Civilian Health Care Systems Must Recognize and Study Military Service as a Social Determinant of Health

Military and Veterans and Population Health

Military service can be viewed as a social determinant of health (SDOH) with powerful influences both during and following the end of one’s service commitment. Those who have volunteered to serve in the military in the 50 years since the inception of the All-Volunteer Force comprise a unique population in the United States with risk factors for a range of both unfavorable and positive health outcomes (Gates et al., 1970). And while both exist, it is possible that the negative physical and mental health consequences of military service outweigh the positive outcomes. Unique military stressors may include environmental exposures, war-related injuries, military sexual trauma, and moral distress as well as positive experiences, such as strengthened resiliency, work-related training, potential for economic mobility, and a strong support system stemming from the bonds of serving (Duan-Porter et al., 2018; Fischer et al., 2023; Gates et al., 1970). The failure to view veterans as a unique population with military service-connected determinants of health, both physical and psychological, creates the potential for negative health outcomes. Our military and veterans, regardless of the source of care, are entitled to high quality and informed care that considers the uniqueness of their work within the framework of population health and the triple aim which optimizes individual and population health through the experience of care, focus on overall population health, and costs of care (Institute for Healthcare Improvement, n.d.).

Many health professionals also perceive that health care for every serving military service member and every veteran is delivered solely by two federal health systems—the Military Health System (MHS) within the Department of Defense and the Veterans Health Administration (VHA) within the Veterans Administration (VA)—and that none of this care is rendered by civilian practitioners within the civilian sector. This inaccurate perception leads to the assumption that because veterans are not in their patient population, that the impact and influence of military service are irrelevant in the delivery of care with the potential of a missed diagnosis or an unintentional triggering of a latent PTSD. As an example, Grubbs and colleagues (2018) found, by systematically comparing care of depression in veterans in civilian and VHA clinics, that veteran status was a significant moderator of successful outcomes and that unmeasured patient or system characteristics (population health) contribute to a poor response among veterans in the community setting. This indicates the importance of identifying veterans and their military service as a determinant of health care outcomes.

The most recent VA data indicate, that as of 2015, approximately 9 million of the 18 million veterans in the United States receive their health care from the VHA (US Department of Veterans Affairs). This means that 50 percent of veterans obtain health care in the civilian health care sector. Additionally, the nearly 1 million members of the reserve components (RC), comprised of the federal reserve and the National Guard, receive all of their health care from civilian providers unless they meet stringent eligibility criteria of the MHS or VHA. Furthermore, there is an unknown number of other veterans who served in one of the RCs long enough to receive a military retirement, yet do not meet eligibility requirements for care within the VHA. All of these serving military or veterans may have experienced toxic exposures, military sexual trauma, or other injuries as a result of their reserve or National Guard training and service; unfortunately, there is likely no record of these events in either their military or civilian health records, making them ineligible for care within the MHS/VA systems.

The health records within the MHS and VHA clearly indicate dates of military service, duty assignment locations, socioeconomic data, deployment locations and length, locations of toxins (e.g., burn pits), and other critical epidemiological information. Furthermore, health professionals working within those institutions are well-versed in the many hazards of deployment, especially because many of them also serve in one of the uniformed services.

The distinctiveness of this population and the reported relationships of military service as a SDOH makes them a unique population. The question must then be asked is, “What is known about the health outcomes of this unique population comprised of approximately 12 million Americans across all systems of care, federal and civilian?” At this point in time, the answer is “little to nothing.” To begin to answer this question, there must be data. While there may be evidence on specific conditions, there is no population health data driven by indicators in the health record. Clinicians must start by knowing that a patient is a veteran, but often this status is completely unknown in the civilian health sector. Lacking the ability to identify the members of this population via required data elements in all electronic health records (EHRs)—civilian and federal—it is nearly impossible to fully understand the implications of military service-connected determinants of health on the health outcomes of all members of this unique population.

