the veterans First agenda: Expanding Access and Improving Care for America’s Heroes

Introduction

The America First Policy Institute’s (AFPI) Veterans First Agenda is foundational to the America First Warfighters’ work to keep America’s promise to the brave men and women who have worn the uniform, completed their service, and returned to civilian life. Crafted by policy experts with deep experience in the Veterans Health Administration (VHA) and the Department of War, the Veterans First Agenda will advance the interests of veterans and their families.

AFPI is working to ensure today’s veterans receive timely, world-class medical care, whether from the VHA, Military Treatment Facilities (MTFs), or a community provider close to home. This work is essential because the men and women who have defended our nation deserve a health care system that honors their service and delivers on America’s solemn obligation to those who have made profound sacrifices to protect their fellow citizens. As the American Civil War drew to a close, President Abraham Lincoln issued his Second Inaugural Address (1865), urging his fellow Americans to “Strive on to finish the work we are in; to bind up the nation’s wounds; to care for him who shall have borne the battle, and for his widow, and his orphan.”

These words, inscribed at the entrance to the U.S. Department of Veterans Affairs (VA), define the federal government’s sacred obligation to American veterans. Since the nation’s founding, the United States has asked its sons and daughters to risk everything in defense of liberty. In return, the nation has promised quality medical care that is earned through service and sacrifice.

That promise has too often been broken in practice. Bureaucratic delays, geographic shortages, and outdated information systems have prevented millions of veterans from receiving the timely care they need. In 2011, the VHA directed its facilities to treat veterans within 14 days of the date that they requested an appointment (U.S. Government Accountability Office, 2012). Three years later, whistleblowers and government auditors revealed that many facilities were putting veterans on secret wait lists where they were waiting far longer for care (VA Office of Inspector General, 2014). VHA facilities in Kentucky, Tennessee, and West Virginia forced veterans to wait 35 to 71 days for specialty care.

In 2018, President Donald Trump signed the MISSION Act into law to deliver relief to veterans suffering in the VHA’s long wait lines (S. 2372, 2018). The law empowers veterans to receive healthcare services from local, non-VA providers at the VA’s expense. Unfortunately, VHA officials under President Joseph Biden have stymied veterans from seeking essential care from community providers. From 2020 to 2021, VHA facilities in Georgia and Florida conducted 187,385 appointments for veterans who were eligible for community care (Americans for Prosperity Foundation, 2021). However, only 3.1% of these appointments included documentation that the VHA facility informed the patient of their eligibility for community care. In 2024, a network of VHA hospitals in Midwest states failed to inform 65,900 veterans who were eligible for community care that they could seek care from a local non-VHA provider (Office of Inspector General, 2025).

Even when veterans become eligible for community care, many encounter significant delays in receiving care in their community. Many veterans live in rural areas that have severe shortages of hospitals, physicians, and nurses. Veterans seeking community care in these areas often encounter clinician and facility shortages that impede access to essential medical care. Twenty-four percent of all veterans live in a county with a shortage of primary care physicians (Doyle & Streeter, 2017). Veterans who live in rural areas also face severe shortages of obstetricians, psychologists, and other specialists (Stoneburner et al., 2024; National Center for Health Workforce Analysis, 2023). America’s veterans deserve better.

AFPI will work to deliver on Lincoln’s promise to care for the men and women who have borne the battle. We will strengthen the right of every veteran to obtain timely and high-quality care in their community, enhance the supply of community physicians and hospitals, and bolster the capacity of the VHA to deliver care to veterans in its facilities. Our policies are derived from rigorous research, on-the-ground experience, and partnerships with state lawmakers, frontline clinicians, and veterans themselves. The result: greater options, faster access, and higher-quality care.

The Current State of Veteran Health Care

Today, veterans face long appointment wait times, chronic clinician shortages, and outdated facilities that fail to deliver quality care that veterans need. Fifty-seven percent of veterans live more than 40 miles from a VHA facility that offers cardiology services, and 45% of veterans live more than 40 miles from oncology services (Hussey et al., 2015). Forty-nine percent of male veterans suffer from multiple chronic diseases, compared to 24.1% of non-veterans (Boersma et al., 2021). In 2022, the veteran suicide rate was nearly double the suicide rate for civilians (Ramchand & Montoya, 2025).

President Trump’s MISSION Act of 2018 empowered 3.1 million VHA beneficiaries, nearly one in three veterans and dependents enrolled in the VHA, to obtain care from clinics and hospitals in their community (U.S. Government Accountability Office, 2025). Despite the success of this landmark reform, veterans continue to struggle to access quality care. The VHA’s system for connecting veterans to community providers is plagued by incomplete provider directories and bureaucratic mismanagement. Veterans in some regions often encounter longer wait times to obtain community care compared to care within the VHA (Feyman et al., 2022). In sum, the federal government is failing to fulfill its promise to the men and women who have worn the uniform.

The Veterans First Agenda Pillars

The pillars of AFPI’s Veterans First Health Agenda’s policy goals pare organized into four categories: Restoring the Promise of the MISSION Act, Expanding Patient Choice, Modernize Community Care, and Improving Care Quality Within the Traditional VHA System.

