Project background/rationale: In January 2014, the Affordable Care Act (ACA) will increase health insurance options for many non-elderly Veterans (<65 years old). The ACA will allow states to expand Medicaid coverage to all non-elderly individuals with incomes less than 138% of the federal poverty level. Additionally, individuals with incomes from 138% to 400% of the federal poverty level will be eligible to receive premium subsidies for obtaining private health insurance through newly established insurance exchanges. Currently, there are nearly 900,000 non-elderly Veterans whose only source of health insurance coverage is through the Veterans Health Administration (VHA). Over half (52%) of these Veterans (approximately 450,000) have incomes below 138% of the federal poverty level and could be potentially eligible for the Medicaid expansion. An additional 38% (approximately 328,000) have incomes between 138% and 400% of the federal poverty level and could be eligible for premium subsidies for coverage through the insurance exchanges. Consequently, ACA will increase access to non-VA care for a substantial portion of non-elderly Veterans. Understanding the impact of the ACA on Veterans' coverage and use of VA and non-VA care will be crucial for policymaking and planning. Project objectives: The primary aims of this study are to 1) Determine utilization of VA services overall and among priority demographic and clinical subgroups of Veterans following implementation of the ACA; 2) Determine the impact of the ACA on utilization of non-VA services overall and among priority demographic and clinical subgroups of Veterans; and 3) Describe Veterans' ACA insurance enrollment choices and experiences with care coordination immediately following ACA implementation in VISN 12. Project methods: We will use a mixed methods approach and take maximum advantage of available data sources to accomplish our aims. We will use existing VA administrative data to study VA utilization nationwide (Aim 1), leverage a unique database containing healthcare data from multiple Chicago providers to learn about non-VA use among Veterans residing in Chicago (Aim 2), and collect survey and structured interview data to study non-VA utilization and perspectives on insurance enrollment and care coordination among Veterans in VISN 12 (covering diverse populations in rural and urban areas in 4 states: Illinois, Wisconsin, Michigan, and Indiana) (Aims 2 and 3). In collaboration with stakeholders from VISN 12, key high-interest demographic subgroups (rural/urban, VA copayment required, women) and clinical subgroups (mental illness, diabetes with co-existing comorbidities, spinal cord injury/disorder) of Veterans were identified for special focus.
Implementation of the ACA has the potential to increase health insurance options for a substantial number of Veterans. Although ACA does not change eligibility for VA care, ACA may affect health care for many Veterans due to impacts on utilization of VA and non-VA services as well as through impacts on the healthcare work force and federal expenditures. The overarching objective of this proposal is to understand Veterans' decision making and behavior in regard to non-VA insurance coverage through the ACA and related impacts on VA and non-VA healthcare utilization. Through a survey of Veterans in VISN 12 combined with information from administrative databases and interviews, this study will provide crucial information to VA about the impact of ACA on utilization of VA and non-VA services following implementation of ACA.