Identifying and Managing Veteran Suicide Risk: Proceedings of a Workshop (2023)
Chapter: 3 The Policy Context for Veteran Health Care
3
The Policy Context for Veteran Health Care
DETERMINING VETERAN STATUS AND CRITERIA FOR VA HEALTH CARE
Heather M. Salazar (RAND Corporation’s Office of Congressional Affairs; RAND Epstein Family Veterans Policy Research Institute) explained that 38 U.S.C. §101(2)1 and 38 C.F.R. §3.1(d)2 contain the definition of “veteran,” but several subcategories of this definition—for example, Vietnam-era herbicide-exposed veteran, radiation-exposed veteran, covered veteran, and toxic-exposed veteran—are used to determine veterans’ eligibility for health care.
Generally speaking, Salazar continued, a veteran is “a person who served in the active military, naval, air, or space service,3 and who was discharged or released therefrom under conditions other than dishonorable.” DOD-established military discharge status determines a service member’s access to VA benefits, including health care. Those with an “honorable” discharge have access to VA programs; those with a “general” discharge have access to all VA programs except GI Bill benefits; those with an “other than honorable” discharge have access to some VA programs; and those with a “bad conduct” or “dishonorable” discharge do not have access to
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1 https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title38-section101&num=0&edition=prelim
2 https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title38-section101&num=0&edition=prelim
3 “Space service” refers to those who served in the U.S. Space Force—not National Aeronautics and Space Administration employees.
VA programs. Those with an “other than honorable” discharge, a “bad conduct” discharge, or a “dishonorable” discharge have an opportunity to participate in a VA benefit eligibility review process. During this review process, VA assesses the veteran’s entire period of military service to make a determination about the “character of discharge;” that is, whether the discharge should be characterized as “honorable for VA benefits,” “eligible for health care only” (e.g., for service-connected disabilities), or “dishonorable for VA benefits.”
Salazar indicated that participating in VA health care requires two steps: (a) determination of eligibility and (b) enrollment. She emphasized that health care is not an automatic or guaranteed benefit owing to the state of congressional budgets; therefore, sometimes people are “eligible” based on military service but are unable to “enroll.” For example, when discretionary funds are depleted, not everyone can be covered; those without a service-connected disability and those with a high level of income might face enrollment barriers.
Salazar elaborated that the VA health care package for enrolled veterans typically includes preventive care, primary care, inpatient hospital services, emergency care, medical and surgical specialty care, prescription medications, durable medical equipment, and prosthetic devices. VA care may also include preventive audiology and eye care services and routine vision testing, as well as eyeglasses and hearing aids for veterans who meet certain criteria. She added that enrolled veterans do not pay premiums or deductibles, as VA health care is not a health insurance program.
Salazar noted that veterans who are eligible and enrolled are placed in one of eight “priority groups” (see Table 3-1). These categories are based on income, service connection, and statutory requirements.4 For example, Groups 1 and 2 include veterans with the most severe disabilities who are not required to make copayments for primary or specialty care. Veterans in Groups 7 and 8, which are based on both a national and a geographical threshold for income, are required to make copayments5 for primary and specialty care. Salazar noted that the number of veterans in each priority group varies; Group 1 had the highest number of unique patients in 2022.
Salazar provided an overview of several significant legislative initiatives over the past five years to expand VA health care eligibility and enrollment:
- Commander John Scott Hannon Veterans Mental Health Care Improvement Act of 2019;6
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4 https://www.va.gov/health-care/eligibility/priority-groups/
TABLE 3-1 VA Health Care Priority Groups
| Group | Veterans’ Criteria |
|---|---|
| 1 |
Service-connected disabilities rated at 50%a or greater Received Medal of Honor Determined to be unemployable due to service-connected disability |
| 2 |
Service-connected disabilities rated at 30% or 40% |
| 3 |
Service-connected disabilities rated at 10% or 20% Former Prisoner of War Discharged for a disability incurred or aggravated in the line of duty Received Purple Heart Disabled by treatment or vocational rehabilitation |
| 4 |
Receiving VA Aid and Attendance benefitsb Receiving housebound benefits Determined to be catastrophically disabled |
| 5 |
Receiving VA pension benefits Eligible for Medicaid benefits No service-connected disability or a non-compensable service-connected disability rated at 0% and annual income level below VA adjusted income limits |
| 6 |
Compensable service-connected disability rated 0% Toxic-exposed veteransc Certain statutory authorities Combat veterans Currently/newly enrolled and served in specific theater of combat operations and discharged less than 10 years agod |
| 7 |
Gross household income is below geographically adjusted income limits and agree to pay applicable copays |
| 8 |
Gross household income above VA income limits and geographic income limits and agree to pay copayments, and meet one of the subcategory requirements of this group |
a For more information on VA disability ratings, see https://www.va.gov/disability/about-disability-ratings/
b https://www.va.gov/pension/aid-attendance-housebound/
c Defined in 38 U.S.C. §101(38) per the PACT Act
d Enhanced enrollment period for 10 years after discharge on a rolling basis per the provisions of the PACT Act. At end of this period, veteran will be assigned highest priority group qualified for. Veterans will also have a phased-in enrollment period based on discharge date.
