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Concerning mental and physical health challenges for those who have served vs. civilians

Over the past decade, mental health challenges increased at twice the rate among those who have served compared to civilians. Hearing impairments and chronic pain are significantly more common among those who have served. Despite these challenges, they remain more likely to self-report being in very good or excellent health and benefit from higher access to care in some measures.

Overview

Approximately 19 million Americans have served or are on active duty in the United States Armed Forces.1,2 While many enjoy the education, employment and other benefits of service, others have unique health needs and face serious long-term health challenges.
The demographics of those who have served in the U.S. Armed Forces are projected to change significantly over the next several decades, becoming more diverse in gender, race and ethnicity, decreasing in size and shifting in age.3,4 What’s more, those returning from recent deployments face unique challenges due to longer, more frequent deployments and unprecedented rates of post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI)5 — placing new demands on the health care system and underscoring the need to closely monitor their health and well-being.
Since 2016, America’s Health Rankings® has compared the health of those who have served in the U.S. Armed Forces and civilians — the only national resource providing comprehensive data over time on this population. Using ten years of data, the 2022 Health of Those Who Have Served Report shows worsening rates of mental health challenges among men and women who have served, with suicidal thoughts and depression increasing nearly twice as much compared to those without military service — with females disproportionately affected. In addition, those who have served face higher rates of physical health challenges like hearing impairment and chronic pain. However, those who have served continue to report higher rates of high health status, as well as better access to care and uptake of preventive and clinical services — especially among certain racial/ethnic subpopulations.
The report analyzes 30 measures of health and well-being, including social and economic factors, behaviors, clinical care and health outcomes. It compares those who have and have not served overall and by age, gender, race/ethnicity, education, income and metropolitan status to understand the impact of health trends on specific subpopulations. It also analyzes the health of those who have served who are 65 years and older, demonstrating how seniors with military experience may be differently impacted by key trends.
For nearly all measures, the report features the most recent publicly available data, from 2020, reflecting a decade of trends from 2011-2012 through 2019-2020. Due to limitations of nationally representative surveys, the report may not reflect the full impact of COVID-19. Further, many measures merge 2019 and 2020 data, limiting this report’s ability to isolate the effects of the pandemic.

Mental Health Challenges Rising Faster than Among Civilians

The rates of suicidal thoughts, depression and mental illness increased nearly twice as much among those who have served in the U.S. Armed Forces over the past decade compared to the civilian population, even though overall rates of most mental health challenges do not differ substantially.
Between 2011-2012 and 2019-2020, suicidal thoughts increased 1.6 times as much among those who have served as among civilians — a 51% rise among those who served (4.1% to 6.2%) compared to 32% among those who have not served (3.8% to 5.0%). A variety of factors put the military population at risk for suicidal thoughts and death from suicide, including stressful life events, mental health conditions like PTSD and access to lethal means such as firearms and drugs.6
Among those who have served, the rate of depression7 rose more than twice as much since 2011-2012 compared to those without military service, and the rate of any mental illness rose nearly twice as much. Depression and mental illness increased 27% and 24%, respectively among those who have served versus 11% and 14% among civilians.

Females Who Have Served Report Higher Rates of Mental Health Challenges

Females who have served continue to report higher rates of mental health challenges compared to their civilian counterparts and to males who have served.
In 2019-2020, suicidal thoughts were 1.8 times higher among females who have served (10.1%) as female civilians (5.5%) and 1.9 times higher than males who have served (5.4%). This disparity holds true across several measures of mental health that may contribute to suicide risk. More than one-third of women who have served (37.8%) reported having a serious, moderate or mild mental illness in the past year, significantly higher than among female civilians (26.0%), males who have served (18.2%) and male civilians (16.3%).
Additionally, 27.9% of females who have served reported depression, compared to 23.8% of females who have not served, 17.4% of males who have served and 12.7% of males who have not.

Those Who Have Served Less Likely to Be Able-Bodied

Those who have served experience some physical health challenges at higher rates than their civilian counterparts. In 2019, those who have served were significantly less likely than civilians to be able-bodied (71.9% vs. 85.3%), defined as having no cognitive, visual, auditory, ambulatory, self-care and/or independent living difficulties. This gap is widening over time, as the rate of those who have served that are able-bodied decreased 4% (from 74.8%) since 2011, compared to a less than 1% decrease among the civilian population (from 85.7%).

