Defining "Rural" for Veterans' Health Care Planning

Purpose: The Veterans Health Administration (VHA) devised an algorithm to classify veterans as Urban, Rural, or Highly Rural residents. To understand the policy implications of the VHA scheme, we compared its categories to 3 Office of Management and Budget (OMB) and 4 Rural-Urban Commuting Area (RUCA) geographical categories. Method: Using residence information for VHA health care enrollees, we compared urban-rural classifications under the VHA, OMB, and RUCA schemes; the distributions of rural enrollees across VHA health care networks (Veterans Integrated Service Networks [VISNs]); and how each scheme indicates whether VHA standards for travel time to care are met for the most rural veterans. Results: VHA's Highly Rural and Urban categories are much smaller than the most rural or most urban categories in the other schemes, while its Rural category is much larger than their intermediate categories. Most Highly Rural veterans live in VISNs serving the Rocky Mountains and Alaska. Veterans defined as the most rural by RUCA or OMB are distributed more evenly across most VISNs. Nearly all urban enrollees live within VHA standards for travel time to access VHA care; so do most enrollees defined by RUCA or OMB as the most rural. Only half of Highly Rural enrollees, however, live within an hour of primary care, and 70% must travel more than 2 hours to acute care or 4 hours to tertiary care. Conclusions: VHA's Rural category is very large and broadly dispersed; policy makers should supplement analyses of Rural veterans’ health care needs with more detailed breakdowns. Most of VHA's Highly Rural enrollees live in the western United States where distances to care are great and alternative delivery systems may be needed.