New York's Veterans: An In-depth Profile October 2021 Contents 1 Foreword 2 D emographics of New York State's Veterans 5 Where Veterans Live in New York State 7 Factors Impacting Veterans' Health 16 Veteran Suicide in New York State 18 How Veterans Access Health Care Foreword This document is meant to provide an overview of the New York State veteran population, with an emphasis on health. The data reported come from various sources, including federal agencies and veteran advocacy organizations. Unless otherwise noted, the statistics in this report refer to 2018 data. Since the most recent New York State Health Foundation (NYSHealth) snapshot of veterans and health in New York State, which relied primarily on 2015 data, the veteran population in New York State has declined. New York's veterans are also younger and more diverse. These demographic trends are projected to continue. New York's Veterans: An In-depth Profile 1 Demographics of New York State's Veterans TOTAL NUMBER OF VETERANS IN NEW YORK Home to 790,000 veterans in 2018, New York has the nation's fifth largest veteran population.1 The veteran population in the United States that same year was 20.3 million. 2 Top 5 states with largest veteran population: California 1 1,752,000 Texas 2 1,596,000 Florida 3 1,570,000 Pennsylvania 4 836,000 New York 5 790,000 Source: U.S. Department of Veterans Affairs, National Center for Veterans Analysis and Statistics, "Veteran population. Table 6L: VETPOP2018 Living Veterans by State, Age Group, Gender, 2018-2048" (2018 estimates are shown), https://www.va.gov/vetdata/veteran _ population.asp. The total number of veterans in New York has decreased from 838,000 in 2015 and can be expected to continue to decline in the future, given the aging of the population. 3 1 U.S. Department of Veterans Affairs, National Center for Veterans Analysis and Statistics, "Veteran population. Table 6L: VETPOP2018 Living Veterans by State, Age Group, Gender, 2018-2048," https://www.va.gov/vetdata/veteran _ population.asp. 2 U.S. Department of Veterans Affairs, National Center for Veterans Analysis and Statistics, "Veteran population: Table 6L." U.S. estimate includes veterans in Puerto Rico, island areas, and foreign countries. 3 New York State Health Foundation, "Veterans and Health in New York State," 2017, https://nyshealthfoundation.org/wp-content/uploads/2017/11/veterans-and-health-in-new-york-state-july-2017.pdf. New York's Veterans: An In-depth Profile 2 Demographics of New York State's Veterans (continued) GENDER OF VETERANS IN NEW YORK The vast majority of veterans in New York State were male (92%), but the proportion of female veterans has been steadily rising and is expected to reach more than 10% by 2025. Number of female veterans in New York: 63,000 or 8 % Number of male veterans in New York: 727,000 or 92 % 4 Source: U.S. Department of Veterans Affairs, National Center for Veterans Analysis and Statistics, "Veteran population. Table 6L: VETPOP2018 Living Veterans by State, Age Group, Gender, 2018-2048" (2018 estimates and 2025 projections are shown), https://www.va.gov/vetdata/veteran _ population.asp. RACE/ETHNICITY OF VETERANS IN NEW YORK Over the past few decades, the nation's veteran population has become increasingly diverse. Minorities made up 23% of New York's veteran population. This proportion is expected to reach nearly 30% by 2030. The largest groups of minorities were Black or African American (91,000 or 12%) and Hispanic (67,000 or 9%). 5 AGE OF VETERANS IN NEW YORK As of 2018, slightly more than half (400,000) of veterans in New York were age 65 or older. 6 The veteran population tends to be substantially older than the general population. Approxi- mately 13% of New York's veterans in 2018 were under 40 years old, largely reflecting those that joined after 9/11.7 4 U.S. Department of Veterans Affairs, National Center for Veterans Analysis and Statistics, "Veteran population. Table 6L: VETPOP2018 Living Veterans by State, Age Group, Gender, 2018-2048", https://www.va.gov/vetdata/veteran _ population.asp. 5 U.S. Department of Veterans Affairs, National Center for Veterans Analysis and Statistics, "Veteran population. Table 8L: VETPOP2018 Living Veterans by State, Race/Ethnicity, Gender, 2018-2048", https://www.va.gov/vetdata/veteran _ population.asp. 6 U.S. Department of Veterans Affairs, National Center for Veterans Analysis and Statistics, "Veteran population. Table 6L." 7 Ibid. New York's Veterans: An In-depth Profile 3 Demographics of New York State's Veterans (continued) Distribution of Veteran and General Adult Population by Age Group 50% 51% 40% Veterans 41% 38% G eneral 37% Population 30% 