Impact of VA Disability and Health Benefits on Long-Term Diabetes Outcomes among Vietnam-Era Veterans

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Anticipated Impacts on Veterans Health: This study will determine the extent to which disability compensation and more generous VA health benefits among Vietnam-era Veterans improved short and long- term outcomes of diabetes. This contribution is significant because one-quarter of VA enrollees have diabetes, and the complications related to diabetes account for substantial morbidity and spending among Veterans. Prior research suggests that intermediate and long-range outcomes in diabetes may be related to social determinants of health. We evaluate the health effects of a VA policy that directly intervenes on a key social determinant (income) among Veterans with diabetes. Project Background: In July 2001, the VA expanded the medical eligibility criteria for Vietnam-era Veterans to include diabetes as a service-connected condition. The change in policy was motivated by an Institute of Medicine (IOM) study of the association of Agent Orange, an herbicide used by the U.S. government during the Vietnam War, with the onset of type 2 diabetes. Specifically, any Veterans who had “boots on the ground” (BOG) in Vietnam, Cambodia, or Laos during the 1964 to 1975 period was deemed to be exposed to Agent Orange and therefore eligible for disability compensation and more generous health benefits, including zero medication copayments. The approximately 55% of Vietnam-era Veterans who did not have BOG during the war (Not on Ground (NOG)) were ineligible for disability compensation due to diabetes. Prior work by members of our research team found that the 2001 policy change led to a 30% relative increase in income for Veterans with BOG relative to their NOG counterparts. The value of these benefits is further enhanced because they are not subject to federal taxes and are made in perpetuity irrespective of other employment income. Project Objective: The overall objective of this application is to examine the impact of a major change in VA policy that led to increased disability compensation and health benefits for some, but not all, Vietnam-era Veterans with diabetes. We have the following specific aims: Aim 1. Examine whether increased benefits to Vietnam-era Veterans with diabetes resulted in better control of glycosylated hemoglobin (HbA1c) and blood pressure; and increased adherence to medications. Aim 2. Examine whether increased disability and health benefits to Vietnam-era Veterans with diabetes reduced micro- and macrovascular complications of diabetes. Aim 3. Examine whether more generous benefits to Vietnam-era Veterans with diabetes lowered mortality. Project Methods: Using a quasi-experimental study design that includes 15 years of follow-up data (2001- 2016), we will examine the effects of increased annual income as well as more generous health coverage on a comprehensive set of short and long-term outcomes of diabetes. Data on our main treatment variable, BOG status, will come from the Office of Economic Manpower Analysis (OEMA) of the U.S. Army. This data will be merged at the individual level with data on all Vietnam-era Army Veterans who are enrolled in the VA health care system as of July 2001. This data will provide us with detailed outcomes on medication adherence, glycosylated hemoglobin, blood pressure, diabetic complications, and mortality. Our study population will focus on Veterans with a diagnosis of diabetes prior to July 2001 to avoid the potential bias that eligible Veterans who had BOG may have been motivated to be diagnosed with diabetes after the policy change. In our primary study design, we propose to compare the change in the time trend in the BOG-NOG difference in outcomes before and after the policy change (2001 and prior years vs. 2002 and later years).