Rural Veterans: What Rural Nurses Need To Know
Author: Angeline Bushy, PhD, RN, FAAN, U.S. Army, Col. (Retired)
Since the founding of our country, rural Americans have always responded when our Nation has gone to war. In the American Revolution, rural Americans left their homes and their families to fight the threat of loss to their families and their lands. During the American Civil War, rural Americans again responded to fight the threat of loss to their way of life and to protect their families. However, during the Civil War, the United States government instituted the first-ever military draft. Again, motivated by tradition and values, rural Americans responded.
According to an Issue Paper published by the National Rural Health Association Rural (2007) people respond to such needs because they maintain value structures that are reflective of service to others and service to their country, volunteerism, care of home, and a sense of place. They also respond to economic concerns and certainly through patriotism. Whether motivated by their values, patriotism, and/or economic concerns, the picture has not changed much in 200 years. More than 44 percent of U.S. military recruits come from rural areas, Pentagon figures show. In contrast, 14 percent come from major cities. Youths living in the most sparsely populated Zip Codes are 22 percent more likely to join the Army, with an opposite trend in cities. Regionally, most enlistees come from the South (40 percent) and West (24 percent) (NRHA, 2007).
In the last two decades, the United States has been involved with a number of military conflicts predominately in the Mideast (US Department of Veterans Affairs (VA), 2013), resulting in the deployment of numerous military personnel. Moreover, it is not unusual for a soldier to be deployed multiple times within a 3 year period. Since the U.S. has an all-volunteer military (army, air force, navy, marines) the majority are in the reserve component or the National Guard. Again, a disproportionate number of returning veterans have rural origins and are returning to their home communities having physical and emotional healthcare needs.
Compared to urban veterans, rural veterans have higher prevalence of physical illness, lower health-related quality of life, and greater health care needs. Despite their greater need, rural veterans are less likely than urban veterans to use VA or private sector health care services. The disparity in use of health care may be due in part to longer driving distances to VA medical facilities experienced by many rural veterans, relative to their urban counterparts. VA primary care is available within a 30-minute drive for 91% of urban veterans, 38% of rural veterans, and 22% of highly rural veterans. Fewer than half (49%) of highly rural veterans live within 60 minutes of VA primary care.
The Department of Veterans Affairs (VA) is statutorily required to provide the VA-enrolled veteran with access to timely and quality medical care. It does so through the nation’s largest integrated healthcare delivery system, with more than 150 VA medical centers (VAMCs), 800 community-based outpatient clinics (CBOCs), and a range of other types of facilities (e.g., nursing homes) that provide care to more than 5.5 million patients. Despite this, Congress remains concerned that veterans, in particular, rural veterans, may not be able to access VA health services. Among veterans enrolled in VA health care, 41% reside in rural or highly rural areas. Rural-enrolled veterans share certain characteristics that influence access to and the need for care.
Congress has demonstrated continuing interest in modifying VA delivery of care to expand access for rural veterans. Such interest has been demonstrated through report language, statutory mandates, appropriation of funds, and authorization of demonstration projects. In particular, Congress has encouraged the VA to collaborate with federally qualified health centers (FQHCs)—facilities that receive federal grants and are required to be located in areas where there are few providers, particularly rural areas. The VA is generally a provider—rather than a financer—of health care services; however, the VA has statutory authority to reimburse non-VA providers for services that are not readily available within the VA’s integrated health care delivery system. VA facilities may consider contracting with outside providers to provide services to rural veterans.
One type of facility that the VA has contracted with in the past are FQHCs. Although FQHCs are one type of facility that the VA can collaborate with, FQHCs may be candidates for VA collaboration because, as a condition of receiving a federal grant, they must meet certain requirements that include providing specific types of services, maintaining certain records, and meeting certain quality standards. These requirements, and the leverage that the federal government may have as a funding source may facilitate VA-FQHC collaboration to provide care to veterans in rural areas. Some considerations that may arise during attempts to increase VA-FQHC collaboration include the costs of care to an FQHC, the VA, and veterans; the capacity of an FQHC to serve veterans in addition to its existing patients; and the compatibility of the VA and an FQHC in terms of the services available, quality initiatives, accreditation, and use of electronic health records. To address these considerations and encourage VA-FQHC collaboration, there are a number of policy levers that Congress might use. These include oversight, an incentive fund, directed spending, statutory mandates, and watchful waiting. Congress may also consider a combination of these levers.
Table I: VA-Enrolled Veterans *
Not all veterans are eligible to enroll in the VA. In general, eligibility for enrollment in VA health care operates through a system of eight priority groups, based on veteran status, the presence of service-connected disabilities or exposures, income, and/or other factors, such as status as a former prisoner of war or receipt of a Purple Heart. Once enrolled in the VA health care system, a veteran remains enrolled and does not have to reapply, even if the veteran’s priority group changes (due, for example, to a change in income).Veteran status is established by active-duty status in the U.S. Armed Forces and an honorable discharge or release from active military service. Generally, persons enlisting in one of the armed forces after September 7, 1980, and officers commissioned after October 16, 1981, must have completed two years of active duty or the full period of their initial service obligation to be eligible for VA health care benefits. Service members discharged at any time because of service-connected disabilities are not held to this requirement. Veterans returning from combat operations are eligible to enroll for five years from the date of discharge without having to satisfy a means test or demonstrate a service-connected disability. A service-connected disability is a disability that was incurred or aggravated in the line of duty in the U.S. Armed Forces (38 U.S.C. §101 (16)). The VA determines whether veterans have service-connected disabilities and, for those with such disabilities, assigns ratings from 0% to 100% based on the severity of the disability (38 C.F.R. §§4.1-4.31). Veterans who are eligible on the basis of exposure include those veterans who may have been exposed to Agent Orange during the Vietnam War or veterans who may have diseases potentially related to service in the Gulf War.
*Source: CRS Report R42747, Health Care for Veterans: Answers to Frequently Asked Questions, by Sidath Viranga Panangala and Erin Bagalman.
Congressional Research Service. (2013, April 3). Health Care for Rural Veterans: The Example of Federally Qualified Health Centers. Accessed on May 21, 2013 from http://www.himss.org/files/HIMSSorg/Content/files/20130418-CRS-RptHealthCareRuralVeterans.pdf
National Rural Health Association Issue Paper. (2007). Rural Veterans: A special Concern for Rural Health Advocates. Accessed May 21, 2013 from: http://www.ruralhealthweb.org/go/rural-health-topics/veterans-health
US Department of Veterans Affairs Website, Accessed on May 21, 2013 from: http://www.va.gov
US Department of Veterans Affairs (2013). Rural Health Exchange Information. Accessed on May 21, 2013, from http://www.va.gov/health/NewsFeatures/20110421a.asp