• access;
  • health care;
  • health services research;
  • rural;
  • veterans



Rural areas contribute a disproportionate number of US military recruits compared to urban areas. However, few studies have examined why many rural veterans do not enroll in the Veterans Health Administration (VHA) for health care. Our objective was to elicit reasons rural veterans chose not to use VHA.


This mixed-methods study included quantitative survey and qualitative interview data. Surveys were mailed to 4,176 households with a registered voter in a rural Midwestern county to reach the estimated 1,100 veterans, of whom 600 were not enrolled in VHA. Surveys were designed to assess demographics and basic eligibility requirements for VHA. Themes were derived deductively from survey responses and inductively as they emerged through analysis of interview transcripts.


A total of 180 veterans completed the survey and 165 were eligible based on an approximation of enrollment criteria. Of those, 74 (45%) were current VHA users, and 91 (55%) were nonusers of VHA but appeared to be eligible. The most common reason selected by these potentially eligible veterans for not using VHA was they did not think they were eligible (41%). Interviews revealed the issue of distance was superseded by the perception that enrollees must be poor and have experienced combat, injury, or disability during service. Most reported they had never been told about VHA health care benefits.


Results suggest that lack of awareness of VHA health care benefits may be the biggest barrier identified by rural veterans. Targeted outreach and education efforts related to eligibility for rural veterans are warranted.