Medicaid Expansion Increased Appointment Wait Times in Maine and Virginia

Contextual factors influencing the association between the Affordable Care Act's Medicaid expansion and Veteran VA-Medicaid dual enrollment

OBJECTIVE

To evaluate changes in dual enrollment after Affordable Care Act Medicaid expansion by VA priority group, (e.g., service connection), sex, and type of state expansion.

STUDY SETTING

Our cohort was all Veterans ages 18-64 enrolled in VA and eligible for benefits due to military service-connection or low income from 2011 to 2016; the unit of analysis was person-year.

STUDY DESIGN

Difference-in-difference and event-study analysis. The outcome was dual VA-Medicaid enrollment for at least 1 month annually. Medicaid expansion, VA priority status, whether a state expanded by a Section 1115 waiver, and sex were independent variables. We controlled for race, ethnicity, age, disease burden, distance to VA facilities, state, and year.

DATA EXTRACTION METHODS

We used data from the VA Corporate Data Warehouse (CDW) regarding age and VA Priority Group to select our cohort of VA-enrolled individuals. We then took the cohort and crossed checked it with Medicaid Analytic Extract (MAX) and T-MSIS Analytic Files (TAF) to determine Medicaid enrollment status.

PRINCIPAL FINDINGS

Service-connected Veterans experienced lower dual-enrollment increases across all sex and state-waiver groups (3.44 percentage points (95% CI: 1.83, 5.05 pp) for women, 3.93 pp (2.98, 4.98) for men, 4.06 pp (2.85, 5.27) for non-waiver states, and 3.00 pp (1.58 to 4.41) for waiver states) than Veterans who enrolled in the VA due to low income (8.19 pp (5.43, 10.95) for women, 9.80 pp (7.06, 12.54) for men, 10.21 pp (7.17, 13.25) for non-waiver states, and 7.39 pp (5.28, 9.50) for waiver states).

CONCLUSIONS

Medicaid expansion is associated with dual enrollment. Dual-enrollment changes are greatest in those enrolled in the VA due to low income, but do not differ by sex or expansion type. Results can help VA identify groups disproportionately likely to have potential care-coordination issues due to usage of multiple health care systems.

Geographic Variation in Appointment Wait Times for US Military Veterans

Importance

Timely access to medical care is an important determinant of health and well-being. The US Congress passed the Veterans Access, Choice, and Accountability Act in 2014 and the VA MISSION (Maintaining Systems and Strengthening Integrated Outside Networks) Act in 2018, both of which allow veterans to access care from community-based clinicians, but geographic variation in appointment wait times after the passage of these acts have not been studied.

Objective

To describe geographic variation in wait times experienced by veterans for primary care, mental health, and other specialties.

Design, Setting, and Participants

This is a cross-sectional study using data from the Veterans Health Administration (VHA) Corporate Data Warehouse. Participants include veterans who sought medical care from January 1, 2018, to June 30, 2021. Data analysis was performed from February to June 2022.

Exposures

Referral to either VHA or community-based clinicians.

Main Outcomes and Measures

Total appointment wait times (in days) for 3 care categories: primary care, mental health, and all other specialties. VHA medical centers are organized into regions called Veterans Integrated Services Networks (VISNs); wait times were aggregated to the VISN level.

Results

The final sample included 22 632 918 million appointments for 4 846 892 unique veterans (77.3% male; mean [SD] age, 61.6 [15.5] years). Among non-VHA appointments, mean (SD) VISN-level appointment wait times were 38.9 (8.2) days for primary care, 43.9 (9.0) days for mental health, and 41.9 (5.9) days for all other specialties. Among VHA appointments, mean (SD) VISN-level appointment wait times were 29.0 (5.5) days for primary care, 33.6 (4.6) days for mental health, and 35.4 (2.7) days for all other specialties. There was substantial geographic variation in appointment wait times. Among non-VHA appointments, VISN-level appointment wait times ranged from 25.4 to 52.4 days for primary care, from 29.3 to 65.7 days for mental health, and from 34.7 to 54.8 days for all other specialties. Among VHA appointments, wait times ranged from 22.4 to 43.4 days for primary care, from 24.7 to 42.0 days for mental health, and from 30.3 to 41.9 days for all other specialties. There was a correlation between wait times across care categories and setting (VHA vs community care).

Conclusions and Relevance

This cross-sectional study found substantial variation in wait times across care type and geography, and VHA wait times in a majority of VISNs were lower than those for community-based clinicians, even after controlling for differences in specialty mix. These findings suggest that liberalized access to community care under the Veterans Access, Choice, and Accountability Act and the VA MISSION Act may not result in lower wait times within these regions.