View source for Veterans Health Administration

{{Short description|Health service for former United States military personnel}}
{{Organization 
|OrganizationName=Veterans Health Administration
|OrganizationType=Executive Departments (Sub-organization)
|Mission=The Veterans Health Administration (VHA) provides primary care, specialized care, and related medical and social support services to America's veterans. Its mission is to improve the health of the nation's veterans by delivering high-quality, accessible, and patient-centered health care that promotes wellness and fosters trust.
|OrganizationExecutive=Under Secretary for Health
|Employees=371000
|Budget=$105B (FY 2024)
|Website=https://www.va.gov/health/
|Services=Primary care; Mental health services; Specialty care; Long-term care; Research; Education; Telehealth
|ParentOrganization=United States Department of Veterans Affairs
|CreationLegislation=Veterans' Administration Act of 1930; Department of Veterans Affairs Act of 1988
|Regulations=Administers health care regulations specific to veteran benefits and services
|HeadquartersLocation=38.897328, -77.041357
|HeadquartersAddress=810 Vermont Avenue NW, Washington, DC 20420, USA
}}
{{Infobox government agency
| agency_name     = U.S. Department of Veterans Affairs<br>Veterans Health Administration
| logo            = [[File:US Veterans Health Administration logo stacked.png|300px]]
| logo_caption    = Logo
| formed          = {{start date and age|1865}}<ref>{{cite web |url=https://www.va.gov/about_va/vahistory.asp |title=VA History  |website= VA.gov| publisher= Veterans Health Administration, US Department of Veterans Affairs |archive-url= https://web.archive.org/web/20200424023518/https://www.va.gov/about_va/vahistory.asp |archive-date=April 24, 2020 |access-date=July 9, 2017}}</ref>
| preceding1      = Veterans Health Service
| jurisdiction    = [[Federal government of the United States]]
| headquarters    = Veteran Affairs Building<br>810 Vermont Avenue NW., [[Washington, D.C.]], US
| coordinates     = {{coord|38|54|03|N|77|02|05|W|type:landmark_region:US-DC|display=inline}}
| employees       = 350,790 (2021)<ref name="va">{{cite web |website= VA.gov| publisher= Department of Veterans Affairs |url=https://www.va.gov/budget/products.asp |title=Office of Budget |date=February 2022 |access-date=April 30, 2022}}</ref>
| budget          = FY2022: $97.5 billion [[United States dollar|USD]] (appropriated)<ref name="va" /><br>FY2023: $113.3 billion [[United States Dollars|USD]] (advance appropriation)<br>FY2023: $122.7 billion [[United States dollar|USD]] (budget request)
| chief1_name     = [[Shereef Elnahal]], MD
| chief1_position = [[Under Secretary of Veterans Affairs for Health]]
| chief2_name     = Steven L. Lieberman, MD
| chief2_position = Principal Deputy Under Secretary for Health
| parent_department = [[United States Department of Veterans Affairs]]
| website         = {{URL|https://www.va.gov/HEALTH/}}
| footnotes       = 
}}

The '''Veterans Health Administration''' ('''VHA''') is the component of the [[United States Department of Veterans Affairs]] (VA) led by the [[Under Secretary of Veterans Affairs for Health]]<ref name="va" /> that implements the healthcare program of the VA through a [[Nationalized health care|nationalized healthcare service]] in the United States, providing healthcare and healthcare-adjacent services to [[veteran]]s through the administration and operation of 146 VA Medical Centers (VAMC) with integrated outpatient clinics, 772 Community Based Outpatient Clinics (CBOC), and 134 VA Community Living Centers (VA Nursing Home) Programs. It is the largest division in the department, and second largest in the entire federal government, employing over 350,000 employees. All VA hospitals, clinics and medical centers are owned by and operated by the Department of Veterans Affairs (as opposed to private companies), and all of the staff employed in VA hospitals are federal employees .<ref>{{cite web |last=Wallace |first=Gregory |date=2014-09-19 |title=VA hikes top pay for doctors by $20,000 to $35,000 |url= https://money.cnn.com/2014/09/19/news/economy/veterans-affairs-doctor-pay/index.html |archive-url= https://web.archive.org/web/20200319053058/https://money.cnn.com/2014/09/19/news/economy/veterans-affairs-doctor-pay/index.html |archive-date=March 19, 2020 |access-date=2020-03-18 |website=CNNMoney}}</ref> Because of this, veterans that qualify for VHA healthcare do not pay premiums or deductibles for their healthcare but may have to make copayments depending on the medical procedure.<ref>{{Cite web |date=2019-08-08 |title=Your health care costs |url= https://www.va.gov//health-care/about-va-health-benefits/cost-of-care |access-date=2020-03-18 |website= VA.gov| publisher= Department of Veterans Affairs |language= en}}</ref><ref>{{Cite web |title=Non-Enrolled Veterans -- VA, Affordable Care Act and You |url= https://www.va.gov/health/aca/NonEnrolledVeterans.asp  |website= VA.gov| publisher= Department of Veterans Affairs|access-date= 2020-03-18}}</ref> VHA is not a part of the [[United States Department of Defense|US Department of Defense]] [[Military Health System]].

Many evaluations have found that by most measures VHA care is equal to, and sometimes better than, care provided in the private sector, when judged by standard evidence-based guidelines.{{refn|<ref>{{Cite journal|last1=Barry|first1=Catherine N.|last2=Bowe|first2=Thomas R.|last3=Suneja|first3=Anecia|date=August 1, 2016|title=An Update on the Quality of Medication Treatment for Mental Disorders in the VA|journal=Psychiatric Services|volume=67|issue=8|page=930|doi=10.1176/appi.ps.670804|pmid=27476899|issn=1075-2730|doi-access=free}}</ref><ref>{{Cite journal|last1=Watkins|first1=Katherine E.|last2=Smith|first2=Brad|last3=Akincigil|first3=Ayse|last4=Sorbero|first4=Melony E.|last5=Paddock|first5=Susan|last6=Woodroffe|first6=Abigail|last7=Huang|first7=Cecilia|last8=Crystal|first8=Stephen|last9=Pincus|first9=Harold Alan|date=November 16, 2015|title=The Quality of Medication Treatment for Mental Disorders in the Department of Veterans Affairs and in Private-Sector Plans|journal=Psychiatric Services|volume=67|issue=4|pages=391–96|doi=10.1176/appi.ps.201400537|pmid=26567931|issn=1075-2730|doi-access=free}}</ref><ref>{{Cite journal|last1=Asch|first1=Steven M.|last2=McGlynn|first2=Elizabeth A.|last3=Hogan|first3=Mary M.|last4=Hayward|first4=Rodney A.|last5=Shekelle|first5=Paul|last6=Rubenstein|first6=Lisa|last7=Keesey|first7=Joan|last8=Adams|first8=John|last9=Kerr|first9=Eve A.|date=December 21, 2004|title=Comparison of Quality of Care for Patients in the Veterans Health Administration and Patients in a National Sample|journal=Annals of Internal Medicine|language=en|volume=141|issue=12|pages=938–45|doi=10.7326/0003-4819-141-12-200412210-00010|pmid=15611491|s2cid=35973709 |issn=0003-4819|doi-access=}}</ref><ref>{{Cite journal|last=Kerr|first=Eve A.|date=August 17, 2004|title=Diabetes Care Quality in the Veterans Affairs Health Care System and Commercial Managed Care: The TRIAD Study|journal=Annals of Internal Medicine|language=en|volume=141|issue=4|pages=272–81|doi=10.7326/0003-4819-141-4-200408170-00007|pmid=15313743|s2cid=21756356 |issn=0003-4819|url=https://escholarship.org/uc/item/81h1r96k}}</ref><ref>{{Cite journal|last1=Trivedi|first1=Amal N.|last2=Matula|first2=Sierra|last3=Miake-Lye|first3=Isomi|last4=Glassman|first4=Peter A.|last5=Shekelle|first5=Paul|last6=Asch|first6=Steven|date=2011|title=Systematic Review: Comparison of the Quality of Medical Care in Veterans Affairs and Non-Veterans Affairs Settings|journal=Medical Care|volume=49|issue=1|pages=76–88|jstor=25767038|pmid=20966778|doi=10.1097/mlr.0b013e3181f53575|s2cid=36506752 }}</ref><ref>{{Cite journal|last1=Keating|first1=Nancy L.|last2=Landrum|first2=Mary Beth|author2-link=Mary Beth Landrum|last3=Lamont|first3=Elizabeth B.|last4=Bozeman|first4=Samuel R.|last5=Krasnow|first5=Steven H.|last6=Shulman|first6=Lawrence N.|last7=Brown|first7=Jennifer R.|last8=Earle|first8=Craig C.|last9=Oh|first9=William K.|date=June 7, 2011|title=Quality of Care for Older Patients With Cancer in the Veterans Health Administration Versus the Private Sector|journal=Annals of Internal Medicine|language=en|volume=154|issue=11|pages=727–36|doi=10.7326/0003-4819-154-11-201106070-00004|pmid=21646556|s2cid=207536127 |issn=0003-4819}}</ref><ref>{{Cite book|url=https://www.ncbi.nlm.nih.gov/books/NBK49108/|title=Comparison of Quality of Care in VA and Non-VA Settings: A Systematic Review|last1=Shekelle|first1=Paul G.|last2=Asch|first2=Steven|last3=Glassman|first3=Peter|last4=Matula|first4=Sierra|last5=Trivedi|first5=Amal|last6=Miake-Lye|first6=Isomi|date=2010|publisher=Department of Veterans Affairs (US)|series=VA Evidence-based Synthesis Program Reports|location=Washington (DC)|pmid=21155199}}</ref><ref>{{Cite journal|title= Quality and Equity of Care in the Veterans Affairs Health-Care System and in Medicare Advantage Health Plans|journal=Medical Care|volume=49|issue=6|pages=560–8|language=en-US|doi=10.1097/MLR.0b013e31820fb0f6|pmid=21422951|year=2011|last1=Trivedi|first1=Amal N|last2=Grebla|first2=Regina C|s2cid=23926259 }}</ref><ref>{{Cite journal|last1=Lancaster|first1=Robert T.|last2=Tanabe|first2=Kenneth K.|last3=Schifftner|first3=Tracy L.|last4=Warshaw|first4=Andrew L.|last5=Henderson|first5=William G.|last6=Khuri|first6=Shukri F.|last7=Hutter|first7=Matthew M.|date=June 1, 2007|title=Liver Resection in Veterans Affairs and Selected University Medical Centers: Results of the Patient Safety in Surgery Study|journal=Journal of the American College of Surgeons|volume=204|issue=6|pages=1242–51|doi=10.1016/j.jamcollsurg.2007.02.069|pmid=17544082}}</ref><ref>Longman, Phillip. ''Best care anywhere''. Berrett-Koehler Publishers, 2010.</ref>}} A 2009 [[Congressional Budget Office]] report on the VHA found that "the care provided to VHA patients compares favorably with that provided to non-VHA patients in terms of compliance with widely recognized clinical guidelines — particularly those that VHA has emphasized in its internal performance measurement system. Such research is complicated by the fact that most users of VHA's services receive at least part of their care from outside providers."<ref name="CBO" />[[File:VA 2015-2019 Health Programs Budget Allocation.png|thumb|Medical Program Budget Allocation 2015–2019.  Data comes from VA budget submissions.<ref name=":1">{{Cite web |title=Annual Budget Submission |url= https://www.va.gov/budget/products.asp |access-date=2020-03-18  |website= VA.gov| publisher= Office of Budget, Department of Veterans Affairs |language=en}}</ref>]]

