Category Archives: Veterans

Women in combat zones can face difficulty getting some contraceptives

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Screen Shot 2015-08-11 at 12.43.44 PMBy Michelle Andrews
KHN

Next year, the military will officially lift restrictions on women in combat, the end of a process that may open up as many as 245,000 jobs that have been off limits to women.

But women who deploy overseas may continue to face obstacles in another area that can have a critical impact on their military experience: contraception.

It’s not a minor issue. Rates of unintended pregnancy among women in the military are 50 percent higher than those of women in the general population. And because of strict federal rules, their insurance does not generally cover abortion.

Rates of unintended pregnancy among women in the military are 50 percent higher than those of women in the general population.

Tricare, the health care plan for more than 9 million active and retired members of the military, covers most contraceptive methods approved by the Food and Drug Administration. Active-duty service members pay nothing out of pocket. Spouses and dependents of service members may face copayments in some instances.

But all methods aren’t necessarily available at every military hospital and clinic, and overseas, for example, women may have difficulty getting refills of their specific type of birth control pill.

Nancy Duff Campbell, co-president of the National Women’s Law Center, says, “It is unfortunate that here we have the military, that has one of the best health care systems in the country, and where we still have a gap is in contraception.”

Fifteen percent of active duty service members are women, and 97 percent of them are of childbearing age.

In a 2013 study, based on more than 28,000 responses to the 2008 Department of Defense health-related behaviors survey, researchers found that after adjusting for the larger concentration of young women in the military, the rate of unintended pregnancy among military women was 7.8 percent, compared with 5.2 percent among women in the general population.

“It’s critically important to address unintended pregnancy in the military, because it can be particularly damaging to women’s careers, and it’s hard to access abortion care,” says Dr. Daniel Grossman, a study co-author who is vice president for research at Ibis Reproductive Health, a research and advocacy group.

Abortion is available at a military facility or covered by military health care only if a woman’s life is in danger or if the pregnancy is a result of incest or rape. Women who want an abortion in other circumstances must use a non-military health care provider and pay for the procedure out of pocket, according to Department of Defense health officials.

Coverage for emergency contraception, meanwhile, has recently been expanded to all active duty service women and female beneficiaries without cost sharing.

It can be challenging to use contraceptives while deployed overseas for many reasons. There is the problem of trying to schedule a daily birth control pill when traveling across time zones, and desert conditions may make a contraceptive patch fall off. Although women are allowed a 180-day supply of contraceptives before deploying, obtaining refills of the same pill is sometimes difficult, some women reported in a 2012 study published in Contraception about access to contraception during deployment that was based on survey of 281 servicewomen.

Women also reported that they were told that contraceptives were unnecessary because having sex during deployment was forbidden or that they couldn’t receive an intrauterine device because they hadn’t yet given birth. Neither of those claims is true.

The majority of women surveyed also noted that they weren’t counseled about using contraception for either pregnancy prevention or menstrual suppression before deploying.

Pre-deployment counseling that specifically addresses women’s contraceptive needs could help counter confusion and ensure women have access to birth control methods that meet their needs. According to military health system officials, contraceptive and reproductive counseling is a covered benefit under Tricare and is an expected component of good clinical practice.

The House and Senate versions of the Pentagon’s spending bill for the fiscal year that begins in October contain measures that would affect contraception coverage in the military.

The Senate version of the bill would guarantee family planning education and counseling, while the House version would make available a broad range of FDA-approved contraceptives at military treatment facilities and ensure that women servicemembers have enough contraceptives to last for the duration of their deployment. A congressional conference committee is working to write a compromise between those two bills.

Defense Department officials said they had no comment on the pending legislation.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

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Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

khn_logo_lightKaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

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VA distance requirement will no longer be “as the crow flies”

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A black crowWashington — In order to expand eligibility for the Veterans Choice Program, the Department of Veterans Affairs (VA) today announced that it will change the calculation used to determine the distance between a Veteran’s residence and the nearest VA medical facility from a straight line distance to driving distance.

The policy change will be made through regulatory action in the coming weeks.

The method of determining driving distance will be through distance as calculated by using a commercial product. The change is expected to roughly double the number of eligible Veterans.

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VA makes it easier for you to get your benefits

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See the changes to VA benefits
Its now faster, easier and more efficient to file claims
See the changes to VA benefits

Today, claims become faster, easier and more accurate

Starting today, March 25th, VA is streamlining claims processes; to deliver benefits faster and more accurately.

See the changes to VA benefits

Three important changes are now in affect.

Informal claims have migrated to a new intent to fileprocess.

Use of standardized forms is now required when filing for benefits.

