The health care programs of the Department of Defense (DoD) and the Department of Veterans Affairs (VA) provide insurance and direct care to about 14 million people at a combined cost in 2011 of $104 billion. The DoD program, Tricare, serves active duty personnel, military retirees, and their dependents. Tricare includes several insurance options that provide services directly in DoD facilities and also offer access to contracted networks of civilian providers. The VA health program generally functions as a delivery system, rather than as insurance. Care is provided through a network of hospitals, medical centers, and community-based outpatient clinics. Preference is given to veterans who have a service-connected disability or low income, and, for a limited period, to those who have served in combat in Afghanistan and Iraq. Many active duty personnel and recent veterans who have served in combat have mental health problems, including post-traumatic stress disorder, major depression, or traumatic brain injury. As a result, access and quality of mental health care in both the DoD and VA have been a focus of policy discussion. Active service members may avoid care because of concerns about career effects or doubt about the efficacy of mental health services. Those who do obtain care may have their treatment disrupted when they return to civilian life. The DoD and VA have been working to improve transitions between the two systems, but progress has sometimes been slow. Within the VA, there are numerous programs to improve access to mental health care, but recent veterans still report delays in obtaining needed services and lack of continuity. The problems have been the subject of a federal court case and have received considerable congressional attention. Although the relevant provisions of the Affordable Care Act are ambiguous, it appears possible that many veterans, retirees, and their families will have a choice between obtaining insurance through the ACA exchanges (or, for lower-income families, ACA-expanded Medicaid) or using Tricare or VHA services. For potential Tricare enrollees, the choice could depend on the relative costs of Tricare or ACA coverage. The Administration has proposed new means-based enrollment fees for military retirees; this could shift the balance for lower-income participants. The effects of the ACA on VA users might be larger. Many will now qualify for Medicaid, while others might see lower costs for exchange coverage than for VA services. Some people are arguing that--if most nonelderly VHA users could get low-cost insurance elsewhere and older users have Medicare--it may no longer make sense to go on operating a separate health system for veterans, especially those without service-connected problems.
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