==History==
The first Federal agency to provide medical care to veterans was the Naval Home in [[Philadelphia]], [[Pennsylvania]]. The home was created in 1812 and was followed by the creation of Soldiers Home in 1853 and [[St. Elizabeth's Hospital]] in 1855. Congress created the National Home for Disabled Volunteer Soldiers in 1865 in response to the high number of [[American Civil War|Civil War]] casualties. These homes were initially intended to be room and board for disabled veterans. However, by the late 1920s, the homes were providing a level of care comparable to hospital care.

President Hoover created the Veterans Administration (VA) in 1930 to consolidate all veteran services. General [[Omar N. Bradley]] was appointed to VA administrator and Bradley appointed Major General [[Paul Ramsey Hawley|Paul Hawley]] as director of VA medicine, both in 1945. Hawley successfully established a policy that affiliated new VA hospitals with medical schools.  Hawley also promoted resident and teaching fellowships at VA hospitals. Ultimately, Hawley was responsible for starting the hospital-based research program at the VA.  Bradley resigned in 1947. However, upon resignation, 97 hospitals were in operation and 29 new hospital had been built.  As a result, the VA health system was able to serve a much larger population of veterans than it had served in previous years.

In 1988, President Reagan signed the [[Department of Veterans Affairs Act]], which elevated the VA to [[United States Cabinet|Cabinet]]-level, then becoming known as the Department of Veterans Affairs. The Department of Veterans Affairs oversees the Veterans Health Administration.<ref>{{cite journal|title=VA History in Brief|url=http://www.va.gov/opa/publications/archives/docs/history_in_brief.pdf|publisher=United States Department of Veterans Affairs|access-date=May 30, 2014|archive-date=July 19, 2021|archive-url=https://web.archive.org/web/20210719122457/https://www.va.gov/opa/publications/archives/docs/history_in_brief.pdf|url-status=dead}}</ref>

In the mid-1980s the VHA was criticized for their high operative mortality.  To that end, Congress passed Public Law 99–166 in December 1985 which mandated the VHA to report their outcomes in comparison to national averages and the information must be risk-adjusted to account for the severity of illness of the VHA surgical patient population.  In 1991 the National VA Surgical Risk Study (NVASRS) began in 44 Veterans Administration Medical Centers.  By December 31, 1993, there was information for 500,000 non-cardiac surgical procedures. In 1994 NVASRS was expanded to all 128 VHA hospitals that performed surgery.  The name was then changed to the National Surgical Quality Improvement Program.<ref>{{Cite journal | doi = 10.1001/archsurg.137.1.20 | last1 = Khuri | first1 = SF | last2 = Daley | first2 = J | last3 = Henderson | first3 = WG | year = 2002 | title = The Comparative Assessment and Improvement of Quality Surgical Care in the Department of Veterans Affairs | journal = Archives of Surgery | volume = 137 | issue = 1| pages = 20–27 | pmid = 11772210 | doi-access =  }}</ref>

Beginning in the mid-1990s VHA underwent what the agency characterizes as a major transformation aimed at improving the quality and efficiency of care it provides to its patients. That transformation included eliminating underutilized inpatient beds and facilities, expanding outpatient clinics, and restructuring eligibility rules. A major focus of the transformation was the tracking of a number of performance indicators—including quality-of-care measures—and holding senior managers accountable for improvements in those measures.<ref name="CBO">[http://www.cbo.gov/ftpdocs/104xx/doc10453/08-13-VHA.pdf Quality Initiatives Undertaken by the Veterans Health Administration] [[Congressional Budget Office]] Report, August 2009</ref>

=== 1993-2000: Dr. Kenneth W. Kizer and VHA Reform ===
The Clinton Healthcare Plan was a health care reform proposed by the Clinton Administration. Even though the reform was not successful, a task force was created in response to the Clinton Healthcare Reform proposal to determine if the VA was ready for managed care.<ref>{{cite journal | author = Inglehart J. K. | year = 1996 | title = Reform of the Veterans Affairs Health Care System | doi = 10.1056/nejm199610313351821| pmid = 8857026 | journal = The New England Journal of Medicine | volume = 335 | issue = 18| pages = 1407–11 }}</ref> The negative results of market research forced the VA system to re-evaluate its current operations. Research revealed that three out of four veterans would leave the VA network if a national healthcare system were adopted. They also found that there was a high demand for primary care throughout the VA system. Research showed that many VA facilities believed that 55 percent of patients would choose to receive primary care at the VA facility if a primary care system was fully implemented in 1993. The study also showed that the VA facilities believed that 83 percent of veterans would choose to receive primary care at the VA if fully implemented by 1998. These results made it clear to the administration that it was time for a reform.<ref name="Yano et al. 2007 12">{{cite journal | author = Yano|display-authors=etal | year = 2007 | title = The Evolution of Changes in Primary Care Delivery Underlying the Veterans Health Administration's Quality Transformation | doi = 10.2105/ajph.2007.115709 | pmid = 17971540 | pmc = 2089092 | journal = American Journal of Public Health | volume = 97 | issue = 12 | pages = 2151–59 }}</ref> As a result, the VA issued a directive in 1994, that required all VA healthcare facilities to have primary care teams by year 1996.<ref>Ashton, C., Headley, E., Parrino, T., Starfield, B. (September 1995). Primary Care in VA. Boston: Management decision and Research Center. Washington, DC: U.S. Department of Veterans Affairs. Office of Research and Development. Health Services Research and Development Service</ref> As a result, percentage of patients receiving primary care at the VA increased from 38 percent to 45 percent to 95 percent, during 1993, 1996, and 1999.<ref name="Yano et al. 2007 12" /> This mandate served as the foundation for the VA reorganization under Dr. Kenneth W. Kizer.

Dr. Kizer, a physician trained in emergency medicine and Public Health, was appointed by President Bill Clinton as Director of U.S. Veterans Health Administration in 1994. He was hired to update and modernize the VA health system in order to eliminate negative perception and to align the system with current market trends. Core issues included advancements in technology and biomedical knowledge, aging and socioeconomically disadvantaged Medicare patients, coordinating care, and rising healthcare costs. There was much opposition to a major reform. Many legislators preferred an incremental change over a wide-scale reform. However, Kizer was known as being very innovative. To publicize his vision he expressed his mission and vision of the "new VHA" and outlined seven key principles to guide change. His ultimate goal was to provide coordinated, high quality care at a low cost.

