Freedom is Not Free: Examining Health Equity for Racial and Ethnic Minoritized Veterans

Introduction

“The military of any nation is a reflection of the social milieu within that nation’s borders” (Napier, 2021, p. 4). The United States has one of the largest militaries globally, leads the world in military spending, and is currently engaged in deployments from the Arabian Peninsula and the Horn of Africa to the Philippines (Biden, 2022). In 2019, there were 17-18 million military Veterans in the United States comprising approximately 7 percent of the adult population (Vespa, 2020). The term Veteran refers to “a person who served in the active military, naval, or air service, and who was discharged or released therefrom under conditions other than dishonorable” (U.S. Department of Veterans Affairs, 2019, p. 1). This definition includes anyone who served in any branch of the armed forces (i.e., Army, Navy, Air Force, Coast Guard, Marine Corps, Space Force) as an active-duty service member or a reservist (i.e., National Guard or reservist in the Army, Navy, or Air Force).

There are also various Veteran status types that determine eligibility for benefits programs as outlined by federal government regulations. Veterans who have served less than 20 years and were honorably discharged may be authorized to receive care within the Veterans Health Administration (VHA) and the level of benefit program eligibility is further determined by the presence of service-connected injuries, disabilities, or health conditions. Veterans who have served 20 years or more may qualify to receive care within the VHA, if they have a service-connected condition, and the Defense Health Agency (DHA) which does not require retirees to have a service-related condition. Care within the DHA for military retirees is based on whether there is space available within the system (U.S. Department of Veterans Affairs, 2019).

The United States has a remarkably comprehensive system of assistance for Veterans that has historically sought to entrench non-discriminatory practices into its programs. However, adverse societal and policy-driven influences have adversely affected access to and distribution of this assistance. (Faber, 2020). It is this history that will be described in the subsequent text. Also, a look towards the future of Veterans’ care will also be presented. This editorial is a continuation of the Research in Nursing and Health series on “Learning the Language of Heath Equity” (Squires & Thompson, 2021, p. 869). The goal of this editorial is to broaden understanding of health equity issues with a focus on Veterans from racial and ethnic minoritized groups in the United States military. 1 in 4 (25%) Veterans in the United States are from these minoritized groups (i.e., American Indian and Alaska Native, Asian, Black or African American, Hispanic or Latino of Any Race, Native Hawaiian and Other Pacific Islander, Two or More Races, and Other Races) and they are projected to comprise 40% of the Veteran population by 2045 (U.S. Department of Veteran Affairs, 2020). To build the capacity of students in health professions, as well as nursing researchers, administrators and clinicians, evidence is provided about Veterans’ care in the United States and how it can inform government and healthcare system strategies for advancing health equity among minoritized groups. The history of racial and ethnic minoritized Veterans is used to highlight and provide examples of how structural policies can be implemented to reduce disparities or reinforce them.

Historical Perspective

The U.S. Department of Veterans Affairs is a federal administration with a longstanding history of striving to meet both the medical and non-medical needs of individuals who have served in the military. The administration is comprised of three subdivisions – VHA, VBA (Veterans Benefits Administration) and NCA (National Cemetery Administration). The Continental Congress of 1776, during the Revolutionary War (1775-83), provided the first financial pensions to combat soldiers with disabilities. After the Civil War (1861-65), Veterans homes were established to provide residential care, medical care, and hospital treatment for Veterans with service-related injuries and conditions. In 1865, during the presidency of Abraham Lincoln, an appropriations bill was passed to fund the establishment of the first federal centers for honorably discharged Union Army Veterans called the National Homes for Disabled Volunteer Soldiers (Plante, 2004). During the 19^th century, Veterans’ assistance programs were expanded to provide benefits and pensions not only for Veterans, but for their spouses and dependents under certain circumstances (United States Department of Veterans Affairs, 2021b).

During World War I (1914-18), an improved system of benefits for Veterans was enacted that included programs for disability compensation, insurance, and vocational rehabilitation (Library of Congress, 2023). After World War I, the nation recognized that specialized care for Veterans was needed due to advances in military technology that resulted in distinct injuries and exposures (e.g., machine guns, mustard gas). Federal Veterans programs were consolidated to form the Veterans Bureau in 1921. President Herbert Hoover, in 1930, elevated the Veterans Bureau to a federal administration calling it the Veterans Administration (VA) and in 1989, it was renamed the U.S. Department of Veterans Affairs (Library of Congress, 2023). Funding for this administration to provide benefits and medical services to eligible beneficiaries is budgeted and allocated by the United States Congress.