SOURCE: Adapted from Heather Salazar’s presentation at the Workshop on Identifying and Managing Veteran Suicide Risk in Non-VA Healthcare Settings, May 23, 2023.
- Blue Water Navy Act of 2019;7
- COMPACT Act of 2020;8 and
- Sergeant First Class Heath Robinson Honoring Our Promise to Address Comprehensive Toxics (PACT) Act of 2022.9
The Blue Water Navy Act of 2019 in particular “expanded eligibility for the presumption of service connection due to herbicide exposure conditions already determined to be presumptive” for veterans who served on a Coast Guard or Navy vessel off the coast of Vietnam, based on dates of service and exact coordinates of ship crossings.10 The Sergeant First Class Heath Robinson Honoring Our PACT Act expanded eligibility for certain Vietnam-era veterans and radiation-exposed veterans to include both VA health care and disability compensation. For certain Gulf War and post-9/11-era veterans, the PACT Act grants more than 20 new presumptions related to toxic exposures, extends times and locations of service, and extends periods of enrollment for VA health care based on discharge status by an additional five years.11 She remarked that both the Commander John Scott Hannon Veterans Mental Health Care Improvement Act and the COMPACT Act, as well as the VA Interim Final Rule on Emergent Suicide Care, focus specifically on providing mental health care for veterans in crisis.
APPLYING THE VA/DOD CLINICAL PRACTICE GUIDELINE FOR THE ASSESSMENT AND MANAGEMENT OF PATIENTS AT RISK FOR SUICIDE
Lisa A. Brenner12 (University of Colorado, Anschutz Medical Campus; VA Rocky Mountain Mental Illness Research, Education, and Clinical Center [MIRECC]) expressed her belief that everyone should receive personalized and evidence-based health care. She encouraged leveraging VA funds for interventions that are proven to be effective. For example, the best science to date was used in 2019 to create the current VA/DOD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide (CPG)13 to assess and manage patients at risk for suicide, and this guideline will be revised to support veteran health care further as the
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7 https://www.congress.gov/bill/116th-congress/house-bill/299/text
8 https://www.congress.gov/bill/116th-congress/house-bill/8247
9 https://www.congress.gov/bill/117th-congress/house-bill/3967/text
10 https://www.va.gov/Blue_Water_Navy_Factsheet.pdf#
11 https://www.va.gov/resources/the-pact-act-and-your-va-benefits/
12 The remarks presented by Lisa Brenner reflect her own views and do not necessarily represent the views of the Department of Veterans Affairs or the U.S. government.
science continues to advance.14 She added that the 2019 CPG was the first to be guided by evidence-based ratings instead of mostly expert opinion. Given the high level of oversight in VA, she stressed that accountability to use the best science for decision making is critical.
Brenner explained that the evidence to support the 22 recommendations in the 2019 CPG was “rated” on relative strength of the evidence, “strong” or “weak,” and on the direction of the evidence, “for” or “against.” She described the evidence-based process for creating this CPG, which included multiple meetings among VA and DOD multidisciplinary experts, 12 key questions, a systematic literature review conducted by an independent third party, an evaluation of individual studies as well as of the body of evidence, a peer review process, and feedback from veterans and active-duty service members. This process helped reveal areas for which sufficient research had been conducted and areas for which more research would be beneficial.
Brenner noted that the 2019 CPG recommendations are organized into the following three categories: screening and evaluation, risk management and treatment (non-pharmacologic, pharmacologic, post-acute care, and technology-based modalities), and other management modalities. For example, within the category of screening and evaluation, evidence is “strong for,” and thus the CPG recommends, “an assessment of risk factors as part of a comprehensive evaluation of suicide risk, including, but not limited to, current suicidal ideation, prior suicide attempt(s), current psychiatric conditions (e.g., mood disorders, substance use disorders) or symptoms (e.g., hopelessness, insomnia, and agitation), prior psychiatric hospitalization, recent bio-psychosocial stressors, and the availability of firearms” (Department of Veterans Affairs & Department of Defense, 2019, p. 31). Within the category of non-pharmacologic risk management and treatment, evidence is “strong for,” and thus the CPG recommends, “using cognitive behavioral therapy–based interventions focused on suicide prevention for patients with a recent history of self-directed violence to reduce incidents of future self-directed violence” (Department of Veterans Affairs & Department of Defense, 2019, p. 35). In this same category, the evidence is “weak for,” and thus the CPG suggests (rather than recommends), “completing a crisis response plan for individuals with suicidal ideation and/or a lifetime history of suicide attempts” (Department of Veterans Affairs & Department of Defense, 2019, p. 37). She remarked that evidence related to pharmacologic risk management and treatment is lacking, and more research would be beneficial. Post-acute care risk management and treatment also demands further research, but she shared two “weak fors:” “We suggest sending periodic caring communications (e.g., postcards) for 12–24 months in
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14 The next version will be released in 2024.
