Use of and Outcomes in Veterans Affairs and Other Hospitals Among Veterans Experiencing Homelessness After Expanded...

Veterans in the U.S. Department of Veterans Affairs (VA) health care system experiencing homelessness have high rates of hospitalization. The 2014 Veterans Choice Act and Medicaid expansion programs under the Affordable Care Act expanded access to VA-purchased care and Medicaid for veterans. The authors aimed to examine-in VA and non-VA hospitals-changes in medical-surgical and psychiatric hospitalizations and hospital outcomes after these expansions for homeless veterans versus other veterans.

A longitudinal study (2012-2017) of veterans in 11 states was conducted. Non-VA hospitalizations were ascertained from state inpatient discharge data and linked to VA enrollment, hospitalization, and homelessness data. Probabilities of medical-surgical and psychiatric hospitalizations, by payer and system and before and after access expansions, of homeless veterans and other veterans were estimated in adjusted models for 20 million veteran-years. For homeless veterans, hospital outcomes (mortality, readmission, and length of stay) were compared between VA and non-VA hospitalizations by using inverse probability weighting for 264,610 hospitalizations.

Veterans experiencing homelessness had larger decreases in VA hospitalizations than other veterans and larger increases in hospitalizations covered by VA-purchased care and Medicaid associated with expansions. VA hospitalizations were associated with lower probabilities of mortality and readmission, but with a longer mean length of stay, than non-VA hospitalizations.

Policies expanding veterans' access to non-VA providers had greater impacts on veterans experiencing homelessness than on other veterans. Worse outcomes among homeless veterans with non-VA hospitalizations suggest that policies to increase access for the most at-risk veterans should balance access with quality of care.