Abstract
Context/Objective: Provisions of the Affordable Care Act (ACA) potentially increase insurance options for Veterans with disabilities. We examined Veterans with spinal cord injuries and disorders (SCI/D) to assess whether the ACA was associated with changes in healthcare utilization from Department of Veterans Affairs (VA) healthcare facilities.
Design: Using national VA data, we investigated impacts on VA healthcare utilization pre- (2012/13) and post-ACA (2014/15) implementation with negative binomial regression models.
Setting: VA healthcare facilities.
Participants: 8,591 VA users with SCI/D. Veterans with acute myelitis, Guillain-Barré syndrome, multiple sclerosis, or amyotrophic lateral sclerosis were excluded as were patients who died during the study period.
Interventions: We assessed VA healthcare utilization before and after ACA implementation.
Outcome Measures: Total numbers of VA visits for SCI/D care, diagnostic care, primary care, specialty care, and mental health care, and VA admissions.
Results: The number of VA admissions was 7% higher in the post than pre-ACA implementation period (P < 0.01). The number of VA visits post-implementation increased for SCI/D care (8%; P < 0.01) and specialty care (12%; P < 0.001). Conversely, the number of mental health visits was 17% lower in the post-ACA period (P < 0.001). Veterans with SCI/D who live <5 miles from their nearest VA facility received VA care more frequently than those ≥40 miles from VA (P < 0.001).
Conclusion: Counter to expectations, results suggest that Veterans with SCI/D sought more frequent VA care after ACA implementation, indicating Veterans with SCI/D continue to utilize the lifelong, comprehensive care provided at VA.
Keywords: Affordable Care Act, Veterans Affairs, Health policy, Spinal cord injuries and disorders (SCI/D), Insurance
Introduction
More than 250,000 Americans have a spinal cord injury or disorder (SCI/D),1 and over 20,000 are Veterans who receive free to low-cost health care from the Department of Veterans Affairs (VA). VA provides comprehensive, integrated healthcare services to Veterans with SCI/D. This care is organized and delivered through a “hub-and-spoke” system composed of 25 SCI/D centers (“hubs”) and 134 “spokes” that have SCI/D outpatient clinics or SCI/D designated primary care teams that provide services including primary care, acute rehabilitation, and health maintenance.2
In March 2010, the Patient Protection and Affordable Care Act (ACA) was signed into law requiring most Americans to have health insurance,3 with many of its provisions beginning January 2014. The ACA was implemented to increase access to health insurance through expanded eligibility for Medicaid and through Health Insurance Exchanges (or Marketplaces), where individuals can compare and buy individual health insurance plans. For those with incomes from 100%-400% of the federal poverty level, subsidies are available to reduce the amount individuals pay for insurance purchased through the Exchanges. Under the ACA, Americans, including Veterans with disabilities,4,5 have improved access to non-VA health insurance.1 Implementation of the ACA had the potential to change Veteran’s use of VA healthcare services. Veterans with SCI/D may have chosen to receive non-VA care (i.e. through the Medicaid expansion), thus decreasing their reliance on VA services. However, it should be noted that VA enrollment fulfills the ACA’s requirement that individuals have ‘minimum essential’ health insurance coverage, and preliminary research suggests that VA enrollment increased during ACA open enrollment, particularly among low-income priority groups.6,7
Significant changes in VA healthcare utilization for this population could have important financial and logistic implications for VA. Average annual VA spending for each VA enrollee with SCI/D is $61,900 compared with $19,200 per year for the average VA enrollee.8 The VA operates a capitated system where resources are allocated to VA facilities based on average spending for patient clinical groups. If numbers of patients with SCI/D decreases, VA facilities will subsequently receive less funds. Consequently, it is important to understand patterns of VA healthcare use among this patient population. This study assessed whether there were changes in the amount and type of VA healthcare services used by non-elderly Veterans with SCI/D during the ACA era.
