As an Iraq war veteran currently working on health policy issues for low-income populations, I have taken a special interest in the unraveling story at the Department of Veterans Affairs (VA). I am hopeful that the rapid movement in Congress toward potential solutions, including making it easier for veterans to seek care outside of the VA, signals major steps in the right direction toward assuring veterans the care they have earned.
We can draw many lessons from the situation on how to provide care, not just to veterans, but to many other vulnerable Americans. Given the strong bi-partisan push to restore confidence in the system, and as Congress confirms President Obama’s nomination for the next secretary of veterans affairs, VA leaders have an opportunity to learn from other health care systems that have faced rapid enrollment expansions with limited resources and staffing. They could start with Medicaid.
Finding Similarities across Medicaid and VA Programs
From a financing perspective, Medicaid and the VA have little in common. The VA is solely funded by a federal appropriation (nearly $60 billion in FY 2015) while roughly 40 percent of Medicaid’s more than $400 billion total funding comes from states. The VA is an integrated health system managed nationally; states have broad authority over Medicaid services from a wide array of independent health plans and providers.
Yet the VA is less of a “single payer” or integrated care model than often advertised. Like the 50-state operation of Medicaid, VA health care is coordinated by 23 geographic regions, and management policies vary by region. Conversely, although there is significant state variation in Medicaid eligibility levels, services, etc., individual state Medicaid programs must abide by strict federal regulations and coordinate with federal oversight at both regional and national levels.
Medicaid Takeaways for the VA
Medicaid programs have long confronted access challenges, particularly to specialty care, and many states and organizations have found innovative ways to tackle the problem. The VA can continue to benefit from this work, as it has in the past. Project ECHO, for example, a model started in 2003 to improve the management of patients with complex, chronic conditions living in remote and medically underserved communities, was first tested by New Mexico Medicaid before the VA implemented it nationally in 2012.
Furthermore, through the Affordable Care Act (ACA), the federal government has offered a tantalizing ‘carrot’ to states in the form of 100 percent federal funding if a state exercises the option to expand Medicaid. Further coordination between Medicaid and the VA could ensure that veterans and their families get access to care wherever they are enrolled, particularly as states with greater geographic diversity move to expand Medicaid.
In Washington State, the Veterans Benefits Enhancement Program has used data matches to identify and help nearly 20,000 veterans enrolled in Medicaid and their eligible family members get additional federal benefits, saving the state of Washington more than $45 million in the process. And in California, the San Diego Veterans Coalition coordinates services for veterans and their families in the San Diego area, including enrollment in Medicaid if eligible. If expanded to more communities, elements of these programs could have a significant impact on coverage and access.
VA Lessons for Medicaid
At the same time, the VA has significant experience working with vulnerable populations, including the 12 percent of the adult homeless population that are veterans, and individuals with mental illness arising from traumatic life experiences – up to 20 percent of veterans of the wars in Iraq and Afghanistan, and 30 percent of Vietnam veterans have post-traumatic stress disorder (PTSD). Programs such as veteran treatment courts and the VA’s evidence-based approach to benefit design could be informative as Medicaid programs work to find the most appropriate services for a population they are just starting to serve: the single, low-income men who had limited eligibility for Medicaid prior to the ACA.
The examples above, among others, show communities already working to ensure veterans and their families get the care they need and deserve. Such thorny problems are often best approached by tapping the experience of a wide group of thinkers, and there is an opportunity for regional VA and state Medicaid leadership to come together to identify areas of overlap and opportunities for collaboration in serving vulnerable populations. It is heartening to see national leaders embracing this type of cross-system thinking, particularly if it benefits the veterans and their families who have already given so much of themselves in the service of their country.