Is Care in the Community the Future of the Veterans Health Administration?
Or, is the in-house delivery model better?
Introduction
The Veterans Health Administration (VHA) stands as the largest integrated health care system in the United States, serving millions of veterans annually. In recent years, a significant debate has emerged regarding how health care services should be delivered to veterans: through the VHA's traditional in-house care system or through the expanding VA Community Care Network. This article examines both approaches, their historical context, costs, and the various trade-offs involved.
The Veterans Health Administration (VHA) has increasingly supplemented its direct care with community care, or health services provided by non-VA providers but paid for by VA. This model mirrors other government health care programs like Medicare or Tricare. Despite an overall decline in the veteran population, the number of veterans using VA health care has increased, with VHA patients generally being a clinically complex group with higher rates of serious health conditions. Following legislation in 2014 (Veterans Choice Act) and 2018 (MISSION Act), eligibility for community care expanded significantly, with spending on community care growing from $7.9 billion in 2014 to $18.5 billion in 2021, now representing about 20% of VHA's medical care budget.
However, several pressing issues exist with the community care program. The cost and quality of community care relative to VHA-delivered care remain largely unknown, although some evidence suggests community care may be more expensive. Though this likely depends on the geographic location, the type of care, and the relatively to improved access to care. VHA faces significant challenges coordinating care between its facilities and community providers, potentially resulting in confusion, duplicative tests, increased costs, and lower quality care.
Despite the program's intent to reduce wait times, data suggests access to community care may be no better than access to VHA facilities. Additionally, community care providers may not have the expertise to address veterans' unique health needs. However, with reform and selectivity, can the community care program meet or exceed the needs of the population served by the VHA?
In short, it probably depends on geography and type of service.
Background on the VHA
The VHA's roots trace back to 1921 when Congress created the Veterans Bureau to provide care for World War I veterans. Through subsequent consolidations and expansions, particularly following World War II, the modern VHA emerged as part of the Department of Veterans Affairs (formerly the Veterans Administration). The mission has remained consistent: to provide comprehensive health care services to those who served in the U.S. military.
Eligibility for VHA health care is determined by a veteran's service history, discharge status, and service-connected disabilities. The VHA employs a priority group system that ranks veterans based on factors such as service-connected disability ratings, former Prisoner of War status, receipt of medals like the Medal of Honor and Purple Heart, income level, and period and location of service. Veterans in higher priority groups typically receive more comprehensive coverage with lower or no copayments.
The VHA provides a full spectrum of health care services. These include primary care, specialty care in areas like cardiology and oncology, mental health services, rehabilitation services, long-term care, prescription medications, preventive care, and specialized services for women veterans. Particularly notable are specialized services for conditions strongly associated with military service, such as PTSD and traumatic brain injury.
VHA In-House Care Delivery System
The VHA's in-house system consists of an extensive network of facilities across the country. Approximately 170 medical centers serve as hubs for complex and specialized care. Over 1,000 community-based outpatient clinics (CBOCs) provide more routine care closer to veterans' homes. The system also includes community living centers for long-term care, residential rehabilitation treatment programs, and readjustment counseling centers known as Vet Centers. These facilities are organized into 18 Veterans Integrated Service Networks (VISNs) that coordinate care regionally.
One of the VHA's greatest strengths lies in its specialized expertise in treating conditions common among veterans. Years of focused research and clinical experience have made VHA clinicians leaders in treating post-traumatic stress disorder, traumatic brain injury, prosthetics and adaptive technologies, spinal cord injuries, polytrauma care, and military sexual trauma. This expertise is difficult to replicate in the broader health care system, where providers may see relatively few patients with these specific conditions.
A distinguishing feature of VHA care is its integrated electronic health record system and team-based approach. Primary care is delivered through Patient Aligned Care Teams (PACTs) that coordinate comprehensive care. These teams include primary care providers, nurses, pharmacists, mental health professionals, and social workers who collaborate to address the veteran's complete health needs. This integration allows for coordinated care plans that consider the veteran's full medical history and specific needs related to their military service.
Costs and Challenges of the In-House System
The VHA operates on an annual budget exceeding $80 billion. This substantial funding covers facility maintenance and modernization, medical equipment, personnel costs for over 300,000 health care professionals, research initiatives, and educational programs. The scale of this investment reflects both the nation's commitment to veterans' health care and the complexity of maintaining a nationwide healthcare system.
Despite its extensive network, the VHA has faced persistent challenges in providing timely access to care. Geographic barriers present significant obstacles for rural veterans, who may need to travel hours to reach the nearest VA facility. Specialist shortages in certain regions create bottlenecks for care. The 2014 VA waiting time scandal highlighted systemic issues with appointment scheduling and wait times. Many VA facilities are aging and require significant capital investment to modernize. Additionally, the VHA often struggles to recruit health care professionals in competitive markets, especially when unable to match private sector salaries.
Critics have pointed to various administrative challenges within the system. Bureaucratic processes can delay care as approvals wind through multiple levels of review. Quality metrics vary considerably across facilities, creating inconsistent experiences for veterans depending on location. Workforce management issues, including staff shortages and turnover, affect continuity of care. Some facilities operate in outdated buildings that were not designed for modern health care delivery, creating inefficiencies in workflow and patient experience.
However, the following studies (1, 2, 3) suggest that VHA-operated facilities provide equivalent if not better quality care for patients. Access to care, however, can be an issue particularly with specialty services.
