The Role of VA Community Care in Addressing Health and Health Care Disparities

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Despite significant advances in medical care over the past decade, health and health care disparities persist across populations in the United States.1 These differences lead to poor health outcomes and experiences for many diverse groups, including people of color, women, persons with social and economic disadvantage, lesbian, gay, bisexual, and transgender populations, and individuals living in rural and inner-city areas. Health disparities are preventable, and were estimated to cost the United States over $1 trillion in medical care expenditures, illness-related lost productivity, and premature death between 2003 and 2006.2 As the US population increases in diversity, addressing health disparities becomes critically important to achieve better patient experiences, better population health, and better value in health care.
At the US Department of Veterans Affairs (VA), a renewed focus on health and health care disparities is timely given current shifts in Veteran demographics. Racial/ethnic minority Veterans represented 22% of the total Veteran population in 2014, a proportion that is expected to increase to 34% by 2040.3 Similarly, the number of women Veterans are expected to double to almost 20% of the total Veteran population by 2040.4 A quarter of the total Veteran population resides in rural or highly rural communities, and represent one third of Veterans enrolled in VA health care.5 Between 2006 and 2014, the number of enrolled Veterans living in rural communities increased by 7%.6
VA is evolving its current health care system into an integrated, high-performing network of both VA and community providers focused on delivering the best-quality outcomes and experiences for Veterans.7 This system transformation has the potential to impact health and health care disparities by improving access to care, addressing the social determinants of health, and promoting cultural competency.
First, VA’s integrated, high-performing network can help address health and health care disparities by increasing access to care. Prior research indicates that nonelderly black, Hispanic, and American Indian, and Alaska Native adults are more likely to delay or defer needed care compared with nonelderly white adults.8 In addition, low income and lesbian, gay, bisexual, and transgender individuals experience greater challenges obtaining care than high-income and heterosexual persons, respectively.9,10 Over the past 3 years, VA has focused on improving access to care for enrolled Veterans by expanding VA Community Care, which provides health care options outside of VA facilities and clinics. The Veterans Access, Choice and Accountability Act of 2014 provided resources and tools to assist in this effort. Over 25 million community care appointments were completed in fiscal year (FY) 2016. This represents a 61% increase since FY14. During FY16, >2 million Veterans accessed VA Community Care, a growth of 21% from FY14. Although the current Veteran population is ∼10% female, 12% of the Veterans utilizing VA Community Care are female. Similarly, rural Veterans represent one third of all VA health care enrollees but constitute 39% of all Veterans utilizing VA Community Care in FY15 and FY16. Increasing access to health is one way that VA is reducing health disparities, by allowing Veterans to see providers through VA’s integrated, high-performing network.
Second, reducing health and health care disparities requires a focus on the social determinants of health. It is estimated that 60% of preventable deaths can be traced to the social determinants of health—lifestyle behaviors and exposures that occur in the environment.11 Many organizations and clinicians in the health care industry have recognized the need to partner across sectors to address health-related social needs, like housing, food insecurity, and transportation, to improve outcomes and reduce total health care costs.
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