ACA and Veterans' Mental Health: Policy Analysis & Reform

The ACA and Veterans' Mental Health Services

The enactment of the Affordable Care Act (ACA) gave rise to major concerns regarding greater healthcare expenditure and reduced benefits for the defense population. This prompted the Department of Veterans Affairs (VA), the White House, and TRICARE authorities to invest efforts in public education. The VA maintains that the Act — popularly called Obamacare — has no effect on military veterans' entitlement to, or accessibility of, the mental health services they already receive, and that it does not affect TRICARE for Life or TRICARE benefits enjoyed by households on behalf of the VA. Rather, the department maintained that VA-enrolled individuals require no additional insurance coverage. Nonetheless, the Act provides them an opportunity to enroll in further insurance plans through the new healthcare insurance exchanges, which were set to open in 2014 (Russell & Figley, 2014). Furthermore, the Act stipulates that veterans who hold private insurance may benefit from the new consumer protections it establishes, which prohibit private insurers from dropping the insured when they become ill or injured. Veterans also need no longer be concerned about lifetime coverage ceilings imposed by their insurers.

Most significantly, under the Act, veterans and families who were uninsured and not currently entitled to TRICARE or VA mental health services became eligible for tax credits to purchase insurance coverage through the soon-to-open exchanges, thereby gaining access to key mental health services (Russell & Figley, 2014).

Of the roughly 23.8 million veteran citizens of the United States, the majority — approximately 15.96 million individuals — lack enrollment in a VA healthcare system. A large number of these individuals can access reasonably priced, high-quality healthcare insurance plans through state insurance exchanges that offer increased choice and promote competition. They may also be eligible for cost-sharing reductions and premium tax credits (Haley & Kenney, 2012). Thus, improvements to the private healthcare marketplace can assist several million U.S. veterans as well. The ACA also affirms that the VA retains absolute authority over its own health system, with Congress providing a stipulation that the system satisfies the national healthcare coverage standard. Accordingly, no foreseeable negative effect appears evident for veterans who receive VA mental health services.

Through the VA, several million former servicemembers are able to access health services. However, not all qualify for these facilities, and not all make use of them. Backlogs and extended waiting times have long been a problem for the organization. A 2015 survey conducted by the nonprofit organization Iraq and Afghanistan Veterans of America (IAVA) found that fifty-eight percent of participants reported experiencing mental illness attributable to their service in those two countries (Schreiber & McEnany, 2015). Reduced mental healthcare coverage under Medicaid may prove particularly harmful for ex-servicemembers who develop post-traumatic stress disorder (PTSD) and other psychological conditions, given that this population is more prone to suicide compared to the general American public.

Military Culture, Stigma, and Access to Care

Armed forces culture emphasizes self-reliance, inner strength, and the ability to overcome injuries, thereby contributing significantly to the stigma associated with psychological problems. Commanders face intense pressure to deploy troops at full strength. Units are sent to war with scarce resources if soldiers are not ready for deployment (American Public Health Association, 2014). Consequently, commanders are effectively coerced into pushing subordinates to deploy despite those individuals lacking complete physical or psychological readiness. These incentive structures play a significant role in perpetuating the current state of military culture.

Stigma produces an unwillingness to seek and accept help, along with fear of negative social repercussions. These obstacles to care are recognized as more serious than the VA system's inherent institutional barriers. Only four out of ten veterans suffering from psychological conditions make use of mental health services; moreover, only fifty percent of veterans who do seek care actually attend their referral appointments (American Public Health Association, 2014). These figures are largely attributable to stigma. Nearly a quarter of former servicemembers diagnosed with mental illness report that they did not seek care because their superiors discouraged them from using mental health services.

The stigma associated with psychological conditions and seeking treatment is the most frequently cited reason individuals refrain from pursuing services such as counseling. Stigma renders people unlikely to seek help even when the consequences of not doing so are severe. At the launch of the New Freedom Commission on Mental Health (NFCMH) in April 2002, President Bush affirmed that stigma associated with mental disorders was the primary barrier preventing citizens from accessing the high-quality psychological health services they deserved — a finding consistent with the Surgeon General's mental health report issued in 1999 (American Public Health Association, 2014). That report stated that fear of stigmatization prevented people from acknowledging illness, seeking treatment, and adhering to treatment regimens, thereby producing unnecessary suffering. Both the report and the NFCMH emphasize the importance of developing a deeper understanding of stigma's role in healthcare-seeking behavior in order to implement effective anti-stigma efforts. Self-stigma is predictive of more negative attitudes toward help-seeking and serves as a mediating factor between public stigma and individual perspectives on care-seeking.

Strengths of the ACA for Veterans

Obamacare will extend healthcare insurance to low-income households through state-based healthcare insurance exchanges and Medicaid, which should ensure healthcare coverage becomes available to uninsured former servicemembers. The new coverage options are accessible to numerous VA healthcare recipients, expanding their healthcare alternatives and potentially enhancing care relevance and convenience. However, these options simultaneously carry a risk of care fragmentation. Care fragmentation is concerning because it weakens care coordination and continuity, leading to more emergency room visits, hospital admissions, adverse events, and diagnostic interventions (Bernard, 2016). The VA serves a particularly high proportion of individuals with chronic or mental health conditions — people who are especially vulnerable to the adverse consequences of fragmented care.

Former servicemembers who qualify for two or more healthcare plans typically experience more fragmented care; however, the associated negative effects have yet to be thoroughly examined. Some evidence suggests that veterans who receive care from both VA and non-VA sources are more likely to be readmitted to hospitals and to die within a 12-month period compared to those using only the VA. The reasons for this disproportionate mortality remain unexplained (Bernard, 2016). Medicare/VA dual-eligible veterans who have experienced heart attacks and draw on both benefit sources undergo more extensive cardiac procedures but gain no survival advantage over those using VA care alone. The negative effects of more invasive care by non-VA physicians also remain underexplored.

