Abstract
An estimated 60% of all Operation Enduring Freedom / Operation Iraqi Freedom (OEF/OIF) veterans who have left the military had used the US Department of Veterans Affairs (VA) for health care services as of March 31, 2015. What is not known, however, are the differences in demographic, military, and health characteristics between OEF/OIF veterans who use the VA for health care and OEF/OIF veterans who do not. We used data from the 2009-2011 National Health Study for a New Generation of US Veterans to explore these differences. We found that VA health care users were more likely than non-VA health care users to be non-Hispanic black, to be unmarried, to have served on active duty and in the army, to have been deployed to OEF/OIF, and to have an annual income less than $35 000. The prevalence of 21 chronic medical conditions was higher among VA health care users than among non-VA health care users. OEF/OIF veterans using the VA for health care differ from nonusers with respect to demographic, military, and health characteristics. These data may be useful for developing programs and policies to address observed health disparities and achieve maximum benefit for the VA beneficiary population.
Keywords: OEF/OIF, veterans, Department of Veterans Affairs
The US Department of Veterans Affairs (VA) is the largest provider of health care in the United States, serving 8.8 million veterans each year.1 Studies published in 1987 and 2000 showed that veterans who sought care at VA medical facilities differed from the general US population in age, income, education, and health status; these veterans tended to be older, have lower incomes, and have lowers levels of education.2,3 These 2 studies did not include veterans of Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF).
In 2011, an estimated 50% of all OEF/OIF veterans who had left the military had used VA health care at some point since separation.4 OEF/OIF veterans (ie, those who deployed to the war) are eligible for medical care at any VA medical center for any condition that is possibly related to their service in OEF/OIF theater of operations for 5 years after they are discharged or released from active duty.5 Veterans who served during the OEF/OIF era (ie, those who served during the same period but were not deployed to the war) may also be eligible for VA health care, but their eligibility requirements differ from those of combat veterans.6
We used data on demographic, military, and health characteristics from the 2009-2011 National Health Study for a New Generation of US Veterans to explore differences between VA health care users and nonusers among OEF/OIF veterans. This brief report contributes to the literature by providing population prevalence estimates of 21 chronic medical conditions among OEF/OIF veterans who did not use VA health care services.
Methods
Details on methods for this study are described elsewhere.7 In brief, between 2009 and 2011, 20 563 veterans from a population-based sample of 30 000 deployed OEF/OIF veterans and 30 000 nondeployed veterans from the OEF/OIF era completed a 16-page health survey via Internet, mail, or telephone. The survey included questions about functional status, activity limitations, health perceptions, height, weight, deployment-related military exposures, chronic medical conditions, VA health care utilization, posttraumatic stress disorder, traumatic brain injury, cigarette smoking, alcohol use, risky driving behavior, and sexual risk-taking behaviors. The variables of interest for this analysis were 21 self-reported medical conditions ascertained by asking the question “Has a doctor ever told you that you have any of the following conditions?” to which the respondents would answer with “yes” or “no.” VA health care user status was determined by a yes-or-no answer to the question “Have you used VA health care services since you were separated from active duty?” This study was reviewed and approved by the Washington DC Veterans Administration Hospital Institutional Review Board.
Weights were developed to improve the precision and accuracy of the population prevalence estimates and to adjust for 3 factors: the stratified sampling design, nonresponse, and misclassification in the sampling frame. These methods are described elsewhere.8 In short, basic sampling weights to account for the stratified sampling design and nonresponse were developed to ensure that the respondents reflected the entire population of service members. A proportion of the sampled respondents identified as nondeployed when the sample was drawn had deployed before or during data collection. Poststratification weighting was performed to account for temporal misclassification of deployment status in the sampling frame on the basis of the most current deployment records.8 We calculated unweighted frequencies, unadjusted odds ratios, weighted prevalence and 95% confidence intervals (CIs), and weighted adjusted odds ratios (aORs) and 95% CIs, comparing VA health care users with nonusers, using SAS version 9.3.9 The odds ratios were adjusted for sex, age, race/ethnicity, branch of service, unit component, education, marital status, income, and deployment to OEF/OIF. To our knowledge, this analysis is the first to report the demographic, military, and health characteristics of the OEF/OIF veteran population by VA health care user status.
