Restoring the Promise of the MISSION Act

Overview

Veterans rely on the U.S. Department of Veterans Affairs’ (VA) Veterans Health Administration (VHA) to provide timely, high-quality care for the injuries and illnesses they incurred in the course of military service. However, the agency routinely fails to deliver on this promise by forcing veterans to languish on waitlists for care. In response, President Trump signed the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act into law in 2018, giving veterans the right to obtain care from providers in their own communities when the VHA could not deliver. By 2024, the MISSION Act connected 3.1 million veterans—over a third of the VHA’s veteran enrollees—with high-quality clinics and hospitals in their communities.

Unfortunately, VA officials under the Biden Administration undermined the MISSION Act by rationing community care to preserve funding for the traditional VHA system. This paper proposes reforms to put veterans’ access to community care beyond the reach of bureaucratic interference. Eligibility rules should be set in law, veterans should know what they qualify for, and denials should be explained and open to appeal. These reforms would ensure that a veteran’s care is determined by medical need, not the VA’s budget. Veterans should never have to fight their own government for the care they earned.

Long Wait Times Trap Veterans in a Failing System

VHA is a government-owned and operated health system within the VA that delivers healthcare to veterans and their dependents. The federal government owns the hospitals and clinics, directly employs the physicians, nurses, and specialists who work in them, and funds their care through annual appropriations from Congress. With a nationwide network of 170 medical centers and 1,193 outpatient clinics staffed by 371,000 health professionals and support staff, the VHA is the largest integrated health system in the country (Veterans Health Administration, n.d.). In 2025, 7.6 million veterans and dependents received care through the VHA (U.S. Department of Veterans Affairs, 2026).

The VHA’s rigid top-down structure is the source of the chronic shortages veterans face every day. Because the VHA employs its clinicians directly, it must recruit them through federal hiring rules that limit the pay of physicians, podiatrists, optometrists, and dentists to $400,000, the salary of the president (38 U.S.C. § 7431, 2026). Advanced Practice Registered Nurses (APRNs) and Physician Assistants (PAs) are capped at $253,100, and registered nurses are capped at $228,000 (38 U.S.C. § 7451, 2026).

This pay cap leaves the VHA perpetually outbid by private hospitals for the same scarce physicians and other clinicians. A 2025 report by the VA Office of Inspector General (OIG) found that every VHA medical center reported at least one severe occupational staffing shortage (VA Office of Inspector General, 2025a). Among these facilities, 94% reported severe shortages of physicians and 79% reported severe shortages of nurses—the same two occupations the OIG has flagged every year since 2014. When the system cannot hire enough doctors and nurses, appointments back up and veterans wait.

The VHA also compounds this shortage by building hospitals and other facilities far from where today’s veterans live. The agency constructed most VHA facilities between the 1940s and 1960s to deliver inpatient care to veterans who predominantly lived in urban areas in the Northeast and Midwest. However, many of today’s veterans who served in Vietnam, Iraq, and Afghanistan live in rural areas in the South and Southwest (U.S. Government Accountability Office, 2024). Consequently, there is a surplus of VHA facilities in the Northeast and Midwest, and a shortage of facilities in the South and Southwest where most of today’s veterans live.

In 2011, the agency attempted to reduce wait times by requiring VHA facilities to provide veterans with primary care within 14 days of their desired appointment date (U.S. Government Accountability Office, 2012). Rather than take steps to deliver timely care to veterans, many facilities pretended to care for veterans within this timeframe while continuing to force veterans to wait weeks or months for care. In 2014, whistleblowers revealed that officials in the Phoenix, AZ, facility kept secret, off-the-books appointment lists to hide delays that stretched for months. A 2014 review by the VA OIG found roughly 1,400 veterans on the Phoenix facility’s official electronic waitlist while an additional 3,500 waited for care off the official waitlist (VA Office of Inspector General, 2014). A subsequent nationwide audit of the entire VHA system found that 8% of VHA schedulers were using unofficial waitlists to comply with the official 14-day appointment mandate (U.S. Department of Veterans Affairs, 2014). The audit concluded that the VA’s goal was “not attainable given growing demand for services.”

