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with a growth in same-day surgical procedures and outpatient care, so has the VA, and in 2018 Congress added access to private-sector urgent care outlets as one of the VA’s health care benefits.

Today, the VA operates 172 inpatient VA Medical Centers (VAMCs), which are an average of 60 years old, and 1,113 Community Based Outpatient Clinics (CBOCs), which are newer facilities designed to meet the needs of veterans closer to home. The VA also manages a Community Care Network (CCN) through contracts with Optum and TriWest, third-party health care administrators responsible for building and maintaining a robust population of community providers to meet the needs of veterans referred for care outside of the VA system. Currently, approximately 6.4 million veterans out of 18 million nationally (and out of the 9.1 million who are enrolled) use the VA for health care; the remainder use employer-sponsored plans, Tricare, Medicare, and Medicaid.

The disability benefits system evolved significantly in the years between the Cold War era and the global war on terrorism, a period when the VA enrolled large numbers of veterans from World War II, Korea, and Vietnam who were seeking disability benefits and health care. Disability compensation is the largest VA benefit, but there also are dozens of others, the next largest of which are the GI Bill and the Home Loan Guaranty. These benefits are administered through 56 Regional Benefits Offices (RBOs) and hundreds of satellite sites around the country.

The Agent Orange Act of 1991‘ significantly expanded the scope of disability benefits for those who had deployed to Vietnam, and the cost of those benefits began to increase dramatically as the Vietnam generation of veterans aged and began to experience adverse health conditions, some of which were presumed to have been caused by defoliant chemicals used in Southeast Asia. In 2016 and 2017, a burdensome backlog of appeals of denied disability claims from multiple wartime generations—a backlog numbering in the hundreds of thousands—led to a joint effort by the VA, Veteran Service Organizations (VSOs), and Congress to pass legislation that streamlined appeal processes. Implemented in 2017, this historic “good governance” success has helped the VA to reduce the number of these appeals dramatically.

The Sergeant First Class Heath Robinson Honoring Our Promise to Address Comprehensive Toxics (PACT) Act of 2022° addressed adverse health outcomes presumed to be the result of veterans’ exposure to airborne toxins during the global war on terrorism and further expanded disability benefits to the most recent generation of veterans. These ambitious authorities, like the 1991 authorities, have the potential to overwhelm the VA’s ability to process new disability claims and adjudicate appeals. Currently, the VA is seeking to hire large numbers of personnel to process these claims while exploring the use of an automated process to accelerate claims reviews and decisions. The ever-present lag in the hiring and training of new employees could result in major problems with the timely adjudication of benefits well into the next Administration in 2025.