Initiating an appeal requires a standardized notice of disagreement form.

To learn how the new standardized forms and intent to fileprocess affects you:

See the changes to VA benefits
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New, easier, online way to apply for VA benefits

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Online Tools, Standardized Forms, and More

veteran-affairs-seal-vaEffective March 24th, 2015, VA is implementing improvements to make it easier for you to apply for benefits.

Online application tools, standardized forms, and a new intent to file process will create faster and more accurate decisions on your claims and appeals.

As part of the VA’s full-scale transformation in 2015, these new changes will:

  • Streamline the benefits process, making it faster and easier
  • Use standardized forms to file disability claims and compensation appeals
  • Establish a new intent to file a claim process

See how the changes affect you:

See the changes to VA benefits
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VA eliminates net worth as health-care eligibility factor

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Instead of combining the sum of Veterans’ income with their assets to determine eligibility for medical care and copayment obligations, VA will now only consider a Veteran’s gross household income and deductible expenses from the previous year.

From the Department of Veterans Affairs

veteran-affairs-seal-vaWashington – The Department of Veterans Affairs is updating the way it determines eligibility for VA health care, a change that will result in more Veterans having access to the health care benefits they’ve earned and deserve.

Effective 2015, VA has eliminated the use of net worth as a determining factor for both health care programs and copayment responsibilities.

This change makes VA health care benefits more accessible to lower-income Veterans and brings VA policies in line with Secretary Robert A. McDonald’s MyVA initiative which reorients VA around Veterans’ needs.

“Everything that we do and every decision we make has to be focused on the Veterans we serve,” said VA Secretary Robert A. McDonald. “We are working every day to earn their trust. Changing the way we determine eligibility to make the process easier for Veterans is part of our promise to our Veterans.”

Instead of combining the sum of Veterans’ income with their assets to determine eligibility for medical care and copayment obligations, VA will now only consider a Veteran’s gross household income and deductible expenses from the previous year. Continue reading

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At Phoenix VA, Obama says more work to do for veterans

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veteran-affairs-seal-vaAmid persistent complaints about veterans’ health care, President Barack Obama acknowledged lingering weaknesses Friday in the federal government’s response to the chronic delays and false waiting lists that triggered a national outcry over the Veterans Affairs health system last year.

Obama said that while VA Secretary Robert McDonald is “chipping away” at the problem, it was clear there was still more work to do.

via News from The Associated Press.

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Veterans propose major changes in VA health care

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veteran-affairs-seal-vaA national veterans task force is advocating radical changes in the medical system for America’s former military personnel, including a choice to receive subsidized private care and conversion of the Veterans Health Administration into a non-profit corporation rather than a government agency.

via Veterans propose major changes in VA health care.

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Veterans’ needs ‘should drive where they get their care,’

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On Capitol Hill, lawmakers resume work this week to resolve differences over legislationaimed at alleviating long wait times for medical care at the Department of Veterans Affairs hospitals and clinics after reports that some veterans may have died awaiting appointments and that some VA staff falsified records to cover up excessive wait times.

Five senior VA leaders – including former department secretary Eric Shinseki –have resigned in the past six weeks.

Both the House and Senate have passed bills that would allow veterans to seek medical care outside of the VA system if they meet certain conditions, including living more than 40 miles from a VA medical facility.

Kizer 176

Dr. Kenneth Kizer

Dr. Kenneth Kizer, a former VA undersecretary for health, spoke recently with KHN’s Mary Agnes Carey about the issue of the VA contracting with outsideproviders for medical care.

Kizer, the founding chief executive officer and president of the National Quality Forum, is now director of the Institute for Population Health Improvement at the University of California, Davis.

An edited transcript of that interview follows. Continue reading

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Jerral Hancock and Stacie Tscherny Portrait

Finally home, injured vets face new lives as VA faces costs

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By Jessica Wilde, News21

This report is part of a project on post-9/11 veterans in America produced by the Carnegie-Knight News21 program.

Jerral Hancock wakes up every night in Lancaster, Calif., around 1 a.m. dreaming he is trapped in a burning tank. He opens his eyes, but he can’t move, he can’t get out of bed and he can’t get a drink of water.

Stacie Tscherny dropped everything to take care of her son, U.S. Army veteran Jerral Hancock, when he came home from Iraq without an arm. She helps take care of his two children now as well. (Photo by Jessica Wilde/News21)

Hancock, 27, joined the Army in 2004 and went to Iraq, where he drove a tank. On Memorial Day 2007 — one month after the birth of his second child — Hancock drove over an IED. Just 21, he lost his arm and the use of both legs, and now suffers from post-traumatic stress disorder.