He launched his reorganization plan in 1995 by decentralizing the VA system. He organized all VA operating units into 22 geographic based networks known as Veterans Integrated Service Networks (VISNs).  This allowed networks to manage themselves and adapt to the demographics of their location.  Patients were then assigned to a group of doctors who would provide coordinated care.  One director was hired for each VISN network. Instead of hiring all directors internally, a third of the newly hired VISN directors were hired outside of the VA system. The directors were responsible for meeting performance goals and improving upon measurable key efficiency and quality indicators. Directors monitored performances and reports were generated to show each network's performance. Some of these indicators included chronic disease quality, prevention performance, patient satisfaction ratings, and utilization management.

The reform also changed the procedure for allocating funds to the various VISNs. Historically, funds were distributed between hospitals based on historical costs. However, it was found that this method affected efficiency and quality of services. Therefore, funding for each VISN was distributed based on the number of veterans seen in each network, rather than on historical values.<ref>Kizer et al. (Jun 2000). Reinventing VA Healthcare: Systematizing Quality Improvement and Quality Innovation ''Medical Care'' 38(6 Suppl 1)</ref>

The New England Journal of Medicine conducted a study from 1994–2000 to evaluate the efficacy of the healthcare reform. They gathered the results of the evaluated key indicators from each of the networks and interpreted the results.  There were noticeable improvements, compared with the same key indicators used for the Medicare fee for service system, as soon as two years after the reorganization. These improvements continued through year 2000. These results indicate that the changes made throughout the VA healthcare system, under the leadership of Kizer, did improve the efficiency and quality of care in VA healthcare system.<ref>{{cite journal | author = Kizer K.W | display-authors = etal | title = (May 2003). Effects of the Transformation of the Veterans Affairs Health Care System on the Quality of Care | journal = New England Journal of Medicine | volume = 348 | page = 22 }}</ref>

===Veterans Health Administration scandal of 2014===
{{main|Veterans Health Administration scandal of 2014}}

In 2014, Congress passed the [[Veterans' Access to Care through Choice, Accountability, and Transparency Act of 2014|Veterans Access, Choice, and Accountability Act]], commonly known as simply the Choice Act.  VA Secretary Robert Wilkie assured veterans that the VA wouldn't be privatized and that veterans would still be able to get the same quality of care they had been receiving.<ref>Attia, Essam. 4 May 2020. https://indypendent.org/2020/05/as-covid-rages-will-the-va-be-there-for-future-generations-of-veterans/</ref> In May 2014, major problems with scheduling timely access to medical care became public. According to a retired doctor at the center interviewed by CNN, at least 40 veterans died waiting for care at the [[Phoenix, Arizona]] Veterans Health Administration facilities. An investigation of delays in treatment throughout the Veterans Health Administration system was conducted by the Veterans Affairs Inspector General, but it only found six deaths during the delay.<ref>{{cite news |author1=Scott Bronstein |author2=Drew Griffin |title=A fatal wait: Veterans languish and die on a VA hospital's secret list |publisher=CNN |url=http://www.cnn.com/2014/04/23/health/veterans-dying-health-care-delays/ |access-date=May 31, 2014}}</ref><ref>{{cite news |date=2014-05-21 |title=Obama vows action on any VA 'misconduct' |work=BBC News |url=https://www.bbc.co.uk/news/world-us-canada-27508745 |access-date=May 31, 2014}}</ref> On May 30, 2014, [[Secretary of Veterans Affairs]] [[Eric Shinseki]] resigned from office due to the fallout from the scandal.<ref name="Veterans Secretary Eric Shinseki resigns">{{cite news |date=2014-05-30 |title=Veterans Secretary Eric Shinseki resigns after report |work=BBC News |url=https://www.bbc.co.uk/news/world-us-canada-27640375 |access-date=May 31, 2014}}</ref>  Despite the negative exposure and the subsequent vows by Washington lawmakers to take action, the major problems still exist.<ref>{{Cite web |last=Cohen |first=Tom |date=2014-06-12 |title=VA crisis: solutions exist, but haven't happened, panel hears {{!}} CNN Politics |url=https://www.cnn.com/2014/06/12/politics/va-reforms/index.html |access-date=2022-04-30 |website=CNN |language=en}}</ref><ref>{{Cite web |last=Richardson |first=Bradford |date=2015-10-30 |title=IG probes uncover more problems at VA hospitals |url=https://thehill.com/policy/defense/258652-ig-probes-uncover-more-problems-at-va-hospitals/ |access-date=2022-04-30 |website=The Hill |language=en-US}}</ref>{{when|date=May 2017}}

On June 24, 2014, Senator Tom Coburn, Republican from Oklahoma, and a medical doctor, released a report called Friendly Fire: Death, Delay, and Dismay at the VA which detailed the actions and misconduct of employees of the Department of Veteran Affairs. The report is based on yearlong investigations conducted by Senator Coburn's office on Veterans Health Administration facilities across the nation. The report details the many veterans who have died waiting for health care as a result of the VA misconduct. Secret waiting lists, poor patient care, the millions of dollars that are intended for health care that has gone unspent every year and reports of bonuses paid out to employees who have lied and covered up statistics are also detailed in the report.<ref>{{Cite web|url=http://stripes.com/polopoly_fs/1.290429.1403627335!/menu/standard/file/Friendly%20Fire%20VA%20report.pdf|title=Friendly Fire: Death, Delay, and Dismay at the VA – Stripes.com<!-- Bot generated title -->}}</ref>

However, a VA Inspector General's report issued on August 26, 2014, reported that six, not forty, veterans had died experiencing “clinically significant delays” while on waiting lists to see a VA doctor, and in each of these six cases, “we are unable to conclusively assert that the absence of timely quality care caused the deaths of these veterans.”<ref name="Mundy">{{Cite web |date=2016-03-13 |title=The VA Isn't Broken, Yet |url=http://washingtonmonthly.com/2016/03/13/the-va-isnt-broken-yet/ |access-date=2022-04-30 |website=Washington Monthly |language=en-US}}</ref><ref>[http://www.va.gov/oig/pubs/VAOIG-14-02603-267.pdf Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System] VA Office of Inspector General, Veterans Health Administration. August 26, 2014. Pub. No. 14-02603-267</ref>

=== 2014 - present: Improving care, MISSION Act/Community Care, expansion of Mental Health eligibility ===
With the Choice Act in place, wait times (and ultimately care) at VHA facilities began to improve.  According to a study conducted by the Journal of the [[American Medical Association]] (JAMA) in 2014, the average wait times to receive health care were 22.5 for VHA and 18.7 days for the private sector. However, by 2017, VHA wait times were significantly shorter than wait times to see a private doctor dropping to 17.7 days for VHA, while the wait for a private doctor increased to 29.8 days.<ref>{{Cite journal |last1=Penn |first1=Madeline |last2=Bhatnagar |first2=Saurabha |last3=Kuy |first3=SreyRam |last4=Lieberman |first4=Steven |last5=Elnahal |first5=Shereef |last6=Clancy |first6=Carolyn |last7=Shulkin |first7=David |date=2019-01-04 |title=Comparison of Wait Times for New Patients Between the Private Sector and United States Department of Veterans Affairs Medical Centers |journal=JAMA Network Open |language=en |volume=2 |issue=1 |pages=e187096 |doi=10.1001/jamanetworkopen.2018.7096 |pmid=30657532 |pmc=6484544 |doi-access=free}}</ref> Based on the successes of the original program, Congress expanded the eligibility of the program by passing the John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 {{USStatute|115|182|132|1393||||S|2372}}), which permanently codified the Choice Act features access (wait time and travel distance) standards into a new Veterans Community Care Program. It also established several additional criteria that qualify the Veteran to receive community care, such as if  a Veteran needs a service not available at any VA facility (i.e., maternity care for women), a Veteran lives in a U.S. state (Alaska, Hawaii, New Hampshire) or territory (Guam, American Samoa, Northern Mariana Islands, U.S. Virgin Islands) without a full-service VA medical facility, or it is in the best medical interest of the Veteran, based on Veteran and provider agreement. Additional regulations issued by VA also changed the access standards that would make a Veteran eligible reducing the time from 30 days to 20 days of a request or at a facility within 30 minutes of average driving for a primary care appointment or 28 days and 60 minutes for a specialty appointment.<ref>{{CodeFedReg|38|17|4040}}</ref>

In 2018, as a result of the passage of the [[Consolidated Appropriations Act, 2018|2018 Consolidated Appropriations Act]], VHA was allowed to combat veterans and victims of [[military sexual trauma]] who were discharged administratively with an [[other than honorable discharge]] (OTH) to access mental health treatment in VA or community care facilities. it also allowed all veterans with a discharge that would typically bar veterans' health care and benefits to petition the Secretary (through the [[Veterans Benefits Administration]]) to determine whether or not the character of their discharge is a complete bar to benefits. Even if VBA makes a determination that they are ineligible for monetary and educational benefits, they may still find that such a Veteran is eligible for health care benefits for any service-connected disability.<ref>{{Cite web |title=Applying for Benefits and Your Character of Discharge - Veterans Benefits Administration |url=https://www.benefits.va.gov/benefits/character_of_discharge.asp |access-date=2022-04-30 |website=www.benefits.va.gov}}</ref>

