Utilization and Health Outcomes for Veterans With Expanded Health Care Access 2.0

Background: Improving access to high-quality care is a top priority for VHA. In 2018, Congress passed the MISSION Act, which further expanded access to VA-purchased care. The VA is now at a crossroads. Some lawmakers want VA to expand access further, but costs have increased rapidly and are unsustainable. Before the Choice Act, the VA spent about $8 billion on purchased care, or 14% of the 2013 medical care spending. In FY24, VA overspent on VA purchase care, exceeding its budget of $33 billion. VA purchased care now exceeds 25% of VA medical care spending, and VA is facing a >$6 billion deficit. Evaluating the benefit of expanded access is difficult because Veterans that use VA purchased care are different than those that do not. Using causal inference models, our team showed that the Choice Act increased utilization, but did not improve outcomes even among higher risk subgroups. Preliminary research suggests that one explanation for why we are seeing no benefits from the increased use of purchase care is payer shifting. Payer shifting happens when individuals who are covered by more than one insurer, change their payer to make their life easier (e.g., reduce their out-of-pocket expenses, increase convenience). Knee jerk reactions to the preliminary payer shifting data could hurt Veterans. More research on payer shifting is critically needed. This study will fill that gap. Significance: If payer shifting is happening then the VA needs evidence that it can use to address it without harming Veterans. Our proposed study is designed to examine payer shifting among VA enrollees. We will leverage the date at which the MISSION Act was implemented (June 6, 2019) and a difference-in-differences analysis to examine the relative change in utilization over time. This research will conclusively address whether payer shifting is happening, the magnitude of payer shifting, and for which groups of Veterans. Innovation and Impact: Understanding payer shifting is necessary to help VA improve access while simultaneously manage its financial health. We apply novel econometric techniques to take advantage of natural experiments and find the causal effects of increasing access. We will also use subgroup analyses to understand possible mechanisms and equity effects. This research is directly aligned with HSR's priorities on access to care, research related to the MISSION Act, and advancing health services research methods across conditions or care settings. Specific Aims: We have three specific aims. First, we will examine payer shifting among all Veterans in Colorado using a recently acquired all payer claims dataset. Second, we will examine payer shifting among VA enrollees who are age-eligible for Medicare. Finally, we will examine payer shifting among VA enrollees who are disability-eligible for Medicare. Methodology: We will leverage the date at which the MISSION Act was implemented (June 6, 2019) and a difference-in-differences analysis to examine the relative change in utilization over time. Across all three aims, we will also conduct analyses for heterogeneous treatment effects to determine if subgroups differ in their payer-shifting response. The subgroups will include: priority groups, distance, urbanicity, age/service era, length of time with VA, previous VA use intensity, comorbidities, and specific procedures. These subgroups were chosen to inform mechanisms and also address potential equity concerns. Next steps/ implementation: We will work with operational partners to understand payer shifting and its potential impact on Veterans and the VA. If we identify payer shifting, we will work with our operational partners to understand the scope of payer shifting and then design approaches to address it. Evidence of no payer shifting will also be helpful as VA considers expanding access to VA purchased care. Project Number: 1I01RD000612-01A1 | Fiscal Year: 2026 | NIH Institute/Center: Veterans Affairs (VA) | Principal Investigator: TODD WAGNER | 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/11243446