Veteran caretaker perspectives of the need for childcare assistance during healthcare appointments

Abstract

Purpose:

In 2020, Congress passed legislation to establish the national Veteran’s Childcare Assistance Program (VCAP) targeting eligible veterans receiving care through the Veterans Health Administration (VA). This needs assessment describes the childcare needs of veteran caretakers of young children and explores the implications of inadequate childcare on health care engagement.

Methods:

Survey data were collected from 2,000 VA users with dependent children; data were analyzed using standard descriptive statistics. Qualitative data was collected from 19 veterans through focus groups and analyzed using rapid thematic analysis.

Findings:

Over 75% of veterans surveyed indicated that they required childcare assistance during health care appointments and 73% reported barriers to finding childcare. Prominent barriers included the high cost of childcare and not having a trusted source of childcare. Nearly 58% of survey respondents reported missed or cancelled VA health care appointments due to childcare challenges. Furthermore, 35% of surveyed veterans reported that their children had accompanied them to an appointment in the past year. Among these veterans, 59% brought their children into the exam room. Focus group participants discussed how having children present during their health care appointments hampered communication with health care providers.

Conclusions:

Veterans report that lack of childcare keeps them from attending and remining focused on the provider during their health care visits which could compromise quality of care. As one of the only health systems in the US that will offer childcare assistance, VCAP presents an opportunity to improve health care access and quality by reducing missed appointments and suboptimal care.

The limited supply of accessible and affordable childcare in the United States is a major public health problem. Lack of childcare requires some parents¹ to delay health care to prioritize childcare; this delay leads to significant deferral in diagnosis, appropriate treatment, and other poor health care outcomes (Chapman et al., 2022; Gaur et al., 2020; McQueenie et al., 2019; Parsons et al., 2021).

US veterans who are parents represent a uniquely challenged cohort for whom health care access and continuity of care are critical given the complex, chronic medical conditions resulting from military service (Hastings et al., 2011). Lack of childcare is a barrier to health care access for veterans (Tsai et al., 2013). Furthermore, findings from studies that employ the perspectives of VA providers to examine how to improve VA healthcare for women veterans suggest that lack of child care is an access barrier most acutely felt by women (Brunner et al., 2019; Marshall et al., 2021) and could be mitigated through drop-in childcare centers at VA sites (Brunner et al., 2019; Tsai et al., 2013).

The number of veterans enrolled in the Department of Veterans Affairs (VA) services who need childcare is likely high. First, VA is increasingly providing care for women veterans in the height of their reproductive years who are managing sensitive and complex health conditions. The proportion of women veterans using VA services is projected to reach 18% by 2040, up from 4% in 2000 (Frayne SN, 2020). In 2019, 41% of women veterans were younger than 40 (Frayne SN, 2020). Women veterans experience high rates of sensitive health conditions, including intimate partner violence (18%) (Kimerling et al., 2016), military sexual trauma (25%) (Gundlapalli et al., 2017), and posttraumatic stress disorder (41%) (Sheahan et al., 2022). Women also seek care at VA for these conditions. Between, 2000 and 2019, women veteran’s use of mental health/substance use specialty care increased five-fold (Frayne SN, 2018). However, these types of health care visits require private interactions between veterans and their providers. Second, while data is limited on parental status of US military veterans, Department of Defense (DoD) demographic reports show that over 35% of active duty service members have children under 23 years old. This figure amounts to 964,485 children of whom over 40% are less than five years old (Department of Defense, 2020). These numbers also suggest that while women veterans may be proportionally more impacted by lack of childcare, childcare is an issue for many veterans, not just women. Third, through the Sergeant First Class Health Robinson Honoring our Promise to Address Comprehensive Toxics (PACT) Act (House-Veterans’ Affairs; Armed Services, 2021–2022) eligibility for VA services will expand to veterans with substantial medical needs due to exposure to burn pits and other toxic substances. VA anticipates that many of these veterans will be in the height of their reproductive years. While projected health care visits resulting from this expansion have not yet been released, current VA users under 55 years have an average of 13 health care appointments per year (VA administrative data). These statistics suggest that a large proportion of veteran parents and caregivers are at risk of forgoing needed care due to childcare responsibilities; alternatively, veterans may attempt to engage in appointments (virtually or in-person) with children present leading to lesser quality engagement and receipt of care due to distractions or inability to discuss sensitive topics (e.g., substance use, sexual activity) or receive certain physical examinations (e.g., pelvic exams). To our knowledge, this study is the first to characterize veteran caretaker perspectives about need for childcare assistance during health care visits.

