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Health Care Access and Quality for Rural Veterans

About two in five VA health care enrollees are rural residents (including the 1.5 percent that VA defines as "highly rural"). Rural enrollees are slightly more likely than urban ones to use VA care (68 percent vs. 65 percent), and from 2006 through 2009 the number of rural enrollees grew faster (by 11 percent) than the number of urban enrollees (2 percent). Overrepresentation of rural residents among OEF/ OIF troops, and casualties, will likely increase rural Veterans' health care needs further.

Fully understanding Veterans' access to health care requires much more nuance than utilization alone can reveal. Nevertheless, utilization sheds light on major aspects, such as the availability of financial resources to pay for services and the burden of traveling to reach them. VA provides a "safety net" of health care that many Veterans might not otherwise obtain for financial reasons. But because VA's specialized and high-technology treatment is centralized, many rural Veterans must travel far to reach it. Many current VA patients obtain much of their health care from non-VA providers. Comparing rural and urban enrollees on their use of VA services, and to other Veterans and non-Veterans on the use of non-VA health care, provides contextual information on rural Veterans' medical needs as well as their provider options, travel demands, insurance coverage, out-of-pocket medical expenses, and reliance on VA and other government support such as Medicare/Medicaid.

Total medical expenditures incurred by male Veterans, rural or urban, who use VA for any of their health care, are much higher, on average, than for other health care using men. Most of the treatment received by these VA users, however, is non-VA care: for those 65 or older, the largest payer is Medicare, and for those younger, it is commercial insurance; in either age group, average out-of-pocket payments for services also are substantial. Despite similar co-morbidities and worse health self-ratings, adjusted medical expenditures for working-age rural VA users average 20 percent lower than for urban users; the difference is largely due to rural users receiving less inpatient care and having less private insurance coverage and lower incomes.1

For a current HSR&D-funded project, we have acquired administrative data for all VA and non-VA hospitalizations obtained in recent years by any VA enrollees living in eight states (Arizona, Iowa, Louisiana, Florida, Tennessee, South Carolina, Pennsylvania, and New York). These data permit analyses of regional variations in urban-rural VA/non-VA utilization for common medical conditions and procedures. The eight states vary greatly in "ruralness," from Florida, where one in five enrollees is rural, to Iowa, where two in three are rural. The states also vary in how much rural enrollees relied on non-VA care: non-VA hospitalizations outnumbered VA Medical Center (VAMC) admissions by 2 to 12 times for those 65 or older (mostly paid by Medicare), and by 1 to 3 times for younger enrollees. In either agegroup, reliance on the VA was less for rural than urban enrollees in six states, but greater in Florida and Louisiana. In the more rural states (Iowa, Louisiana, Tennessee, South Carolina), rural and urban enrollees were hospitalized at similar rates; for elderly rural enrollees in Florida there was a trade-off — these enrollees use non-VA care less and VAMCs more than expected. In Arizona, Pennsylvania, and New York, however, rural enrollees had fewer admissions, either VA or non-VA, than might be expected from their numbers alone. This finding suggests that rural residents in states with concentrated population centers might have less referral access to urban hospitals in addition to greater travel burden.

Across the eight states, most urban patients lived within a half hour and most rural patients lived within an hour of the nearest non-VA hospital. For VAMC inpatients the nearest VAMC averaged more than a half hour away if they were urban residents, and one to one and a half hours if rural. For enrollees who used non-VA hospitals instead, driving to the VAMC would have averaged at least one half to one and a quarter hours for urban residents and one and a quarter to two hours for rural. Patients with multiple admissions over time who used VAMCs exclusively lived about a half hour closer to those hospitals than those who used non-VA hospitals only. Such findings suggest that greater distance to VA inpatient care has some dampening effect on its use by both urban and rural enrollees; average travel time, however, is considerably higher for rural than urban residents, in effect establishing a different threshold for normative, perhaps acceptable, distances. Rural Veterans must travel a long way to hospitals anyway, so quality considerations should outweigh relative convenience in their treatment choices; we have shown elsewhere,2 for example, that those who need high-risk surgeries could be redirected from lower to higher performance non-VA hospitals with minimal impact on their travel burden.

  1. West AN, Weeks WB. Health Care Expenditures for Urban and Rural Veterans in Veterans Health Administration Care. Health Services Research 2009; 44, 1718-34.
  2. West AN, Weeks WB, Wallace AE. Rural Veterans and Access to High-Quality Care for High-Risk Surgeries. Health Services Research 2008; 43, 1737-51.

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