National Alliance on Mental Illness
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Treating Veterans with Serious Mental Illness—The VA’s Ability to Deliver Quality Care

by Kim Tomlinson, NAMI senior policy analyst

A number of NAMI members use the Department of Veterans Affairs (VA) and/or military facilities for psychiatric care for themselves or a family member. Since 1989, NAMI members have advocated on behalf of veterans and the need for high-quality supports and services in the nation’s largest health care provider. As states across the country face budget deficits and health care costs continue to rise, veterans not previously enrolled in VA health care are rushing to the VA for care. With the surge in enrollees, the VA faces a crisis—how to serve the mounting numbers of veterans and still deliver top-notch care for special categories of veterans, such as those with severe mental illness.

The VA has the potential to serve as a model health care system, and many veterans receive high-quality and often life-saving care. NAMI has strongly supported the VA’s implementation of evidence-based programs and services, and hopes that it does not make the same mistakes seen in other public systems of underfunding vital treatments and community-based services.

The Veterans Health Administration (VHA) is divided into 21 Veterans Integrated Service Networks (VISNs), which were instituted to administer the health services (including mental illness treatment) for VA hospitals and clinics. The idea behind the VISNs was to decentralize services, increase efficiency, and shift treatment from inpatient care to less costly outpatient settings. There is great variation within and among VISNs in the services they offer, and a VA mental health benefits package can vary from network to network.

The VA health system has grown tremendously, from 54 hospitals in 1930 to more than 1,300 facilities, clinics, and programs that provide a broad spectrum of medical, surgical, and rehabilitative care to veterans. Over the years, the VA has shifted care from inpatient settings to community-based outpatient clinics (CBOCs). CBOCs are instituted in areas where VA health services are not easily accessible, and allow veterans to access care closer to their homes. However, many of the CBOCs offer only minimal treatment services for veterans with severe mental illness, and many others offer no mental health treatment services at all.

Services and eligibility for veterans are determined on a priority scale of eight categories. Veterans in Category 1 are high-priority veterans with serious service-connected health needs and low incomes, while Category 8 veterans are likely to be veterans with higher incomes and non-service-connected health care needs. In January 2003, Anthony Principi, secretary of veterans affairs, announced that in the future, Category 8 veterans would be unable to enroll in the VA health system. This controversial announcement was aimed at limiting the number of new veterans coming into the system, in an effort to ensure that the VA has the resources to provide quality care without a long wait to disabled and high-priority veterans.

With the influx of lower priority veterans into the VA health system, many resources have been diverted from special populations toward the care of an ever-increasing group of veterans who are looking for low-cost medications. NAMI’s Committee on Care of Veterans with Serious Mental Illness (SMI) reported that, from FY 1996 to FY 2001, there was an increase of 568 percent in the number of low-priority veterans who came to the VA, seemingly for the prescription benefit. NAMI fears that many resources saved from the closure of inpatient beds have not been effectively reinvested in community services but rather have been directed toward the care of low-priority veterans. While all our nation’s veterans deserve quality care, expanded care should not come at the expense of high-priority veterans living with severe mental illness.

Serving Veterans with Severe Mental Illness

NAMI strongly supports treating veterans with severe mental illness in the community when the proper intensive community supports and treatment are available and easily accessible. In FY 2000, of the 192,982 veterans who were treated for a severe mental illness, only 19.7 percent received treatment in an inpatient setting, and preliminary data indicate that the number of veterans treated in an inpatient setting will further decline in future years. However, NAMI remains concerned that veterans who do need inpatient care are unable to access the treatment because of the limited supply of inpatient beds and the shift to outpatient treatment.

The VA offers several specialized programs aimed at helping veterans live healthy, productive lives in the community. Access to programs that provide outreach, rehabilitation, and supported housing are critical for veterans with severe mental illness. Mental Health Intensive Case Management (MHICM), the VA’s PACT program, can be a very effective service for veterans with acute care needs. The VA also offers specialized services for post-traumatic stress disorder and substance abuse; however, these programs must be expanded to meet the needs of veterans.

Are Veterans Receiving the Services They Need?

NAMI feels strongly that the VA must do more to maintain capacity for veterans with severe and chronic mental illness. The lack of access to treatment and community supports for veterans with severe mental illness is one of the greatest unmet needs in the VA. In 2001, Congress passed the Department of Veterans Affairs Health Care Programs Enhancement Act (P.L. 107-135). This law strengthened the VA’s capacity to serve veterans with mental illness, requiring improvements to the current system to ensure that veterans have access to necessary treatment and services. The law requires the VA to maintain capacity for serving veterans with mental illness and to replace lost capacity as well.

The SMI Committee reported that, during FY 2002, VHA spent only 77 percent of the amount that it spent in FY 1996 for care of veterans with serious mental illness—a decrease of $478 million annually. This reduction has occurred despite mandates that VHA focus on its high-priority veterans, including veterans with serious mental illness.

Currently, about 20 percent of veterans in the health care system are in need of mental health treatment and far below the expectations of the VA’s capacity law. While the VA reports that it has maintained capacity for veterans with severe mental illness, many advocates argue that it has not, citing higher numbers of veterans enrolled in the system, decreased staffing levels, and budgets that are not adjusted for inflation.

NAMI Advocacy on Behalf of Veterans

The members of the NAMI Veterans Committee include persons with mental illness, family members and friends of persons living with a severe mental illness, and those who have an active involvement and interest in issues affecting veterans and the military. The committee has grown over the years, and its volunteers advocate on behalf of veterans and family members who need assistance accessing medication, services, and treatment within the veterans health system. Since the VA reorganized its medical system into the 21 VISNs, the NAMI Veterans Committee has worked in each VISN to ensure that the goal of greater access to care is met and to educate VA employees so that recovery for veterans with a severe mental illness is a real option.

VISN (Veterans Integrated Services Network) Map