Downloaded from http://journals.lww.com/lww-medicalcare by BhDMf5ePHKbH4TTImqenVBLNPkpHwi7kfxnd+xQxxRDGYpYFarlAMmziFQ0oAdQ6jSdlscyh6l8= on 10/06/2020 Did the Affordable Care Act Decrease Veteran Enrollment in the Veterans Health Administration? Abigail Silva, PhD, MPH,*† Elizabeth Tarlov, PhD, RN,*‡ Beverly Gonzalez, PhD,* Bridget M. Smith, PhD,*§ Dustin D. French, PhD,*§ Timothy P. Hogan, PhD,∥¶ Neil Jordan, PhD,*§ Zhiping Huo, MS,* Rachael N. Martinez, PhD,* Dolores Ippolito, MPH,* and Kevin T. Stroupe, PhD*† Background: Provisions of the Affordable Care Act (ACA) pro- vided nonelderly individuals, including Veterans, with additional health care coverage options. This may impact enrollment for health care through the Veterans Health Administration (VHA). National enrollment data was used to: (1) compare characteristics of enrollees at 3 time points in relation to the implementation of ACA insurance provisions (2012); and (2) examine enrollment trends. Methods: The study population included a 10% sample of Veterans under age 65 who were VHA enrollees between January 2012 and September 2015. Demographic and baseline characteristics were com- pared between 3 enrollment groups: pre-2012, pre-ACA (2012–2013), and post-ACA (2014–2015). Using an interrupted time series approach, we employed pooled logistic regression to assess trends in new VHA enrollment, overall, and by select enrollee characteristics. Results: A total of 429,833 enrollees were identified. Compared with pre-ACA enrollees, post-ACA enrollees were more likely to be older, have a service-connected disability, live further away from a VHA medical center, but less likely to use primary care within 6 months. The post-ACA quarterly trend in the odds of being a new enrollee was 3% lower (95% confidence interval: 0.96, 0.98) as compared with the pre-ACA trend. This decline was consistent across sex, geography, (all but 1) priority group, and state Medicaid-expansion subgroups. Conclusions: The ACA appears to have contributed to a decline in new VHA enrollment. In addition, the profile of newer enrollees differs from that of pre-ACA enrollees. The VHA must continue to monitor trends in demand in order to continue delivering high-quality, efficient care. Key Words: Affordable Care Act, veterans, enrollment, Veterans Health Administration (Med Care 2020;58: 703–709) I n 2010, 10.5% of the estimated 12.5 million US military Veterans under age 65 lacked health insurance. 1 Health care through the Veterans Health Administration (VHA) is an option for some of these Veterans if they meet eligibility criteria 2 ; however, many do not enroll. 3 It is not entirely clear why eli- gible Veterans do not enroll for VHA benefits, particularly if they have no health insurance. It may be that they live too far from the nearest VHA facility, have no need for care, or are unaware of the benefits available to them. 3–8 Some may per- ceive barriers related to quality or culture. 6,9,10 Recent health care reform may impact VHA enrollment, however. Health care coverage-related provisions of the 2010 Patient Protection and Affordable Care Act (ACA) aimed to reduce the number of uninsured individuals, including Veterans. 11,12 One way that the ACA aimed to increase coverage is by implementing the shared responsibility provision (ie, the individual mandate) which required everyone to have “minimum essential health coverage.” This may have encouraged substantial new VHA en- rollment among the estimated 1.3 million previously uninsured Veterans not using VHA services because enrollment qualifies as “minimum essential coverage.” 1,11 In addition, it requires little or no out-of-pocket expenses. Uninsured Veterans could also meet the mandate by tapping into other options brought about by the ACA. For instance, Veterans with incomes at or below 138% of the federal poverty level would become eligible for Medicaid coverage in some states. For Veterans with incomes between 100% and 400% of the federal poverty level, the federal govern- ment would help subsidize monthly premiums for plans purchased through the Individual Health Insurance Marketplace. While the ACA does not target Veterans specifically, its mechanisms for increasing non-VHA insurance may have substantial, yet un- certain, implications for VHA. Data from national population-based surveys and the US census show a decrease in the proportion of uninsured Veterans since the implementation of ACA insurance provisions in 2014, From the *Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines; †Parkinson School of Health Sciences and Public Health, Loyola University Chicago; ‡College of Nursing, University of Illinois at Chicago; §Northwestern University Feinberg School of Medicine, Chicago IL; ∥Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; and ¶Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX. This study was supported by the Department of Veterans Affairs, Office of Research and Development, Health Services Research and Development Service project IIR 14-069-2. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. The authors declare no conflict of interest. Correspondence to: Abigail Silva, PhD, MPH, Center for Innovation in Complex Chronic Healthcare, Hines VA Hospital, 5000 South 5th Ave- nue (151H), Hines, IL 60141. E-mail: asilva8@luc.edu. Supplemental Digital Content is available for this article. Direct URL cita- tions appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website, www.lww-medicalcare. com. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0025-7079/20/5808-0703 ORIGINAL ARTICLE Medical Care  Volume 58, Number 8, August 2020 www.lww-medicalcare.com | 703 Copyright r 2020 Wolters Kluwer Health, Inc. All rights reserved.