The Department of Veterans Affairs pays him $10,000 every month for his disability, his caretakers, health care, medications and equipment for his new life.

Jerral Hancock and Stacie Tscherny Portrait

Stacie Tscherny dropped everything to take care of her son, U.S. Army veteran Jerral Hancock, when he came home from Iraq without an arm. She helps take care of his two children now as well. (Photo by Jessica Wilde/News21)

No government agency has calculated fully the lifetime cost of health care for the large number of post-9/11 veterans of the wars in Iraq and Afghanistan with life-lasting wounds.

But it is certain to be high, with the veterans’ higher survival rates, longer tours of duty and multiple injuries, plus the anticipated cost to the VA of reducing the wait times for medical appointments and reaching veterans in rural areas.

“Medical costs peak decades later,” said Linda Bilmes, a professor in the Kennedy School of Government at Harvard University and coauthor of “The Three Trillion Dollar War: The True Cost of the Iraq Conflict.”

As veterans age, their injuries worsen over time, she said. The same long-term costs seen in previous wars are likely to be repeated to a much larger extent.

Post-9/11 veterans in 2012 cost the VA $2.8 billion of its $50.9 billion health budget for all of its annual costs, records show. And that number is expected to increase by $510 million in 2013, according to the VA budget.

Like Hancock, many veterans returning from Iraq and Afghanistan have survived multiple combat injuries because of military medicine’s highly advanced care. Doctors at Brooke Army Medical Center in San Antonio repaired Hancock’s body with skin grafts and sent him to spinal-cord doctors for the shrapnel that ultimately left him paralyzed. He still has his right arm, but he can only move the thumb on his right hand.

Injuries like Hancock’s likely will lead to other medical issues, ranging from heart disease to diabetes, for example, as post-9/11 veterans age.

“So we have the same phenomenon but to a much greater extent,” Bilmes said. “And that drives a lot of the long-term costs of the war, which we’re not looking at the moment, but which will hit in 30, 40, 50 years from now.”

Veterans like Hancock with polytraumatic injuries will require decades of costly rehabilitation, according to a 2012 Military Medicine report that analyzed the medical costs of war through 2035. More than half of Iraq and Afghanistan veterans are between the ages of 18 and 32, according to 2011 American Community Survey data. They are expected to live 50 more years, the Institute of Medicine reports.

About 25 percent of post-9/11 veterans suffer from post-traumatic stress disorder, and 7 percent have traumatic brain injury (TBI), according to Congressional Budget Office analyses of VA data. The average cost to treat them is about four to six times greater than those without these injuries, CBO reported. And polytrauma patients cost an additional 10 times more than that.

Post-9/11 veterans use the VA more than other veterans and their numbers are growing at the fastest rate. Fifty-six percent of Iraq and Afghanistan veterans use the VA now, and their numbers are expected to grow by 9.6 percent this year and another 7.2 percent next year, according to a VA report from March 2013.

Jerral Hancock Drinking Water

Hancock drove over an IED in Iraq in 2007. Hancock’s stepfather, Dirrick Benjamin, helps him take his medication. He and Hancock’s mother take care of him full time, helping him with everyday tasks like getting dressed and drinking water. (Photo by Jessica Wilde/News21)

 

In response to multiple injuries suffered by Iraq and Afghanistan veterans, the VA established its polytrauma care system in 2005, creating centers around the country where veterans are treated for multiple injuries, ranging from TBI and PTSD to amputations, hearing loss, visual impairments, spinal-cord injuries, fractures and burns.

Post-9/11 veterans make up around 90 percent of polytrauma patients, said Susan Lucht, program manager of the polytrauma center at the Southern Arizona VA Health Care System in Tucson.

Each polytrauma patient costs the VA on average $136,000 a year, according to a CBO report, using VA data from 2004 through 2009. And many of their medical issues will never go away.

One TBI patient at the Tucson center, Erik Castillo, has received speech, physical, occupational, psychological and recreational therapies for all of the paralysis, cognition and memory issues associated with injuries he received in a bomb blast in Baghdad.

But Castillo’s treatment is exactly what medical professionals and economists say could potentially be cost-saving as well as life-saving.

If the VA treats primary injuries early on and creates a community and family support system, it might be able to lower costs later, said Dr. James Geiling, Dr. Joseph Rosen and Ryan Edwards, an economist, in their 2012 Military Medicine report.

“And those are the costs that we’re trying to reduce by giving the care that we do,” said Dr. G. Alex Hishaw, a staff neurologist at the Tucson center.

Castillo has been living with TBI for nine years, and he still goes to the VA three times a week for therapy. “I’ll utilize the VA for the rest of my life,” he said.