Study context

The VA is one of the first health systems in the US to tackle childcare needs for veterans to boost access to health care services. Congress established the Caregivers and Veterans Omnibus Health Services Act of 2010 that required a pilot program in at least three Veteran Integrated Service Networks (VISNs) to assess the feasibility of providing childcare assistance. Eligibility criteria for use of childcare at the time of a health care appointment were that the veteran received regular mental health care services or intensive health care services from the VA and was a primary caretaker for a child under the age of 13 or aged 13–18 with a disability. From 2011–2018, four VA sites offered on-site childcare through contracts with licensed childcare centers. Total outlays for the initial seven-year period were $7.9 million and over 30,000 children used the program. While a pilot evaluation was unable to quantify the effect of offering childcare assistance on missed appointments, the majority of veterans surveyed who used the program indicated high levels of satisfaction and reported that they would have cancelled their appointment without access to childcare (Department of Veterans Affairs Office of Women’s Health, 2019).

In 2020, Congress signed into law the Johnny Isakson and David P. Row Act of 2020. This law included a provision to establish a national program of childcare assistance to target qualified veterans receiving care through the VA (VA users) to enhance access to health care, including mental health care. The VA is required to implement this national program at all VA medical facilities, including community-based outpatient centers, by 2026. Eligible veterans will be the primary caretaker of a child and have an outpatient health care appointment scheduled at a VA facility. The purpose of this needs assessment is to describe the childcare needs of veteran caretakers of young children and explore the possible implications of inadequate childcare on health care access and engagement. The findings will provide insights for future rollout and implementation of childcare programming across the VA.

Materials and Methods

Design

This study followed a parallel convergent mixed methods design (Figure 1) (Fetters et al., 2013). Survey data were collected over a three-month period from veterans with dependent children who reported that they needed childcare to attend health care appointments. The survey portion of the study provided a population-level understanding of veteran needs and perspectives of childcare assistance. In parallel, we conducted three focus groups with veterans who met these same eligibility criteria. We mapped questions from the survey onto focus group scripts to collect information about similar constructs (Castro et al., 2010). We merged the qualitative and quantitative data using a narrative approach to weave together the quantitative and qualitative findings (Fetters et al., 2013) and through joint displays (Creswell & Plano Clark, 2018). The qualitative data expanded the quantitative findings by providing a nuanced understanding of veteran experiences around need for childcare when seeking health care (Figure 1). This non-research need assessment was conducted under the authority of the VA Office of Women’s Health and VA Quality Enhancement Research Initiative (QUERI) and was classified as quality improvement (VA Handbook 1058_05, Veterans Health Administration 2011).

Figure 1.

Overview of mixed methods study design

Quantitative methods

Participants

Using VA electronic health records pulled on December 20, 2021, we identified a national sample of veterans between the ages of 18 and 55 as of October 1, 2021. From this national sample, we randomly selected a cohort of 20,000 veterans comprised of 70% female (self-reported and identified in administrative data) and 30% male, 50% living in rural versus urban areas, and that equally represented four US geographic regions: Midwest, Northeast, South and West. Living in urban vs. rural areas was determined by the rural-urban commuting area (RUCA) code associated with a zip code of an address in administrative data. Screening eligibility criteria included that the veteran was: 1) a parent or guardian for a child 12 and under or ages 13–18 who had special needs, 2) the veteran required childcare at some point in order to attend a VA health care appointment, and 3) the veteran was able to complete a survey online or over the phone in English.

Data collection procedures

Survey instrument development and pilot testing. The survey was developed in close coordination with the VA Office of Women’s Health and included fewer than 20 questions to reduce burden on the veterans. Survey topics included the number and ages of children in their care and other demographic information, sources of childcare, barriers to finding childcare, and if childcare interfered with health care utilization and engagement. The online survey was designed to take fewer than 10 minutes to complete and the telephone survey to take 15 minutes.

Next, the survey content was piloted with veterans and clinicians who care for women veterans. The clinicians who reviewed the survey had either participated in a women veterans’ health research engagement group or were VA Women Veteran Program Managers. Feedback from clinicians was used to develop narrative scripts to introduce the survey. We then programmed the survey into the online software and piloted the survey tool to improve flow and usability. A professional survey research company was contracted to collect the survey data. The team administering the survey was trained in the survey protocol and coached on ways to address questions from veteran participants, including handling situations in which veterans became distressed during data collection.