20% 21% 10% 13 % 0% <40 years 40-64 years ≥65 years Source: U.S. Department of Veterans Affairs, National Center for Veterans Analysis and Statistics, "Veteran population. Table 8L: VETPOP2018 Living Veterans by State, Race/Ethnicity, Gender, 2018-2048" (2018 estimates and 2030 projections are shown), https://www.va.gov/vetdata/veteran _ population.asp. U.S. Census Bureau, "2018 ACS 1-Year Estimates Subject Tables," https://data.census.gov/cedsci/table?q=&t=Age%20and%20Sex&g=0400000US36&tid=ACSST1Y2018.S0101. Note: General population proportions are calculated using a denominator of ages ≥18 years to be comparable to veteran population. PERIOD OF SERVICE Nearly three-quarters of veterans in New York State served during wartime. 13% of veterans began serving during the post-9/11 era. This proportion is steadily increasing and is expected to reach 22% by 2025.8 Distribution of New York Veterans by Period of Service 40% 30% 32% 30% 20% 10% 13 % 4% 8% 0% WWII Korean Conflict Vietnam Era Gulf War Era Post-9/11 Only Source: U.S. Department of Veterans Affairs, National Center for Veterans Analysis and Statistics, "Veteran population. Table 7L: VETPOP2018 Living Veterans by State, Period of Service, Gender, 2018-2048" (2018 estimates are shown), https://www.va.gov/vetdata/veteran _ population.asp. Note: Veterans who served in multiple periods are counted in each category, but only counted once in the denominator. 8 U.S. Department of Veterans Affairs, National Center for Veterans Analysis and Statistics, "Veteran population. Table 7L: VETPOP2018 Living Veterans by State, Period of Service, Gender, 2018-2048," https://www.va.gov/vetdata/veteran _ population.asp. New York's Veterans: An In-depth Profile 4 Where Veterans Live in New York State Long Island and New York City are home to large numbers of veterans. The 5 Counties with the Most Veterans: Suffolk Erie Kings Queens Nassau 64,000 59,000 47,000 46,000 45,000 Although the total numbers are smaller, the highest concentrations of veterans are typically found in less populated and more rural counties such as New York's North Country and Southern Tier counties. The 5 counties with the Highest Density of Veterans per 1,000 Residents: Jefferson Hamilton Tioga Clinton Chenango 134 125 85 84 82 New York's Veterans: An In-depth Profile 5 Where Veterans Live in New York State (continued) D ensity of Veterans by County, 2018 Vete ra n Po p ul at i o n Pe r 1 ,0 0 0 Re s i de nt s 0 20 40 60 80 100 120 140 Sources: U.S. Department of Veterans Affairs. National Center for Veterans Analysis and Statistics. Veteran population. Table 9L: VetPop2018 County-Level Veteran Population by state, age group, gender, 2018-2048 (2018 estimates are shown) https://www.va.gov/vetdata/veteran _ population.asp. United States Census Bureau. County Population Totals: 2010-2019. https://www.census.gov/data/tables/time-series/demo/popest/2010s-counties-total.html. New York's Veterans: An In-depth Profile 6 Factors Impacting Veterans' Health As is the case for civilian populations, a wide range of factors-including employment, income, education, food security, and substance use-influence veterans' health.9 Below, we discuss the impact of these and other factors on veterans' health; when data are available, we compare how these factors are associated with veteran and nonveteran populations. VETERAN STATUS Being a veteran can itself can either positively or negatively affect health.10 For example, the military population is generally healthier than the civilian population because of physical screenings to enlist in military service, standards of physical health to remain in the military, and better access to medical care during and after service. This "healthy solider effect" can promote health and protect against poor health outcomes among veterans. Veterans may also benefit from social supports associated with belonging to a military community. In contrast, being a veteran may also be associated with negative health outcomes. For example, veterans may experience combat injuries or traumatic events during military service, which can increase the risk for negative physical and mental health outcomes. UNEMPLOYMENT Unemployment may affect health outcomes by reducing income, increasing stress, and re- stricting access to employer-based insurance coverage. Existing research shows that unem- ployment increases poor mental health outcomes, including increased depression, anxiety, and low self-esteem.11 Unemployment may also impact physical health, including increasing cardiovascular risk factors and susceptibility to respiratory infections. Nationally, the unemployment rate for veterans tends to be lower than that of nonveterans. However, this has generally not been the case in New York. In 2020, as with the nonveteran population, veterans experienced a high level of job loss because of the health and eco- nomic fallout of the coronavirus pandemic. 