addition to usual care after psychiatric hospitalization for suicidal ideation or a suicide attempt . . . [and] offering a home visit to support reengagement in outpatient care among patients not presenting for outpatient care following hospitalization for a suicide attempt” (Department of Veterans Affairs & Department of Defense, 2019, pp. 44–45). She indicated that almost no evidence exists about how to use technology-based modalities for risk management and treatment or about community-based interventions and partnerships, but both areas are ripe for opportunity.
Brenner stressed that the CPG should be accessible to providers as well as to patients and families so that they understand what care exists and what care is being offered; a CPG website15 is now available to increase access to the best evidence to date. She reiterated that everyone should have access to the best care, and these high standards of evidence and quality are critical for both mental and physical health care. For example, the Suicide Risk Management Consultation Program16 presents an opportunity for any provider who serves veterans to consult with experts at the Rocky Mountain MIRECC about using the best evidence-based practices to support their individual patients.
DISCUSSION
Edward R. Hirt (Department of Psychological and Brain Sciences, Indiana University; workshop planning committee member) moderated a discussion among the session’s speakers.
Rajeev Ramchand (RAND Epstein Family Veterans Policy Research Institute; RAND Corporation; workshop planning committee member) asked how VA ensures that its providers adhere to the CPG. Brenner replied that all VA health care providers are held accountable based on specific metrics for evidence-based interventions. The implementation of an intervention (e.g., universal screening for suicide risk) can be tracked in real time using dashboards that provide feedback down to the patient level (e.g., who should be screened and who has not been screened for suicide risk). She said that these metrics highlight how VA sites are performing as well as enable facilitation, education, and problem-solving around clinical care pathways to improve health care systems. Timothy Strauman (Department of Psychology and School of Medicine, Duke University; workshop planning committee chair) commended VA for developing and continually revising the CPG and for putting its own practices “under the microscope.” He noted that such a high level of accountability for individual practitioners does not yet exist in many non-VA health care systems.
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Ramchand wondered whether the criteria for quality and evidence-based practice can be applied more broadly when such a limited supply of mental health care providers is available—that is, is some care better than no care? Brenner responded that having a provider who will listen to a veteran’s story is beneficial, but care that is neither evidence-based nor of high quality is less likely to alleviate symptoms of posttraumatic stress disorder. She added that the Rocky Mountain MIRECC and the VA Office of Mental Health and Suicide Prevention are working together to develop online evidence-based interventions (e.g., online cognitive behavioral therapy for suicide prevention and for depression) for veterans who may not want to see a mental health provider to work through in real time in the privacy of their own homes.
Workshop participant Thomas Kauffmann observed that the health care community would benefit from a better, more consistent definition of “evidence based.” According to Brenner, rigorous evidence review requires examination of comparators. For example, evidence for a particular intervention is considered “strong” when several studies demonstrate that the treatment outperforms other treatments.
With regard to clinical practice guideline levels of evidence, Matthew Miller asked how a particular intervention could advance to a “strong for” if VA has not implemented it because evidence is lacking. Brenner explained that new methods are emerging to overcome the challenges associated with the slow-moving nature of clinical trials, which provide most of the evidence. For example, in the case of universal screening for suicide risk, “strong” evidence does not yet exist, but evidence is being collected while the intervention is being implemented and may be noted as “strong for” universal screening in the next version of the CPG. She added that VA also de-implements interventions that are no longer successful and replaces them with more effective, evidence-based interventions. Miller posed a follow-up question about areas in which VA succeeds and areas that need improvement in terms of implementing evidence-based care while still offering personalized care. Brenner proposed developing mechanistic flow pathways and processes ahead of time to increase efficiency, so that providers can better focus on providing personalized care to veterans.
Miller pointed out that VA does not have input in defining “veteran” and “eligibility,” as this responsibility falls solely with Congress. As a result, the law sometimes prevents VA from being able to provide care to certain veterans in need. He suggested better equipping communities and veterans to advocate to Congress on issues of veteran health care eligibility. Salazar agreed and echoed the frustration that arises when VA cannot implement proposed improvements to better support veterans due to the restrictions determined by Congress.
REFERENCE
Department of Veterans Affairs & Department of Defense. (2019). VA/DOD clinical practice guideline for the assessment and management of patients at risk for suicide. https://www.healthquality.va.gov/guidelines/MH/srb/VADoDSuicideRiskFullCPGFinal5088212019.pdf