Recruitment and data collection. Survey data collection occurred either online or via telephone between March and May, 2022. We identified a cohort of 28,000 veterans from VA electronic records who met our initial eligibility criteria; all veterans received at least one contact from the study team via a letter sent by mail or an email or text that introduced the project and included a link to the online survey. We provided a number they could call to opt-out of the survey. If they did not opt-out, the data collection team (“interviewers”) followed up via with several phone calls to encourage the veteran to complete the survey online or to administer the survey to the veteran via telephone. The study team reached 6,718 veterans; of these 652 refused to participate and 4,066 were not eligible. We completed 2,000 surveys; of those 1,165 were completed by interviewers over the phone and 835 were completed using an online survey link (Figure 2). Veterans received a $15 gift card for participating.

Figure 2.

Study Flow Diagram

Data analysis

For each survey variable study statisticians (MB, SW) calculated sample means, standard deviations, and proportions of responses to each question.

Qualitative methods

Participants

Veterans were recruited through flyers and email announcements disseminated by WVPMs and coordinators at health care centers across the VA, prior to implementation of the national childcare program. Eligible focus group participants were veterans or the spouse of a veteran, who: 1) received health care at VA, 2) had at least one child in their care for whom they arrange childcare, and 3) consented to audio recording of the focus group interview.

Data collection procedures

Three virtual focus groups were held over two months during Spring 2022 consisting of approximately six participants each. Study team members in attendance included a qualitative researcher who conducted the interview, a research assistant who took notes, and additional team members who joined as listeners. Each focus group lasted approximately one hour and was audio recorded and transcribed, with participant consent. Interview questions related to findings presented here centered on experiences with missing VA health care appointments due to lack of childcare. Each veteran received $50 to participate in the focus groups.

Data analysis

Rapid qualitative analysis methods guided our analysis of the data (Gale et al., 2013; Taylor et al., 2018). The lead qualitative researcher created a structured summary template that mirrored interview guide domains, which a note taker used to summarize focus group data for each interview. After the lead qualitative researcher validated notes for each interview, the lead and another qualitative researcher created “summary of summaries” matrices by dividing domains and summarizing findings across focus groups, which included deductive themes as well as other themes that emerged inductively from the data (and not represented by focus group questions/domains). Resulting themes were then reviewed and validated by two qualitative researchers, and a third team member identified illustrative quotes in the transcripts for key themes. Analysis template is included in a supplementary file.

Results

Demographic statistics

Survey participant descriptive statistics

The survey sample comprised 2,000 veterans from across the US. Mean age was 38.5 years and almost 75% of veterans identified as female (via self-report in administrative records). In our sample, 67% of participants self-reported as White, 17% as Black or African American, and 8% as Hispanic/Latino. Veterans had on average 2.1 children, though the number of children ranged from 1 to 8. Thirty percent of children were of preschool age or younger, 50% were of grade school age (5–12 years), and 20% were adolescent aged (13–18 years). Seventeen percent (n=342) of veterans reported that they had a child with special needs and, of those, nearly 30% (n=98) reported that their children were unable to be cared for in a typical childcare setting (Table 1).

Table 1 –

Demographics of survey participants

	Total (N=2000)
Age
Mean (SD)	38.5 (7.21)
Min, Max	20.0, 64.0
Missing	58 (2.9%)
Gender (self-reported)
Female	1489 (74.5%)
Male	490 (24.5%)
Other	9 (0.5%)
Prefer not to respond	12 (0.6%)
Race 1
American Indian or Alaska Native	33 (1.7%)
Asian	35 (1.8%)
Black or African American	331 (16.6%)
Native Hawaiian or other Pacific Islander	24 (1.2%)
White	1341 (67.1%)
Unknown by Patient	27 (1.4%)
Missing	209 (10.5%)
Ethnicity 1
Hispanic or Latino	156 (7.8%)
Not Hispanic or Latino	1532 (76.6%)
Unknown by Patient	57 (2.9%)
Missing	255 (12.8%)
Region
Midwest	509 (25.5%)
Northeast	473 (23.7%)
South	505 (25.3%)
West	513 (25.7%)
How many children 18 and under are in your care?
Mean (SD)	2.10 (1.05)
Min, Max	1.00, 8.00
Age of Child(ren)
Infant (Birth – 24 months)	380 (9.0%)
Toddler (24 – 48 months)	447(10.6%)
Preschooler (4 – 5 years)	456(10.9%)
Grade schooler (5 – 12 years)	2085 (49.6%)
Older child who needs care (13–18 years)	833 (19.8%)
Do you have a child or children in your care with special needs?
No	1621 (81.1%)
Yes	342 (17.1%)
Prefer not to respond	37 (1.9%)
Can that child be cared for in a typical childcare setting, such as a drop off childcare center or childcare program?
No	98 (28.7%)
Yes	229 (66.9%)
Prefer not to respond	15 (4.4%)

¹The race and ethnicity variables were pulled from VA electronic health records. The labels available for the race of the patient used standardized versions implemented by the Office of Management and Budget (OMB) in 2003. For both race and ethnicity, ‘Unknown by Patient’ is a validated pre-existing response option in VA electronic health records.