Materials and methods
Study design and patients
Key features of the ACA were implemented January 1, 2014 (e.g. expansion of Medicaid eligibility, implementation of Health Insurance Exchanges). We assessed VA healthcare utilization pre- (2012/13) and post-ACA (2014/15) implementation of these key features by VA enrollees with SCI/D. We identified VA enrollees with SCI/D as of January 1, 2012 who were younger than 65 years of age on December 31, 2014. These Veterans were identified using the VA Corporate Data Warehouse (CDW) and a list from the VA National SCI/D Program Office that was derived from clinical patient records maintained at VA SCI/D Centers and other VA healthcare facilities.2 Due to differences in health utilization, we excluded Veterans with acute myelitis, Guillain-Barré syndrome, multiple sclerosis, or amyotrophic lateral sclerosis. We also excluded patients who died during the study period, resulting in a final analytic sample of 8,591 Veterans (Fig. 1).
Figure 1.
Study sample.
Data sources and measures
The Medical SAS® Datasets contain information on all VA inpatient and outpatient encounters.9,10 They also include marital status. The VA Vital Status File provided date of birth, date of death, and sex. The VA Corporate Data Warehouse (CDW) Patient Domain provided race and ethnicity. VA Planning Systems Support Group provided data on VA enrollment priority.11 Injury characteristics were from the VA SCI/D National Program Office.
We examined factors that could impact access to VA care and assessed their association with VA healthcare utilization during the ACA era. We calculated distance from patients’ home ZIP code to the nearest VA facility. Distance was measured in miles as a Euclidean distance between the location of a healthcare facility and the centroid of the ZIP code of the patient’s residence and was obtained from the VA Planning Systems Support Group.11 To address concerns of nonlinearities, distance was categorized into 5 intervals (0–5, 6–10, 11–20, 21–39, 40+ miles) with those residing 40 or miles as the reference group.12 Moreover, characteristics of the cities and towns where patients reside could influence healthcare utilization. Rural Urban Commuting Area (RUCA) codes, version 2.0 were used to identify type of town by patient ZIP code.13 To facilitate analysis, the 33 RUCA codes were collapsed into four groups (urban, large rural city/town, small rural town, isolated small rural town), and isolated small rural town was the reference group.13,14
Financial incentives may also impact VA utilization. VA enrollment priority levels of 1–8 are assigned to all VA enrollees based on service-connected disability and income. The priority level influences VA copayment amounts. We created 4 groups: priority 1 and 4 (catastrophically disabled), priority 2, 3, and 6 (moderate disability), priority 5 (Medicaid assistance/low income), and priority 7 and 8 (no service-connected disability) that served as the reference group. States were assigned Medicaid expansion categories: “early expansion” states expanded Medicaid before 2014,15 “expansion” states expanded Medicaid in 2014 or 2015 (16), and the remaining states were categorized as “non-expansion”.16
SCI/D characteristics (SCI/D duration, SCI/D etiology) were provided by the VA National SCI/D Program Office.17
Healthcare utilization outcomes
Outcomes identified included total number of VA admissions and numbers of outpatient VA visits for SCI/D care, diagnostic care, primary care, specialty care, and mental health care. Outpatient utilization was categorized using CPT (current procedural terminology) codes.18
Analysis
VA healthcare utilization pre- (2012/13) and post-ACA (2014/15) implementation was examined with unadjusted bivariate analyses and regionally nested, multiple negative binomial regression models. Incident rate ratios and their 95% confidence intervals were computed. Analyses used SAS®, version 9.4 Cary, NC. This protocol was approved by the Edward Hines, Jr. VA Hospital institutional review board.
Results
Sample description
Table 1 presents patient characteristics of Veterans with SCI/D from 2011, the year before the study period (2012-2015). Our cohort was predominantly male (94.5%) with an average age of 52.2 (SD = 9.5), with an SCI/D for longer than 10 years (32.2%). Most Veterans with SCI/D were living in urban areas (85.5%) and were either catastrophically disabled (58.1%) or Medicaid assisted/low-income (21.2%).