9 Center for New American Security, "New York State Minority Veteran Needs Assessment," 2020, https://www.cnas.org/publications/reports/new-york-state-minority-veteran-needs-assessment. 10 Ruth McLaughlin, Lisa Nielsen, and Michael Waller, "An Evaluation of the Effect of Military Service on Mortality: Quantifying the Healthy Soldier Effect," Annals of Epidemiology 18, no. 12 (December 2008): 928–36, https://doi.org/10.1016/j.annepidem.2008.09.002. 11 Larisa Antonisse and Rachel Garfield, "The relationship between work and health: Findings from a literature review," August 2018, https://www.kff.org/medicaid/issue-brief/the-relationship-between-work-and-health-findings-from-a-literature-review/. New York's Veterans: An In-depth Profile 7 Factors Impacting Veterans' Health (continued) Comparison of Unemployment Rate for Veterans and Nonveterans in New York and Nationally: 2016–2020 10% NY Nonveterans Veterans 8% U n e m p loym e nt Rate 6% 4% 2% 2016 2017 2018 2019 2020 10% US Nonveterans Veterans 8% U n e m p loym e nt Rate 6% 4% 2% 2016 2017 2018 2019 2020 Source: U.S. Bureau of Labor Statistics, "Table 6. Employment Status of the Civilian Noninstitutional Population by State and Veteran Status, Not Seasonally Adjusted," (Source: Current Population Survey). Tables for veterans and nonveterans, 18 years of age and older in 2019 and 2020 were made available by special request from the U.S. Bureau of Labor Statistics. New York's Veterans: An In-depth Profile 8 Factors Impacting Veterans' Health (continued) INCOME Prior research also shows that people with higher income tend to live longer and healthier lives than those with lower incomes.12 People with lower incomes typically have less money to spend taking care of themselves, whether paying for doctors' visits or healthy food. They may also experience more stress, which can lead to increased risk for heart disease, stroke, cancer, and diabetes. Meanwhile, people with higher incomes live in areas where healthier resources are more available, such as parks to exercise, clean air, better schools, and better food markets. Nationally, veterans are associated with higher incomes, on average, than nonveterans.13 However, in New York, veterans tend to have lower family incomes than nonveterans. Comparison of Average Family Income for New York Veterans and Nonveterans: 2014–2020 $120,000 $100,000 Ave rag e Tot al Fa m i ly I n co m e $80,000 $82,725 $65,067 $60,000 $40,000 Nonveterans Veterans $20,000 $0 2014 2015 2016 2017 2018 2019 2020 Source: NYSHealth analysis of 2014–2020 CPS Annual Social and Economic (March) Supplement. Data available from: https://data.census.gov/mdat/#/search?ds=CPSASEC2020&vv=*FTOTVAL&cv=PEAFEVER&rv=ucgid&wt=MARSUPWT&g=0400000US36 12 Angus Deaton, "Policy Implications of The Gradient Of Health And Wealth," Health Affairs, 2002, 21(2), 13–30. https://www.healthaffairs.org/doi/10.1377/hlthaff.21.2.13. 13 Francesco Renna and Amanda Weinstein, "The veteran wage differential," Applied Economics, 2018, 51(12), https://doi.org/10.1080/00036846.2018.1527445. New York's Veterans: An In-depth Profile 9 Factors Impacting Veterans' Health (continued) While average incomes are lower, fewer veterans in New York live at or below the poverty line relative to nonveterans. Comparison of Poverty Status for New York Veterans and Nonveterans: 2014–2020 18% 16% 14% Pe rce nt of Po p ul at i o n B e low 12% 11.4% Pove r t y Leve l 10% 8% 7.7% 6% 4% Nonveterans Veterans 2% 0% 2014 2015 2016 2017 2018 2019 2020 Source: NYSHealth analysis of 2014–2020 CPS Annual Social and Economic (March) Supplement. Data available from: https://data.census.gov/mdat/#/search?ds=CPSASEC2020&cv=PEAFEVER,FAMLIS&rv=ucgid&wt=MARSUPWT&g=0400000US36 EDUCATION Similar to income, more years of education have been strongly associated with longer life spans and better health.14 Research points to several reasons for this relationship, including the ability of people with higher education to get higher paying jobs, which can lead to bet- ter access to health care. Higher education has also been associated with the better social, psychological, and interpersonal resources that improve people's ability to cope with stress, recognize symptoms of ill health in a timely manner, and seek appropriate medical help. A high school diploma or GED is required to enter the military. Accordingly, the vast majority of veterans in New York report having at least this level of education, much higher than the nonveteran population. However, there is a slightly lower percentage of veterans that reported having graduated from college or a technical school relative to nonveterans. 