Policies, Problems, and Planning to Reach Rural Veterans

Suicide accounts for 8.3% of deaths among U.S. adults, and Veterans alone represent an unignorable 14.3% of these tragedies (Department of Veterans Affairs [VA], 2018). Consequently, death by suicide for the veteran patient population is 1.5 times the rate of non-veteran sufferers (VA, 2018). Our current and previous presidential administrations have contributed to the funding and development of veteran suicide research and interventions. Since the inception of the Veterans Access, Choice and Accountability Act (CHOICE Act) of 2014, veteran suicide data and research has enabled policy makers to focus on reaching veterans living in rural areas.  Veterans living in rural areas account for nearly one fourth of the veteran population (VA,2018). Veterans living in rural areas have a 20%-22% greater risk of death by suicide in comparison to veterans living in urban areas. According to the Veterans Affairs Office of Rural Health, 4.7 million veterans return from active military careers to live in rural areas, only 2.5 million are enrolled to receive VA health care services, and far more than half of enrolled veterans living in rural areas have service-connected disabilities (VA.gov: Veterans Affairs 2016).

In 2014, President Barrack Obama and Senator John McCain III set the groundwork for veteran mental health care reform with the passage of the Veterans Access, Choice and Accountability Act (CHOICE Act) of 2014. With this act, veterans in rural areas had expanded options to receive care from non-VA providers with the VHA’s coordination and approval. The CHOICE Act also highlighted health care staffing disparities via staff shortage reports required by the VA Office of Inspector General, and the identification of the need to increase Graduate Medical Education (GME) residency positions in the mental health specialty.

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A new piece of legislation, the Jeff Miller and Richard Blumentha Veterans Health Care and Benefits Improvement Act, was passed in 2016, which increased the number of GME residency seats from five to ten while also extending the program through 2024, as originally intended (Albanese et al., 2019). Despite the expansion of GME residency positions and budget extensions, rural health care inequities continued to worsen. There is a physician shortage gap in rural areas, which is a mission-critical priority for the Veterans Health Administration (VHA). Advocates and policymakers started working towards the John S McCain III (Daniel K Akaka) VA Maintaining Internal System and Strengthening Integrated Outside Networks Act of 2018 (MISSION).

Discussion: Presidential Agendas NURS 6050

In June 2018, the Obama administration laid the framework for the Trump Administration’s MISSION Act, paving the path for it to become a reality. Mission Act actions based on physician shortages now influence GME residency locations, specialties, and the number of positions available within stated constraints. The focus has switched from bringing veterans to health care providers (HCP) to bringing health care providers to veterans. In addition, these measures include expanding the VA Health Care Profession Scholarships (HPSP) to graduate studies for nurse practitioners who are allowed to practice without physician supervision. Expansions such as these will alleviate staffing shortages in remote veteran communities while also improving patient access to high-quality health care (American Association of Colleges of Nursing [AACN], 2016). Non-VA facilities can now help vets in need without fear of repercussion thanks to GME changes.

The Sgt. Ketchum Rural Veterans Mental Health Act of 2021 was recently passed by the Biden Administration. Many sailors, marines, and soldiers have lost their lives due to a lack of access to treatment for suicide thoughts, so this law is dedicated to Sergent Brandon Ketchum. Military veteran Sgt. Ketchum had post traumatic stress disorder and substance misuse issues when he returned home to rural Iowa after serving in Iraq and Afghanistan. At the Iowa City VA Hospital in 2016, he requested to be admitted, but the psychiatrist ruled that inpatient care was not required at the time. Brandon went back to his house and died that night by suicide. Although no health care professionals were determined to be directly responsible for his death, quality patient education on suicidal ideation, risk factor ratings and access to routine outpatient psychiatric mental health services or the lack of these could be to blame. RANGE (Rural Access Network for Growth Enhancement) programs will be available to rural veterans who have been diagnosed with schizophrenia, schizoaffective disorder, bipolar affective disorder, major depression, PTSD, or any other severe or persistent mental health illness (Veterans Health Administration, VA.gov: Veterans Affairs 2013). Veterans with major mental illness who are homeless or at danger of homelessness can receive intense case management through the RANGE program, which focuses on recovery. Rural veterans who require more rigorous mental health treatment than typical outpatient therapy are entitled to a study and report under the Sgt. Ketchum Rural Veterans Mental Health Act of 2021, which mandates that the government do so (Monteith et al., 2020).

Although on a smaller scale, VA healthcare reform faces similar obstacles to achieving universal coverage. There are a number of factors that contribute to the creation of policies that appear to be insurmountable obstacles to healthcare reform. However, change is a process. The Sgt. Ketchum Rural Veterans Mental Health Act of 2021, which will replace the CHOICE Act, is a hopeful step forward. Policymakers will use the findings from this ongoing amount of data and study on veteran health. We owe those who have given their lives to defend us an extra layer of protection with each new bill and amendment that is passed.