Racial and Ethnic Minoritized Veterans

Veterans from racial and ethnic minoritized groups have served in every war and conflict the U.S. has fought. Crispus Attucks, a man of African and Native American ancestry, was the first American patriot to die in support of this nation’s founding. He died in 1770 during a massacre that sparked the start of the American Revolution (1774-83; Kiger, 2021). Thousands of free and enslaved descendants of Caribbean Black and African Americans served in the Continental Army during the Revolutionary War (1775-83) and hundreds of thousands fought in the Union Army during the Civil War (1861-65). John Tomney was the first Chinese American to serve by joining the Union Army during the Civil War (1861-65) and was followed in 1863 by William Ah Hang, the first Asian American to enlist in the U.S. Navy, (Library of Congress, 2023). All-Black regiments called Buffalo Soldiers were formed in the late 1860s, following the Civil War, during the United States’ westward expansion into the American frontier. The Buffalo Soldiers were pivotal in the development of the United States into a world power and their service was a strategy used by Black men to obtain recognition as citizens. The history of the Buffalo Soldiers is complicated, however, by the United States Army’s use of war to remove Native American communities from the land of the Southwest and Great Plains (NMAAHC, 2021).

In 1901, President William McKinley signed an executive order in support of the enlistment of servicemembers of Filipino descent into the United States Navy (Library of Congress, 2023). Hundreds of Native Americans served as legendary Navajo Code Talkers during World War II (1940-45) and over 40,000 Native Americans served in the Vietnam Conflict (colloquially known as the Vietnam War although an act of war was not officially declared (Thatcher et al., 2016; U.S. National Archives, 2016). Hundreds of thousands of Latinx and Hispanic Americans served in World War I (1914-18) and World War II (1940-45), and this group is projected to be the fastest growing among racial and ethnic minoritized Veterans (U.S. Department of Veterans Affairs, 2016).

The trend of acknowledging the contribution of racial and ethnic minoritized service members while also instituting separationist practices contributed to unequal treatment based on race and ethnicity (Wilson, 2010). Black and African Americans who served during the Civil War (1861-65) were a part of this nation’s first attempt at a large-scale social support program known as the Union Army pension system. Laws dictating eligibility for war-related disability compensation attempted to provide pensions regardless of race and ethnicity. Black and African Americans were afforded the same voluntary admission privileges to national veterans’ homes but living quarters and activities remained segregated (Plante, 2004). Black and White Veterans were entitled to the same pension eligibility requirements and financial benefits, but racial inequities persisted due to biases in the implementation of this pension system. A law enacted in 1890 helped to rectify these inequities by eliminating the requirement for verification of service-related disability via medical records) which subsequently increased Black enrollment in the pension program (Wilson, 2010). Due to racial discrimination, service members from racial and ethnic minority groups were much less likely to be hospitalized and to receive treatment for their injuries. This left them without the documentation needed to prove that their disabilities were war related when applying for the financial support they had earned. Additionally, illiteracy and poverty put them at a considerable disadvantage in navigating processes to access and obtain pension support (Wilson, 2010).

The U.S. Veteran population grew exponentially following World War II (1940-45). Veterans who served domestically and those returning home from overseas hoped to realize the promises of the Servicemen’s Readjustment Act (GI Bill). This legislation was passed in 1944 and held a promise of education, housing, and unemployment benefits. Although the armed forces were one of the largest employers of Black and African Americans in the 1940s, the GI Bill demonstrated how policies can contribute to inequities when administered in prejudiced environments (U.S. National Archives, 2022). The United States government declared that all Veterans should receive access to these additional benefits to aid their transition from military to civilian life. Many Veterans from racial and ethnic minority groups faced barriers and discrimination when trying to access the benefits this socio-economic program promised (Blakemore, 2021). At that time, many Predominantly White Institutions (PWIs) of higher education in the United States opposed the enrollment of Black and African American students. Therefore, the vast majority that sought collegiate education attended historically black colleges and universities (HBCUs). Similarly, the Federal Housing Administration’s (FHA) adoption of racial exclusion in its neighborhood appraisal practices in 1936 restricted access to housing assistance for Veterans from racial and ethnic minority groups. The FHA frequently categorized low-income, immigrant, and neighborhoods of majority Black and African residents as less desirable for home loans (Faber, 2020). “Racial inequality ran parallel to a key component of economic inequality—unequal access to home equity, the key tool for asset accumulation” (Faber, 2020, p. 744).