14 Viju Raghupathi and Wullianallur Raghupathi, "The Influence of Education on Health: An Empirical Assessment of OECD Countries for the Period 1995–2015," Arch Public Health 2020, 78, 20, https://doi.org/10.1186/s13690-020-00402-5. New York's Veterans: An In-depth Profile 10 Factors Impacting Veterans' Health (continued) Comparing Veteran and Nonveteran Highest Educational Attainment in New York: 2019 40% Veterans N onveterans 33.3 % 33.4% 30% 30.6% 29.9% 25.9% 26.3 % 20% 14.3 % 10% 6.2% 0% Did Not Graduate High School Some College College or Technical High School Graduate (only) or Technical School School Gracuate Source: NYSHealth analysis of 2019 New York State Behavioral Risk Factor Surveillance Survey data. Data available from: https://www.cdc.gov/brfss/annual _ data/annual _ data.htm DISABILITY Given the nature of the work, military service is associated with heightened risk for various physical and psychological injuries. These can occur in training, combat, or garrison environments. Disability is associated with worse overall health, including more frequent mental distress, in comparison to people without disabilities.15,16 15 Centers for Disease Control and Prevention, "Disability and Health Related Conditions," https://www.cdc.gov/ncbddd/disabilityandhealth/relatedconditions.html 16 Centers for Disease Control and Prevention "The Mental Health of People with Disabilities," https://www.cdc.gov/ncbddd/disabilityandhealth/features/mental-health-for-all.html New York's Veterans: An In-depth Profile 11 Factors Impacting Veterans' Health (continued) About one-quarter of veterans across the country have a service-related disability.17 This figure is higher (40%) for post-9/11 veterans. By comparison, the proportion of the general population that has a disability is approximately 11%.18 While part of this disparity may be because of the older average age of veterans relative to nonveterans, prior research has also shown that veterans tend to have higher disability rates within similar age groups.19 According to survey data from New Yorkers, consistent with national trends, a substantially larger proportion of veterans compared with non-veterans identified themselves as having at least one of six conditions associated with disability. Proportion of Veterans and Nonveterans in New York with at Least One of Six Disability-Related Conditions (2019) Veterans: 34% Nonveterans: 25% Source: NYSHealth Analysis of 2019 Behavioral Risk Factor Surveillance System Data. Survey respondents were identified as having a disability condition if they answered affirmative to any of the following: (1) deaf/difficulty hearing; (2) blind/serious difficulty seeing; (3) difficulty concentrating, remembering, or making decisions; (4) serious difficulty walking or climbing stairs; (5) difficulty dressing or bathing; or (6) difficulty doing errands alone. Data available from: https://www.cdc.gov/brfss/annual _ data/annual _ data.htm. 17 U.S. Department of Labor, Bureau of Labor Statistics, "Employment Situation of Veterans: 2020," https://www.bls.gov/news.release/pdf/vet.pdf. The Bureau of Labor Statistics disability information for veterans is based on how the U.S. Department of Veterans Affairs (VA) identifies service-related disabilities as resulting from all types of diseases and injuries encountered as a result of or incident to military service. The VA focuses on disabilities that result in limitations in functional abilities, particularly in the ability to work and are generally based on medical examinations. For more information on how the VA defines disability please see: https://www.benefits.va.gov/WARMS/bookc.asp#c. 18 U.S. Department of Labor, Bureau of Labor Statistics, "Persons with a Disability: Labor Force Characteristics Summary," 2021, https://www.bls.gov/news.release/disabl.nr0.htm. The estimates of disability in the general population based on survey- response data. More specifically, the U.S. Department of Labor estimates are based on a set of six questions to identify persons with physical, mental, or emotional conditions that cause serious difficulty with their daily activities. For more details, please see: https://www.bls.gov/news.release/disabl.tn.htm. 19 Kelly Ann Holder, "The Disability of Veterans," U.S. Census Bureau, Social, Economic, and Housing Statistics Division, https://www.census.gov/content/dam/Census/library/working-papers/2016/demo/Holder-2016-01.pdf