References

Albanese, A. P., Bope, E. T., Sanders, K. M., & Bowman, M. (2019). The VA mission act of 2018: A potential game changer for rural GME expansion and Veteran health care. The Journal of Rural Health, 36(1), 133–136. https://doi.org/10.1111/jrh.12360

American Association of Colleges of Nursing. (2016, December 13). VA ruling on APRN practice: a breakthrough for veterans health care. Message posted on the American Association of Colleges of Nursing Listserv:web@aacn.nche.edu

Department of Veterans Affairs (2018b). VA National Suicide Data Report: 2005–2015. Retrieved from

https://www.mentalhealth.va.gov/ docs/data-sheets/OMHSP_National_Suicide_Da ta_Report_2005-2015_06-14-18_508-compliant.pdf

Monteith, L. L., Wendleton, L., Bahraini, N. H., Matarazzo, B. B., Brimner, G., & Mohatt, N. V. (2020). Together with veterans: Va national strategy alignment and lessons learned from community‐based suicide prevention for rural veterans. Suicide and Life-Threatening Behavior, 50(3), 588–600. https://doi.org/10.1111/sltb.12613

VA.gov: Veterans Affairs. RURAL VETERANS. (2016, January 19).

https://www.ruralhealth.va.gov/aboutus/ruralvets.asp.

Veterans Health Administration, D. U. S. for O. and M. (2013, May 8). VA.gov: Veterans Affairs. Enhanced RANGE Program. https://www.lexington.va.gov/services/Enhanced_RANGE_Program.asp.

Discussion: Presidential Agendas NURS 6050

            Agenda setting is the process where special interest groups or lobbyist set their problem to government attention (Milstread & Short 2019). In nursing, we have seen a rising plague that leaves patients and families broken and mourning, I am speaking of opioid addiction. Nurses and other interprofessional healthcare workers have taken this systemic agenda and propelled it through the institutional agenda to a decision agenda (Milstread & Short 2019). The current and past Presidents of the United States have acknowledged this agenda and have attempted to curtail this growing epidemic of opioid abuse.

President George W Bush said on his first national address that illegal drugs were the gravest domestic threat (Weedon, 2002). Continuing President Bush said that drugs were an  “Individual tragedy, And, as a result, a social crisis.” (state.gov). Identify the problem came from lobbyists bringing it up the channels and making it a forefront issue. President Bush created at $19 Billion dollars congressional budget to fight drug addiction with the goals to limit the drug supply and reduce the demand. Funding for reducing demand went to public education forums, drug addiction in schools. The goals set by President Bush and his administrative team was to see a “10 percent reduction in teenage and adult drug use over the next two years, and a 25 percent reduction in drug use, nationally, over the next five years.” (state.gov).

President Obama followed President Bush and the opioid crisis continued to ravage the nation. The rate of opioid-related overdose deaths increased more than 200% within the 15 years (Abraham et, al 2017). One of the greatest counter attacks to the opioid crisis was the formation and enactment of the Affordable Care Act. Among other benefits of the Affordable Care Act was the empowerment of the individual states to take action on the opioid crisis. Another great benefit of this legislature was the ability of patients to access substance abuse disorder treatments such as outpatient treatment, residential treatment programs, detoxification, recovery support services, and assistive medications (Abraham et, al 2017). It is estimated 1.6 million Americans with substance abuse disorder gained insurance and access to health care related to the Affordable Care Act (Abraham et, al 2019).

Following President Obama President Trump continued the fight on opioids. President Trump declared opioid addiction a public health emergency (Thompson, 2019).  President Trump signed into law October 24^th 2018, SUPPORT for Patients and Communities Act. This bipartisan bill was introduced June 3, 2018, and was negotiated and finalized October 3, 2018 (Thompson 2019). Within the confines of this legislature was the Medicaid patient access to substance abuse disorder medications such as but not limited to buprenorphine and naltrexone. Additionally, physicians are now required to include opioid addiction in documenting patient histories (Thompson 2019.)

All three Presidents have contributed to the ongoing domestic war of opioid addiction and substance abuse disorders. The legislation is only as effective as the lobbyist that propel them through the levels of political agenda (Milstread & Short 2019). I would like to see all insurance Medicaid or commercial to work more transparently with physicians and local health officials to have a more transparent screening of the number of opioids being prescribed. I agree with harsher criminal sentencing for illegal drug manufacturing and sale. I would like to see more public education on signs of addiction and greater access to community resources, especially in more rural America.  I believe all three Presidents had great success in identifying and combating this crisis. We as nurses must continue to agenda-setting with our representatives to see the continual change in this arena.

References:

Abraham, A. J., Andrews, C. M., Grogan, C. M., Pollack, H. A., D, A. T., Humphreys, K. N., & Friedmann, P. D. (2017). The Affordable Care Act Transformation of Substance Use Disorder Treatment. American Journal of Public Health, 107(1), 31–32. https://doi-org.ezp.waldenulibrary.org/10.2105/AJPH.2016.303558

Milstead, J. A., & Short, N. M. (2019). Health Policy and Politics a nurses Guide   (6th ed.). Burlington, MA: Jones & Bartlett Learning.

President Bush Announces Drug Control Strategy. (2002, February 12). Retrieved           September 01, 2020, from https://2001-2009.state.gov/p/inl/rls/rm/8451.htm

Thompson, C. A. (2019). Trump signs legislation to combat opioid crisis. American Journal of Health-System Pharmacy : AJHP : Official Journal of the American Society of Health-System Pharmacists, 76(1), 5. https://doi-org.ezp.waldenulibrary.org/10.1093/ajhp/zxy028

Weedon, J. R. (2002). Drug war undergoes reform. (Legislative Issues).   Corrections Today, 5, 24.

Discussion: Presidential Agendas NURS 6050