By Mike Hostutler
Veterans in the United States require extensive healthcare following their service to our country as they are disproportionally affected by chronic injuries and illness resulting from their work. As such, it is vital that veterans access quality care to manage these long-term medical conditions. Rural veterans are defined by the VA using the Rural-Urban Commuting Areas (RUCA) system, which is also used for the US Census. This system considers population density as well as how closely a community is linked socio-economically to larger urban centers. The state of North Carolina has the second highest number of rural veterans of any state, yet it only has four VA medical centers to service this dispersed population. Most veterans who served on active duty who were not dishonorably discharged are eligible to receive care at VA hospitals. Despite its service to veterans, according to a 2014 NIH study on the effects of distrust on the VA health system, many do not trust the VA and see the institution as another example of extreme government bureaucracy and inefficiency. The most common issues rural veterans face when trying to access healthcare, including lack of accessibility to VA locations, disproportional numbers of the elderly, and higher rates of chronic illness. Through an analysis of interviews from the UNC Southern Oral History Program database, there are common themes and issues that veterans and their families experienced in their interactions with the VA hospital system. Taking the direct experiences of those who receive care from the current veteran healthcare system is the best method to guide reform and inform policy makers in order to improve healthcare outcomes for rural veterans.
The VA, especially in rural areas, struggle to provide quality healthcare. While there is significant research comparing the healthcare outcomes of veterans in urban versus rural settings, many interviewees felt that they did not receive quality care at VA facilities, particularly at VA clinics. Ken Smith, a real estate agent and resident of Burlington, NC, described his dad’s experience with hospice care in Fayetteville, NC through the VA. When asked about his experience with rural healthcare, he stated, “… I don’t think it was very good. You know, my dad got a lot of care from the VA and, frankly, I think the care was terrible.” Hospice care at the VA is limited, especially in rural areas with many veterans looking for end-of-life care outside the VA system. In one 2007 study on VA hospice care, Edes, Shreve, and Casarett, found that veterans may not be choosing to use hospice care services because of the VA’s lack of service options, especially in rural areas. In another interview with veteran Charles Anderson, he describes his difficulties in accessing quality healthcare for his mental health issues through the VA system, explaining, “When I got out, I didn’t want to go back through that system, and I was afraid to go to the VA.” Veterans should not be afraid or worried about receiving inadequate healthcare through the VA. The consequences of the lack of care at the VA, especially seeking mental health services, can be deadly. Later in his interview, Charles describes his spiraling state of mind after failing to receive mental healthcare, explaining, “Had I been in [a worse] state – and I very well could have put a gun in my mouth in the parking lot of the VA.” While Charles found suitable care at a private center which is separate from the VA, systematic change is necessary to improve veterans’ healthcare outcomes. The VA is supposed to be the best resource to receive care for veterans. No one should leave an appointment frustrated and contemplating suicide.
Charles Anderson’s fear of accessing care at the VA speaks to another important issue for veterans seeking health care—their distrust of the VA as a whole. According to the VA, an estimated 11-20% of veterans will be diagnosed with PTSD. These veterans require quality mental health resources for these long-term diagnoses, yet their previous experiences receiving poor care from the VA causes many to distrust the system. Charles Anderson suffered from PTSD after one of his Humvees was hit by an IED. When asked in an interview his thoughts on the VA, he said, “we already have this kind of view of the VA – we view the VA with suspicion, usually. Most veterans I know don’t particularly want to be treated there.” If veterans do not trust the health care system charged with helping them, there is little room for actual improvement in the quality of care. Rural physician Dr. Dick Merwarth also mistrusts the quality of care at the VA hospitals. When asked to discuss the health care options for veterans in North Carolina, he explains, “an example of the worst that government can do is the veteran’s system.” He attributes many of the VA’s problem as “the result of administrative factors than it is medical factors.” If both patients and providers do not trust the VA system, we will continue to see poor healthcare outcomes. Especially for mental illnesses like PTSD, trust is an important part of the therapy process. It is imperative that the VA improve care and reach out to veterans to reestablish a better relationship.
