The gap to access to care for mental illness for veterans can be dated back to World War I. British soldiers that returned from the war were being diagnosed and treated for what was called “Shell Shock”. Instead of veterans going to mental hospitals due to not having them labeled as mentally ill, specialized treatment facilities were set up for neuropsychiatric casualties. However, 27% of WWI veterans were neuropsychiatric cases in 1921, and by 1927, it grew to 46.7%. The rise in numbers led to the American Legion giving vets a pension to get the best treatment.

When World War II came around in 1941, the gap in access to care had its ups and downs for veterans since only serve cases of mental health were being treated. Veterans were classified as being mentally distressed since many were presumed to have been emotionally flawed before the war. That any type of mental issue post-war was said to have had anxiety and hostility that was roused by the war. Mental distress was not considered service-related, so many veterans were not entitled to Veterans Administration (VA) benefits. Veterans that exhibited severe mental and behavioral problems were institutionalized in VA Hospitals for treatment. In the 1950’s the VA had over 109 hospitals and 38 neuropsychiatric hospitals. More than half of the cases for veterans hospitalized were psychiatric cases. While hospitalized veterans received shock treatment that left many with organic brain damage. They had psychosurgery to severe the frontal lobes to relieve anxiety and psychological distress.

It wasn’t until after the Vietnam War that psychiatrists started to take an interest in war-related psychiatric disabilities. A survey conducted 15 years after the war showed that 15% of the

3.15 million veterans that served were suffering from PTSD related to service. 30% of participants had effects classified as PTSD at some point years after the war ended. In 1970, the Vietnam Veterans Against the War was created where Vietnam vets can meet and discuss their health and well-being. The group lobbied for increased mental health access for Vietnam veterans and gained acceptance of the PTSD diagnostic category in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. The diagnostic category included that psychiatric symptoms can have a delayed onset and appear years after the initial trauma.

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20% of the veterans that served in Iraq and Afghanistan suffer from depression and PTSD. 19.5 percent of the vets have experienced traumatic brain injury. Many vets affiliated with combat-related mental disorders are not receiving any mental health care, half of the vets that met the criteria for PTSD or depression are receiving treatment from a provider and fewer are receiving little treatment. In 2006, billions of dollars have been given to the Veterans Health Administration to help expand mental health care and do more research on PTSD and traumatic brain injury. Consequently, the Defense Center of Excellence (DCoE) for Psychological Health and Traumatic Brain Injury was established for the Department of Defense (DoD) and the VHA to collaboratively address issues surrounding the prevention, recognition, and treatment of combat-related psychological and cognitive injuries.

In 2011, the VHA created the healthcare equality workgroup to help determine how the

VA can achieve a more equitable health care delivery system. The workgroup established the

Office of Health Equity 2012 released the National Veterans Health Equity report in October 2016. The report provides details on race and ethnicity, gender, age, geography, and mental health status. Findings showed that all of the racial and ethnic minorities used mental/substance use disorder services more than that white veterans. It also showed that mental health and substance use disorders are more common in women than in men.

A study of 66,000 veterans at a patient-center medical home, conducted by the Center for Health Equity Research and Promotion (CHERP), indicated that racial and ethnic minorities had less satisfaction with their healthcare. African American and Hispanic veterans reported having a more negative experience with obtaining access to healthcare than that whites. Blacks had communication problems, while Hispanic veterans had fewer positive experiences with help from office staff than that whites.

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Most combat veterans have access to community-based practitioners through TRICARE military insurance active duty and reserve soldiers as well as those who are Veterans. VHA services are also an option for veterans that has been used by eligible veterans. However, the distance to VHA facilities and lower priority status deter many veterans from seeking access to care. Many VHA facilities do not have the psychiatric labor necessary to treat the mental health cases of veterans. Veterans that live in rural areas have a shortage of mental health providers. Some very few therapists are trained to treat trauma and war-related trauma. The cost of mental health care is a disparity that many young veterans face. Since they work low-income jobs, they cannot take time off to attend therapy sessions.

If the gap in access to mental health is not closed for veterans, then many of them will continue to lead toward suicidal behavior, especially those veterans that have completed multiple deployments to Afghanistan and Iraq. Veterans will come to be homeless and unemployed because they cannot access the treatment needed for them to obtain employment and adequate housing. Many veterans will result to substance abuse such as drugs and alcohol to help them cope with their disorder or help them to dull the pain they have from battle wounds. The rate of mental illness case for veterans will increase if access to care do not become available.