VA Community Care Program
The concept of the VA purchasing care from community providers is not new, but it expanded significantly over the past decade. The Veterans Access, Choice, and Accountability Act of 2014, commonly known as the "Choice Act," was created in direct response to the waiting time scandals that revealed veterans waiting months for necessary care. This program was later replaced by the VA MISSION Act of 2018, which established the current Community Care Network with expanded eligibility criteria and improved implementation processes.
The Community Care Network operates through contracts with third-party administrators, like employer-sponsored insurance, who maintain networks of community providers. Veterans may receive care through this network under several circumstances: when the VHA cannot provide the required service, when the veteran lives too far from a VA facility (typically defined as more than 30 minutes drive time for primary care or 60 minutes for specialty care), when wait times exceed designated standards, or when the veteran and their VA provider determine it is in the veteran's best medical interest to seek community care.
Community Care covers virtually all health care services available within VA facilities. This includes primary care, specialty care, mental health services, urgent and emergency care, hospital care, skilled nursing, and home health services. The program aims to ensure that veterans can access timely care regardless of whether that care is delivered directly by the VA or by community providers working in partnership with the VA.
Tradeoffs Between In-House and Community Care
The quality of care received by veterans varies between the in-house and community care systems in several important ways. The in-house system offers specialized understanding of military-related conditions that community providers may rarely encounter. VA providers receive consistent training in veteran-centric care, understanding the unique context of military service and its impacts on health. The integrated care coordination within the VA system helps ensure that veterans' complex needs are addressed holistically. Additionally, the VA conducts research specifically focused on veteran health issues, leading to innovations that directly benefit the veteran population.
Community care quality considerations present a more mixed picture. Community providers may have variable familiarity with veteran-specific health issues and the complex interplay between physical and mental health conditions common among veterans. However, in some cases, community providers may offer access to cutting-edge technologies or specialized treatments not yet available in all VA facilities. Care coordination between community providers and the VA system can be inconsistent, potentially leading to fragmented care. Cultural competence regarding military experience also varies widely among community providers, affecting the patient-provider relationship and treatment outcomes.
Access to care represents perhaps the most visible tradeoff between the systems. The in-house VA system offers a comprehensive one-stop care model where veterans can receive primary care, specialty care, mental health services, and pharmacy services under one roof. However, geographic coverage is limited, with significant gaps in rural areas. Potential waiting times for appointments, especially with specialists, continue to be a challenge despite improvement efforts. On the positive side, the consistent veteran-focused approach means that all aspects of the facility and care delivery are designed with veterans' specific needs in mind.
Community care often provides greater geographic convenience, with more providers available closer to veterans' homes. The larger number of provider options potentially allows veterans more choice in who delivers their care. Appointment scheduling is sometimes faster in the community system, especially for routine care. However, community care comes with risks of fragmentation as veterans may see multiple providers across different systems, potentially leading to coordination challenges and gaps in information sharing. These are well-known issues in non-VHA health care settings for the majority of Americans.
Cost implications differ significantly between the two approaches. The in-house system carries fixed infrastructure costs regardless of utilization—facilities must be maintained, and core staff retained even if patient volumes fluctuate. However, the VA often has lower variable costs per patient for many services due to its scale and federal purchasing power. The system has developed economies of scale for treating common veteran conditions, with specialized protocols and treatments refined over decades. The direct budget control and predictability of the in-house system allows for long-term planning and investment in veteran-specific needs.
Community care typically involves market-rate reimbursements that are often higher than VA costs for equivalent services. While this approach reduces the need for capital investments in VA facilities, it comes with higher administrative costs for coordination between systems. Budget requirements for community care are less predictable, as utilization patterns and market rates can change rapidly. There is also potential for overutilization without the integrated care management that characterizes the VA system, potentially leading to unnecessary tests, procedures, or appointments.
Coordination of care represents a final critical tradeoff. The in-house system benefits from a unified electronic health record where all providers can see a veteran's complete medical history. The team-based care model ensures regular communication between providers serving the same patient. Referrals within the system are relatively seamless, with standardized processes and information sharing. All of this contributes to a comprehensive view of the veteran's health needs that can be difficult to achieve when care is distributed across multiple systems.
Community care faces significant information exchange challenges, as community providers often use different electronic health record systems that may not communicate effectively with VA systems. Veterans receiving care from multiple unconnected providers must often serve as their own care coordinators, remembering to share information about medications, treatments, and recommendations between providers. This fragmentation creates risks of duplicate services when providers are unaware of care received elsewhere, or gaps in care when follow-up responsibilities are unclear.
Conclusion
The ultimate goal must remain providing veterans with the high-quality, accessible healthcare they have earned through their service, regardless of the delivery mechanism. As the veteran population continues to evolve, with aging Vietnam-era veterans and younger post-9/11 veterans having different needs and expectations, the VHA must adapt accordingly. The challenge lies in preserving the specialized expertise and integrated approach that distinguishes VA care while addressing legitimate access concerns through judicious use of community providers.
The future of veteran health care will likely depend on finding the right balance between these approaches—leveraging the specialized expertise and integration of the VA system while strategically incorporating community resources to address access challenges. By focusing on the veteran's needs rather than ideological preferences for government or private sector solutions, policymakers can work toward a system that truly honors veterans' service through excellent, accessible health care.