Residential addiction care was 4 percent of veterans’ community behavioral health referrals and 43 percent of VA’s spending on them, GAO found.
Key Takeaways
- The concentration: Residential substance use treatment made up about 4 percent of veterans’ community behavioral health referrals in fiscal 2021 through 2024 and 43 percent of the spending, roughly $1.9 billion.
- The coordination gap: GAO found a third of behavioral health referrals missing initial medical records, and about 2 percent of community providers completing VA’s core trainings.
- The contract reset: VA is replacing its regional Community Care Network contracts with a next-generation structure it says will give it real-time oversight of care.
- The open legislation: A House package that would set screening and admission timelines for residential treatment stalled in July, and its Senate companion remains pending.
Most of the behavioral health care the Department of Veterans Affairs buys from private providers happens in an outpatient office, an hour at a time. Most of the money goes somewhere else.
From fiscal 2021 through 2024, veterans received more than 600,000 referrals for behavioral health care from community providers, and VA spent $4.29 billion on the care those referrals produced, according to an April 14, 2026, Government Accountability Office report (full PDF). More than half of the referrals were for outpatient psychotherapy. More than two-thirds of the spending went to inpatient care, including residential treatment. Residential substance use treatment alone accounted for over 25,000 referrals, about 4 percent of the total, and about $1.9 billion, or 43 percent of the dollars.
GAO did not report a per-referral cost, and stays vary widely in length. Divided out, the totals come to roughly $75,000 per residential referral. For the private residential programs that take veterans through VA’s networks, that arithmetic makes the department one of the more consequential payers in addiction treatment, and one whose rules, records demands, and contracting structure are all in motion.
How VA Community Care Purchases Residential Substance Use Treatment
Veterans have received care from private providers through various VA programs since 1945. The current one, the Veterans Community Care Program created by the 2018 MISSION Act, began in June 2019 and expanded eligibility. The number of veterans receiving care under VA’s community programs rose from about 1.1 million in 2014 to about 2.8 million in 2023, GAO reported in a May 2025 review of behavioral health referrals. Veterans generally qualify when VA cannot furnish care within its access standards, when a service is not available at a VA medical center, or when a VA provider judges community care to be in the veteran’s best medical interest.
The behavioral health slice of that program looks different from the medical side. In GAO’s 2025 analysis, about 55 percent of behavioral health referrals were for outpatient psychotherapy, and about 44 percent were for anxiety and stress-related disorders such as post-traumatic stress disorder, with the remainder split among depression and mood disorders, other mental health conditions, and substance use disorders. The veterans using those referrals were mostly urban (about 72 percent), mostly male (about 77 percent), and 50 years old on average. Behavioral health referrals were about 2 percent of the roughly 20.6 million community care referrals VA issued over those three years. The 28 percent of referral users outside urban areas live in places where 38 states have written behavioral health into their federal rural transformation plans. Some states also run their own programs for veterans outside VA’s system, such as state-funded TMS initiatives for veterans and first responders.
Networks are built and managed by contractors. Under the current Community Care Network, Optum administers three regions and TriWest two, and community providers must enroll with the administrator for their region. VA can also contract directly with providers through Veterans Care Agreements, which are intended for situations the regional networks do not cover.
For a residential operator, joining means credentialing through the administrator, accepting VA’s payment terms, and meeting its documentation rules. Inpatient and residential referrals require the community provider to return medical documentation within 30 days, at minimum a discharge summary, according to GAO’s description of VA’s contracts.
GAO Findings on Records and Training in Community Behavioral Health Care
That documentation requirement is where GAO’s earlier review found the most slippage. From fiscal 2021 through 2023, 224,741 veterans used 357,299 behavioral health referrals, generating about 4 million visits to community providers. About 33 percent of those referrals were missing initial medical documentation in VA’s data. Final documentation, which should cover everything after the first visit, could not be measured at all, because VA had not issued guidance for obtaining it or collected data on it.
The gap matters because most veterans come back. About 71 percent of the veterans in GAO’s review later returned to a VA medical center for behavioral health services, and about 43 percent of those returning veterans were missing initial documentation from at least one community referral. VA staff told GAO that chasing records was labor intensive, especially at understaffed community care offices and small practices without administrative support, a strain that mirrors the wider behavioral health workforce shortage. VA prefers that providers exchange records through its HealthShare Referral Manager platform, but only about 10 percent of community behavioral health providers used it to send initial documentation, and VA decided not to require it for fear of shrinking participation in its networks.
