In a national population-based study, we found that almost 1 in 5 women veterans delayed healthcare or went without needed care in the prior 12 months. Delayed healthcare or unmet healthcare need was present to a varying degree in all subgroups, including all age groups, VA enrollment priority groups, and among VA users and nonusers. A wide range of predisposing, enabling, and need-related healthcare factors had measurable and substantial impacts on women veterans’ access to needed services.
Access barriers present in the general non-veteran population influenced women veterans’ likelihood of delaying or foregoing needed healthcare. For example, a broad range of studies on U.S. healthcare access documents the central role of insurance coverage, which was the impetus behind healthcare reform to expand access.18,19
The VA is an equal access system for eligible veterans in that healthcare services are mostly free at the point-of-care, with a small copayment for certain categories of veterans, but no annual premium. Despite VA availability, unmet need was greatest in high priority enrollment groups, primarily related to the large numbers of low income and uninsured veterans experiencing delayed healthcare or unmet need. Seven percent of Canadians, with their equal access national healthcare system, experience delayed care or unmet need, in contrast to the 19% we found.20
Forty-three percent of uninsured women veterans had healthcare affordability barriers underlying these delays, similar to the 46% reported for predominantly female, uninsured, low income public health clinic users.21
Health reform in the U.S. is slated to be fully implemented by 2014. However, research on healthcare and outcomes in England, which already has a national universal health coverage system, documents socio-economic and class-related healthcare disparities, confirming our finding that healthcare eligibility, though necessary, is not sufficient for assuring healthcare use when it is needed.22,23
Higher rates of delayed care or unmet need were also present in racial/ethnic minorities, women veterans lacking a regular source of healthcare, and those with low income. Though these general barriers to healthcare access are not unique to women veterans,24
what is unique is that the VA healthcare system is in a special position to create programs that offset the socioeconomic and insurance-related barriers that other public programs may be less able to accomplish.
Veteran-related factors, including those specific to women veterans, were also important determinants of access to care. In a prior regional study, we identified women veteran-related corollaries to the Behavioral Model framework’s predisposing, enabling, and need domains.6
That regional study found women veterans’ perceptions about VA healthcare quality, gender-appropriateness, and the VA environment, and their knowledge of VA eligibility and services, predicted VA healthcare use. With the current national study, we found that these women veteran-specific factors are also determinants of delayed healthcare and unmet need, independent of VA enrollment priority and VA use. Nonusers have much worse perceptions of VA care than VA users,6
suggesting that VA should better market its services and quality so that nonusers will learn that it has something to offer. However, a small segment of VA users also have poor VA perceptions, implying a need to improve VA care, e.g., by tailoring it to women’s needs and preferences.25
Some women veterans are not eligible for VA care, or choose to obtain their healthcare in the private sector. VA nonusers, particularly the uninsured, are at risk for not receiving needed care. Our findings suggest that the health plans they use should account for the general and veteran-specific need factors that veteran status confers (e.g., posttraumatic stress disorder and military sexual assault). The predictors and access barriers we identified could inform implementation of healthcare reform activities so that non-VA health plans are responsive to women veterans’ access barriers and healthcare needs.
VA market penetration for OEF/OIF women veterans is much higher than that for women veterans of other military eras (44% versus 14%, respectively, in 2008 VA administrative data).3
Despite this greater VA use, we found that OEF/OIF women veterans still experience barriers to healthcare access. To comprehensively address access to care for women veterans, it is critical to understand the barriers to healthcare in both VA and community settings for OEF/OIF veterans. Re-integration concerns, while recognized within the VA, may be barriers to non-VA care. Within VA, gender-sensitivity of healthcare personnel has been identified as an area for improvement;26
we found that gender-sensitivity issues were independent predictors of healthcare access. Coordination of obstetrical and mental healthcare has been identified as an issue as well.27
Further research should explore patient perception of and navigation among the many VA clinical sites that serve as entry points for OEF/OIF women veteran (e.g., post-deployment clinics, women’s clinics, primary care clinics, and mental health clinics).28
A limitation of this study is that we did not assess the seriousness of the condition for which healthcare was delayed or not obtained, the length or number of delays over 12 months, or the health consequences. Nonetheless, our measure allows comparison with non-veteran populations, and is a useful starting point for a follow-up study to better characterize unmet need and to address potential solutions. Future research should also characterize unique access barriers for women in rural settings. Our measure of caregiver responsibilities did not distinguish among childcare, elder care, and other caregiver responsibilities. Given women’s age-related caregiver roles, it is possible that the trend we observed for higher rates of caregiver responsibility in the youngest and oldest age groups, represented childcare and elder-care responsibilities, respectively, which may have been apparent had we assessed these caregiver functions separately.29
A limitation of our sampling method is under-coverage of those without a telephone – a group likely to have significant access barriers. Though we could verify VA use with the administrative databases used to construct our sampling frame, a similar assessment of care-seeking behavior for VA nonusers was beyond the scope of this study. Despite these limitations, this study contributes a comprehensive assessment of access to care and healthcare utilization issues of women veterans, that is providing an evidence base for national VA strategic planning for programs and services for women veterans.30
Many of the access barriers that we identified are potentially modifiable through expanded VA healthcare and social services. However, since barriers to care varied by age and other population characteristics, no one blanket remedy is likely to comprehensively address all access issues for women veterans. The VA provides care for women veterans across their lifespan, and women’s entry into and preference for VA healthcare varies by age group (including through women’s health, primary care, and geriatrics clinics), therefore interventions need to be designed and targeted to specific age groups and risk categories of women veterans.31
Healthcare affordability was a barrier for age groups under 35 and 50–64, therefore affecting large numbers of OEF/OIF women veterans and women who do not meet age criteria for Medicare. Since demand for obstetric care and menopause-related care, respectively, is likely greatest in those age groups, it’s possible that healthcare delays may be related to reproductive needs in these cohorts.27
Inability to take off from work was a barrier for those under age 50, and transportation difficulties were a barrier for those 65 and older. History of military sexual assault was a barrier that was independent of age group and other factors, suggesting that general and veteran-specific barriers are especially important for our most vulnerable women in VA and non-VA settings.
To address healthcare access barriers for women veterans, VA after-hours care should be considered, as should expanded VA transportation services and tele-medicine alternatives to current settings for care. Efforts are also warranted to improve women veterans’ knowledge of availability and affordability of VA healthcare. Increasing knowledge of VA services is a marketing issue, and the VA has recently launched a telephone call center to reach women veterans. In addition, greater use of social marketing such as peer support and social networking internet sites could expand the potential for reaching different segments of the women veteran population. Outreach, education, and expanded VA access, to reduce barriers to entry into VA care, must be coupled with actions to enhance the gender-sensitivity and gender-appropriateness of this care. Veteran-centered care is a focus of current VA transformation activities to improve VA care. Future research should be directed toward assessing and adapting these VA transformation activities to further improve the fit between the VA environment, VA healthcare, and the needs and healthcare delivery preferences of women veterans.