1. Veterans Using and Uninsured Veterans Not Using VA Health Care Karin Nelson, MD, MSHS Gordon A. Starkebaum, MD Gayle E. Reiber, PhD, MPH VA Puget Sound Health Care System Department of Medicine, University of Washington Departments of Health Services and Epidemiology, University of Washington Seattle, WA

2. Background Department of Veterans Affairs (VA) is the largest integrated health care system in the US Department of Veterans Affairs (VA) is the largest integrated health care system in the US Entry into the VA based on military service- related conditions, disability or financial need Entry into the VA based on military service- related conditions, disability or financial need Some veterans who are uninsured do not seek care despite eligibility for VA coverage Some veterans who are uninsured do not seek care despite eligibility for VA coverage

3. Background Veterans can receive VA and non-VA care in both outpatient and inpatient settings Veterans can receive VA and non-VA care in both outpatient and inpatient settings VA data systems capture encounters within VA system VA data systems capture encounters within VA system Extent of other health care use has been hard to quantify, especially among veterans less than 65 years of age Extent of other health care use has been hard to quantify, especially among veterans less than 65 years of age

4. Study Objectives Describe the characteristics of veterans who receive all or some of their care through the VA Describe the characteristics of veterans who receive all or some of their care through the VA Describe other sources of health care coverage for veterans Describe other sources of health care coverage for veterans Describe uninsured veterans (no health insurance and no use of VA services) Describe uninsured veterans (no health insurance and no use of VA services)

5. Methods Data from 2000 Behavioral Risk Factor Surveillance System (BRFSS) Data from 2000 Behavioral Risk Factor Surveillance System (BRFSS) –cross sectional telephone survey –civilian, non-institutionalized population –state specific probability sample of households 2000 BRFSS only year with both veteran and health insurance questions 2000 BRFSS only year with both veteran and health insurance questions

6. Study population n=184,450 BRFSS interviewed individuals n=26,265 served in US Armed Forces n=23,880 not active military service n=23,797 veterans responded to questions about use of VA health care facilities

7. Measures Health insurance coverage Health insurance coverage Demographics: age, gender, race/ethnicity, education, annual income Demographics: age, gender, race/ethnicity, education, annual income Health care access Health care access –Time since last health care visit –Couldn’t afford a doctor visit in the past year Health status Health status Disability: mental and physical health Disability: mental and physical health Tobacco use Tobacco use

8. Data Analysis Bivariate analysis to describe the differences in socioeconomic characteristics, health status and health care access by use of VA services Bivariate analysis to describe the differences in socioeconomic characteristics, health status and health care access by use of VA services Multivariate analysis to assess the independent association of socioeconomic status and receiving all care at the VA Multivariate analysis to assess the independent association of socioeconomic status and receiving all care at the VA

9. Veteran Characteristics by use of VA services % All VA Care n=1,647 Some VA care n=1,744 No VA care n=20,406 Age > 65364736 * White African American Hispanic 74 15 8 75 13 9 85 7 5 * Annual Income < $15,00023146* > 8 disability days/month19187* Fair or poor health status373316* * p<0.001

10. Adjusted odds of veterans receiving all health care at the VA Population characteristic OR 95% CI African American Hispanic White Annual income <$15,000 $15-35,000 >$35,000 < High School education High School education College 1.8 1.3 6.3 2.9 2.4 1.6 1.3, 2.4 0.8, 2.2 Reference 4.6, 8.7 2.3, 3.8 Reference 1.6, 3.4 1.2, 2.1 Reference Adjusted for age and gender

11. Type of health care coverage by use of VA care among veterans <65 yrs % All care at the VA n=435 Some care at the VA n=669 No VA care n=12,835 Private insurance Medicare Medicaid or IHS Other insurance No insurance 42.6 36.3 1.8 5.4 13.8 67.3 21.4 1.3 1.4 8.6 83.2 5.2 1.3 1.7 8.6 p<0.001

12. Characteristics of uninsured veterans, % Uninsured veterans Veterans with insurance Veterans with insurance Population estimate Sample size 1,324,040 1,216 25,877,256 20,953 Age 18-45 years 46-64 years 46-64 yearsFemaleWhite African American Hispanic Annual Income < $15,000 $15,000-35,000 $15,000-35,000 Could not afford MD/past yr 55.9 41.2 8.7 78.1 10.0 9.4 16.0 54.5 36.7 21.3 39.7 5.2 84.3 7.8 5.3 6.9 31.8 4.8 *††***††** *p<0.001, † p<0.05

13. Limitations Self report Self report Suboptimal response rate Suboptimal response rate Does not include individuals without phones, homeless individuals or those living in institutions Does not include individuals without phones, homeless individuals or those living in institutions Measures health insurance at one point in time Measures health insurance at one point in time Does not assess enrollment in VA system or VA eligibility Does not assess enrollment in VA system or VA eligibility

14. Conclusions Veterans who utilize the VA for all of their health care are more likely to be disabled and from disadvantaged groups Veterans who utilize the VA for all of their health care are more likely to be disabled and from disadvantaged groups A large number of veterans who could use VA services are uninsured A large number of veterans who could use VA services are uninsured –Potential enrollment target given the detrimental effects of being uninsured