Severe Hearing Impairment Nearly Four Times More Likely Among Those Who Have Served

For each disability component in the able-bodied measure, those who have served were between 1.4 and 3.8 times more likely to be impaired. Most notably, those who have served were nearly four times more likely to have severe auditory or hearing impairment than those who have not served (14.1% vs. 3.7%).
The difference in severe hearing impairment between those who have and have not served is pronounced among certain subpopulation groups. Among American Indian/Alaska Native (17.3% vs. 5.5%), Asian (8.3% vs. 2.2%), Hispanic (10.2% vs. 2.4%) and white (15.8% vs. 4.4%) adults, those who have served had rates of severe hearing impairment more than three times greater than civilians. In addition, there were significant differences in the impact of severe hearing impairment between various subpopulations among those who have served. Males who have served had rates of severe hearing impairment three times higher than females who have served (15.1% vs. 5.0%).
Additionally, 14.8% of those who have served reported ambulatory difficulties, 1.9 times higher than civilians (8.0%).

Chronic Pain 1.3 Times More Common Among Those Who Have Served

More than 29.1% of adults 18 years and older who have served report chronic pain — defined as having pain most days or every day in the past three months — compared to 22.0% of their civilian counterparts, a rate 1.3 times higher.
Chronic pain can have a negative impact on health and well-being, limiting a person’s ability to work and perform daily life activities. It can also contribute to substance abuse; veterans with chronic pain are more likely to smoke and to be prescribed addictive opioid medications.8,9
Research has shown that onset of chronic pain often occurs at an earlier age for those who have served versus civilians.10 In 2019-2020, adults ages 26-34 who have served reported chronic pain at a rate 2.6 times higher than adults of the same age who have not served (27.3% vs. 10.6%).

Self-Reported Health Status Higher Among Those Who Have Served

Despite the ongoing — and in some cases, worsening — health challenges facing those who have served in the U.S. Armed Forces, they remain more likely to self-report excellent or very good health than the civilian population.
In 2019-2020, 55.5% of those who have served reported that their health is very good or excellent, compared with 53.0% among those without military service. Further, where there are significant differences at the subpopulation level, those who have served report higher rates of high health status. For example, 52.4% of Hispanic adults who have served reported their health was very good or excellent in 2019-2020, compared with 39.2% of Hispanic civilian adults.
However, as mental and physical health challenges have risen, the difference in health status between those who have served and civilians has narrowed gradually. Since the first edition of this report, the rate of high health status among the civilian population has increased 4%, while it has remained essentially unchanged among those who have served.

Higher rates of access to care

Access to health care continues to be high among those who have served. 92.4% of adults who have served reported having health insurance in 2019-2020, compared to 85.8% of civilians. Veterans receive a variety of benefits from the U.S. Department of Veterans Affairs (VA),11 and most working-age veterans are covered by employer-sponsored insurance.12
Relatedly, in 2019-2020 the percentage of adults who reported a time in the past 12 months where they needed to visit a doctor but could not because of cost was significantly lower among those who have served (8.5%) than among civilians (13.0%).

Higher Uptake of Preventive Clinical Services Compared with Civilians

Those who have served had higher rates of receiving key preventive clinical services than civilians. For example, the percentage of adults who reported receiving a flu vaccine in the past year is 1.3 times higher in those who have served than those who have not served (52.5% vs. 41.8% in 2019-2020). Unfortunately, neither group meets the Healthy People 2030 objective of 70% among all people ages 6 months and older.

Lower Rates of Avoided Care Due To Cost For Hispanic and Black Adults Who Have Served

Some subpopulations of those who have served benefit greatly from higher access to care. 88.5% of Hispanic adults who have served had health insurance, compared to just 70.6% of Hispanic civilians. They were also less likely to report avoiding care due to cost than their civilian counterparts (11.0% vs. 18.6%). In general, Hispanic adults lag behind other groups in terms of insurance coverage, use of preventive care and health status13 — making the positive effect notable for Hispanic adults who have served.
Other groups benefited as well; half as many Black adults who have served (8.1%) reported avoiding medical care due to cost in the past 12 months compared to those who have not served (15.6%).

SPOTLIGHT ON THE HEALTH OF SENIORS WHO HAVE SERVED

Depression Lower Among Seniors Who Have Served, but Rates Rising Nearly Three Times Faster

In 2019-2020, 12.2% of those 65 and older who have served reported experiencing depression, while 14.6% of their civilian counterparts reported the same.
However, while overall depression is lower among older adults who have served than older civilians, it is rising nearly three times faster among those 65 years and older who have served than civilians since 2011-2012. Depression increased 17% among adults over 65 who have served, compared with just 6.6% among civilians.