New York's Veterans: An In-depth Profile 12 Factors Impacting Veterans' Health (continued) FOOD INSECURITY Food insecurity is broadly defined as the lack of consistent access to enough food to live an active, healthy life. 20 Adults who are food insecure may be at an increased risk for a variety of negative health outcomes, including obesity and chronic disease. In New York, veterans have generally had lower rates of food insecurity than nonveterans. Comparing Veteran and Nonveteran Food Insecurity Rates: 2009–2019 18% 16% 14% 12% 10.6% 10% 8.7% 8% 6% 4% Nonveterans: Low & Very Low Food Security Veterans: Low & Very Low Food Security 2% 0% 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Source: NYSHealth analysis of the 2009–2019 Current Population Survey Food Security Supplement (CPS-FSS). Data available from: https://data.census.gov/mdat/#/search?ds=CPSFOODSECURITY201912&cv=PEAFEVER,HRFS12M1&rv= ucgid&wt=PWVETWGT&g=0400000US36. Notes: Food insecurity (or having low and very low food security) is measured on the CPS-FSS based on self-reported survey data on food access. In general, households are characterized as "low food secure" if they have reduced the quality, variety, and desirability of their diets, but the quantity of food intake and normal eating patterns were not substantially disrupted. "Very low food security" refers to reporting that, at times during the year, eating patterns of one or more household members were disrupted and food intake reduced because the household lacked money and other resources for food. 20 Office of Disease Prevention and Health Promotion, "Food Insecurity," https://www.healthypeople.gov/2020/topics-objectives/ topic/social-determinants-health/interventions-resources/food-insecurity New York's Veterans: An In-depth Profile 13 Factors Impacting Veterans' Health (continued) MENTAL HEALTH AND SUBSTANCE USE CHALLENGES FACING VETERANS For veterans, mental health and substance use problems can present an obstacle to returning to normal post-service life activities. Substance Use Based on survey data from 2015 to 2018, about 10% of veterans in New York have reported ever receiving treatment for drug or alcohol use. 21 This percentage is about twice as high as for the nonveteran population (5%). Mental Health Historically, veterans generally have had lower rates of self-reported feelings of stress, depression, or emotional problems than the general population. Reasons for this may include underreporting in the veteran population because of a military culture that can emphasize toughness. However, those who enter military service may be more mentally resilient and better at handling stress compared with the general population. The experience with high-stress situations during service might make also veterans better at handling stress in daily civilian life. 22 Based on survey data from 2015–2018, approximately 6% of veterans in New York were identified as having serious psychological distress in the past year.23 Approximately 20% of veterans in New York identified as ever feeling sad, empty, or depressed for several days or longer. These rates are lower than those for the nonveteran population. In New York, there has been a recent concerning trend of increased reports of poor mental health. In fact, 2019 was the first year when the rate of self-reported poor mental health was higher for veterans than nonveterans. 21 National Survey on Drug Use and Health, "4-Year RDAS (2015 to 2018)," https://rdas.samhsa.gov/#/survey/NSDUH-2015-2018- RD04YR 22 Emily Pedneau, "Impact of Combat Stress on Mental Health Outcomes: BRFSS Survey Data 2006," 2007, https:// scholarscompass.vcu.edu/cgi/viewcontent.cgi?referer=https://scholar.google.com/&httpsredir=1&article=1941&context=etd 23 National Survey on Drug Use and Health, "4-Year RDAS (2015 to 2018)." New York's Veterans: An In-depth Profile 14 Factors Impacting Veterans' Health (continued) Proportion of Veterans and Nonveterans that Self-report Being in Poor Mental Health Within the Past 30 Days 14% 12% 10% 8% 6% 4% Nonveterans Veterans 2% 0% 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Source: NYSHealth analysis of Behavioral Risk Factor Surveillance Survey data. Data available from: https://www.cdc.gov/brfss/annual _ data/annual _ data.htm Notes: The analysis is based on the question: "Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?" Respondents that reported 14 or more days in the last month are categorized as being in poor mental health. Post-Traumatic Stress Disorder (PTSD) A particular mental health issue that impacts veterans more than nonveterans is PTSD. PTSD can develop after experiencing or witnessing