Increased healthcare alternatives can negatively affect certain veterans' quality of care in ways beyond fragmentation. Private practitioners may be ill-equipped to treat veterans' specific conditions. For instance, Pennsylvania's Reaching Rural Veterans program found that private primary care practitioners lacked awareness of psychological conditions such as PTSD common among servicemembers, as well as knowledge of VA therapeutic resources to address those conditions (Bernard, 2016). Additionally, several studies reveal that VA patients are substantially more likely to receive recommended preventive services, evidence-based therapies, and timely diagnoses of cardiovascular conditions, infectious diseases, cancer, and diabetes than non-VA patients.

The following specific strengths of the ACA for veterans are noteworthy:

No requirement for additional coverage. Because veterans' healthcare programs meet legally recognized health standards, VA beneficiaries are not required to obtain additional healthcare coverage. They may do so voluntarily, but the law does not mandate it.

Expanded affordable care alternatives. The ACA includes provisions to ensure that veterans have access to more affordable, high-quality care options. VA healthcare recipients may also enroll in insurance plans through healthcare insurance exchanges. For moderate-income users, the decision to move from VA to an exchange plan may involve cost-sharing comparisons (Boscarino et al., 2015). Servicemembers with non-service-related health conditions, who therefore pay steep VA co-payments, may find exchange plans more beneficial.

Enhanced flexibility. The ACA does not require modifications to existing military or former-military healthcare plans; at the same time, it guarantees additional insurance options and strengthens consumer protections that prevent private insurers from refusing coverage or imposing arbitrary limits on it (Boscarino et al., 2015).

Covering uninsured veterans and family members. Among the ACA's greatest benefits to the armed forces community is its provision to cover approximately half of uninsured former servicemembers who would qualify for expanded Medicaid, plus an additional forty percent who could potentially qualify for government-subsidized coverage through insurance exchanges if they cannot access affordable employer-based coverage (Haley & Kenney, 2012). Of the approximately 520,000 uninsured veterans who served in the past two decades — along with nearly 950,000 members of their households — almost fifty percent are under the age of 45 (Haley & Kenney, 2012).

Coverage for adult dependents. Many beneficiaries with dependent children have inquired about the ACA's impact on dependents under the age of 26. The 2011 National Defense Authorization Act (NDAA) had already addressed this issue by establishing the TRICARE Young Adult (TYA) program, which mandates that civilian healthcare plans cover adult children up to age 26, effective January 1, 2012 (Boscarino et al., 2015).

Increased veteran coverage options. For prospective TRICARE beneficiaries, the decision to shift to a civilian exchange plan may depend on whether income-based membership fees are implemented. For example, one proposal required a four-person household earning approximately $22,589 per year to pay $680 annually in 2014 (Kilbourne & Atkins, 2015). Given household size, such a family falls below the poverty line and qualifies for free Medicaid under the ACA. A household earning $32,000 in 2014 paid $920 toward TRICARE, while that same household would pay roughly $960 — or three percent of total family income — for subsidized coverage through an exchange plan (Kilbourne & Atkins, 2015). On the whole, the decision to switch healthcare plans depends on whether an exchange plan or TRICARE Prime offers lower cost-sharing for military personnel and their households.

Conclusion

Some general ACA provisions and goals with respect to veteran mental healthcare have not succeeded, while others are insufficient for addressing this population's unique psychological health needs. There is no single approach that will resolve all these problems. Some provisions should be replaced entirely, others require targeted modification, and still others should be expanded. The five recommendations outlined — eliminating clinical dualism, emphasizing prevention and resilience, removing stigma and inequality, building a qualified mental health workforce, and ensuring timely detection and intervention — together form an advocacy framework for substantively improving the ACA's impact on veteran mental health. Achieving these goals will require coordinated commitment from policymakers, defense leadership, healthcare providers, and the veteran community itself.

References

American Public Health Association. (2014). Removing barriers to mental health services for veterans. Policy statements and advocacy.

Bernard, D. (2016, June). The Affordable Care Act, expanded insurance eligibility and financial burdens among veterans. In 6th Biennial Conference of the American Society of Health Economists. AcademyHealth.

Boscarino, J. A., Hoffman, S. N., Pitcavage, J. M., & Urosevich, T. G. (2015). Mental health disorders and treatment seeking among veterans in non-VA facilities: Results and implications from the Veterans' Health Study. Military Behavioral Health, 3(4), 244–254.

Boudiab, L. D., & Kolcaba, K. (2015). Comfort theory: Unraveling the complexities of veterans' health care needs. Advances in Nursing Science, 38(4), 270–278.

Haley, J., & Kenney, G. M. (2012). Uninsured veterans and family members: Who are they and where do they live? Urban Institute.

Kilbourne, A., & Atkins, D. (2015). Evidence-based policy making: Balancing rigor with real-world health care for veterans and military personnel. North Carolina Medical Journal, 76(5), 339–342.

Kizer, K. W. (2012). Veterans and the Affordable Care Act. Journal of the American Medical Association, 307, 789–790.

Russell, M. C., & Figley, C. R. (2014). Overview of the Affordable Care Act's impact on military and veteran mental health services: Nine implications for significant improvements in care. Journal of Social Work in Disability & Rehabilitation, 13(1–2), 162–196.

Schreiber, M., & McEnany, G. P. (2015). Stigma, American military personnel and mental health care: Challenges from Iraq and Afghanistan. Journal of Mental Health, 24(1), 54–59.