The shrapnel that entered Castillo’s brain from a bomb in Baghdad in 2004 burned a portion of his frontal lobe, which had to be removed. Doctors told his parents that he wouldn’t survive and that if he did, he would need care for the rest of his life.

Slowly, Castillo started to re-create himself. He learned to talk again, to eat again, to move his left arm and leg. Now, he is going to college.

“We want them to graduate,” Lucht said. “But they always know that this is their foundation. This space is here. And their needs will change as they age.”

As Hancock and other post-9/11 veterans age, they will need increased medical care and will become more expensive for the VA. The injuries they have now will likely lead to more complicated and expensive medical issues. TBI, for example, may lead to greater risk of Alzheimer’s disease, psychological, physical and functional problems, and alcohol-abuse disorders.

Doctors and economists argue that today’s conversation should not only be about the primary wounds of war, but about the medical issues that are often associated with them. PTSD, for example, is often associated with smoking, substance abuse, depression, anxiety, heart disease, obesity and diabetes. Amputations are associated with obesity, cardiovascular disease, osteoarthritis, back pain and phantom limb pain.

“We should help an amputee to reduce his cholesterol and maintain his weight at age 30 to 40, rather than treating his coronary artery disease or diabetes at age 50,” Geiling, Rosen and Edwards wrote.

“Society is not yet considering the medical costs of caring for today’s veterans in 2035 — a time when they will be middle-aged, with health issues like those now seen in aging Vietnam veterans, exacerbated by comorbidities of post-traumatic stress disorder, traumatic brain injury and polytrauma,” they wrote.

Polytrauma centers have expanded across the country. But that doesn’t mean that all veterans live close enough to access them. In many parts of country, health care is hampered by distance because veterans who use the VA live far away from their closest VA hospital.

For Army Spc. Terence “Bo” Jones, it is more important that he live near his family.

U.S. Army Spc. Terence “Bo” Jones stepped on an IED in Afghanistan in 2012, and lost both of his legs. Now an outpatient at the VA polytrauma center in San Antonio, Texas, Jones is learning to walk on prostheses and drive an adapted car with only his hands. (Photo by Jessica Wilde/News21)

Jones lost both of his legs to an improvised explosive device blast in Afghanistan in 2012. Like Hancock, Jones woke up at Brooke Army Medical Center with his family by his side.

He was 21 when he stepped on the IED. It shot him 10 feet into the air and he landed in a nearby well. He doesn’t remember it, but his friends told him he was conscious and trying to climb out.

Now an outpatient at the VA polytrauma center in San Antonio, Jones is learning to walk on prosthetic legs, provided to him by the VA. The VA also provides adaptive driving equipment for his car, and he is taking driver education to learn how to drive with only his hands. One day, he hopes to get a service dog, and the VA will pay for veterinary care and equipment for the dog to help its owner.

“We can get them anything that they need,” Lucht said.

The VA provides other assistive accommodations for injured veterans — from grab bars and walk-in showers to wheelchairs and specialized seating. And a lot of veterans wear out their prosthetic limbs because they’re active, Lucht said.

When Jones finishes rehab, he plans to move home to Idaho, go to college and open his own shop doing custom cars and motorcycles. But in Idaho, Jones won’t be near a polytrauma center anymore.

One of the most rural veteran populations in the country is served by the Reno, Nev., VA hospital, said Darin Farr, the hospital’s public affairs officer. “We’re actually considered frontier,” he said.

The hospital’s patients come from as far away as 280 miles. More than 29,000 veterans are enrolled in the Reno hospital, staffed by 1,200 employees, only 40 to 50 percent of whom actually provide medical care.

Many VA hospitals fall behind in entering data from private health records or following up with patients, especially mental health patients for whom follow-up care is particularly important, according to VA Office of Inspector General reports.

The VA doesn’t always provide timely mental health evaluations for first-time patients, and existing patients often wait more than the recommended 14 days for their appointments, the OIG reported last year.

Veterans have complained for many years about long wait times to schedule appointments. “Long wait times and inadequate scheduling processes at VA medical centers have been long-standing problems that persist today,” the U.S. Government Accountability Office reported in February. Inconsistent scheduling policies, staffing, phone access and an outdated scheduling system make the problem worse.

Meanwhile, both the GAO and OIG have reported that VA’s data on wait times for medical appointments is unreliable, and some schedulers entered incorrect dates or changed them to meet performance standards.

Farr says the Reno hospital faces unique challenges that might contribute to wait times. The hospital competes with other hospitals for employees who might pay more than the government does.

“We don’t have a lot of space,” he added. The hospital schedules more than 373,000 outpatient visits and 4,200 inpatient visits every year. But it only has 64 hospital beds — 14 psychiatric, 12 ICU and only 38 for general use.

