Accessing healthcare can be difficult for the over 4.4 million American veterans living in rural America. Barriers to care include long travel distances, a shortage of healthcare workers, and limited broadband access. Such obstacles are especially pronounced in American Indian and Alaska Native communities—groups that have traditionally served in the military at higher rates than the general population. These challenges persist even for the 2.7 million rural veterans enrolled for care through the Veterans Health Administration (VHA), an administration of the Office of Veterans Affairs (VA).
In addition to health concerns common to the general population, veterans may experience service-connected conditions such as tinnitus and hearing loss, PTSD, musculoskeletal issues, and migraines. These conditions can be more severe in rural veterans, who are typically older and more likely to have disabilities than their urban counterparts. In addition, while research suggests rural living may mitigate certain mental health issues, rural veterans are ultimately at a higher risk of suicide.
Testifying before the Senate Committee on Veteran Affairs earlier this year, Alyssa M. Hundrup, Director of Health Care at the U.S. Government Accountability Office, observed that “It is imperative the VA do all it can to ensure access for all veterans, including those in rural areas.” However, the VA cannot address these challenges on its own. The agency operates within the broader framework of federal laws, which are at times in conflict with its policy objectives.
Transportation and Distance as Barriers to Care
For rural veterans, the geographic isolation that provides privacy and open space often puts healthcare services far from reach. While the VHA’s network of 170 medical centers and 1,193 outpatient clinics reflects the agency’s mission to “Honor America’s Veterans by providing exceptional health care that improves their health and well-being,” its facilities are still difficult for many rural veterans to access. In 2023, rural veterans using the Veterans Transportation Service traveled an average of 74 miles each way for medical appointments at VHA offices.
To put the challenge in perspective, at least half of all states have at least one county that meets the VHA’s definition of ‘highly rural,’ with fewer than seven people per square mile. While service organizations and state veterans’ agencies serving these remote areas can qualify for transportation grants, reimbursement rates for volunteers are often lower than the transportation rates allowed for federal employees.
Transport by ground or air ambulance can be lifesaving for patients with emergent medical conditions or traumatic injuries. Yet, many rural veterans live in “ambulance deserts,” with the nearest ground ambulance stationed more than 25 minutes away. Although some VA facilities have partnered with local emergency medical service providers for emergency transports, these agreements can be tenuous at a time when many rural hospitals are at risk of closing. In fact, there are eight states with fewer than three ambulances for every 1,000 square miles.
Air medical transport introduces additional complexities, as, unlike ground transport, it falls under the regulations of the No Surprises Act. The VA recently postponed implementing a rule that would reduce reimbursement rates for air ambulance providers until 2029, following concerns raised by Senators Jerry Moran (R-Kan) and Jon Tester (D-Mont). Critics argue that lowering payments to air ambulance providers would put operators in financial jeopardy and could ultimately limit veterans’ access to emergency care in rural areas. The delay allows the VA to work with stakeholders to create policies that sustain essential transportation services.
Workforce Shortages and Recruitment Efforts
Recruiting and retaining healthcare professionals in rural areas is a nationwide problem. In Health Professional Shortage Areas (HPSAs), VHA offices often compete with critical access hospitals and federally qualified health centers for a limited pool of talent.
Congress has passed legislation aimed at giving the VA a competitive edge in attracting healthcare workers. The Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics (PACT) Act provides benefits for veterans exposed to toxic substances. It also includes targeted recruitment provisions for rural healthcare. The act authorizes the VHA to “buy out” service contracts for specific healthcare professionals, encouraging them to work in rural VA facilities.
The VA has prioritized recruiting rural healthcare providers. Its careers page emphasizes investments in rural facilities and invites applicants to consider careers at these locations. However, a VA Office of Inspector General (OIG) review of a multiyear hiring initiative focused on expanding substance use disorder treatment found that the VHA did not “clearly communicate hiring priorities, define and assign responsibilities for implementation and oversight, and generally ensure accountability for achieving the initiative’s goals.”