== Structure ==
[[File:VHA VISN Map.gif|thumb|335x335px|Map of the 21 VHA service regions, called Veterans Integrated Service Networks.]]
The system is divided into 21 distinct service regions, called '''Veterans Integrated Services Network (VISN)''', that provide funding and care to the systems 1,293 medical centers and their associated clinics. Funding for each VISN is based on the anticipated number of Veterans enrolled in care within the covered region. When a VISN sees a large influx of number of Veterans, the funding levels for that region will increase proportionally, while other areas may see a decrease (especially if they are losing Veteran population). As of 2021, the Desert Pacific Network (VISN 22) was the largest region by population, with over 1.7 million total veterans (2018 estimate),<ref>{{Cite web |last=National Center for Veterans Analysis and Statistics |title=Veteran Population - National Center for Veterans Analysis and Statistics |url=https://www.va.gov/vetdata/veteran_population.asp |access-date=2022-04-30 |website=www.va.gov |publisher=Office of Policy and Planning, U.S. Department of Veterans Affairs |language=en}}</ref> while the Pacific Northwest Network (VISN 20) is the largest by geography -- {{Convert|817,417|sqmi|km2|abbr=unit}}, including the highly rural state of Alaska.<ref>{{Cite report |url=https://www.visn21.va.gov/docs/FY2019AnnualReportVISN21.pdf |title=VISN 20 Annual Report (2012) |last=Veterans Health Administration |date=2012 |publisher=Department of Veterans Affairs }}</ref>

Doctors who work in the VHA system are typically paid less in core compensation than their counterparts in private practice. However, VHA compensation includes benefits not generally available to doctors in private practice, such as lesser threat of malpractice lawsuits, freedom from billing and insurance company payment administration, and the availability of the government's open-source electronic records system [[VistA]].<ref name="Bloomberg1" /> Currently the VHA is experiencing a physician shortage and as of 2018 10% of jobs in the VHA remain unfilled.<ref>{{Cite web |last=Affairs |first=Office of Public and Intergovernmental |title=News Releases - Office of Public and Intergovernmental Affairs |url=https://www.va.gov/opa/pressrel/pressrelease.cfm?id=5104 |access-date=2020-03-18 |website=www.va.gov |language=en}}</ref>  This shortage can be especially harmful to Veterans since a quarter of Veterans live in rural areas.  These are the kind of areas that are most vulnerable to a shortage since they are already isolated and it can be hard to get access to the healthcare they need.<ref>{{Cite journal |last1=Albanese |first1=Anthony P. |last2=Ayvazian |first2=Jemma |last3=Bope |first3=Edward |last4=Van Gilder |first4=Amanda |last5=Pelic |first5=Christopher |last6=Sanders |first6=Karen |last7=Lypson |first7=Monica |last8=Clary |first8=Christyann |last9=Klink |first9=Kathleen |date=February 2018 |title=A Year 3 Progress Report on Graduate Medical Education Expansion in the Veterans Access, Choice, and Accountability Act |journal=Federal Practitioner |volume=35 |issue=2 |pages=22–27 |issn=1078-4497 |pmc=6248221 |pmid=30766339}}</ref> However, since 2018, these shortages have been decreasing steadily, with the greatest need being mental health providers and nursing corps.<ref>{{Cite report |url=https://www.va.gov/oig/pubs/VAOIG-21-01357-271.pdf |title=OIG Determination of Veterans Health Administration's Occupational Staffing Shortages Fiscal Year 2021 |last=Office of the Instyector General |date=}}</ref>

== Funding ==
The funding the VA receives is split into mandatory, which is an amount of spending dictated by law, and discretionary spending, which is spending that can be adjusted year to year. VHA's budget is part of the discretionary spending and is by far the largest portion of the department, reaching nearly 90% of the department's annual amount allocated annually by [[United States Congress|Congress]] in FY2022.<ref name=":1" /> For FY2022, the department's budget requested a total of $269.9 billion [[United States dollar|USD]], of which $97.5 billion [[United States dollar|USD]] was allocated for various VHA programs, including $58.8 billion to support direct care in VA facilities, and $23.4 billion in support of community care claims. This was an increase of 10% over the FY 2021 appropriations, which were under $250 billion [[United States dollar|USD.]]<ref name=":1" />

==Initiatives==
The VHA has expanded its outreach efforts to include men and women veterans and homeless veterans.

The VHA, through its academic affiliations, has helped train thousands of physicians, dentists, and other health professionals. Several newer VA medical centers have been purposely located adjacent to medical schools.

The VHA support for research and residency/fellowship training programs has made the VA system a leader in the fields of [[geriatrics]],<ref>{{cite web|url=http://www1.va.gov/grecc/ |title=Geriatric Research Education and Clinical Center Home |access-date=April 10, 2017 |url-status=bot: unknown |archive-url=https://web.archive.org/web/20080329235717/http://www1.va.gov/grecc/ |archive-date=March 29, 2008 }}</ref><ref>{{cite web|url=http://www.va.gov/oaa/specialfellows/programs/SF_RWJ.asp |title=VA Fellowship for Robert Wood Johnson Clinical Scholars – Office of Academic Affiliations |publisher=Va.gov |date=November 1, 2013 |access-date=May 16, 2014}}</ref> [[spinal cord injury research|spinal cord injuries]],<ref>{{cite web|author=Spinal Cord Injury & Disorders Services |url=http://www.sci.va.gov/ |title=Spinal Cord Injury & Disorders Home |access-date=April 10, 2017 |url-status=bot: unknown |archive-url=https://web.archive.org/web/20080427193846/http://www.sci.va.gov/ |archive-date=April 27, 2008 }}</ref> [[Parkinson's disease]] [http://www.parkinsons.va.gov/ VA.gov | Veterans Affairs], and [[palliative care]].

The VHA has initiatives in place to provide a "seamless transition" to newly discharged veterans transitioning from [[United States Department of Defense|Department of Defense]] [[TRICARE|health care]] to VA care for conditions incurred in the [[Iraq War]] or [[War in Afghanistan (2001–present)|war in Afghanistan]].

The [[Veterans Health Administration Office of Research and Development]]'s research into developing better-functioning [[prosthetic]] limbs, and treatment of [[PTSD]] are also heralded. The VHA has devoted many years of research into the health effects of the herbicide [[Agent Orange]] used by [[military]] forces in the [[Vietnam War]].

The VHA has also adopted Boston University's Project RED program,<ref>{{cite news|url=https://www.bu.edu/fammed/projectred/ |title=Project RED (Re-Engineered Discharge) |publisher=Boston University }}</ref> designed to improve the discharge process for veterans in hopes that, by educating patients, the VHA will experience a reduced number of readmission among veterans and provide more information on [[Telemedicine#Telerehabilitation|telerehabilitation]].<ref>{{cite news|url=http://www.charleston.va.gov/features/Transforming_discharge_processes_for_Veterans.asp |title=Transforming discharge processes for Veterans |publisher=U.S. Department of Veterans Affairs }}</ref>

=== Use of electronic records ===
VHA is especially praised for its efforts in developing a low cost [[Open-source model|open source]] electronic medical records system [[VistA]]<ref name="RAND04" /> which can be accessed remotely (with secure passwords) by health care providers.  With this system, patients and nurses are given bar-coded wristbands, and all medications are bar-coded as well. Nurses are given wands, which they use to scan themselves, the patient, and the medication bottle before dispensing drugs. This helps prevent four of the most common dispensing errors: wrong med, wrong dose, wrong time, and wrong patient. The system, which has been adopted by all veterans' hospitals and clinics and continuously improved by users, has cut the number of dispensing errors in half at some facilities and saved thousands of lives.<ref>[http://www.washingtonmonthly.com/features/2009/0907.longman.html "Code Red"] by [[Philip Longman]], [[Washington Monthly]], September 7, 2009</ref>

At some VHA medical facilities, doctors use wireless laptops, putting in information and getting electronic signatures for procedures. Doctors can call up patient records, order prescriptions, view X-rays or graph a chart of risk factors and medications to decide treatments. Patients have a home page that have boxes for allergies and medications, records every visit, call and note, and issues prompts reminding doctors to make routine checks. This technology has helped the VHA achieve cost controls and care quality that the majority of private providers cannot achieve.<ref name="Bloomberg1" />
The [[Veterans Health Administration Office of Research and Development]]'s research into developing better-functioning [[prosthetic]] limbs, and treatment of [[PTSD]] are also heralded. The VHA has devoted many years of research into the health effects of the herbicide [[Agent Orange]] used by [[military]] forces in [[Vietnam]].

== Services ==

=== Eligibility ===
[[File:VAID Obverse.png|thumb|A VA Veteran identification VIC card for Veterans eligible for VA health care benefits]]
To be eligible for VA health care benefit programs one must have served in the active military, naval or air service and separated under any condition other than dishonorable. Current and former members of the Reserves or National Guard who were called to active duty (other than for training only) by a federal order and completed the full period for which they were called or ordered to active duty also may be eligible for VA health care.<ref name="hbco-eligibility">{{cite web |author=<!--Not stated--> |title=VA Health Care Enrollment and Eligibility |url=https://www.va.gov/healthbenefits/resources/publications/hbco/hbco_enrollment_eligibility.asp |access-date=May 5, 2020 |website=va.gov |publisher=U.S. Department of Veterans Affairs}}</ref>

The minimum duty requirements are that veterans who enlisted after September 7, 1980, or who entered active duty after October 16, 1981, must have served 24 continuous months or the full period for which they were called to active duty in order to be eligible. The minimum duty requirement may not apply to veterans who were discharged for a disability incurred in the line of duty, for a hardship or "early out." The VA determines the minimum requirements when the veteran enrolls for VA health care benefits.

