By Annette M. Boyle

Dr. Baligh Yehia, deputy under secretary for Health for Community Care

PHILADELPHIA — Shifting demographics and commitment to creating an integrated network that combines community providers and VA facilities has propelled the agency into a leadership position in addressing the healthcare disparities that continue to cost lives and drive up medical expenses.

Between 2003 and 2006, racial/ethnic health disparities alone are estimated to have cost the United States more than $230 billion in direct medical expenditures and more than $1 trillion, when lost productivity and the costs of premature death are included.1

“As the largest integrated health care system in the nation, VA has an opportunity to lead the rest of the country in reducing health and health care disparities,” explained Baligh Yehia, MD, deputy under secretary for Health for Community Care and other senior VA executives in an editorial that accompanied a special supplement to the September issue of Medical Care.2


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The VA’s long-term relationship with patients and the growing diversity of the veterans served by the VA have made reducing healthcare disparities an urgent matter for the organization. Racial or ethnic minorities now account for 22% of veterans and are expected to represent 34% of veterans by 2040. During the same period, the percentage of women veterans is projected to double to 20%.

To ensure appropriate and equitable treatment for these groups and others, the VHA established the Office of Health Equity (OHE) in 2012. In a move that put VA in the lead nationally in health equity research and efforts, “the OHE charter broadened the definition of vulnerable populations beyond racial and ethnic minorities to include gender identity, age, geographic location, religion, socioeconomic status, sexual orientation, mental illness and disability,” Yehia told U.S. Medicine.

In addition, the VA supports two Health Services Research and Development Centers of Innovation focused on health equity and research and has implemented care coordination techniques in its patient-aligned care teams that have been shown to reduce healthcare disparities, noted Said A. Ibrahim, MD, MPH, MBA; Leonard E. Egede, MD, MS; and Michael J. Fine, MD, MSc. in another editorial. Ibrahim and Fine direct the VA’s Center for Health Equity Research and Promotion (CHERP), while Egede is a former director of the Health Equity and Rural Outreach Innovation Center (HEROIC).3

Disparities Persist


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Still, research published in the supplement found that significant disparities in utilization and outcomes persist. African-American and Latino veterans with post-traumatic stress disorder (PTSD), for instance, discontinue psychotherapy and medications at higher rates than white veterans. In both groups, treatment continuation closely correlated to the veteran’s perception of the provider as caring and helpful.4

Patient perception also strongly influenced veteran women at risk for unintended pregnancy. A study of 1,341 women veterans found that 11.3% of blacks and 11.2% of Hispanics perceived race-based discrimination when receiving care at the VA, and those women were 35% less likely to use contraception, especially an intrauterine device or long-acting implant, than women who did not perceive discrimination in their healthcare. The authors concluded that “VA efforts to enhance respectful interactions may not only improve patient health care experiences, but also represent an opportunity to improve reproductive health outcomes for women veterans.”5

Lesbian, gay, bisexual and transgender (LGBT) veterans expressed general satisfaction with their healthcare at the VA, although transgender men had somewhat lower satisfaction with their mental healthcare.

Developing, implementing and evaluating interventions designed to more effectively engage and treat vulnerable patient populations must be a priority for the VA “to ensure the quality and equity of health and health care for the growing number of vulnerable veterans managed in the VA Healthcare System,” said Ibrahim and his co-authors.

Increasingly, the VA needs to transfer that knowledge to community providers. The Veterans Access, Choice and Accountability Act expanded access to providers outside the VA, many of whom have had little experience working with veterans. Last year, more than two million veterans attended more than 25 million community care appointments, according to Yehia and his co-authors.

The increased access to healthcare through the Choice program might reduce healthcare disparities, but it also expands the number of providers who may benefit from “increased awareness of cultural competency, sex sensitivity and provider bias” to promote “more effective communication and clinical judgment,” they noted.

Education that increases military cultural competence in a healthcare setting is particularly important for veterans. “VHA Train portal has been successful in giving community providers easy access to training topics such as military cultural awareness, military organization and roles, stressors, and treatment tools,” Yehia said. “Since its launch in April 2015, healthcare communities in all 50 states and 145 countries have utilized VHA TRAIN.”  

To better address healthcare disparities, the VA and its community partners will need to work together to develop and implement and assess the effectiveness of new programs. “As VA care evolves, monitoring how the VA Community Care Provider Network performs will be important to ensuring that all veterans receive equitable health care,” concluded Yehia and his co-authors. “VA’s health services research program is in a unique position to evaluate these changes to VA health care delivery and consider new models of care that truly impact health outcomes and address health equity.”

  1. LaVeist TA, Gaskin D, Richard P. Estimating the economic burden of racial health inequalities in the United States. Int J Health Serv. 2011;41(2):231-8.
  2. Yehia BR, Greenstone CL, Hosenfeld CB, Matthews KL, Zephyrin LC. The Role of VA Community Care in Addressing Health and Health Care Disparities. Med Care 2017 Sep;55 Suppl 9 Suppl 2:S4-S5.
  3. Ibrahim SA, Egede LE, Fine MJ. New Evidence Reflecting VA’s Commitment to Achieve Health and Health Care Equity for All Veterans. Med Care. 2017 Sep;55 Suppl 9 Suppl 2:S1-S3.
  4. Spoont M, Nelson D, van Ryn M, Alegria M. Racial and Ethnic Variation in Perceptions of VA Mental Health Providers are Associated With Treatment Retention Among Veterans With PTSD. Med Care. 2017 Sep;55 Suppl 9 Suppl 2:S33-S42.