In 2007, the U.S. Department of Veterans Affairs (VA) began implementing a nationwide program referred to as the Primary Care-Mental Health Integration (PC-MHI). PC-MHI was created to enhance access to mental health services for Veterans and to promote effective treatment for mental health and substance use problems that are being treated in a primary care setting. They put specialists and/or care managers in primary care facilities to collectively care for veterans with psychiatric illnesses. PH-MHI has programs in place that are meant to meet the needs of primary care patients that may be unwilling to receive treatment in specialty mental health clinics or have unmet mental health treatment needs. Care managers, usually nurses or social worker, monitor the patient’s treatment needs and provides feedback to the primary care physician so that the patient’s mental health treatments meets their needs.

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In 2010, the Veterans Health Administration (VHA) adopted Patient Aligned Care Teams (PACTs) that had patient-centered medical homes that nationally assigned veterans to an interdisciplinary care team that also provided staffing and resources in primary care. Both PACTs and PC-MHI focused on delivering services for mental health in a primary care setting for Veterans. Meaning focusing on Veterans that had mild-to-moderate psychiatric illnesses as such depression, anxiety, and alcohol use disorder. They also addressed behavioral health issues such as chronic pain or sleep problems.

Although PACT aims to promote the emotional and mental well-being of Veterans, the quality of mental healthcare provided to patients with mental health symptoms is lower than that of medical care for patients with diabetes or heart disease. A quarter of primary care patients that are Veterans have mental health symptoms at levels consistent with mental health diagnosis at any point in time. Only two-thirds of patients have received care for mental health while the percentage of these Veterans that received care at a level consistent with guidelines for mental health is much lower.

Although the VA has worked to bridge the gaps, they remain. The treatment for alcohol misuse, standardized clinical assessment and follow-up measures and tools, and quality improvement initiatives are three gaps that PC-MHI and PACT must address to improve their initiative. Alcohol misuse is one of the most evidence-based programs in mental health however the impact of managing the continued misuse of alcohol on the overall health status of Veterans cannot be overstated. There are limited effective interventions for health for those misusing alcohol but with the availability of PC-MHI staff, they can educate primary care providers on interventions to fully implement the programs within the VA. Having a routine use of assessment and symptom measures can help develop individual treatment plans, outcome measurements, and program evolution. Having access to these tools in a clinical setting can help generate data and reports for the improvement of PC-MHI and quality monitoring.

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In 2014, the Veterans Access, Choice, and Accountability Act of 2014 (VACAA), also referred to as the Veterans Choice Act, was put into place by Barack Obama. This act required that hospital care and medical services be furnished to veterans through an agreement with specified non-Department of Veterans (VA) facilities for veterans. The veterans include those that have been unable to schedule appointments at a VA facility and those that reside over 40 miles from the nearest VA facility. It also includes those that reside in a state that does not have a VA facility that provides hospital care, surgical care, and emergency medical services and those that do live within 40 miles but have to travel by air, boat, or ferry to reach the facility.

In April 2017, President Donald Trump signed the Veterans Choice Improvement Act, which is an extension of the VACAA. With the new bill enacted, it allows for the VA to cover copays and deductibles to private care directly instead of reimbursing veterans for paying up front. The act also is supposed to untangle a web of community-care programs and access for veterans across the country.

Since the VACAA was signed into order by the president, the regulation is an executive regulation that must comply with federal laws. However, the VACAA and the Veterans Access to Care Act were introduced to the Senate and the House where both sectors passed measures on the acts. With the House and the Senate being legislative sectors of the government, this puts both acts at the legislative level.

The regulation in place helps with closing the gap in access to coverage for

veterans with mental health by targeting the lack of healthcare for the veterans. Veterans are being able to receive the needed care for their disorders, even if it means them having to find other providers. They can be seen in a timelier manner versus having to wait days to get an appointment scheduled for the VA. They are also having to pay less due to the updates made by President Trump that requires the VA to cover the cost of co-pays and deductibles for veterans. This leaves the veterans to have to pay little to nothing out of pocket on doctor visits. However, the VACAA and the Choice programs are diminishing due to the heavy usage of medical attention and a high order of funding. The benefits of medical outsourcing will no longer be accessible to Veterans if funding does not become a top priority. This means the gap in access becomes a problem once again.