on October 30, 2015
for a 30-day supply, whereas others are charged $9.
(http://tinyurl.com/o9nq5s6). Currently, Congress is
According to VHA, the average annual out-of-pocket costs
discussing various proposals (among them S. 2633, S. 2646,
for veterans receiving care through VHA across all priority
and some provisions in S. 2921) to consolidate and/or
groups with co-pays (for outpatient, inpatient, medication,
streamline various community care programs and establish
and long-term care) were $325.66 in FY2015, and ranged
one unified VCP. As Congress debates the future state of
from $203.26 for Priority Group 2 veterans to $402.69 for
VA care, it is essential to understand how veterans currently
Priority Group 8 veterans.
receive care from the VHA and other federal and private
health care sources.
Veterans with Other Health Coverage
Based on the Independent Assessment (http://tinyurl.com/
VA Health Care Is Not Health Insurance
gsyzgyd) of the VA health care system—conducted by the
Compared with the predominant health care delivery model
Centers of Medicare and Medicaid Alliance for
in the United States—where there is a payer (e.g., Medicare
Modernizing Health, operated by MITRE Corporation—a
or private health insurance), a provider (e.g., hospital,
majority of veterans enrolled in VHA have access to other
physician), and a recipient of care (the patient)—the VA is a
health care coverage (Assessment A, p. 65). According to a
very different model of care. In general, private health
separate analysis done by VHA of the American
insurance plans charge premiums from beneficiaries for
Community Survey (ACS) data for 2014, of the
enrolling in those plans. Furthermore, most private health
approximately 22.5 million veterans identified,
insurance plans have cost-sharing requirements (that is the
approximately 11.3 million reported having coverage
amount that beneficiaries are required to pay out of pocket
through Medicare, about 6.4 million had care through the
when they use health care services). These could include
VHA, and about 3.3 million veterans had care through the
deductibles (the amount a beneficiary must pay out of
Department of Defense (DOD) TRICARE program
pocket before the insurance plan begins paying for services),
(TRICARE and TRICARE for Life—veterans are eligible
coinsurance (a specified percentage a beneficiary pays out
for TRICARE if they served for at least 20 years in the
of pocket to providers after meeting any deductible
military; veterans are eligible for TRICARE for Life if they
requirements), or copayments (a fixed amount paid for a
qualify for Medicare and it is available as a wraparound
health care service, at the time of service). In contrast, VA
coverage for costs not covered by Medicare). According to
is primarily a direct provider of care funded through annual
the ACS survey data analyzed by VHA, approximately
discretionary appropriations—although VHA does pay for
980,000 veterans did not have health insurance coverage
care in the community under certain circumstances. In
(see Figure 1).
addition, in the VHA system, enrolled veterans do not pay
any premiums, deductibles or coinsurance. Furthermore,
Figure 1. Sources of Health Coverage Among U.S.
generally not all veterans are eligible to enroll in the VA
Veterans
health care system—the system is neither designed nor
funded to care for all living veterans (The Journal of Law,
Medicine & Ethics, Volume 36, Issue 4, p.680, Winter
2008).
Veterans Out of Pocket Costs
Some veterans are required to pay copayments for medical
services and outpatient medications related to the treatment
of a nonservice-connected condition (see CRS Report
R42747, Health Care for Veterans: Answers to Frequently
Asked Questions). Generally, veterans who have been rated
Source: Figure adapted by CRS based on VHA analysis of 2014
with a service-connected disability of 50% or more (Priority
American Community Survey (ACS) data.
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Do Veterans Have Choices in How They Access Health Care?
Notes: Totals do not add up to 22.5 million. Persons covered by two
Figure 3. VHA Enrollees with Medicare, Medicaid, and
or more programs are included in the count of each program through
TRICARE
which they have coverage. Therefore the total number of those with
coverage across all programs is greater than the approximately 22.5
million total unique veterans covered through these programs.
Census Bureau classifies health insurance coverage as private
insurance or government insurance, which includes VA provided care.
“Individuals are considered to be uninsured if they do not have health
insurance coverage for the entire calendar year” (Source: U.S. Census
Bureau, Health Insurance Coverage in the United States: 2013)
Figure 2. Veterans Interacting with Other Health
Coverage
Source: Figure prepared by CRS based on VHA analysis of 2014
Survey of Enrollees data; VHA presentation made to the Commission
on Care on September 21, 2015.
Notes: Percentages may not add up due to rounding. “No other
insurance” means no other form of private or public coverage other
than VA health care.
Limitations
The above data should be interpreted with caution. First,
there are differences in the definitions of veterans between
the VA Enrollee Survey and the ACS. Second, these are
self-reported survey data and not based on exact matching
of administrative data, which could result in under- or over-
Source: Figure adapted by CRS based on VHA analysis of 2014
estimates of certain populations—sampling errors.
American Community Survey (ACS) data.
Notes: Figure excludes private insurance (6.0 million) or no health
Concluding Observations
insurance (980,000). Also see note in Figure 1.
As discussed in the Independent Assessment and shown
by VHA’s analysis of its enrollee survey, some
Based on VHA analysis of ACS data, many veterans who
veterans
have health care coverage also qualify for more than one
receive all of their health care from the VA health care
system, while others have coverage through health
form of health care coverage. Figure 2 depicts veterans’
interaction with Medicare, Medicaid, and TRICARE. As
insurance programs such as Medicare, TRICARE, or
shown in Figure 2, some veterans could have double or
private coverage.
triple health care coverage options. For instance, a veteran
could have TRICARE for Life, be enrolled in the VA health
While some veterans may have double or triple health
care system, and be enrolled in Medicare because of
care coverage options, other veterans may rely solely on
eligibility at age 65 (individuals could qualify for Medicare
the VA health care system, such as the 1.8 million
at age 65 or with certain disabilities if under age 65). In this
veterans (shown in Figure 2)—the VA serves as a
example, 670,000 veterans have all three sources of
safety-net provider for these veterans. Approximately
980,000 veterans report not having any other form of
coverage (Figure 2).
public or private coverage.
VHA also annually conducts a national survey of veteran
enrollees’ use of health care (VA Enrollee Survey). Based
Generally, veterans who have multiple coverage options
on the 2014 survey results, VHA reported that 78% of
could face complicated choices in deciding which forms
veterans enrolled in the VA health care system had another
of coverage best suits their health needs based on costs,
form of health care coverage in addition to VA health care.
ease of access, dependent/spousal coverage, and quality
About 22% of those enrolled in the VA health care system
of care.
reported no public or private insurance coverage (see
Figure 3). Of those veteran enrollees with other coverage,
Should the VA health care system take on a new role as
51% had Medicare coverage and 18% had TRICARE
a health insurer, as opposed to a direct care provider,
Congress may wish to consider imposing health
(TRICARE and TRICARE for Life) coverage.
insurance elements such as premiums, deductibles, or
coinsurance to control costs and to restrain spending.
Sidath Viranga Panangala, Specialist in Veterans Policy
IF10418
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Do Veterans Have Choices in How They Access Health Care?
Disclaimer
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https://crsreports.congress.gov | IF10418 · VERSION 2 · NEW