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The Keckley Report

Veterans Health: Out of Sight, Out of Mind

By November 11, 2019March 1st, 2023No Comments

Today is Veterans Day. It’s been observed for 101 years.

For those who have served, are actively serving and will serve our country, we can’t thank you enough for what you do!

The U.S. Department of Veteran’s Affairs (VA) was created by President Herbert Hoover in 1930 and elevated to Cabinet status by President Ronald Reagan in 1988. It now employs 383,083 and has an FY20 operating budget of $220.2 billion. That includes $90.5 billion set aside for the Veterans Health Administration (VHA) which bills itself as “America’s largest integrated health care system, providing care at 170 medical centers and 1,074 outpatient clinics.”


The Veteran population is large and diverse

  • There are 20 million living Americans who served in our military. They comprise 7.3% of U.S. adults and 48% of Americans older than 75.

  • More than 23.5 million Veterans and their dependents are eligible for VA services including healthcare.

  • Between today and 2043, the veteran population will decrease to 15 million, females will increase from 10% of total vets today to 16%, and minority populations will increase from 24% today to 35%.

  • Veterans are less likely to be unemployed, less likely to be living below the poverty line, more likely to be insured, and more likely to have graduated from high school, on average, than non-Veterans but over-represented among America’s homeless..

Veterans health programs (the VHA) serve a population of vets who are unable to access care through private options. They’re clinical and social needs are unique.

  • 9 million Vets depend on the VHA for healthcare services. They tend to be older and less socioeconomically well-off than Veterans who do not rely on VHA for care. Their health status is sub-optimal and their health risk behaviors more prevalent than their civilian counterparts.

  • Behavioral health and substance abuse are growing problems among younger vets: 22 commit suicide daily as a result of depression, anxiety, PTSD and addiction disorders.

The quality of care provided in VHA programs is equal to or better than care provided in other private settings.

  • Since 1985, Congress has required VHA facilities to monitor and publicly report risk adjusted outcomes compared to national averages: most facilities have performed equal to or better than national averages though timely access to care was a flash point in May 14 when a Phoenix facility where six avoidable deaths were attributed to these significant delays in access to care. Related: VA’s 2018 survey to measure the Veteran Experience with VHA’s outpatient services: VA’s trust score was at 84.7%, September 2018, 86.8%, in January 2019, 87.9%.

  • The VHA is a major innovator in the use of electronic health records (Vista, VA Decision Support Tools, Cerner et al), care coordination (VA Primary Care Directives, Homeless Patient Aligned Team, et al), self-care technologies (iPhone apps), applied research (prosthetics, spinal cord injuries, PTSD, women’s health et al), medical education and others.


The two unique challenges facing the VHA are…

  • Public support: polling indicates general support for Veterans programs is strong but awareness of Veterans health issues low. Unless a Veteran, dependent or family member, Veterans programs are not a primary focus.

  • Politics: Congress role in Veterans’ services complicates its performance. Example: the FY20 budget includes $8.9 billion in 2020 and $11.3 billion in 2021 to implement the MISSION Act that expand Veterans’ care access to primary and specialty care (VA Community Care) and decreases in funding for its own facilities and medical research about the unique medical circumstances of veterans. The 116th Congress includes 96 who served in the military: down 6 from the 115th Congress. The majority of members (82%) never served, so understanding the programmatic needs and funding for Veterans health programs in increasingly problematic.

To 9.3 million Veterans, the VHA health system is a lifeline. To 11 million veterans who choose or are unable to access the VA system, it’s an option if other options don’t pan out. And for the rest of us, the VHA is out of sight, out of mind.



Out of Pocket a Problem for Most Medicare Enrollees: Affordability hits seniors hard per a Commonwealth Fund study released last week:

  • “In a national survey, seriously ill Medicare beneficiaries described financial hardships resulting from their illness—despite high beneficiary satisfaction with Medicare overall and the fact that many have supplemental insurance. About half (53%) reported a serious problem paying medical bills, with prescription drugs proving most onerous” “Financial Hardships Of Medicare Beneficiaries With Serious Illness” Health Affairs November 2019

Healthcare Lobbying 2019 YTD: Getting state/federal elected officials to advance favored legislation, modify rules or regulations or oppose laws that are contrary to an organization’s business interest is big business. Per the Congressional Quarterly, four of the Top 10 spenders for lobbying for the period January 1, 2019 through September 30, 2019, are healthcare: #3-PhrMA ($16.4 mil), #4-Blue Cross Blue Shield Association ($12.3 mil), #6-American Medical Association ($12.0 mil), #5-American Hospital Association ($12.3 mil). Per the Center for Responsive Politics, as of October 23, the 10 largest hospital systems have invested $7,004,500 in their collective lobbying activity—24% less than $9,331,200 spent in the same period last year. And per AdAge and Kantar CMAG, Doctor Patient Unity, the advocacy group created to defeat surprise medical bill regulation, has spent $26.9 million (through 9/23). Influencing legislators in a big business.

Bloomberg considers Presidential race: As New York City’s mayor (2002 to 2013), he instituted smoking bans, calorie counts on menus and limits the size of sodas. He’s a major contributor to his alma mater Johns Hopkins’ public health programs, a critic of Medicare for All and cites healthcare affordability as his major concern. In fact, recent polling data shows Bloomberg would beat out President Trump in a hypothetical 2020 matchup by 6 percentage points (Politico/Morning Consult).

Urban Health focus on Super-Utilizers: This week, the National Center for Complex Health and Social Needs and Regional One Health, Memphis, are hosting “Putting Care at the Center 2019” in Memphis. Of particular interest is Regional’s ONE Health program focused on the 5% ‘super-utilizers’ who account for more than 50% of the nation’s health care spending, according to the Medical Expenditure Panel Survey. What CEO Reg Coopwood and his team have done is impressive and worth a look. You can register online at


“I served in Trump’s Cabinet. My Interview was a window into the Chaos” David Shulkin; Time; November 4, 2019; David Shulkin It Shouldn’t be this Hard to Serve our Country

National Center for Veterans Analysis and Statistics

Eibner at al “Current and Projected Characteristics and Unique Health Care Needs of the Patient Population Served by the Department of Veterans Affairs” RAND Health Quarterly, 2016; 5(4):13

Schult et al “The Health Status of Veteran Employees Compared to Civilian Employees in Veterans Health Administration” Mil Med. 2019 Jul 1;184(7-8):e218-e224. doi: 10.1093/milmed/usy410.

Veterans Administration Office of Budget