The Department of Veterans Affairs (VA) is the largest integrated healthcare delivery system in the nation (The Department of Veterans Affairs [VA], 2007a), providing care to over five million veterans in it’s more than 800 locations (The Department of Veterans Affairs [VA], 2007b). This organization provides a variety of benefits and services which include but are not limited to in-patient and out-patient medical care, non-institutional care, and nursing home care. Veterans are also entitled to receive disability compensation depending upon the severity of their disability and VA pension. The Department of Veteran Affairs core mission is to provide services for combat veterans that are low income, have special needs (e.g., mental health, substance abuse, chronic health conditions), or have a service or non-service connected disability (The Department of Veterans Affairs [VA], 2007b). Higher income non-disabled veterans are not eligible for these benefits. However, a pair of proposals is being considered that may allow them to participate in the system based upon specific pre-determined criteria (The Department of Veterans Affairs [VA], 2007b). A decision has not been made regarding these proposals and they are currently being considered by legislation (The Department of Veterans Affairs [VA], 2007b).

All veterans that are low income, special needs, or have suffered a service connected or non-service connected disability are eligible for VA benefits. The following are specific criteria that veterans must meet in order to be eligible (a) veterans must be honorably discharged from service, (b) veterans that have been discharged dishonorably are not eligible for benefits, and (c) veterans that have been imprisoned or paroled may be entitled to certain VA benefits (McMurray-Avila, 2001). Veterans with service connected disabilities are also eligible for disability compensation depending upon the severity of their disability (McMurray-Avila, 2001). Disabilities are rated in 10% increments the higher the rating the more the compensation (McMurray-Avila, 2001). General benefits are available to all enrolled veterans and they include but are not limited to (a) medical and surgical care, (b) hospital, home based care, and out-patient services, and (c) mental health care and substance abuse treatment (McMurray-Avila, 2001).

Low income veterans are veterans that live at or below the poverty line. These veterans are deemed as one of the populations that have highest priority regarding eligibility for VA programs and services. Special needs veterans are those that suffer from one or more debilitating conditions that interfere with their ability to earn a living and take care of themselves and their families. This population is also deemed as high priority regarding eligibility for VA programs and services.

Homeless veterans are primarily male (98%) and over the years are a population that has risen higher than the general populations as compared to civilians of the same age and gender (McMurray-Avila, 2001). Research has indicated that the population of veterans that are most at risk for being homeless are those that served during the Vietnam era (McMurray-Avila, 2001). Reasons for this include (a) more veterans in this era suffered from substance abuse before, during, and after military service than the general population, and (b) back then screening tests used to identify qualified applicants were inadequate and thus more “potentially ineligible” recruits were selected to enlist in the service (McMurray-Avila, 2001). Homeless veterans are eligible for a comprehensive array of services regarding VA benefits but often lack the knowledge and resources to take advantage of them (McMurray-Avila, 2001).

High income non-disabled veterans are deemed as lower priority and are not eligible for benefits. However, in 1999 a new law was enacted that allowed these veterans to enroll in the system eventually this law was overturned because the rapid growth of this population threatened the VA’s ability to provide quality care to it’s core population (e.g., low income, special needs, disabled) participants (The Department of Veterans Affairs [VA], 2007b). Currently two proposals are being considered that if approved will allow these veterans to participate in the program if an annual enrollment fee is paid or a higher drug co-pay (The Department of Veterans Affairs [VA], 2007b). These proposals are still in the development and consideration phase.

The Department of Veterans Affairs offers a multitude of services to eligible applicants and they include (a) disability compensation, (b) VA pension, (c) enrollment in VA healthcare, (d) out-patient dental care, and a host of other benefits that veterans have at their disposal (McMurray-Avila, 2001). Although these services are available a large proportion of veterans do not take advantage of them because they don’t know what services are available to them or how to go about accessing them, they often do not value the benefits because they feel that the government is doing a mediocre job of providing care to veterans that have fought for their country, they are concerned about welfare stigma, the apparent lack of continuity of care due to high turnover regarding physicians and the fact that a large number of interns and residents that are not experienced and thus do not have the capacity to meet their needs are primarily employed at these facilities, and the perceived lack of respect from medical personnel (Damon-Rodriquez, 2004). However, other veterans that have not experienced the aforementioned incidents rated the system as “above average” or “excellent” thus a veterans experience develops their perception about these services positively or negatively (Damon-Rodriquez, 2004).

Eligible veterans can receive non-institutional care. This type of care involves providing services in the home in an effort to keep the patient in their homes for as long as possible (The Department of Veterans Affairs [VA] Fact Sheet, 2005). Home-based primary care primarily provides medical care to patients in the home setting (The Department of Veterans Affairs [VA] Fact Sheet, 2005). In 2003 this type of service was available in more than 76 VA medical centers (The Department of Veterans Affairs [VA] Fact Sheet, 2005). “Adult day care programs provide health maintenance and rehabilitation services to veterans in a group setting during daytime hours” (The Department of Veterans Affairs [VA] Fact Sheet, 2005, para. 5). Home hospice care provides services to veterans that are in the advanced stages of a terminal illness (The Department of Veterans Affairs [VA] Fact Sheet, 2005). The main premise of this program is to provide palliative care and increase quality of life in the participants last days (The Department of Veterans Affairs [VA] Fact Sheet, 2005). These and many other non-institutional services are available to all veterans that qualify.