Results
Data on VA health care use were available on 20 547 of 20 563 (99.9%) respondents. VA health care users were more likely than nonusers to be non-Hispanic black, to be unmarried, to have served on active duty and in the army, to have been deployed to OEF/OIF, and to have an annual income less than $35 000 (Table 1). Compared with nonusers, VA health care users had higher adjusted odds of having each chronic medical condition—notably, chronic fatigue syndrome (aOR = 2.45; 95% CI, 1.94-3.09), arthritis (aOR = 2.40; 95% CI, 2.20-2.62), sleep apnea (aOR = 2.34; 95% CI, 2.09-2.61), diabetes (aOR = 1.86; 95% CI, 1.54-2.26), hypertension (aOR = 1.83; 95% CI, 1.66-2.01), migraines (aOR = 1.79; 95% CI, 1.62-1.98), irritable bowel disease (aOR = 1.77; 95% CI, 1.56-2.02), significant hearing loss (aOR = 1.76; 95% CI, 1.61-1.93), and sinusitis (aOR = 1.55; 95% CI, 1.41-1.70)—after adjusting for sex, age, race/ethnicity, branch of service, unit component, education, marital status, income, and deployment to OEF/OIF (Table 2).
Table 1.
Demographic and military characteristics of US Department of Veterans Affairs (VA) health care users and nonusers who served in or during Operation Enduring Freedom or Operation Iraqi Freedom: National Health Study for a New Generation of US Veterans, 2009-2011
| VA Health Care Users | Non-VA Health Care Users | |||||
|---|---|---|---|---|---|---|
| Characteristic | Total No. of Veteransa | No. | Weighted % (95% CI)b | No. | Weighted % (95% CI)b | P Valuec |
| Total | 20 547 | 7593 | NC | 12 954 | NC | |
| Birth year | <.001 | |||||
| Pre-1960 | 3128 | 1288 | 10.5 (9.9-11.1) | 1840 | 8.2 (7.8-8.6) | |
| 1960-1969 | 5728 | 2276 | 23.5 (22.6-24.5) | 3452 | 19.1 (18.5-19.8) | |
| 1970-1979 | 6033 | 2123 | 30.2 (28.9-31.3) | 3910 | 30.6 (29.7-31.5) | |
| 1980 or later | 5658 | 1906 | 35.8 (34.5-37.1) | 3752 | 42.1 (41.1-43.1) | |
| Deployment status | <.001 | |||||
| Deployed | 13 201 | 5271 | 62.1 (61.3-62.9) | 7930 | 52.6 (51.9-53.3) | |
| Not deployed | 7346 | 2322 | 37.9 (37.1-38.7) | 5024 | 47.4 (46.7-48.1) | |
| Sex | .02 | |||||
| Male | 16 199 | 5868 | 83.0 (82.8-83.3) | 10 331 | 84.3 (84.1-84.5) | |
| Female | 4348 | 1725 | 17.0 (16.7-17.2) | 2623 | 15.7 (15.5-15.8) | |
| Branch of service | <.001 | |||||
| Army | 11 153 | 4741 | 56.1 (55.7-56.6) | 6412 | 45.8 (45.5-46.2) | |
| Air Force | 4336 | 1107 | 15.0 (14.7-15.3) | 3229 | 22.4 (22.1-22.7) | |
| Navy | 3089 | 1053 | 16.6 (16.3-17.0) | 2036 | 19.0 (18.6-19.3) | |
| Marine Corps | 1969 | 692 | 12.2 (12.0-12.4) | 1277 | 12.8 (12.6-13.0) | |
| Unit component | <.001 | |||||
| Active duty | 7858 | 3152 | 56.9 (56.5-57.3) | 4706 | 51.6 (51.3-51.9) | |
| National Guard | 5610 | 2092 | 21.9 (21.6-22.2) | 3518 | 21.1 (20.9-21.4) | |
| Reserve | 7079 | 2349 | 21.2 (20.9-21.5) | 4730 | 27.2 (27.0-27.5) | |
| Race/ethnicity | <.001 | |||||
| Hispanic | 2164 | 891 | 12.1 (11.2-12.9) | 1273 | 10.4 (9.6-10.8) | |
| Non-Hispanic white | 14 420 | 4867 | 65.6 (64.4-66.8) | 9553 | 73.6 (72.7 74.5) | |
| Non-Hispanic black | 2658 | 1332 | 16.2 (15.3-17.1) | 1326 | 10.2 (9.6-10.8) | |
| Non-Hispanic otherd | 1183 | 447 | 6.1 (5.5-6.8) | 736 | 5.8 (5.4-6.3) | |
| Not reported | 122 | 56 | NC | 66 | NC | |
| Marital status | <.001 | |||||
| Married | 14 538 | 5084 | 64.7 (63.4-65.9) | 9454 | 69.3 (68.4-70.3) | |
| Divorced/separated | 2311 | 1047 | 12.8 (12.0-13.7) | 1264 | 9.1 (8.6-9.7) | |
| Never married | 3630 | 1424 | 22.5 (21.3-23.6) | 2206 | 21.5 (20.6-22.4) | |
| Not reported | 68 | 38 | NC | 30 | NC | |
| Annual income | <.001 | |||||
| <$35 000 | 5084 | 2299 | 36.2 (34.9-37.5) | 2785 | 28.8 (27.8-29.7) | |
| $35 000-$49 999 | 3510 | 1447 | 19.2 (18.2-20.3) | 2063 | 17.8 (17.0-18.6) | |
