Veterans Using and Uninsured
Veterans Not Using VA Health Care
Karin Nelson, MD, MSHS
Gordon A. Starkebaum, MD
Gayle E. Reiber, PhD, MPH
VA Puget Sound Health Care System
Department of Medicine, University of Washington
Departments of Health Services and Epidemiology,
University of Washington
Seattle, WA
Background



Department of Veterans Affairs (VA) is the
largest integrated health care system in the US
Entry into the VA based on military servicerelated conditions, disability or financial need
Some veterans who are uninsured do not seek
care despite eligibility for VA coverage
Background



Veterans can receive VA and non-VA care in
both outpatient and inpatient settings
VA data systems capture encounters within
VA system
Extent of other health care use has been
hard to quantify, especially among veterans
less than 65 years of age
Study Objectives

Describe the characteristics of veterans
who receive all or some of their care
through the VA

Describe other sources of health care
coverage for veterans

Describe uninsured veterans
(no health insurance and no use
of VA services)
Methods

Data from 2000 Behavioral Risk Factor
Surveillance System (BRFSS)
– cross sectional telephone survey
– civilian, non-institutionalized population
– state specific probability sample of households

2000 BRFSS only year with both veteran
and health insurance questions
Study population
n=184,450 BRFSS interviewed individuals
n=26,265 served in US Armed Forces
n=23,880 not active military service
n=23,797 veterans responded to questions
about use of VA health care facilities
Measures



Health insurance coverage
Demographics: age, gender, race/ethnicity,
education, annual income
Health care access
– Time since last health care visit
– Couldn’t afford a doctor visit in the past year



Health status
Disability: mental and physical health
Tobacco use
Data Analysis


Bivariate analysis to describe the
differences in socioeconomic
characteristics, health status and health
care access by use of VA services
Multivariate analysis to assess the
independent association of
socioeconomic status and receiving all
care at the VA
Veteran Characteristics by use
of VA services
%
All VA Some
Care VA care
No VA
care
n=1,647
n=20,406
n=1,744
Age > 65
White
African American
Hispanic
Annual Income < $15,000
> 8 disability days/month
36
74
15
8
23
19
47
75
13
9
14
18
36
85
7
5
6
7
*
Fair or poor health status
37
33
16
*
*
*
*
* p<0.001
Adjusted odds of veterans
receiving all health care at the VA
Population characteristic
OR
95% CI
African American
Hispanic
White
Annual income <$15,000
$15-35,000
>$35,000
< High School education
High School education
College
1.8
1.3
1.3, 2.4
0.8, 2.2
Reference
6.3
2.9
4.6, 8.7
2.3, 3.8
Reference
2.4
1.6
1.6, 3.4
1.2, 2.1
Reference
Adjusted for age and gender
Type of health care coverage by use of VA
care among veterans <65 yrs
%
All care at the Some care No VA care
VA
at the VA n=12,835
n=435
n=669
Private insurance
42.6
67.3
83.2
Medicare
36.3
21.4
5.2
Medicaid or IHS
1.8
1.3
1.3
Other insurance
5.4
1.4
1.7
No insurance
13.8
8.6
8.6
p<0.001
Characteristics of uninsured veterans, %
Uninsured
veterans
Population estimate
1,324,040
Sample size
1,216
Age 18-45 years
55.9
46-64 years
41.2
Female
8.7
White
78.1
African American
10.0
Hispanic
9.4
Annual Income < $15,000
16.0
$15,000-35,000
54.5
Could not afford MD/past yr
36.7
Veterans with
insurance
25,877,256
20,953
21.3 *
39.7
5.2 †
84.3 †
7.8
5.3
6.9 *
31.8
4.8 *
*p<0.001, † p<0.05
Limitations
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
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Self report
Suboptimal response rate
Does not include individuals without phones,
homeless individuals or those living in
institutions
Measures health insurance at one point in
time
Does not assess enrollment in VA system or
VA eligibility
Conclusions
Veterans who utilize the VA for all of their
health care are more likely to be disabled
and from disadvantaged groups
 A large number of veterans who could
use VA services are uninsured

– Potential enrollment target given the
detrimental effects of being uninsured