Table 1. Patient characteristics during pre-period.
| Characteristics | N (n = 8,591) |
% |
|---|---|---|
| Age | ||
| Mean (in years) | 52.2 (sd = 9.5) | |
| Sex | ||
| Female | 475 | 5.5 |
| Male | 8,116 | 94.5 |
| Ethnicity | ||
| Hispanic | 490 | 5.7 |
| Non-Hispanic | 8,101 | 94.3 |
| Race | ||
| White | 5,493 | 63.9 |
| Black | 2,120 | 24.7 |
| Other | 978 | 11.4 |
| Medicaid Expansion under ACAa | ||
| Non-expansion state | 4,463 | 52.0 |
| Early expansion state | 1,173 | 13.7 |
| Expansion state | 2,955 | 34.3 |
| SCI Type | ||
| Tetraplegia | 2,818 | 32.8 |
| Paraplegia | 2,710 | 31.5 |
| Other SCI | 3,063 | 35.7 |
| SCI Trauma | ||
| Traumatic | 2,423 | 28.2 |
| Nontraumatic | 6,168 | 71.8 |
| SCI Duration | ||
| 0–5 YRS | 2,085 | 24.3 |
| 6–10 YRS | 984 | 11.5 |
| >10 YRS | 2,766 | 32.2 |
| Unknown | 2,756 | 32.1 |
| Type of disability | ||
| Catastrophic Disability | 4,990 | 58.1 |
| Moderate Disability | 1,163 | 13.5 |
| Medicaid Assistance/Low Income | 1,822 | 21.2 |
| No Service-Connected Disability | 427 | 5.0 |
| Unknown | 189 | 2.2 |
| Setting | ||
| Urban Focus | 7,349 | 85.5 |
| Large Rural City | 650 | 7.6 |
| Small Rural Town | 323 | 3.8 |
| Isolated Rural Town | 264 | 3.1 |
| Missing | 5 | <0.01 |
| Distance to VA | ||
| 0–5 miles | 3,155 | 36.7 |
| 6–10 miles | 1,108 | 12.9 |
| 11–20 miles | 1,205 | 14.0 |
| 21–39 miles | 1,562 | 18.2 |
| >40 miles | 1,561 | 18.2 |
Note: ACA, Affordable Care Ace; SCI, spinal cord injury; VA, Department of Veterans Affairs.
aStates were assigned into one of three categories of Medicaid expansion under the ACA. “Early expansion” states expanded Medicaid prior to 2014 (15). “Expansion” states were those that expanded Medicaid in 2014 or 2015 (16). The remaining states were delegated to the “non-expansion” category (16).
Healthcare utilization for Veterans with SCI/D
In unadjusted comparisons, all utilization outcomes showed an increase from the pre- to post-ACA implementation period, except for VA mental health visits (Fig. 2). All differences between pre- and post-ACA implementation utilization outcomes were significant except for VA SCI/D clinic visits.
Figure 2.
Unadjusted comparison of healthcare utilization among Veterans with SCI/D in the pre- and post-ACA implementation periods.
VA admissions. The total number of VA admissions were 7% higher in the post- than the pre-ACA implementation period (P < 0.01) (Table 2). Results indicated 5% fewer admissions from Hispanic than non-Hispanic Veterans (P < 0.05). Veterans with tetraplegia had 16% fewer admissions than Veterans with paraplegia (P < 0.001). Veterans with a duration of injury of less than 5 years had 44% more admissions than those who had an injury for longer than 10 years (P < 0.001). Veterans living less than 20 miles from their nearest VA facility received inpatient care more frequently than those living over 40 miles from the VA (P < 0.001).
