Defining Veteran Rurality: An Analysis of the U.S. Veterans Health Administration Rural-Urban Taxonomy.

purposeRurality is a key consideration for the Veterans Health Administration (VHA) in improving access to care. However, VHA's rural-urban taxonomy, which seeks to guide these efforts, has not been evaluated since new VHA geographic access standards were implemented. Therefore, we examined the degree to which VHA's and University of Washington's "Categorization B" rural-urban taxonomies designate the same veterans as rural and compared drive times to VHA care based on these taxonomies.

methodsWe determined Rural Urban Commuting Area (RUCA) codes of census tracts of VHA enrollees in Fiscal Year 2023 and rural-urban designations under VHA and Categorization B taxonomies, which each have three designations: urban/rural/highly rural and urban/large rural/small rural, respectively. For each RUCA code and rural-urban designation, we calculated frequencies and percentages of enrollees overall, and percentages of enrollees with drive times >30 minutes to VHA primary care sites and >60 minutes to VHA secondary and tertiary care sites, which parallel drive-time eligibility standards for VHA-purchased care under the 2018 Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act.

findingsMost (81.0%) enrollees had similar rural-urban designations under VHA and Categorization B taxonomies; divergence was primarily due to RUCA 2.0, which is considered rural by VHA but urban by Categorization B. Compared with the Categorization B large and small rural designations, the VHA rural and highly rural designations captured more veterans with drive times that meet eligibility standards for VHA-purchased care under the MISSION Act. For example, 85.5% of veterans with tertiary care drive times >60 minutes were considered rural/highly rural by VHA while only 59.8% with tertiary care drive times of this length were considered large/small rural by Categorization B.

conclusionsAligning with VHA's access-to-care priorities, VHA rural and highly rural designations better capture veterans who may experience geographic barriers to care. For other VHA access priorities, such as temporal access, integrating additional data may be necessary to refine rural-urban taxonomies.