Repealing and replacing the Affordable Care Act would likely have negative consequences for veterans, a group that Republicans lawmakers typically champion, according to a report released by the nonprofit Rand Corporation on Thursday.
Between 2013 and 2015, when the ACA’s Medicaid expansion provision went into effect and boosted enrollment, the number of uninsured non-elderly veterans fell by 36 percent ― from 9.1 percent to 5.8 percent.
It’s a common misconception that all veterans are eligible for health benefits from the Department of Veterans Affairs. According to Rand, just more than half ― 56.8 percent of non-elderly veterans ― were eligible for VA health care in 2015. And of those eligible, only 38 percent of non-elderly veterans actually enroll in VA health care. Some veterans may live too far from a VA health center to travel there, or may prefer to use a different type of health care, such as one offered through their employer. Among those who do enroll, the majority only use the VA for a portion of their health needs.
“One of the reasons we undertook the report was that we were concerned that the potential spillover effects of ACA repeal on the VA health system weren’t getting a lot of attention from the general public and potentially also from policymakers,” said Michael Dworsky, report author and associate economist at Rand.
Dworsky and his co-authors looked at three scenarios and the effect on veteran health: the current environment with the ACA in place, if the ACA had never passed in the first place, and if the ACA were to be replaced by the American Health Care Act, the stalled Republican alternative plan. This is what they found.
If the ACA had never passed
If the ACA had never been implemented, non-elderly veterans would have used 1 percent more VA health services in 2015. And while the report didn’t specifically analyze the VA’s capacity to handle that increased demand, those increases would have translated to 125,000 more VA office visits, 1,500 more VA inpatient surgeries and 375,000 more VA prescriptions in 2015.
With the ACA implemented
Thanks to the ACA’s passage, uninsured veterans fell between 2013 and 2015, with the largest reductions concentrated in states that expanded Medicaid under the ACA, including Oregon, Arkansas, Nevada, Kentucky and Washington. (Naturally, since the ACA passed, the researchers estimate that coverage changes resulted in a reduction of VA office visits, inpatient surgeries and prescriptions, by the same figures outlined above.)
If the ACA were replaced by the AHCA
To make sure lawmakers consider veteran interests in the ongoing health care debate, researchers compared the ACA to a GOP replacement plan ― the deeply unpopular AHCA ― to determine how such a change would affect veterans and their health care.
The researchers projected that if the AHCA had been in effect in 2015, 9.6 percent of non-elderly veterans would be uninsured by by 2020. By 2026, that number would climb even higher, to 10.4 percent, meaning that not only would the AHCA provisions undo the insurance gains veterans made under the ACA, but they would actually create more uninsured veterans than if the ACA had never passed in the first place.
“That goes way beyond just turning the clock back to pre-ACA status quo,” Dworsky noted.
Losing health insurance would disproportionately affect vulnerable veterans who are older, lower income and in poor health. Two of the qualifying criteria for VA health care eligibility are having a lower income or having a military service-related health condition, meaning vulnerable veterans are more likely to be VA patients in the first place.
“Coverage losses for that population are going to essentially magnify the impact of any coverage loss on VA demand,” Dworsky explained.
The Rand study also found that if the AHCA had been in effect in 2015 veterans would have likely increased their dependence on the VA. That increased dependence would translate to 245,000 more VA visits and 910,000 more VA prescriptions.
“My biggest concern would be for the veterans who become uninsured and are not eligible for VA care; or would disengage from care if their non-VA coverage were lost,” said Matthew Ronan, a hospitalist at the VA Boston Healthcare System.
The prospect of increased dependence on the VA doesn’t necessarily mean veterans would be turned away.
“With respect to the VA, I do not fear that the system as a whole could not absorb the increase in services described,” Ronan said.
“However, the distribution of those increased services would not be homogenous across the entire system. The usage rate would vary state by state, clinic by clinic, hospital to hospital, and dependent on the demographics of their veterans, individual VAs could certainly be strained if the increased population demands aligned with a resource poor area.”
While it’s unlikely that the version of the AHCA Dworsky and his coauthors analyzed will pass in that exact form, policymakers may do well to consider how health care reform that includes similar provisions would affect the VA health system.
“The goal from the outset of this was to make sure that any debate about the future of the ACA took into account the potential effects on veterans, especially the potential for spillover effects on the VA, which is also part of the federal budget,” Dworsky said.