Table 2. Incident rate ratios from negative binomial regression analyses indicating the association of Veteran characteristics with utilization of VA healthcare services.
| Characteristic | Total # of VA Admissions | Total # of VA visits to SCI clinic | Total # of VA visits to mental health | Total # of VA visits to diagnostic care | Total # of VA visits to primary care | Total # of VA visits to specialty care |
|---|---|---|---|---|---|---|
| Post ACA Implementation effect (Ref = pre-ACA implementation) | 1.07** (1.03–1.12) |
1.08** (1.03–1.13) |
0.83*** (0.78–0.90) |
1.03 (1.00–1.06) |
1.02 (0.98–1.05) |
1.12*** (1.09–1.16) |
| Age (continuous variable) | ||||||
| Years | 1.02*** (1.01–1.02) |
1.00 (1.00–1.00) |
1.00 (1.00–1.00) |
1.02*** (1.02–1.02) |
1.02*** (1.02–1.02) |
1.01*** (1.01–1.01) |
| Sex (Ref = male) | ||||||
| Female | 1.10 (0.99–1.21) |
1.14** (1.03–1.26) |
1.58*** (1.35–1.84) |
1.33*** (1.25–1.42) |
1.51*** (1.40–1.63) |
1.37*** (1.27–1.47) |
| Ethnicity (Ref = non-Hispanic) | ||||||
| Hispanic | 0.95* (0.91–1.00) |
1.14*** (1.09–1.20) |
0.99 (0.92–1.07) |
0.91*** (0.88–0.94) |
0.90*** (0.87–0.94) |
0.97 (0.95–1.01) |
| Race (Ref = white) | ||||||
| Black | 0.95* (0.91–1.00) |
1.15*** (1.09–1.20) |
0.99 (0.92–1.07) |
0.91*** (0.88–0.93) |
0.90 (0.87–0.94) |
0.98 (0.94–1.01) |
| ACA Expanders (Ref = Non- Expansion states)a | ||||||
| Early expansion state | 1.04 (0.97–1.11) |
1.57*** (1.47–1.69) |
1.10 (0.98– 1.23) |
0.92*** (0.88–0.96) |
0.94* (0.89–0.99) |
0.87*** (0.83–0.92) |
| Expansion state | 1.02 (0.97–1.07) |
0.82*** (0.78–0.87) |
1.16*** (1.07–1.26) |
0.92*** (0.89–0.95) |
1.14*** (1.09–1.19) |
0.94** (0.91–0.98) |
| SCI Level (Ref = paraplegia) | ||||||
| Tetraplegia | 0.84*** (0.79–0.88) |
0.91*** (0.86–0.96) |
0.93 (0.84–1.01) |
1.05** (1.01–1.09) |
1.04 (1.00–1.09) |
1.03 (0.99–1.08) |
| Other SCI | 0.77*** (0.70–0.84) |
0.21*** (0.19–0.22) |
1.56*** (1.34–1.82) |
1.06 (1.00–1.13) |
1.55*** (1.43–1.68) |
0.95 (0.89–1.01) |
| SCI Etiology (Ref = nontraumatic) | ||||||
| SCI traumatic | 1.13** (1.05–1.22) |
0.95 (0.88–1.02) |
0.68*** (0.60–0.77) |
0.83*** (0.78–0.87) |
0.72*** (0.67–0.76) |
0.84*** (0.80–0.89) |
| SCI unknown | 1.09* (1.01–1.18) |
1.03 (0.96–1.11) |
0.72*** (0.64–0.81) |
0.86*** (0.82–0.91) |
0.74*** (0.70–0.79) |
0.89*** (0.84–0.94) |
| SCI Duration (Ref>10yrs) | ||||||
| 0–5 YRS | 1.44*** (1.36–1.54) |
1.32*** (1.24–1.40) |