| $50 000-$74 999 | 4630 | 1737 | 22.2 (21.1-23.3) | 2893 | 21.6 (20.8-22.4) | |
| $75 000-$99 999 | 2954 | 928 | 10.7 (9.9-11.4) | 2026 | 13.5 (12.9-14.2) | |
| $100 000-$149 999 | 2803 | 775 | 8.7 (8.0-0.3) | 2028 | 12.5 (12.0-13.1) | |
| ≥$150 000 | 1292 | 295 | 3.0 (2.6-3.4) | 997 | 5.8 (5.4-6.2) | |
| Not reported | 274 | 112 | NC | 162 | NC | |
| Education | <.001 | |||||
| ≤High school degree | 3098 | 1102 | 16.0 (15.0-17.0) | 1996 | 19.7 (18.8-20.5) | |
| ≤Bachelor degree | 14 636 | 5661 | 76.2 (75.2-77.3) | 8975 | 69.8 (68.9-70.7) | |
| Advanced degree | 2759 | 807 | 7.8 (7.2-8.3) | 1952 | 10.6 (10.0-11.1) | |
| Not reported | 54 | 23 | NC | 31 | NC | |
Abbreviations: CI, confidence interval; NC, not calculated.
aVA user status was available for 20 547 of 20 563 respondents. Includes veterans from Operation Enduring Freedom and Operation Iraqi Freedom.
bEach weighed proportion is based on the number of respondents for each demographic or military characteristic.
c P values calculated per the Rao-Scott χ2 test.
d“Non-Hispanic other” includes Asian, American Indian / Alaska Native, Native Hawaiian / Pacific Islander.
Table 2.
Unweighted frequency, weighted prevalence, and adjusted odds of self-reported medical conditions among US Department of Veterans Affairs (VA) health care users and nonusers who served in or during Operation Enduring Freedom or Operation Iraqi Freedom: National Health Study for a New Generation of US Veterans, 2009-2011
| VA Health Care Users | Non-VA Health Care Users | ||||||
|---|---|---|---|---|---|---|---|
| Health Outcomea | Total No. of Veteransb | No. (n = 7609) | Weighted Proportion (95% CI)c | No. (n = 12 970) | Weighted Proportion (95% CI)c | Adjusted Odds Ratio (95% CI)d,e | P Valuef |
| Total | 20 579 | 7609 | 12 970 | ||||
| Chronic fatigue syndrome | 475 | 296 | 3.7 (3.2-4.2) | 179 | 1.3 (1.1-1.5) | 2.45 (1.94-3.09) | <.001 |
| Arthritis | 4775 | 2507 | 31.5 (30.4-32.7) | 2268 | 15.2 (14.5-15.9) | 2.40 (2.20-2.62) | <.001 |
| Sleep apnea | 2158 | 1204 | 16.7 (15.7-17.6) | 954 | 7.0 (6.5-7.5) | 2.34 (2.09-2.61) | <.001 |
| Other liver trouble | 514 | 262 | 3.8 (3.3-4.3) | 252 | 1.8 1.6-2.1) | 1.99 (1.61-2.46) | <.001 |
| Diabetes | 700 | 384 | 4.8 (4.3-5.3) | 316 | 2.1 (1.8-2.4) | 1.86 (1.54-2.26) | <.001 |
| Repeated seizures, convulsions, or blackouts | 281 | 161 | 2.4 (2.0-2.8) | 120 | 1.1 (0.9-1.3) | 1.86 (1.38-2.49) | <.001 |
| Multiple sclerosis | 118 | 62 | 0.8 (0.6-1.1) | 56 | 0.4 (0.3-0.6) | 1.84 (1.16-2.94) | .01 |
| Hypertension | 3304 | 1618 | 20.9 (19.8-21.9) | 1686 | 11.3 (10.7-11.9) | 1.83 (1.66-2.01) | <.001 |
| Any other cancer | 469 | 234 | 2.9 (2.5-3.4) | 235 | 1.5 (1.3-1.7) | 1.80 (1.43-2.26) | <.001 |
| Migraines | 2699 | 1339 | 18.8 (17.8-19.8) | 1360 | 10.8 (10.2-11.5) | 1.79 (1.62-1.98) | <.001 |
| Irritable bowel syndrome | 1457 | 720 | 9.5 (8.7-10.3) | 737 | 5.5 (5.0-5.9) | 1.77 (1.56-2.02) | <.001 |
| Significant hearing loss | 3656 | 1761 | 22.5 (21.5-23.6) | 1895 | 13.4 (12.7-14.0) | 1.76 (1.61-1.93) | <.001 |
| Coronary heart disease or artery disease | 453 | 234 | 2.6 (2.2-3.0) | 219 | 1.3 (1.1-1.5) | 1.60 (1.26-2.04) | <.001 |
| Sinusitis | 3311 | 1495 | 18.4 (17.5-19.4) | 1816 | 12.2 (11.6-12.8) | 1.55 (1.41-1.70) | <.001 |
| Frequent bladder infections | 500 | 246 | 2.9 (2.5-3.4) | 254 | 1.7 (1.5-1.9) | 1.52 (1.22-1.90) | <.001 |
| Asthma | 1408 | 652 | 9.2 (8.5-10.0) | 756 | 6.0 (5.5-6.5) | 1.51 (1.32-1.72) | <.001 |
| Cirrhosis | 125 | 59 | 0.8 (0.6-1.1) | 66 | 0.5 (0.4-0.6) | 1.46 (0.91-2.33) | .11 |
| Stroke | 154 | 78 | 0.9 (0.7-1.2) | 76 | 0.6 (0.4-0.7) | 1.42 (0.95-2.14) | .09 |
| Hepatitis | 372 | 173 | 2.1 (1.8-2.5) | 199 | 1.4 (1.2-1.6) | 1.41 (1.07-1.85) | .01 |