President Harry S. Truman signed an executive order in 1948 to desegregate the military and declare that all forms of discrimination in the armed forces were illegal, but unequal practices and barriers persisted (U.S. National Archives, 2022). Uneven distribution of GI Bill benefits along racial and regional lines can be attributed, in part, to implementation that failed to uphold the universal spirit of the federal legislation (Katznelson & Mettler, 2008). U.S. states were left to dispense funds making Veterans from racial and ethnic minority groups more vulnerable to southern state-sanctioned Jim Crow laws (1877-1954), residential redlining practices (1935-68), home mortgage or lending discrimination and segregated institutions of higher learning (Blakemore, 2021; Sistrunk et al., 2022). The determinations of eligibility for GI Bill benefits varied greatly between northern and southern states. For example, in 1947, only 2 out of 3,229 VA home loans in the state of Mississippi were given to Black Veterans (Katznelson & Mettler, 2008). Due to structural discrimination in the educational and financial institutions responsible for implementing the GI Bill’s policies, many Veterans from racial and ethnic minority groups did not benefit as substantially from this assistance as their White counterparts (Katznelson & Mettler, 2008). Rather than being uplifted into the middle class, the economic and educational gap widened for many Veterans from minoritized and underserved communities (Faber, 2020). The overall impact of the GI Bill on the United States’ economic recovery after World War II was positive, but the barriers experienced by racially and ethnically minoritized Veterans were so pronounced that it impelled the NAACP (National Association for the Advancement of Colored People) to engage in advocacy work on their behalf. The NAACP’s Armed Services and Veterans Affairs committee lead activism efforts against racially exclusionary practices that obstructed access to GI Bill benefits (Wood, 2013). These several examples demonstrate how policies can exacerbate racial disparities by not considering culturally sensitive and real-world implementation from a lens of equity and justice.

Research Implications: Advancing Equity for Veterans

The significant sacrifice of racial and ethnic minoritized groups in the United States military should not be understated and prioritizing their needs is of upmost importance. According to the U.S. Department of Veterans Affairs:

Equity means intentionally committing to consistent and systematic fair, just and impartial treatment of all individuals and a just distribution of tools and resources to give Veterans, including Veterans who are members of underserved communities, what is required to enjoy a full, healthy life.

(2021a, p.1)

The prioritization of underserved Veterans was reemphasized by the passing of an executive order in 2021 entitled, Advancing Racial Equity and Support for Underserved Communities Through the Federal Government. This executive order took effect on the day of President Joseph Biden’s inauguration and dictates that all federal agencies “pursue a comprehensive approach to advancing equity for all, including people of color and others who have been underserved, marginalized, and adversely affected by persistent poverty and inequality” (Biden, 2021, p.1). Lessons can still be learned from Veterans from racial and ethnic minority groups that are applicable to health equity research. The implementation of policies and practices intended to address health disparities should incorporate plans for program evaluation that assess whether they are reaching intended audiences, effectively achieving objectives, and being distributed equitably. These evaluation plans should also provide opportunities to reflect, and course correct, as necessary. The experiences of racial and ethnic minoritized groups within the U.S. Department of Veterans Affairs highlights the role healthcare systems can play in promoting research to identify internal and external barriers to accessing care and assessing social determinants of health for marginalized populations, such as housing stability, financial security, education, and employment.

Not only are health disparities unjust, but they are also harmful and costly. Health inequities cost the United States $320 billion (about $960 per person) annually (Bhatt, 2022). The U.S. Department of Veterans Affairs’ Office of Health Equity, established in 2012, aims to identify strategies and actionable steps to advance equity and improve services for at-risk veteran populations. The U.S. Department of Veterans Affairs’ Center for Health Equity Research and Promotion (CHERP) is a national health services research and training center. It was established in 2001 to better understand and address health disparities among vulnerable Veteran populations. This office and center further their mission by collaborating with other centers including the Center for Minority Veterans (CMV), LGBTQ+ (Lesbian, Gay, Bisexual, Transgender, Queer or Questioning) Health Program, Women’s Health Services, and the Office of Community Engagement (OCE).

The following are examples of recent efforts to promote health equity and reduce barriers to care for racial and ethnic minoritized Veterans. The VA Office of Health Equity partnered with the FDA (U.S. Food and Drug Administration) Office of Minority Health in 2018 to launch an initiative and video series promoting the inclusion of Veterans in clinical trials. In January 2023, the Department of Veterans Affairs released a proposal to waive copays for eligible Native American and Alaska Native Veterans that is currently under consideration. The VHA Health Equity-Quality Enhancement Research Initiative released a report in February 2023 focused on the patient experiences of Black or African American Veterans. Additionally, the feasibility and acceptability of screening for health-related social needs, such as food security, housing stability, social support, and transportation access, is being explored at select VHA medical centers. The Equity Action Plan put forth by the U.S. Department in Veterans Affairs in 2021 outlines progress made in this effort as well as plans for furthering this work into the future. Strategies include rigorous equity assessments, economic initiatives to support minority Veteran-owned businesses, equity-focused quality improvement and performance measures, and human-centered design research (United States Department of Veterans Affairs, 2021a).

Conclusion

The development and implementation of novel programs and interventions are needed to reduce racial and ethnic health disparities and facilitate more equitable distribution of resources. Veterans’ care in the United States is a lesson in how structural policies can be used to impede or foster health equity on a population level. The improper implementation of programs and policies can further exacerbate health disparities in disadvantaged populations by not considering the contextual factors that influence outcomes. Practices and efforts rooted in justice and equity can close these gaps and improve health for historically minoritized racial and ethnic groups.