a traumatic event that is beyond a typical stressor, such as warfare, sexual assaults, natural disasters, or other life-threatening events.24 PTSD is associated with persistent mental and emotional stress, substance use, smoking, increased violence, poor work performance, and poor quality of life in U.S. war veterans. Indi- viduals with PTSD also have a relatively high prevalence of comorbidities associated with low physical activity such as obesity and diabetes. The rate of PTSD in the veteran population has been found to be double that of the general population (12.9% compared with 6.8%).25 Incidence of PTSD among U.S. veterans: 12.9% Estimated lifetime incidence of PTSD among the general population: 6.8% 24 National Institute of Mental Health, "Post-Traumatic Stress Disorder (PTSD)," https://www.nimh.nih.gov/health/statistics/post-traumatic-stress-disorder-ptsd 25 Jan Müller, Sarmila Ganeshamoorthy, and Jonathan Myers, "Risk Factors Associated with Posttraumatic Stress Disorder in U.S. Veterans: A Cohort Study," PloS one, 2017, 12(7), e0181647. https://doi.org/10.1371/journal.pone.0181647. New York's Veterans: An In-depth Profile 15 Veteran Suicide in New York State In 2019, 156 veterans died by suicide in New York.26 From 2015-2018, more than 3% of veterans in New York thought about suicide in the past 12 months. This was a similar percentage as for the general population. 27 However, veterans in New York die by suicide at a much higher rate than the general State population (nearly twice as high in 2019).28 Comparing Veteran and General Population Suicide Rates in New York State, 2010–2019 25 S u i c i de Rate (p e r 10 0,0 0 0) 20 20.2 15 10 10.7 NY Veterans NY General Population 5 0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Source: U.S. Department of Veterans Affairs. "2020 National Veteran Suicide Prevention Annual Report: State Data Appendix." https://www.mentalhealth.va.gov/suicide _ prevention/data.asp. Part of the reason for the difference in suicide rates between the veteran and general population may be attributable to the mode of suicide attempts. Veterans are more likely than the general population to use firearms as a method of suicide. 29 Percent of NY veteran suicides in 2019 that used a firearm: 55.1% Percent of NY general population suicides in 2019 that used a firearm: 26.8% Younger veterans in New York State tend to have higher suicide rates. Although suicide is a devastating event at any age, suicide among younger veterans results in the greatest number of years of life lost. 26 U.S. Department of Veterans Affairs, "2020 National Veteran Suicide Prevention Annual Report: State Data Appendix," https://www.mentalhealth.va.gov/suicide _ prevention/data.asp. 27 National Survey on Drug Use and Health, "4-Year RDAS (2015 to 2018)." 28 U.S. Department of Veterans Affairs. "2020 National Veteran Suicide Prevention Annual Report: State Data Appendix." 29 Ibid. New York's Veterans: An In-depth Profile 16 Veteran Suicide in New York State (continued) New York Veteran Suicide Rate by Age Group per 100,000, 2019 40 39.3 35 30 S u i c i de Rate (p e r 10 0,0 0 0) 25 25.0 20 17.7 15 15.6 10 5 0 18-34 years 35-54 years 55-74 years ≥75 years Source: U.S. Department of Veterans Affairs. "2020 National Veteran Suicide Prevention Annual Report: State Data Appendix." https://www.mentalhealth.va.gov/suicide _ prevention/data.asp. New York's Veterans: An In-depth Profile 17 How Veterans Access Health Care THE VETERANS AFFAIRS HEALTH CARE SYSTEM The Veterans Health Administration provides world-class medical, surgical, and rehabilitative care in New York through 12 medical centers, dozens of community-based outpatient centers, and 16 Vet Centers (community-based facilities that offer a variety of free services to veterans and their families, including counseling and social services). In general, all veterans are eligible for U.S. Department of Veteran Affairs (VA) health care benefits, with some exceptions for people who received a dishonorable discharge. The VA has spent more than $3 billion annu- ally on health care for veterans in New York.30 In 2017, nearly half (378,361) of New York veter- ans were enrolled in VA health care, with approximately 59% of them visiting a VA health care facility during the year. 31 A large proportion of veterans across the State rely on private sector care-even when utiliz- ing VA. Since as far back as 1945, VA has had a variety of programs that allow it to purchase private care for eligible veterans who could not receive services in a timely manner because of the capacity or capability of the nearest VA facility.32 These programs were consolidated