2.18*** (1.97–2.42) |
1.32*** (1.26–1.38) |
1.43*** (1.35–1.51) |
1.43*** (1.36–1.50) |
| 6–10 YRS | 1.00 (0.92–1.08) |
1.11** (1.03–1.21) |
1.16* (1.01–1.32) |
1.08** (1.03–1.15) |
1.03 (0.96–1.11) |
1.08* (1.02–1.15) |
| Unknown | 1.17** (1.06–1.30) |
0.37*** (0.34–0.41) |
1.81*** (1.54–2.14) |
1.16*** (1.09–1.25) |
1.41*** (1.30–1.54) |
1.35*** (1.26–1.46) |
| Type of disability (Ref = no service-connected disability) | ||||||
| Catastrophic Disability | 1.20*** (1.09–1.34) |
1.06 (0.95–1.17) |
1.66*** (1.41–1.96) |
1.25*** (01.17–1.34) |
1.26*** (1.16–1.37) |
1.39*** (1.29–1.50) |
| Moderate Disability | 1.18** (1.05–1.32) |
1.01 (0.90–1.14) |
1.95*** (1.63–2.34) |
1.24*** (1.15–1.34) |
1.27*** (1.15–1.39) |
1.36*** (1.26–1.48) |
| Medicaid Assistance/Low Income | 1.16** (1.04–1.30) |
0.85** (0.76–0.95) |
1.81*** (1.52–2.16) |
1.23*** (1.14–1.32) |
1.20*** (1.10–1.31) |
1.32*** (1.22–1.43) |
| Setting (Ref = Isolated rural town) | ||||||
| Urban Focus | 0.97 (0.85–1.11) |
1.27*** (1.11–1.45) |
1.10 (0.89–1.35) |
1.00 (0.91–1.09) |
0.99 (0.89–1.10) |
1.16** (1.05–1.27) |
| Large Rural City | 1.03 (0.88–1.19) |
1.07 (0.92–1.25) |
1.12 (0.88–1.43) |
0.96 (0.87–1.06) |
1.03 (0.91–1.16) |
1.03 (0.92–1.14) |
| Small Rural Town | 0.95 (0.80–1.13) |
1.04 (0.88–1.24) |
1.00 (0.76–1.31) |
0.92 (0.82–1.03) |
0.98 (0.86–1.13) |
1.02 (0.90–1.15) |
| Distance to VA (Ref≥40 miles) | ||||||
| 0–5 miles | 1.29*** (1.20–1.38) |
1.74*** (1.62–1.86) |
1.50*** (1.34–1.67) |
1.29*** (1.23–1.35) |
1.11*** (1.05–1.17) |
1.71*** (1.63–1.80) |
| 6–10 miles | 1.20*** (1.10–1.30) |
1.71*** (1.57–1.86) |
1.01 (0.89–1.15) |
1.19*** (1.13–1.26) |
1.00 (0.94–1.07) |
1.48*** (1.40–1.58) |
| 11–20 miles | 1.21*** (1.12–1.31) |
1.56*** (1.44–1.69) |
1.10 (0.96–1.25) |
1.11*** (1.05–1.17) |
1.04 (0.97–1.11) |
1.38*** (1.30–1.46) |
| 21–39 miles | 1.03 (0.96–1.11) |
1.17*** (1.09–1.27) |
0.92 (0.82–1.04) |
1.09** (1.03–1.14) |
1.00 (0.94–1.06) |
1.21*** (1.15–1.28) |
Note: ACA, Affordable Care Ace; SCI, spinal cord injury; VA, Department of Veterans Affairs. (*P < 0.05, **P < 0.01, ***P < 0.001).
aStates were assigned into one of three categories of Medicaid expansion under the ACA. “Early expansion” states expanded Medicaid prior to 2014 (15). “Expansion” states were those that expanded Medicaid in 2014 or 2015 (16). The remaining states were delegated to the “non-expansion” category (16).