Restoring the Promise of the MISSION Act

The MISSION Act of 2018, signed into law by President Donald J. Trump, gave veterans the right to access medical care outside the VHA system when it cannot deliver care in a timely manner. But the law relies on VHA bureaucrats to determine whether a veteran is eligible for community care. Those bureaucrats often manipulate the eligibility status of veterans to keep them locked inside the VHA. Veterans should not have to navigate a bureaucratic maze to access the care they have earned. The following are specific actions policymakers could take to strengthen access to community care for veterans:

★ Codify in statute that veterans are eligible for community care if the VHA cannot provide care within a 30-minute drive for primary care or 60-minute drive for specialty care, or within 20 to 28 days.

★ Allow all veterans to choose community care, regardless of how far they live from a VHA facility or how long they must wait for care from their local VHA facility.

★ Amend the VHA’s Designated Access standards to reduce the number of days veterans must wait and the distance veterans must travel before they are eligible to access community care.

★ Designate veterans seeking mental health and substance abuse treatments as automatically eligible for community care, regardless of how far they must travel or how long they must wait to receive VHA care.

★ Direct the VHA to count wait times from the date a veteran first requests an appointment, not from the date the VHA schedules one.

★ Require the VHA to proactively inform veterans of their community care eligibility when they seek medical services, rather than assume veterans will know they are eligible.

★ Direct the VHA to provide veterans who are ineligible for community care with a complete explanation of the agency’s determination, along with clear instructions on how to appeal.

Expanding Patient Choice

Veterans have voted with their feet under the MISSION Act, increasingly seeking community providers for their medical needs. Federal and state policies that restrict high-quality clinicians and medical facilities from opening and caring for veterans stand between veterans and the care they have earned. Commercial hospitals and medical practices have proven they can deliver high-quality care to veterans—and veterans should be free to access these providers regardless of their local VHA facility’s wait times.

The following are specific actions policymakers could take to enhance access to community care:

★ Give veterans the option to receive VHA benefits as a defined contribution they can spend on commercial health insurance.

★ Empower veterans, particularly those with service-connected disabilities, to enroll in TRICARE, the health plan that already serves America’s active duty service members and their families.

★ Allow veterans to obtain care in MTFs that deliver care to active duty service members.

★ Loosen and repeal Certificate of Need laws that block the construction of new hospitals, clinics, and ambulatory surgical centers in communities where veterans live.

★ Urge states to expand the scope of practice of physician assistants and nurse practitioners, particularly in rural and underserved areas where veterans face the longest travel times for care.

★ Recommend that states recognize the licenses of out-of-state physicians, nurses, and other clinicians so they do not need to obtain a costly, duplicative license to deliver care to veterans.

Modernize Community Care

The VHA’s system for connecting veterans with community care providers is outdated, plagued by incomplete provider directories, and vulnerable to fraud, waste, and abuse. The following are specific actions policymakers could take to modernize community care:

★ Open the VHA community care program to a larger number of regional and national third-party administrators (TPAs) that compete on quality, cost, and network adequacy.

★ Deploy routine audits of provider directories so veterans know which providers are actually available and accepting new patients.

★ Leverage predictive analytics to identify and stop fraudulent billing by providers participating in the community care program.

★ Require participating TPAs to adhere to industry-standard quality measurements, so veterans, the VA, and the public can evaluate the care being delivered.

★ Issue a Performance Work Statement that holds participating TPAs accountable to these reforms and ensures the VHA’s community care program delivers high-quality, cost-effective care.

Improving Care Quality Within the Traditional VHA System

The traditional VHA system suffers from chronic shortages of essential clinicians, operates facilities far from where today’s veterans live, and often fails to deliver the specialty care veterans need. To serve the modern veteran population, the VHA must realign its workforce, infrastructure, and resources around high-quality, appropriate care. A strong community care program does not replace the traditional VHA. Both must work in tandem to deliver on the nation’s promise. The following are specific actions policymakers could take to expand health care delivery within the traditional VHA system:

★ Increase pay for high-demand medical professionals to attract talent to regions with veteran population growth and provider shortages, leveraging the Secretary’s authority under 38 U.S.C. § 7431(e)(5) to direct awards, advance payments, and recruitment, relocation, and retention bonuses.

★ Establish a national standard of practice for physician assistants and certified registered nurse anesthetists that frees these clinicians to practice to the full extent of their training without unnecessary physician supervision.

★ Add new clinics in areas with high veteran populations by leasing space in existing buildings or contracting with developers to build and lease back outpatient facilities.

★ Remove burdensome mandates on faith-based organizations to deliver mental health support to veterans.

★ Repurpose underutilized inpatient facilities toward outpatient care through the VA’s Strategic Capital Investment Planning process.

★ Deploy additional mobile medical units, procured through the General Services Administration, to reach veterans in counties without a brick-and-mortar VHA facility.

Way Forward

AFPI is dedicated to keeping America’s promise to the men and women who served in uniform. Our veterans embody our country’s founding values of liberty, sacrifice, and duty. It is our responsibility to defend those who have defended us through research, policy, and advocacy.

There is no silver bullet to strengthen America’s health care system for veterans. Some prefer to receive care primarily from the traditional VHA system and that system must be modernized to deliver high-quality, accessible services to those who depend on it. Others will increasingly turn to community providers, and the federal government must remove the bureaucratic barriers standing between them and timely care. AFPI will work across both fronts to reform the VHA from within while expanding veterans’ freedom to choose care outside the system.

Our policy recommendations will be guided by veterans, frontline clinicians, and policymakers on what works in delivering high-quality medical care. AFPI’s health policy experts will collaborate with the Institute’s other policy teams to advance an integrated America First agenda. Most importantly, our work will be measured by a single outcome: whether veterans receive the timely, world-class medical care this nation owes them.