Smoking and Excessive Drinking Higher Among Seniors Who Have Served

Those ages 65 and older who have served reported higher rates of behavioral health challenges than older adults who have not served, specifically in cigarette smoking and excessive drinking. In 2019-2020, the rate of smoking among older adults who have served is 1.4 times higher than among civilians, at 11.0% — an increase from 9.3% in 2011-2012. Among seniors who have served, large disparities exist based on socioeconomic status; smoking was 4.7 times higher among those with less than high school education (23.6%) than college graduates (5.0%) and 4.1 times higher among those making less than $25,000 (21.2%) than those making $75,000 or more (5.2%).
As discussed in the Senior Report, smoking rates among adults 65 and over did not change over the past decade, even as they declined across all other age groups. However, smoking and excessive drinking are lower among adults 65 and older overall (both those who have and have not served) than nearly all other age groups.
A similar gap between seniors who have served and civilians exists in excessive drinking, or the percentage of adults who reported either binge drinking or chronic drinking.14 In 2019-2020, 8.9% of those ages 65 and older who have served reported excessive drinking, compared to 6.8% of those ages 65 and older who have not served.

Take Action

The United Health Foundation urges policymakers to use the findings of this report to better understand the unique health challenges of those who have served and to support efforts to connect those who have served with the care they need. We encourage providers to focus on addressing and effectively treating the challenges faced by this population, particularly surrounding mental health, through culturally competent and individualized care in order to help those who have served live healthier lives and thus improve the health of all communities.

1. U.S. Bureau of Labor Statistics. “Labor force participation rate for veterans was 46.8 percent in October 2021.” The Economics Daily, November 10, 2022. https://www.bls.gov/opub/ted/2021/labor-force-participation-rate-for-veterans-was-46-8-percent-in-october-2021.htm
2. Manzanetti, Z. “2021 Military Active-Duty Personnel, Civilians by State.” Governing, 2021. Accessed May 15, 2022. https://www.governing.com/now/2021-military-active-duty-personnel-civilians-by-state - :~:text=There were a total of,from the Department of Defense
3. Schaeffer, K. “The changing face of America's veteran population.” Pew Research Center, 2021. https://www.pewresearch.org/fact-tank/2021/04/05/the-changing-face-of-americas-veteran-population/
4. Parker, K., Cilluffo, A. & Stepler, R. “6 facts about the U.S. military and its changing demographics.” Pew Research Center, 2020. https://www.pewresearch.org/fact-tank/2017/04/13/6-facts-about-the-u-s-military-and-its-changing-demographics/
5. Burnam, M.A., Meredith, L.S., Tanielian, T., & Jaycox, L.H. “Mental Health Care for Iraq and Afghanistan War Veterans.” Health Affairs 28, no. 3 (2009). https://www.healthaffairs.org/doi/10.1377/hlthaff.28.3.771
6. Souetre, E., Wehr, T.A., & Darcourt, G. “Influence of environmental factors on suicidal behavior.” Psychiatry Res 32, no. 3 (1990). https://doi.org/10.1016/0165-1781(90)90030-9
7. Depression: Percent of adults who reported ever being told by a health professional that they have a depressive disorder including depression, major depression, minor depression or dysthymia.
8. Chapman, S. & Wu, L. “Associations Between Cigarette Smoking and Pain Among Veterans.” Epidemiologic Reviews 37, no. 1 (2015). https://doi.org/10.1093/epirev/mxu008
9. Edlund, M., Steffick, D., Hudson, T., Harris, K.M., & Sullivan, M. “Risk factors for clinically recognized opioid abuse and dependence among veterans using opioids for chronic non-cancer pain.” Pain 129, no. 3 (2007). https://doi.org/10.1016/j.pain.2007.02.014
10. National Center for Complementary and Integrative Health. “Pain: U.S. Military and Veterans.” U.S. Department of Health and Human Services, 2016. https://www.nccih.nih.gov/health/pain/veterans
11. U.S. Department of Veterans Affairs. “Health Benefits – Determine Cost of Care.” https://www.va.gov/HEALTHBENEFITS/cost/
12. Holder, K.H. & Cheeseman Day, J. “Health Insurance Coverage of Veterans.” U.S. Census Bureau, 2017. https://www.census.gov/newsroom/blogs/random-samplings/2017/09/health_insurancecov0.html
13. United Health Foundation. America’s Health Rankings Health Disparities Report, 2021. https://assets.americashealthrankings.org/app/uploads/2021_ahr_health-disparities-comprehensive-report_final.pdf
14. Binge drinking: Having four or more (women) or five or more (men) alcoholic beverages on a single occasion in the past 30 days. Chronic drinking: Having eight or more (women) or 15 or more (men) alcoholic beverages per week

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