The MISSION Act Gave Veterans the Right to Community Care

To provide desperately needed relief to veterans languishing on the VA’s waiting list, Congress enacted and President Trump signed into law the MISSION Act in 2018 (S.2372, 2018). The law created the Veterans Community Care Program (VCCP), which empowers veterans to obtain care from commercial non-VHA facilities in their communities if they meet at least one of several qualifications, including the following:

1. The VHA does not offer the services the veteran is seeking.
2. The VHA has no full-service facility in the veteran’s state of residence.
3. The veteran and their referring clinician believe it is in the veteran’s best medical interest if they obtain community care.
4. The veteran has requested an appointment with their local facility and the facility is unable to deliver care in a timely manner, based on a standard established by the VA.

In 2019, the VA finalized a rule establishing the access standards that determine when a veteran can seek care outside the VHA (38 C.F.R. § 17.4040, 2019). The rule stipulates that a veteran can obtain community care if the VHA cannot deliver a primary care visit within 20 days of the patient’s request for care or within a 30-minute drive from the veteran’s residence. For specialty care, veterans can seek community services if the VHA cannot deliver care within 28 days of the patient’s request or within a 60-minute drive from the veteran’s residence.

When a veteran opts into community care and the VCCP determines their eligibility, the program will schedule an appointment with a local clinic or hospital that participates in the Community Care Network. After the provider delivers care, the program will reimburse the provider based on Medicare’s payment rate for the same service. Congress primarily funds the VCCP through annual discretionary appropriations from the Military Construction, Veterans Affairs, and Related Agencies Appropriations Act, supplemented by mandatory funding from the Cost of War Toxic Exposures Fund under the PACT Act (Panangala et al., 2025; S.3373, 2022).

Veterans jumped at the opportunity granted by the MISSION Act to obtain high-quality care from community providers. In 2024, 3.1 million veterans—over a third of all VHA veteran enrollees—obtained community care through the MISSION Act (U.S. Government Accountability Office, 2025). In 2025, 27% of all care paid for by the VHA was provided by non-VHA clinicians and facilities (U.S. Department of Veterans Affairs, 2026).

VHA Bureaucracy Still Blocks Veterans from the Care They Need and Earned

Despite the popularity of community care, VA leaders under the Biden Administration hindered veterans from obtaining care outside the VHA. When Congress funds the VHA, it appropriates funding for community care to the agency’s Medical Community Care Account and appropriates funding for in-house VHA care through the Medical Services Account (U.S. Government Accountability Office, 2020). The VHA distributes funding from both accounts to VHA facilities to reimburse in-house VHA clinicians and non-VHA community care providers when they deliver care to veterans (U.S. Government Accountability Office, 2019). Congress also appropriates funding for the operation and administration of the VHA through two other accounts: the Medical Facilities Account and the Medical Support and Compliance Account.

As community care’s share of the VHA’s budget increased, critics of community care within the Biden Administration worried that increased spending on community care would crowd out funding for traditional VHA care (Kizer et al., 2024). If the VHA’s Medical Community Care Account faces a shortfall, the VA can transfer up to 1% of the funding from the Medical Services Account and the Medical Support and Compliance Account per year to the Medical Community Care Account. The VA secretary can also submit a request to the House and Senate Committees on Appropriations to transfer funds from the Medical Facilities Account or funds in excess of 1% from the VHA’s Medical Services Account and the Medical Support and Compliance Account to bolster funding for community care (H.R. 1865, 2019). Congress can also provide additional supplemental funding for community care.

