Veterans Healthcare Policy Institute
S. 1906 - Improve Well-Being for Veterans Act
August 29, 2019
S. 1906 Improve Well-Being for Veterans Act, and its companion H.R. 3495, is a bill intended to provide pilot funds to non-VA entities to offer suicide prevention services to veterans who either never use the VA for healthcare or live in geographic areas where the risk of suicide is high. However, at its core, it would duplicate and erode VA’s existing successful mental health services, ignore what interventions are most needed to reduce veteran suicide, and hasten outsourcing of veterans’ health care to the private sector.
1. Foremost, the bill is based on the false premise that non-VA mental health care entities are what’s missing to reach veterans who do not seek VA mental health care or live in areas where suicide rates are highest.
Veterans who do not seek VA mental health care were studied extensively last year in the National Academies of Sciences, Engineering and Medicine Evaluation of the Department of Veterans Affairs Mental Health Services.1 It found the main reasons that veterans do not seek VA care are that they do not know how to apply for VA benefits, are unsure whether they are eligible, are unaware that the VA offers mental health care or do not perceive a personal need for mental health services whether within or outside of the VA. The National Academies offered excellent recommendations for reaching this subset of veterans (see recommendations section below).
Regarding the 20 veterans who die by suicide daily, much is known about the 6 who used VA recently for health care. However, very little is understood about the remaining 14. It is not known whether they are already receiving mental health care in the community, lack knowledge about VA eligibility, or would refuse care in the community or VA even if offered. Community mental health entities awarded grants in this bill would not reach veterans in any of these scenarios.
2. Relatedly, the bill ignores VA’s growing telemental health capacity to reach vulnerable veterans, especially those who reside in rural areas where veteran suicide rates are highest.
VA’s evidence-based telemental health is the industry leader, and soon will be able to access nearly every veteran with mental health and suicide prevention services. It is closing the gaps in rural America, where mental health resources are sparse.
VA’s telemental health will also facilitate younger veterans obtaining services from the VA, given that younger veterans tend to be amenable to receiving mental health care using technology.
VA’s telemental health also resolves the impediments to in-person appointments for veterans with chronic health conditions, work/family schedule conflicts or discomfort with the pressures of a large institution.
3. For decades, the VA has used grants in special circumstances when outside entities could effectively augment services the VA could not provide itself. This bill, for the most part, duplicates and potentially supplants the critical function of the VA’s Office of Mental Health and Suicide Prevention to address veterans’ mental health needs.
The grantee entities are permitted to set up programs in the same locales where VA medical centers or CBOCs exist.
The mental health services offered by grantee entities are all provided by VA medical centers and CBOCs. (See Appendix A below for the list of grantee mental health services identified in the bill that duplicate the VA’s.)
One component of the bill provides up to 6 months of financial assistance and housing, vocational, childcare, legal, employment and rehabilitation counseling services for homeless veterans. That aspect does augment the VA and is to be commended and supported.
4. The National Strategy for Preventing Veteran Suicide 2018-20282 promotes expanded community partnerships, with VA as the hub of its efforts. VA is capable of coordinating, training and monitoring outside entities, and this organizing role is key to the appropriate and necessary organizing structure. However, the bill empowers outside entities to be the coordinator of suicide prevention services to veterans in many communities. VA is simply to be identified as “the payor” of such services. Fracturing VA efforts into multiple, disjointed programs dilutes the overall endeavor, splinters resources, and impedes care coordination – the very opposite of effective veteran suicide prevention and something at which the VA demonstrably excels.
Further, sending veterans to the community for suicide prevention eliminates the ability to use VA’s predictive analytics “REACH VET” for at-risk individuals who are at the very highest risk of suicide – those who have a 30-fold increased risk of death by suicide within a month. This cutting-edge, big-data approach allows the VA to identify veterans at risk for suicide and offer them enhanced care before a crisis occurs. The system notifies each veteran’s provider of the risk assessment and enables providers to reevaluate and enhance these veterans’ care. Some of these ultra-high-risk veterans might not have been identified based only on clinical signs. This is a crucial distinction because many veterans who die by suicide do not have a history of suicide attempts or recently-documented suicidal ideation.
5. There is no expectation that outside entities would be held to the high standards (or actually any standards) of training, provider qualification and documented best practices for mental health care to which VA holds itself.