In recent years, American veterans’ need for high-quality mental healthcare has become painfully apparent as rates of veteran suicide have reached new and troubling heights.
The suicide rate for veterans currently stands at 1.5 times higher than that for non-veteran adults, even after adjusting for population differences in age and sex. According to statistics provided by the Department of Veterans Affairs, the suicide rate among veterans reached 27.7 per 100,000 veterans in 2017, with 6,139 current- or ex-servicemembers lost to suicide that year.
This high toll is unfortunately not new, as the number of veteran suicides has topped 6,000 every year since 2008 and continued to grow year-over-year. In 2008, an average of 15.9 veterans lost their lives per day; by 2017, that loss had increased to 16.8. Troublingly, Veterans Affairs also reports that over half (62 percent) of the veterans who passed due to suicide in 2017 had not sought care at a VA facility in the year leading up to their death.
The continued prevalence of suicide has made addressing veteran mental healthcare a national and well-funded priority. In mid-February, the VA filed a budget request that would allocate $10.2 billion towards mental health services — a $682 million increase from the prior year’s proposal. The budget would also earmark $313 million specifically for suicide prevention programs, a full 32% more than allotted in 2020.
This budget demonstrates a hope that if the VA has more resources to support veteran mental healthcare, it may be able to lower suicide rates. However, some in the community believe that the answer may exist beyond the VA’s traditional scope.
Last June, Senators John Boozman and Mark Warner introduced the Improve Well-Being for Veterans Act as a means to better coordinate mental health and suicide prevention services for veterans. The act would take the novel step of including community mental health organizations in the VA’s efforts, essentially privatizing at least a portion of the department’s care offerings. Most notably, the Improve Act would allow patients to seek out private care without first obtaining a referral from a VA physician.
“This legislation will target that group by providing grant funding to private organizations with a proven track record of strong mental health and suicide prevention efforts among veterans,” bill sponsor Mark Warner shared of the bill in a press release. “It’s my hope that broad coordination between the VA, state veterans affairs departments, first responders, and local leaders, will allow us to support more at-risk veterans and make a meaningful impact on reducing veteran suicide rates in this country.”
The bill could significantly expand mental health access. The proposed legislation would require the VA to award three-year grants to eligible organizations for the provision of mental healthcare and suicide prevention services. These offerings would include — but are not limited to — mental health consultations, medication management, therapy, and employment and job training services. If the bill passes, the VA would distribute these grants across high-need areas and give preference to organizations that have an already-proven track record in suicide prevention. The bill’s proponents hope that in doing so, the VA will be able to reach more veterans and better-leverage existing community resources in the fight against veteran suicide.
However, the idea of even partially privatizing the VA’s care offerings has faced contention. Opponents believe that the privatization of veteran care will permit lower care quality and erode the VA’s ability to support veterans.
“[The] VA’s better than the private sector on mental health. You can’t match it,” Russell Lemle, former chief psychologist for the San Francisco VA Healthcare System, commented for the Pittsburgh Post-Gazette.
In the article, Lemle argued that community mental health providers would not need to meet the VA’s gold standard for care. He further pointed out that community organizations usually rank lower in treatment quality and patient outcomes when compared to VA clinics.
It is worth noting that lawmakers took criticisms like Lemle’s into account. During a review session in December, the House Veteran Affairs Committee voted in favor of amending the Improve Act to overhaul the bill’s eligibility requirements and impose stricter expectations for community organizations. The proposal has since been submitted to the House and will undergo broad review sometime this year.
But as it waits, those in the mental healthcare sector need to ask — is privatization such an adverse outcome, given the pressing circumstances?
The VA has long faced long wait times and access concerns. According to one 2018 evaluation conducted by the National Academies of Sciences, Engineering, and Medicine, more than half of VA facilities were “below or far below the benchmark” for timely access to mental healthcare. By bringing outside organizations into the fold, the VA could theoretically expand access and cut down on wait times for its mental healthcare patients. That said, it is also worth noting that some studies have shown that increased privatization can lead to higher spending without comparable improvements in patient outcomes.
However, private-public care collaborations can be successful. Consider the role that Medicare Advantage has played in the insurance sector as an example. Under Medicare Advantage, a private company contracts with Medicare to provide the majority of a patient’s healthcare benefits.
This method of private-public collaboration tends to work well. According to MarketWatch, those enrolled in value-based Medicare Advantage plans tend to receive less unnecessary care and experience lower rates of hospital readmissions than traditional Medicare patients. The costs associated with emergency department use, imagine, and ambulatory surgery also tends to be 20 to 30 percent lower with Medicare Advantage. Moreover, as one reporter for MarketWatch writes, “The evidence suggests that risk-adjusted mortality is lower in Medicare Advantage plans, which may reflect better care coordination and greater use of preventive services.”
The issue at hand is complex. Privatization could provide a necessary expansion to veteran mental healthcare access and potentially limit the rise of veteran suicide — if it were implemented in a system that, like Medicare Advantage, was centered on value-based care. However, if the Improve Act were passed and implemented in a conventional fee-for-service-based system, it seems likely that the VA will struggle to ensure that the organizations it partners with provide a high caliber of care. The Improve Act may not be able to resolve the veteran suicide crisis — but, if privatization were implemented within a value-based context, it might be able to provide some much-needed support.