Focus group participant descriptive statistics

Focus group participants included 19 veterans from several US geographic regions, including the Northeast, Southeast, Southwest, and West. Eighteen of the participants were parents and one was a grandparent. The mean age was 36 years with a range of 24 to 48 years and 84% identified as female. Approximately 31% identified as Black/African American, 31% as non-Hispanic White, and 38% reported other racial/ethnic identities or declined to answer (Table 2).

Table 2 –

Focus Group Demographics

	Total (N=19)
Age
Mean (SD)	36.3 (6.08)
Median [Min, Max]	36.0 [24.0, 48.0]
Gender (self-reported)
Female	16 (84.2%)
Male	3 (15.8%)
Race/Ethnicity
Asian American	1 (5.3%)
Black/African American	6 (31.6%)
Hispanic/Latinx	3 (15.8%)
Non-Hispanic White	6 (31.6%)
Prefer Not to Answer	3 (15.8%)
US Geographic Region
Northeast	2 (10.5%)
Southeast	10 (52.6%)
Southwest	5 (26.3%)
West	2 (10.5%)
Branch of Service
Air Force	2 (10.5%)
Army	7 (36.8%)
Marine Corps	4 (21.0%)
Multiple Branches	1 (5.3%)
Navy	5 (26.3%)

Sources of childcare

The most common sources of childcare reported by veterans when scheduling clinic-based and telehealth appointments were a family member or friend, or scheduling the appointment during school hours (Figure 3). Fewer than 6% of respondents paid for a babysitter and 6% reportedly took their child to a licensed childcare center. Ten percent reported taking their children with them to their health care appointment. For the 1,249 veterans who cited using telehealth, nearly 37% reported that they did not secure childcare, but 28% reported that they scheduled appointments during school hours, and 16% reported that a family member watched the child during the appointment (Figure 3).

Figure 3.

Sources of childcare for clinic and telehealth-based visits

Scope of the problem and barriers to childcare

Over 75% of veterans surveyed indicated they required childcare assistance during health care appointments. While veterans might have available sources of childcare, accessing childcare when they have health care appointments or scheduling health care appointments to align with when they have childcare was a challenge. For example, nearly 56% (n=1,115) of veteran respondents reported frequently being unable to schedule a health care appointment during times when they had childcare available.

Furthermore, 73.6% of survey respondents reported barriers to finding childcare when they had a health care appointment. The two most common barriers were high cost of childcare and not having a trusted childcare source available (Table 3). Over 45% of veterans in the sample reported that they had at some point paid for childcare so they could attend a health care appointment (n = 916). Among these veterans, the average cost reported for the most recent time that the veteran had paid for childcare to attend a health care appointment was $60.40 (SD=47.9) although average costs varied by geographic region (range of mean cost: $50-$68).

Table 3.

Barriers to finding childcare for health care appointments: Comparing findings across data from survey and focus groups

Barriers identified in survey	Barriers identified in focus groups1
Childcare too expensive (22%)	“Thank God [my mother] has the flexibility to do that [help with childcare], but I have to pay her. She is expensive.”
Childcare source not available (21%)	“My wife is at work, and I don’t have anyone to watch my son, so he’s with me.”
Can’t schedule VA appointment when have childcare (18%)	“My mother usually watches my daughter and there are occasions when our medical appointments intersect, and she is not able to watch her”
No trusted person to watch children (11%)	“I’m over-protective of my son so I do extensive research. I don’t trust him with anyone.”
No available spots in childcare (6%)	Not addressed
Child-related concerns (6%)	“…my son is high functioning autistic, so I can’t just leave him with anybody.”
Transportation challenges (<1%)	“Well, where I work at in [city] I’ve experienced traffic as bad here, so to get my son and then come back for an appointment it’s been crazy.”
Other (1%) Examples included: transportation, child-related concerns	Not applicable

¹Veterans could choose multiple barriers and therefore the denominator is all responses and not the 2,000 survey respondents.

