Introduction to Veterans Health Care

Introduction to Veterans Health Care

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Updated June 28, 2023
Introduction to Veterans Health Care
The federal government’s role in providing health care to
service-connected disabilities; Medal of Honor recipients;
the nation’s veterans can be traced back to World War I.
Purple Heart recipients; former prisoners of war; World
The veterans’ health care system was first developed in
War II veterans; veterans exposed to toxic substances and
1919 with the enactment of P.L. 65-326, which authorized
environmental hazards, including burn pits; and veterans
the Public Health Service to provide needed care to
whose attributable income is not greater than an amount
veterans injured or sick as a result of military service—
established by a “means test.” The second eligibility
having a disability that is incurred or aggravated during
category includes veterans who may be eligible to receive
active military, naval, or air service (today known as a
care through VA to the extent resources permit. Once
service-connected disability). In 1924, with the enactment
veterans are determined to be eligible for care in VHA,
of the World War Veterans Act (P.L. 68-242), veterans with
most eligible veterans are required to formally enroll in
no service-connected disability but who were “financially
VA’s health care system to receive services (38 U.S.C.
unable to pay” for care were also given access to
§1705). Once a veteran is enrolled, the veteran remains in
Department of Veterans Affairs (VA) health care, thus
the system and does not have to reapply for enrollment
creating a safety net mission. Congress has enlarged the
annually. Veterans are placed in one of eight priority
scope of VA’s health care mission, and it has enacted
enrollment groups. Veterans in some priority enrollment
legislation to create new programs and expand benefits and
groups are required to pay co-payments for certain benefits.
services. This In Focus briefly outlines the mission,
Enrolled veterans do not pay any premiums, deductibles, or
eligibility and enrollment requirements, health care delivery
coinsurance for their care. This is in contrast to major
system, and funding for veterans health care. Selected
medical insurance plans, which typically have premiums,
trends in enrollment and budget are provided as well.
deductibles, coinsurance, and co-payments.
Mission of the VA Health Care System
Trends in Enrollment
VA provides health care and health-related services through
P.L. 104-262 required VHA to establish a patient
the Veterans Health Administration (VHA). VHA’s
enrollment system. Before the law was passed, VA medical
primary mission is to provide health care services to
centers used different methods to provide care to eligible
eligible veterans. It also provides health care to some family
veterans based on available resources. VHA started
members through the Civilian Health Medical Program of
enrolling veterans in FY1999. Figure 1 shows the trends in
the Department of Veterans Affairs (CHAMPVA). The
enrollment and the number of unique veteran patients from
VHA is statutorily required to conduct medical research, to
FY2000 to FY2024. In FY2000, the total veteran
train health care professionals, to serve as a contingency
population was 26.75 million, 4.94 million veterans were
backup to the Department of Defense medical system
enrolled in the VA health care system, and 3.46 million
during a national security emergency, to provide support to
unique veteran patients received care. In FY2024, it is
the National Disaster Medical System (NDMS), and to
estimated that the total veteran population would be 17.91
provide assistance to the federal emergency response efforts
million, an estimated 9.05 million would be enrolled, and
(also known as VHA’s “Fourth Mission”), as necessary (38
an estimated 6.38 million veteran patients would receive
U.S.C. §§7301-7303; §8111A; §1785).
care. In a given year, not all enrolled veterans receive their
Eligibility and Enrollment for Care
care from the VA, either because they do not need services
or because they have other forms of health coverage, such
Not all veterans are eligible to receive care, and not every
as Medicare, Medicaid, or private health insurance.
eligible veteran is automatically entitled to medical care
from the VHA. Eligibility for VA health care has evolved
Figure 1. Veteran Population, VA Enrollees, and VA
over time, and laws governing eligibility have been
Patients, FY2000-FY2024
amended by Congress many times—ultimately creating two
broad categories of eligibility. Two significant laws that
have affected eligibility include the Health Care Eligibility
Reform Act of 1996 (P.L. 104-262) and the Sergeant First
Class Heath Robinson Honoring our Promise to Address
Comprehensive Toxics Act of 2022 (PACT Act; P.L. 117-
168). The PACT Act, among other things, made several
changes to veterans’ health care eligibility for veterans
exposed to burn pits or other toxic substances during their
military service (see CRS Report R47542, Honoring Our