To apply for entry into the VA health care system the veteran must complete VA Form 10-10EZ, Application for health care benefits.

Eligible veterans will receive a VA Veterans Health Identification Card (VHIC) formerly [[Veteran identification card]] (VIC) for use at all [[List of Veterans Affairs medical facilities by state|VA medical facilities]].

By federal law, eligibility for benefits is determined by a system of eight priority groups. Retirees from military service, veterans with service-connected injuries or conditions rated by VA, and [[Purple Heart]] recipients are within the higher priority groups.

Current and former members of the [[Reserve components of the United States Armed Forces|Reserves]] and the [[National Guard of the United States|National Guard]] who were called to active duty (other than for monthly drills and annual training) by a federal executive order may be eligible for VA health care benefits.<ref>{{Cite web|url=https://www.va.gov/health-care/|title=VA health care|date=June 27, 2024|website=Veterans Affairs}}</ref>

Veterans without rated service-connected conditions may become eligible based on financial need, adjusted for local cost of living. Veterans who do not have service-connected disabilities totaling 50% or more may be subject to copayments for any care they received for nonservice-connected conditions.

=== Medical Care ===

==== Primary  & Specialty Care ====
Primary care is provided through what is referred to as Patient Aligned Care Teams (PACT). PAC Teams provide accessible, patient-centered care and are managed by primary care providers with the active involvement of other clinical and non-clinical staff. Veteran patients will be at the center of a "teamlet," which will include a primary care provider, RN care manager, LPN/health tech, and a medical support assistant (MSA). This teamlet is supported by a broader "team," which includes social workers, dieticians, pharmacists, and mental health specialists.

General care includes health evaluation and counseling, disease prevention, nutrition counseling, weight control, smoking cessation, and substance abuse counseling and treatment as well as gender-specific primary care, e.g., cervical cancer screens (Pap smears), breast cancer screens (mammograms), birth control, preconception counseling, Human Papillomavirus (HPV) vaccine and menopausal support (hormone replacement therapy). This care is provided mainly by VA-owned hospitals but may also be done in VA-owned community-based outpatient clinics (CBOC).  VA hospitals are also capable of providing [[Emergency medicine|emergency care]], although a Veteran can go to any hospital in an emergency.

VHA also provides management and screening of a number of chronic conditions includes heart disease, diabetes, cancer, glandular disorders, osteoporosis and [[fibromyalgia]] as well as [[sexually transmitted disease]]s such as HIV/AIDS and hepatitis. Rehabilitation, home care, and long-term care referrals are given to those in need of rehabilitation therapies such as physical therapy, occupational therapy, speech-language therapy, exercise therapy, recreational therapy, and vocational therapy.

VA also provides some home health care through its Skilled Home Health Care Services (SHHC) and Homemakers and Home Health Aide Services (H/HHA) programs.  SHHC services are in-home services provided by specially trained personnel, including nurses, physical therapists, occupational therapists and social workers. Care includes clinical assessment, treatment planning and treatment provision, health status monitoring, patient and family education, reassessment, referral and follow-up. H/HHA Services are personal care and related support services that enable frail or disabled Veterans to live at home.

If the need arises, veterans are eligible for transplant service. VA has sixteen transplant centers across the country that provides solid organ transplants for most major organs, such as the heart, lung and kidneys, Patients will be referred to these transplant centers  by their Primary Care Team. Travel to these centers is either free of charge to the Veteran or is reimbursed to them upon completion.

[[File:Veterans Petersburg Clinic 2020.jpg|thumb|Outpatent clinic in [[Petersburg, West Virginia]]]]

==== Mental health ====
Mental health treatment includes evaluation and assistance for issues such as depression, mood, and anxiety disorders; intimate partner and domestic violence; elder abuse or neglect; parenting and anger management; marital, caregiver, or family-related stress; and post-deployment adjustment or post-traumatic stress disorder (PTSD). Veterans who may also have experienced [[sexual harassment]] or [[sexual assault]], known as [[military sexual trauma]] (MST) during their service are also eligible for service. VHA provides free, confidential counseling and treatment for MST-related mental and physical health conditions. The percentage of patients with a [[mental illness]] was 15 percent in 2007.  The percentage of veterans with mental illnesses has trended up. The VHA allocated an extra $1.4 billion per year to mental health program between 2005 and 2008. Mental health services in 2006 were evaluated as a part of the Mental Health Strategic Plan.<ref name="Watkins, K.E. 2011">Watkins, K.E., Pincus, H.A. et al., (2011). Veterans Health Administration Mental Health Program Evaluation: Capstone Report, Santa Monica, Calif.: RAND Corporation, TR-956-VHA</ref><ref>{{cite web|url=http://www.rand.org/pubs/technical_reports/TR956.html |title=Veterans Health Administration Mental Health Program Evaluation: Capstone Report |publisher=RAND |date=October 19, 2011 |access-date=May 16, 2014|last1=Watkins |first1=Katherine E. |last2=Pincus |first2=Harold Alan |last3=Smith |first3=Brad |last4=Paddock |first4=Susan M. |last5=Mannle |first5=Thomas E. |last6=Woodroffe |first6=Abigail |last7=Solomon |first7=Jake |last8=Sorbero |first8=Melony E. |last9=Farmer |first9=Carrie M. |last10=Hepner |first10=Kimberly A. |last11=Adamson |first11=David M. |last12=Forrest |first12=Lanna |last13=Call |first13=Catherine }}</ref> The report concluded:

{{blockquote|"Quality of care at the VA was shown to be better than the private sector. The VA had a higher level of performance then the private sector for 7 out of 9 indicators. In fact, they "exceeded private plan performance by large margins....Patients did not indicate improvement in their conditions. However, they had a very favorable opinions of their care.<ref name="Watkins, K.E. 2011"/>}}

In 2009, the VA implemented an initiative called Suicide Assessment and Follow-Up Engagement: Veteran Emergency Treatment (SAFE VET) to identify and treat veterans at risk of suicide by providing care coordination for outpatient mental health services and community-based support.<ref>{{cite web |publisher=Agency for Healthcare Research and Quality |url=https://innovations.ahrq.gov/profiles/emergency-departments-identify-and-support-veterans-risk-suicide-enhancing-their-access |title=Emergency Departments Identify and Support Veterans at Risk of Suicide, Enhancing Their Access to Outpatient Mental Health Services |date=November 20, 2013 | access-date=November 25, 2013}}</ref>

===== PTSD =====
Veteran Affairs utilization rates among Iraqi and Afghanistan-war veterans in the mid-Atlantic region with PTSD diagnosis between 2002 and 2008 were tracked using ICD-9 codes of those newly diagnosed.  When compared to veterans already being treated, veterans new to VA treatment program were less likely to complete follow up visits, and had fewer medication-possession days (74.9 days versus 34.9 days); also long wait times hindered VA medical utilization.<ref>{{Cite journal|title = Mental Health Service Utilization by Iraq and Afghanistan Veterans After Entry Into PTSD Specialty Treatment.|last = Aakre|first = JM|date = 2014|journal = Psychiatric Services| volume=65 | issue=8 | pages=1066–1069 | doi=10.1176/appi.ps.201300117 | pmid=24882427 }}</ref>  Limitations to this study included: type of treatment intervention was not delineated; only looked at PTSD treatment over a short period of time (180 days).

Another study found there was an increase in demand of the VA health system among veterans.  Nearly 250,000 veterans were identified between 2001 and 2007; Iraq and Afghanistan war veterans had a 40 percent utilization rate, compared to only 10 percent of Vietnam veterans.<ref name=":0">{{Cite journal|title = Mental Health Diagnoses and Utilization of VA Non-Mental Health Medical Services Among Returning Iraq and Afghanistan Veterans.|last = Cohen|first = B|date = 2009|journal = Journal of General Internal Medicine|volume = 25|issue = 1|pages = 18–24|doi = 10.1007/s11606-009-1117-3 |pmid = 19787409|pmc = 2811589|display-authors=etal}}</ref>  Veterans were categorized into three groups:  non-mental health diagnosis, non-PTSD mental diagnosis, and PTSD mental diagnosis.<ref name=":0" />  The most prevalent diagnosis was PTSD.  The typical veteran affected by PTSD was male, from the Army or Marines, and a lower-ranked officer.<ref name=":0" />  Veterans with PTSD had a high utilization of the VA system at over 91 percent.<ref name=":0" />

While this was a comprehensive study, there is more to be studied and understood about the effects of PTSD on returning veterans from active combat.  A major limitation is that this study only captured the utilization of veterans within the VA health system.  There was no data on veterans who sought medical services outside of the VA health system.  We can have a better understanding of the mental health needs of veterans returning to civilian life.  Moreover, it would be beneficial to explore and examine how utilization of mental health services is affected by the stigma that persists among veterans.  Additional awareness of medical resources available to veterans can help to erase the stigma of seeking mental health treatment.