Findings about lack of childcare support and the high cost of childcare were echoed in the focus group interviews. For example, one participant explained:

“I tried to get my family to help me out, because I have three kids so it’s expensive to try to pay somebody for the day because VA appointments take so long. Also, your family and friends have jobs, too, so they get kind of frustrated...”

Not being able to get an appointment that fit their childcare schedule was another major barrier that emerged in both the survey (18%) and focus groups. For example, one focus group participant described the important role that schools play in the care of children and the challenge of making appointments that coincide with school calendars:

“[We] try to look at the school calendar, and we try to schedule them [health care appointments] when they’re not going to be home, but during the wintertime, like January, it was impossible.”

Implications of inadequate childcare on health care

Implications on health of not having childcare included impacts on health care access and quality. For each implication we present survey findings and then use quotes to demonstrate lived experiences.

Health care access

For veterans in our sample, lack of childcare impeded their access to health care services. Nearly 58% of survey respondents and 16 out of 19 focus group participants reported that they missed or cancelled a scheduled VA-paid health care appointment in the past 12 months due to challenges with childcare.

“I had a physical therapy appointment that I [recently] had to reschedule because I couldn’t find childcare. I’ve had to reschedule a couple of appointments because of not being able to find somebody.”

Focus group participants discussed the negative consequences of missing health care appointments due to lack of childcare. For example, several participants noted that missing appointments resulted in delayed care because appointments were limited when participants tried to reschedule.

“I want to say it was more than 60 days just to reschedule an appointment because she [the provider] was already booked all the way to February of this year. So, I had to basically just wait.”

Health care engagement

Participants described experiencing limited ability to be fully present and interact with a health care provider during a visit in health care due to lack of childcare, and they felt that such difficulties may have resulted in sub-optimal care, 10% of survey respondents reported that bringing their children to their own health care appointment was a usual source of childcare. Furthermore, 35% (n = 696) of surveyed veterans reported that their children had accompanied them to a health care appointment in the past 12 months. Among these 696 veterans, 59% brought their children into the exam room (Figure 4).

Figure 4.

Locations that children wait when they accompany a caretaker to the VA (n=696)

According to focus group participants, taking children into the exam room in the absence of childcare hampered communication with providers and the ability to supervise children. A father of a young child without childcare explained:

“I was trying to talk to my physical therapist, but he [my son] was already agitated because we were there for 45 minutes already, he was getting up, messing with me, and the physical therapist was trying to talk to me. So, it’s kind of hard trying to do things when a child is getting up and moving around.”

Similarly, a mother described the challenge of taking her child with autism to appointments that involve procedures:

“I have a son who has autism, except he is low functioning…I have been able to take him to a couple of therapy appointments, and it’s been fine, because he is sitting there and he has his headphones on and he does well with those situations, but when I’m out on my belly [getting injections in my back] I can’t watch him. I can’t do that.”

In addition, one participant stated that canceling appointments resulted in being marked as a “no show” which she feared compromised her quality of care.

“[If] I miss appointments because of childcare, or I show up to an appointment and they say, ‘No, you actually can’t bring them in,’ they mark you down as a “no show”, and they put [it] in your chart. You’re [an] uncompliant patient. You’re not following what they’re telling you to, and you can tell they sort of treat you different after a few years of that, because they’re saying you’re not doing what you’re supposed to do. You’re not responsible.”

Telehealth

In the absence of childcare and due to limited in-person appointments during the COVID-19 pandemic, focus group participants turned to telehealth. Approximately half of participants stated that telehealth helped alleviate childcare issues because they could stay at home with their children during appointments, but several found virtual care limiting. For example, one participant felt that telehealth compromised care quality due to poorer communication and interactions with providers, as compared to in-person visits. In addition, a few remarked that having children at home during a telehealth appointment could be distracting:

“So I do like the virtual, but…if my kids are home, they’re just at an age where they will always distract me. I still have to help them with their pants with the bathroom [and] if you’re trying to focus on your health and having to care for toddlers, it’s hard.”

Discussion

Many veterans in our sample reported misalignment between their need for childcare and the availability of their usual childcare at the time of their scheduled VA health care appointments. Veterans cited numerous barriers to accessing childcare in the community, including cost and lack of trusted care providers, which they reported led to missed and cancelled appointments and impacted the veteran’s ability to fully engage in their health care. Veterans also reported bringing children to in-person medical appointments or scheduling telehealth appointments in lieu of arranging childcare. Our findings about the impacts that lack of childcare might have on health care engagement align with results from a paper that documents providers’ concerns about delivering a virtual domestic violence intervention and discussing sensitive topics when there may be children nearby (Montesanti et al., 2022). However, these findings may illustrate one potential underrecognized challenge of telehealth as having children present during a telehealth visit may detract from the quality of patient-provider interaction. Future research on this topic is needed.

