Impact of Dual Enrollment in the VA and Medicare Advantage on Care and Outcomes for Veterans

Background: The share of Medicare beneficiaries enrolled in private health plans through Medicare Advantage (MA) has increased rapidly over the past 2 decades with half of Medicare beneficiaries enrolled in MA. Our preliminary data suggest 1.8 million Veterans (nearly 20% of all VA enrollees) were enrolled in an MA plan in fiscal year 2020. The vast majority of prior studies focused on Veterans dually enrolled in VA and the traditional Medicare (TM) program, but fundamental differences in program design preclude prior estimates of dual use from being applicable to Veterans in MA. There are major gaps in knowledge about the recent growth of dual VA-MA enrollment, whether certain subpopulations of Veterans were more likely to enroll in MA, and how VA-MA enrollment impacts use and reliance of VA services (as a proportion of total care) and health outcomes. Significance: The VA must address the challenges of financing and caring for dually enrolled Veterans, especially as enrollment in MA is projected to cover a majority of Medicare beneficiaries over the next several years. Recent growth in MA enrollment has been substantially higher among racial/ethnic minority and low- income populations, but whether these trends extend to Veterans and the implications of MA enrollment on disparities in the VA population have been unexplored. Innovation & Impact: This proposal will be among the first to examine reliance for Veterans in MA, it will perform a novel linkage of VA, Medicare Advantage encounter, and detailed contract-level information on MA network breadth, benefit design, and provider integration, and it will extend prior research comparing outcomes in TM and MA that relied on cross-sectional approaches by using quasi-experimental methods to account for favorable selection into MA. Specific Aims: Aim 1 will characterize trends in dual VA-MA enrollment among Medicare-eligible veterans and VA spending, utilization, and reliance of dually enrolled veterans from 2016-2023 and examine the role of VA facility characteristics. Aim 2 will compare differences in VA utilization of different types of services and health outcomes between Veterans who enroll in MA versus traditional Medicare. Aim 3 will examine in more depth the consequences of MA enrollment by estimating VA reliance by Veteran factors such as clinical complexity and social risk factors and MA plan factors for VA-MA enrollees. Methodology: This quantitative project will use national VA-Medicare linked datasets on enrollment, utilization, costs, and payments to measure trends in dual enrollment, VA utilization, spending and reliance for VA-MA patients compared to VA-TM patients over a seven-year period. We will use quasi-experimental methods to address the favorable selection of enrollees into MA versus TM and to compare outcomes for these two dually enrolled populations before and after Medicare enrollment. Next Steps/Implementation: Data from this proposed study will be used to update the VA Enrollee Projection Model by the VA Chief Strategy Office for strategic planning and budgeting of VA health care. These data will also be used by the VA Office of Integrated Veteran Care to implement the Maintaining Internal Systems and Strengthening Integrated Outside Networks Act to allocate resources and also develop new legislation to fund VA purchased care. These national program offices need better data on dual VA-MA enrolled Veterans for programs to support older and disabled Veterans and ensure adequate federal funding to support Veterans’ health care needs. Project Number: 5I01HX003893-02 | Fiscal Year: 2026 | NIH Institute/Center: Veterans Affairs (VA) | Principal Investigator: Jean Yoon (+1 co-PI) | Institution: VETERANS ADMIN PALO ALTO HEALTH CARE SYS, PALO ALTO, CA | Activity Code: I01 | Study Section: HSR-5 Health Care System Organization and Delivery and Women's Health[HSR5] View on NIH RePORTER: https://reporter.nih.gov/project-details/11282606