Despite the availability of these funding options, President Biden’s VA actively discouraged veterans from choosing community care in an effort to prioritize funding for in-house VHA care. In 2021, the Office of Community Care (OCC) issued an internal directive to VHA facilities instructing them to consider their spending levels on community care when veterans call seeking community care (Veterans Health Administration, 2021). The directive instructed facilities to encourage veteran callers to choose VHA-facility care over community care in geographic areas where there is already high veteran demand for specialty community care. The stated purpose of this guidance was to maintain financial resources within the VHA rather than allow funding to go to community care.

Following instructions from leadership, local VHA facilities threw significant roadblocks in the way of veterans seeking high-quality community services. Although the MISSION Act allows veterans to access community care if they encounter a 20-day or 28-day waiting time, some VHA facilities denied veterans access by booking an initial appointment, canceling the appointment, and then rebooking it for a later date. From January 2020 to May 2021, 62% of all appointment cancellations at the North Florida/South Georgia VHA facilities occurred without any documentation that they were canceled with the patient’s permission, suggesting these facilities were canceling appointments to game wait times (Americans for Prosperity Foundation, 2021).

Even when veterans become eligible for community care, many do not access it because the VHA does not inform them of their eligibility. The MISSION Act requires the VHA to provide veterans with information that is “clear, useful, and timely” so they can make informed decisions about community care. Unfortunately, VHA care schedulers flouted this duty and failed to inform veterans of their eligibility. A 2024 review of the 12th Veterans Integrated Service Network (VISN), a VHA regional network that encompasses four Midwestern states, found that 37% of appointments made at VHA facilities were for veterans who were eligible for community care (VA Office of Inspector General, 2025b). Yet the audit found no evidence that VHA care schedulers informed these patients that they qualified for it.

Policy Options to Restore Veterans’ Access to Care

President Trump and the 115th Congress enacted the MISSION Act to empower veterans with the freedom to choose the best care in their community for their unique medical needs. The Act allowed millions of veterans, especially those in rural areas that lack reliable access to VHA facilities, to obtain high-quality services to live longer, healthier lives after serving their country.

Unfortunately, VHA officials during the Biden Administration abused their discretion under the MISSION Act to delay and deny veterans community care to conserve funding for the traditional VHA system. It is essential that Congress clarify the rights of veterans to access high-quality community care through the following reforms:

Codify Community Care Eligibility in Statute: The VA implemented the MISSION Act by finalizing a rule making veterans eligible for community care if they must wait more than 20 days for primary care and 28 days for specialty care. Veterans would lose this lifeline if a future administration promulgated a new rule that increased the number of days veterans must wait for community care. Congress could enact the VA’s current eligibility requirements into law to ensure government bureaucrats cannot interfere with veterans seeking necessary care from community providers. The Take Care of America’s Veterans Act, introduced by Rep. Mike Bost (R-IL) and Sen. Jerry Moran (R-KS), would do exactly that by codifying the current wait-time and drive-time standards in statute (H.R. 9237, 2026; S. 4744, 2026). This reform also commands overwhelming support from the people it would protect: 71% of veterans support enacting community care eligibility into statute (Concerned Veterans for America, 2025).

Expand Eligibility for Community Care: The VA also could expand eligibility for community care by modifying the Designated Access Standards that veterans must meet to qualify for non-VA care (38 C.F.R. § 17.4040, 2019). The agency could reduce the number of days a veteran must wait before they can seek community care. The VA could also decrease the minimum time that a veteran must drive to a VHA facility before they are eligible for community care.

Stop Bureaucrats from Manipulating Wait Times: Congress should require the VA to calculate the start of a veteran’s wait time to obtain VHA care based on the date the veteran first requested an appointment. The Take Care of America’s Veterans Act would do exactly this by requiring the VA to measure wait times from the veteran’s initial request, preventing VHA schedulers from canceling and rebooking appointments to strip veterans of their eligibility for community care (H.R. 9237, 2026; S. 4744, 2026). The VA need not wait for Congress: the agency could implement this policy today by amending its internal scheduling directive to require VHA schedulers to start a veteran’s wait time when the veteran makes their initial appointment request (VHA, 2024).