PACT Act of 2022 (P.L. 117-168): Expansion of Health
Source: Chart prepared by CRS based on numbers VA budget
Care Eligibility and Toxic Exposure Screenings).
justifications.
Note: FY2024 total veteran population projected as of September
The first eligibility category includes veterans who shall be
30, 2022. FY2023 and FY2024 veteran enrol ee and patient data are
furnished care. This category comprises veterans with
estimates.
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Introduction to Veterans Health Care
VA Health Care System
Health Care Appropriations
Once veterans are eligible and enrolled, they receive their
Congress annually provides discretionary appropriations to
care directly through an integrated health care system (i.e.,
fund VA health care and support services for enrolled
VHA). VHA is the largest public integrated direct health
veterans. In addition to annual discretionary appropriations,
care delivery system in the United States, with over 1,200
Congress has provided VHA the authority to bill some
sites of care, including hospitals, community living centers,
veterans and most health care insurers for nonservice-
health care centers, community-based outpatient clinics
connected care provided to veterans to defray costs.
(CBOCs), other outpatient service sites, and dialysis
Toxic Exposure Fund (TEF)
centers. To administer this system, the VHA has divided
The PACT Act established the Cost of War Toxic Exposure
the country into Veterans Integrated Service Networks
Fund (TEF) to be used for costs associated with the delivery
(VISNs), based on geography. There are currently 18
of health care associated with environmental hazards during
VISNs, which vary regarding the types and number of
active military service. In addition, TEF funds may be used
facilities, and in geographic size. Each VISN has a VISN
for costs associated with medical and other research related
Director, who has oversight of the VA facilities within that
to environmental hazards, administrative expenses related
VISN and who supervises the facility director at each
to benefits (including information technology), benefit
facility. Although policies and guidelines are developed at
claims processing, and adjudicating appeals from veterans.
VA headquarters for the VHA health care system as a
TEF is considered “direct spending” and will be treated as
whole, management authority for decisionmaking and
an “appropriated entitlement.” (See TEF discussion in CRS
budgetary responsibilities is delegated to the VISNs.
Report R47423, Department of Veterans Affairs FY2023
VHA operates under a different model from the
Appropriations).
predominant health care financing and delivery model in
Trends in Appropriations
the United States, in which there is a payer for health care
In FY2023 Congress provided $118.75 billion for VHA,
services (e.g., Medicare or private health insurance plan), a
excluding medical research and collections. In FY1995 (the
provider (e.g., hospital, physician), and a recipient of care
year prior to major reforms of 1996), this amount was
(the patient). VHA is not a health insurance financing
$16.22 billion (in nominal dollars). Between FY1995 and
program that provides reimbursement to providers for all or
FY2023, VHA’s appropriations grew in real terms by a
a portion of a patient’s health care costs. VHA is primarily
compound annual growth rate of 5.06% (Figure 2).
a direct provider of care; VHA owns the hospitals and
employs the clinicians. However, VHA does pay for care in
Figure 2. VHA Appropriations, FY1995-FY2023
the community under certain circumstances. The VA
Maintaining Internal Systems and Strengthening Integrated
Outside Networks Act of 2018 (VA MISSION Act; P.L.
115-182) created the Veterans Community Care Program
(VCCP), which applies eligibility for care in the community
broadly to all enrolled veterans. For example, a veteran can
seek care in the community if he or she needs a service that
is unavailable at the VA, resides in a state with no full-
service VA medical facility, meets certain access standards
for drive- or wait-time, qualifies under standards for
previous programs, or if it is in the best medical interest of
the veteran. Under VCCP, third-party administrators
(TPAs) administer a national Community Care Network

(CCN) contract and provide eligible veterans access to
Source: Chart prepared by CRS based on appropriation figures
medical care through a network of community providers as
provided by VA Office of Management, Office of Budget.
authorized by VHA.
Notes: Chart excludes medical and prosthetic research funding, and
Health Care Services
medical care col ections. Nominal (or current) dol ar values are
All enrolled veterans are eligible for a standard medical
adjusted to real (constant) dol ars using the Gross Domestic Product
package, which includes a full range of health care, gender-
(GDP) Price Index Series deflator where 2023 (1st quarter) = 100.
specific medical services, prescription drugs, prosthetics
and sensory aids, long-term care, and social support
CRS Products
services. The medical package provides benefits generally
not found in private health insurance plans, such as travel
CRS Report R42747, Health Care for Veterans: Answers to
reimbursement for medical appointments, family caregiver
Frequently Asked Questions.
stipends, homeless veterans programs, and dental care (38

C.F.R. §17.38). Under the Whole Health approach, veterans
have access to acupuncture, mindfulness, tai chi, yoga, and
Sidath Viranga Panangala, Specialist in Veterans Policy
other complementary and integrative health services.
Jared S. Sussman, Analyst in Health Policy
IF10555

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Introduction to Veterans Health Care

Disclaimer
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