Gaps in Electronic Medical Records

As the United States recognizes the multitude of social factors that influence health, strategies are being developed to capture these factors at the point of care. It is being increasingly recognized that SDOH data are not sufficiently captured in EHRs and that many social determinants, such as military service, are not being captured (Chen et al., 2020). Half of America’s veterans and members of the RC are receiving care within a civilian health sector that does not typically recognize, ask, or document their military history or service-connected conditions. Even in systems that are required to document the number of veterans served, such as in federally qualified health systems, there is no mandated use of a systematic electronic method to collect these data to ensure visibility and comprehensive data collection and reporting (HRSA, 2023). This often results in an undercount in the number of veterans served (Howen et al., 2020). There is not yet an agreed-upon and required Minimal Data Set that routinely records critical details about military affiliation, military service history, and related health exposures (Wilmoth et al., 2024). This gap in knowing about military experience may impact the timely and appropriate diagnosis of military related health problems, effects the care received, and hinders outcome evaluation of patient outcomes across civilian and federal health sectors. Further, the Individual Longitudinal Exposure Record recently developed by the MHS and VHA will not capture exposures from active or reserve component training events nor will this electronic documentation method extend to the civilian sector (Seileen Mullan, personal communication with authors, November 20, 2023).

Overcoming the Gaps

Two actions must occur simultaneously in order to provide the highest quality of health care to all who serve or have served in our military. First, recognize these individuals as a unique population within the larger population health construct and, second, mandate that all EHRs used in the United States have the capacity to capture essential demographic and exposurerelated data points secondary to military service. The policy levers to make this a reality are challenging. One strategy starts with the standards advancement process developed by the Office of the National Coordinator for Health IT (recently renamed as the Office of the Assistant Secretary for Technology Policy). It prioritizes missing content from the set of data required of EHR developers to be included in the US Core Data for Interoperability. Once adopted, the EHR developers must include it in the demographics of their software and the user communities must implement it. Finally, a thoughtful review of who should record it must be explored. With the clinical workforce facing increased burdens in providing care, adding required demographic info must not overburden their workload. Similarly, once recorded, it should be permanent and not required at subsequent encounters. Another option is to have the individual veteran (or a designated representative) to enter the data. Two recently published papers call for increased participation in EHR documentation by the patient or designated representative (Detmer and Gettinger, 2023; Wilmoth et al., 2024). Regardless of the strategy, it must be accompanied by a broad educational initiative to succeed in recording this critical information. There are other possible approaches, such as Centers for Medicare and Medicaid (CMS) quality reporting or The Joint Commission standards, but each of these will miss potential groups of the veterans. A second-order action must include broadening health professions education to include critical information about the health effects secondary to military service. Having military history and service-connected conditions as part of the medical record, whoever records it, will also bring awareness to clinical providers of the effects and sequela of military service and consideration for treatment plans.

Conclusion

The ability to improve health outcomes of an identified population begins with the ability to identify members of the population. To date, members of the military and veterans have been invisible, are frequently overlooked by health professionals working in the civilian health sector, and are not considered a population of great concern by those who work outside of the MHS or the VHA. Those who volunteered to serve the United States are profoundly proud of that service and carry the pride of service, the resiliency of character, and the knowledge that they were a part of something bigger than themselves for their entire lives. Those who work in the civilian sector owe it to these Americans to make them visible and to acknowledge their dedication and sacrifice. However, there is a greater expectation: The imperative to improve health outcomes for the population of those who volunteer to serve in the military by requiring that EHRs in all settings (civilian, military, and veteran) are collected and shared with appropriate and adequate data on military service and all exposures.

Join the conversation!

Half of U.S. veterans receive health care in civilian systems—but their military history often goes unnoticed. A new #NAMPerspectives explores why recognizing military service as a social determinant of health is essential. Read more: https://doi.org/10.31478/202501b #HealthEquity

Veterans bring unique health risks and strengths from military service. Civilian health care must adapt to address this. Dive into the latest #NAMPerspectives commentary: https://doi.org/10.31478/202501b #VeteranHealth #SDOH

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References

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