==== Women Veterans Programs ====
With the population of women veterans projected to rise from 1.6 million in 2000 to 1.9 million in 2020, the VA has worked to integrate quality women's medical services into the VA system.<ref>[http://www1.va.gov/womenvet/docs/womenvet_history.pdf (2007). Women Veterans: Past, Present, and Future] {{Webarchive|url=https://web.archive.org/web/20140824100152/http://www.va.gov/womenvet/docs/womenvet_history.pdf |date=August 24, 2014 }}. Department of Veterans Affairs.</ref> However, studies show that 66.9 percent of women who do not use the VA for women's services consider private practice physicians more convenient. Also, 48.5 percent of women do not use women's services at the VA due to a lack of knowledge of VA eligibility and services.<ref>{{Cite journal | pmid = 16637939| year = 2006| last1 = Washington| first1 = D. L.| title = To use or not to use. What influences why women veterans choose VA health care| journal = Journal of General Internal Medicine| volume = 21| pages = S11–18| last2 = Yano| first2 = E. M.| last3 = Simon| first3 = B| last4 = Sun| first4 = S| issue = Suppl 3| doi = 10.1111/j.1525-1497.2006.00369.x| pmc = 1513176}}</ref>

Women's care at VHA hospitals and clinics include reproductive health care such as limited maternity care, infertility evaluation and limited treatment, sexual problems, tubal ligation, urinary incontinence, and others. VHA is prohibited from providing either in-vitro fertilization or abortion services.  Maternity and pregnancy care is usually provided in non-VA contracted hospitals at VA expense; care is usually limited to a mother. (VA may furnish health care services to a newborn child of a woman Veteran who is receiving maternity care furnished by VA for not more than seven days after the birth if the Veteran delivered the child in (1) a VA facility, or (2) another facility pursuant to a VA contract for services relating to such delivery).

==== Dental Care ====
For VA dental care a veteran must have a service-connected compensable dental disability or condition. Those who were prisoners of war (POWs) and those whose service-connected disabilities have been rated at 100 percent or who are receiving the 100 percent rate by reason of individual unemployability (IU) are eligible for any needed dental care, as are those veterans actively engaged in a 38 USC Chapter 31 vocational rehabilitation program and veterans enrolled who may be homeless and receiving care under VHA Directive 2007–039.

=== Non-Medical Programs ===

==== Family Caregivers Program ====
VA's Family Caregivers Program provides support and assistance to caregivers of post 9/11 Veterans and Servicemembers being medically discharged. Eligible primary Family Caregivers can receive a stipend, training, mental health services, travel and lodging reimbursement, and access to health insurance if they are not already under a health plan care. Each state has their own criteria and board members for approval, denial, and appeal.

As part of this program, VHA also will provide respite supportive care to Veterans on a short-term basis to give the caregiver planned relief from the physical and emotional demands associated with providing care. Respite care can be provided in the home or other institutional settings.

==== Residential Care ====
The Domiciliary Care Program of the [[Department of Veterans Affairs]] provides residential rehabilitative and clinical care to veterans who have a wide range of problems, illnesses, or rehabilitative care needs which can be medical, psychiatric, substance use, homelessness, vocational, educational, or social. The Domiciliary Care Program provides a 24-hour therapeutic setting utilizing a peer and professional support environment. The programs provide a strong emphasis on psychosocial rehabilitation and recovery services that instill personal responsibility to achieve optimal levels of independence upon discharge to independent or supportive community living. The VA Domiciliary Care Program also provides rehabilitative care for [[homeless veterans in the United States|homeless veterans]]. Eligibility is extended to veterans whose annual gross household income does not exceed the maximum annual rate of VA pension or to veterans who the Secretary of Veterans Affairs determines have no adequate means of support. The copays for extended care services apply to domiciliary care.

VA also provides [[nursing home]] services to Veterans through VA owned and operated Community Living Centers (CLC), State Veterans' Homes, owned and operated by the states, and the community nursing home program. Each program has admission and eligibility criteria specific to the program. Nursing home care is available for enrolled Veterans who need nursing home care for a service-connected disability, or Veterans or who have a 70 percent or greater service-connected disability and Veterans with a rating of total disability based on individual unemployability. VA provided nursing home care for all other Veterans is based on available resources.

The Vet Center Program was established by Congress in 1979 in response to the readjustment problems that a significant number of Vietnam-era veterans were continuing to experience after their return from combat. In subsequent years, Congress extended eligibility to all combat veterans who served on active duty from previous conflicts. All community based Vet Centers provide readjustment counseling, outreach services and referral services to help veterans make a satisfying post-war readjustment to civilian life. Services are also available for their family members for military related issues. Vet Centers are staffed with small multidisciplinary teams some of whom are combat veterans themselves.

==== VA travel reimbursement ====
Veterans may be eligible for mileage reimbursement or special mode transport in association with obtaining VA health care services if the veteran has a service-connected rating of 30 percent or more, or is traveling for treatment of a service-connected condition, receives a VA pension, the veteran's income does not exceed the maximum annual VA pension rate, the veteran is traveling for a scheduled compensation or pension examination, is in certain emergency situations. has a medical condition that requires a special mode of transportation and travel is pre-authorized, as are certain non-veterans when related to care of a veteran (caregivers, attendants and donors).

=== Other Specialized Care ===

==== OEF/OIF/OND Care Management Team ====
The [[Operation Enduring Freedom]]/[[Operation Iraqi Freedom]]/[[Operation New Dawn (Afghanistan)|Operation New Dawn]] (OEF/OIF/OND) Care Management Team helps returning service members achieve a smooth transition of health care services. A specialized OEF/OIF/OND care management team provides case management and care coordination for all severely ill, injured and impaired combat veterans, including those suffering from:
* [[Mental illness]]
* [[Traumatic brain injury]]
* [[Spinal cord injury]]
* Blindness
* Burns
* Amputation
* Terminal Illness/Injury
* [[Polytrauma]]
* Other conditions not mentioned above that cause significant impairment to daily living

==== Intimate Partner Violence Prevention ====
VHA also programs for women (and men) veterans who are victims of intimate partner violence (IPV).  A 2017 study found that nearly one in five VHA women had experienced IPV in the preceding year, and research has shown that many military women reporting IPV experiences in the past year use VHA primary care as their main source of healthcare.<ref>Dichter ME, Wagner C, Borrero S, Broyles L, Montgomery AE. Intimate partner violence, unhealthy alcohol use, and housing instability among women veterans in the Veterans Health Administration. Psychological Services. 2017; 14(2): 246-249. {{doi|10.1037/ser0000132}}</ref><ref name="ReferenceA">{{cite journal |author=Kimerling R, Iverson KM, Dichter ME, Rodriguez AL, Wong A, Pavao J |year=2016 |title=Prevalence of intimate partner violence among women veterans who utilize Veterans Health Administration Primary Care |journal=Journal of General Internal Medicine |volume=31 |issue=8 |pages=888–94 |doi=10.1007/s11606-016-3701-7 |pmid=27130619 |pmc=4945568 |doi-access=free}}</ref>  VHA does not have an upper age limit for IPV screening, acknowledging that IPV is not limited by age.<ref name="ReferenceA" /> However, it is believed that early detection is helpful towards allowing victims to access much needed resources earlier and thus the U.S. Preventive Services Task Force suggests providers especially regularly screen women of childbearing age for IPV.<ref>{{cite journal |author=Dichter ME, Haywood TN, Butler AE, Bellamy SL, Iverson KM |year=2017 |title=Intimate partner violence screening in the Veterans Health Administration: Demographic and military service characteristics |journal=American Journal of Preventive Medicine |volume=52 |issue=6 |pages=761–768 |doi=10.1016/j.amepre.2017.01.003|pmid=28209282 }}</ref> The best care is provided when practitioners do not make assumptions about IPV on the basis of an individual's sexual orientation or other factors.<ref name="ReferenceA" />

No matter one's age, there are chronic health risks associated with IPV victimization, for both men and women.<ref name="ReferenceB">Cerulli C, Bossarte R, Dichter ME. Exploring intimate partner violence status among male veterans and associated health outcomes. American Journal of Men's Health, 2014; 8: 66-73</ref> Early detection is key to providing effective support systems to victims in the armed forces and reducing potential negative health consequences that are associated with such violence.<ref name="ReferenceB" />

Barriers to disclosure of IPV to providers in the VHA include lack of universal routine screening, patients not being comfortable about disclosure, and individual concerns over potential negative consequences on benefits or personal items, depending on how info is shared or used.<ref name="doi.org">Dichter ME, Wagner C, Goldberg EB, Iverson KM. Intimate partner violence detection and care in the Veterans Health Administration: Patient and provider perspectives. Women's Health Issues, 2015; 25(5): 555-560. DOI: https://doi.org/10.1016/j.whi.2015.06.006</ref> &nbsp;Barriers to providing the most effective responses to IPV cases include providers lacking time and information to help, and untrained personnel creating more harm than good.<ref name="doi.org" />