Our findings support existing non-VA studies which finds high rates of missed and delayed health care appointments due to lack of childcare and other family responsibilities (Chapman et al., 2022; Gaur et al., 2020). For example, one study of 300 female patients from a hospital system in Texas found that women delayed an average of 3.7 appointments per year due to lack of childcare (Gaur et al., 2020). Missed appointments have profound implications for health care quality leading to delays in diagnosis, appropriate treatment, and poor health outcomes. Another population-based study found that people who missed two or more appointments over a 16 month-period had a 3-fold increase of premature all-cause mortality. This risk went up with more missed appointments (McQueenie et al., 2019). This study also found that individuals with chronic mental health conditions who missed two or more appointments were at an 8-fold greater risk of all-cause mortality compared with those who missed no appointments (McQueenie et al., 2019).

Studies from civilian populations show that patients who miss appointments tend to be younger, female, have mental health comorbidities, and come from low socio-economic and historically marginalized groups (Elkhider et al., 2022; McQueenie et al., 2019; Parsons et al., 2018; Tempier et al., 2021). Therefore, it is possible that lack of childcare could be compounded for women veterans, a population that is using an increasing share of VA services (Frayne SN, 2020). Among women veterans under 45 years who use VA care, mental health conditions comprised three of the top 5 most common health problems (Frayne SN, 2020). Furthermore, in a recent survey among women veterans using VA health care, 41% screened positive for PTSD, 32% for anxiety, and 27% for depression (Sheahan et al., 2022). Our data about the negative impact of children attending health care visits also suggests that veterans may be at-risk for low quality provider-patient communication due high rates of sensitive health conditions, if children are present. Therefore, lack of childcare could fuel missed appointments and deepen inequities in health care for women veterans and veterans with fewer resources.

This needs assessment study has limitations. First, the study is a cross-sectional, single time-point description of childcare barriers and perceived consequences. We did not design this study to evaluate the impact of not having childcare on health care access and engagement nor did we directly assess health care quality. Instead, our intention was to collect a rich set of data to inform the initial design stage and roll-out of the VA’s Childcare Assistance Program (VCAP). Despite the potential implications for equity, we are also not able to evaluate the direct impact of not having childcare for specific subgroups. A limitation of the focus group data is that the views represented may not capture the breadth of perspectives of veteran caregivers who may use VA childcare. Future work should further examine the perspectives non-parent caregivers (e.g., grandparents) as well as veterans spanning a range of socio-economic statuses. Strengths of our study include a large, national survey of men and women veteran caretakers who use VA services and complementary qualitative and quantitative data to enrich our understanding of the problem studied.

Implications for Policy/Practice

The Veteran Child Care Assistance Program (VCAP) will have important implications for the VA system. Currently, the proportion of missed appointments in the VA is high. While we were unable to find newer statistics, a 2008 audit by the Office of Inspector General of the Veterans Health Administration (VA) estimated that in Fiscal Year 2008, 18% of all scheduled outpatient appointments—or 4.9 million—went unused. These visits were valued at $76 million (Department of Veteran Affairs Office of Inspector General, 2008). The VCAP has an opportunity to reduce resource loss by minimizing missed and cancelled appointments. As one of the only health systems in the US to offer childcare assistance, VCAP also presents an opportunity to increase veteran enrollment in VA to improve care coordination, communication, and satisfaction (Schlosser et al., 2020; Vanneman et al., 2020). The VA Office of Women’s Health is using the information from this needs assessment to inform the design of the VCAP and project the need for childcare services across VA catchment areas. Our findings confirm the need to address childcare availability.

Conclusions

Lack of high-quality childcare is a major public health problem and may exacerbate disparities in health care access. Efforts on behalf of the VA to provide resources for childcare during scheduled health care appointments could mitigate missed care among veterans. However, given that this program will be the first childcare assistance program embedded within a national US health care system, rigorously designed longitudinal evaluation studies will be needed to promote desired outcomes and equity in program design and implementation. Furthermore, our results are relevant beyond VA and can serve as a guide for non-federal health care systems to address an important determinant of missed and sub-optional care—lack of childcare.