A study published in The Lancet sheds light on a little-discussed issue affecting U.S. military veterans — a lack of health insurance coverage. Most people assume that veterans automatically receive health care coverage through the Veterans Health Administration, but that’s actually not the case, according to the authors of the study published Sunday, Dr. Dave A. Chokshi of NYU Langone Medical Center and Dr. Benjamin Sommers of the Harvard School of Public Health. Using numbers from the Census Bureau’s American Community Survey, they determined that more than 1.2 million veterans lacked health insurance in 2012, the latest year for which data is available, in line with previous studies that came to similar conclusions. In fact, just 8.9 million out of the 22 million veterans in the U.S. are enrolled in VA health benefits, which are reserved for those who have been disabled through military service or are very low-income. Other vets tend to obtain insurance on the private market. The researchers found that most uninsured veterans lived in states that had decided not to accept the Affordable Care Act’s federal funding to expand Medicaid, the government’s insurance program for low-income people. For example, they determined that there were 126,000 uninsured military veterans living in Texas, 95,000 in Florida, 54,000 in North Carolina and 53,000 in Georgia. None of those states, all with Republican governors, are expanding their Medicaid coverage, programs to cover people living at or below 138 percent of the federal poverty line, or a combined income of just under $33,000 for a four-person household. Click here for statistics on uninsured veterans But the authors also determined that 87 percent of currently uninsured veterans are probably eligible for coverage through Medicaid expansion, through subsidized plans offered on the ACA’s insurance marketplaces or through the VA. “With the introduction of the ACA, universal coverage for veterans could be an achievable goal, albeit one that requires renewed commitment and policy attention,” the authors wrote. “To call for expanded coverage might seem ill-timed when the VA health system is struggling to keep pace with demand. Yet, paradoxically, the present crisis could provide an opportunity to address these related access problems,” they said.

States expanding Medicaid Implementing the Medicaid expansion Not moving forward at this time Open debate

Notes: Data are from Aug. 28, 2014. States marked as "open debate" are on the basis of analyses by the Sources: The Henry J. Kaiser Family Foundation Notes: Data are from Aug. 28, 2014. States marked as "open debate" are on the basis of analyses by the Kaiser Commission on Medicaid and the Uninsured

While the number of uninsured Americans has decreased by 26 percent by the close of the first-open enrollment season for the ACA's insurance exchanges, which began in October 2013, the Department of Health and Human Services hasn’t indicated how many veterans were among the 7.1 million people who enrolled in coverage through the marketplaces in that time. But previous studies have suggested that obtaining health insurance is a problem for veterans. For example, a 2007 study conducted at the VA Puget Sound Health Care System found that many veterans didn’t know they were eligible for VA care. The researchers also said that those vets who did use the VA for all their health care needs tended to be from lower-income, less educated and minority populations. Genevieve Kenney, co-director of the Urban Institute’s Health Policy Center and an expert on Medicaid, confirmed that vets without health insurance resemble their civilian counterparts — they tend to be younger, lower-income and have lower levels of education. “So the Affordable Care Act has the potential to address some of the holes for veterans” through Medicaid expansion and the insurance exchanges, she said. However, Kenney, who co-authored a study about the Medicaid eligibility of uninsured veterans, pointed out that fewer vets have gone without insurance than civilian adults, and that is because of the VA. “It [the VA] does provide coverage and care to millions of other veterans who don’t have other options,” she said. Dr. Steffie Woolhandler, a professor of public health at the CUNY School of Public Health at Hunter College, said she began to treat veterans who didn’t have insurance coverage during the decades she spent working as a primary-care physician at the Cambridge Hospital and Massachusetts General Hospital, in Massachusetts. Like most doctors, she assumed they were covered through the VA. “I said, ‘Why don’t we call the VA?’ and they’d say ‘No, no, you’re not eligible,’” she told Al Jazeera. “They were mostly these lower-income, low- to middle-income working people whose incomes were too high to qualify for [VA-covered health insurance for the poor], but they still couldn’t afford private health insurance,” she said. Woolhandler, who has been a vocal advocate for adopting a single-payer health insurance program in the United States, says that hundreds of thousands of veterans will remain without coverage across the board because the ACA “doesn’t get us to universal coverage.” “You can go serve your country — you can even be a combat veteran — but you can come home and be uninsured,” she said. Joanna Kao contributed to this report.

Many uninsured veterans reside in states that are not expanding Medicaid Highlighted states are those that are expanding Medicaid

State Percentage of veterans uninsured Estimated veterans uninsured Expanding Medicaid? Alabama 4.52% 18,000 No Alaska 8.32% 6,000 No Arizona 6.03% 32,000 Yes Arkansas 8.26% 20,000 Yes California 4.51% 88,000 Yes Colorado 7.14% 29,000 Yes Connecticut 2.19% 5,000 Yes Delaware 2.61% 2,000 Yes District of Columbia 3.25% 1,000 Yes Florida 5.91% 95,000 No Georgia 7.55% 53,000 No Hawaii 3.55% 4,000 Yes Idaho 7.15% 9,000 No Illinois 5.30% 40,000 Yes Indiana 7.04% 33,000 Open debate Iowa 4.71% 11,000 Yes Kansas 5.03% 11,000 No Kentucky 5.94% 19,000 Yes Louisiana 7.35% 23,000 No Maine 6.12% 8,000 No Maryland 3.65% 16,000 Yes Massachusetts 1.75% 7,000 Yes Michigan 5.34% 37,000 Yes Minnesota 3.18% 12,000 Yes Mississippi 8.19% 17,000 No Missouri 6.67% 33,000 No Montana 9.18% 9,000 No Nebraska 4.77% 7,000 No Nevada 6.97% 16,000 Yes New Hampshire 4.33% 5,000 Yes New Jersey 3.71% 17,000 Yes New Mexico 8.53% 15,000 Yes New York 3.03% 29,000 Yes North Carolina 7.31% 54,000 No North Dakota 5.48% 3,000 Yes Ohio 5.82% 52,000 Yes Oklahoma 6.83% 22,000 No Oregon 6.00% 20,000 Yes Pennsylvania 3.97% 39,000 Yes Rhode Island 4.00% 3,000 Yes South Carolina 7.06% 28,000 No South Dakota 5.73% 4,000 No Tennessee 6.28% 31,000 No Texas 7.82% 126,000 No Utah 6.14% 9,000 Open debate Vermont 3.94% 2,000 Yes Virginia 4.90% 36,000 No Washington 5.38% 32,000 Yes West Virginia 6.67% 11,000 Yes Wisconsin 3.54% 15,000 No Wyoming 5.86% 3,000 No National 5.54% 1,217,000 N/A 2012 American Community Survey (ACS) five-year estimates

Notes: Estimates are based on the authors' analysis of data from the 2012 American Community Survey as of Oct. 26, 2014. The percentages of uninsured were calculated by using the number of veterans in each state, based on the 2012 ACS five-year estimates. Sources: The Lancet Notes: Estimates are based on the authors' analysis of data from the 2012 American Community Survey as of Oct. 26, 2014. The percentages of uninsured were calculated by using the number of veterans in each state, based on the 2012 ACS five-year estimates.