When Terence Jones finishes rehab at the polytrauma center in San Antonio, he hopes adaptive equipment will help him return to a normal life. Jerral Hancock, on the other hand, knows that he never will.

Hancock misses the adrenaline rush of life before his injury. He longs for a wheelchair that will go faster than 5 mph. He described the time he fell out of his hospital bed as exhilarating. He busted his cheek open, but he loved it.

With the $100,000 the Defense Department gave Hancock for his injuries when he was discharged, he bought two mobile homes outside Los Angeles, one for him and his two children, ages 9 and 6, and one for his mother and stepfather, who take care of him full time. Hancock supports all of them with his monthly disability check from the VA.

The VA bought him a wheelchair and put a lift into his front porch. They widened the doors in his mobile home so his wheelchair could fit in and out. They will pay for his medications and all of his medical care for the rest of his life.

When Hancock arrived at his new mobile home, he couldn’t fit his wheelchair in the front door. So he kept one wheelchair inside, and his stepdad carried him through the door and down the steps to a second wheelchair that he paid for himself. It took eight months for the VA to pay him $1,000 for the second wheelchair, and four months to put a lift into his front porch.

“I was stuck in the house for six months over this fight,” Hancock said. “I had a wheelchair upstairs and I had a wheelchair downstairs. And my caretaker carried me up and down the stairs from wheelchair to wheelchair. It was ridiculous.”

The VA also bought Hancock an $85,000 arm that he could attach to his shoulder to use. But he can’t seem to get it to work.

The VA gave Hancock $11,000 toward a car, but his mother said that doesn’t come close to the cost of a handicap-equipped vehicle. Instead, he bought a seven-passenger bus with a lift for his wheelchair.

Even with all of the money that the VA spends on Hancock’s medical and family care, he still lives in a mobile home, and his bedroom has little extra space with a hospital bed and a wheelchair in it. He can’t fit into his kids’ bedrooms. He can’t drink a glass of water on his own. And his air conditioning hardly works, even though he can’t be in the heat for too long because his burns prevent him from sweating.

Hancock’s children also have had to adjust.

“My son watched me walk off — he was going on 3 — and I jumped on a bus with a couple hundred pounds of gear,” he said. “The next time he saw me, I lost 100 pounds … I looked like a skeleton and I had tubes coming out everywhere … My daughter, this is all she knows.”

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Backlogs for veterans could grow under shutdown

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Purple Heart_ThumbnailBy Pamela M. Prah
Stateline Staff Writer

Veterans, who already face a lengthy backlog in getting help, risk not getting their disability and pension benefits at all next month if the federal government shutdown lasts several weeks.

The Department of Veterans Affairs said it has enough money to process veterans’ claims for pensions, compensation, education and vocational rehabilitation programs through late October, but a prolonged shutdown would suspend those programs once the money runs out.

And while veterans’ medical care is protected, some call centers and hotlines have already been suspended under the budget impasse between Congress and the White House.

“B/c of #shutdown, @VAVetBenefits overtime ends today. After decreasing backlog 30%, we project it will start increasing,” Tommy Sowers, assistant secretary for public and intergovernmental affairs at the VA, tweeted on the first day of the shutdown.

States play a key role in ensuring that veterans receive their benefits. Ever since World War II, each state has developed its own department or agency specifically to manage veterans’ affairs.

Once the state processes a veteran’s pension, compensation and disability claim, that claim is then sent to the federal VA “and at that time, it’s out of our control,” said Robert Horton, spokesman for the Alabama Department of Veterans Affairs, with the federal VA either approving or rejecting the claim.

The federal VA has been widely criticized for the backlog. As of Sept. 28, the VA said there were 725,469 casespending, 58 percent of them for more than 125 days.

State veterans agencies can offer additional programs to veterans. Collectively, states contribute more than $6 billion annually for veterans and their families, according the National Association of State Directors of Veterans Affairs, an organization that dates back to 1946.

“If the federal VA has to lay off employees, then claims won’t be processed and veterans possibly won’t receive their benefits or payments for pension and compensations, but right now there is no effect on the state VA,” Horton of the Alabama VA said.

Which VA Services Are Protected?

All VA medical facilities and clinics will remain fully operational during the federal shutdown, including VA hospitals. In 2009, Congress passed a law to fund the VA one year in advance.

This allows the VA health care system to plan ahead and ensures that VA health care is funded for an additional year beyond the government shutdown, according to a  “Government Shutdown FAQ” from Tom Tarantino, chief policy officer for the Iraq and Afghanistan Veterans of America (IAVA), a nonprofit, nonpartisan organization for new veterans.