Telehealth and Digital Access
In establishing an Office of Telehealth Services in 2003, the VA was one of the first health systems to adopt the use of telehealth. In FY2023, nearly 40% of veterans enrolled in the VHA received at least part of their care through telehealth, and this option has become an essential link to healthcare providers for rural veterans. However, virtual care can be disrupted by the fact that many veterans lack access to devices or consistent broadband. The VA’s Digital Divide Consult service addresses these gaps with programs like Accessing Telehealth through Local Area Stations (ATLAS), which provides telehealth kiosks in community centers. Some VA offices loan tablets to veterans and partnerships with cellular providers allow many to access telehealth on mobile devices without data fees.
The need for broadband access remains a national issue. The Bipartisan Infrastructure Investment and Jobs Act allocated $65 billion to bridge the digital divide. The U.S. Department of Commerce’s National Telecommunications and Information Administration (NTIA) administers the majority of this funding through its Broadband Equity, Access, and Deployment (BEAD) Program, prioritizing underserved and rural areas. BEAD received mixed reviews at the House’s Communications and Technology Subcommittee hearing in September. While all states have submitted funding requests under the program, some members of Congress complain that BEAD has been characterized by red tape and delays.
Bureaucratic delays in broadband expansion are not the only hurdles to telehealth growth. Variations in state and federal regulations regarding the prescribing of controlled substances mean that VA providers often find themselves navigating a regulatory maze—particularly when treating addiction. The Ryan Haight Online Pharmacy Consumer Protection Act requires an initial in-person visit before providers can prescribe controlled substances such as buprenorphine for opioid use disorder. Temporary flexibilities introduced during COVID-19, which permitted these prescriptions to be initiated through telehealth, are set to expire next month.* In anticipation of the end of these flexibilities, Representatives Steve Womack (R-Ark) and Sanford D. Bishop (D-Ga) introduced the bipartisan Protecting Veteran Access to Telemedicine Services Act of 2024. This legislation would allow qualified VA providers to prescribe controlled substances via telemedicine without an initial in-person visit. If passed, the act could streamline access to care for rural veterans managing conditions like opioid use disorder (OUD) and ADHD across state lines.
American Indian and Alaska Native Veterans
The challenges in rural health are magnified for American Indian and Alaska Native (AI/AN) veterans. Despite only being granted U.S. citizenship in 1924, American Indians and Alaska Natives have a long-standing tradition of military service, historically enlisting at rates five times higher than the national average. Still, state and federal policies and a legacy of mistrust have complicated their access to and use of healthcare.
While AI/AN veterans tend to be younger than the average veteran, they are more likely to live with disabilities. They are also among the most geographically isolated of veteran populations and often the last to be aware of eligibility for services.
The VA has recently made several efforts to increase outreach to AI/AN veterans and to ensure that its provision of care to Native American veterans is based in respect for traditions, customs, and beliefs. Additionally, in 2023, the VA began waiving co-pays for eligible AI/AN Veterans receiving care at VA facilities.
*On November 15 2024, the DEA released another temporary rule issuing the third extension of the temporary COVID-19 telemedicine flexibilities for the prescribing of controlled medications via telehealth.
The rule extends these flexibilities to ensure ongoing patient access to care, prevent in-person evaluation backlogs, address the opioid crisis by allowing telemedicine-based initiation of buprenorphine, provide time for stakeholders to prepare for future telemedicine prescribing regulations, evaluate expansion alternatives, and limit problematic prescribing practices. The extension lasts until December 31, 2025.
The DEA and HHS are implementing this rule to allow adequate time for providers to come into compliance with any new standards or safeguards that will eventually be adopted in a final set of regulations for telemedicine prescribing of controlled substances. DEA is still considering comments received in the Telemedicine Listening Sessions in September 2023 and Tribal Consultations held in June 2024.