temporarily under the Veterans Choice Act in 2014 to increase access, which was made perma- nent under the VA MISSION Act of 2018. According to research conducted by the RAND Corpo- ration, approximately half of the veteran population in New York would prefer to receive their care from private providers, while the other half would prefer VA. 33 PUBLIC AND PRIVATE COVERAGE In New York, nearly 70% of veterans under the age of 65 have private health insurance coverage either through their employer, through the New York State of Health insurance marketplace, or by purchasing directly from an insurance company. Approximately 9% of non-elderly veterans in New York only have health care coverage through VA. 34 Almost all veterans over the age of 65 have Medicare coverage. 35 30 US Department of Veterans Affairs, National Center for Veterans Analysis and Statistics, "Expenditures. (FY 2020)," https://www.va.gov/vetdata/expenditures.asp. 31 US Department of Veterans Affairs, "Locations: New York," https://www.va.gov/directory/guide/state.asp?STATE=NY&dnum=ALL. 32 United States Government Accountability Office, "VA Health Care: Estimating Resources Needed to Provide Community Care," June 2019, https://www.gao.gov/assets/gao-19-478.pdf. 33 Carrie Farmer et al., "A Needs Assessment of New York State Veterans," 2011, https://doi.org/10.7249/TR920. 34 This includes a small percentage of veterans who also have TriCare coverage. 35 NYSHealth analysis of 2019 American Community Survey. Data available from: https://www.census.gov/programs-surveys/ acs/microdata/access.html. New York's Veterans: An In-depth Profile 18 How Veterans Access Health Care (continued) Health Insurance Coverage for non-elderly (under age 65) New York Veterans, 2019 Private: Medicaid: VA: 68.5% 16.3% 29.3% Source: NYSHealth analysis of 2019 American Community Survey. Data available from: https://www.census.gov/programs-surveys/acs/microdata/access.html. Note: Categories are not exclusive. For example, those with private insurance coverage may also have other forms of coverage. PRIVATE SECTOR PROVIDER READINESS Veterans disproportionately experience higher rates of substance use, post-traumatic stress, suicide, and disability when compared with their civilian counterparts. In addition, exposure to toxic chemicals, high rates of cancer, and rampant military sexual harassment produce complex health needs that are unique to the veteran community. Because of the increased reliance on private sector health care in recent years, there is a growing need for non-VA health care providers to be aware of a patient's military history and provide veterans with culturally competent care. However, using survey data of New York health care practitioners, the RAND Corporation found that only a small percentage (2.3%) of practitioners fully meet recommended criteria to be able to provide timely, high-quality care to veterans. New York's Veterans: An In-depth Profile 19 How Veterans Access Health Care (continued) Readiness Criteria Prepared to Uses clinical Screens for Accommo- Familiar Screens Accepting treat conditions practice conditions com- dates patients with military patients for new patients common guidelines mon among with disabilities culture military/veteran among veterans veterans affiliation Prepared to Uses clinical Screens for Accommo- Familiar Accepting treat conditions practice conditions com- dates patients with military new patients common guidelines mon among with disabilities culture among veterans veterans Prepared to Uses clinical Screens for Accommo- 92 % Accepting treat conditions practice conditions com- dates patients new patients common guidelines mon among with disabilities among veterans veterans Prepared to Uses clinical Screens for 58.8 % Accepting treat conditions practice conditions com- new patients common guidelines mon among among veterans veterans Prepared to Uses clinical 41.8 % Accepting treat conditions practice new patients common guidelines among veterans Prepared to 24.6 % Accepting treat conditions AS THE NUMBER OF new patients common among veterans CRITERIA FOR READINESS INCREASES, THE PERCENTAGE 17 % Accepting OF READY PROVIDERS PLUMMETS. new patients 4.7 % 2.3 % Source: Maria Olenick, Monica Flowers, and Valerie Diaz, "U.S. veterans and their Unique Issues: Enhancing Health Care Professional Awareness," Advances in Medical Education and Practice, 2015, 6, 635. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4671760/ New York's Veterans: An In-depth Profile 20 VOICE: FAX: MAIL: WEB: 212-664-7656 646-421-6029 1385 Broadway, www.nyshealth.org 23rd Floor New York, NY 10018 Improving the state of New York's health