Also not affected are VA medical appointments, prescription drug phone lines, home loan processing and veterans’ crisis lines, according to the VA’s “Field Guide to Government Shutdown.”

“While veterans may be more protected than other constituencies, a government shutdown does not bode well for top priorities within the veterans’ community,” Tarantino wrote.

Among the VA services that are affected under the shutdown:

  • Call centers and hotlines related to education and consumer affairs are suspended as well as the Inspector General Hotline (1-800-488-8244).
  • No decisions on claims appeals or motions will be issued by the Board of Veterans Appeals.
  • The VA’s Veterans Benefits Administration will not be able to continue overtime for claims processors.
  • Recruiting and hiring of veterans job applicants will cease with the exception of the Veterans Health Administration.

Bill Allman, project analyst at the Washington state’s veterans benefit enhancement projects, called the shutdown unfortunate. His department has spearheaded a project that has moved nearly 10,000 veterans from the state’s Medicaid rolls to the VA’s health care system using a federal database known as the “Public Assistance Reporting Information System,” or PARIS.

Allman said the federal manager of the PARIS system has been furloughed until a budget resolution can be reached.  “This may drag on much longer than any of us predicted,” he said. “It really drives home the impact that the shutdown has on people’s lives, as well as the additional work that it creates for others.”

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Stateline is a nonpartisan, nonprofit news service of the Pew Center on the States that provides daily reporting and analysis on trends in state policy.

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A quarter-million uninsured vets will miss out on Medicaid expansion

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By Michael Ollove
Stateline Staff Writer

More than a quarter-million veterans who lack health insurance will miss out on Medicaid coverage because they live in states that have declined to expand the program under the Affordable Care Act.

Expanding Medicaid eligibility is a key component of the new federal health law, which aims to provide coverage to the vast majority of uninsured Americans.

In January, uninsured adults with incomes at or below 138 percent of the federal poverty level ($15,415 for an individual and $32,527 for a family of four) will become eligible for Medicaid benefits in states that expand their programs.

Many people assume that the nation’s 12.5 million non-elderly veterans receive health benefits through the Department of Veterans Affairs (VA). But only two-thirds of those veterans are eligible for VA health care and only one-third are enrolled.

Nationwide, there are about 1.3 million uninsured veterans.

Medicaid vet

In a recent report, the Urban Institute estimated that if every state embraced the new Medicaid rules, as many as 535,000 uninsured veterans and 174,000 veterans’ spouses would become eligible for Medicaid coverage.

But last June the U.S. Supreme Court, while upholding the Affordable Care Act as a whole, ruled that states were not required to expand their Medicaid programs. Twenty-three states have declined to do so, and another six have not made a final decision.

In the 23 states rejected the expansion, there are approximately 258,600 uninsured veterans who would have been eligible for Medicaid, according to the Urban Institute report.

Like most other Americans, the veterans who don’t have health insurance will have to get it by January or risk paying a penalty under the Affordable Care Act.

However, some of the uninsured veterans who don’t qualify for Medicaid coverage might be eligible for federal subsidies that will be available under the law. Uninsured Americans—veterans and non-veterans—will be able to use those subsidies to purchase private insurance on the state health care exchanges that will launch in January.

Some worry that the expanding—and potentially confusing—array of health insurance choices available to veterans will lead to worse care.

The federal government created a separate VA health care system in the belief that veterans would get better care from doctors and nurses knowledgeable about the unique health conditions facing them, which include post-traumatic stress as well as other mental illnesses and physical injuries.

But the Department of Veterans Affairs expects only 66,000 uninsured veterans to enroll in the VA system to meet the insurance requirement under the new health law.

The income limits for VA benefits are much less stringent than they are for Medicaid. A veteran with no dependents and an annual income of as much as $30,978 (the amount varies based on the cost of living in a particular area) is eligible.

But conditions other than income—such as length of time since combat, service medals, and service-related injuries or illnesses—also affect eligibility for VA health benefits.

In addition, “there may be a variety of factors why a veteran would choose (Medicaid) or the (VA), such as proximity to VA facilities or their knowledge of the fact that VA care is available to them,” according to Jennifer Haley, who co-authored the Urban Institute report.

Kenneth W. Kizer, a former Clinton administration official widely credited for enacting substantial improvements to the VA health care system during the 1990s, has warned that there are risks to providing care to veterans in a variety of venues.

In an article published last year, he argued that doing so “diminishes continuity and coordination of care, resulting in more emergency department use, hospitalizations, diagnostic interventions and adverse events.”

