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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
JAMA Forum

“Have You Ever Served?” The VA and the Private Sector

I’m a veteran. I served in the US Army Nurse Corps for 3 years after I graduated from nursing school, the last 2 years of which were paid for by the Army. From 1970 to 1973, I served as a lieutenant, then a captain, at Walson Army Hospital at Fort Dix, NJ, while colleagues of mine were serving in Vietnam. Now we’re all eligible for health benefits through the Department of Veterans Affairs (VA), although those who served in Vietnam have access to a higher level of benefits and priority for enrollment in the VA health system than I do. I have never used the VA health system as a patient, but by most reports, veterans in the system receive very good care.

Diana Mason, PhD, RN

The VA runs the largest integrated health system in the country, with a budget set by Congress. Until recently, it has received widespread acclamation as a leader in patient safety and use of electronic health records with patient access. Recent disclosures of excessive wait times for veterans to enroll in the VA health system and the administrative cover-ups and falsification of wait-time data led to the resignation of VA secretary Eric Shinseki in late May. Congress called for the resignation despite the Senate’s failure to confirm 2 of 3 open assistant secretary positions for more than a year. And Congress has also passed House and Senate versions of bills that would, among other things, increase the private sector’s involvement in the care of veterans. But the private sector may be ill-prepared to ensure better care for US veterans.

In April of this year, the VA released a report showing that, of the approximately 22 million veterans, roughly 5.7 million received treatment at a VA facility in 2013.* Only about a quarter of our veterans receive care through the VA health system. Why aren’t more using it? According to the 2010 National Survey of Veterans, 72% of veterans report being in good to excellent health and are able to carry out activities of daily living without assistance. But 42% of those who have never used VA health benefits said they didn’t know about them and 26% didn’t know how to apply.

Clearly, the VA health system would be even more overwhelmed if more veterans tried to use it. With about three-quarters of veterans either not getting health care or getting it from the private sector, the suggestion that non-VA health care clinicians and facilities play a greater role in providing care to veterans seems reasonable. But Linda Schwartz, RN, PhD, commissioner of the Connecticut Department of Veterans’ Affairs and a veteran who served as an Air Force nurse during the Vietnam War (and who, for the past 10 months, has been awaiting confirmation by the Senate as assistant secretary of the VA’s Office for Policy and Planning), has argued that the private sector may be ill-equipped to deal with the special health problems arising from veterans’ occupational and military exposures—exposures that vary according to when and where they served and what work they did. For example, veterans could have health problems arising from exposure to Agent Orange (Vietnam and Korea), contaminated water (Camp Lejeune, 1957-1987), oil-well fires and open burn pits (Iraq and Afghanistan), and radiation (“Atomic Veterans”).

The VA’s health care professionals are experts in the diagnosis and management of the consequences of these exposures. Most clinicians in the private sector are not. In fact, a 2011 online survey of community-based mental health and primary care professionals found that 56% of the respondents failed to ask patients whether they have ever served in the military or are family members of those who have served. If this is never asked, it’s easy to understand how, as Schwartz noted in her commencement address at Quinnipiac University School of Nursing in May, a veteran may be living with chronic pain or other debilitating condition arising—perhaps unknowingly by even the veteran and his or her health care providers—from a service-related injury or exposure that may be treatable if properly diagnosed.

Schwartz was instrumental in the development of an initiative of the American Academy of Nursing (disclosure: Schwartz is an academy fellow and I am the academy’s current president), in partnership with the National Association of State Directors of Veterans Affairs, called “Have You Ever Served in the Military?” The initiative seeks to raise the awareness of veterans’ health needs among clinicians in the private sector and includes materials for health care professionals that link time and site of military service, occupation, potential exposures and injuries, and relevant diagnoses. In addition, the initiative aims to embed the question “Have you ever served?” into electronic health records and include an algorithm to direct clinicians’ subsequent line of assessments.

It all begins by asking: “Have you ever served in the military?”

In May, the state of Connecticut passed Public Act 14-141, requiring, among other things, that “Whenever a person is admitted to a hospital, such person shall be asked if he or she is a veteran.”  Schwartz told the graduates at Quinnipiac about the genesis of that law. A couple of years ago she was involved in helping a veteran from Maine, a man hospitalized with a life-threatening condition while visiting his mother in Connecticut. A veterans services officer questioned the patient about his service; the officer realized that the man had been exposed to Agent Orange in the 1960s. The patient was subsequently diagnosed with non-Hodgkin’s lymphoma—a possible consequence of the exposure.

In writing this blog post, I realize that I have never disclosed to any health care provider in the past 40 years that I am a veteran. Even as a nurse, I never thought to offer the information during a health care visit. And no one has ever asked.

*Exact numbers on veterans are difficult to obtain and vary by source.

About the author: Diana J. Mason, PhD, RN, is the Rudin Professor of Nursing and Codirector of the Center for Health, Media, and Policy at the Hunter College; Professor at the City University of New York; and President of the American Academy of Nursing.