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2011 HSR&D National Meeting Abstract

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2011 National Meeting

1082 — VHA Enrollment Rates across the Rural-Urban Continuum

Vogel B (REAP-Gainesville), Kairalla J (REAP-Gainesville), Cowper-Ripley D (REAP-Gainesville), Litt E (REAP-Gainesville)

To measure the impact of rural-urban status on county-level VHA enrollment rates both before and after controlling for travel times to VHA and community hospitals, per capita income/poverty, health insurance status, and veteran population.

We merged county-level data on VHA enrollment with county-level estimated veteran population. These data were then merged with county-level data on (a) per capita income, (b) percent of population below the federal poverty level, (c) the percentage of the population without health insurance, and (d) Rural Urban Commuting Area (RUCA) codes from the Area Resource File (ARF). GIS tools were used to estimate travel times from county population centroids to the nearest VA Medical Center and nearest community hospital as reported in the American Hospital Association Annual Survey. We then estimated regression models using VHA enrollment rates, VHA enrollment, and their natural logarithms as dependent variables and the independent variables listed above.

Rural-urban status has a substantial impact on VHA enrollment rates. More urbanized counties have lower VHA enrollment rates (averaging approximately 30%) while more rural counties have higher VHA enrollment rates (averaging 45%-48%). As would be expected, greater travel time to the nearest VAMC reduces VHA enrollment rates. Surprisingly, however, the observed high rural-urban variation in VHA enrollment rates remains virtually unchanged even after accounting for VHA and community travel times, per capita income/poverty, health insurance status, and veteran population.

The impact of rurality on VHA enrollment rates is more than the sum of the effects of rural-urban differences in population, travel times, income/poverty, and health insurance coverage. While increasing access to VHA services for rural veterans is a policy priority in VHA, cross-sectional rural-urban variation in VHA enrollment rates may not be a reliable indicator of the success or failure of such policies.

These results have major implications for attempts to expand access to veterans living in rural areas. While increasing the number VA facilities and services in rural areas may reduce travel times for veterans who live in these areas, our results suggest that this alone may not be sufficient to change observed rural-urban differences in VHA enrollment rates.

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