Racial and Ethnic and Rural Variations in Access to Primary Care for Veterans Following the MISSION Act.

Publisher: American Medical Association Country of Publication: United States NLM ID: 101769500 Publication Model: Electronic Cited Medium: Internet ISSN: 2689-0186 (Electronic) Linking ISSN: 26890186 NLM ISO Abbreviation: JAMA Health Forum Subsets: MEDLINE

Original Publication: Chicago, IL : American Medical Association, [2020]-

Health Services Accessibility*/statistics & numerical data ; Primary Health Care*/statistics & numerical data ; Rural Population*/statistics & numerical data ; United States Department of Veterans Affairs*/statistics & numerical data ; Veterans*/statistics & numerical data; Adult ; Aged ; Female ; Humans ; Male ; Middle Aged ; Access to Primary Care ; Black or African American/statistics & numerical data ; Cross-Sectional Studies ; Ethnicity/statistics & numerical data ; Healthcare Disparities/ethnology ; Healthcare Disparities/statistics & numerical data ; Hispanic or Latino/statistics & numerical data ; United States ; White/statistics & numerical data

Importance: The 2018 Veterans Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks (VA MISSION) Act was implemented to increase timely access to care by expanding veterans' opportunities to receive Veterans Affairs (VA)-purchased care in the community (community care [CC]). Because health equity is a major VA priority, it is important to know whether Black and Hispanic veterans compared with White veterans experienced equitable access to primary care within the VA MISSION Act.
Objective: To examine whether utilization of and wait times for primary care differed between Black and Hispanic veterans compared with White veterans in rural and urban areas after the implementation of the VA MISSION Act.
Design, Setting, and Participants: This cross-sectional study used VA and CC outpatient and consult data from the VA's Corporate Data Warehouse for fiscal years 2021 to 2022 (October 1, 2020, to September 30, 2022). Separate fixed-effects multivariable models were run to predict CC utilization and wait times. Each model was run twice, once comparing Black and White veterans and then comparing Hispanic and White veterans. Adjusted risk ratios (ARRs) were calculated for Black and Hispanic veterans compared with White veterans within rurality status for both outcomes.
Main Outcomes and Measures: VA and CC primary care utilization as measured by primary care visits (utilization cohort); VA and CC primary care access as measured by mean wait times (access cohort).
Results: A total of 5 046 087 veterans (994 517 [19.7%] Black, 390 870 [7.7%] Hispanic, and 3 660 700 [72.6%] White individuals) used primary care from fiscal years 2021 to 2022. Utilization increased for all 3 racial and ethnicity groups, more so in CC than VA primary care. ARRs were significantly less than 1 regardless of rurality status, indicating Black and Hispanic veterans compared with White veterans were less likely to utilize CC for primary care. There were 468 246 primary care consultations during the study period. The overall mean (SD) wait time was 33.3 (32.4) days. Despite decreases in wait times over time, primary care wait times remained longer in CC than in VA. Black veterans compared with White veterans had significantly longer wait times in CC (ARRs >1) but significantly shorter wait times in VA (ARRS <1) regardless of rurality status in VA and CC. CC wait times for Hispanic veterans compared with White veterans were longer in rural areas only and in VA rural and urban areas (ARRs >1).
Conclusion and Relevance: The results of this cross-sectional study suggest that additional research should explore the determinants and implications of utilization differences among Black and Hispanic veterans compared with White veterans. Efforts to promote equitable primary care access for all veterans are needed so that policy changes can be more effective in ensuring timely access to care for all veterans.

Med Care. 2021 Jun 1;59(Suppl 3):S292-S300. (PMID: 33976079)
J Clin Epidemiol. 2011 Jul;64(7):749-59. (PMID: 21208778)
Annu Rev Public Health. 2012 Apr;33:89-106. (PMID: 22224892)
JAMA Cardiol. 2018 Feb 1;3(2):133-141. (PMID: 29299607)
Health Aff (Millwood). 2020 Aug;39(8):1368-1376. (PMID: 32744943)
Med Care. 2018 May;56(5):441-447. (PMID: 29578951)
JAMA Netw Open. 2022 Aug 1;5(8):e2228783. (PMID: 36006640)
Health Serv Res. 2009 Feb;44(1):288-302. (PMID: 18793213)
Ann Surg. 2019 Dec;270(6):1103-1109. (PMID: 29794842)
Med Care. 2021 Jun 1;59(Suppl 3):S286-S291. (PMID: 33976078)
J Gen Intern Med. 2011 Nov;26 Suppl 2:676-82. (PMID: 21989621)
JAMA. 2020 Jul 28;324(4):343-344. (PMID: 32602896)
Health Econ. 2011 Feb;20(2):239-51. (PMID: 20169587)
Ann Intern Med. 2018 Oct 2;169(7):487-489. (PMID: 30039157)
J Gen Intern Med. 2021 Aug;36(8):2274-2282. (PMID: 34027612)
Milbank Q. 2005;83(3):457-502. (PMID: 16202000)
Annu Rev Public Health. 2016;37:375-94. (PMID: 26789384)
JAMA Netw Open. 2023 Jan 3;6(1):e2252061. (PMID: 36689224)
J Gen Intern Med. 2023 Mar;38(4):889-897. (PMID: 36307640)
J Gen Intern Med. 2018 May;33(5):644-650. (PMID: 29299816)
Med Care. 2021 Jun 1;59(Suppl 3):S270-S278. (PMID: 33976076)
Med Care. 2021 Jun 1;59(Suppl 3):S301-S306. (PMID: 33976080)
Health Soc Care Community. 2020 Jan;28(1):1-11. (PMID: 31524327)
BMC Health Serv Res. 2018 Nov 20;18(1):869. (PMID: 30458761)
Med Care. 2020 Dec;58(12):1091-1097. (PMID: 32925455)
Arthritis Care Res (Hoboken). 2017 Aug;69(8):1171-1178. (PMID: 27788302)
JAMA Netw Open. 2020 Aug 3;3(8):e2014313. (PMID: 32845325)
Health Serv Res. 2021 Jun;56(3):400-408. (PMID: 33782979)
J Gen Intern Med. 2023 Jul;38(Suppl 3):871-877. (PMID: 36941422)

Date Created: 20240621 Date Completed: 20240621 Latest Revision: 20240624

20240624

PMC11193128

10.1001/jamahealthforum.2024.1568

38904952