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Association Between Local Area Unemployment Rates and Use of Veterans Affairs Outpatient Health Services

Wong, Edwin S. PhD*,†; Hebert, Paul L. PhD*,†; Hernandez, Susan E. MPA; Batten, Adam BA*; Lo, Sophie MS; Lemon, Jaclyn M. BS*; Fihn, Stephan D. MD, MPH; Liu, Chuan-Fen PhD, MPH*,†

doi: 10.1097/MLR.0000000000000079
Original Articles

Background: Prior research indicates that federal spending on Medicare, Medicaid, and other government health programs accelerated during the Great Recession.

Objectives: To examine whether local unemployment was associated with utilization of Veterans Affairs Health Care System (VA) primary care, specialty care, and mental health services during 2004–2012.

Research Design: We analyzed utilization of VA health services at the clinic level using fixed-effects negative binomial models. We stratified analyses by veterans’ copayment status (exempt and nonexempt) and age (under 65 and 65+) to account for differences in VA utilization because of Medicare eligibility.

Subjects: A total of 11,041,855 veterans assigned to 892 clinics identified in the VA Primary Care Management Module, representing nearly all veterans receiving primary care from VA, were included.

Measures: Clinic-level utilization was calculated quarterly as the total number of visits for patients assigned to a clinic. Local area unemployment rates were defined as quarterly unemployment rates within VA geographical planning sectors.

Results: Higher local unemployment was associated with greater use of VA care in all categories among veterans exempt from copayments. The association between local unemployment and utilization differed by age group among veterans subject to copayments. Higher local unemployment was associated with lower use of primary and specialty care among Medicare-eligible veterans aged 65+, but greater use of primary care among veterans under age 65.

Conclusions: Our findings highlight the importance of the state of the economy in interpreting and forecasting demand for government health programs including VA, particularly during periods focused on deficit reduction.

Supplemental Digital Content is available in the text.

*Northwest Center for Outcomes Research in Older Adults, VA Puget Sound Health Care System

Department of Health Services, University of Washington

Office of Analytics and Business Intelligence, Veterans Health Administration, Seattle, WA

Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website,

Supported by the Veterans Health Administration Patient Centered Medical Home Demonstration Laboratory Coordination Center (XVA-61-041). E.S.W. supported by a VA HSR&D Career Development Award (CDA 13-024).

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the University of Washington.

Dr Wong reports stock ownership in Humana, Inc. All other authors declare no conflicts of interest.

Reprints: Edwin S. Wong, PhD, Northwest Center for Outcomes Research in Older Adults, VA Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101. E-mail:

© 2014 by Lippincott Williams & Wilkins.