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Despite significant advances in medical care over the past decade, health and health care disparities persist across populations in the United States. 1 These differences lead to poor health outcomes and experiences for many diverse groups, including people of color, women, persons with social and economic disadvantage, lesbian, gay, bisexual, and transgender populations, and individuals living in rural and inner-city areas. Health disparities are preventable, and were estimated to cost the United States over 1 trillion in medical care expenditures, illness-related lost productivity, and premature death between 2003 and 2006. 2 As the US population increases in diversity, addressing health disparities becomes critically important to achieve better patient experiences, better population health, and better value in health care. At the US Department of Veterans Affairs (VA), a renewed focus on health and health care disparities is timely given current shifts in Veteran demographics. Racial/ethnic minority Veterans represented 22% of the total Veteran population in 2014, a proportion that is expected to increase to 34% by 2040. 3 Similarly, the number of women Veterans are expected to double to almost 20% of the total Veteran population by 2040. 4 A quarter of the total Veteran population resides in rural or highly rural communities, and represent one third of Veterans enrolled in VA health care. 5 Between 2006 and 2014, the number of enrolled Veterans living in rural communities increased by 7%. 6 VA is evolving its current health care system into an integrated, high-performing network of both VA and community providers focused on delivering the best-quality outcomes and experiences for Veterans. 7 This system transformation has the potential to impact health and health care disparities by improving access to care, addressing the social determinants of health, and promoting cultural competency. First, VA’s integrated, high-performing network can help address health and health care disparities by increasing access to care. Prior research indicates that nonelderly black, Hispanic, and American Indian, and Alaska Native adults are more likely to delay or defer needed care compared with nonelderly white adults. 8 In addition, low income and lesbian, gay, bisexual, and transgender individuals experience greater challenges obtaining care than high-income and heterosexual persons, respectively. 9, 10 Over the past 3 years, VA has focused on improving access to care for enrolled Veterans by expanding VA Community Care, which provides health care options outside of VA facilities and clinics. The Veterans Access, Choice and Accountability Act of 2014 provided resources and tools to assist in this effort. Over 25 million community care appointments were completed in fiscal year (FY) 2016. This represents a 61% increase since FY14. During FY16, >2 million Veterans accessed VA Community Care, a growth of 21% from FY14. Although the current Veteran population is ∼10% female, 12% of the Veterans utilizing VA Community Care are female. Similarly, rural Veterans represent one third of all VA health care enrollees but constitute 39% of all Veterans utilizing VA Community Care in FY15 and FY16. Increasing access to health is one way that VA is reducing health disparities, by allowing Veterans to see providers through VA’s integrated, high-performing network. Second, reducing health and health care disparities requires a focus on the social determinants of health. It is estimated that 60% of preventable deaths can be traced to the social determinants of health—lifestyle behaviors and exposures that occur in the environment. 11 Many organizations and clinicians in the health care industry have recognized the need to partner across sectors to address health-related social needs, like housing, food insecurity, and transportation, to improve outcomes and reduce total health care costs. One approach is the Centers for Medicare and Medicaid Services’ (CMS) Accountable Health Communities Model, which helps local communities bridge the gap between clinical and community service providers. 11, 12 VA assists in identifying and providing wrap-around social support services like housing, employment, and legal support to Veterans. Since 2010, VA has worked to permanently house, rapidly rehouse, or prevent over 480, 000 Veterans and family members from falling into homelessness through over a dozen internal programs as well as external partnerships. Through its Community Care Provider Network, VA also partners with over 475, 000 hospitals, practices, and providers across the country to deliver care to Veterans, including those delivering home-based and social support services. VA is well-positioned to grow these programs to address the social determinants of health and reduce health and health care disparities. Lastly, promoting cultural competency and training for patients with diverse values, beliefs, and backgrounds through VA’s high-performing network will also help minimize disparities in health care. Increased awareness of cultural competency, sex sensitivity, and provider bias (ie, stereotypes, prejudice, or discrimination toward patients) leads to more effective communication and clinical judgment. 13 Utilizing this competency helps providers direct patients to resources, such as housing and job training, that influence health. Additional training on military cultural competency is a unique aspect of Veteran-centric care that is critical to promote within VA’s Community Care Provider Network. VA has developed a platform for sharing valuable continuing medical education with an emphasis on Veteran-centered care. This training platform, the TRAIN portal (https: //vha. train. org), is designed to help community-based health care providers and public health professionals better understand the unique aspects of providing care to Veteran patients. 14 As the VA Community Care Provider Network evolves, VA will work with providers to increase their awareness of the role social determinants play in health and the availability of VA’s nonclinical support services, as well as ensure that community providers have the appropriate awareness of and training in military cultural competencies. 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. Strategically partnering with community providers, from both the public and private sectors, to build an integrated, high-performing network that is patient-centered and focused on achieving excellence in health care is key to tackling the clinical and nonclinical determinants of health. By rebuilding the infrastructure by which health care is delivered, VA can improve access to care, increase care continuity, implement and evaluate innovations to improve outcomes, and incorporate social determinants of health and cultural competencies into care. 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. 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.
Yehia et al. (Fri,) studied this question.