| Bronchitis | 2668 | 1136 | 15.5 (14.5-16.5) | 1532 | 11.6 (10.9-12.2) | 1.38 (1.24-1.53) | <.001 |
| Skin cancer | 654 | 233 | 2.6 (2.2-2.9) | 421 | 2.4 (2.1-2.6) | 1.09 (0.77-1.32) | .39 |
Abbreviations: CI, confidence interval.
aBased on the question “Has your doctor ever told you that you have any of the following conditions?”
bIncludes veterans from Operation Enduring Freedom and Operation Iraqi Freedom.
cEach weighted percentage is based on the number of respondents for the health outcome/condition.
dAdjusted for sex, age, race/ethnicity, branch of service, unit component, education, marital status, income, and deployment to Operation Enduring Freedom and Operation Iraqi Freedom.
eNon-VA health care users are the referent group for adjusted odds ratios.
f P values calculated from maximum likelihood estimators.
Discussion
This study showed that, since having left the military, OEF/OIF veterans who used the VA for health care were more likely to have chronic medical conditions than OEF/OIF veterans who had not used the VA for health care, even after adjustment for deployment. To some degree, this finding is expected, because veterans may be using the VA to treat an illness or injury that occurred during their service and is covered by the VA. Additionally, the VA provides care for veterans at certain income levels regardless of eligibility for injury or illness occurring in the line of duty.6 Poor health is a major driver of health care utilization. For example, in our study, VA health care users reported an average of 2 chronic medical conditions, whereas nonusers reported an average of 1 chronic medical condition (P < .001).
The most common reason that VA nonusers cited for not having used the VA for health care was that they did not know if they were eligible (39%). Education about VA health care services is recommended for veterans who do not use VA health care, because early assessment and treatment of health conditions through primary prevention may lead to improved outcomes. Nearly 20% of VA health care nonusers indicated that VA health care services were inconvenient, although they did not specify why. Future studies should evaluate the impact of the Veterans Access, Choice, and Accountability Act of 2014 to assess use of VA health care services and the extent to which veterans receive care from non-VA entities that satisfy the law’s timeliness and distance-from-care requirements.10
A strength of our study was that we used data on an underutilized comparison group—veterans of the OEF/OIF era who do not use VA health care services—from a nationally representative population-based study of veterans. Previous studies used data on veterans from the National Health Interview Survey to compare VA health care users with nonveterans in the general patient population, but these analyses were conducted with data from 1979 and the early 1990s.2,3 More recent studies were limited to small geographic areas or to female veterans.11 Additionally, the stratified sampling design of the entire known population of those who served in OEF/OIF—including the reserve/National Guard component and those who were not deployed but who served during that period—as coupled with the weighting techniques provided prevalence estimates for 21 chronic medical conditions. Data from this study can be used to set benchmarks for the health experience of the OEF/OIF veteran population and may be useful for developing programs and policies to address observed health disparities and achieve maximum benefit for the VA beneficiary population.
Footnotes
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the US Department of Veterans Affairs.
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