Training showed a similar pattern. VA identified eight core trainings for community providers in September 2021, one required (opioid safety) and seven recommended, including military cultural competency and post-traumatic stress disorder. Of 22,725 community providers with at least one behavioral health referral in the review period, about 2 percent had completed at least one of them. VA officials told GAO that enforcing the required training by halting referrals could threaten network adequacy. VA concurred or concurred in principle with GAO’s five recommendations and estimated completion dates between September 2025 and March 2026.
VA Residential Treatment Access Standards and the Stalled Veterans Legislation
Residential care sits awkwardly within VA’s access rules, which are written around appointments. The Veterans’ ACCESS Act, H.R. 740, introduced in January 2025 by House Veterans’ Affairs Committee Chairman Mike Bost, with a Senate companion, S. 275, from Senate Veterans’ Affairs Committee Chairman Jerry Moran, would codify the drive-time and wait-time standards that trigger community care eligibility. It would also create a standardized screening process for VA’s residential mental health and substance use programs and allow placement in accredited non-VA facilities when VA cannot meet admission timelines. The bill text also proposes a three-year pilot, at a minimum of five sites, under which enrolled veterans could get outpatient mental health and substance use care from specified community providers without a referral or prior authorization. For residential operators, the screening and placement provisions are the ones that would change referral volume most directly, since they would set a clock on VA’s own admission decisions.
VA’s own residential capacity frames the stakes. As of March 2025, the department operated about 260 Residential Rehabilitation Treatment Programs at 125 locations with about 6,600 beds, and more than 97 percent of their patients had a substance use disorder diagnosis, according to a Wounded Warrior Project fact sheet citing VA figures. The same document reports that 70 percent of veterans were admitted within 20 days in the first quarter of fiscal 2025.
The ACCESS Act’s provisions were later folded into the Take Care of America’s Veterans Act (H.R. 9237 and S. 4744), a package of more than 60 bills introduced on June 10, 2026. House floor action on the package was postponed on July 16. On July 29, Chairman Moran asked for unanimous consent to pass it in the Senate, and Democrats objected. As of early November, the Senate bill’s latest recorded action remained its June 11 placement on the legislative calendar. The package’s financing has drawn the sharpest debate. The American Legion has urged passage, citing long-stalled benefits the package would fund, while Senate Veterans’ Affairs Committee Ranking Member Richard Blumenthal has objected to offsets that would reduce disability benefits for some veterans.
Community Care Network Contracts and What Residential Operators Should Watch
The contracts that govern network participation are also changing. In a January 2026 industry presentation, VA contracting officials listed the final option periods for the current regional contracts, running through September 30, 2026, for Optum’s three regions and through March 31, 2027, for TriWest’s Region 4, and described next-generation contracts intended to give VA the data and systems to manage veterans’ care in real time. VA awarded the first piece of that structure, a 10-year national dental network contract to Optum Serve, on September 30, 2026.
For residential programs, the operational questions are familiar ones in a new wrapper: which administrator holds a given region, how credentialing transfers, and whether documentation requirements tighten. VA officials told GAO in 2025 that medical documentation return had been at the forefront of planning for the upcoming contracts. Operators already juggling network adequacy scrutiny from commercial payers and billing rules that split co-occurring care will be reading the same fine print. Clinical scope is the other variable. More than 97 percent of patients in VA’s own residential programs had a substance use disorder diagnosis and 92 percent also had a co-occurring mental health condition, according to the same Wounded Warrior Project fact sheet, which suggests the veterans VA sends to community residential programs will often need trauma and psychiatric care alongside addiction treatment. VA researchers are testing new approaches on that front, including an MDMA-assisted couples therapy pilot for PTSD run out of its San Diego health system.
In GAO’s 2026 figures, a small share of referrals carries most of the dollars. Whether that ratio holds will depend on decisions still pending in two places: the Senate calendar, where the residential access provisions wait, and VA’s procurement office, where the next generation of network contracts is taking shape.