== Evaluations ==
"Patients routinely rank the veterans system above the alternatives", according to the American Customer Satisfaction Index. In 2008, the VHA got a satisfaction rating of 85 for inpatient treatment, compared with 77 for private hospitals. In the same report VHA outpatient care scored 3 points higher than for private hospitals.<ref name="Bloomberg1">[https://web.archive.org/web/20120203141859/http://www.bloomberg.com/apps/news?pid=newsarchive&sid=aLIc5ABThjBk Vets Loving Socialized Medicine Show Government Offers Savings] Bloomberg, October 2, 2009</ref>

"As compared with the Medicare fee-for-service program, the VA performed significantly better on all 11 similar quality indicators for the period from 1997 through 1999. In 2000, the VA outperformed Medicare on 12 of 13 indicators."<ref>[http://content.nejm.org/cgi/content/abstract/348/22/2218 "Effect of the Transformation of the Veterans Affairs Health Care System on the Quality of Care"] New England Journal of Medicine, May 29, 2003</ref>

A study that compared VHA with commercial managed care systems in their treatment of diabetes patients found that in all seven measures of quality, the VHA provided better care.<ref>[http://www.annals.org/content/141/4/272.full Diabetes Care Quality in the Veterans Affairs Health Care System and Commercial Managed Care: The TRIAD Study] Annals of Internal Medicine, August 17, 2004</ref>

A [[RAND Corporation]] study in 2004 concluded that the VHA outperforms all other sectors of American health care in 294 measures of quality. Patients from the VHA scored significantly higher for adjusted overall quality, chronic disease care, and preventive care, but not for acute care.<ref name="RAND04">[http://www.annals.org/content/141/12/938.full Comparison of Quality of Care for Patients in the Veterans Health Administration and Patients in a National Sample] Annals of Internal Medicine, December 21, 2004</ref>

A [[Harvard Medical School]]-led study shows that cancer care provided by the Veterans Health Administration for men 65 years and older is at least as good as, and by some measures better than, Medicare-funded fee-for-service care obtained through the private sector.<ref>[http://news.harvard.edu/gazette/story/2011/06/vha-vs-medicare-winner-is-…/ VHA vs. Medicare: And the winner is …] Harvard Gazette, June 6, 2011</ref>

==LGBT healthcare==
The United States [[Veterans Health Administration]] (VHA) has an [[LGBT|LGBTQ+]] Program through the Office of Patient Care Services.<ref name=LGBTPatientCare> Lesbian, Gay, Bisexual and Transgender (LGBT) Veteran Care.   Retrieved May 13, 2016, from http://www.patientcare.va.gov/Lesbian_Gay_Bisexual_and_Transgender_LGBT_Veteran_Care.asp</ref>  The “+” sign captures identities beyond LGBTQ, including but not limited to questioning, pansexual, asexual, agender, gender diverse, nonbinary, gender-neutral, and other identities. VHA began collecting data on veteran’s sexual orientation and gender identity in 2022 to inform policy and improve clinical care. There are estimated to be more than one million [[LGBT Americans|LGBTQ+ Americans]] who are [[military veterans]].<ref>Gates, G. (2010). Lesbian, gay, and bisexual men and women in the US military:  Updated estimates. Other Recent Work. The Williams Institute, UCLA School of Law, UC Los Angeles.</ref><ref>Gates, G. J., & Herman, J. (2014). Transgender Military Service in the United States. Policy, 3. </ref><ref>Elders, J., & Steinman, A. M. (2014). Report of the transgender military service commission: Palm Center.</ref> If LGBTQ+ veterans use VHA at the same rate as non-LGBTQ+ veterans, there could be more than 250,000 LGBTQ+ veterans served by VHA.<ref name=Kauth5> Kauth, M. R., & Shipherd, J. C. (2016). Transforming a System: Improving Patient-Centered Care for Sexual and Gender Minority Veterans. LGBT Health. </ref> Using diagnostic codes in medical record data, Blosnich and colleagues found that the prevalence of transgender veterans in VHA (22.9/100,000) is five times higher than reported prevalence of transgender-related diagnoses in the general population (4.3/100,000).<ref>{{cite journal | last1 = Blosnich | first1 = J. R. | last2 = Brown | first2 = G. R. | last3 = Shipherd | first3 = J. C. | last4 = Kauth | first4 = M. | last5 = Piegari | first5 = R. I. | last6 = Bossarte | first6 = R. M. | year = 2013 | title = Prevalence of gender identity disorder and suicide risk among transgender veterans utilizing Veterans Health Administration care | journal = American Journal of Public Health | volume = 103 | issue = 10| pages = e27–e32 | doi=10.2105/ajph.2013.301507 | pmid=23947310 | pmc=3780758}}</ref> Brown and Jones identified 5,135 transgender veterans receiving care in VHA using a broader set of diagnostic codes.<ref>{{cite journal | last1 = Brown | first1 = G. R. | last2 = Jones | first2 = K. T. | year = 2014 | title = Racial Health Disparities in a Cohort of 5,135 Transgender Veterans | journal = Journal of Racial and Ethnic Health Disparities | volume = 1 | issue = 4| pages = 257–266 | doi=10.1007/s40615-014-0032-4| doi-access = free }}</ref>  Brown also notes that this methodology fails to identify [[transgender]] veterans who have not disclosed their gender identity to providers, those who don’t meet criteria for a diagnosis, or veterans who get their transition-related care outside of the VHA. 

===History===
In 2011, the [[United States Department of Defense|Department of Defense]] repealed its [[Don’t Ask, Don’t Tell]] policy, allowing openly gay, lesbian and bisexual military personnel to serve in the [[armed forces]]. However, ending Don’t Ask, Don’t Tell did not change the military’s policy toward transgender people who continued to be banned from military service. Department of Defense’s policy on transgender service has fluctuated over the years, but as of 2023 there are no restrictions on transgender individuals’ military service. Although VHA, as a separate entity from Department of Defense, did not ever exclude LGBTQ+ veterans from accessing VHA resources, the repeal of Don’t Ask, Don’t Tell and the transgender military ban was expected to increase the numbers of LGB military personnel and consequently increase the number of LGB veterans who seek care at the VHA after service.<ref>{{cite journal | last1 = Mattocks | first1 = K. M. | last2 = Kauth | first2 = M. R. | last3 = Sandfort | first3 = T. | last4 = Matza | first4 = A. R. | last5 = Sullivan | first5 = J. C. | last6 = Shipherd | first6 = J. C. | year = 2014 | title = Understanding health-care needs of sexual and gender minority veterans: How targeted research and policy can improve health | journal = LGBT Health | volume = 1 | issue = 1| pages = 30–37 | doi = 10.1089/lgbt.2013.0003 | pmid = 26789509 }}</ref>

===Concerns from LGBTQ+ veterans===
Some researchers have raised concerns that LGBTQ+ veterans may not feel welcome at the VHA.<ref name=Sherman11> {{cite journal | last1 = Sherman | first1 = M. D. | last2 = Kauth | first2 = M. | last3 = Shipherd | first3 = J. C. | last4 = Street | first4 = R. | year = 2014 | title = Communication between VA providers and sexual and gender minority Veterans | journal = Psychological Services | volume = 11 | issue = 2| pages = 235–242 | doi=10.1037/a0035840| pmid = 24588107 }}</ref>  Sherman and coauthors found that 24% of a sample of 58 LGBT veterans had not disclosed their sexual orientation to any VHA provider.  The researchers noted that LGBT veterans may be uncomfortable disclosing their sexual orientation or gender identity because when they were in the military this information could lead to their discharge from service. Although VHA never had a policy prohibiting care to LGBTQ+ veterans, former military personnel often associate military policy with VHA policy.<ref name=Sherman11 />  Sherman and colleagues also found that some LGBTQ+ veterans worried that disclosing their sexual or gender minority status would lead to losing VA medical benefits, even though there is a Patient’s Rights and Responsibilities Policy<ref name=PatientRights> Rights and Responsibilities of VA Patients and Residents of Community Living Centers.   Retrieved May 13, 2016, from http://www.va.gov/health/rights/patientrights.asp </ref> that prevents this type of discrimination.  

In the same study, Sherman and colleagues examined attitudes and practices of 202 VHA providers at two mid-western hospitals and found that only half of providers had asked their patients about sexual orientation in the past year, despite it being relevant to health care.<ref name=Sherman11 />  Mental health providers were more likely to ask patients about sexual orientation than medical providers, perhaps due to an awareness of the stress associated with being a member of a minority group.  Less than half of the VHA providers overall (43%) had received any kind of training in  LGBTQ+ health issues since they began practicing. 

A later study by Kauth and colleagues found improvements in some areas related to LGBTQ+ veterans’ experiences with VHA care. For example, nearly two-thirds of a sample of LGBTQ+ veterans rated their primary care and mental health care providers at VHA as “somewhat” or “very welcoming.” Similarly, 64% of LGBTQ+ veterans endorsed feeling “somewhat” or “very comfortable” disclosing their sexual orientation to their VHA providers, and 67.5% of transgender participants reported feeling comfortable disclosing their gender identity.  

