American Indians and Alaska Natives (AI/ANs) have a long and proud history of military participation. In fact, AI/ANs have a high rate of service and the highest rate of women serving compared to all other service members. For example, over 22% of all 45- to 54-year-old AI/ANs are veterans, compared to 15% among all other races in the same age group. Due to physical injuries and mental trauma sustained during combat, veterans in the United States have high levels of disabilities. The long-term health needs of Native veterans are particularly complex due to a combination of geographic and demographic factors.
The complexities that Native veterans face lead to a high need for long-term services and supports (LTSS) among elderly and disabled veterans in Indian Country. LTSS are a set of health care, personal care, and social services delivered over an extended period to persons unable to perform their activities of daily living independently. LTSS may be provided in a variety of settings or in the person’s own home.
LTSS includes home and community-based services (HCBS) which are care programs delivered in the home or community, and facility-based settings where care is provided in an institutional setting outside of a home. Examples of LTSS that Native veterans and their families might utilize include:
- Nursing homes (including VA nursing homes, tribal nursing homes, and state veterans’ homes);
- Assisted living facilities
- Adult day health care
- Home-based primary care
- Support for caregivers, including respite care
- Case management services. Need for LTSS Among Native Veterans
The need for LTSS among Native veterans is affected by the general age distribution, income trends, disability status, and rate of post-traumatic stress disorder throughout the Native veteran When compared to veterans of the general population, Native veterans tend to be younger (VA, 2015a). Data from the 2013 American Community Survey finds that the median age for Native veterans is 57, compared to 63 among the general population (VA, 2015a). While the Native veteran population is currently younger than that of other veteran populations, the elderly Native veteran population is expected to increase (Holiday, Bell, Klein, & Wells, 2006). Overall, the elderly AI/AN population is one of the fastest growing groups of elderly minorities in the United States.
Alongside age distribution, one study examined income trends among Native veterans (Holiday et al., 2006). The authors found that Native veterans over 65 have lower incomes than younger Native veterans and veterans of all races (Holiday et al., 2006). For example, 20.7% of Native veterans over 65 have an annual family income of $10,000-$19,999, compared to 12% among Native veterans under 65 and 10.4% among veterans of all races (Holiday et al., 2006).
Lower incomes for elderly Native veterans impede their access to LTSS and health care in general. Another major disparity among Native veterans is disability. Native veterans are more likely to have a disability, service-connected or otherwise, than veterans of all races. Further, AI/ANs have the highest rate of disability of any ethnic group in the United States. The combination of a rapidly aging population and high rate of disability have led to an increased need for LTSS in Indian Country, specifically among Native veterans.
Post-Traumatic Stress Disorder
Post-traumatic Stress Disorder (PTSD) is, “a mental health problem that some people develop after experiencing or witnessing a life-threatening event, like combat, a natural disaster, a car accident or sexual assault”.6 Native veterans may have higher rates of PTSD than white veterans. PTSD resulting from combat situations is compounded by a high rate of PTSD among the AI/AN general population.
The contributing factors to PTSD among the general AI/AN population are complex and include historical trauma and high rates of interpersonal violence. Although PTSD does not always result in a loss of ability to live independently and perform activities of daily living, PTSD can severely impact an individual’s ability to function, particularly in elderly individuals. A 2010 study funded by the U.S. Department of Defense found that male veterans ages 55 years and older with a PTSD diagnosis were more than twice as likely to develop dementia than male veterans of the same age group without a PTSD diagnosis. Based on this data and the increasing elderly population, the LTSS needs related to dementia are likely to increase among Native veterans.
Barriers to LTSS among Native Veterans
Native veterans experience several barriers to LTSS. These barriers result from Native veterans’ poor access to care and complications from accessing care through Indian Health Service (IHS) and VA.
Poor Access to Care
Several studies report that Native veterans are more likely to lack health insurance than other groups of veterans. In addition, Native veterans are more likely to delay care than White veterans due to their inability to obtain timely appointments and lack of transportation to health care facilities. Native veterans are also more likely to live in highly rural areas than non-Native veterans. Within these rural areas, Native veterans must travel significant distances to receive any health care services, including LTSS, yet they lack reliable transportation options.
Native Veterans' Use of IHS and VA
Several studies report that Native veterans are more likely to use Indian Health Service (IHS) than VA for their health care needs. Native veterans appear to utilize IHS more frequently than VA due to several practical, geographical, and cultural reasons. While many of IHS’ facilities and programs are underfunded, IHS employs culturally specific care. TIHS cultural awareness and sensitivity makes IHS a more attractive option than VA for Native veterans. Native veterans may also distrust or become frustrated with VA, adding to their preference for IHS. Further, Native veterans living in rural communities have limited or no access to VA Medical Centers. These barriers to VA care are problematic, as VA is better equipped to provide LTSS to Native veterans than IHS. Despite a preference for IHS, Native veterans do utilize VA. One study found Native veterans more likely to report use of VA health care services than veterans of all other races.
Overall, the literature conveys a lack of coordination between IHS and VA to provide quality care, including LTSS, to Native veterans. Although there are Native veterans who use IHS and VA, the providers do not routinely share medical information with each other. Improved coordination between IHS and VA is critical, as dual use of IHS and VA may be the best approach to handle the complex health and LTSS needs of Native veterans.
