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Publication Briefs

Study Identifies External Determinants of VA Healthcare Use

The importance of appropriately aligning resource availability with demand for VA healthcare services was recently underscored by revelations of long waiting times, and the subsequent passage of the 2014 Choice Act. As most Veterans live and work in community settings, the choice to use VA healthcare services is likely influenced by factors both internal and external to VA. Thus, a better understanding of these factors is important for VA's continued ability to meet Veterans' healthcare needs. This study measured the sensitivity of VA healthcare use to changes in "external determinants" such as unemployment and Medicaid expansion following the Affordable Care Act. Investigators examined VA healthcare enrollment and utilization data with area-level data on Medicaid policy, unemployment, employer-sponsored insurance, housing prices and non-VA physician availability. Using VA data, investigators identified 8,016,250 Veterans, aged 18 and older, who had either received or were enrolled to receive VA healthcare during 2008-2014. The primary outcome was VA healthcare use, measured by the cost of all acute inpatient care, outpatient care, and pharmacy use provided by VA for each individual annually (adjusted for inflation).


  • All external determinants were associated with small but significant changes in VA healthcare use. The largest change occurred between 2013 and 2014 following a 55% increase in Medicaid eligibility in the 26 Medicaid expansion states. Among Veterans aged 18-64, this was associated with a 9% ($833 million) reduction in VA healthcare use in these states.
  • Among Veterans ages 18-64, a 10% increase in unemployment was associated with a 0.65% increase in VA healthcare utilization, while a 10% increase in private employer-sponsored coverage was associated with 1.4% decrease in VA healthcare utilization.
  • Among Veterans aged 18-64, increases in non-VA physician availability and housing prices were associated with an increase in VA healthcare use. Among Veterans aged 65 and older, a 10% increase in housing prices was associated with a 2.2% increase in VA healthcare use.


  • Changes in alternative insurance coverage (Medicaid and private) and other external determinants may affect VA healthcare spending. Policymakers should consider these factors in allocating VA resources to meet local demand.


  • Investigators did not have data on non-VA healthcare utilization; only VA healthcare utilization data merged with area-level changes in external determinants was examined.

This study was funded by HSR&D (IIR 12-338); Dr. Kressin was supported by an HSR&D Senior Research Career Scientist Award, and Dr. Linsky was supported by an HSR&D Career Development Award (CDA 12-166). Drs. Hanchate, Kressin, and Linsky are part of HSR&D's Center for Healthcare Organization and Implementation Research (CHOIR); Dr. Frakt leads HSR&D QUERI's Partnered Evidence-based Policy Resource Center (PEPReC); and Dr. Trivedi is with HSR&D's Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans.

PubMed Logo Hanchate A, Frakt A, Kressin N, Trivedi A, Linsky A, et al. External Determinants of Veterans’ Utilization of VA Healthcare. Health Services Research. July 31, 2018;Epub 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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