Kizer, who is now director of the Institute for Population Health Improvement at the University of California Davis, pointed to data suggesting that patients who receive care in both VA and non-VA facilities are more likely to be re-hospitalized and to die within a year, compared to those who receive VA-only care.

Some veterans’ organizations, including the American Legion, urge all eligible veterans to turn to the VA health care system first.

“The American Legion believes that all veterans should be treated by the VA,” said Jacob Gadd, deputy director for health care at the American Legion.
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Stateline is a nonpartisan, nonprofit news service of the Pew Center on the States that provides daily reporting and analysis on trends in state policy.

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Health law offers veterans new options

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ACA health reform logoBy Michelle Andrews

Military veterans will have more health insurance options under the Affordable Care Act, but some vets, like many Americans, may still struggle to find affordable, accessible care that meets their needs.

Roughly 40 percent of the 22.3 million military veterans receive health-care services from the Veterans Health Administration, which operates a nationwide network of medical centers, hospitals and clinics.

Many veterans are eligible for both VA health care and Medicare, Medicaid or Tricare, the health plan for active and retired military and their families. About half of veterans have private insurance; approximately one in 10 veterans younger than 65 are uninsured.

Veterans who were honorably discharged after being on active duty for at least two years may qualify for VA health services. Since funding for the VA health program is limited, however, priority is given to veterans who have service-related disabilities or low incomes.

Although there are no premiums for VA health care, some veterans may owe co-payments for services. Veterans who return from active military duty are typically eligible for free VA health care for five years.

Under the Affordable Care Act, most people will have to have health insurance starting in January or pay a penalty. Veterans who are enrolled in VA health care won’t have to buy additional coverage, although they can supplement their coverage if they want to.

Mike Sage, 64, a Vietnam War combat veteran, pays $15 per visit for primary-care services and $50 for specialist care at the VA clinic near his home in Monmouth, Ill.

Prescription drugs are $8 for a 30-day supply. But his wife, Kay, like many veterans’ spouses, doesn’t qualify for VA health care. They plan to check out the policies offered on the Illinois health insurance exchange this fall to see if there’s a better option than the catastrophic-coverage plan with a $5,000 deductible that she currently carries.

Sage was relieved to learn that his VA health care counts as coverage under the ACA. “As long as I’m not subject to a penalty [for not having insurance], we’ll do some comparative shopping for her,” he says.

Kay Sage might qualify for a premium tax credit for coverage on the exchange if the couple’s household income is between 100 percent and 400 percent of the federal poverty level ($15,510 to $62,040 for a family of two in 2013), according to the Treasury Department.

The expansion of Medicaid under the Affordable Care Act — which states are currently wrestling over whether to implement — could also affect veterans’ health care. The law allows the expansion of the federal-state program for low-income people to include adults with incomes up to 138 percent of the federal poverty level ($15,856 in 2013).

According to an analysis published by the Urban Institute last month, four in 10 uninsured veterans have incomes below 138 percent of the federal poverty level, potentially enabling them to qualify for Medicaid if their states expand the program. Most of those veterans have incomes below 100 percent of the poverty level.

“For these veterans, it’s critical that their state expand Medicaid,” says Jennifer Haley, a research associate at the Urban Institute who co-authored the report.

In states that don’t expand their programs, veterans whose income falls below 100 percent of the poverty level will generally not qualify for Medicaid, nor for subsidized coverage on the exchanges.

Even though a non-disabled veteran may meet the income threshold for VA health care — nationally, about $34,000, further adjusted by geographic location — he or she may not live near VA facilities or know that VA care is available, according to the report.

At a hearing last month before the House Committee on Veterans’ Affairs, VA officials said they expect a net increase of 66,000 veterans seeking health care through VA facilities when the mandate to have health insurance kicks in next year.

Some veterans will come into the VA system but others will leave to seek coverage on the exchanges or through Medicaid, they said. Those who are eligible for more than one health program may pick and choose, using one program for cheaper prescription drugs, for example, and another for specialist care.

But more choices may not mean better care, says Kenneth Kizer, director of the Institute for Population Health Improvement at the UC Davis Health System.

In an opinion piece published last year in the Journal of the American Medical Association, Kizer, a former VA official, noted that having access to multiple plans can lead to fragmented care, increasing the chances of errors and other complications.

“Tests get repeated, drugs get prescribed that may not be compatible with each other,” he says. “One provider may not realize what the other is doing.”

This article was produced by Kaiser Health News with support from The SCAN Foundation.

Please send comments or ideas for future topics for the Insuring Your Health column toquestions@kaiserhealthnews.org.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Women veterans report poorer health despite access to health services, insurance

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By Glenda Fauntleroy, Contributing Writer
Health Behavior News Service

As more and more soldiers return from recent conflicts overseas, new research reveals that female veterans experience poorer health than other women.