Require the VA to Notify Veterans of Their Eligibility: Congress can direct the VHA to disclose to veterans in writing their eligibility for community care under the MISSION Act after they request an appointment. The Take Care of America’s Veterans Act would require the VHA to notify veterans of their eligibility within five days of their request (H.R. 9237, 2026; S. 4744, 2026). In the meantime, the agency could amend its internal directives to instruct facilities to inform veterans of their eligibility for community care when they make their initial request (VHA, 2024).

Make Every Denial Transparent and Appealable: If the VHA determines a veteran seeking community care is ineligible, the agency must promptly provide a full explanation outlining the reason they were denied. This explanation should detail the specific eligibility requirements under the MISSION Act and the VA’s regulations enforcing the Act that the applicant failed to satisfy. The agency must also provide veterans with clear instructions on how to appeal such denials.

Let Veterans Schedule Their Appointments: The VHA can further assist veterans eligible for community care by creating an online portal that would allow them to directly request primary care and specialist appointments from a reliable list of in-network community care providers. The agency currently provides a website where veterans can view community care providers in their area (U.S. Department of Veterans Affairs, n.d.). However, this site often lists providers that are no longer in business or in-network and does not allow veterans to make appointment requests (U.S. Government Accountability Office, 2022). Creating a self-scheduling portal with a reliable list of providers would empower veterans to take ownership and control of their care.

Cut Red Tape on Mental Health and Substance Abuse Treatments: Veterans experience higher rates of mental health and substance abuse issues than civilian patients. Congress could empower veterans in need of mental health and substance abuse treatments to seek community care without any preauthorization from the VA. The Veterans’ ACCESS Act would create a three-year pilot program that would provide this essential flexibility in areas that have higher rates of veteran suicides and overdoses, as well as longer wait times for these services (H.R. 740, 2025; S. 275, 2025).

Free All Veterans to Automatically Receive Community Care: Congress could also bolster access to community care by allowing all veterans the option to obtain care outside the VHA, regardless of whether they meet a specific eligibility criterion, such as facing long wait times. The Veterans Health Care Freedom Act, introduced by Rep. Andy Biggs (R-AZ) and Sen. Marsha Blackburn (R-TN), would create a three-year pilot program allowing enrolled veterans within at least four VISNs to become automatically eligible for community care (H.R. 71, 2025; S.219, 2025). Once the pilot concludes, veterans throughout the United States would become eligible for community care under this proposal.

Let Veterans Enroll in TRICARE: Congress could also expand care options by allowing veterans to enroll in TRICARE, the Department of War’s health program for active-duty service members, military retirees, and their families. Letting veterans obtain TRICARE coverage would allow them to visit TRICARE’s network of clinics and hospitals in the vicinity of America’s domestic military bases (Defense Health Agency, 2025). Rep. Greg Steube (R-FL) introduced the Veterans’ True Choice Act of 2025, which would give veterans with service-connected disabilities, Purple Heart recipients, and certain other veterans the option to enroll in TRICARE (H.R. 244, 2025).

Conclusion

President Trump signed the MISSION Act to empower veterans to obtain timely, high-quality care from community providers when the VHA could not deliver these essential services. Millions have exercised that choice, with over a third of all VHA veteran enrollees now relying on community care. Unfortunately, VA officials have denied veterans their right to community care by manipulating wait times, concealing their eligibility, and steering veterans away from community options.

Congress should not leave veterans’ access to community care at the mercy of government bureaucrats. The reforms outlined above would transform community care from a privilege that agency officials can quietly ration into a durable right that no future administration can erode through rulemaking or internal directives. They would restore the foundational promise of the MISSION Act: to put veterans in control of their healthcare decisions. The men and women who served this country deserve a system that works for them, not one they must fight against.