Long term care is provided through VA nursing programs which include more than 114 nursing homes in 47 states (The Department of Veterans Affairs [VA] Fact Sheet, 2005). VA has also contracted with more than 2,500 community nursing homes to provide services to qualified participants (The Department of Veterans Affairs [VA] Fact Sheet, 2005). Veterans with a disability rating of 70% or more are eligible for these services (The Department of Veterans Affairs [VA] Fact Sheet, 2005).

Due to the high volume of participants that are eligible for disability compensation financial benefits regarding the system have often been compromised due to the number of days it takes to process a claim (The Department of Veterans Affairs [VA], 2007b). In 2005 the number dropped from a whopping 230 days to approximately 167 (The Department of Veterans Affairs [VA], 2007b). The VA’s aim is to shorten processing times to 125 days by continually developing was to improve the system and streamlining operations (The Department of Veterans Affairs [VA], 2007b).

During the Bush administration the number of uninsured veterans (including homeless uninsured) continued to rise. This population increased by an astounding 290,000 when President Bush took taken office (Culea, 2007). Research indicates that approximately 8.5 and 12.9 percent of Vietnam and Persian Gulf veterans respectively are uninsured (Culea, 2007). Data also reveals that well over 40% of veterans in the 18-44 age range remain uninsured (Culea, 2007). Reasons for this are attributed to the Bush administration limiting access to those with non-service related injuries and those making less than $30,000 (Culea, 2007). This change was initiated in an effort to maintain benefits for the rapidly growing veteran population (Culea, 2007). However it seems as if it has done more harm than good.

As healthcare costs continue to skyrocket and the amount of intensity of care continues to increase the cost expected to care for each participant will continue to escalate (The Department of Veterans Affairs [VA], 2007b). As this population continues to age and the complexity of their illness increases they will require more advanced and more costly treatments (The Department of Veterans Affairs [VA], 2007b). In addition, those that have primarily relied on traditional insurance are increasingly beginning to rely on VA more due to the increased cost of this insurance and the fact that VA has improved access and quality of services (The Department of Veterans Affairs [VA], 2007b). Moreover, an increase in the use of prosthesis and mental health services has been initiated to a larger proportion of veterans than in the past (The Department of Veterans Affairs [VA], 2007b). The 2008 budget has allocated more than $750 million to the VA program in an effort to meet the complex health needs of this growing population (The Department of Veterans Affairs [VA], 2007b). Furthermore, in an effort to save money, reduce paperwork burden, streamline spending, and eliminate needles duplication of services the VA and Department of Defense (DOD) have collaborated by implementing a new electronic medical records system (The Department of Veterans Affairs [VA], 2007b). This allows the two-way transfer of health information between the two entities. This will free up much needed funding that can be allocated to other areas of the system that may need greater resources (The Department of Veterans Affairs [VA], 2007b).

In 1999 the Government Accountability Office (GOA) determined that VA was wasting monumental amounts of money in the sum of more than $1 million dollars a day on the upkeep of outdated or underutilized facilities (The Department of Veterans Affairs [VA], 2007b). VA’s system was primarily designed for institutionalized in-patient care, however as technology advanced to more out-patient care and home-based services this approach became obsolete in response VA implemented project (CARES) (The Department of Veterans Affairs [VA], 2007b).

The main premise of this initiative was to eliminate sporadically or unused facilities and to convert these to smaller clinics that could be utilized to better meet the needs of the population (The Department of Veterans Affairs [VA], 2007b). This projects aim also included relocating hospitals to areas where veterans lived thus improving access (The Department of Veterans Affairs [VA], 2007b).

Rising healthcare cost and the increasing number of veterans that are using the system has forced this organization to enact initiatives to increase its sustainability. As previously discussed enacting electronic medical records, eliminating obsolete medical facilities, and considering proposals that would require higher-income non-disabled veterans to pay either an annual enrollment fee or higher co-pays in order to participate are some of the initiatives aimed at saving money and reducing costs. However, to continue to survive this organization must be constantly seeking new innovative ways to provide cost effective, timely, quality care to its core population.

In an effort to streamline separation from active duty to civilian status, VA outreach programs have been developed to ensure that veterans separating from service know how to access available services with less paperwork burden (The Department of Veterans Affairs [VA], 2007b). VA caseworkers will now be available on site at hospitals to ensure that veterans are receiving this vital information (The Department of Veterans Affairs [VA], 2007b). The dissemination of discharge documentation from the Department of Defense to the VA has been reduced from thirty days to less than three (The Department of Veterans Affairs [VA], 2007b).

The DOD and VA have collaborated in an effort to enact initiatives aimed at educating more veterans regarding the services that are available to them (The Department of Veterans Affairs [VA], 2007b).