Veteran Mental Health and Rurality

Written by: 
Amber Hadley

Many families have made wonderful lives in rural communities. They’ve raised families, held onto traditional moral values, and enjoyed every second of peaceful country living. But there are struggles that need to be addressed for our veterans there. It is no secret that they are underserved in these communities when it comes to medical care. It’s even documented that rural veterans have a higher prevalence of both physical and mental comorbidities. Couple this with the fact that veterans are more likely than the general population to live in rural areas, and we have a multi-faceted problem.

How Many Veterans Live in Rural Areas?

More than 460,000 veterans served in Iraq and Afghanistan. 36% of those veterans live in rural areas, in contrast with only 15-20% of civilians living in rural areas.  Of these rural veterans, 58% are signed up for VA healthcare. This is a high number -- only 37% of urban veterans utilize VA health care.

The “Choice Act”

In order to fulfill Lincoln’s promise to "care for him who shall have borne the battle, and for his widow, and his orphan," we need to make care accessible and high-quality for all our servicemen and women. To this effect, a bipartisan bill passed in 2014 called the Veterans Access, Choice and Accountability Act, or the “Choice Act”. This act, when a veteran pre-approves for care, allows them to see a community provider if the closest VA center is too far away (40 plus miles), or if they need urgent care and their local VA hospital’s wait is too long (over 30 days). 

Of the claims that come to the VA for outside care, 70% of them are for psychiatric care. This is a sign of the VA’s lack of mental health care in general, which has long been under scrutiny. Why would so many veterans look for outside care if the VA says mental health is their ‘highest priority’?

This bill is much needed, since the average distance between a rural veteran and a VA facility is 64 miles, and this distance is the highest predictor of veterans dropping out of mental health and substance abuse programs.

Many rural areas have a general lack of health care providers in their area. This issue is not just a challenge for the VA. There are about 16 psychologists for every 100,000 rural residents, veteran and non. This means that more than 85 percent of all rural residents live in a mental health professional shortage area.

Now, this bill is the beginning of changes enacted in hope of getting rural veterans better care. However, the Choice Act is not without its concerns, either. The common criticism of this act is that it’s complex, bureaucratic, and slow. These complexities often have adverse effects on the veterans and their financial standing. The VA will sometimes take a year or more to reimburse these medical facilities, which is a burden on these rural facilities, who already have very little money. Sometimes, these bills come back on the patient, for tens of thousands of dollars, and end up negatively affecting their credit scores.

The bill was made in response to the 2014 scandal involving disastrous wait times for veterans seeking treatment. This bill, which was initially funded through to 2018, has had trouble continuing to raise funds thereafter. The program was time limited, and extensions have been difficult to procure.

The VA Mission Act

Recently, a bill called the VA Mission Act was signed by President Donald Trump. This bill is meant to improve veteran’s care outside of the VA. Firstly, the bill

- Does away with the 30-day, 40-mile parameters in which a veteran must fall into to seek outside care.

- Ensures that veterans seeking outside treatment will not pay more than their veteran counterparts who utilize the VA

- Create a system for more timely payments from the VA to community providers

- Ensures providers who are suspended by the VA cannot treat Veterans in the community

- Create local provider agreements to “remove bureaucratic red tape and to meet veterans’ needs for care in the community”

- Create an educational program for veterans and VA health providers, making them aware of veteran’s health care options

The hope is to help veterans, especially ones in rural communities, find the help that they need. Though this bill should make things easier for veterans seeking treatment, there are still issues that all residents, veteran and non-veteran, must deal with in these country communities. There is a fundamental lack of specialized providers available, even in private practice. Mental health is of grave concern, as veteran suicide has increase 25.9% since 9/11. Suicide in general is higher in rural areas, and the specific culture of these regions make it hard for people to reach out. It is more common for someone living in a rural community to speak with family, church leaders, or other veterans than with healthcare professionals.

One of the biggest concerns in rural mental health care is the lack of anonymity. If there are very few mental healthcare providers in your area, or if your town is made up of only 3,000 or so people, the chances are higher that neighbors or friends know that you are reaching out for help. The stigma of seeking treatment is strong, and sometimes encourages people to deal with their problems on their own.

There are also vocal critics of the Mission Act and the Choice Act who say that the private sector is not prepared to care for veterans with combat injuries like TBI, PTSD, or MST. They are entities that are set up for the general public, and they might not understand the needs of a veteran who has been in specific circumstances. There are also vocal opponents who point out that, in a 2017 study done by the Journal of the American Medical Association, wait times for private sector care was on average 30 days. Comparatively, wait times for the VA were reported to be 18 days. As these changes are implemented into the system, we will see how it impacts the care for our rural veterans.


The VA hopes that telehealth initiatives can help rural veterans reach care that is inaccessible to them otherwise.

Telehealth is defined by as such:

“The Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services defines telehealth as the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.”

For more information on telehealth within the VA health system, look here.

Resources for Rural Veterans and their Families:

VA Choice Support Line: 866-606-8198

VA Adverse Credit Helpline: 877-881-7618

VA Office of Rural Health

SAMHSA Outreach & Support for Rural Veterans

 ORH – VHA Office of Rural Health

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