IHS and VA's Efforts to Improve Care for Native Veterans
IHS and VA are working to improve their coordination of care, availability of services, and understanding of each other’s abilities and limitations to better serve Native veterans. Coordination and educational efforts are detailed in the IHS-VA Memorandum of Understanding (MOU), while improved access to VA services is a highlight of the Veterans Access, Choice and Accountability Act (Choice Act). VA is also developing some promising LTSS practices that may improve Native veterans’ access to care.
Memorandum of Understanding
IHS and VA acknowledge the need to improve their coordination and have taken several steps to address their shortcomings. In 2003, IHS and VA signed an MOU to improve their coordination of care for Native veterans. The MOU was updated in 2010 to further address the need to coordinate LTSS implementation for Native veterans, particularly as VA already provides LTSS
The Choice Act was signed into law in 2014. The Choice Act aims to improve veteran access, including Native veterans, to health care by allowing veterans to “receive care from eligible non-VA health care entities or providers.” The law further states that “Eligible non-VA entities or providers must enter into agreements with VA to furnish care.” TIHS language initially caused concern in Indian Country, as IHS is not part of VA. However, in a tribal consultation letter, VA clarified that IHS and tribal health programs “will remain members of [VA’s] core providers network”. The Choice Act seeks to strengthen VA’s relationship with IHS and further their partnership, which could lead to improved access to care for Native veterans.
The Alaska Native Tribal Health Programs (ATHP) exemplifies the strengthened partnership between VA and IHS. In 2012, ATHP entered into an agreement with VA that enabled VA to pay IHS and tribal facilities for health care services provided to Alaska Native veterans. TIHS agreement led to increased access to health care services for Alaska Native veterans in Alaska. Given the remote nature of many communities in Alaska, this increased access to care is especially promising. Further innovative collaboration between IHS and VA has the potential to improve access to LTSS for Native veterans throughout Indian Country.
VA's Home-Based Care (HBPC)
HBPC provides primary care in the home to elderly, frail, or chronically ill veterans who are homebound and would otherwise have to receive care in an institution. AI/AN communities have an overall cultural preference to provide care for family members in their own homes and communities, rather than in formal institutions, which makes the HPBC program particularly appealing. Fourteen VA medical centers have expanded access to HBPC through collaborations with IHS or tribal programs. The HPBC program’s holistic approach and focus on case management appears to lend itself to a high level of cultural sensitivity and respect for Native veterans. Furthermore, HPBC programs engage in proactive outreach to tribal communities and are generally well received by those communities.
Medical Foster Home
VA also has a Medical Foster Home (MFH) program, which is now nation-wide and is a viable, community-based alternative to VA nursing homes. The MFH program allows veterans with physical and mental disabilities to reside in their communities by pairing veterans with trained caregivers who share their homes with the veterans. The MFH program is intended for veterans with no available family caregiver and VA inspects and approves all MFH facilities. A study of the program found that MFH residents experience fewer hospitalizations due to mental health problems and bacterial infections than those in VA nursing homes, which alludes to a higher quality of care and a higher quality of life for MFH residents. Although the effectiveness of the MFH program has not yet been evaluated among Native veterans, it is a promising model that should be explored.
“A Veteran is a person who served in the active military, naval or air service and who was discharged or released under conditions other than dishonorable.
Basic Eligibility Criteria
- Must be Active Duty for 24 months or more (after 9/7/80 – Enlisted, or 10/16/81 – Officers)
- If not active duty, must have be activated by Title 10 orders and have completed the period for which activated
- If discharged with less than 24 months due to convenience of the government, hardship or for medical reasons, the time in service requirement is waived
- Must have a discharge that is Honorable or General Under Honorable Conditions
- If Other Than Honorable, must be adjudicated by sending VA Form 7131 to VBA
- If Bad Conduct or Dishonorable, Veteran is barred from receiving Federal Benefits.
- Non-Service-Connected Veterans Eligibility is based on income. We ALWAYS consider income from the previous year. EXCEPT when the Veteran has a hardship. Hardship Applications consider this year’s projected income.
There are two thresholds (MT & GMT) Means Test and Geographical Means Test. MT is a national threshold. GMT is based on zip code. The higher of the two is the one that usually applies. The threshold varies based on the number of dependents in the household (restrictions apply on who is considered a dependent) When a Veteran is made eligible based on low income, they are placed in PG5.
Additional income thresholds apply that determine if Priority Group 5, (PG5) Veterans may or may not be eligible to receive travel reimbursement.
Once enrolled, a Veteran is placed into a Priority Group (PG) based on their individual status.
The following links contain information including but not limited to:
- VA Health Administration
- Outpatient Clinics
- Community Outpatient Clinics
- VA Nursing Homes and Assisted Living
- Vet Centers
- Veterans Cemeteries
- Homeless Veterans Services
- Veterans Crisis Line
Link to VA facilities by state:
Veterans Administration https://www.va.gov
1 Centers for Medicare & Medicaid Services (CMS). (2016). LTSS Overview. Retrieved November 1, 2016, from https://www.cms.gov/Outreach-and-Education/American-Indian-Alaska-Native/AIAN/LTSS-TA-Center/info/ltssoverview.html 2CMS. (2015). Long-Term Services and Supports Fact Sheet for Tribal Leaders. Retrieved November 1, 2016, from https://www.cms.gov/Outreach-and-Education/American-Indian-Alaska-Native/AIAN/LTSS-TACenter/pdf/LTSS_Models_Fact_Sheet_072015.pdf 3 VA. (2015). Geriatrics and Extended Care. Retrieved November 15, 2016, from https://www.va.gov/GERIATRICS/Long_Term_Services_and_Supports_Overview.asp