VA SCI/D clinic visits. The total number of VA visits to SCI/D clinics were 8% higher in the post- than in the pre-ACA implementation period (P < 0.01) (Table 2). Women Veterans with SCI/D sought care more frequently than their male Veteran counterparts in the post-ACA implementation period with 14% more VA visits to SCI/D clinics (P < 0.01). While Hispanic Veterans sought less VA care overall, this group utilized 14% more SCI/D care at the VA than non-Hispanic Veterans in the post-ACA period (P < 0.01). Veterans with tetraplegia had 9% fewer visits to SCI/D clinics than Veterans with paraplegia (P < 0.001). Veterans with SCI/D with a duration of injury of less than 5 years had 32% more visits to SCI/D clinics than those with an injury for longer than 10 years (P < 0.001). Veterans living in urban areas had 27% more visits to SCI/D clinics than Veterans living in isolated rural areas (P < 0.001). Moreover, Veterans with SCI/D living less than 39 miles from the nearest VA facility received SCI/D care more frequently than those living over 40 miles from the VA (P < 0.001).
VA mental health visits. The total number of VA mental health visits were 17% lower in the post-ACA implementation period compared to the pre-ACA period (P < 0.001). Women Veterans with SCI/D received 58% more VA mental health visits than male Veterans in the post-ACA implementation period (P < 0.001). Veterans with tetraplegia had 7% fewer VA mental health visits than Veterans with paraplegia. Veterans with a duration of injury of less than 5 years or duration of injury between 6 and 10 years utilized more VA mental health visits than those with an injury for longer than 10 years – 118% (P < 0.001) and 16% (P < 0.05) – respectively. Veterans living less than 5 miles from the nearest VA facility received mental health care at the VA more frequently than those living over 40 miles from the VA (P < 0.001).
VA diagnostic care visits. Women Veterans sought 33% more VA diagnostic care visits than male counterparts in the post-ACA implementation period (P < 0.001). Results indicated that Hispanic Veterans had 9% fewer VA diagnostic care visits than non-Hispanic Veterans (P < 0.001). Veterans with tetraplegia sought 5% more VA diagnostic care visits than those with paraplegia (P < 0.01). Veterans with a duration of injury of less than 5 years or duration of injury between 6 and 10 years utilized more VA diagnostic care visits than those who had an injury for longer than 10 years – 32% (P < 0.001) and 8% (P < 0.01) – respectively. Findings also indicated that distance to nearest VA was associated with healthcare utilization. Those living less than 39 miles from their nearest VA facility received diagnostic care more frequently than those living over 40 miles from the VA (P < 0.01).
VA primary care visits. Consistent with other outcomes, women Veterans with SCI/D received 51% more VA primary care visits than male Veterans in the post-ACA implementation period (P < 0.001). Hispanic Veterans had 10% fewer VA primary care visits than non-Hispanic Veterans (P < 0.001). Duration of injury was also associated with the number of primary care visits with newly injured Veterans (less than 5 years) seeking 43% more VA primary care visits (P < 0.001). Distance was also an important factor where those living less than 5 miles from the nearest VA facility had more VA primary care (P < 0.001).
VA specialty care visits. The total number of VA specialty care visits was 12% higher in the post- than the pre-ACA implementation period (P < 0.001). Women Veterans utilized 37% more specialty care visits (P < 0.001). Newly injured Veterans (less than 5 years) used 43% more (P < 0.001) and those with injuries from 6 to 10 years and used 8% more (P < 0.05) specialty care visits than those with older injuries (over 10 years). Veterans living in urban areas had 16% more specialty care visits than Veterans living in isolated rural towns (P < 0.01). Veterans living less than 39 miles from the nearest VA facility received VA specialty care more frequently than those living over 40 miles from the VA (P < 0.001).
Discussion
Veterans with SCI/D sought both inpatient and outpatient care more frequently at VA facilities even after ACA implementation, suggesting that the Veteran population with SCI/D continues to utilize the lifelong, comprehensive care provided at the VA. However, when examining specific services, results revealed decreased utilization of VA mental health visits for Veterans with SCI/D. This study also identified important associations between VA utilization and sex, level and duration of injury, and distance to VA facilities.