In 2010, women made up 8 percent of the U.S. veteran population, according to the U.S. Department of Veterans Affairs (VA).The study, appearing in the American Journal of Preventive Medicine, is the first to demonstrate how female veterans’ health status differs from their civilian and active duty counterparts, even when controlling for access to health care.

KEY POINTS

  • Female veterans are more likely to smoke, be overweight or obese and have heart disease compared to civilian women and women in the National Guard or Reserves, even when controlling for access to health care, according to a new study.
  • Women serving in active duty have better access to health care, report better physical health and engage in fewer risky health behaviors than civilian or veteran women.

“While we found that women veterans were more highly educated, had higher incomes and were more likely to have health insurance, they reported worse health compared to active duty, National Guard or Reserves and civilian women across a host of outcomes,” said lead author Keren Lehavot, Ph.D., of the VA Puget Sound Health Care System in Seattle.

The study used data from the 2010 Behavior Risk Factor Surveillance Survey, a national phone survey that included 274,399 civilian women, 4,221 veterans, 661 active duty military and 995 women in the National Guard or Reserves. Researchers asked each person about her access to health care and health status.

Women veterans were more apt to smoke, be overweight or obese and have heart disease compared to civilian and National Guard or Reserve women. Veterans also reported more instances of depression and anxiety.

Yet, it was not all bad news for women in the military. Women who were serving on active duty had better access to health care, better physical health and were less prone to engage in risky health behaviors.

The researchers did not determine potential reasons for these disparities, but Lehavot said previous studies suggest that women veterans’ increased exposure to violence as well as inadequate social support might be associated with poorer health.

“We need additional research to determine if these, and other factors, help explain the differences we found,” she said.

Lehavot added that there have been changes in the Veterans Health Administration in recent years to reach out to women veterans and facilitate their access to care.

So why aren’t women currently using the health services available to them within VA medical system?

Chloe Bird, Ph.D., a senior sociologist at the RAND Corporation and expert on women’s health issues, said many factors, including geography, could determine whether women utilize the VA.

“For example, not all veterans live within easy access to a VA medical center, and the VA is far better recognized for their men’s health care than for women’s health care,” she explained. “Many women veterans may associate the VA with images of a place that serves a population of older men.”

Bird agreed that specialized outreach and other targeted interventions could improve the health and well being of the women veteran population.

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This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.

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Scientists to review brain-injury treatment for soldiers

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Scientific review kicks off to weigh treatment for brain-injured soldiers

by T. Christian Miller, ProPublica, and Daniel Zwerdling, NPR

The Institutes of Medicine kicked off its yearlong study of cognitive rehabilitation therapy on Monday, a process that will help the Pentagon decide whether its health plan will cover the treatment for troops who have suffered brain injuries in Iraq and Afghanistan.

We’ve previously reported that Tricare, which covers troops and many veterans, relied on a controversial study to deny coverage for the treatment, which helps rewire soldiers’ brains to perform basic tasks such as memorizing lists and following orders. Tricare said the study showed there wasn’t enough evidence to support paying for the treatment, which can cost more than $50,000 per soldier. The Pentagon says nearly 200,000 troops have suffered traumatic brain injuries since the wars began, though our own reporting shows the numbers are probably a lot higher.

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The IOM panel of experts will review scientific literature and ultimately render a decision on whether it supports the efficacy of cognitive rehabilitation therapy. If the experts reach this conclusion, they will hardly be the first to do so. In April 2009, a consensus panel assembled by the Pentagon said the therapy works, especially for soldiers suffering more severe forms of brain injury. Other groups, such as the Brain Injury Association of America, have weighed in to support it. Even some major private insurance companies pay for it.

The head of the IOM panel, Georgetown University neurologist Ira Shoulson, pointedly quizzed Tricare on this issue at Monday’s session, asking what the current review would produce that previous reviews had not.

Capt. Robert DeMartino, Tricare’s director of behavioral health, said he hoped the panel would be able to pinpoint what types of cognitive rehabilitation works best, and what kind of civilian doctors and clinicians were best qualified to provide it. He noted that stories published last year by ProPublica and NPR have cast a “shadow” over the issue, prompting congressional committees and lawmakers to pressure Tricare to provide cognitive rehabilitation therapy.

“For us, we know that we’re in a field like a gray zone,” said DeMartino, who addressed the panel by speakerphone. “We want to make sure the [treatments] that work are the ones we are going to use.”

The IOM review will continue through the end of the year, and the panel expects to convene other public sessions to help them arrive at a determination.

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