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Research Questions

  1. What are veterans' current demographics and health care needs and how are these likely to change in the future?
  2. What are VA's resources and capacity to deliver health care and how might this impact veterans' access?
  3. What should policymakers consider when examining changes to VA's use of purchased care?

In response to concerns that the Department of Veterans Affairs (VA) has faced about veterans' access to care and the quality of care delivered, Congress enacted the Veterans Access, Choice, and Accountability Act of 2014 ("Veterans Choice Act") in August 2014. The law was passed to help address access issues by expanding the criteria through which veterans can seek care from civilian providers. In addition, the law called for a series of independent assessments of the VA health care system across a broad array of topics related to the delivery of health care services to veterans in VA-owned and -operated facilities, as well as those under contract to VA.

RAND conducted three of these assessments: Veteran demographics and health care needs (A), VA health care capabilities (B), and VA authorities and mechanisms for purchasing care (C).

This report summarizes the findings of our assessments and includes recommendations from the reports for improving the match between veterans' needs and VA's capabilities, including VA's ability to purchase necessary care from the private sector.

Key Findings

The Three-Decade Decline in the Number of Veterans Will Continue

  • The total number of veterans is expected to decrease by 19 percent between 2014 and 2024, assuming no major policy changes or large-scale conflicts.
  • The median age of this population will continue to increase, and veterans are projected to become more geographically concentrated over this period.

Veterans Who Use VA for Health Care Are Typically Older and Sicker Than Other Veterans

  • However, veterans who rely most on VA care tend to be younger and poorer and to live in rural areas and lack health care from other sources.

Through 2019, the Demand for VA Services May Outpace Supply

  • From 2020 and onward, demand for VA care may level off or decline, barring any major conflicts or changes in eligibility policy.

We Observed Considerable Variability in Access to Care

  • We found opportunities to improve access, even at the top-performing VA facilities.
  • Some veterans face barriers to accessing VA health care in a timely manner, especially in a number of key specialties.

Quality of Care Delivered by VA Is Generally Equal to or Better Than Care Delivered in the Private Sector

  • However, there is considerable variation across centers and types of care.

VA Has Stepped Up the Purchase of Care From the Private Sector

  • But its purchased care programs currently lack an overarching strategy, and little is known about the timeliness and quality of the care.

Congress May Need to Revise VA's Authority to Purchase Outside Care, Depending on the Strategy Adopted for Purchased Care

Recommendations

  • VA should prepare for a changing veteran landscape by balancing the need for short-term capacity increases with longer-term preparations for declines in patient numbers and assessing the best way to provide care in different areas of the country and for different types of care.
  • Policymakers could improve and expand data collection to inform estimates and planning for future demand of VA care by working to re-implement data collection on veteran status in the 2020 U.S. Census. VA should also closely monitor the needs of post-9/11 veterans and collect better data on all health care used by veterans.
  • VA should take significant steps to improve access to VA care; policy options with the highest potential impact include increasing the number of VA physicians, formalizing independent nursing practice, and expanding virtual access to care.
  • VA should also work to reduce variability in access and quality to ensure all veterans receive timely, high-quality care. In addition, VA should consider alternative standards of timely access to care and develop and implement more-sensitive standards of geographic access to care.
  • Policymakers and VA must define a strategy for purchased care, streamline management of the current purchased care system, and monitor the quality and timeliness of care purchased outside VA.

Table of Contents

  • Chapter One

    Demand: How Much Care Do Veterans Use?

  • Chapter Two

    Supply: What Is VA's Capacity to Deliver Health Care and How Might This Impact Veterans' Access?

  • Chapter Three

    What Should Policymakers Consider When Examining Changes to Purchased Care?

Research conducted by

The analyses upon which this publication is based were performed under a contract for the Department of Veterans Affairs and conducted by RAND Health, a division of the RAND Corporation. The development and production of this summary volume was funded through a generous philanthropic gift from Charles Zwick.

This report is part of the RAND Corporation research report series. RAND reports present research findings and objective analysis that address the challenges facing the public and private sectors. All RAND reports undergo rigorous peer review to ensure high standards for research quality and objectivity.

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