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VHA Enrollment Rates across the Rural-Urban Continuum

Vogel WB, Kairalla J, Cowper Ripley DC, Litt ER. VHA Enrollment Rates across the Rural-Urban Continuum. Paper presented at: VA HSR&D National Meeting; 2011 Feb 17; National Harbor, MD.


Ultimate goal is the prediction of the demand for VHA rehabilitation care among returning OEF/OIF veterans to aid in locating new rehabilitation facilities. This work involves looking at variations in overall VHA enrollment rates. 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. Geographic Information System used for measuring travel distances and times to nearest VAMC and community hospital. OLS regression models of VHA enrollment rates (VHA market share) with natural log transformations to adjust for skewness. Duan's smearing factor applied to remove retransformation bias. All results are significant at .05 level. 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. 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. These results have major implications for attempts to expand access to veterans living in rural areas. While increasing the number of 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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