As the largest integrated health care system in the U.S., the Veterans Health Administration provides care to more than 9.1 million veterans. And in a bid to give former military service members more choice, Congress passed the 2014 CHOICE Act and 2018 MISSION Act, first allowing, and then expanding veterans’ options to obtain care outside of VA facilities. 

Payments for non-VA care—known as Community Care—rose from $7.9 billion in 2014 to $18.5 billion in 2021. By 2024, Community Care was projected to account for 25 percent of the VA’s total health care expenditures. Expanded choice would seem to improve access, but were there unintended consequences?

A recent study from LDI Senior Fellows Peter Groeneveld, Jay Giri, Ashwin Nathan, and colleagues measured the impact of the 2018 MISSION Act on travel times and outcomes for veterans who received major cardiovascular procedures. Through a retrospective analysis from October 2016 to September 2022, the study found that travel times for those eligible for non-VA care fell substantially after the MISSION Act was implemented. However, for veterans who received certain procedures, including coronary artery bypass surgery (CABG), rates of major adverse cardiovascular events (MACE) within 30 days worsened.

Groeneveld discusses the study and its policy implications below.

What is the current state of outside care in the Veterans Health Administration?

Groeneveld: The VA has far less control over the quality of care delivered by outside facilities than within VA, and it is doubtful that many veterans or their referring VA clinicians have access to the quality-of-care data needed to make truly informed choices. Without such data, veterans are at risk of unknowingly choosing non-VA hospitals and clinicians that are not as good as VA-based hospitals and clinicians.

What is your most important finding about the impact of the MISSION Act on major cardiovascular procedure outcomes?

Groeneveld: We found that the 2018 MISSION Act, which greatly expanded veterans’ access to care outside the VA—especially among veterans who live far from VA hospitals—substantially reduced the travel time to care for veterans needing major cardiovascular procedures, yet it also was associated with worsened outcomes for some cardiovascular procedures among the subgroup of veterans whose eligibility for non-VA care was expanded. To our knowledge this is the first study that has directly examined the MISSION Act’s impact on high-technology cardiovascular care.

How do your findings fit into the existing literature?

Groeneveld: Prior studies have investigated the impact of the Veterans Choice Program (2014), which was the first major expansion of VA-paid care outside VA facilities, and those studies had similar findings to ours. The VA has long been a leader in the provision of high-quality (i.e., better-than-average) cardiovascular procedural care, so in some ways it is not surprising that policies that enticed some veterans away from VA-based cardiovascular care resulted—on average—in worsened outcomes.

What limitations about studying the MISSION Act’s impact on cardiac procedure outcomes should readers be aware of?

Groeneveld: The design of the MISSION Act, particularly its eligibility criterion of a greater than 60-minute drive time to VA specialty care, naturally suggested a difference-in-differences analytic approach (comparing those who were less than or greater than 60-minute travel time from the VA before and after the policy was implemented). It’s the type of natural experiment that health services researchers frequently seek when investigating policy changes that have both a temporal and geographic component. Weaknesses are that some patients living close to VA were also eligible for Community Care (via other criteria), and enactment of the MISSION Act may have changed the population of VA-paid cardiovascular care recipients in a manner that biased findings. However, neither of these was likely to “explain away” our primary findings.

What recommendations do you have for policymakers about VA Community Care?

Groeneveld: Policies that have increased veterans’ choices of health care providers are here to stay, and these policies have clearly provided better health care access and greater convenience—in a nutshell, choice is popular! However, the VA’s Community Care program needs to evolve so that veterans are fully informed about the quality of the providers they are choosing among. Choosing a hospital for elective cardiac procedures is a critically important decision with major consequences, and we owe it to our veterans to give them the best possible information to make the most informed choices. Policymakers continue to wrestle with how much VA-paid care should be offered via non-VA providers, and how much care should be delivered by VA providers in VA facilities. The results of these deliberations have enormous implications for the VA’s future, yet there is surprisingly limited data to guide these decisions. I’m therefore excited that data from our study could potentially contribute to the policies that will greatly define VA’s future.

Where are you going next with the research?

Groeneveld: Three particular areas would be interesting to explore in the future. One is whether there are similar findings among patients who undergo elective non-cardiac surgery and/or other non-cardiac major interventional procedures. A second issue is whether a decision aid using existing hospital “Report Cards” could be developed that could assist veterans making a choice among hospitals in real time. A final issue is whether VA might leverage Medicare data on patient outcomes to provide useful decision support to veterans facing these critical choices.

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The article “Impact of the MISSION Act on Quality and Outcomes of Major Cardiovascular Procedures Among Veterans” appeared in JAMA. Authors include: Jingyi Wu, Genevieve P. Kanter, Todd H. Wagner, Danny Chu, John P. Cashy, Jason M. Prigge, Thomas J. Glorioso, Natalia Rahman, Nandini Murali, Jay Giri, Ashwin S. Nathan, Stephen W. Waldo, and Peter W. Groeneveld.

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