Increased VA utilization after ACA implementation may have resulted from multiple factors, which may have been related to general increases in utilization rather than the ACA. There may have been increased efforts by VA SCI/D centers, along with ongoing training of VA SCI/D providers in spoke sites, to encourage Veterans to identify signs of potentially developing issues (e.g. signs a pressure ulcer is developing) and seek care for those issues and to encourage Veterans to obtain the recommended comprehensive annual evaluation at an SCI/D center. Additionally, increased clinical video telehealth (CVT) visits from patients at SCI/D spoke sites with providers at SCI/D centers VA may have identified health concerns that led to increased referrals for clinics and admissions. While reasons for increased VA admissions are largely speculative, it is well accepted that VA facilities do not have pressure to meet the same insurance driven admission criteria as private-sector hospitals. Consequently, less acute medical issues may be treated in acute care admissions. For example, patients with SCI/D with wounds in the private sector would go to skilled nursing facilities. However, in VA, those patients would have inpatient admissions and then begin rehabilitation after the wound had healed. Additionally, VA SCI/D centers and other VA facilities might be more attractive compared to private-sector facilities because they provide other services, including recreational and vocational services and camaraderie among other Veterans (which Veterans have reported as an important benefit of using VA facilities).18
Although the current study found an increase in VA utilization after the ACA for Veterans with SCI/D, a past study discovered significant reductions in VA utilization among Veterans aged 18–64 in states that expanded Medicaid in 2014.19 Having alternative insurance options may affect where Veterans choose to receive their health care. Other research found that nonelderly Veterans who were dually enrolled in Medicaid and VA used VA outpatient and inpatient care at similar rates as those enrolled in VA only. The exception was for outpatient specialty services like gynecology and dental care. Medicaid-reimbursed inpatient care was used more with the exception of services for mental health and respiratory issues.20 However, for Veterans with SCI/D, the VA has placed an emphasis on specialized services that are not readily available in the private sector. This decreases the need to seek non-VA specialty services. Findings of the current study confirm that VA enrollees with SCI/D continue to seek substantial care at the VA regardless of external determinants including implementation of the ACA.
Both Veterans and their providers have reported difficulties understanding and navigating policy changes under the ACA, which can impact Veteran decision-making regarding how they choose to receive their care.21 States that embraced the ACA typically chose to expand Medicaid and provide further support, such as navigators, to assist people with the ACA. Research has suggested that people often make poor judgements regarding their coverage and healthcare.20 Having access to supportive services may enhance individuals’ knowledge regarding ACA and their ability to navigate the online website, which should help them make well-informed decisions. States that did not facilitate ACA implementation (e.g. by neither expanding Medicaid nor providing additional services such as navigators) did not see these positive attenuating effects.22
Veterans with durations of injury less than 10 years tended to utilize more VA care compared to those with older injuries. In particular, Veterans with durations of injury less than 5 years appear to use VA as their primary source of care. Veterans with newer SCI/D often require more frequent, specialized services at the start to address immediate, urgent needs. For example, they have higher rates of urinary tract infections, pressure ulcers, or issues related to muscle stiffness or spasticity during the first several years post injury. Higher utilization during the early years post-injury may also reflect Veterans’ appreciation of the value of receiving coordinated care by specialists with access to their shared health information. As time progresses, secondary complication in Veterans with SCI/D shift, thus altering healthcare patterns.23,24 Veterans with tetraplegia showed lower utilization for VA admissions, SCI/D clinic visits, and mental health visits but higher utilization for diagnostic care visits, compared to Veterans with paraplegia. Veterans with paraplegia may suffer from higher rates of pain and spasticity, and possibly bladder issues. Additionally, access may be more difficult for Veterans with tetraplegia because they may be more dependent, requiring more coordination with caregivers to obtain care at VA facilities.
We found that distance to the nearest VA also plays an important role in healthcare seeking of Veterans with SCI/D. VA SCI/D Centers tend to be located in larger urban areas. However, over a third of Veterans with SCI/D reside in rural or very rural areas,25 making transportation a significant barrier to accessing care through traditional in-person clinic visits.26–28 As transportation for Veterans with SCI/D is especially difficult, those living closer to VA SCI/D Centers may be more likely to seek out VA care than those living in rural areas. Even among those seeking care at VA healthcare facilities, Veterans with SCI/D have significant mobility limitations or secondary conditions that create challenges for accessing routine and specialty health care.29,30 Consequently, expanding access to care is important to improving outcomes for this population.26,31,32 The VA has responded to these challenges by implementing telehealth technologies to allow Veterans to receive healthcare services closer to home at local VA facilities and/or in their homes.
