Abstract: Can the Veterans Affairs (VA) health care system, long an important part of the safety net for disabled and poor veterans, survive the loss of World War II veterans—once its largest constituency and still its most important advocates? A recent shift in emphasis from acute hospital-based care to care of chronic illness in outpatient settings, as well as changes in eligibility allowing many more nonpoor and nondisabled veterans into the VA system, will be key determinants of long-term survivability. Although allowing less needy veterans into the system runs the risk of diluting services to those most in need, the long-run effect may be to increase support among a larger and younger group of veterans, thereby enhancing political clout and ensuring survivability. It may be that the best way to maintain the safety net for veterans is to continue to cast it more widely.
IN 2002, the Veterans Health Administration (VHA) provided health care to more than 4 million U.S. veterans at a cost of more than $24 billion, not quite half of the total Department of Veterans Affairs (VA) budget. Although those numbers pale in comparison to Medicaid spending ($259 billion to provide care to 51 million Americans), the VHA serves as an important part of the safety net for our veterans who are most in need. The great majority of those who used VHA services in 2002 were disabled and/or impoverished: 13% were rated as at least 50% disabled, another 4% were homebound, and 19% had disabilities rated between 10% and 50%; another 37% had incomes below the VA means test level of $24,304, or $29,168 for a veteran with one dependent (Veterans Health Administration, 2003a). Many veterans were not only economically but also psychologically disadvantaged: 17% of VA hospital spending went for psychiatric admissions. Previous surveys found that homeless veterans accounted for 13.5% of all VA hospital admissions, 24% of general psychiatric admissions, and 47% of substance abuse admissions (Wilson & Kizer, 1997). A majority of those who used VA services had no private insurance and, even for those with Medicare, a majority had no supplemental or “medigap” insurance and therefore would have difficulty affording physician services and medications otherwise.
From the Department of Medicine, VA Connecticut Health Care System and Yale University School of Medicine, West Haven, Conn.
Corresponding author: John S. Hughes, MD, Department of Medicine, Yale School of Medicine, New Haven, CT 06515.