LGBTQ+ people who disclose their sexual orientation to healthcare providers and feel comfortable talking to their providers about sexuality and sexual health also report greater satisfaction with their healthcare.<ref>{{cite journal | last1 = Sherman | first1 = M. | last2 = Kauth | first2 = M. | last3 = Ridener | first3 = L. | last4 = Shipherd | first4 = J. C. | last5 = Bratkovich | first5 = K. | last6 = Beaulieu | first6 = G. | year = 2014 | title = An empirical investigation of challenges and recommendations for welcoming sexual and gender minority Veterans into VA care | doi = 10.1037/a0034826 | journal = Professional Psychology: Research and Practice | volume = 45| issue = 6| pages = 433–442}}</ref>  LGBTQ+ people, including LGBTQ+ veterans, have unique health needs that need screening and follow up, which require healthcare providers initiate conversations about sexuality and gender identity and expression with patients.

===Responses from the Veterans' Health Administration===
The Veterans Health Administration (VHA) is working to be a national leader in health care for LGBTQ+ Veterans and assure that high-quality care is provided in a person-centered, respectful environment. To address the healthcare needs of LGBTQ+ veterans and create a more welcoming environment at VHA facilities, as well as increase the competency of providers, VHA has taken several actions, starting with several policy changes. For example, patient<ref name=PatientRights /> and Department of Veterans Affairs (VA) employee <ref>McDonald, R. (April 20, 2015). Equal Employment Opportunity, Diversity and Inclusion, No FEAR, and Whistleblower Rights and Protection Policy Statement.   Retrieved May 13, 2016, from http://www.diversity.va.gov/policy/files/EEO_Policy_Statement.pdf</ref> non-discrimination policies now include protections for sexual orientation, gender identity and expression and also have an inclusive definition of family.<ref name=FamilyRights> Rights and Responsibilities of Family Members of VA Patients and Residents of CLCs.   Retrieved May 13, 2016, from http://www.va.gov/health/rights/familyrights.asp </ref> A policy on the rights of veterans’ family members includes a broad definition of “family” that allows LGBTQ+ veterans to decide who is regarded as part of their family.<ref name=FamilyRights /> VHA also issued a national transgender healthcare policy in 2011 (now VHA Directive 1341) and began training providers on transgender care. VHA has a separate healthcare policy on LGBQ health care (VHA Directive 1340).

In 2011, VHA established the [http://www.va.gov/healthequity/ Office of Health Equity] to work at a systems level to reduce [[health disparities]] in a number of vulnerable populations, including LGBTQ+ veterans, by raising awareness and advocating for healthcare system changes.<ref>Sharpe, V. A., & Uchendu, U. S. (2014). Ensuring appropriate care for LGBT veterans in the Veterans Health Administration. Hastings Center Report, 44(s4), S53-S55. </ref> One important activity by the Office of Health Equity has been their championing of VA facility participation in the Human Rights Campaign Healthcare Equality Index survey. In the most recent survey, 115 of 171 VA facilities participated in the HEI. 

The VHA has also established the [http://www.patientcare.va.gov/LGBT/index.asp LGBTQ+ Health Program within the Office of Patient Care Services]. The LGBTQ+ Health Program supports an internal SharePoint website which hosts archived staff trainings, links to policies, links to professional society guidelines, journal articles, facility information about LGBTQ+ support groups, patient education materials, and LGBTQ+ awareness campaign materials. The LGBTQ+ Health Program also worked with subject-matter experts to create a series of educational trainings and webinars on LGBTQ+ Veteran health, which are available internally and publicly through VHA TRAIN,<ref>VHA TRAIN Employee Education System.   Retrieved May 13, 2016, from https://vha.train.org/</ref> a free service of the Public Health Foundation, and VA eHealth University.<ref>Virtual VA eHealth University.   Retrieved May 13, 2016, from http://www.vehu.va.gov/ {{Webarchive|url=https://web.archive.org/web/20190807143507/https://www.vehu.va.gov/ |date=2019-08-07 }}</ref> 

There is an LGBTQ+ Veteran Care Coordinator (LGBTQ+ VCC) at every facility to help veterans get the care they need. The LGBTQ+ VCC can answer questions, advocate for the right to quality care, handle complaints or concerns veterans have about your care, and help veterans get started with services for LGBTQ+ Veterans. [https://www.patientcare.va.gov/LGBT/VAFacilities.asp Contact the LGBTQ+ VCC at your nearest facility.] 

The LGBTQ+ Health Program also worked to develop clinical support for VHA providers. E-consultation on transgender care is available to any VHA provider at any facility through the veteran’s electronic health record..<ref>Shipherd, J. C., Kauth, M., & Matza, A. R. (in press). Nationwide interdisciplinary e-consultation on transgender care in the Veterans Health Administration. Telemedicine Journal and e-Health. </ref>  Providers asking a question get a case-specific response from an interdisciplinary team of experienced clinicians. The national e-consultation program began in 2014 and became completely national in spring 2015. 

Another training program consists of nine [http://www.patientcare.va.gov/LGBT/LGBT_Veteran_Training.asp interprofessional postdoctoral psychology fellowships in LGBTQ+ health] sponsored by the VHA Office of Academic Affiliations and Mental Health Services.<ref>LGBT  Veteran Training.   Retrieved May 13, 2016, from http://www.patientcare.va.gov/LGBT/LGBT_Veteran_Training.asp </ref> The LGBTQ+ Health Program advises these nine fellowship sites, which include VA medical centers at Bedford, MA; Boston, MA; Chicago, IL; Honolulu, HI; Houston, TX; Milwaukee, WI; San Diego, CA; San Francisco, CA; and West Haven, CT. Fellows provide direct clinical services to LGBTQ+ veterans in a variety of clinical settings, as well as train staff and outreach to LGBTQ+ community agencies.

In addition to responding to the needs of LGBTQ+ Veterans, the VHA Office of Diversity and Inclusion (ODI) has taken steps to foster a supportive environment for LGBTQ+ employees.<ref name=LGBTProgram> LGBT Program.   Retrieved May 13, 2016, from http://www.diversity.va.gov/programs/lgbt.aspx </ref> Employees enjoy the same discrimination protections as patients, including protections for sexual orientation and gender identity. For example, the Office of Personnel Management (OPM) offers protections to transgender VA employees, including access to sanitary facilities, use of preferred name and pronouns in employee files, and avenues through which to report workplace discrimination, as well as healthcare coverage for transition related care.<ref>Guidance Regarding the Employment of Transgender Individuals in the Federal Workplace.   Retrieved May 13, 2016, from https://www.opm.gov/policy-data-oversight/diversity-and-inclusion/reference-materials/gender-identity-guidance/ {{Webarchive|url=https://web.archive.org/web/20180408194941/https://www.opm.gov/policy-data-oversight/diversity-and-inclusion/reference-materials/gender-identity-guidance/ |date=2018-04-08 }}</ref> Protections are in place for both sexual orientation and gender minority federal employees.<ref>Addressing Sexual Orientation and Gender Identity Discrimination in Federal Civilian Employment: A Guide to Employment Rights, Protections, and Responsibilities. (June 2015).   Retrieved May 13, 2016, from https://www.opm.gov/policy-data-oversight/diversity-and-inclusion/reference-materials/addressing-sexual-orientation-and-gender-identity-discrimination-in-federal-civilian-employment.pdf </ref> ODI has established an LGBTQ+ Special Emphasis Program (SEP), which works to ensure that there is equal opportunity for LGBTQ+ employees to work at VHA facilities. One goal of the SEP is to establish a manager at each VHA facility who serves as the facility expert on LGBT policy and leads the staff in creating a welcoming environment to LGBTQ+ employees through educational activities and cultural competency trainings.<ref name=LGBTProgram />

In March 2024, it was announced that IVF treatment will also cover single individuals and same-sex couples within the US Military - not just for heterosexual couples.<ref>[https://www.lgbtqnation.com/2024/03/military-will-soon-cover-ivf-services-for-lgbtq-veterans-servicemembers/]</ref>

===See also===
* [[LGBT healthcare in prison]]

===References===
{{reflist}}

===Further reading===
* ''[https://archive.today/20190308152242/https://usasucks.net/2017/10/13/department-of-veteran-affairs-marginalization-and-disenfranchisement-of-intersex-veterans/ Department of Veteran Affairs marginalization and disenfranchisement of intersex veterans]''

===External links===
* [https://www.albuquerque.va.gov/ALBUQUERQUE/services/lgbt/index.asp Lesbian, Gay, Bisexual and Transgender Veteran Care], at Albuquerque.va.gov

{{Queer people and military service in the United States}}
{{LGBT in the United States}}

[[Category:LGBTQ and health care]]
[[Category:LGBTQ people and military service in the United States]]
[[Category:United States Department of Veterans Affairs]]

==VA police Department==
{{main|United States Department of Veterans Affairs Police}}

==See also==
* [[Veterans benefits for post-traumatic stress disorder in the United States]]
* [[EBenefits]]
* [[Gerontology]]
* [[Rehabilitation Research and Development Service]]

==References==
{{reflist}}

==External links==
*[http://www.va.gov/health/ Veterans Health Administration]

{{USVA agencies}}
{{Authority control}}

[[Category:Healthcare in the United States]]
[[Category:United States Department of Veterans Affairs]]
[[Category:Public services of the United States]]