The Veterans Health Administration (VHA), operated by the Department of Veterans Affairs (VA), is the largest integrated health system in the United States, with 1,298 facilities nationwide (including four medical centers and 36 clinics in North Carolina alone). Despite the VHA’s size, many of the 9 million Veterans enrolled in the VA health care program have difficulties accessing the system’s facilities. To make it easier for these Veterans to access quality care for which they are eligible, Congress passed the VA Maintaining Internal Systems and Strengthening Integrating Outside Networks (MISSION) Act of 2018, which went into effect in June 2019.1

The MISSION Act covers a wide range of issues includ­ing in-home care, access to walk-in VA care, telehealth, and prescription drug programs. A key element is the VA Community Care (VACC) program, which replaced the Veterans Choice program. VACC enables enrolled Veterans to access VA-supported care more easily through select community health care facilities that are not part of the VHA system. A Veteran is eligible for VACC by meet­ing any one of the following criteria: needs a service not available at the VA medical facility, lives in a state or ter­ritory without a full-service VA medical facility, qualifies under the “grandfather” provision related to distance eligi­bility for the Veterans Choice Program, VA cannot furnish care within certain designated access standards, it is in the Veteran’s best medical interest, and a VA service line does not meet certain quality standards.2 The goal is to ensure timely and appropriate care and to widen the avail­ability of Veteran-centric care beyond the walls of the VHA.

With the recent enactment of the PACT Act substan­tially increasing the number of Veterans who will be eligi­ble for VA care, and therefore putting additional pressure on the system,3 now is a good time to evaluate whether the MISSION Act is achieving this goal effectively.

Are Eligible Veterans Accessing VA Community Care?

Eligibility for VACC first requires enrollment in the VHA. Of the nation’s 16.5 million Veterans (approximately 700,000 in North Carolina), almost 10 million are enrolled in the VHA (about 400,000 in North Carolina).4 Of those Veterans enrolled in the VHA, about 23% qualify for VACC (86,712 in North Carolina).5,6 This means approximately 14% of the total Veteran population are eli­gible for VACC.7

These Veterans are eligible to use commercial facilities in a Community Care Network (CCN) that is contracted and managed regionally through one of two companies— TriWest or OptumServe. There are 20 CCN outpatient clinics scattered throughout North Carolina, which is in a region managed by OptumServe, providing significant additional access to care for North Carolina’s eligible Veterans. The question of whether eligible Veterans are using facilities in the CCN is more difficult to answer—data are spotty at best, with no available information directly assessing Veterans’ utilization of the CCN. Most impor­tantly, in most cases, Veterans must receive approval from VA staff members, who generally make all eligibility determinations, before receiving care from a community provider.8 A 2021 investigation by USA Today indicated that the VA itself is, in some cases, hindering access to outside care:

“A review of thousands of pages of department manuals and medical records, along with interviews with dozens of patients, advocates and providers, shows that VA administrators are overruling doctors’ judgments and preventing them from sending their patients outside the VA health care system”.9

The extent to which the CCN can effectively supple­ment VHA care is also an open question. In a report published in November 2022 under the title, “VA Health Care: Incomplete Information Hinders Usefulness of Market Assessments for VA Facility Realignment,” the Government Accountability Office (GAO) wrote:

“GAO identified gaps in the data VA compiled and certified for the market assessments that were relevant to determining both the supply of and demand for non-VA care…. VA lacks a full understanding of the extent to which community care is able to supplement VA facility care to meet veterans’ current and future demand”.10

Despite the lack of data directly pointing to CCN use, tangential data indicate that the VACC program has had a positive effect on wait times at VHA facilities, indicating that some Veterans who would have used those facilities are finding care at CCN facilities instead.

Are Veterans Getting Community Care Commensurate with Care at a VHA Facility?

The MISSION Act establishes standards for quality at CCN facilities commensurate with those at VHA facili­ties. These standards are measured by patient experience indicators, including effective care, safe care, and Veteran-centered care, which “anticipates and responds to veter­ans’ and their caregivers’ preferences and needs, and ensures that veterans have input into clinical decisions”.2 VA releases comparison data annually that allow con­sumers to examine VHA and regional community provider performance on these indicators. The most current score­card for North Carolina Community Care facilities indi­cates that VHA facilities are “BETTER” than CCN facilities on every measured “Effective Care” and “Safe Care” indi­cator, and “SAME” or “BETTER” on all “Veteran-Centered Care” indicators.8 While VACC has opened opportuni­ties for eligible Veterans to receive care more easily out­side the VHA system, the quality of that care may not be equal to VHA standards.

Are Veterans in North Carolina Getting the Health Care They Need and Deserve?

Any discussion about the VA or the MISSION Act needs to acknowledge that Veterans represent a vulnerable pop­ulation by virtue of significant health gaps brought about by the harsh and often toxic conditions of military service.

While the MISSION Act appears to have improved some Veterans’ access to Veteran-centric care, most are still using commercial health care facilities outside both the VHA and CCN systems. Here they are rarely screened for military status, much less receiving treatment that could be described as “Veteran-centric” in any way. Just as there is no specific information available about how many eligible Veterans are taking advantage of the benefits of VACC, no one knows how many are not getting quality care at facilities where their Veteran status goes unseen.

This situation—a large, distinct population displaying significant health gaps brought about by the conditions under which they have lived and worked—represents a classic health equity challenge. The MISSION Act may have made a dent in access to Veteran-centric care, but several larger challenges were identified by the GAO tes­timony to Congress in February 2023: ensuring Veterans’ health care appointments are scheduled in a timely man­ner, having complete information to determine if there are adequate health care providers to meet Veterans’ needs, effectively identifying and meeting the demand for men­tal health and other behavioral health services among Veterans, and ensuring timely implementation while addressing data quality issues and working to modernize the electronic health record system.11

Disclosure of interests

No interests were disclosed.