This study assessed barriers to use of exclusive VA healthcare services among veterans of OEF and OIF who were on active duty or discharged military personnel of all military services who were either receiving or registered for VA health care. However, we found almost two thirds reported one or more barriers to receiving VA care. Both the OEF-OIF and the PNS groups described barriers that hindered receiving exclusive VA care. These veterans reported that barriers included wait times, distance to the VA facility, concerns about VA staff reputation, paperwork hassle, lack of information, limited service hours, fear/embarrassment/stigma, and having other insurance.
Both those in the OEF-OIF and the PNS groups reported fear/embarrassment/stigma. For example, participants reported embarrassment and concern associated with using VA services, such as “being a burden to the system,” perceiving this as “welfare,” or thinking they “don’t deserve it,” and that “other people need it more,” or “feeling embarrassed [because] older veterans need it more.”
We found that absence of these reported barriers predicted exclusive use of VA healthcare services from the perspective of these U.S. OEF-OIF returnees. Experiencing any barriers doubled the returnees’ odds of not using VA, the distance to VA barrier resulted in a 7 fold increase in the returnees’ odds of not using VA, and the wait time barrier doubled the returnees’ odds of not using VA. This analysis shows associations in this cross sectional study about barriers that are consistent with other reports. However, given this mounting evidence an interventional study design would be needed to see whether or not removing these barriers would increase access and use of VA care.
Selected barriers and stigma (e.g., military record access, being active duty) in this sample of participants from all military services are similar to those of active duty Army and Marine returnees . Participants in the current study reported having other insurance and funds to see private care providers outside of VA (3.3%) as a barrier to exclusive use of VA services. While the Hoge  sample reported concerns about the costs of care (10-25%), participants in the current study did not report costs as a barrier. While the current sample described distance to a VA facility as a barrier, the Hoge  sample saw the barrier to service utilization as a transportation issue.
We placed barriers and stigma within the Andersen behavioral model of service use to explain the impact of delivery system, population characteristics, and external environment and societal factors on utilization of VA services in this population of returnees while attending to variation in practice in different geographical regions and VA organizations. External environment determinants included any barriers and the specific barriers of distance and wait times. Societal determinants included three stigma, fear/embarrassment, access to military records, and being active duty .
The Behavioral Model of health care utilization and the barriers and facilitators that our returnees reported suggest targets for intervention. Findings indicate 2 specific areas that warrant attention: 1) wait times; and 2) distance and location of VA services. As participants described in their own words, “wait times for appointments are very long,” “long wait in ER,” “get seen quicker in private facility,” “pharmacy takes too long”. Wait times are a commonly reported barrier of health care systems .
Distance to a facility, a well-known barrier, was identified even among these active and retired military, who have access to care during active service and following retirement, given their benefits. Distance to VA facilities has previously been studied, using informatics approaches as geographic information system (GIS) tools to map VA patients and their access to specialty care [30, 31]. However, these studies have not included a focus on the OEF-OIF population . While 5 PRCs and numerous other levels of the VA polytrauma system of care were implemented, it is not clear if travel bands to the nearest VA facility with polytrauma specialty care clinics were developed in the original planning.
Access barriers in these veteran groups could have a wide range of negative effects on service utilization and outcomes. The findings highlight areas where VA decision makers may act to enhance access to care that is available to OEF-OIF returnees by targeting distance and wait time barriers that are particularly salient among this population. Such efforts will ultimately contribute to maximizing exclusive use of VA among OEF-OIF returnees.
A major advantage of this study is its ability to provide insight into the experiences of a sample of OEF-OIF returnees from two regions of the country. However the sample accepting our invitation to participate in the study is not necessarily representative of all returnees. Due to limitations in our sampling and tracking within sampling frames, the results may not represent all veterans using VA. If OEF-OIF returnees who were less satisfied with their care were more likely to participate in the study, then the results may overestimate barriers to use of VA care for all services. Another limitation is that qualitative data describe up to 3 different barriers per veteran. While the majority listed 0–1 barriers, and only 57 participants listed 3 barriers, it is possible we have undercounted the barriers and other difference might emerge in future studies and different veteran samples. While we were able to gain insights into a variety of important stigma and barriers to VA care, studies that can assess barriers to care of OEF-OIF returnees who do not use VA services are also needed.
Many returnees may not seek needed mental health care due to public stigma and personal fear and embarassment that constitute barriers to using VA care . Forty-five percent of the current study’s sample was still on active, reserve, or temporary duty release from the military services. Unique cultural factors contributing to perceived stigma and other barriers, such as fear/embarassment/stigma reported by 14% of participants, present unique challenges for health care systems and providers. As these participants stated, they saw their use of services as a “burden to the system” or perceived it as taking “welfare” from the public while their military role has been to protect the public. These participants stated they “do not deserve” the service while “other people need it more.” Cultural awareness of this population can inform strategies to retain OEF-OIF returnees in exclusive VA health care .
Access barriers are highly actionable factors. Efforts to address barriers to care in VA should include greater emphasis on the problems of wait times and distance to facilities, as well as fear/embarrassment/stigma and other barriers to using VA services for all care. Reducing these barriers among OEF-OIF returnees is a priority for policymakers, researchers, clinicians, and leaders who are involved in providing care to these service members who have borne the battle.