The Rural Health Crisis Hits Veterans Hard

By Suzanne Gordon

VHPI Senior Policy Analyst

Author, Wounds of War: How the VA Delivers Health, Healing and Hope to the Nation’s Veterans

Sixty million Americans,19.3% of the population, live in rural areas – including millions of veterans. Many veterans who are lucky enough to be eligible to get care from the Veterans Health Administration (VHA) complain of having to drive hours to get care. Too many believe that the VA MISSION Act will allow them to get high-quality care in the private sector without long waits or long drives. While this may be true in some instances, most veterans will find that the promise of the MISSION Act is little more than a chimera.

Why? Because the serious, long-standing crisis in rural health in the United States is getting worse, not better. Rural Americans are often out of luck, whether it’s finding someone who will treat opioid addiction, scheduling a routine primary care visit, making an appointment with a cardiologist, oncologist, psychologist, or psychiatrist.

Consider primary care. The nation has been plagued by a persistent shortage of primary care physicians (PCPs). A study by the American Association of Medical Colleges (AAMC) warns that the U.S. will need 52,000 more PCPs by 2025. The problem is worse in rural areas, which is why the Health Resources and Services Administration has designated many rural areas as primary care shortage areas. In spite of the documented need, not enough physicians-in-training are choosing to enter primary care. Once again, the problem is more serious in rural areas. Only 4% of medical school graduates surveyed in 2016 would consider practicing in a small community, whether as primary care or specialty providers.

Rural residents also have trouble getting care in a conveniently located hospital – whether for elective surgery or an acute care crisis. Between 2010 and 2019, 102 rural hospitals have closed, and it is estimated that another 700 will close in the next decade.

When it comes to mental health treatment, the situation is even worse. The Substance Abuse and Mental Health Services Administration (SAMSHA) found that 77% of U.S. counties face a severe shortage of practicing psychiatrists, psychologists, or social workers; 55% of U.S. counties – all rural – have no mental health professionals at all. According to studies by the National Institute of Mental Health, 40% of people with schizophrenia and 51% of people with bipolar disorder go untreated in any given year. Many of them live in rural areas. This problem was also highlighted in a report by the National Alliance on Mental Illness (NAMI), entitled The Doctor Is Out.

In April, PBS’ Independent Lens broadcast an excellent documentary called The Providers, which followed primary care and mental health providers in rural New Mexico. The show cataloged the problems of providing health care to rural patients, many of whom suffer from opioid abuse and resulting deaths due to opioid addiction. In 2016, five of the ten states with the highest rates of death due to opioid use were rural.

Last week, Truth Out published an article about the crisis of rural hospital closures entitled, “Rural Hospital Closings Are Leaving Millions of People in a Health Care Crisis.” The authors, Jane Bolin, Bree Watzak, and Nancy Dickey, explain that “More than 20% of our nation’s rural hospitals, or 430 hospitals across 43 states, are near collapse. This is despite the fact that rural hospitals are not only crucial for health care but also the survival of their small rural communities. Since 2010, 113 rural hospitals across the country have closed, with 18% being in Texas.”

They go on to write that, “About 41% of rural hospitals nationally operate at a negative margin, meaning they lose more money than they earn from operations. Texas and Mississippi had the highest number of economically vulnerable facilities, according to a national health care finance report in 2016.”

All of these long-standing problems give the lie to the promises of the architects of the VA MISSION Act, who promise rural veterans increased access to medical and mental health services outside of the VA. In many instances, VHA clinics and hospitals are the only providers of care in rural areas. Any erosion or elimination of these facilities and services would be catastrophic for rural veterans.

As a global leader in Telehealth, the VHA also serves veterans in rural America through its unparalleled telehealth capacity. The VHA now delivers care via telehealth at over 900 locations. Making use of continually evolving communication and information technology, patients separated from providers by geographical location can receive high fidelity services in their homes or in VHA facilities. Patients are also able to receive in-home monitoring via telehealth. In 2016, nearly 12% of veterans – or 2.17 million episodes of care – received some of their care via telehealth.

Here are only a few examples:

• A veteran in rural Vermont was able to get physical therapy from a VA therapist in North Carolina.

• Family members may be trained via telehealth as they learn to help veterans with low or no vision in the VHA’s system of 13 Blind Rehabilitation Centers.

• At the San Francisco VA Health Care System, integrated pain teams at the San Francisco VA’s Medical Center at Fort Miley deliver services to outlying clinics in Ukiah, Eureka, and Clear Lake, California.

• At the same facility, a neurologist can deliver cognitive behavioral therapy to a veteran with psychogenic epilepsy who lives six hours away from the hospital.

   

It is not surprising that discussions of the crisis in rural health often fail to consider the role the VHA provides in serving the needs of rural Americans and bolstering the economies of rural areas. Veterans Service Organizations, Congressional Democrats and Republicans should be doing more to assure that veterans will continue to benefit from the services the VHA provides to rural Americans. They should also expose, rather than perpetuate, the myth that the private sector can deliver care to rural veterans when it has long failed – and even abandoned – millions of rural Americans.