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Publication Briefs

Early Expansion of Benefits under Choice Act Increased Community Hospital Use but Did Not Change Mortality

Healthcare access for Veterans has increased in recent years due to the expansion of Medicaid programs under the Affordable Care Act and the Veterans’ Choice Act (VCA), which increased VA-paid community care. However, it is unknown how these policies affected healthcare utilization and outcomes. This longitudinal study examined changes in VA enrollees’ use of VA and non-VA hospitals from 2012-2017, as well as mortality associated with these policies. To get a comprehensive set of hospitalization records for Veterans enrolled in VA healthcare, investigators linked VA enrollment records, VA acute hospital records, and all-payer hospital discharge data. This resulted in a total of 13 million Veteran-years in five diverse states: Arizona, California, Florida, New York, and Pennsylvania. Using both VA and U.S. Census data, investigators also examined patient characteristics (i.e., age, gender, race/ethnicity, marital status), community characteristics (i.e., median income and education), number of hospitalizations (VA and non-VA), and date of death.


  • Over the five-year study period, Veterans increased their use of community hospitals paid by VA and Medicaid and decreased their use of VA hospitals when access to non-VA care expanded.
  • The shift in hospitalizations from VA to the community was not associated with changes in mortality rates, however, other outcomes need to be assessed to understand how changes in hospital use affected the quality of care for Veterans.


  • The VA MISSION Act of 2018 further expanded Veterans’ access to community care and is expected to amplify the trends observed in this study.
  • Shifting inpatient care to non-VA hospitals poses significant challenges for care coordination across providers and healthcare systems and requires that outcomes be closely monitored.


  • This study lacked the ability to draw causal inferences. Further, there was a lack of data regarding outpatient care, and a lack of generalizability beyond the states included in this study.

This study was funded by HSR&D, and Dr. Vanneman is supported by an HSR&D Career Development Award. Drs. Yoon and Phibbs, and Mr. Chow are part of HSR&D’s Health Economics Resource Center (HERC). Dr. Ong is with HSR&D’s Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP). Drs. Zhang and Vanneman are part of HSR&D’s Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0). Dr. Kizer is with the Sean N. Parker Center for Asthma and Allergy Research at Stanford University and was formerly VA Under Secretary for Health (1995-1999).

Yoon J, Kizer K, Ong M, Zhang Y, Vanneman M, Chow A, and Phibbs C. Health Care Access Expansions and Use of Veterans Affairs and Other Hospitals by Veterans. Research Letter. JAMA Health Forum. June 10, 2022; online ahead of print.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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