The distance effect may also partially explain the decrease in VA mental healthcare visits as the ACA may provide more options to Veterans who live far away from their nearest VA facility. One challenge is that mental health services are often needed weekly for several months, which may be burdensome for Veterans with SCI/D who live a substantial distance from a VA facility. The ACA has opened a reimbursement stream for private providers and coverage for patients that did not previously exist that may enable patients to seek non-VA services. To ease the travel burden for VA mental healthcare services, VA has implemented several phone applications that can be downloaded on smart phones to address post-traumatic stress syndrome (e.g. PTSD Coach) and depression; however, the implications of this for Veterans with SCI/D is unknown. It is important to note that decreased utilization of VA mental health services post-ACA may also reflect factors that are unrelated to the ACA, such as concerns about stigma.33 More research is needed to understand the role of mental healthcare services available through VA and non-VA providers for Veterans with SCI/D.
These study findings have implications related to the Institute for Healthcare Improvement’s Triple Aim: improve experience of care, health of population, and cost efficiency of care. Veterans with SCI/D appear to prefer using VA care over non-VA care, as indicated by the higher utilization of VA care after the ACA was implemented. However, having alternative options for care may improve overall experience of care for Veterans with SCI/D in certain circumstances. For example, Veterans may benefit from having access to procedures/specialty care that are not readily available at the VA and/or are geographically closer at a non-VA facility. In these instances, challenges with coordinating care between VA and non-VA facilities should be considered both for the health of Veterans with SCI/D and the costs associated with care. Dual healthcare utilization has the potential to create fragmentation of care, which i may reduce efficiency in care, increase costs of care, and prevent early recognition of the need for intervention. Fragmentation of care may also reduce patient satisfaction when the patient is unclear of his/her role in the process. Gathering information and performing interventions on Veterans with SCI/D to improve their health is more easily achieved in the VA system where data are shared nationally, practice standards are established, and patients are tracked even when geographical location changes. In addition, coordination of care between VA and non-VA facilities necessitates additional VA funds to support interfacing with non-VA providers. To optimize experiences of care, health, and costs of care, VA can assist Veterans with SCI/D with centralizing care at VA facilities while also providing non-VA options to meet Veteran’s needs. If the ACA were to be repealed, Veterans with SCI/D who are eligible for VA care would still be able to receive care within the VA. However, the health and budgetary effects of repealing the ACA would need to be examined considering other policies that influence Veterans’ access to non-VA services (e.g. the VA MISSION Act).
Limitations
We assessed utilization of VA healthcare services among Veterans with SCI/D following implementation of key features of the ACA. Although we found increases in utilization of VA after ACA implementation (with the exception of mental healthcare services), we were unable assess the impact of ACA implementation on non-VA healthcare utilization.
Conclusions
VA utilization by currently enrolled Veterans with SCI/D increased from pre- to post-ACA implementation periods for total VA admissions, SCI/D visits, and specialty care visits. Overall utilization of mental health services decreased from pre- to post-ACA implementation periods. Sex, level and duration of injury, and distance to VA facilities were associated with higher VA utilization for Veterans with SCI/D. Given the associated impacts of the ACA on VA healthcare utilization, future policy research is needed to examine subsequent impacts of policies that facilitate Veterans’ access non-VA healthcare services (e.g. the VA MISSION Act) on this important and vulnerable sub population.34
Disclaimer statements
Contributors None.
Funding This study was supported by the Department of Veterans Affairs, Office of Research and Development, Health Services Research and Development Service under project IIR 14-069. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
Conflicts of interest Authors have no conflict of interests to declare.
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