Why rural veterans struggle to access VA medical care

A quarter or so of veterans enrolled in VA health care live in rural areas, and the system was not built around them. It was built around cities with medical centres in them.

I live in El Paso, which has a facility. Most of the men I interview do not.

The distance problem, stated plainly

A VA medical centre can be two or three hours away. A specialist clinic may be further.

For a routine appointment that is a full day off work, fuel, and possibly a hotel the night before if the appointment is early. For a course of treatment requiring weekly visits it is not sustainable, and people stop going.

Community based outpatient clinics fill part of the gap and there are a lot of them. They handle primary care and some mental health. They do not handle specialist care, and the referral still sends you to the main facility.

The other barriers people do not think about

Transport, for veterans who no longer drive. The Disabled American Veterans transportation network runs volunteer drivers and it is genuinely valuable, and it is thinly spread and depends entirely on whether anyone locally volunteers.

Internet. Telehealth is the obvious answer to distance, and it assumes a connection that works. Broadband in rural counties ranges from adequate to absent, and a video appointment over a connection that drops is worse than useless because it burns the appointment slot.

Staffing. Recruiting clinicians to rural facilities is difficult, and mental health professionals in particular. A clinic may exist and still have a three month wait because one person covers it.

And the cultural one, which nobody writes on a form. Rural veterans skew older and lean heavily toward handling things themselves. Asking for help is not the default, and a system that requires persistence filters out exactly the people who are least inclined to persist.

Community care

The Mission Act in 2018 expanded the ability to use civilian providers at VA expense when the VA cannot provide care within certain distance or wait time standards.

It helps, and it has real problems in practice.

Eligibility is determined by criteria that are not always obvious to the veteran. Authorisations have to be in place before care, and getting care first and asking afterwards leads to bills. Rural areas sometimes lack the civilian specialist too, so the alternative is not actually there. And civilian providers have dropped out over slow payment, which reduces the network further.

The people I would tell you to call

The single most useful person for most rural veterans is a county veterans service officer.

They are usually county employees or work for a state department, they are free, and they know the local system in a way that no national phone line does. They file claims, they chase referrals, and they know which clinic actually has appointments.

Accredited service officers at the major veterans organisations do the same work and are also free. You do not need to be a member of the organisation to use them.

If you take one thing from this, it is that. Find your county veterans service officer and go and see them in person.

Practical things that help

Ask specifically whether your appointment can be done by telephone rather than video. Audio only is often available and works over a connection that cannot carry video.

Ask about travel reimbursement. Mileage reimbursement exists for eligible veterans and a lot of people do not claim it.

Stack appointments. If you are driving three hours, ask the scheduler to put your primary care, your labs and any specialist on the same day. They will do it if you ask and they will not if you do not.

Keep your own copy of everything.

What I actually think

The distance is a real constraint and no policy erases it. But a good deal of what keeps rural veterans out of care is not the miles. It is complexity, and complexity is a choice somebody made.

The veterans who do best are almost always the ones who found one person locally who knows the system and stuck with them. That is not how it should work. It is how it works.