While many veterans and their families distrust the VA, they also have trouble accessing particular specialized services in rural areas. Many of the VA locations lack specialized and advanced care, forcing rural residents to travel hundreds of miles. Additionally, there is a large disparity in quality between many VA hospitals. In his interview, Ken Smith describes the vast differences in the quality of care at particular VA locations, saying, “[my father] was in Fayetteville. There was a VA there. I don’t think he really got good healthcare till he ended up coming to the Durham VA.” Accessibility is vital in order for rural veterans to receive healthcare. Many veterans lack the transportation or support to travel hundreds of miles to large VA hospitals in urban areas. According to a 2017 study on increasing healthcare accessibility for rural veterans, Dr. Thomas Klobucar explains that the average rural veteran has to travel over 30 mins to receive primary care and 90 minutes to receive advanced, specialized care. Many older veterans with chronic conditions do not have the ability to travel these distances on a regular basis to receive care. Charles Anderson, failing to access mental health services from the VA, found care through the “Vets’ Center” a healthcare NGO which he described as “small, stand-alone clinics designed specifically to help people with psychological problems.” These small rural clinics are vital to the rural healthcare system, especially to treat mental illness for veterans. Focusing resources on creating similar clinics in rural areas can help increase accessibility by reducing physical distance needed to travel. While there will always be healthcare accessibility barriers in rural areas as well as other vital services, it is imperative that the VA work to increase accessibility so the majority of veterans can receive adequate care.
Through this analysis of primary research of rural North Carolina veterans and their families, it becomes apparent that a three-prong approach is necessary to improve the VA system: improve quality of care through better staffing, renew the image of the VA to improve trust, and add more specialized locations in rural areas to improve accessibility. With the rise of the internet, the medical field has seen exciting technological advancements, including the rise of telehealth medicine. While increasing telehealth services can positively impact rural veterans, it is useless without expanding broadband access in rural areas. According to the North Carolina Division of Broadband and Digital Equity, almost 1.1 million North Carolina residents lack high speed internet, cannot afford it, or lack the skills to access it. The VA, in partnership with the federal government, must increase telehealth options for veterans, while simultaneously increasing rural broadband access to improve access to care. The VA is a vital piece in our country’s healthcare system, charged with helping some of the most vulnerable in our community. More effort is clearly needed to provide those who sacrificed their health and safety with the care they so rightfully deserve.
Davila, Heather, et al. “Rural Veterans’ Experiences With Outpatient Care in the Veterans Health Administration Versus Community Care.” Medical Care, vol. 59, June 2021, p. S286. journals.lww.com, https://doi.org/10.1097/MLR.0000000000001552.
Engel-Smith, Liora, et al. “COVID Breathes Life into North Carolina’s Rural Telehealth, but Broadband Remains an Obstacle.” North Carolina Health News, 14 May 2020, http://www.northcarolinahealthnews.org/2020/05/14/coronavirus-rural-telehealth/.
“How Common Is PTSD in Veterans?” Department of Verteran Affairs, https://www.ptsd.va.gov/understand/common/common_veterans.asp. Accessed 25 Apr. 2022.
“North Carolina Broadband Infrastructure Office.” North Carolina Division of Broadband and Digital Equity, https://www.ncbroadband.gov/. Accessed 26 Apr. 2022.
Smith, Tonia. “Differences in Hospice Care Between Veterans and Non-Veterans.” St. Catherine University, p. 38.
Thomas F. Klobucar. “Increasing Rural Veterans’ Access to Care Through Research.” Department of Verteran Affairs FORUM, Summer 2017.
Smith, Ken. Interview with Isabell Moore. 30 July 2019 (Y-0127). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Anderson, Charles. Interview with Betsy Brinson. 27 May 2006 (R-0377). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Merwarth, Charles. Interview with Nicholas Allen. 04 September 2018 (Y-0074). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.